Eradication of Dracunculiasis from Dera Ismail Khan Region of Pakistan: Reality or Myth?

Irum, Akram Shah, Qaisar Jamal, Sobia Wahid

*Department of Zoology, University of Peshawar, Pakistan

Corresponding author: Professor Akram Shah, Department of Zoology, University of Peshawar,

Peshawar, Pakistan. Email: akram_shah@upesh.edu.pk; Cell: +92-3339247725; Telephone: 92-

91-921-6754.

Abstract

Objectives: To reconfirm the claim of eradication of dracunculiasis in Dera Ismail Khan Region

of KP, Pakistan and to investigate the presence of Cyclops species in drinking water sources.

Methods: Questionnaire survey and microscopy.

Results: The present study was carried out in adult population of five villages (Kath Garh,

Wanda Dost Ali, Chah Mundar Wala, Ketch and Gara Bloch ) at Dera Ismail Khan Region, KP,

Pakistan during October-November 2011 to approve or disapprove the claim about

dracunculiasis eradication by health officials. A total of 206 (age range 40-96 years) randomly

selected individuals were interviewed and examined for dracunculiasis lesions. The sample

consisted of 106 male subjects and 100 female subjects. Water samples from main drinking

water sources including tube wells, Persian wells and hand pumps were examined for Cyclops

vernalis, main vector of the parasite in the study area and elsewhere in the world, through light

microscopy. It is pleasant to share that no single patient of dracunculiasis was encountered in the

present study, 11 subject, however, had previously suffered from the infection during the period

1
from 1972-1992. Water samples tested were also negative for the presence of Cyclops

vernalis―a fact that was also confirmed by WHO team.

Conclusion: Our study approves so far as the claim of health officials regarding dracunculiasis

eradication from Dera Ismail Khan Region in KP, Pakistan.

Key Words: Dracunculiasis, Cyclops vernalis, Naru, Pakistan.

Introduction female body cavity is occupied by the uterus

that contains about 1-3 million first-stage

Dracunculiasis is a helminth parasitosis
larvae 1, 2, 3.
characterized by debilitating and painful

blisters usually on leg. Eruption of the After the papule ulcerates the female worm

blisters is usually accompanied by itching, extrudes its rear part through the lesion,

swelling, burning sensation fever, pruritus especially when it is stimulated by contact

and eosinophilia. Secondary bactrial with water, and releases thousands of stage

infection of the lesion may aggravate it. 1larvae to the water (streams, ponds, step

Excretory metabolites of the female worm wells etc). The larvae are ingested by

often elicit severe allergic response causing cyclopoid copepods (water fleas) that act as

rash, nausea, diarrhea, dizziness and localize intermediate hosts of the parasite. Eight

edema. The causative parasite, Dracunculus species and two subspecies of these

medinensis commonly called Guinea Worm copepods have been so far recognized to

or Medina Worm, lives in the subcutaneous transmit the parasite that include:

tissue. Female worm is a slender (2 mm) but Thermocyclops neglectus decipiens, T.

reaches to a length of 100 cm, while males crassus consimilis, T. incisus, T. inopinus, T.

usually do not exceed 40 mm. most of the emini, Mesocyclops major, M. ogonnus, M.

2
kieferi, Cryptocyclops linjanticus and also Sudan id the country that has the

Cyclops vernalis 4, 5. When a human ingests highest prevalence of guinea worm

these infected microcrustaceans in the infection, as among the 542 cases in 2012,

contaminated water gets infected and stage 2 521 were reported from Sudan. The claim to

larva emerges that bore the intestinal wall eradicate the disease from Sudan by 2015-

and is taken to the subcutaneous tissue via 2020 seems realistic. However, the disease

the lymphatic vessels. It takes almost a year has been tremendously controlled due to

for the infection to establish to the adult and effective multipronged eradication

the female to protrude ultimately through an programmes of WHO on global level. As

ulcerated lesion on especially the lower such the eradication programme was

vicinity of the patient body 6, 7. initiated in 1920s but it was seriously

endorsed in 1980 and then in 1991 in the

Guinea worm infection is mainly prevalent
forty fourth World health Assembly to
in poor lots especially of the rural areas of
eradicate the infection by the end of 19995.
where the sanitary conditions are of low
The goal has been reached in many areas of
standard and drinking water sources are not
the world including Pakistan. The estimated
reliable. It is a serious problem in 13 sub-
prevalence has been reduced from 3.5-4
Saharan African countries as well as India.
millions in 1986 to 25,000 in 2006 and
In 1980 a global prevalence was an
2,000 cases in 2010 due to these effective
estimated 5-10 million cases that reduced to
eradication strategies 8, 9, 10, 11, 1, 12.
3.5-4 million in 1986 and 113,399 cases in

19995, this time all the cases reported from In Pakistan, the disease was eradicated 1n

Africa. In 2007, 97% cases were reported October 1993 under the Pakistan’s National

from Ghana and Sudan alone. Currently, Guinea Worm Eradication Programme that

3
was a joint venture of the NIH Pakistan, Methods

Global 2000 Project of the Carter Center and

Sampling
CDC. The disease was present in Dera
The survey was carried out by random
Ismail Khan also. Our study’s main aim was
house-to-house visits in the study area and
to confirm the eradication claim of the
the data was collected by in person
government in the area.
examination and interviews using structured
Table 1. Global prevalence (1989-2012)*.
15 points questionnaire. The questionnaire

Year Number of Year Number was designed keeping in view the main

global of global objectives of the study. It included

cases cases information regarding age, gender,

1991 423326 2002 54638 education, occupation, type of house,

1992 374202 2003 32193 domestic animals, signs and symptoms of

1993 229773 2004 16026 dracunculiasis and treatment of the disease if

1994 164977 2005 10674 any.

1995 129852 2006 25217

Water Analysis
1996 152814 2007 10040
To investigate the presence of Cyclops,
1997 77863 2008 4619
water samples were collected from all the
1998 78557 2009 3190
reservoirs of the drinking water using
1999 96293 2010 1797
rectangular dip nets (0.5mm mesh) kindly
2000 75223 2011 962
provided by UNICEP teams doing routine
2001 63717 2012 542
work for water quality assessment in the
*[17, 18]

study area. Each sample was surface

4
sampled three times a day: morning (8 am), age group was the then at risk when

afternoon (2 pm) and evening (8 pm). The dracunculiasis was present in Pakistan as

samples were preserved in sorbex vials for well. Among a total of 105 subjects from

subsequent microscopy for Cyclops vernalis. village Kath Garh including 51 males and 54

The preservative was composed of 30% females examined and interviewed, none

glycerin, 20%distilled water and 50% of showed any sign of active dracunculiasis

70% alcohol. The samples were observed lesions. However, one 52 year old female

under 4X-40X objectives of the microscope subject was carrying a scar on her forehead

for the presence of the Cyclops. from a previous infection in 1988. Village

water supply was from hand pumps and it

quality was according to the WHO standard.

No Cyclops species were detected during

microscopic examination. Of the 60 (27

males and 33 females) subjects from Wanda

Dost Ali again none was showing any sign

of active lesion and no previous infection

was recorded among the subjects. Water

Figure 1. Prevalence of dracunculiasis in
supply was through hand pumps and
Sudan, 2007-11 .
[12]

microscopy for Cyclops gave negative

Results results. The sample of 10 subjects from

village Ketch was also negative for active

All of the subjects randomly included in the
lesions but one subject, however, was found
study were of 40 years of age or above.
with a scar from previous infection in 1980.
They were included on purpose because this

5
Drinking water source was hand pumps and

water tanks provided by the government. 120

Number of Subjects Examined

100
Water quality was normal and no Cyclops 80
60
was observed in the water samples collected
40
in the village. The 21 subjects from village 20
0
Chah Mundar Wala (17 males and 4 Kath Wand Ketch Chah Bara
Garh Dost Ali Mundar Bloch
Wala
females) were also found negative for active
Villages Surveyed
lesions, however, 7 people were carrying

scars from previous infections in 1984-1988. Figure 2. Village wise distribution of

Village water supply was through wells subjects interviewed and examined.

whose water quality was perfect except

traces of arsenic. The water was always

Infection Status
treated with cyclopsicides and the samples
uninfected Previously infected
were found negative for Cyclops. Only 2 out Infected

5%
of ten subjects from village Gara Bloch were

carrying scars from previous infection while

no active lesion could be seen on the

subjects’ bodies. The source of water supply 95%

was government provided tanks and the

Figure 3. Prevalence of active and previous
samples examined were negative for
and previous infections.
Cyclops.

6
Discussion 1988-1994, the number of villages in

Pakistan with endemic dracunculiasis were

It is beyond doubt that a strong political
156, 146, 56, 35, 07, 01 and 0 respectively,
commitment is indispensible in bringing
while the number of cases were 1110, 534,
improvement in the health facilities and
160, 106, 23, 02 and 0 respectively 14.
strategies. Due to unbroken attention of the

government to the disease under the No recurrence of the disease has been

Pakistan Guinea Worm Eradication confirmed in Pakistan, however, sporadic

Programme, Pakistan was the first among cases of recurrence has been reported in

the affected countries that controled the other parts of the world 15. The future of the

indigenous transmission of the disease 13. Guinea Worm Eradication Program (GWEP)

The success in the eradication of is on the disposal of two countries, Mali and

dracunculiasis from Pakistan became Southern Sudan where the disease has been

possible due to multipronged strategies and estimated to be eradicated by 2015-2020 16.

involvement of multiple stakeholders.

Community education and training of
Immediate and committed response of the
volunteers at village level to report the
government, attention by the WHO, various
disease cases immediately and timely
NGOs, proper village to village surveillance,
accompanied by facilitation of safe drinking
mass education by volunteers, provision of
water, Cyclops control and mass
safe drinking water and control of the
chemothraphy is expected to bring an early
intermediate host were the factors that
end to the dracunculiasis.
proved effective in the prevention and

ultimate eradication of the disease from

Pakistan. For each calendar year during

7
Accnowledgements 4. The Carter Center Case Total

Available at:
We gratefully accknowledge the UNICEF
www.cartercenter.org/health/guinea-
and WHO surveillance staff for their
worm/mini-site/current.html; 2011
technical support during data collection.
(Last accessed: August, 2011).
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