Dracunculiasis

Dracunculiasis, also called Guinea-worm disease (GWD), is an infection by the Guinea worm.5 A person becomes infected when they drink water that contains water fleas infected with guinea worm larvae. Initially there are no symptoms. About one year later, the female worm forms a painful blister in the skin, usually on a lower limb. Other symptoms at this time may include vomiting and dizziness. The worm then emerges from the skin over the course of a few weeks. During this time, it may be difficult to walk or work. It is very uncommon for the disease to cause death.

In humans, the only known cause is Dracunculus medinensis. The worm is about one to two millimeters wide, and an adult female is 60 to 100 centimeters long (males are much shorter at 12–29 mm or 0.47–1.14 in). Outside humans, the young form can survive up to three weeks, during which they must be eaten by water fleas to continue to develop. The larva inside water fleas may survive up to four months. Thus, for the disease to remain in an area, it must occur each year in humans. A diagnosis of the disease can usually be made based on the signs and symptoms.

Prevention is by early diagnosis of the disease followed by keeping the person from putting the wound in drinking water to decrease spread of the parasite. Other efforts include improving access to clean water and otherwise filtering water if it is not clean. Filtering through a cloth is often enough to remove the water fleas. Contaminated drinking water may be treated with a chemical called temefos to kill the larva. There is no medication or vaccine against the disease. The worm may be slowly removed over a few weeks by rolling it over a stick. The ulcers formed by the emerging worm may get infected by bacteria. Pain may continue for months after the worm has been removed.

Signs and symptoms
Dracunculiasis is diagnosed by seeing the worms emerging from the lesions on the legs of infected individuals and by microscopic examinations of the larvae.

As the worm moves downwards, usually to the lower leg, through the subcutaneous tissues, it leads to intense pain localized to its path of travel. The burning sensation experienced by infected people has led to the disease being called “the fiery serpent”. Other symptoms include fever, nausea, and vomiting. Female worms cause allergic reactions during blister formation as they migrate to the skin, causing an intense burning pain. Such allergic reactions produce rashes, nausea, diarrhea, dizziness, and localized edema. When the blister bursts, allergic reactions subside, but skin ulcers form, through which the worm can protrude. Only when the worm is removed is healing complete. Death of adult worms in joints can lead to arthritis and paralysis in the spinal cord.

The pain caused by the worm’s emergence—which typically occurs during planting and harvesting seasons—prevents many people from working or attending school for as long as three months. In heavily burdened agricultural villages fewer people are able to tend their fields or livestock, resulting in food shortages and lower earnings. A study in southeastern Nigeria, for example, found that rice farmers in a small area lost US$20 million in just one year due to outbreaks of Guinea worm disease.

Prevention
Guinea worm disease can be transmitted only by drinking contaminated water, and can be completely prevented through two relatively simple measures:

Prevent people from drinking contaminated water containing the Cyclops copepod (water flea), which can be seen in clear water as swimming white specks.
Drink water drawn only from sources free from contamination.
Filter all drinking water, using a fine-mesh cloth filter like nylon, to remove the guinea worm-containing crustaceans. Regular cotton cloth folded over a few times is an effective filter. A portable plastic drinking straw containing a nylon filter has proven popular.
Filter the water through ceramic or sand filters.
Boil the water.
Develop new sources of drinking water without the parasites, or repair dysfunctional water sources.
Treat water sources with larvicides to kill the water fleas.
Prevent people with emerging Guinea worms from entering water sources used for drinking.
Community-level case detection and containment is key. For this, staff must go door to door looking for cases, and the population must be willing to help and not hide their cases.
Immerse emerging worms in buckets of water to reduce the number of larvae in those worms, and then discard that water on dry ground.
Discourage all members of the community from setting foot in the drinking water source.
Guard local water sources to prevent people with emerging worms from entering.

Treatment
There is no vaccine or medicine to treat or prevent Guinea worm disease. Untreated cases can lead to secondary infections, disability and amputations. Once a Guinea worm begins emerging, the first step is to do a controlled submersion of the affected area in a bucket of water. This causes the worm to discharge many of its larvae, making it less infectious. The water is then discarded on the ground far away from any water source. Submersion results in subjective relief of the burning sensation and makes subsequent extraction of the worm easier. To extract the worm, a person must wrap the live worm around a piece of gauze or a stick. The process may take several weeks. Gently massaging the area around the blister can help loosen the worm. This is nearly the same treatment that is noted in the famous ancient Egyptian medical text, the Ebers papyrus from c. 1550 BC. Some people have said that extracting a Guinea worm feels like the afflicted area is on fire. However, if the infection is identified before an ulcer forms, the worm can also be surgically removed by a trained doctor in a medical facility.

Although Guinea worm disease is usually not fatal, the wound where the worm emerges could develop a secondary bacterial infection such as tetanus, which may be life-threatening—a concern in endemic areas where there is typically limited or no access to health care. Analgesics can be used to help reduce swelling and pain and antibiotic ointments can help prevent secondary infections at the wound site. At least in the Northern region of Ghana, the Guinea worm team found that antibiotic ointment on the wound site caused the wound to heal too well and too quickly making it more difficult to extract the worm and more likely that pulling would break the worm. The local team preferred to use something called “Tamale oil” (after the regional capital) which lubricated the worm and aided its extraction.

It is of great importance not to break the worm when pulling it out. Broken worms have a tendency to putrefy or petrify. Putrefaction leads to the skin sloughing off around the worm. Petrification is a problem if the worm is in a joint or wrapped around a vein or other important area.

Use of metronidazole or thiabendazole may make extraction easier, but also may lead to migration to other parts of the body.

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