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The global Guinea worm eradication program represents one of the great public health success stories of our time. Since the program’s inception in 1980, the number of annual human cases has reduced by 99.9%, from an estimated 3.5 million cases in 21 countries1 to only 54 cases in three countries at the end of 2019.2,3 Causing significant disability and pain, Guinea worm infection occurs through the ingestion of freshwater copepods (small water crustaceans) infected with stage 3 Dracunculus medinensis larvae. After approximately 10–14 months, a blister forms (usually on a lower limb) where the pregnant adult female Guinea worm ruptures the skin.4 Upon detection of a possible Guinea worm case, patients are transported to health centers where they receive care. The worm is extracted via “controlled immersion,” in which the wound is submerged in a water-filled container to induce worm emergence without the risk of contaminating public water sources.5 Guinea worm is a disease of poverty, primarily impacting people in remote areas who do not have access to safe water for drinking and are forced to drink from stagnant water sources such as ponds, pools, and unprotected open wells that may contain infected copepods.5 The seasonality of disease incidence varies geographically owing to the timing of precipitation patterns and abundance of stagnant water sources.5 For example, in the Sahel (Mali, Niger, Chad), cases historically peaked in the months May through October when stagnant water sources are most abundant. Young adults (15–45 years of age) are most likely to be infected with D. medinensis, although persons of all ages can develop infection.5 Guinea worm cases have historically been equally distributed among men and women, though some exceptions have been noted.5 Occupation is an important risk factor; farmers and persons who fetch drinking water are commonly infected.5 In some countries (i.e., Mali, Niger, and Burkina Faso), certain ethnic groups are at higher risk of infection because of seasonal migration across long distances and, in some cases, the seasonal search for water or pasture for cattle.5 Conventional thought about Guinea worm transmission ecology was challenged in 2012 when canine cases were first reported in Chad in significant numbers,6 spurring new research on transmission dynamics. Today, Chad is the epicenter of D. medinensis transmission, reporting 88% of human cases (N = 48) and virtually all canine cases (99%, N = 1,927) worldwide in 2019.2,3,7 Recent case-control studies conducted in Chad have shown that water sources associated with increased risk for Guinea worm include lagoons, ponds, and untreated water from hand-dug wells.8,9 No associations have been observed to date between human Guinea worm and consumption of fish and frogs,9 which has been demonstrated in dogs.10 This is could be because humans are less likely than dogs to consume uncooked small fish/fingerlings and frogs, which can serve as transport or paratenic hosts.11,12 Over five years have passed since Eberhard et al.6 first described the unusual epidemiological patterns in Chad, noting that human cases are sporadic and rare in comparison with canine cases, with no apparent association with common water sources and no clustering by village. Since that time, the number of canine cases has generally increased steadily as surveillance expanded,2,3,13 whereas human cases have remained generally constant and at low numbers.2,3 Here, we use additional surveillance data to determine whether those epidemiologic patterns persist and to characterize in greater depth human Guinea worm in Chad, with the broader goal of furthering our understanding D. medinensis transmission and epidemiology.

Dracunculiasis, slated for global eradication, typically is acquired by drinking stagnant water containing microscopic crustaceans (copepods) infected with Dracunculus medinensis larvae, causing clusters of case persons with worms emerging from the skin. Following a 10-year absence of reported cases, 9–26 sporadic human cases with few epidemiologic links have been reported annually in Chad since 2010; dog infections have also been reported since 2012. We conducted an investigation of human cases in Chad to identify risk factors. We conducted a case–control study using a standardized questionnaire to assess water and aquatic animal consumption, and links to dog infections. Case persons had laboratory-confirmed D. medinensis during 2013–2017. Each case person was matched to one to three controls without history of disease by age, gender, and residency in the village where the case person was likely infected. We estimated odds ratios (ORs) using simple conditional logistic regression. We enrolled 25 case persons with 63 matched controls. Dracunculiasis was associated with consumption of untreated water from hand-dug wells (OR: 13.4; 95% CI: 1.7–108.6), but neither with consumption of aquatic animals nor presence of infected dogs in villages. Unsafe water consumption remains associated with dracunculiasis. Education of populations about consuming safe water and using copepod filters to strain unsafe water should continue and expand, as should efforts to develop and maintain safe drinking water sources. Nevertheless, the peculiar epidemiology in Chad remains incompletely explained. Future studies of dogs might identify other risk factors.

This report summarizes the status of the global Dracunculiasis Eradication Program as of the end of 2017. Dracunculiasis (guinea worm disease) has been eliminated from 19 of 21 countries where it was endemic in 1986, when an estimated 3.5 million cases occurred worldwide. Only Chad and Ethiopia reported cases in humans, 15 each, in 2017. Infections of animals, mostly domestic dogs, with Dracunculus medinensis were reported in those two countries and also in Mali. Insecurity and infections in animals are the two main obstacles remaining to interrupting dracunculiasis transmission completely.

Despite several periods of stagnating guinea worm disease (GWD) incidence in Ghana during its national eradication campaign in the 1990s and early 2000s, the last reported case of GWD was in May 2010. In July 2011, Ghana celebrated the interruption of guinea worm (GW) transmission. Although it has been established that GWD causes disability, pain, and socioeconomic hardship, there is a dearth of population-based evidence collected in post-GW–endemic countries to document the value attributed to GWD eradication by residents in formerly endemic communities. Given Ghana’s recent history of GWD and a concentrated burden of the disease in its Northern Region, a pattern which remained true through to the final stage of the eradication campaign, seven villages in the Northern Region were targeted for a retrospective, cross-sectional study to detail the perceptions, attitudes, and beliefs about the impact of eradication of GWD in northern Ghana. The study revealed that respondents from the sampled communities felt GW eradication improved their socioeconomic conditions, as the impact of infection prohibited the pursuit of individual and social advancement. The value residents placed on the absence of GWD highlights both the impact infection had on the pursuit of social and economic advancement and the newfound ability to be disease-free and productive. Of the 143 respondents, 133 had GWD in the past and were incapacitated for an average of 6 weeks annually per GW infection, with each infected person affected nearly four times in his or her lifetime.

Dracunculiasis was rediscovered in Chad in 2010 after an apparent absence of 10 years. In April 2012 active village-based surveillance was initiated to determine where, when, and how transmission of the disease was occurring, and to implement interventions to interrupt it. The current epidemiologic pattern of the disease in Chad is unlike that seen previously in Chad or other endemic countries, i.e., no clustering of cases by village or association with a common water source, the average number of worms per person was small, and a large number of dogs were found to be infected. Molecular sequencing suggests these infections were all caused by Dracunculus medinensis. It appears that the infection in dogs is serving as the major driving force sustaining transmission in Chad, that an aberrant life cycle involving a paratenic host common to people and dogs is occurring, and that the cases in humans are sporadic and incidental.

By the end of 1998, Asia was free of dracunculiasis (Guinea worm disease), with Pakistan, India, and Yemen having interrupted transmission in 1993, 1996, and 1997, respectively. Transmission of the disease was also interrupted in Cameroon and Senegal during 1997. Chad reported only 3 cases during 1998. Dracunculiasis is now confined to only 13 countries in Africa. The overall number of cases has been reduced by more than 97% from the 3.2 million cases estimated to have occurred in 1986 to 78,557 cases reported in 1998. Because the civil war in Sudan remains the major impediment to eradication of dracunculiasis, the interim goal is to stop all transmission outside that country by the end of 2000. The most important operational need now is for national programs to improve the frequency and quality of supervision of village-based health workers in order to enhance the sensitivity of surveillance and effectiveness of case containment.

The serum antibody responses (specific IgG1, IgG4, and IgE, and total IgE) to Dracunculus medinensis infection in humans from a highly endemic area of northern Ghana were examined regularly by ELISA over a period of one year in cohorts of individuals who developed a patent D. medinensis infection during the study period (actively infected category), or who claimed to have never had a patent infection (endemic normal category). The results were analyzed in relation to seasonality and time of patency of infection. For individuals in the actively infected category, a clear seasonal variation in the mean levels of specific IgG1 and IgG4 was found, with the highest levels late in the dry season and early in the rainy season, when transmission is high, and the lowest levels late in the rainy season and early in the dry season. Endemic normal individuals responded with low and fluctuating levels of specific IgG1 and with low and nonfluctuating levels of specific IgG4. For specific and total IgE, no seasonal variation was observed in any of the two infection status categories. In relation to time of patency of infection (only involving the category of actively infected individuals), the mean levels of specific IgG1 and IgG4 increased from two months before patency of infection, peaked during patency, and then gradually decreased for four months until a constant level was reached. No significant fluctuations in the levels of specific and total IgE were observed in relation to time of patency. The present study thus showed extensive variation in levels of D. medinensis-specific IgG1 and IgG4 (but not IgE) over time. Seasonal variations in antibody responses may also occur in other helminth infections, especially those with seasonal transmission, and these should be taken into consideration when interpreting the results of immunologic studies.

The Falcon assay screening test-enzyme-linked immunosorbent assay (FAST-ELISA) and the enzyme-linked immunoelectrotransfer blot (EITB) technique were used to test human sera with Dracunculus medinensis adult worm antigen in order to assess their potential value in the immunodiagnosis of dracunculiasis. The human sera used were from patients with prepatent and patent D. medinensis infections or from patients infected with other nematodes (Onchocerca volvulus and Loa loa) or trematodes (Schistosoma mansoni and S. haematobium), as well as uninfected Nigerian and Puerto Rican normal controls. In the FAST-ELISA, the sera from prepatent and patent dracunculiasis patients gave the highest absorbance values relative to normal human sera. The highest cross-reactivity was observed with onchocerciasis sera; no cross-reactivity was seen with sera from individuals with loiasis or schistosomiasis mansoni or haematobia. By the EITB, sera from dracunculiasis patients specifically recognized a 16 kDa protein (Dm 16) and antibodies to Dm 16 disappeared 2 months after worm extraction. Recognition of Dm 16 occurred from the late prepatent stage. A 17 kDa protein (Dm 17) was also recognized by dracunculiasis sera, but antibodies to Dm 17 disappeared more slowly and were present 1 year after recovery. The 16 kDa and 17 kDa antigens of D. medinensis may be useful in the immunodiagnosis of dracunculiasis.

Immunoelectroblotting and enzyme-linked immunosorbent assay were used to identify non-cross-reacting antigenic components of Dracunculus medinensis and the filarial worms Onchocerca volvulus, Loa loa, Wuchereria bancrofti, Brugia malayi, and Mansonella ozzardi. Parasite specific serodiagnostic ELISA systems for onchocerciasis and dracunculiasis were devised based on these findings. Phosphate buffered saline extracts of adult worms were passed through a column of monoclonal antibodies to phosphorylcholine (PC). Crude and PC-depleted extracts were reacted on ELISA plates with individual sera from subjects infected with a range of nematodes. Binding of total antibody (Ig) or IgG class antibody and IgG4 subclass antibody was revealed using goat antihuman-Ig-phosphatase conjugate, or appropriate mouse monoclonal antihuman-Ig-type-specific reagents, followed by goat antimouse-Ig-phosphatase conjugate. Specificity of ELISA was improved by restricting reaction to the host's IgG4 antibody subclass, and/or by removing PC determinants from crude antigens. In parallel immunoelectroblots, crude and PC-depleted extracts probed with pooled sera showed potentially useful diagnostic antigens, including a 12 kDa protein from D. medinensis and 14, 18, and 27 kDa proteins from O. volvulus. Two Onchocerca specific ELISA systems non-reactive with antibodies to D. medinensis were devised.

In a controlled field trial of treatment for dracontiasis, mebendazole (Vermox) was found to be effective in eliminating the adult worm and preventing clinical relapses, but it did not achieve significant amelioration of symptoms, subsidence of inflammation, or healing of ulcers. The failure is attributed to poor absorption and lack of anti-inflammatory action of the drug. Mebendazole was well tolerated and although two patients reported mild gastrointestinal disturbances, which may be attributed to the drug, the study confirms that mebendazole is one of the safest anthelmintics in current use and is in that respect ideal for mass therapy.

Dracunculus medinensis and D. insignis are morphologically indistinguishable. Experiments to test the susceptibility of various mammalian hosts to these two guinea worm species are described. Infective 3rd-stage larvae of D. medinensis were administered to each of four raccoons (Procyon lotor): infective 3rd-stage larvae of D. insignis were administered to a rhesus monkey (Macaca mulatta), two dogs, two ferrets (Mustela putorius furo), and a marten (Martes americana). D. medinensis was not found in the raccoons when necropsies were performed on days 247, 283, 354, and 390 post-infection, respectively. Nine female D. insignis containing eggs, embryos, and motile 1st-stage larvae were found in the rhesus monkey 180 days post-infection. Lesions had not formed and the larvae were presumed to be immature and not yet infective as they were comparatively inactive and attempts to infect suitable copepods failed. D. insignis was not found in the dogs or the marten, although both ferrets were successfully infected. Variations in susceptibility of various mammalian species to the guinea worm are discussed together with comments on variations in migration routes and sites of emergence in hosts which may be partially refractory. D. insignis and D. medinensis may represent physiological strains of a single species, or they may in fact be two distinct species which have evolved in different geographical locations.