THE GLOBAL DRACUNCULIASIS ERADICATION CAMPAIGN By Eric A. Butvidas A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Geography—Master of Science 2015 ABSTRACT THE GLOBAL DRACUNCULIASIS ERADICATION CAMPAIGN By Eric A. Butvidas Dracunculiasis , also referred to as Guinea worm disease (GWD), is an ancient scourge on the brink of eradication. It is contracted when humans drink water from sources infested by microcrustacean copepods harboring Guinea worm (GW) larvae. The copepods dissolve in the stomach and release the GW larvae which make their way to the gut of the final host. Soon after, male and female GWs mate and approximately one year after entering the human body, a gravid female GW protrudes through the final host’s skin to release her larvae, causing extreme pain and debilitation. The most common treatment involves the slow extraction of the GW over time, but the cycle can be repeated without education/prevention and control interventions. In 1981, a global campaign to eradicate GWD was initiated simultaneously with the United Nations’ International Drinking Water Supply and sanitation Decade (1981-1990). This thesis contributes to the existing body of literature on GWD by providing a review of the disease’s history, research, and global programmatic findings from 1981 to 2013. It reconstructs the Global Dracunculiasis Eradication Campaign (GDEC) using the data made publicly available by the Centers for Disease Control and Prevention, the World Health Organization, and their affiliates chiefly through three publications: Guinea Worm Wrap-Up , Morbidity and Mortality Weekly Report , and Weekly Epidemiological Record . Through this reconstruction of GDEC, hypotheses are generated about why GWD continues to persist in four sub-Sahara African countries: Chad, Ethiopia, Mali, and South Sudan. Ši tezė skirta Viktorijai Marijai, viskas ką darau yra dėl tavęs, mano Mažyle. iii ACKNOWLEDGEMENTS Composition of this thesis has been quite a journey to say the least. Three years have passed since I successfully completed all required coursework and participated in a graduation ceremony. Between then and now, life happened, but at least I was able to return to campus and complete writing my thesis in residence. My daughter, Viktorija Maria is why I continue to keep my head up as she makes everything worthwhile. The unwavering love and support from my father and mother, Michael and Barbara, are what got me through what has so far been the toughest time of my life. My three brothers, Damen, Bryan, and Cory, stood by my side and made sure I knew I would never be alone. I am eternally grateful. Thank you, Agnė Sadauskaitė for the Lithuanian translation of my dedication. My advisor, Sue Grady, Ph.D., MPH, never gave up on me and somehow always stayed positive and believed I could accomplish this and for that I am forever thankful. Thanks to Kyle Evered, Ph.D., for his input while developing my topic and exposing me to a vast trove of literature on human geography. Originally my thesis committee included the late professor, David Campbell, Ph.D. He was the “Africanist” that I selected based on his many years of research involving the continent. I thank Alan Arbogast, Ph.D., for volunteering to sit in Dr. Campbell’s place and especially for being honest with me. A special thanks to Sharon Ruggles for her unfaltering support. Lastly, thank you Scott R. Ison for insisting I come back. iv TABLE OF CONTENTS LIST OF TABLES. vii LIST OF FIGURES. xii KEY TO ABBREVIATIONS . xiv 1. INTRODUCTION . 1 1.1. Research Purpose . 4 1.2. Research Goals . 5 2. BACKGROUND. 7 2.1. Biological Agent. 9 2.1.1. The Transmission Cycle of Dracunculiasis/Life Cycle of D. medinensis . 10 2.1.1.1. Embryogenesis . 11 2.1.1.2. Intermediate Host . 11 2.1.1.3. Definitive Hosts . 12 2.1.1.3.1. Humans . 13 2.1.1.3.2. Other animals . 13 2.2. Dracunculiasis . 13 2.2.1. Clinical Manifestations. 14 2.2.1.1. Symptoms . 14 2.2.1.2. Diagnosis . 15 2.2.1.3. Site of Emergence . 16 2.2.2. Treatment . 16 2.2.2.1. Surgical Removal . 17 2.2.3. Transmission. 17 2.2.3.1. Seasonality of Transmission . 18 2.2.4. Morbidity . 21 2.2.4.1. Populations at Risk . 21 2.2.4.2. Socioeconomic Impact . 22 2.2.5. Mortality . 24 3. DATA AND METHODS . 25 3.1. Data Sources . 25 3.2. Methods. 25 3.3. Limitations. 26 4. RESULTS . 27 4.1. Events Leading to the Global Dracunculiasis Eradication Campaign . 28 4.2. 1981 . 30 4.3. 1982 . 33 4.4. 1983 . 37 v 4.5. 1984 . 44 4.6. 1985 . 47 4.7. 1986 . 51 4.8. 1987 . 56 4.9. 1988 . 62 4.10. 1989. 70 4.11. 1990. 78 4.12. 1991. 86 4.13. 1992. 94 4.14. 1993 . 102 4.15. 1994 . 112 4.16. 1995 . 121 4.17. 1996 . 130 4.18. 1997 . 143 4.19. 1998 . 153 4.20. 1999 . 167 4.21. 2000 . 183 4.22. 2001 . 192 4.23. 2002 . 196 4.24. 2003 . 201 4.25. 2004 . 209 4.26. 2005 . 214 4.27. 2006 . 220 4.28. 2007 . 224 4.29. 2008 . 229 4.30. 2009 . 234 4.31. 2010 . 238 4.32. 2011 . 245 4.33. 2012 . 253 4.34. 2013 . 261 4.35. Summary. 270 5. DISCUSSION . 277 5.1. Research Goals. 277 5.1.1. Question 1: What are the most effective prevention and control measures that have led to the successful interruption of Guinea worm transmission in previously endemic countries . 277 5.1.2. Question 2: What preventative methods are available to ensure previously endemic and at-risk countries from preventing the (re)introduction of Guinea worm disease today?. 281 5.1.3. Question 3: What factors do the last four endemic countries share in common that allow the transmission of Guinea worm to continue? . 283 6. CONCLUSION AND RECOMMENDATIONS . 287 WORKS CITED . 293 vi LIST OF TABLES Table 1. Months of GW transmission in endemic and previously endemic countries (Hopkins et al., 2010; Hopkins, Ruiz-Tiben, Eberhard, & Roy, 2013; Ruiz-Tiben & Hopkins, 2006) . 20 Table 2. Case totals and percentage of the global case total from countries that reported incidents of GWD (WHO, 1986a, 1987a) . 36 Table 3. Case totals, percentage of the global case total from countries that reported incidents of GWD, and the percent change in case totals compared to 1982 (WHO, 1986a) . 43 Table 4. Case totals, percentage of the global case total from countries that reported incidents of GWD, and the percent change in case totals compared to 1983 (WHO, 1989e) . 46 Table 5. Case totals, percentage of the global case total from countries that reported incidents of GWD, and the percent change in case totals compared to 1984 (WHO, 1990g). 50 Table 6. Case totals, percentage of the global case total from countries that reported incidents of GWD, and the percent change in case totals compared to 1985 (WHO, 1990g) . 55 Table 7. Case totals, percentage of the global case total from countries that reported incidents of GWD, and the percent change in case totals compared to 1986 (WHO, 1990g) . 61 Table 8. Case totals, percentage of the global case total from countries that reported incidents of GWD, and the percent change in case totals compared to 1987 (WHO, 1991b) . 69 Table 9. Case totals, percentage of the global case total from countries that reported incidents of GWD, and the percent change in case totals compared to 1988 (WHO, 1991b) . 76 vii Table 10. Case totals, percentage of the global case total, and percent change in case totals compared to 1989; number of localities that reported ≥ 1 cases of GWD, and percentage of the global number of localities that reported ≥ 1 cases (CDC, 1991a, 1991b; Greer, 1992; WHO, 1991b, 1993b) . 84 Table 11. Case totals, percentage of the global case total, and percent change in case totals compared to 1990; number of localities that reported ≥ 1 cases of GWD, percentage of the global number of localities that reported ≥ 1 cases, and percent change in the number of localities that reported ≥ 1 cases compared to 1990(CDC, 1992d; WHO, 1993b) . ..