An Evaluation of Dracunculiasis and the Intervention Strategies

AN EVALUATION OF DRACUNCULIASIS AND THE
INTERVENTION STRATEGIES ADOPTED FOR ITS
ERADICATION IN BORNO STATE, NIGERIA
Celine Movihinze Adeiyongo
B.Sc. (Hons) Zoology, M.Sc. Applied Entomology and Parasitology
(Jos)
PGNS/UJ/13737/02
A thesis in the Department of ZOOLOGY,
Faculty of Natural Sciences,
Submitted to the School of Postgraduate Studies, University of Jos,
in partial fulfillment of the requirements for the award of the degree
of DOCTOR OF PHILOSOPHY IN PARASITOLOGY of the
UNIVERSITY OF JOS
MAY, 2008

i
DECLARATION
I hereby declare that this work is the product of my own research
efforts; undertaken under the supervision of Professor C.O.E. Onwuliri and
has not been presented elsewhere for the award of a degree or certificate. All
sources have been duly distinguished and appropriately acknowledged.
Celine Movihinze Adeiyongo
PGNS/UJ/13737/02

ii
CERTIFICATION
This is to certify that the research work for this thesis and the
subsequent preparation of this thesis by Celine Movihinze Adeiyongo
(PGNS/UJ/13737/02) were carried out under my supervision.
____________________
Supervisor
Professor C. O.E. Onwuliri

iii
ACKWOLEDGEMENTS
I must first of all acknowledge the Most High God for his faithfulness,
abundant mercies and protection over me.
I owe a special debt of appreciation to my wonderful supervisor,
Professor C. O. E. Onwuliri, for his excellent academic guidance, interest in
the research, unwavering support and patience during the course of this
research.
Similarly, I thank my head of department, Professor P. C. Ofojekwu, for
his support, general principle about staff training and development and above
all, for his show of understanding towards me.
My thanks also go to Professor J. A. Ajayi for all his encouragement
which boosted my morale immeasurably.
I am also grateful to all members of staff of Global 2000 national office
in Jos especially Mr. Adamu Sallau, Mr. Ayo Faghemi, Mr. E. W. Adamani, and
all the other Global 2000 staff members for providing the necessary logistics,
information and assistance during the course of this work.
I want to express my deepest appreciation to Dr. D. A. Dakul (Reader)
and Dr. (Mrs.) O. O. Ajayi for their invaluable suggestions and wonderful
contributions and for constantly urging me to work hard and finish up the
work.
In the same vein, I thank all my other senior colleagues both in the
faculty and the department and my friends who have contributed to this work
in one way or the other to make it a real big success. This gratitude especially
goes to my Dean, Professor Y. N. Lohdip, Professor E. B. Alo, Professor (Mrs.)
N. N. James-Rugu, Dr. G. N. Imandeh (Reader), Dr. (Mrs.) G. S. Mwangsat,

iv
Dr. D. P. Yakubu, Mr. G. T. Tarkumbul, Mrs. S. O. Musa, Mrs. K. V. Absalom,
Mrs. L. E. Akpa, Mr. B. S. Audu, and Mrs B. A. Ogwurike.
I am also grateful to Mrs. D. Oyelami for typing this work and Miss
Regina Anih for the final formatting of this work.
I am short of words for the most important man in my life, my
husband, Dr. J. A. Adeiyongo, for always being there for me, and to my
wonderful children, Kator, Kwaghdoo, Msaan and Serumun (Angel), for your
prayers and patience. I love you all.
Finally, I am really grateful to the University of Jos for sponsoring me
for this programme under her staff development initiative.
Celine Movihinze
Adeiyongo
2008

v
DEDICATION
To
JESUS CHRIST

vi
TABLE OF CONTENTS
CERTIFICATION - - - - - - - ii
ACKNWOLEDGEMENT - - - - - - iii
DEDICATION - - - - - - - - v
TABLE OF CONTENTS - - - - - - vi
LIST OF TABLES - - - - - - - xii
LIST OF FIGURES - - - - - - - xiv
LIST OF PLATES - - - - - - - xv
LIST OF APPENDICES - - - - - - xvi
ABSTRACT - - - - - - - - xvii
CHAPTER ONE
INTRODUCTION
1.1 DEFINITION AND BACKGROUND - - - - 1
1.2 LIFE CYCLE OF DRACUNCULUS MEDINENSIS - - 3
1.3 SIGNIFICANCE OF THE STUDY - - - - 6
1.4 AIM AND OBJECTIVES - - - - - 19
CHAPTER TWO
REVIEW OF RELATED LITERATURE
2.1 INTRODUCTION AND HISTORIC ACCOUNTS - - 20
2.2 THE ZOONOTIC ASPECTS - - - - - 21
2.3 GEOGRAPHICAL DISTRIBUTION - - - 23
2.4 THE VECTORS - - - - - - 24
2.5 CLINICAL MANIFESTATIONS - - - - 28
Page

2.6 COMPLICATIONS - - - - - - 29
2.7 DIAGNOSIS - - - - - - 31
2.8 TREATMENT - - - - - - 31
2.9 SOCIO ECONOMIC IMPACT - - - - 35
2.9.1 Disability - - - - - - - 36
2.9.2 Economic Impact - - - - - 37
2.9.3 Nutrition, Education and Perpetual Benefits - - 39
2.10 EPIDEMIOLOGY - - - - - - 40
2.10.1 Water Sources - - - - - - 40
2.10.2 Villages of Endemicity - - - - - 42
2.10.3 Seasonality - - - - - - 43
2.10.4 Individual Risk Factors - - - - - 45
2.11 THE ERADICATION INITIATIVE - - - 46
2.12 INTERVENTIONS - - - - - 49
2.12.1 Filtration of Drinking Water - - - - 49
2.12.2 Safe Water Supply - - - - - 51
2.12.3 Case Management - - - - - 54
2.12.4 Preventing Patients’ contact with ponds - - 56
2.12.5 Killing or Removing of Cyclops - - - 56
2.12.6 Case Containment - - - - - 59
2.12.7 Village-Based Health Workers (VBHWs) - - 61
2.13 CURRENT ISSUES ON GUINEA WORM - - 62
2.13.1 The Integration Debate - - - - 62
2.13.2 Geographic Information System - - - 65
2.13.3 The Certification of Dracunculiasis Eradication - 68
vii

viii
CHAPTER THREE
MATERIALS AND METHODS
3.1 THE STUDY AREA - - - - - 71
3.2 SAMPLING PERIODS AND PROCEDURE - - 74
3.2.1 Surveillance - - - - - - 75
3.2.2 Passive Surveillance - - - - - 75
3.2.3 Mobilization of Participants and Active Surveillance 76
3.2.4 Taking Stock of Intervention Strategies - - 79
3.2.5 Questionnaire and Interviews - - - - 82
3.2.6 Abate (Temephos) Application - - - 86
3.2.7 Determination of the Density and Infectivity
Rate of Cyclops Population in Borno State
During 2003/2004 - - - - - 87
3.2.8 Impact of Abate Application to Water Bodies
in Borno State (July-October 2003) - - - 89
3.2.9 The Cost Implication of the Intervention
Strategies in Borno State from 1995-2004 - - 90
CHAPTER FOUR
RESULTS
4.1 DRACUNCULIASIS IN NIGERIA, NORTH EAST ZONE,
AND BORNO STATE FROM 1995-2007 - - - 92
4.2 STATUS AND DISTRIBUTION OF GUINEA WORM
CASES IN BORNO STATE - - - - - 92
4.3 PREVALENCE OF DRACUNCULIASIS IN BORNO STATE 97
4.4 SEX AND AGE RELATED DISTRIBUTION OF
DRACUNCULIASIS IN THE STUDY COMMUNITIES - 100
4.5 PREVALENCE OF GUINEA WORM INFECTION IN
RELATION TO THE SOURCES OF DRINKING WATER - 100

4.6 PREVALENCE OF GUINEA WORM INFECTION IN
RELATION TO THE OCCUPATIONAL GROUPS OF
THE SAMPLED INDIVIDUALS - - - - 103
4.7 INDIGENOUS AND IMPORTED CASES ENCOUNTERED
IN THE STUDY - - - - - - 103
4.8 MONTHLY VARIATION OF DRACUNCULIASIS IN
BORNO STATE - - - - - - 103
4.9 ANATOMICAL DISTIRBUTION AND DEGREE OF
DISABILITY OF THE AFFECTED INDIVIDUALS - - 106
4.10 THE STATUS OF INTERVENTION STRATEGIES
IN BORNO STATE - - - - - - 109
4.10.1 Health Education (HE) - - - - - 111
4.10.2 Filter Distribution and Usage - - - - 111
4.10.3 New Water Supply - - - - - 114
4.10.4 Village Health Worker Needs - - - - 121
4.10.5 Case Containment/Management Strategy (CCS) - 121
4.10.6 Abate (Temephos) Treatment/Application - - 124
4.10.7 The Cash Reward Strategy - - - - 124
4.11 IMPACT OF KNOWLEDGE, ATTITUDES, PRACTICES
AND BELIEFS OF THE SAMPLED INDIVIDUALS
ON DRACUNCULIASIS AND THE INTERVENTION
STRATEGIES PUT IN PLACE - - - - 129
4.11.1 Knowledge - - - - - - 129
4.11.2 Attitudes - - - - - - - 133
4.11.3 Practices - - - - - - - 135
4.11.4 Beliefs - - - - - - - 136
4.12 DENSITY AND INFECTIVITY RATES OF THE CYCLOPS
IN THE VILLAGES STUDIED - - - - 136
4.13 MONTHLY VARIATION OF INFECTIVITY OF CYCLOPS - 138
ix

4.14 EFFECT OF ABATE LARVICIDE ON CYCLOPOID DENSITY
IN BORNO STATE (JULY-OCTOBER2003) - - - 138
4.15 THE COST IMPLICATION OF INTERVENTIONS IN BORNO
STATE 1995-JUNE 2004 - - - - - 141
x
CHAPTER FIVE
DISCUSSION AND CONCLUSION
5.1 TREND OF DRACUNCULIASIS CASES IN BORNO
STATE FROM 1995 – 2003 - - - - - 143
5.2 DISTRIBUTION OF DRACUNCULIASIS IN BORNO
STATE - - - - - - - 143
5.3 AGE AND SEX RELATED DISTRIBUTION OF
DRACUNCULIASIS IN BORNO STATE - - - 145
5.4 DIFFERENT LEVELS OF INFECTION IN RELATION TO
SOURCES OF DRINKING WATER - - - - 148
5.5 PREVALENCE OF INFECTION IN RELATION TO
THE OCCUPATIONAL STATUS OF THE SAMPLED
INDIVIDUALS - - - - - - 150
5.6 SEASONAL VARIATION OF DRACUNCULIASIS CASES - 150
5.7 DEGREE OF DISABILITY, ANATOMICAL SITES AND
DURATION OF INCAPACITATION - - - - 152
5.8 THE IMPACT OF THE INTERVENTION STRATEGIES
ON DRACUNCULIASIS IN BORNO STATE - - 155
5.8.1 Successes of Eradication Programme in Borno State - 161
5.9 THE IMPACT OF KNOWLEDE, ATTITUDES, BELIEFS
AND PRACTICECES ON THE DISEASE AND ON THE
INTERVENTIONS PUT IN PLACE - - - - 162
5.10 THE DENSITY AND INFECTIVITY RATES OF THE
CYCLOPOID COPEPODS IN THE VARIOUS
VILLAGES SAMPLED IN BORNO STATE - - - 164
5.10.1 Seasonal Variation of the Density and Infectivity
of the Cyclops - - - - - - 165

5.11 EFFECTS OF ABATE (TEMEPHOS) APPLICATION
ON THE CYCLOPOID COPEPOID DENSITIES IN
BORNO STATE - - - - - - 166
5.12 THE COST IMPLICATION OF GUINEA WORM
PROGRAMME IN BORNO STATE - - - - 167
5.13 IMPEDIMENTS OF THE ERADICATION PROGRAMME
IN BORNO STATE - - - - - - 168
5.14 RECOMMENDATIONS AND CONCLUSION - - 171
5.15 SUMMARY OF RESULTS - - - - 173
5.16 CONTRIBUTION TO KNOWLEDGE - - - 175
5.17 RECOMMENDATIONS FOR FURTHER STUDIES - - 176
REFERENCES - - - - - - - 177
APPENDICES - - - - - - - 198
xi

xii
LIST OF TABLES
1 Reported cases of Dracunculiasis and the Number
Contained in the Endemic Villages of Borno State
(1995-2007) - - - - - - - 96
2 Current Cases of Dracunculiasis During 2003/
2004 Survey in Borno State - - - - 98
3 Dracunculiasis as Observed in the Various
Villages of Borno State that Were Still Endemic
(2003/2004 Survey) - - - - - 99
Page
4 Dracunculiasis in the Various Age and Sexes of
the Individuals During 2003/2004 Survey in Borno State 101
5 Sources of Water and Prevalence of Dracunculiasis - 102
6 Guinea worm Cases in Relation to the Occupational
Status of the Individuals in Borno State - - - 104
7 Indigenous and Imported Cases of Guinea worm
Encountered in Borno State During 2003/2004 - - 105
8: Status of Interventions and Natural Sources of
Water in Endemic Villages of Borno State - - 110
9: Number of Villages in the Various Endemic Local
Government Areas of Borno State that have Received
Health Education - - - - - - 112
10 Use of Filter in Dracunculiasis Endemic Villages of
Borno State - - - - - - 115
11 Proportion of Villages Receiving New Water Supply
in Endemic Villages of Borno State - - - 118
12 Types of New Water Supply Provided to Endemic
Villages of Borno State - - - - 119
13 Status of Water Supply in the Endemic Villages of
Borno State - - - - - - - 120
14 Number of villages that have Village-Based Health
Workers (VBHWs) in the study Area of Borno State - 123
15 Proportion of Villages in Borno State Where Infected
People Received Treatment During the2003/2004 Survey 125

xiii
16 Number of Ponds in the Various Endemic Villages
of Borno State that were Treated with Abate During
2003/2004 Survey - - - - - 128
17 Knowledge, Attitudes, Practices and Beliefs of
the Sampled Individuals on the Disease in Borno
State During 2003/2004 survey - - - 130
18 Density and Infectivity Rates of Cyclops in the
Villages Studied - - - - - - 137
19 Effect of Abate Larvicide on Cyclopoid Density in Borno
State (July-October2003) - - - - - 140
20 The Cost Implication of Interventions in Borno State,
1995-June 2004 - - - - - - 142

xiv
LIST OF FIGURES
1 Life Cycle of Dracunculus medinensis - - - 4
2 Map of Nigeria Showing the 5 Global 2000 Zones - 9
3 Current Endemic African Countries and Their
Cases (2007) - - - - - - 25
4 Map of Borno State Showing the Study Local
Government Areas - - - - - - 72
5 Maps of Bama and Dikwa Local Government
Areas Showing the Study Villages - - - 73
6 Cases of Dracunculiasis Reported in Nigeria
(1995 – 2007) - - - - - - 93
7 Reported Cases of Dracunculiasis in North East
Zone (1995–2007) - - - - - - 94
8 Cases of Dracunculiasis Reported in Borno
State (1995 – 2007) - - - - - 95
Page
9 Monthly Variation of Dracunculiasis in Borno
State (2003/2004) - - - - - - 107
10 Monthly Variation of Infectivity of Cyclops in
Borno State (2003/2004) - - - - 139

xv
LIST OF PLATES
Page
I Guinea Worm Emerging from the Lower Limb of a
Patient in Masa, Dikwa Local Government Area - - 108
II Nomads and Farmers Receiving Health Education
on the Grazing Ground - - - - - 113
III A Woman Using Monofilament Cloth Filter to Filter
Water at Ngozoduwa in Bama Local Government
Area - - - - - - - - 116
IV Nomads Using Straw/pipe Filters for Drinking Water
on the field - - - - - - - 117
V Women Fetching Water from a Newly Rehabilitated
Free-Flow Borehole in Masa Village, Dikwa Local
Government Area. - - - - - 122
VI A Typical Sign Post to a Case Containment Centre - 126
VIII Patients Admitted in a Case Containment Centre - 127

xvi
LIST OF APPENDICES
A1 LOCAL GOVERNMENT AREAS AND VILLAGES
OF BORNO STATE SURVEYED DURING 2003/2004 - 198
A2 NIGERIAN GUINEA WORM ERADICATION
PROGRAMME FORM 2: VILLAGE REPORT - - 204
A3 QUESTIONNAIRE: AN EVALUATION OF GUINEA
WORM ERADICATION STRATEGIES IN BORNO
STATE, NIGERIA - - - - - - 205
B1 Chi- Square Analysis of the Prevalence of Dracunculiasis
in Borno State In Relation to Ages and Sexes of the
individuals Sampled - - - - - 207
B2 T-test Analysis of the Prevalence of Dracunculiasis
According to Their sources of Drinking Water. - - 208
B3 T-test Analysis of the Distribution of Guinea Worm
Cases in Relation to the Occupational Status of
the Individuals - - - - - - - 209
B4 Two Way Analysis of Variance of the effect of Abate on
cyclopoid Densities in the Sampled Communities
of Borno State - - - - - - - 210
C PUBLICATION FROM THE THESIS - - - - 211

xvii
ABSTRACT
Interventions adopted for the eradication of dracunculiasis in Borno State
were evaluated between July 2003 and June 2004 to assess the feasibility of
the 2009 target date set for the eradication of guinea worm. Data on cases in
Nigeria; North east zone, and Borno State from 1995 - 2007 were obtained
from Nigeria Guinea Worm Eradication Programme. Primary data on the
cases occurring during the 2003/2004 were obtained through active
surveillance. The various intervention strategies were ascertained through
direct inspection of the facilities. Knowledge, Attitudes, Practices and Beliefs,
(KAP), of members of the affected communities were carried out through
administration of questionnaire. Studies on vector density, infectivity and
impact of Abate on cyclops were also carried out. Results showed that in
Nigeria, during the period under review, cases reduced from 16,374 in 1995
to 12,282 in 1996; rose to 13,417 in 1998 and then declined to 73 in 2007.
In the North east zone, cases dropped from 2,794 in 1995 to 2,134 in 1996,
rose to 4,077 in1998 and dropped to 0 in 2007. In Borno State, cases rose
from 587 in 1995 to 2,053 in 1998 before declining to 0 in 2007. During the
2003/2004 survey, 5(55.55%) Local Government Areas out of the 9 and
12(8.1%) villages out of the 148 studied were still endemic. Thirty-four
(0.01%) out of 310,092 persons examined were infected. All age groups in
the male category were infected while only age groups 0-40 in the female
category were infected. More males (25; 0.02%) than females (9; 0.01%)
were infected although there was no significant difference (P>0.05) in
infection rate between the sexes. Twenty-six (76.5%) out of the 34 cases
were people who still depended on pond water. Farmers, (17; 0.02%)) and
nomads (2; 0.04%) had higher infection rates than other occupational groups
but showed no significant difference (P>0.05). Twenty-six (76.5%) cases
were contained while 8(23.5%) were not. One (2.94%) imported case was
encountered. The 34 cases were observed between July and November with
September recording 12(35.29%) while November recorded the least (2;
5.88%). The status of intervention strategies showed that Health Education,
filter usage, Abate application, Case Containment Strategy and Village-Based-
Health-Workers were operational in all the study villages. There were 55
functional hand-dug-wells, 3 boreholes and 5 Case Containment Centres. KAP
studies revealed that persons in affected communities became aware of the
disease’s transmission, treatment, prevention, and control. Vector studies
showed that 25(0.35%) out of the 7,052 cyclops examined were infected with
Dracunculus medinensis larvae. Infection rates were observed between July
and November 2003 with the highest in September (11).The impact of
Temephos on cyclops density showed that the cyclops densities before
application of Abate were twice higher than the figures two weeks after
application and just slightly higher than or equal to the figures obtained 4
weeks after. The outcomes of the study showed that increased health
education, funding, partnership between local, state, federal governments
and endemic communities can enhance eradication globally.

1
CHAPTER ONE
INTRODUCTION
1.1 DEFINITION AND BACKGROUND
Guinea worm disease or dracunculiasis is a debilitating tropical disease
caused by the largest filarid nematode known as Dracunculus medinensis
(WHO, 1989a, Hopkins 1982). The disease is caused primarily by emergent
gravid female worms in a bid to release their larvae from their uterus. These
female worms sometimes burst in the host tissue leading to a very large pus-
filled abscess. Also, when there is involvement of the joints of the legs, they
produce fibrous ankylosis, contracture of the tendons, septic and aseptic
arthritis. There could be secondary infection of worm tracts by bacteria.
These conditions give rise to serious disabilities leading to absence from farm
work and school and other activities for weeks or even months.
Stoll (1947) estimated that there were 48.3 million cases of guinea
worm infections annually throughout the world; about 30 million in Asia, 15
million in Africa and 3.3 million in other parts of the world. Hunter (1997) also
reported that in 1986, there were an estimated 3.5 million cases of
dracunculiasis worldwide and that by 1990 there were 623,000 cases. This fell
to 165,000 by 1994 in 18 countries. Pilotto and Gorski (1992 cited by Hunter
1997) suggested gross under-reporting of the cases.
The disease is of public health importance in the interior savannah of
West Africa where the population, which is entirely rural, often depends on
ponds, streams and rivers that are shared by a large number of people for
their water use. The disease is commonly associated with dry climates

2
because of the concentration of water supplies in artificial ponds, step wells
and a greater opportunity for the people to become more and more infected.
It imposes a period of misery, poverty and disablement annually, of villagers
who have no safe drinking water sources, who are ignorant of the mode of
transmission and prevention of the disease and who lack the necessary
resources to tackle the problem on their own.
Augustus Aikhomu (1989) on the occasion of the second national
conference of guinea worm disease in Nigeria described the disease as that
of “deprived rural communities”, while Jerry Rawlings, the former Ghanaian
president, characterized the disease as “a disease of under-development”,
during a weeklong tour of 21 affected villages in Ghana‟s highly endemic
Northern region (Hopkins, 1989). Hopkins (1989) preferred to call the disease
as that of ignorance, of suffering villagers who do not have this disease
because they want to, but because they do not understand how they get it
and how they can protect themselves from becoming infected. Ignorance of
national officials in endemic countries who have not been aware of the
enormous hidden economic, social and scholastic costs of the disease, and
ignorance of international officials, all of whom themselves have unlimited
supplies of safe drinking water, who appear not to recognize the opportunity
to contribute to real developments by eliminating dracunculiasis, however
obvious that opportunity may seem to any rational person.
Dracunculiasis affects both the physical and mental development of
children and greatly diminishes productivity and strength of the adults. Thus,
it has been associated with low academic performance among school children

3
(Onabamiro, 1952; Belcher et al. 1975; Adekolu-John, 1983; Edungbola,
1983; watts, 1984; Nwosu, et al. 1982).
The disease also predisposes patients to other secondary infections like
tetanus (Lauckner et al. 1961; Primae and Becquet, 1963), through ulcers
caused by worm emergence and disease progression (Kale, 1977; Nwosu et
al. 1982); consequently, dracunculiasis is of great medical and socio-economic
importance. Education, food and health have been described as the building
blocks of societies, guinea worm disease attacks all these three (Hopkins,
1989)
1.2. LIFE CYCLE OF DRACUNCULUS MEDINENSIS
Infection of man by guinea worm is by drinking contaminated water
containing cyclops that have ingested guinea worm larvae. Cyclops are small,
freshwater crustaceans and are infected by larvae discharged by infected
individuals into water bodies during feeding. When an infected person with an
emergent worm from the leg or any part of the body, deliberately or
ignorantly wades into the water body during process of water collection,
bathing, swimming or to cool the burning sensation of the blisters, the gravid
female guinea worm releases first stage larva (L1) into the water (Figure 1).
The larvae, on average measure 643 x 23 , having fully formed guts
(although they do not feed). The tail is long and pointed and the cuticle is
striated. They are extremely active in water; their thrashing movements
resemble those of free-living nematodes. They live for 4-7 days in pond water
and for further development have to be ingested by various predatory species
of cyclops, which are small (1-2mm). The larvae penetrate the gut of the

4
Figure 1: Life Cycle of Dracunculus medinensis

5
cyclops and after two weeks in the haemocoel reach the infective third stage
larvae at appropriate temperature (24 0 C). The infective larva measures on
average 450 x14 m and has a short bi-lobed tail.
When infected cyclops are ingested by human hosts in drinking water
or other liquids, the gastric juice (dilute hydrochloric acid, HCL) in the
stomach activates the release by the larvae. These burrow through the wall of
the duodenum and migrate across the abdominal mesenteries and penetrate
the abdomen and thorax in about 15 days. The presence of adult worms in
the retro-placental region of a pregnant woman led George (1975) to propose
that larvae may gain entry into the body through the vagina as well. The
acidic vaginal exudates destroy the cyclops releasing the larvae, which then
migrate to the retro-placental region in a similar manner as the migration
from the stomach. However, this still needs actual confirmation. There is no
increase in size during this early migration but after about two months, they
become sexually mature. They then meet and mate in the subcutaneous
tissue approximately 100 days after infection. After fertilization, the male
becomes encapsulated and dies. Any female that does not mate dies also,
and is reabsorbed by the body system. Occasionally, calcified specimens have
been seen on x-ray (Muller, 1971). The fertilized females then continue to
enlarge, reaching at times up to one meter in length as she becomes fully
gravid. After a period of 9-12 months, the female desires to continue the life
cycle and therefore seeks for ways of reaching the external environment to
discharge the larvae (Hopkins, 1989). The female then first forms a blister on
any part of the body, which turns into an ulcer, from where it emerges to

6
discharge its larvae into water bodies, and thus continue the life cycle. More
than one gravid female can emerge from a single individual at the same
period, mostly from the lower abdominal region (Udonsi, 1987b). Sometimes
mature females fail to emerge and become calcified.
1.3 SIGNIFICANCE OF THE STUDY IN RELATION TO
INTERVENTION STRATEGIES SO FAR
This evaluation study has measured the successes of each ongoing
intervention, identified and determined the causes of problems in
implementing interventions; subsequently, these evaluation findings will be
used to improve on planning and implementation of future community
programmes relating to other diseases. It has also assessed the feasibility of
the new target date/deadline, 2009, after the last three deadlines (1995,
2000, and 2005) have been missed for the complete eradication of
dracunculiasis from the face of the globe.
Dracunculiasis is one of the most easily preventable diseases and much
has been achieved to eradicate the disease with more than 95% reduction in
cases reported worldwide as at December 1997 (News and Info 1998). Many
believe that because of the rural nature of the disease, it is very difficult to be
eradicated. In the rural communities affected, illiteracy has continued to
remain above 60% and as a result, ignorance, culture and lack of modern
amenities aid its persistence (Ward et al. 1979). What is worse is that so far,
no curative drug has been found effective against the disease (Muller, 1979).
However the disease can easily be controlled or actually eradicated using
cultural methods including health education and provision of good water, all

7
of which would lead to a reduction of contact between natural vector and
humans. Thus, for about a decade now, efforts have been geared towards
cultural control strategies usually supplemented with the provision of control
materials like filters and “Abate” larvicides for water treatment and other
modern amenities (Hopkins, 1988).
The impulse, momentum and commitment to eradicate dracunculiasis
emerged in 1981 when the steering committee of international drinking water
supply and sanitation decade (1981-1990) adopted the eradication of guinea
worm disease as a sub goal of the decade.
About a year after the historic national conference on dracunculiasis
(the first of its kind) was held in Ilorin, Kwara state, Nigeria in March 1985;
the World Health Assembly (WHA) in May 1986 passed a resolution targeting
dracunculiasis for global eradication. About two years after the WHA‟s
resolution, the first African regional conference was held in Niamey, Niger
republic, from July 1-3, 1988. Thereafter, in rapid successions, the African
health ministers and WHO in 1988 and 1991 respectively, set December 1995
as the target date for eradication of the disease globally (Edungbola and
Ologe, 1995).
Nigeria signed an agreement with the Bank of Credit and Commerce
International and former US President Jimmy Carter, now the Chairman of
The Carter Centre/Global 2000, on March 13 1988, to eradicate Guinea worm
disease in Nigeria by 1995. In 1988, Nigeria formally inaugurated a Guinea
Worm Eradication Programme in conformity with the resolution of African
Health Ministers at the World Health Assembly of 1986. For this purpose, the

8
country has been divided into 5 Global 2000 zones (Figure 2). A national task
force was established with the mandate to eradicate guinea worm disease by
December 1995 with a National Plan of Action prepared to guide the
implementation of the objective (Nwobi, 1996). All the 30 states in the
country, which were subdivided administratively into 589 (then) local
government areas (LGA) plus the Federal Capital Territory (FCT) were actively
engaged in this national campaign. Nigeria was mobilized to attack this
disease through four distinct overlapping phases namely documentation,
demonstration, mobilization and implementation.
Phase one: Documentation (1980-1983)
Starting from the pioneering work of Professor S.D. Onabamiro, who studied
and classified the copepod vectors of dracunculiasis in Nigeria in the early
1950‟s, many other university- based researchers have contributed to the
knowledge of the clinical and public health aspects of the disease in Nigeria.
These contributions increased during the 1980‟s. Major ones relevant to this
report include the extent and epidemiology of dracunculiasis in Nigeria (Kale
1977, Abolarin, 1981; Nwosu et al. 1982; Edungbola, 1983 and 1984;
Edungbola and Watts, 1984 and 1985; Osisanya, 1986; Edungbola et al.
1987; Onwuliri et al. 1988-1990 a and b; Braide et al. 1989; Ugwu and
Nwaorgu 1988- 1990; Suleiman and Abdullahi, 1988- 1990); its impact on
school attendance( Kale, 1977; Edungbola, 1984; Edungbola and Watts,
1984; Ilegbodu et al. 1986; Nwosu et al. 1982); the duration and frequency
of associated disability (Smith et al. 1989), the relevance of dracunculiasis to

OYO
OGUN
KEBBI
LAGOS
KWARA
EKITI
OSUN
SOKOTO
ONDO
ZAMFARA
NIGER
EDO
DELTA
Scale: 1: 1,000,000
KOGI
BBAYELSA
BBAYELSA
RIVERS
9
KATSINA
FCT
KANO
KADUNA
BENUE
EBONYI
ANAMBRAENUGU
ANAMBRAENUGU
IMO ABIA
IMO ABIA
NASARAWA
CROSS CROSS RIVER RIVER
AKWA AKWA IBOM IBOM
JIGAWA
BAUCHI GOMBE
BAUCHI GOMBE
PLATEAU
YOBE
TARABA
BORNO
ADAMAWA
North-West
North-East
North-Central
South-West
South-East
Figure 2: Map of Nigeria Showing Global 2000 Zones
Source: Nigeria Guinea Worm Eradication Programme, 1991.
N
W E
S

10
maternal and child health (Yacoob et al. 1989; Watts et al., 1989, Brieger et
al. 1989a); and its impact on agriculture (Edungbola et al. 1987; Nwosu,
1989). These and other studies developed the scientific basis for a fuller
understanding of the effects of guinea worm disease on health, education and
agriculture in Nigeria and in other endemic countries.
One of the most important features of the documentation phase was
ascertaining the full extent and distribution of dracunculiasis throughout the
country. Guinea worm disease was not an officially noticeable disease in
Nigeria, which reported only a few cases annually to the WHO in the early
1980‟s. Although some surveys of state ministries of health were made in
1984, the first comprehensive information on the nationwide status of the
disease was obtained in the compilation of reports presented to the first
national conference on dracunculiasis in Nigeria in March 1985, (Edungbola et
al. 1985, WHO 1985, Edungbola et al. 1986). Even though these data were
crude and qualitative, indicating the location and level of endemicity of
affected status by LGA‟s, it confirmed for the first time that guinea worm
disease occurred in every state in Nigeria. This information, plus the estimate
that Nigeria had approximately 25% of the cases of dracunculiasis remaining
in the world, had a significant impact that was only superseded when the
results of the first national search for cases became available in 1989.
Most of the financial support for activities in this phase prior to 1986
was provided by University Research Grants, the Federal Ministry of Science
and Technology and the United Nations Children‟s Fund (UNICEF). The
UNICEF-funded study of the impact of guinea worm disease on rice

11
production in a fertile area of South Eastern Nigeria in late 1987, (which cost
about N110, 000) and the report of the first national conference were the two
most influential early documents for mobilizing national leaders.
Phase Two: Demonstration (1983-1986)
The second major thrust of the early years was to demonstrate that
guinea worm disease is vulnerable to intervention (Hopkins, 1982, Edungbola
et al. 1988) and show that effective action against the disease was possible in
Nigeria. The main part of this phase may be dated as starting in 1983, when
Richard Reid, the UNICEF representative in Nigeria, in collaboration with the
Nigerian government agreed to an indicator of the efficacy of an extensive
rural water supply project that UNICEF and The Federal Government of
Nigeria were beginning to expand to several states starting in Kwara, Imo,
and Gongola states (Edungbola et al. 1988; WHO, 1984); the disease was
also used for prioritizing endemic villages for participating in the project.
During this phase, Luke D. Edungbola assumed a leading role in
planning and evaluating the impact of the UNICEF- assisted water and
sanitation project in Kwara state. In the first targeted LGA, the project
subsequently reduced the overall prevalence of guinea worm disease in 20
villages from 59.6% during the 1983-1984 seasons to 11.3% during the
1986-1987 seasons. Three of these villages had their prevalence rates
reduced from 62%, 52.7% and 44.8% to zero (Edungbola et al. 1988).
Similar dramatic results were seen in Imo state, thus demonstrating the
reproducibility of this approach.

12
Phase Three: Mobilization (1986-1988)
Early in 1986, professor A.B.C Nwosu, a university-based parasitologist
and researcher on guinea worm disease, became the commissioner for health
in Anambra state. He immediately began an aggressive campaign to eliminate
dracunculiasis in Anambra state, making full use of his official position and
budget. His new position and efforts greatly strengthened the mobilization of
the eradication of dracunculiasis in Nigeria.
Anambra state inaugurated a task force on guinea worm eradication
with great fanfare in 1986. Other states followed by forming their own
taskforces starting in 1988. With the full backing of the then Military Governor
of Anambra State, Col. Robert Nnaemeka Akonobi, the Commissioner for
Health successfully solicited external assistance from the Government of
Japan and UNICEF for rural water supply projects targeted specifically to
highly endemic villages in Anambra, from Rotary international for construction
of cisterns for rainwater catchments in some endemic communities, from
global 2000, which helped arrange a donation of the larvicide, temephos
(abate) from the American Cyanamid company, from the United States
Agency for International Development which financed two consultants for
training local personnel in temephos usage, and from the Federal Ministry of
Health Nigeria, which provided funds for logistics.
To promote an effective public awareness campaign and to mobilize
community participation, the Anambra state ministry of health used traditional
town criers, posters and radio jingles, and they also developed a video
documentary for the State Television. A highly successful movie, “Guinea

13
worm, the fiery serpent”, was filmed in Anambra state in 1988 by the US
Center for Disease Control, Global 2000, UNICEF, and the United Nations
Development Programme for local and international uses. Several of the other
state task forces also prepared video documentaries on the disease that were
aired on their State Television Stations. In addition to increasing public
awareness and helping to generate political support at LGA, State and
National levels, these mobilization activities were intended to help inform
villagers on how to help themselves, by keeping infected people out of
drinking water sources and by supporting other interventions such as drilling
or digging of wells.
In August 1987, the African Concord published a heavily illustrated 13-
paged cover story detailing the horrors and shame of guinea worm disease in
Nigeria. Mass media attention to the problem reached its peak when former
US President, Jimmy Carter, visited Nigeria to sign a memorandum of
understanding with the Federal Ministry of Health, in which the Global 2000
project of the Carter Center agreed to assist the Government of Nigeria in its
battle to eradicate guinea worm disease. Carter‟s visit resulted in numerous
articles about guinea worm disease and the new eradication programme in
Nigerian Newspapers and Magazines, including front-page feature stories,
editorials, cartoons and letters to Editors. The mass media had another flood
of coverage in July, 1989, when former President Babangida of Nigeria,
former US President, Jimmy Carter and Alhaji Dasuki, the sultan of Sokoto,
led several other dignitaries to the International Donor‟s Conference that was
held in Lagos for the Global Guinea Worm Disease Eradication Initiative.

14
By the middle of 1988, the National Council of Health, which is the
highest policy-making body for health in the country, declared guinea worm
disease to be an officially reportable disease, adopted the goal of eradicating
dracunculiasis from Nigeria by the end of 1995, and took several other steps
to launch an effective nationwide eradication programme. By the end of 1988,
all the 21 States in Nigeria and the Federal Capital Territory had established
State Task Forces for guinea worm eradication, and the first national search
for cases, which began in August 1988, was almost completed.
The successful conclusion of the first national village-by-village search
for cases of dracunculiasis in March 1989 was another very important
milestone in mobilizing the Nation. This first search enumerated over 650,000
cases of dracunculiasis in about 6,000 endemic Nigerian villages (WHO, 1989;
Withers, 1989). These totals were higher than had ever been reported to
health authorities. Moreover, these results gave an unprecedented specificity
to the problem of guinea worm disease in Nigeria, namely lists of affected
villages and the numbers of victims therein. These results were released
during the second National Conference on dracunculiasis in Nigeria, which
met in Lagos in March 1989 (Edungbola and watts, 1989)
Phase four: Implementation (1988)
The first major bench work in this phase was the initial national search
for dracunculiasis cases, which was completed in early 1989. This provided for
the first time a firm basis for quantifying the scope of the problem and hence
of the effort needed to eradicate the disease in Nigeria. Standard forms and
training procedures developed by the National Task Force were used in this

15
and subsequent case searches to help assure uniformity of methods and
comparability of results. All case searches used the standard WHO case
definition: “an individual exhibiting or having a recent (about one year)
history of a skin lesion with emergence of a guinea worm”.
Financial support for the searches came from cost sharing by LGA‟s,
State and Federal Government, Global 2000, UNICEF and other international
or private donors. Substantial support “in kind” was provided by villagers
themselves and the other levels of government as well as by other non-
Governmental Organizations (example local rotary clubs). (The cost of the
first search was approximately $100,000 that was donated by all sources,
Edungbola et al. 1992). The data from the first search were used to prepare a
national plan of action, which was presented at the Second National
conference in 1989, when in a speech, read on behalf of the federal
government by a representative of Nigeria‟s Vice-President, it was announced
that from thence, all nationally and internationally supported rural water
supply projects were to give priority to villages where guinea worm disease
was endemic. Nigeria Guinea Worm Eradication Programme (NIGEP) now
commemorate the day of that momentous announcement, March 20, as
National Guinea Worm Day, to continue to educate the public about the
disease and maintain public support for its eradication. On March 20, 1991,
the vice-president of Nigeria, Augustus Aikhomu, presided at the issuing of
three commemorative postage stamps as a part of ceremonies marking the
second observance of national guinea worm day.
After the establishment of the national task force in 1988, a zonal

16
facilitator was appointed to oversee operations in each of the country‟s four
established primary health care quadrants, each of which included 5-6 states
at that time. This arrangement facilitated the integration of NIGEP activities
into the existing primary health care structure of the country as well as the
effective identification training and supervision of village-based health workers
in endemic villages.
The results of the second and third national searches were announced
at the third and fourth national conferences on dracunculiasis, which were
convened in 1990 and 1991 respectively (WHO, 1991a; Brieger, 1989)
Multiple spot checks by NIGEP supervisors and an evaluation of the
search by a team of person‟s not involved in the programme were conducted
after each of the first two searches, which between them reached an
estimated 90% of the target population at least once. During the third
national search for cases, which was limited to the known endemic villages
identified during the previous two searches and other suspect villages
reported since then, concomitant health education efforts and some treated
cases were conducted in many areas to mark the beginning of full-scale
implementation of interventions. Data from the third case search were used
to prepare a map showing LGA-specific incidence levels for the first time.
Some intervention strategies for example health education (which
involved placement of posters, demonstration of the use of cloth filters);
provision of safe drinking water, topical treatment of cases otherwise known
as case containment, were being conducted by some agencies such as
UNICEF, State Ministries of Health and Water Boards and the Directorate of

17
Food, Roads, and Rural Infrastructure, even before the NIGEP was formed
but such efforts were sporadic and uncoordinated nationally. Even during the
first two case searches and on other occasions, the search teams and
accompanying primary health care workers conducted some health education.
However, systemic extension of the interventions to eventually include all
known endemic villages began with the third case search.
The role of WHO in the Guinea Worm Eradication Programme is to
provide technical advice and to certify countries that have eliminated the
disease. Eradication deadlines have been missed repeatedly. The first was set
for 1995, the second 2000 and the third 2005. WHO now hopes to certify
eradication by 2009 (Hopkins et al. 2005).
The objectives of NIGEP in eradication programme are to collect,
analyze, interpret and disseminate information that will help to realize the
goal of disease eradication (Nwobi, et al. 1996).
NIGEP started its activities to ensure eradication of guinea worm
disease from the North-East zone comprising Adamawa, Bauchi, Borno,
Gombe, Jigawa, Kano, Nasarawa, Plateau, Taraba, and Yobe in 1988 with a
case search which reported 43,662 cases from 1,189 villages. Interventions to
disrupt the life cycle and break the disease transmission started in 1991 when
NIGEP/Global 2000 established its Northeast zone with the office in Jos
(Figure 2). The intervention strategies put in place include provision of
portable water through drilling of boreholes, sinking wells or Hand-Dug Wells
(HDWs), Intensive Health Education on the need to filter or boil all drinking
waters through provision of Monofilament Nylon Filters, protection of drinking

18
water sources and case containments/detection and management,
introduction of vector control through the application of temephos (abate) to
sources of drinking water (Hopkins 1998). Case containment strategy implies
the complete management of each identified case within 24hours of worm
emergence in such a manner as to forestall any further possible transmission
of the disease by that infected person (Nwobi et al. 1996). WHO (2003)
stated that guinea worm disease is said to be contained if all of the following
conditions are met:
i. The patient is detected before or within 24hours of worm
emergence
ii. The patient has not entered any water source since the worm
emerged.
iii. The village volunteer has properly managed the case by cleaning
and bandaging until the worm is fully removed, and by giving
health education to discourage the patient from contaminating
any water source (if two or more emerging worms are present,
the case is not contained until the last worm is pulled out and
iv. The containment process, including verification that it is a case
of guinea worm disease, is validated by a supervisor within
7days of the emergence of the worm.
But Ukoli (1990) has maintained that the installation of control
materials has had disastrous consequences simply because of poor
maintenance which fails to keep the materials beyond a time limit. In most
places, it was not seen as suitable for the traditional practices. Furthermore,

19
while these measures could help to prevent infection of the majority of the
people, they do not take care of the interest of these farmers and fishermen
whose occupational needs make daily water contact inevitable.
In any eradication programme, the following steps are necessary and
must be incorporated.
i. Problem diagnosis and adequate definition of objectives
ii. Careful selection of intervention strategies/implementation
iii. Evaluation of project success which leads to
iv. Modifications
1.4 AIM AND OBJECTIVES
This study has assessed and evaluated the successes and impact of
each of the ongoing intervention strategies in dracunculiasis eradication
programme in Borno State. The study has:
1. Reviewed cases of dracunculiasis in Nigeria, Northeast zone and
Borno state from 1995-2002.
2. Identified and ascertained the various interventions put in place in
the various endemic villages, their cost implications and the
impediments in the implementation of the interventions.
3. Determined the current status of the disease and its vector in the
various endemic communities
4. Assessed the impact of knowledge, attitude, practices and beliefs
(KAP) of the sampled individuals on the disease and on the
interventions with regards to sustainability of the Eradication
Programme.

20
CHAPTER TWO
REVIEW OF RELATED LITERATURE
2.1 INTRODUCTION AND HISTORICAL ACCOUNTS
Guinea worm disease, also known as dracunculiasis is a long-
established human infection which has been with man on earth since ancient
times. This was clearly referred to by various authors from India, Greece, and
the Middle East. In antiquity, interesting historical accounts of dracunculiasis
have been given by several authors (Castiglioni, 1947; Hughes 1967; Muller
1967; Geoneratne, 1969) and female worms have been seen in Egyptian
mummies (Adamson, 1988; Watts, 1998). James Africanus Horton, the first
West African to be trained in Europe as a medical doctor wrote a book about
the disease (cited by Cairncross 2002) mistakenly supposing that it was
transmitted through the soles of the feet. The physician, Galen first named
the condition “dracontiasis” a little over 100 years before the birth of Christ,
although Galen himself saw no case of this disease in his practice in Rome.
Among the early pioneers who contributed to the knowledge of the disease
are Rhazes, (865-925), an Arabic physician, who first attributed the cause of
a typical guinea worm swelling to a parasite; Avicenna (980-1037),a Persian
Philosopher, gave detailed clinical presentations of “medina sickness”, so-
called because it was prevalent in Medina from where it was believed to have
spread to other parts of the world through pilgrimage routes (Hopkins, 1983);
and Bastian (1863) described the morphology of the parasite.
The connection of infection with water sources was recognized early
and it is probable that if the prepatent period were not so long, the mode of

21
infection would have been obvious many years earlier. This was determined in
1870 by a Russian scientist, Alexei Fedchenko, who found that larvae expelled
from emerging female worms in the limbs of sufferers developed in
freshwater micro crustaceans (cyclops) living in ponds which were then
ingested in drinking water (Fedchenko, 1971). This was the first time an
invertebrate host was implicated in the transmission of a medically important
disease.
2.2 THE ZOONOTIC ASPECTS
The sole cause of this disease in man is D. medinensis (Linnaeus, 1758
as cited by Cairncross et al. 2002; Onabamiro, 1951). There is no evidence
that animals act or have ever acted as reservoir hosts of human guinea worm
infection (Hopkins et al. 1997) and the theoretical possibility that they could
do so has been conclusively disproved. Studies of animal infection in areas
where dracunculiasis has been recently eliminated but without much
improvement in drinking water sources may provide useful information
regarding this question (Cairncross et al. 2002).
Emerging female worms are recovered sporadically from a wide range
of mammals from both endemic and non endemic parts of the world,
(Ghensis, 1972; Lalitha and Anandan, 1980; Hsu and Li, 1981; Batliwada,
1983; Davidson et al. 1992; Keeling et al. 1993; Richardson et al. 1993;
Seville and Addison, 1995; Fu et al. 1999). Unfortunately, in almost all cases
only a portion of a female worm is recovered usually in a flaccid state after
the enclosed larvae have been ejected, and identification with regard to
species is impossible (Cairncross et al. 2002). In general, worms in mammals

22
are regarded as D. medinensis in the old world and South Americas and as D.
isignis in North America. Dracunculus has a very short patent period, at most
a few weeks, and an emerging worm is not easily seen in fur – bearing
carnivores. So it is likely that infection is much more common in many
countries than currently recognized.
An isolated autochthonous human case of dracunculiasis has been
reported from Japan (Kobayashi et al. 1986); Indonesia (Heutsz, 1926 cited
by Cairncross et al. 2002), and Korea (Hashikura, 1927 cited by Cairncross et
al. 2002; WHO, 1996). In all of these presumably zoonotic cases, there was
the possibility that infection was contracted from ingesting raw fresh water
fishes as paratenic hosts (in which the immature parasites ingested in cyclops
can survive but do not develop) rather than from drinking water. Crichton and
Beverly-Burton (1977); Eberhard and Brandt (1995) have shown that
Dracunculus in North America can be transmitted experimentally by
amphibians.
The infections in domestic animals reported from areas of endemicity
are possibly of human origin (Cairncross et al. 2002). This supposition is
supported by the higher prevalence found in surveys of the human population
than by the dissection of dogs culled during the 1920s in Uzbekistan.
However, worms are still found in dogs in the former areas of endemicity of
Uzbekistan and Tamil Nadu (Lalitha and Anandan, 1980), and in dogs also
and cats in the areas of Kazakhstan and Turkmenia where the disease is not
endemic (Ghensis, 1972; Velikanov, 1984 cited by Cairncross et al.2002).

23
It is very likely that in many parts of the world there is widespread but
under-reported animal cycles completely independent of human infection. For
example, there was a recent report from China of infection with D.
medinensis in a cat (Fu et al. 1999).
Animal infections are however, unlikely to pose a human public health
problem once complete eradication of the human diseases has been achieved,
particularly if safe water sources are provided.
2.3 GEOGRAPHICAL DISTRIBUTION
In historical times, infection occurred in Algeria and Egypt (Watts,
1998); Gambia, Guinea Conakry, Iraq, Brazil and the West Indies (Watts,
2000) but died out spontaneously in those countries and was eliminated from
Uzbekistan in 1932 and from Southern Iran in 1972 (WHO, 2000b).
Muller (1971) updated a list of global distribution of dracunculiasis
earlier on made by Stiles and Hassel in 1920. The disease was widely
distributed in West and Central Africa, India, Pakistan, Middle East and Asia
(Ramsay, 1935; Onabamiro, 1952; Raffier, 1966). The World Health
Organization (WHO, 1987, 1991a) reported that up to 120 million people
were affected from its African countries including Nigeria and about 10 million
others from Pakistan and India. Other endemic areas included Yemen, Iran,
and Saudi Arabia (Hopkins, 1985).
In 1989, WHO received reports from fourteen countries on the disease
with a total of 845, 143 cases (>98%) of these coming from Africa (WHO,
1990a, 1990b). A breakdown of this figure showed that the largest number of
cases occurred in the West African sub-region with a large proportion coming

24
from Nigeria. WHO (1985) had earlier estimated that 2.5 million cases
occurred annually in Nigeria alone. Ramsay (1935), Raffier (1966), Muller
(1971), and Belcher et al. (1975) among others had noted that the disease
was endemic in West Africa. Ramsay (1935), found the disease common in
different parts of Nigeria especially in the north. The disease had been shown
to be endemic in the South West of Nigeria (Onabamiro, 1950; 1951; 1952;
Edungbola, 1983; and also in the South East (Nwosu et al. 1982, Udonsi,
1987b; Braide et al. 1991; Okoye et al. 1995; Anosike et al. 2000; Onwuliri et
al. 2005), other parts of the north (Thompson, 1956; Suleiman and Abdullahi,
1988 - 90); Bauchi, Sokoto, Plateau, Benue and Nasarawa (Fabiyi, 1991;
Osisanya et al. 1986; Onwuliri 1982; Onwuliri et al. 1988 - 1990a and b).
Thus the disease had long been recognized as a public health problem in
Nigeria.
Recent reports have shown that it has been eradicated from Pakistan,
India and Yemen (Hopkins et al. 1995, WHO, 1996b). It is also being rapidly
eradicated in many African villages (Edungbola and Ologe, 1995). The disease
is now found in 5 countries including Nigeria where 73 cases were reported in
2007 from four villages (NIGEP, 2007). All the 100% of reported cases occur
on the African continent with Sudan having the highest number of cases of
5,074 followed by Ghana with 3191 (Figure 3).
2.4 THE VECTORS
The vectors of the disease are cyclopoid copepods that inhabit
stagnant ponds and the disease is prevalent in rural villages among people
who obtain their drinking water from such ponds.

No. of Reported Cases
6,000
5,000
4,000
3,000
2,000
1,000
0
5,074
3,190
25
191
Sudan Ghana Mali Nigeria Niger
Countries
Figure 3: Current Endemic African Countries and Their Cases
(2007)
Source: World Health Organization, 2007.
73
8

26
Until a few years ago, these were all included in the single genus
Cyclops, but this has now been subdivided and the most important
intermediate hosts belong to the genera Mesocyclops (M. aequatorialis) and
M. kieferi); Metacyclops (M. margaretae) and Thermocyclops (Th. crassus,
Th. incisus, Th. inopinus and Th. oblongatus (Muller, 1991).
The development of the larvae in cyclops was observed by the Russian
scientist, Fedchenko in 1870 (Moorthy, 1938; Fedchenko, 1971). He found
out that only one infective larva is found in naturally infected cyclops hosts.
Further investigations revealed that infected adult cyclops might carry up to
five larvae, although their immature stages have only one larva (Onabamiro,
1956, Onwuliri et al. 1991). These cyclops are mainly distributed in ponds in
endemic foci of the disease, where the availability of food and some
immunological conditions (varying seasons, rainfall, temperature,) affect their
growth, population density, reproduction and infectivity (Muller, 1971;
Onwuliri et al. 1991).
The density of cyclops however does not determine the rate of
infection. In an experiment, Onabamiro (1954) observed only approximately
5% larval infection out of 152 cyclops. Lyons (1972) found a much lower
density of cyclops in Wa district of Ghana. It has been observed that the
population density of cyclops increases during the dry months, but decreases
drastically with the approach of the rains. Rainfall, temperature, dissolved
oxygen concentration; pH , salinity and bicarbonate alkalinity generally affect
the population density and infectivity of the cyclopoid copepods. Low
dissolved oxygen in ponds influences a higher density of cyclops and most

27
studied cyclops prefer a pH range of 5.8- 6.8 (Onwuliri et al. 1991).
Onabamiro (1951); Boxshall and Braide (1991), described the cyclops fauna
of Nigeria but restricted themselves to species from southern parts. Onwuliri
et al. (1991) first documented Northern Nigerian cyclops species and
implicated some species in the transmission of dracunculiasis. No other
comprehensive work on Northern Nigerian cyclops fauna has been
documented.
Dracunculus medinensis exhibits a high degree of host-specificity.
Onwuliri et al. (1991) observed that out of the five species of cyclops,
Thermocyclops nigerianus, Mesocyclops aequatorialis, Microcyclops
linjanticus, Tropocyclops confines, and Platycyclops phaleratus; only Th.
nigerianus was found to have been significantly more infected than M.
aequatorialis. Of the over 40 different species of cyclopoid copepods identified
in Nigeria, only six are implicated as vectors of guinea worm in nature, and in
the laboratory (Boxshall and Braide, 1991; Onwuliri et al. 1991). Onabamiro,
whose work in the early 50s remains the only definitive work on the biology,
distribution and ecology of cyclops in ponds in West Africa, showed that, of
the 30 species and sub-species of cyclops identified in Nigerian ponds and
streams, only Th. nigerianus and M. leukarti were found to be naturally
infected with D. medinensis. However, it has been established that M. leukarti
does not even occur in Africa and India where it had been widely implicated
to be a vector of guinea worm disease (Van de velde, 1984). Attempts by
Boxshall and Braide (1991) to verify what Onabamiro (1951) identified as M.

28
leukarti was unsuccessful as the British Museum of Natural History does not
have the specimen any longer.
Onwuliri et al. (1991) showed that M. aequatorialis could be infected
experimentally in the laboratory. He further confirmed the assertion of Muller
(1972) that infection of cyclops is limited to tropical and sub-tropical regions
because the larvae of D. medinensis develop best between 25 0 C and 30 0 c and
do not develop below 19 0 C.
2.5 CLINICAL MANIFESTATIONS
A number of clinical manifestations due to the disease are varied. Pre-
emergent female worms can move easily through the connective tissues but
when they are about to emerge to the surface, a few larvae are released into
the sub-dermis through a rupture at the anterior end. The host reaction
results in the formation of a burning, painful blister. The first symptoms
appear simultaneously with the beginning of a blister formation and consist of
nausea, vomiting, diarrhoea, giddiness and fainting. Some or all of these
symptoms may be present (Edungbola, 1983).
Muller (1979) believes that they are due to the absorption of the toxins
employed by the worm to form the blister. According to him, they are intense
inflammatory reactions along the entire length of the worm with cells closely
adhering to the worm and preventing its removal. The blister bursts in a few
days to give a shallow ulcer. The bacteriologically sterile blister fluid contains
larvae surrounded principally by polymorphonuclear neutrophils with
macrophages, lymphocytes, and eosinophils (Muller, 1976). After the
expulsion of thousands of larvae, the end of the worm dries up and this

29
process is repeated a few times in a few weeks. The lesion then resolves
quickly. Unfortunately, the tract of the worm becomes secondarily infected in
about half of all cases and patients become severely incapacitated (Smith et
al. 1989; Hours and Cairncross, 1994). Muller (1971) and Kale (1977)
reported that over 90% of the ulcers were infected by bacteria. In another
study in Benin, there was 0.3% mortality from tetanus and septicaemia
(blood poisoning) (Chippaux and Massougbodji, 1991 cited by Cairncross et
al. 2002).
Female worms sometimes burst in the tissue, resulting in a very large
pus-filled abscess and severe cellulites. Infertile females or males elicit a
slight inflammatory reaction and sometimes calcify, showing up on a
roentgenogram (x-ray). Dracunculiasis is unusual among parasitic infections
in that there is little evidence of acquired immunity and the same individual
can be re-infected many times.
2.6 COMPLICATIONS
The complications of dracunculiasis result in the discomfort of the
patient. Larvae released provide abscesses which can lead to chronic
ulcerations. When the worm bursts deep in the subcutaneous tissue, it
provides abscesses which can lead to chronic ulcerations. Such abscesses can
be secondarily infected by bacteria along the tract of the worm especially if it
damages the tissue or if it retracts into the body. These conditions give rise to
serious disabilities and when there is involvement of the joints of the legs,
they produce fibrous ankylosis, contracture of the tendons, septic and aseptic

30
arthritis (Reddy et al. 1968; Muller, 1979; Ukoli, 1990). Cases of
dracunculiasis abscesses in extra-dural space of the spinal canal resulting in
paraplegia and motor weakness of the legs have been reported, (Mitra and
Haddock, 1970).
Sometimes worms which do not emerge die and become calcified near
the joints like the pelvis and the knee. It is possible that such worms
contribute to arthritis observed in such patients. Over 90% of the
blisters/ulcers marking the site of emergence of the worms are located in the
lower limbs particularly the ankles and feet (Onabamiro, 1951 and 1952)
while the abdomen, upper limbs, head and neck account for less. Some of the
unusual sites include the urinogenital system, scrotum, vulva, penis, buttocks,
and chin. Guinea worm ulcer is one of the commonest sites of entry of
tetanus spores so the risk of tetanus as a complication of dracunculiasis
infection is very high. The ulcers sometimes may become so severe that
amputation of the affected limb may become necessary, or may cause fatal
blood poisoning (Muller, 1979). The disease is also known to cause habitual
abortion in pregnant women (George, 1975), adverse effects on health
(WHO, 1991c), allergic reactions including urticaria, fever, nausea, giddiness,
asthma, vomiting, and severe inflammation due to damage to worms in the
skin (Reddy et al. 1969). The disease also causes bleb or blisters (Reddy et
al. 1969; Fairley and Liston, 1924b); giddiness, gastrointestinal symptoms,
intra-orbital oedema (Fairley, 1924a), allergic pruritis (Hodgson and Barret,
1964), constructive pericarditis due to worm presence in the thoracic cavity

31
(Kinare et al. 1962), urinogenital disease (Pendse et al. 1987; Raffi and Dutz,
1967).
Guinea worm disease is a painful disabling and incapacitating affliction
(WHO, 1982, 1991a), causing human misery and extensive suffering (Lyons,
1972; Belcher et al. 1975). The painful lesions caused by emerging worms
cripple up to 40% or more of the children and adults in affected rural areas
for weeks or months (Wurapa et al., 1975; Ukoli, 1990).
2.7 DIAGNOSIS
Patients in an area of endemicity have no doubt about the diagnosis.
When or just before the blister forms, there is localized itching then sharp
pain and often general allergic symptoms, including urticaria, follow. Once the
blister has burst, cold water will encourage the release of larvae, which can
be seen microscopically under low power. Immunodiagnostic methods are not
useful in practice because it has not been proved that they can detect
prepatent infections, mainly because of the lack of prepatent serum samples.
2.8 TREATMENT
Despite the fact that extensive work has been done in the area of
chemotherapeutic treatment of guinea worm, its treatment has continued to
pose a serious challenge to man. Muller (1971) cited some of the earlier
works in this area. Trewn (1937) and Shastry (1946) reported the efficacy of
tartaremetic but this was disputed by Fairley and Liston (1924). Guinea
worms are easily expelled from the skin tissue by injection of Trimelarsanmel-
W or Phenothiazine emulsion (Elliot, 1942). The worms are normally

32
mechanically extracted by carefully winding the emergent worms around a
small stick, a few centimetres a day, for as long as it can be completely
removed. This method has been practised since antiquity and is still useful,
particularly when combined with a clean dressing and antibiotics to prevent
secondary bacteria infection (Magnussen et al. 1994).
Many antihelminthic drugs have been tested. These include:
Thiabendazole, Mentazole and Cambendazole (Merck, Sharp & Dohme, Ltd.).
Others include Methyridine (Prometic Imperial Chemical Ltd.), Metronidazole
(Flagyl – May and Baker Ltd.). Muller (1979) estimated that about 20 clinical
drug trials have been made in West Africa alone. Rousset (1952) found
Hetrazan can give 50% cure in Sudan. He also observed that large oral doses
of Diethyl Carbamazine, (DEC), would kill the adults and in prophylactic
amount kill the larvae. The systemic side effects of this drug, according to
him, can be relieved by epinephrine or anti-histamine drugs. Following these
clues, Onabamiro (1956) tested hetrazan on the worm since Rousset‟s
experiment could not show how the worms were destroyed. He observed that
the drug even in strong concentrations had only a very slow effect on freshly
discharged larvae. He explained that it is possible due to toxic effect of the
waste products of the cyclops. In a previous investigation, he had found that
cyclops with infective larval stage died off in large numbers.
This however led to his suggestion of a possible prophylactic use of
hetrazan by travellers journeying through guinea worm endemic areas. The
drug was confirmed safe at correct dose for two weeks. Onabamiro (1956)
confirmed the prophylactic efficacy of DEC against larval guinea worm inside

33
cyclops. Raffier (1966), Oduntan et al. (1967), and Antani et al. (1970), have
respectively tested the efficacy against guinea worm of such drugs as
niridazole, commonly called ambilhar, (containing 1-C5-nitro-2-thrizolyl),
thiabendazole of the trade name mintezol, and metronidazole known by the
commercial name as flagyl.
Shafel (1976) worked on the preliminary report of the therapeutic
effects of dracunculiasis and discovered that mebendazole proved to be an
efficient drug of choice for the treatment. His findings indicated that
mebendazole affected mature adult worms especially after discharge of larval
content of the uterus, but the appearance of fresh lesions after healing of the
original lesions indicated that mebendazole did not have a full effect on
relatively premature worms. Wurapa et al. (1975) in a similar study found
that allergic swellings of the limbs before appearance of the guinea worm
under the skin subsided with thiabendazole or metronidazole treatment but
this was considered to be an anti-inflammatory effect only as the worms were
not killed or readily expelled.
Muller (1979) in a study of 20 clinical trials carried out with some of
these drugs in West Africa, discovered that the effects of these drugs have
always been very similar and that the drugs have no effects on pre-emergent
female worms which discharged the load of larvae that were infective in the
usual way. It appears likely that in man these compounds act against the host
inflammation reaction rather than on the worms themselves (Lyons, 1972;
Muller, 1979) a role which can better be served by local treatment with
hydrocortisone cream containing an antibiotic (Muller, 1979). Nwoke (1992)

34
observed that there was no evidence that any chemotherapeutic agent has a
direct action against guinea worm, although various benzidamizoles may have
an anti-inflammatory action, aiding elimination. Chippaux (1991) found that
treatment with mebendazole was associated with aberrant migration of
worms which were more likely than usual to emerge at places other than the
lower limbs.
Widely reported chemotherapeutic failures in guinea worm treatment
have been confirmed by Kale (1974; 1975), and Belcher et al. (1975). More
so infection due to dracunculiasis provoked no immunity so people are
infected year after year (Hopkins, 1987). This means that even if tested drugs
were effective, previously cured patients will not be prevented from re-
infection if re-exposed. The need for drug of chemotherapeutic value is
important and according to Muller (1979) there is hope in the evidence that
some chemotherapeutic agents are active against developing guinea worm
parasites.
As none of the drugs had a prophylactic effect, so infection can always
re-occur after infection (Onabamiro, 1956), efforts were then shifted to
traditional African medicine (herbal). Before this time, these herbs were
acknowledged as having varying degrees of cure (Muller, 1971). Combretum
mucronatum, long prescribed by herbalists produced 97.7% cure with
extrusion of the worms and reduction in inflammation around the ulcer and
healing of the ulcer in two weeks following the application of sterile palm oil
(Ampofo, 1977). In other trials, Mitrogyna stipulosa gave 52.2%; leaves of
Elaceophobia drupitera and Hellaria latifolia, taken in palm oil soup were

35
effective against dracunculiasis. The major shortcomings of herbs are the
unquantifiable dosages and the refusal of local herbalists to disclose the
combination of herbs for scientific evaluation.
As success through chemotherapeutic means was not forth coming,
Muller (1979) observed that the most urgent need was for carefully monitored
control scheme capable of reducing or eliminating infection in the locality be
put in place.
However, of recent, Anosike et al. (2006), working on the treatment of
Dracunculus medinensis infection with cotrimoxale in endemic population of
Ebonyi South Eastern Nigeria, observed that inflammation signs subsided
within the first 2 – 4 days of treatment. Specifically, symptoms were more
pronounced in the untreated than in the treated groups. The drug enhanced
healing of septic wounds and reduced both swollen legs and pains in over
67% of the cases.
2.9 SOCIO-ECONOMIC IMPACT
In recent years, the understanding has grown that biological, technical
feasibility costs and benefits are the criteria to consider before launching an
eradication programme (Dowdle and Hopkins, 1998 cited by Cairncross et al.
2002). The benefits of dracunculiasis eradication will occur almost exclusively
to the population in which the disease is endemic (Aylward et al. 2000). In
the past, most cases of dracunculiasis went unreported for a number of
reasons. Most health centres had little to offer the patient besides palliative
treatment; most patients lived in poor, remote rural areas and were hindered
by their disease from walking to a health facility, and most recovered

36
spontaneously after expulsion of the worm. Since few cases were reported,
the disease was often considered an exotic curiosity rather than a major
public health problem. However, in areas of endemicity, its social, economic,
nutritional and educational consequences and the costs incurred by the
individuals, households and communities that suffer from it, can be
substantial (Caincross et al. 2002).
2.9.1 Disability
Human infection with guinea worm is rarely fatal but causes much
incapacitation. Studies in India based on medical records suggested a case
fatality rate of 0.1% or less, and this was probably a generous estimate
because only persons with severe complications usually seek treatment from
health facilities (Adeyeba, 1985). The proportion of patients permanently
disabled by the disease is also small. A number of studies have found it to be
less than 10% (Singh and Raghavan, 1957; Rao and Reddy, 1965; Imtiaz et
al. 1990).
The social aspects of the disease are attributable to the temporary
disability suffered by the patient. Two studies in Nigeria, (Adeyeba and Kale,
1991; Smith et al. 1989); found that 58 to 76% of patients were unable to
leave their beds for appropriately a month during and after emergence of the
worm. The more severe and protracted disability is associated with
secondary infection of the lesion; this occurs in roughly half the cases
(Wurapa et al. 1975; Nwosu et al. 1982). The impact of this temporary
disability is reinforced by the seasonal pattern of worm emergence, often
peaking at stages of the agricultural year where labour is in maximum

37
demand. There is seasonal variation in agricultural activity peaking in the dry
season (South zone) and some in the wet season (North zone). Dracunculus
cases also peak at the same periods (Muller, 1976, 1979). The one for the
south zone also corresponds with the period of yam and rice harvesting
(Smith et al. 1989). This seasonality means that a whole community can be
laid prostrate simultaneously and household members can be prevented from
substituting for one another in agricultural and other tasks (Belcher et al.
1975).
Indeed, the Dogon people in Mali refer to the infection as “the disease
of the empty granary‟‟ (WHO, 1998c). The impact of guinea worm disease
does not end when the worm is out and the sufferer returns to work. A study
in Ghana by Hours and Caincross (1994) found that between 12 and 18
months after emergence of a worm, 34% of patients still had some difficulty
performing everyday activities, usually due to pain attributable to its location
and the date of onset of the episode of dracunculiasis. While the disability is
not necessarily permanent, it extends beyond the incapacity occurring during
worm emergence. Osaba et al. (1977) observed that joints in some cases
when involved, lead to permanent deformities.
2.9.2 Economic Impact
Some attempts to estimate the economic impact of dracunculiasis have
simply multiplied the number of days of labour lost by the mean value of
production per day or by the wage rate. From this, it is easy to calculate the
loss per household to derive an estimated cost for a whole region. In a study

38
carried out by de Rooy and Edungbola (1988 cited by cairncross et.al. 2002)
based on a survey of 87 households, estimated that rice-growing areas in
three states of southern Nigeria sustained an annual loss of $20 million due to
guinea worm disease. This argument was extremely effective in mobilizing the
support of senior politicians in Nigeria for the eradication of the disease
(Edungbola et al. 1992). Adeiyongo(2004) in a research carried out in Central
Nigeria observed that quantity of rice and yams output lost as a result of
guinea worm infection for the 1999 cropping season was 27.1 metric tonnes
of rice and 225,785 tubers of yams valued at N406,200.00 and N5,644,618.25
respectively. It has been argued that this method of calculation uses an over
simplified field approach and is likely to over estimate the cost (Paul, 1988
cited by Cairncross et al. 2002) as it does not allow for the various coping
strategies by which households respond to illness (such as abandoning other
tasks and using additional labour) which qualitative studies have found to be
common in peasant farming (Brieger et al. 1989; Chippaux et al. 1992). A
more sophisticated approach is to examine the impact on actual production
(Brieger and Guyer, 1990) or even to include the incidence and duration of
dracunculus-induced disability as predictive variables in an agricultural
production function. Audibert (1993 cited by Cairncross et al. 2002) used this
method and approach in a setting in northeast Mali where the incidence of
guinea worm disease was relatively low (3-33% in the villages studied) to
show that temporary disability accounted for a reduction of 5% in the overall
production of two important subsistence crops, sorghum, mainly grown by
men, and peanuts, cultivated by women. There is also a cost to the coping

39
strategies which cannot be measured using this approach. Mutual assistance,
(Watts et al. 1989), simply transfers the cost of the disease to other
households and is of little help to wage labourers (Chippaux, 1992).
2.9.3 Nutrition, Education and Perpetual Benefits
There is an unequal distribution of costs within the family and the way
in which disease, by impacting more on the production of some crops than
others (Brieger and Guyer, 1990) can have a disproportionate effect or
nutritional status. A survey in south Kordofan, Sudan (Tayeh and Cairncross,
1996) found that in households where more than half the adult members had
suffered from dracunculiasis in the previous year, the children under 6 years
of age were nearly three times as likely to be malnourished as indicated by
wasting.
Children also suffer in other ways from guinea worm disease in their
families. The disease affects the mental development of the children as well.
They miss school when they have no substitute for their ill parents in doing
agricultural work and other household tasks. As a result, school attendance
suffers during the peak season (Nwosu et al. 1982; Brieger et al. 1983;
Edungbola and Watts 1985; Ilegbodu et al. 1986; Edungbola et al. 1988) and
schools in areas of endemicity often have to close for one month in each year
as a result of this. This school absenteeism often leads to poor academic
performance leading finally to drop out from school (Lyons 1972, Belcher et
al. 1975; WHO, 1982; Edungbola, 1983).
Guinea worm disease is of special interest to economist not only
because of its direct and measurable impact on production but also because

40
of the singular ability of disease eradication to produce a perpetual stream of
benefits at no ongoing cost. It is therefore surprising that recent cost-benefits
analysis of the eradication effort by the World Bank considers only the
benefits from incidence reduction during the campaign, which they estimate
to have cost more than $90 million to date is certainly pessimistic (Cairncross
and Muller, 2002).
2.10 EPIDEMIOLOGY
2.10.1 Water Sources
Dracunculus larvae need a period of 12-14 days to develop in the
cyclops and become infective; therefore, dracunculiasis is not normally caught
from flowing water sources such as rivers and streams. Deep wells are rarely
implicated in transmission (Cairncross and Tayeh, 1988; Muller, 1979) few
cyclops are found in them, probably because the lack of light at the bottom
constrains the population of zooplankton, which are the cyclops‟ natural diet.
Thus, ponds and sometimes shallow or step wells are the main sources of the
disease and the epidemiology of dracunculiasis is chiefly determined by the
use of such sources for drinking water. Numerous studies have illustrated the
predominant role of ponds in dracunculiasis transmission in various parts of
Nigeria (Kale 1977; Edungbola, 1980, 1983; Edungbola and Watts, 1984,
1985, 1990; Osisanya et al. 1986); Ghana (Scott 1960, Lyons 1972); Pakistan
(Hopkins et al. 1995); India (Johnson and Joshi, 1982) and Uzbekistan (WHO,
1998a).

41
Most of the ponds involved in transmission are human-made. Steib and
Mayer (1988) while working in a village in North east Burkina Faso
demonstrated large numbers of ponds which can be found in a single village,
even in semi and Sahelian setting, and the degree to which relatively few
human-made ponds with specific characteristics play a significant role in
transmission. Other types of human-made ponds implicated elsewhere include
„boullies‟ which are large dew ponds excavated for community water storage
on the Mossi Plateau of central Burkina Faso (Kambire et al. 1993); small
dams in northern Ghana (Tayeh and Cairncross, 1998); “ataparas” or valley
tanks which are similar reservoirs in northern Uganda (Henderson et al.
1988); hundreds of drinking water-ponds recently built in Anambra State
Nigeria (Cairncross et al. 2002); “hafirs” built to store water from empheral
streams in Sudan (Cairncross and Tayeh, 1988); and municipal ponds in old
Bukhara, Uzbekistan (Cairncross et al. 2002). Outbreaks of guinea worm
disease blamed on dam construction are as a result of the use of ponds left
by the receding water during drawdown of the water level (Adekolu-John,
1983; Edungbola and Watts, 1984).
Various types of wells and storage tanks have been known to become
sources of the disease. Rectangular masonry-lined step wells were the
principal sources of infection in Rajasthan, India (Singh and Raghavan, 1957).
Shallow wells have been implicated in Mali (Ranque et al., 1979 cited by
Cairncross et al. 2002). Scoop wells dug in sandy riverbeds can also be a
source but if the drawing of water each day exhausts the water holes, no
cyclops population can be sustained in them and so transmission cannot occur

42
(Cairncross and Tayeh, 1988). In Iran, „‟berkeh‟‟ – traditionally covered water
storage cisterns with a diameter of over 10 metres were implicated (Sahba et
al. 1973).
Transmission has also occurred from rainwater storage reservoirs used
by individual households such as the „‟karkour‟‟ of the Nuba mountains of
Sudan (Cairncross and Tayeh, 1988) and in isolated incident in 1993 in El
Rohaibat, Libya, from a buried reservoir filled from a farm tank which an
infected migrant worker had contaminated (Karam and Tayeh, 1999). Few
cases are caused in this way, because there must be an index case in the
household to contaminate the reservoir, but when they do occur, transmission
is more intense than usual because the infected cyclops are contained in a
smaller volume of water and this is reflected in a higher average number of
worms per patient (Cairncross and Tayeh, 1989).
2.10.2 Villages of Endemicity
Dracunculiasis occurs only in a limited number of so-called “villages of
endemicity”, on which eradication activities can focus. For example, in 1980
the National Case Search conducted in all 8,068 villages in Burkina Faso found
cases in only 2,621 (Kambire et al. 1993). Local health staff in Bam province
found that villages known to have ponds were twice as likely as others to be
among these villages of endemicity. There has been a tendency in some
countries for the list of villages of endemicity to “drift” by some 30% per year
and sometimes even twice this but, the appearance of a large proportion of
new villages seems to be largely the consequences of cases reappearing in
villages removed prematurely from the endemicity list rather than a change in

43
the set of villages susceptible to the disease. A period of one year without
cases is insufficient evidence that transmission has been interrupted as the
full cycle from emergence of a worm in the index case to detection of a
secondary case can take up to 16 months.
2.10.3 Seasonality
Dracunculiasis takes roughly a year from ingestion of an infected
cyclops by the human host to emergence of an adult worm. This makes it well
suited for environments in which transmission can occur only at a particular
time of the year. As a result, there is a strong seasonal peak in incidence
rates in most communities of endemicity. Two broad patterns of seasonality
are found in the African areas of endemicity, depending on climatic factors. In
some countries, both patterns occur each in a different climatic zone. To the
North in the Sahelian zone, transmission of dracunculiasis is generally limited
to the rainy season from May to August with a peak in June and July
(Guiguemde, 1985). Steib and Mayer (1988) attributed this pattern to the
presence of Thermocyclops inpinus in the surface and shallow water used for
drinking. Others however have found it more difficult to correlate occurrence
of cyclopoids in the local water sources with the prevalence of infection
among the people using them (Yelifari et al. 1997). More fundamentally,
many water sources involved dry up and hand pumps are repaired in the dry
season, so that the population turns to safe ground water sources (Curtis et
al. 1993 cited by Cairncross et.al. 2002)).
Further south in the humid savannah and forest zone, the opposite
pattern is found, with the peak in the dry season. This may be the early dry

44
season (September-January) as in some parts of Oyo state, Nigeria
(Edungbola and Watts 1990; Kale, 1977); and south Togo, particularly in
villages with shallow ponds which usually dry up by January. The disease
often occurs or continues towards the end of the dry season (January- May)
in Ghana (Scott, 1960; Lyons, 1972; Belcher et al. 1975) southern Benin
(Chippaux and Massougboji, 1991 cited by Cairncross et al. 2002), Kwara and
Anambra states in Nigeria (Abolarin, 1981; Nwosu et al. 1982; Edungbola,
1983; Edungbola and Watts, 1985;), and Uganda (Henderson et al. 1988).
This dry season transmission is often associated with the consumption of
water from ponds or water holes formed or dug in the beds of seasonal rivers
when flow has ceased (McPherson, 1981; Chippaux et al. 1992). Chippaux
and Massougbodj, (1991 cited by Cairncross et al. 2002) suggested that
transmission does not occur when there is less than one susceptible cyclopoid
per litre in the pond and that this accounts for seasonal variations in
incidence.
There are local variations in these patterns. The duration and intensity
of transmission in particular villages often depend on whether and when the
local dams or ponds dried up the previous year (Tayeh and Cairncross, 1998)
and some villages have very different seasonal peaks from those of the
surrounding areas because of local circumstances. For example in some
villages along the banks of the Niger and Volta rivers the incidence peaks
when the river level falls and water is taken from holes dug in the river bed
(Cairncross et al. 2002).

2.10.4 Individual Risk Factors
45
The incidence of the disease has been found to vary with age and sex
in different ways, but these can generally be understood from the way that
people of different ages and genders behave with regard to their sources of
drinking water. For example, a significantly higher prevalence has been
found in women in Ethiopia (Jamaneh and Taticheff, 1993) and in men in
India (Johnson and Joshi; 1982) and sometimes in west Africa (Adekolu-
John, 1983; Chippaux et al. 1991 in Cairncross et al. 2002; Nwoke, 1992),
however when behavioural risk factors (such as work in the fields or collection
of water) are taken into account, the difference between the sexes is not
significant (Tayeh et al. 1993).
Cairncross and Tayeh (1989) in Sudan discovered two possible age
prevalence profiles. One for high-prevalence villages each with an infected
water source, showing similar prevalence in children and in adults. Two for 23
villages showing a lower prevalence in all ages but significantly less in
children than in adults. The first is characteristic of communities where the
water carried home is infected, while the latter is indicative of an association
with mobility where infection is acquired from water sources outside the
community.
Other important individual risk factors are those associated with
mobility (Watts, 1984), however the strongest of all is infection in the
previous year. A minority of people suffer recurrent infection in spite of
drinking from the same water sources as the rest of the populations reflecting

46
the variability in individuals‟ susceptibility to the disease (Lyons, 1972; Tayeh
et al. 1993).
2.11 THE ERADICATION INITIATIVE
Muller (1979) pointed out that guinea worm disease is a promising
candidate for successful eradication. The cyclops is not a mobile vector like a
mosquito, and the carrier state in both the cyclops and human hosts is of
limited duration. Diagnosis is easy and unambiguous, cheap and effective
measures are available to prevent transmission. The disease has a limited
geographical distribution and even within this area it is found only in certain
communities of endemicity. Its markedly seasonal distribution in time also
permits a more intense focus on its prevention in seasonal campaign and
transmission from animals to people is practically unknown. Therefore the
suggestion that dracunculiasis might be eradicable fell on fertile grounds.
Choosing a target was easy, however compared with the task of
mobilizing the resources for the battle much of the credit for that
achievement goes to members and former members of the staff of the
Centres for Disease Control and Prevention (CDCP), who through an advocacy
campaign beginning in 1980 and sustained over more than a decade
(Hopkins, 1983;1985b; 1987; 1990 and 1993) succeeded in convincing former
U.S. President, Jimmy Carter, the United Nations Children‟s Fund, (UNICEF),
Executive board, the 1989 African regional committee of the WHO and the
1990 World Summit for children to take up the challenge. In 1991 World
Health Assembly declared “its commitment to the goal of eradicating

47
dracunculiasis by the end of 1995, this date being technically feasible given
appropriate political, social and economic support”. The target date was set in
order to enhance the advocacy effort at the international level and in the
countries of endemicity as well. This advocacy effort needed to be replicated
in each country to get a national programme established (Edungbola et al.
1992). In 1982, India was the first to initiate a national eradication campaign.
By 1990, four other countries followed namely Pakistan, Ghana, Nigeria, and
Cameroon. In the following five years, all the other known countries of
endemicity also established national eradication programmes and substantial
and progressive reductions in disease incidence were recorded each year,
particularly at the beginning of the campaign.
The advocacy needed to be maintained as the initiative advanced. This
was, on the other hand, to kindle and sustain the interest of donor agencies,
which supported water supply programmes, technical assistance, vehicles,
cloth filter, Temephos, training of staff and volunteers, and field allowances.
On the other hand, it was aimed at keeping up the commitment of
government of countries of endemicity and the enthusiasm of programme
staff, an essential function, since the bulk of the staff engaged in the initiative
were health workers whose salaries were supported from the budgets of
National Ministries of Health (Cairncross et al. 2002).
An important means to this end has been the series of regional
conferences and meetings of national programme coordinators, together with
programme review meetings. Donor involvement and coordination were also
supported by regular inter agency meetings, usually held in the United States

48
of America and attended by representatives of the carter centre, UNICEF, the
U.S. Agency for International Development, the World Bank, WHO, and other
agencies. High-level advocacy was also supported by the continuing
involvement of Jimmy Carter and two former African Heads of State whom he
persuaded to play a similar role, A.T. Toure of Mali and Yakubu Gowon of
Nigeria (Cairncross et al. 2002).
The principal international stakeholders in the programme have been
relatively few in number. The Cater Centre, UNICEF, the World Bank and
WHO. Other major supporters include Bill and Melinda Gates foundation and
the British and Japanese bilateral aid programmes and have channelled their
funding through these agencies (Cairncross et al. 2002). The major players
liaise periodically to identify major gaps in the funding of national
programmes and in most countries of endemicity, one of them has, by
consensus, taken the leading role.
From 1992 to 1996, when National Eradication Programmes were
being established, UNICEF and WHO maintained a joint technical team based
in Ouagadougou, Burkina Faso, to provide technical support to national
programme coordinators in the region and external support agencies. The
Carter centre also seconded one of its staff to this team in 1994 (Cairncross et
al. 2002).
The out come of all this effort has been a remarkable reduction in the
number of cases, from an estimated 3.3million world wide in 1986 (Watts,
1987) to 75,223 (WHO 2001). Only 14 countries, including Nigeria, all on the
African continent, reported indigenous cases in 2000 (WHO, 2001).

2.12 INTERVENTIONS
49
Given the transmission cycle of the parasite and the absence of an
effective vaccine, a number of interventions seemed a priority to be worth
considering.
i. Filtration of one‟s drinking water to remove cyclops.
ii. Provision of safe water supplys
iii. Searching for patients with active cases and proper
management of the cases
iv. Ensuring that patients avoid contact with ponds/case
containment
v. Killing or removing cyclops in ponds using Temephos (Abate)
2.12.1 Filtration of Drinking Water
The adult cyclops is over 1mm long and therefore it can easily be
removed by filtering the water through an ordinary cloth. The filtration may
be easy but convincing the people to do it is another problem. For millions of
poor and mostly illiterate villagers, living in thousands of remote and
frequently inaccessible communities and speaking hundreds of different
languages, to change their behaviour in this way is by any standard a major
challenge to health education planning.
As the National Eradication Programme took shape during the early
1990s, it became clear that it would rely largely on health education to
promote the use of cloth filters. Early eradication programmes distributed
cotton cloth, but this was sometimes used as clothing or for decoration, and

50
homemakers also complained that it soon became clogged with sediments in
the water so that too much time was needed to do the family‟s filtering. The
right type of filter cloth was then introduced in the early 1990s, the cotton
cloth was replaced by a monofilament nylon cloth, which was donated in huge
quantities by Precision Fabrics Group through the Carter Centre and which is
less susceptible to clogging (Duke, 1984). More recently, a somewhat cheaper
polyester fabric has been found to be equally effective and acceptable (Olsen
et al. 1997).
Several hundred thousand square metres of this cloth were donated
during the 1990s; at the cost price of the fabric, this represents a donation of
over US$14million (Carter, 1999). A study in Pakistan (Imtiaz et al. 1990)
found the filters in satisfactory condition after 12-15 months of use.
Unfortunately it gradually became clear that in Africa the cloth could not be
expected to last for more than a year particularly when people washed it
regularly, with the vigour that they customarily used on other items of
domestic laundry. This meant that filters had to be replaced regularly
(Cairncross et al. 2002). The fabric donation ended in 1998 and since then
national programmes have had to distribute cotton cloth or to find the
funding to purchase monofilament fabric at US$4 per square metre. The cost
of the cloth has encouraged national programmes to find more economical
ways of using it, such as stitching a patch of it into a hole made in a larger
piece of ordinary cotton cloth. One other cost effective use of the material is
to fix it over the end of a piece of 10-20mm diameter plastic pipe, 100-
200mm long. This “straw” filter can then be taken on journeys or to the

51
fields and used to drink from ponds. A hole can be drilled through the pipe so
that it can be hung around the neck from a string. First introduced with
successes by the Mauritanian Programme, it has been used in Niger, southern
Sudan and Nigeria especially in the North West and North East zones
(Cairncross et al. 2002, Hopkins and Withers, 2002).
When the nylon cloth was being donated, some National Programmes,
especially Burkina Faso and Togo, sold the filters for a nominal sum. This was
to help pay for the cost of making up the cloth into a handy form and also
seen as ensuring that those who acquired the filters would value them.
Ironically, now that the National Programmes have to purchase the filter
cloth, all of them have decided to distribute filters free of charge in
communities of endemicity, with a view to ensuring complete coverage.
2.12.2 Safe Water Supply
In the early strategies for eradication of dracunculiasis provision of safe
water supply was generally seen as the intervention of choice although water
supplies are built and maintained for many other reasons besides the
prevention of guinea worm disease. The eradication goal was originally
proposed as a target for the international water decade (Hopkins, 1983;
1984). Early eradication efforts in Nigeria (Edungbola et al. 1988; Edungbola
and Watts, 1990; Huttly et al. 1990) and Benin invested the major part of
their budgets in water supply construction. The former vice president of
Nigeria, Augustus Aikhomu, while declaring open the second national guinea
worm conference in March 1989, directed all water providers including the

52
governments Directorate of Food, Roads and Rural Infrastructures (DFRRI) to
give priority to villages with guinea worm in their water projects.
There is a lot of evidence on the success story of the impact of water
supplies on dracunculiasis (Reddy et al. 1969; Lyons, 1972; Bhatt and Palan,
1978; Johnson and Joshi, 1982; Udonsi, 1987a; Cairncross and Tayeh, 1988;
Edungbola et al. 1988; Henderson et al. 1988). India‟s rural water supply
programme gave priority to villages of endemicity and by the time the
National Eradication Programme was concluded, had provided water supply to
every village of endemicity in the country. This was an important contribution
to that country‟s successful elimination of the disease in 1997. There are
however some important limitations to the effectiveness of water supply as a
preventive intervention.
i. Water supplies cannot function without proper maintenance. Many
water systems in Africa have fallen into disuse for this reason within
a few years of construction and in some cases the resulting reversion
to unprotected water sources have allowed the disease to persist
(Bhatt and Palan, 1978, Steib and Mayer, 1988) or in peri- urban
settings, to develop in epidemic form (Edungbola, 1980; Brieger et al.
1982).
ii. The provision of water supply to every village and hamlet is not
always feasible. Studies carried out by Tempalski (1991 cited by
Cairncross et al. 2002) in a Benin project revealed that the
prevalence of guinea worm disease in the villages of endemicity with
fewer than 150 inhabitants was four times that in the largest villages,

53
but they were specifically excluded from the borehole programme as
they were considered too small to justify the cost of drilling and
maintaining a hand pump sustainably (Yellott, 1990 cited by
Cairncross et al. 2002).
iii. A functioning water supply will still be ineffective if it is not used. It
has been shown that the most common cause of non-use is that the
supply is not close enough to people‟s homes (Cairncross et al.
2002). In the countries of endemicity of the Sahel, a hand pump may
be the only source of water for miles around in the dry season;
however, guinea worm transmission peaks during the rains, when
people are often infected from the many ephemeral ponds which are
within a few hundred yards of their houses.
iv. Much of the population in the rural Sahel migrates. In addition to the
movement of the nomadic pastoral population, it is common practice
in countries such as Burkina Faso and Niger for a village to disperse
during the growing season (which is also the peak of dracunculiasis
transmission season) to a number of small and seasonally occupied
hamlets, some of which may be in other districts, or even to sow
their crops in several different areas and tend those where the
region‟s unpredictable rainfall turns out to be most plentiful. When a
borehole can cost as much as US$10,000, it is not a cost effective
option to provide one for every such hamlet (Cairncross et al. 2002).
v. Water supplies alone cannot eliminate dracunculiasis if they are not
used exclusively. Guinea worm infection is often acquired through

54
casual use of unprotected sources when people are away from home,
especially when they are working on the fields. The findings of
Belcher et al. (1975) and Cairncross and Tayeh (1988) have
confirmed this where adults, particularly farmers were more
commonly infected than were children and that people travelling
away from their villages were at greater risk (Tayeh et al. 1993).
vi. Water supplies are very expensive. WHO (1992a) has shown that
typical rural water supplies in sub-Saharan Africa have a median
capital cost of US$40 per person served with an additional recurrent
maintenance cost. This however, does not mean water has no role to
play, in some cases, particularly in the few urban foci of
dracunculiasis, it has been decisive, but its impact must be assessed
realistically. It can be seen as transforming a high prevalence
community where all water is contaminated to a low prevalence
community where only those who use unprotected sources are at
risk.
2.12.3 Case Management
Surgical extraction of the worm was first recommended by Avicenna
(980 to 1037) and was practiced by traditional healers in Iran and in what is
now Uzbekistan (WHO, 1998). Great skill is required to avoid breaking the
worm, which is sometimes caught around joints or tendons. Extraction before
emergence avoids the pain and suffering caused as the worm emerges and
also contains the case by preventing contamination of water sources. B.L.
Sharma, an ayurvedic practitioner supported by UNICEF refined this technique

55
and applied it in India, and with this, a further advantage was apparent in
that people could come from far and wide to have their worms extracted,
greatly improving the effectiveness of case detection and hence of case
containment (Rohde et al. 1993). Although the technique was an important
component of the eradication programme, the measures were never accepted
by the Indian medical profession or adopted by the National Eradication
Programme. Ghana was the only African country to include this intervention
in its dracunculiasis eradication programme but abandoned it in the early
2000; this was because the measure distracted the attention of health
workers who received a reward for each worm extracted, from the
implementation and supervision of the basic community-based interventions
(Cairncross et al. 2002).
A more widely used form of case management is to apply an occlusive
bandage to the lesion where the worm is emerging. This does not prevent the
larvae from being released into the environment but it does discourage the
patient from immersing the affected part in a pond; immersion transforms a
neat bandage into a soggy mass of wet cotton wool which is likely to fall off.
There are also other palliative treatments by the village health worker,
example, “controlled emersion” of lesion in a bucket of water, disinfection of
the lesion by topical application of emollient creams and even antibiotic
ointment (WHO, 1990b), bandaging by a VBHW has been used to promote
early self-reporting of cases.

56
2.12.4 Preventing Patients’ Contact with Ponds
Preventing patients‟ contact with ponds was an important component
of the world‟s first endeavour at dracunculiasis elimination conducted in the
old city of Bukhara, Uzbekistan, in the 1920s (WHO, 1998a). Efforts were
made to identify patients early and keep them under observation during the
two weeks following initial emergence of their worms, and Muslim
worshippers were prevented from approaching the main ponds in the town to
perform their ablutions.
In the early stages of the worldwide eradication campaigns, however,
such measures were ruled out as impractical in a rural context where case
detection within even a month of emergence could be considered an
impressive achievement. Instead, the message that patients should not
contaminate ponds was usually a secondary one in the general health
education materials. As a result, people were far more aware of how one
catches the disease than of how one passes it on. Example, an evaluation
survey by Cairncross in 1994 of 26 villages in Niger showed that while 54% of
householders knew that dracunculiasis is transmitted in drinking water, only
13% could say how ponds became infected with it (Cairncross, 1995).
More recently, it has become clear that people sometimes respond so
well to this message that it can have a significant effect on transmission in
the complete absence of filter cloth (Cairncross et al. 2002).
2.12.5 Killing or Removing of Cyclops
The intervention of killing or removing cyclops has also been tried since
the earliest efforts to control transmission of the disease. Leiper (1911) used

57
steam to kill cyclops in Indian step wells and Turkhud (1914) used potassium
permanganate. Ten years later, when Isaeu tried to apply their methods to
the ponds of old Bukhara, he found them impractical, an average pond
required 300kg of disinfectant, and the water became undrinkable (Isaev,
1956).
In more recent times, Temephos (Abate), an organophosphate
insecticide safe for use in drinking water sources, has been used in many
countries of endemicity and $2million worth has been donated to the
campaign by its manufacturer (Carter, 1999). Cyclopicide played a prominent
role in the eradication programmes launched in the 1980s in India, Pakistan
and Cameroon. All these programmes have successfully achieved elimination
but this took many years.
In Africa, vector control has not proved as easy as initially anticipated,
in spite of their being fewer ponds per person than there were step ponds in
India. Chemical treatment of African ponds, even by highly qualified research
teams has been found on a number of occasions to be of questionable
effectiveness (Guiguemde et al. 1990, Sullivan, 1991 as cited by Cairncross et
al. 2002). When the treatment is not fully effective, there is an increased risk
of cyclops developing resistance to the cyclopicide. Even treatment, which
successfully removes the cyclops from the pond, does not always eliminate
guinea worm disease, as other contaminated water sources are often in use
(Lyons, 1973).
Transmission is most intense in ponds which are in the final stages of
drying up (Belcher et al. 1975; Tayeh and Cairncross, 1998) and which

58
therefore may be missed by the treatment team. This is because the infected
cyclops which tend to sink to the bottom are increasingly likely to be scooped
up as the pond became a shallow puddle (Nugent et al. 1955; Onabamiro,
1954).
Treatment of ponds can also consume substantial resources,
particularly in terms of trained staff. It is harder to calculate the volume of an
irregular pond than of a rectangular Indian step well, although this is essential
in order to estimate the dose of insecticide required (Centre for Disease
Control, 1989). Faced with these difficulties, the health technicians usually
take almost half a day to measure the volume of some ponds.
The pond volume also varies with time; if rainfall after the treatment
does not dilute the insecticide to harmless levels, the pond may still need to
be re-measured the following month, although a solution used in India to
avoid continued measurement of the volume is to insert a calibrated scale in
the pond. Treatment has to be applied at least monthly to be effective, and
there is evidence to suggest that an even shorter treatment interval is
required. With as many as 10 ponds to treat per village it becomes a very
labour-intensive activity. There is some evidence that it has diverted staff
from other more important activities (Cairncross, 1995).
Some exceptional cases were found in northern Ghana where in 1997,
the eradication programme staff found that most of their cases came from
only four district towns each of which used water from a dam. The dams were
nearly ten times the maximum size recommended for treatment (Centre for
Disease Control and Prevention 1989). Nevertheless, after some

59
experimentation they found that cyclopicides could be applied very effectively
to these dams (Cairncross et al. 1999).
2.12.6 Case Containment
By the middle of the 1990s as case numbers began to drop, there was
increased enthusiasm to step up the level of intervention and move towards
“case containment”. This involves a shift of emphasis from helping individuals
to protect their own health by avoidance or filtration of infected water
towards the protection of ponds and the community at large from
contamination by infected people.
If this is to be effective, it requires detection of each case before or
immediately after the emergence of the worm and measures to ensure that it
could give rise to no subsequent case. Case containment helps to encourage
self-reporting of cases, essential if the cases are to be detected in time and
also discourage patients from immersing their lesions in water. Patients and
their families are urged to keep out of water sources until the worms have
completely emerged and are also interviewed to ascertain whether they have
already contaminated any ponds. If so, remedial measures are taken, such
as alerting the community to this possibility, treatment of the affected ponds
with cyclopicide and checking that every household in the village has a cloth
filter in good condition and knows how to use it. To ensure the effective
implementation of case containment each case should be reported to the
supervisor of the village health worker within seven days, and the supervisor

60
should visit to verify the diagnosis and ensure that all necessary measures
have been taken.
These measures require substantial additional resources (Greer et
al.1994). The cost per village is probably at least double the cost of the
conventional approach (Cairncross et al. 1996). Some of the principal
international agencies involved expressed concern that these resources
should be deployed effectively, so in 1994 at a meeting organised in Nairobi,
Kenya, technical standards for effective case containment were defined and
agreed on (Anonymous, 1994, cited by Caincross et al. 2002). According to
these criteria, a case is considered to have been successfully contained only
if:
i. it was detected before or within 24 hours of worm emergence
ii. the patient has not entered any water source since the worm
emerged or if so, the source has been treated in time to prevent
transmission
iii. the case has been properly managed by cleaning and bandaging
until the worm is fully removed, and the patient has been
discouraged from contaminating any water source
iv. the diagnosis and containment of the case have been verified by
a supervisor within seven days of worm emergence.
The implication of this is that eradication programmes where the
resources did not permit a supervisor to visit each village of endemicity more
than once a month could not be considered to be implementing case
containment even if the village health worker did carry out some containment

61
activities. The Nairobi participants referred to this as „‟intensified case
management‟‟. It has taken several years for all the countries of endemicity to
adopt these standards. For example, Niger maintained that a case had been
contained if the case was detected in a week. Even now, a number of
countries do not confirm the diagnosis and containment within a week
(Cairncross et al. 2002).
2.12.7 Village-Based Health Workers (VBHWs)
The annual case search for 1990/91 was the last, and in 1992, the
programme emphasis was shifted from case reduction to case containment.
Village-based health workers (VBHWs) were trained to assist with monthly
surveillance and intervention activities which commenced in January 1992
have been in operation to date. The collection and management of
surveillance and intervention data are now ongoing activities and form an
integral part of the eradication programme involving communities, Local
Government Areas, States, Federal Government and supporting agencies.
In Nigeria, government launched a village-level guinea worm
eradication initiative after four successive National case searches. In this
regard, VBHWs nominated by the village health committee and leaders were
trained and given flip charts as aids in educating villagers on the benefits and
practical use of filtering water. The over 6000 unpaid village-based health
workers, apart from engaging in filter distribution and health education,
undertake surveillance activities by counting number of guinea worm cases in
each household and taking stock of sources of drinking water in the
communities. WHO assisted in the logistics with the provision of bicycles.

62
The surveillance and intervention strategies were also supported not
only by the VBHWs but also by about 94 National Youth Corp Members
(NYSC) who were recruited, trained and assigned to the then 86 most highly
endemic Local Government Areas in the country. Other support manpower
resources include American Peace Corp Volunteers and Canadian Co-
operants, LGA guinea worm coordinators, State task force members, zonal
facilitators and the staff of the Federal Ministry of Health and Social services
which, in collaboration with Global 2000, sends directives to all the States and
the LGAs.
2.13 CURRENT ISSUES ON GUINEA WORM
2.13.1 The Integration Debate
The strategy followed by most endemic countries as they set up
eradication programmes during the 1990s was built on the experience of
Pakistan, Ghana, and Nigeria (Hopkins and Ruiz-Tiben, 1991). Volunteer
VBHWs, providing health education, distributing cloth filters, and carrying out
surveillance, were central to the strategy. It was foreseen that they would
cover more villages in less time than the provision of safe water supplies
required. It was proposed that where Primary Health Care (PHC) workers
already exist, they should be used. But where they do not exist, an
appropriate villager should be designated (who may later be incorporated into
the country‟s PHC programme).
In the ensuing years, the networks of villager volunteers which were
being established proved remarkably effective in carrying out surveillance and
health education (Cairncross et al., 1996). However, the degree of their

63
integration into the PHC programme was a subject of intensive debate. Their
success led some stakeholders in the global campaign to advocate that they
should be used to monitor conditions other than dracunculiasis, such as
immunization status and acute flaccid paralysis as a marker for possible polio
epidemics. As they saw it, the cost of establishing the network was an
investment which should serve health objectives.
The main item in such a network is the salaries of those who supervise
the volunteers and in most countries these are met from the general health
budget and not from funds earmarked for guinea worm eradication. The other
major items are the cost of annual retraining for the volunteers and
occasional gifts- in- kind to motivate them such as T-shirts or the salt and
soap given to the volunteers in South Sudan (Cairncross et al., 2002).
Others doubted the wisdom of integration wary of putting the
eradication effort at the mercy of an often-weak PHC system and dissipating
eradication resources on other activities (Hopkins, 1998). Prior experience of
inappropriate „‟integration of smallpox eradication with measles control and
yaws control in Ghana (Hopkins, 1985a) influenced their thinking.
The danger of over-burdening the volunteers, though a recent field
assessment of integration surveillance in Northern Ghana found no objective
evidence that the surveillance activities were interfering with health workers‟
ability to effectively carry out the work on eradication (Zucker, 1998 cited by
Cairncross et al., 2002). Another source of unease with some justification
was that the collection of surveillance data is useless if, as has occurred in a
number of countries of endemicity, it is not used for any action.

64
However, the integration debate led to a joint statement in favour of
the integrated surveillance by the four principal agencies involved in the
eradication effort, WHO, UNICEF, Global 2000 and WHO Collaborating centre
at Centre for Disease Control (WHO, 1993). But the question of whether to
“integrate, or not to integrate” does not have a universal answer; the answer
can only be worked out on the ground in each specific context. Moreover,
surveillance is only one component of a public health system, and others may
benefit from a degree of integration. There have been substantial synergies
from combining dracunculiasis eradication activities with others in a number
of cases. Both dracunculiasis eradication and the wider health agenda can
benefit as long as the combination is opportune and has been made
judiciously. Examples:
i. The integration surveillance for guinea worm, immunization, yellow
fever, and cerebrospinal meningitis in the 3,743 villages of Northern
region, Ghana (Zucker, 1998 cited by Cairncross et.al., 2002) where
initial difficulties in harmonizing case definitions were ironed out during
the first year of operation.
ii. The mobilization of underused government field staff to supervise the
village health workers in Mopti Region, Mali (Cairncross et al., 1997)
while also supporting their work to promote latrine construction and
better agriculture.
iii. The use of guinea worm surveillance system for implementation and
monitoring of trachoma (a chronic contagious disease of the eye

65
caused by Chlamydia trachomatis) infection elimination activities in
Zinder Region, Niger.
iv. Also in southern Sudan, the use of Guinea worm programmes training
and supervision system for a pilot programme in which village health
volunteer in remote villages were trained to identify and treat fever
and malaria, cough and difficult breathing, and dehydration due to
diarrhoea.
v. The use of the Polio national immunization days to detect 400 new
villages of endemicity in southern Sudan during the first campaign in
this area in 1998 (WHO, 1999a) where the same process in the
following 2 years led to the detection of a further 350 villages of
endemicity.
2.13.2 Geographic Information System
The use of Geographic Information System (GIS) is another area
where dracunculiasis eradication has interacted positively with other public
health activities. The dracunculiasis eradication campaign was the first global
public health initiative to pioneer the use of GIS as a planning tool.
The application of GIS had its origin in the link between water and
health sectors from the beginning of the campaign. Rural water supply
programmes in the countries of endemicity of West Africa are largely based
on boreholes with hand pumps. Rural water projects in a number of countries
supported by the Cooperation Francaise and United Nations Development
Programme were developing computer databases of the boreholes drilled, for
purposes of asset management and geohydrological analysis. These

66
databases naturally included data on the borehole positions and maps could
be drawn from them by using GIS software. From this it was a small step to
using this software to map other items of rural infrastructure such as schools,
health posts, and the presence of VBHWs and also guinea worm surveillance
data. Thus, villages of endemicity and safe water points were plotted on
digitised maps early in the 1990s by UNICEF water sector in most of the
countries of endemicity of Francophone Africa (Clarke et al., 1991). In the
Anglophone countries of endemicity such as Ghana, Nigeria, and Uganda, a
specific mapping exercise was yet to be acquired to enhance dracunculiasis
elimination programme. GIS was not used in Pakistan and India before the
disease was eliminated from these countries although other computer
databases were set up to manage the surveillance data (Cairncross et al.,
2002).
In 1993, the WHO-UNICEF Joint Programme on Data Management and
Mapping, called Health map was established at WHO headquarters in order to
implement and maintain a GIS for the guinea worm eradication programme at
global, national, and local levels. Commercial software was used at
international and national levels to enter, store, and maintain data on over
80, 000 geo-referenced villages in Sub-Saharan Africa, such as village
populations and schools, health, and water supply infrastructure in addition to
the epidemiological information on guinea worm disease.
In 1997, it was felt necessary to develop dedicated software, adapted
to the specific needs of dracunculiasis eradication as well as other public
health initiatives which can be easily used by technical staff at national and

67
sub-national levels in the countries of endemicity. The health mapper
software was therefore developed by the Health Map Unit. It contains a
standardized geo-referenced database of country, regional, district, and sub-
district boundaries with rivers, roads, villages, and water health and social
infrastructure. The system also comprises a user-friendly mapping interface
and a database management facility (WHO, 1999b). The main users have
been involved in the refinement of this software and in several workshops
held to ensure that they can use it to enter, update, and analyse their
epidemiological and programme data and to show the data and analytical
results in map form.
The costs of the development of GIS database and the software to
manage them have largely been borne by International Agencies. The
national staff that maintains them would in any case be required to collate
and analyse surveillance data, so that the opportunity cost to the countries
concerned is very small. The databases have begun to prove their worth. For
example, the requirements to maintain them have proved to be a powerful
means of encouraging programme staff to continue maintaining the status of
villages which, for a lack of dracunculiasis cases would otherwise be dropped
from surveillance.
These databases would also prove their worth in establishing the
completeness of the surveillance arrangements for the certification of
eradication. The International Commission for the Certification of
Dracunculiasis Eradication (ICCDE) has determined that at least 9 out of 12
monthly reports must be received from all villages of endemicity („‟acceptable‟‟

68
surveillance) or all 12 from at least 85% of villages of endemicity (“effective‟‟
surveillance) for the surveillance results to be used for certification purposes
(WHO, 1996a). Functions have been added to the GIS software to permit
these indicators to be shown by village or by administrative division.
The positive experience of using GIS for dracunculiasis eradication
formed the bases on which the same team has subsequently developed GIS
software to support elimination control programmes for other diseases,
particularly leprosy, lymphatic filariasis, and onchocerciasis.
2.13.3 The Certification of Dracunculiasis Eradication
general to:
In 1991, the World Health Assembly (WHA) urged the WHO Director
Immediately initiate country-by-country certification of
elimination so that the certification process can be
completed by the 1990s
In May 1995, the International Commission for the Certification of
Dracunculiasis Eradication (ICCDE) was established to verify and confirm
information from countries claiming the absence of indigenous dracunculiasis.
The Commission is made up of 12 independent public health experts from all
regions of the world (WHO, 1996). The criteria for the certification of
dracunculiasis eradication were developed by WHO in consultation with the
main partners and were given their final revision and endorsement at the first
meeting of the ICCDE held in Geneva, Switzerland, in March 1996. They are
complemented by number of explanatory documents and guidelines (WHO,
1996b and 2000b).

69
All the countries with dracunculiasis transmission after 1980 are
required to maintain active surveillance for at least 3 years after achieving
interruption of transmission. In addition, a country report needs to be
submitted to the ICCDE through WHO, describing the procedures undertaken
and providing evidence of the reliability of the surveillance system and its
ability to detect any case of dracunculiasis, even in the most remote areas of
the country. A panel of specialists has been created and the members have
been assigned to the International Certification Teams (ICTS). The visits of
the ICTS are necessary in all countries of previous endemicity in order to
assess the reliability of the surveillance system in the field and to review and
document the overall process which led to the interruption of transmission.
After its first meeting in March 1996, the ICCDE met again in January
1997, February 1998, and February 2000. International Certification Teams
have visited Iran, Pakistan, Egypt, India and Libya. On the basis of the
recommendations produced by the ICCDE 151 countries and territories have
so far been certified as free of dracunculiasis transmission by WHO (WHO,
1998b and 2000b).
Among these countries, Pakistan and India achieved interruption of
transmission after the beginning of the global eradication campaign in the
1980s. Kenya, Cameroon, and Senegal have also achieved interruption of
transmission, reporting zero case for more than 3 years (WHO, 2003). They
are now in the pre-certification phase during which active surveillance needs
to be maintained for at least 3 consecutive years with no cases reported.
Countries bordering countries of high endemicity like Sudan cannot be

70
certified unless interruption of transmission is also achieved in the cross-
border areas. This means that the pre-certification phase will last longer than
3 years for Kenya and probably Uganda, Ethiopia and Central African Republic
despite the fact that interruption of transmission may have been or may be
achieved in these last three countries during 2001 or 2002.
The ICCDE has been useful not only for the certification process but
also some of its recommendations have focused on critical aspects of the
eradication campaigns, like the surveillance systems and their implication for
the certification criteria or the revision of guidelines and tools for the
production of country reports and the ICTS visits.
For countries approaching the target of elimination at the national
level, vigilance must be maintained and not limited to the formerly known
areas of endemicity. Several types of surveillance activity, for example, the
collection and prompt investigation of rumours and the offering of rewards for
confirmed indigenous cases are needed to complement official notifiability and
specific community-based surveillance and to give wider geographic coverage.
Also at the final phase of the campaign, it is becoming more important to link
the work of the ICCDE to the context of the countries where dracunculiasis is
still endemic, which represent the most difficult areas in which to interrupt
transmission. Nomadism and transhumance are also common in areas of
endemicity. There is a need for innovative strategies to conduct preventive
interventions as well as to maintain active surveillance in these very difficult
areas.

3.1 THE STUDY AREA
71
CHAPTER THREE
MATERIALS AND METHODS
Borno State (Figures 4 and 5) selected for this study lies between
Latitude 11 o and 15 o E and Longitude 10 o and 25 o N. It covers an area of
69,436 square kilometres and is the largest State in Nigeria in terms of land
mass. It is located in the North eastern corner of Nigeria and occupies the
larger part of the Chad Basin while sharing borders with the Republics of
Niger to the North, Chad to the North-East, and Cameroon to the East. Within
the country, its neighbours include Adamawa State to the South, Yobe state
to the West and Gombe State to the South-West. Based on the 1991
provisional census, Borno state has a population of 2, 596, 589 and a
population density of approximately 38 inhabitants per square kilometre.
Borno State has a climate which is hot and dry for a greater part of the
year although the Southern part is cooler and less dry. The wet season
period varies from place to place due to the influence of the various climatic
factors such as the direction of the rain-bearing winds and topography but
generally the rainy season is normally from June to September in the North
and May to October in the south with relative humidity of about 49% and
evaporation of 203mm per year. (Source: Borno State Diary 2004).
The State has two major vegetation zones: Sahel in the North with
severe desert encroachment covering most of the Chad Basin areas; and the
Sudan Savannah in the South which consists of scrubby vegetation

Scale: 1:2,000,000
72
Figure 4: Map of Borno State Showing the Study Local Government
Areas
Source: Nigeria Guinea Worm Eradication Programme 1991

73
Figure 5: Map of Bama and Dikwa Local Government Areas Showing
the Study Villages
Source: Nigeria Guinea Worm Eradication Programme 1991
Dikwa

interspersed with tall tree woodlands.
74
The major ethnic groups comprise Kanuri, Shuwa Arabs, Babur/Bura,
Gwoza, and Gemargu. Also spread across the State are the Hausa and
Fulani. The State is essentially an agrarian society but is making efforts to
progress into agro-industrial economy.
Borno state was chosen because it was one of the states still reporting
cases at the time of this study and where intervention strategies were in
place. All the 148 endemic villages for dracunculiasis from the 9 Local
Government areas of the State that had ever reported cases at one time or
the other between 1995 and June 2003 were covered (Figures 4 and 5). The
year, 1995, was chosen because it was the first target date set by African
Health ministers(1988) and WHO(1991) for the eradication of guinea worm
disease (Dracunculiasis) from the face of the earth that was missed.
3.2 SAMPLING PERIODS AND PROCEDURE
The study was carried out for a period of 12 months (July1, 2003- June
30, 2004). The period between July1 of the previous year to June 30 of the
following year is the only recommended reporting period defined by Nigeria
Guinea Worm Eradication Programme (NIGEP 1990/91). During this period, a
total of 310,092 individuals were examined from 148 formerly and currently
endemic villages/communities of the State. The work was divided into 5
parts.
The first part involved active surveillance for the presence of active
guinea worm cases. The second part dwelt on passive surveillance of

75
recorded cases of guinea worm from 1995 – 2007. The third involved
administration of questionnaire and conduction of interviews. This was done
concurrently with active surveillance. The fourth part of the research handled
the taking stock of all the available intervention strategies/ materials, their
functional states and cost implication. The fifth segment centred on field and
laboratory studies of the vector density/abundance and infectivity and the
effect of Abate larvicide on the vector density.
3.2.1 Surveillance
This involved the monthly collection of data from the physical
examination of diagnosed cases of guinea worm infection for the purpose of
identifying high-risk groups in the population and understanding modes of
transmission of the disease. Both passive and active forms of surveillance
were utilized.
3.2.2 Passive Surveillance
This is also referred to as secondary data and it involved the analysis
of monthly and annually accumulated data on guinea worm disease that
filtered up through the established reporting channels involving disease
control agents. Secondary data was obtained from the NIGEP/Global 2000
annual statistical summaries obtained from the Global 2000 national office
located in Jos, Plateau state. The review of cases for the stipulated years for
Nigeria; Northeast zone, and Borno state were collected and compiled.

3.2.3 Mobilization of Participants and Active Surveillance
76
This is also termed primary data and it focused on the community as
well as the demographic characteristics and behaviours of the population. It
was used to confirm passive surveillance data. There was close collaboration
with NIGEP/Global 2000 trained Village-Based-Health Worker (VBHWs),
resident in these villages under survey. A total of 147,120 females and
162,972 males from 136,892 households in the 148 villages were examined
for the presence of dracunculiasis. Assistants were also recruited into the
research team from the locality to help in the interpretation and explanation
of the research mission and to conduct the team round the locality. Such a
presence in the team, it was noted, won for the research team an almost total
cooperation of villagers who appeared reassured and more convinced of the
importance of the exercise.
On getting to a particular village in this study, the cooperation of the
Village Head/Chief and also that of the VBHW was sought. This was done with
the aid of letters of introduction from the University of Jos and also from the
Global 2000 Northeast zonal coordinator.
Active searches were conducted in all the households in all the
formerly and currently endemic villages. All persons in each household
present were examined. Diagnosis was based on finding the characteristic
protruding D. medinensis from the body or presence of at least one typical
ulcer with guinea worm. A case of dracunculiasis is defined as any individual
exhibiting or having a history of a skin lesion with the emergence of a guinea
worm (WHO 1996b). A recent history (within one year) of a skin lesion with

77
the emergence of a guinea worm is the only time frame which must be used
in surveillance programmes (WHO, 1996b).
Case searches were done monthly and each case encountered was
recorded according to month, sex, age, occupational status and source of
drinking water of the individual. The anatomical site of the lesions was also
noted. Taken into account were also whether the cases were contained or
not, indigenous or imported, and any imported case was traced to its origin.
Generally, all the individuals examined were grouped according to sex, age,
occupational status, month and their sources of drinking water.
Lesions of dracunculiasis encountered in this study were grouped into
five types based entirely on the perception of each lesion-type as a separate
pathological entity of guinea worm disease, and as distinct in form of
manifestation from other related lesions.
i. Ulcer - was taken as a shallow open or closed sore which had
formed from the bursting of a blister.
ii. Emergent-worm - this was when a portion of worm slightly
protruded from an open or closed ulcer or when emergent end of a
worm came out long enough to be knotted with a thread, rolled on a
twig, match or broomstick or even left dangling from point of
emergence.
iii. Abscess - was any painful pyogenic swelling of any part of the body
including arthritic swelling of a joint among individuals in guinea
worm endemic communities.

78
iv. Purulent lesion - was a secondary lesion in form of any pus-
contained open sore which may or may not have ulcerated in a
chronic form or visible portion of an emergent worm.
v. Deformity - was also taken as a complication in form of deep, ugly
or morbid cicatrix (pronounced mark or remains of a healed ulcer);
paralysis whose origin or development was linked to history of guinea
worm infection as narrated by patients in answers to a systematic or
prognostic questionnaire.
To ensure an orderly presentation, this clinical study was recorded
under a number of parameters. These include, the anatomical sites of the
body in which lesions manifested, monthly prevalence or variation of the
cases, multiple infections, prevalence and distribution of lesions among sex,
age, occupation and other groups. The duration of the lesions especially the
period between their onset and disappearance were also noted.
Clinical examination as undertaken in this study involved the physical
inspection of the entire body for guinea worm lesions. Individuals in a
household under observation were called in turns into privacy away from
publicity and asked to show lesions (sore, swellings, and ulcers) in parts of
their bodies. The sores and ulcers without guinea worm protruding were only
considered if it was ascertained that the worm actually came out of them.
Swellings were monitored to confirm that guinea worm eventually emerged
from them before such swellings/cases were recorded. Lesions in exposed
parts of the body were easily noticed and examined.

79
Prior to this, members of each community were together addressed
briefly on the purpose of the mission. With the awareness already created (it
seemed) by the Nigeria Guinea Worm Eradication Taskforce Agencies in the
State through health education campaigns, most of the individuals examined
had no difficulty in understanding our mission. It was observed that some
members of a household or community were away on the farms, markets and
other places at certain times of investigation. Such absence was usually
unavoidable so; the communities/villages to be examined were informed far
ahead of time. Some had to be followed to their farms to be examined.
Usually, investigations on market days, working and school hours were
avoided.
3.2.4 Taking Stock of Intervention Strategies
This was done to identify and ascertain the various types of
interventions put in place and their functional status. It was done alongside
with the active surveillance, questionnaire administration and interviews. On
getting to any of the study villages and after the search for active guinea
worm cases had been completed, questions, as stated in the following
subheadings/sub-subsections, were asked.
Health Education Questionnaire
Under Health Education in the questionnaire, questions as contained in
section 3.2.5A were asked. The responses given by the respondents gave
clues as to whether health education was well covered in that particular

80
village or not. Questions were also asked concerning the group of individuals
or organisations that gave such health talks.
New Water Supply
The sources of drinking water in such villages were visited and
physically inspected to know their functional states. If there was any new
water source like hand-dug-wells (HDW), borehole (BH), hand pumps (HP),
such was recorded against new water supply and the names of donor
agencies and the year of donation were all recorded.
Use of Filters
As regards the use of monofilament nylon filters (and straw filters),
each household was inspected for the presence of at least one functional
filter. This was done by physically inspecting the kitchens where the
household‟s drinking waters were normally kept and one of the women asked
to show and demonstrate how the filter was being used to filter the
household‟s drinking water. Nomads and “Almajiris” were requested to show
their straw/pipe filters which they were supposed to hang around their necks
and used in drinking water as they moved about from one place to another.
Both types of filters were closely examined for presence of holes, neatness
and some sign that they were being made use of. The demonstration of the
use of filters was also done to confirm if health education had actually been
carried out in these endemic villages.

Abate Application
81
Questions were asked about Abate application to their ponds for the
2003/2004 and whether it had ever been applied. The number of times the
application was done and the number of ponds it was applied to were all
recorded.
Case Containment Management Strategies (CCS)
As regards case containment and management strategy, the
researcher checked for the presence of at least one village-based health
worker in each of the study villages. Where there was a Case Containment
Centre (CCC), it was also noted. The VBHWs‟ First Aid boxes were
inspected/examined for the presence of antiseptics, bandages, analgesics,
tetanus toxoid vaccine, cotton wool. The individuals with active cases were
also physically examined to see if their lesions/ulcers were properly cleaned
and bandaged. They were also asked if they had been warned not to enter
water bodies in order not to contaminate them.
Reward Strategy
The reward strategy, which was employed as an incentive to make
individuals report cases promptly to the VBHWs, was confirmed by
interviewing the individuals with active cases encountered during the study
period. Where the respondents were too young to answer these questions,
their parents, relations, seniors, were asked to respond.

82
3.2.5 Questionnaire and Interviews
The questionnaire was prepared with a good sampling frame adopted
from WHO (1989) and it was designed to meet the set objectives of this
study. They were administered jointly with interviews and this was done to
investigate the knowledge (awareness), attitudes, practices and beliefs, of the
individuals concerning dracunculiasis. It was also done to assess the level of
disease ascertainment, the status of the various intervention strategies put in
place and the level of acceptance of such strategies by the individuals. The
format was divided into five parts each of which stood for the different
ongoing interventions in the state viz: health education, filter usage, Abate
application, new water supply and case containment/management strategy.
The questionnaire were administered to all categories of respondents and on
members of households surveyed. Health workers, school teachers,
community or public health workers and VBHWs were all interviewed.
Questionnaires were therefore designed to obtain desired information from
multiple sources. A first-hand source was from individual, personal and house
hold experience and the other from a generalized or sum-up view of the
disease in a village. This was necessary to corroborate and validate
information obtained.
In this study, the interview was carried out on a household-to-
household basis. One to two members from each household including the
head of the household were interviewed. It was only those who could express
themselves in a household that were interviewed. Information obtained
during the interview was elicited directly from the respondent about himself

83
or from a member of the household on behalf of the respondent. Answers to
questions were given by each respondent out of the earshot of other
members of the household. This was to avoid parroting of response or
repetition of other respondents‟ words and to allow for the proper assessment
of individual perception and knowledge of the disease and its interventions.
In households with only one eligible respondent, answers were provided
publicly in the presence of other members of the household. In this way,
interview was conducted on monthly visits and jointly done with clinical
survey. Individuals were asked of their knowledge of the disease, its
transmission and interventions as follows:
A. Health Education
The knowledge about the disease, how one gets infected and how it is
spread. The first time the person knew about the cause and spread of the
disease (year), how the spread of the disease could be stopped, the
treatment of the victims of the disease- local herbs or orthodox- whether
there were still any superstitions/taboos about the disease in his/her village
and if yes, such were clearly stated.
B. Use of Filter – whether the individual knew what a filter was and how
it was used.
ii. Whether he/she had any filter at that particular time in his/her
house and also used it to filter water.
iii. How often the individual used the filter; if it was always, sometimes
or never.

84
iv. How long he/she had been using filters and if there were any
constraints in the use of filters and what they were.
C. Abate (Temephos) Application
Questions on this aspect included:
i. If the individual knew what Abate (Temephos) was and what it was
being used for.
ii. When Abate was first applied in his/her village (year) and when it
was last applied.
iii. If he/she had any knowledge about why Abate was applied to the
waters/ponds in the village.
iv. If the villagers accepted Abate treatment of the ponds and the
reasons for accepting or not accepting it.
D. Water Supply: The source of water supply in the village- whether
pond, hand-dug well, bore hole or stream.
i. Whether the source of water supply was serviceable throughout the
year.
ii. If the source of water supply was functional at that moment.
iii. The distance of the source of water supply from the village (km)
iv. What the villagers were doing about improving water sources.
v. Whether there was a new water supply in the village. If yes, the
organization that provided it and the time (year) it was provided was
so stated.

85
E. Case Containment/Management Strategy (CCS)
i. The knowledge of CCS, how it was done and by whom
ii. The perception/impression about CCS
iii. Whether there was a CC centre in the village
iv. If there was any VBHW in the village
v. If the individual had ever suffered from guinea worm disease before
and how he/she was treated – traditionally or orthodox.
vi. The last time any member of his/her family suffered from guinea
worm disease.
Questions were generally asked in a relaxed and friendly atmosphere
to avoid uncoordinated reply and to dissuade respondents from giving reply
intended to please the interviewer. Respondents were not coerced on
providing answers to questions they found difficult to answer. Such questions
were instead re-framed without altering the basic meaning of the question for
ease of understanding any reply. Different interpreters were used for the
different ethnic groups in the study villages. Any distortion in message
through interpretation was carefully noted from nature of reply. Prior to this,
interpreters were advised to be careful in transmitting the exact message. In
order to keep up respondent‟s willingness and memory to communicate,
interviewers were cautioned against show of haste, anxiety, boredom or
disgust during interviews. In the same vein, efforts were made to avoid
exposing respondents to lengthy questions or interviews.
For proper administration of questionnaire, interview, accuracy of field
observation and precision of recording, interviewers were closely supervised

86
and cautioned. To avoid the absence of household members during visits,
message was sent in advance through community head, spokesmen, VBHWs
on the interview schedule. Care was also taken to avoid visits on market days,
farm or working and school hours.
To avoid damage to questionnaire forms due to rain or otherwise, they
were wrapped in big polythene bags and conveyed in a metal box in the field
and stored in marked containers.
3.2.6 Abate (Temephos) Application
This aspect of the study was carried out jointly by the researcher and
the NIGEP/Global 2000 team. According to WHO (1989; 1990a) a popular
transmission site, normally the water sources without barriers and in villages
where new cases were reported were given higher priority. These were first
identified and their volumes of water measured (Muller 1979; Nwosu et al.,
1982; WHO 1989). The length, depth and width of ponds were measured by
using a measuring tape and metre stick.
A circular pond was assumed to have a volume equal to the
relationship given as follows:
Volume= Area x Average depth
Where Area = C 2 /4 Pi and
Pi= 3.14
C= circumference of the pond (WHO, 1989).
A fairly accurate estimate of the volume of an irregular source/pond
was made by measuring out transects on a drawn map of the pond. The

87
width, length and depth were then measured out along these transects. The
volume was then determined by the relationship as follows:
Vol. = Average width x Average depth x Average length
1mg/litre concentration of Abate (50%Ec) was then applied to 500m 3
of water (or 2mls of Abate 50% Ec per cubic metre of water, properly mixed
with sufficient water in a vessel and sprinkled uniformly over the
impoundment). The essence of this application was to reduce the number of
cyclops, the vector of guinea worm disease, from their drinking water sources
thereby breaking transmission of the disease.
3.2.7 Determination of the Density and Infectivity Rate of Cyclops
Population in Borno State During 2003/2004
This was carried out to determine the population density and infection
rates of cyclops in the different water sources used in the communities. Pre-
treatment water samples were taken from 15 sources (ponds) and 5 Hand-
dug wells from the 9 sampled Local Government Areas. The Hand-dug wells
served as the control. The selected ponds had water depth of at least 1
metre while the wells had up to 3 metres. Water samples were collected
from each site on monthly intervals over a period of 6 months (July-December
2003). To collect copepods, the following steps were employed.
Water samples were normally taken in the mornings or evenings when
the cyclopoid copepods had moved to the surface of the water.
A large mouthed bucket (5 litre capacity) was used to take water
samples. Five (25 litres) samples were taken at the same time of the day at
different points around the source.

88
The bucket was lowered just below the surface of the water and
allowed to fill quickly, thus drawing in the rapidly swimming cyclops.
Organisms were concentrated by pouring the water samples through a
standard nylon cloth filter (100 micron mesh; the ones used by endemic
communities to filter water).
These were then backwashed into Petri dishes and concentrated in
2mls of water and transferred into Petri dishes containing 1.12% Hydrochloric
acid in saline (1.8% NaCl), (Muller, 1971). This solution killed the cyclopoid
copepods within 10 minutes and also activated every guinea worm larva
inside them which were then counted. Infection rate was determined by the
number of infected cyclops counted per litre of water (Udonsi, 1987b).
Sorting the Collections
Live collections contain various organisms in addition to copepods.
Copepods were easily distinguished by their unique and prominent „oar-
footed” body, pear-shaped, white in colour and one red eye, naupliar eye,
located at the anterior dorsal part of the head which is not markedly
demarcated from the rest of the body (Muller, 1971, WHO 1989) and by their
characteristic swimming motion (Jerky, Sudden movements). The adult
females had egg pouches on their sides. They measured about 1 – 3mm in
length. Only the adult cyclops were counted. The volume of water filtered,
the village names and the date of collections were recorded. Then the
density of cyclops per litre of water from each pond was obtained by dividing
the total number of cyclops in each 25 litres by 25, while infectivity rate per

89
litre of water was obtained by dividing the total number of infected cyclops in
each 25 litres of water by 25.
Dracunculus larvae were differentiated from carnallinid larvae which
also use copepods as their intermediate hosts by the larger bucal capsule and
trifid tail of the latter which D. medinensis larvae lacked.
3.2.8 Impact of Abate Application to Water Bodies in Borno
State (July – October 2003)
This evaluation was carried out to assess the effect or impact of Abate
(Temephos) larvicide on cyclopoid copepods, the intermediate hosts of guinea
worm. The study lasted for only 4 months, (July – October, 2003);
corresponding to the period that Abate was applied to the water sources.
WHO (1989) stipulated that application of Abate should commence at least
one month before the peak of the transmission period or season. The peak
of the transmission period or season in the Sahelian region which includes
Borno State has been found to be June through October (Cairncross et al.
2002, Adeiyongo, 2006). The procedure for evaluation of Abate treatment as
contained in WHO (1989) working document was adopted. The research
team was pre-informed about the villages to be treated by Guinea worm
Eradication personnel charged with the responsibility of treating sources of
drinking water with Abate larvicide, 2 – 3 days before the application was
carried out. Pre-treatment cyclops populations were sampled by our team
before the application of Abate and then compared with the cyclops
populations sampled 2, and 4 weeks after treatment.

90
Six ponds from 6 villages in 6 Local Government Areas of Borno State
were evaluated. The procedure employed as discussed in 3.2.7 for sampling
of cyclops populations was also adopted here. Cyclops were then backwashed
into Petri dishes and concentrated into smaller bottles containing 10%
formalin. Three glass sample bottles were used for each application/pond,
one for the pre-application samples and one each for the 2 and 4 weeks post
application samples.
The density of cyclops in each pond was obtained by direct counting
using a magnifying glass or a dissecting microscope. The density of cyclops
per litre of water was obtained by dividing the total number of cyclops
counted in each 25 litres of water by 25.
3.2.9 The Cost Implication of the Intervention Strategies in Borno
State from 1995 – 2004
These figures were obtained from various task force offices of the
Nigeria Guinea worm Eradication Programme at the LGA, State, Federal levels
and also from Global 2000 North-east zonal office. This included monies
spent on provision of new water supplies (Boreholes and Hand-dug wells),
purchase of Abate larvicide (Temephos) and its application equipment; cost of
filters distributed during the said period; cost of vehicles (motorcycles and
trucks and fuelling) drugs given to patients to alleviate the pains from guinea
worm infection (antiseptics, analgesics, bandages, tetanus toxoid, antibiotics
and miscellaneous); cost of production of Health Education materials (posters,
pamphlets, Radio and Television jingles, and megaphone). Others included
allowances paid to VBHWs and field supervisors; cash reward paid to those

91
who reported cases to the VBHWs. All these were compiled to obtain the
total cost of the eradication programme in Borno State during the said period.

92
CHAPTER FOUR
RESULTS
4.1 DRACUNCULIASIS IN NIGERIA, NORTH EAST ZONE, AND
BORNO STATE FROM 1995 - 2007
Results obtained showed that in Nigeria, during the period under
review, cases of dracunculiasis reduced from 16,374 in 1995 to 12,282 in
1996, rose to 13,417 in 1998 and then declined to 16 in 2006 and rose again
to 73 in 2007 (Figure 6). Similarly in the North East zone, cases of the
disease declined from 2,794 in 1995 to 2,314 in 1996, rose to 4,077 in 1998
and then dropped to 0 in 2007 (Figure 7). However, in Borno State, cases
rose from 587 in 1995 to 2,053 in 1998 before dropping to 0 in 2007 (Figure
8). The number of endemic villages in Nigeria stood at 1,846 in 1995,
dropped to 1,135 in 1997 then rose again to 1,432 in 1999 and declined to 3
in 2007.In the North East zone, there were 289 endemic villages in 1995 and
this dropped to 0 in 2007. The number of endemic villages for Borno State
were 48 in 1995, rose to 125 in 1999 and then dropped to 0 in 2007 (Table
1). The number of cases reported to have been contained during this period
is also shown on Table 1.
4.2 STATUS AND DISTRIBUTION OF GUINEA WORM CASES IN
BORNO STATE
After an extensive study in the State, it was observed that the disease
was still endemic in 5 Local Government Areas as against 9 former endemic
areas, although the level of endemicity varied from one local government to

Number of Reported Cases
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
16,374
12,282
12,590
13,419 13,447
93
7,897
5,355
3,825
1,459
495
120 16 73
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Years
Figure 6: Reported Cases of Drancunculiasis in Nigeria (1995-2007)
Source: Nigeria Guinea worm Eradication Programme Annual Statistical Data
(2007)

Number of Reported Cases
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
2,794
2,314
2,922
4,077
2,658
94
902
378
258
41 3 0 0 0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure 7: Reported Cases of Dracunculiasis in North East Zone
(1995-2007)
Source: Nigeria Guinea worm Eradication Programme Annual Statistical Data
(2007)
Years

Number of Reported Cases
2500
2000
1500
1000
500
0
587 594
885
2,053
1,094
95
395
231
195
34
3 0 0 0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Years
Figure 8: Reported Cases of Dracunculiasis in Borno State (1995-
2007)
Source: Nigeria Guinea worm Eradication Programme Annual Statistical Data
(2007)

96
Table 1: Reported Cases of Dracunculiasis and the Number
Contained in the Various Endemic Villages of Borno State
(1995-2007)
Year
No. of
Endemic
LGAs
No. of
Endemic
villages
No. of
Cases
No. / (%)
Contained
1995 6 48 587 -
1996 6 52 594 486(81.8)
1997 7 55 844 520(61.6)
1998 7 95 2,053 1,053(51.3)
1999 8 125 1,094 623(56.9)
2000 7 108 395 269(68.1)
2001 6 66 231 160(62.3)
2002 5 28 195 136(69.7)
2003 5 12 34 26(76.5)
2004 1 1 3 3(100)
2005 0 0 0 0
2006 0 0 0 0
2007 0 0 0 0
Source: Nigeria Guinea worm Eradication Programme Statistical Summary,
2007

97
another. It was also observed that only 12 out of the 148 villages studied
were still reporting cases (Table 2).
4.3 PREVALENCE OF DRACUNCULISIS IN BORNO STATE
During the course of this study, between July 1, 2003 and June 30,
2004, 310,092 persons from 148 villages in 9 Local Government Areas of
Borno State were examined for the presence of active guinea worm cases;
34(0.01%) persons were found to be infected with the disease. Magumeri
Local Government Area had the highest infection rate of 1(0.77%) out of the
130 people examined, followed by Damboa with 3(0.04%) cases out of 7,750.
Dikwa had 11(0.01%) out of 10,538; Konduga 2(0.02%) out of 12,883, while
Bama recorded 17(0.01%) out of 264,931. Marte, Mafa, Gwoza and
Monguno Local Government Areas recorded zero cases (Table 2).
Infection rates according to villages showed that Ngozoduwa had the
highest infection rate of 7(2.0%) out of 350 persons examined; this was
followed by Ka‟ajiya with 1(0.77%) out of 130; Mianti had 1(0.67%) out of
150; Masa 11(0.37%) out of 3,000; Bugumari 1(0.33%) out of 3,000; Bula
Manzue 1(0.30%) out of 330 and Ngotori 2(0.17%) out of 1,200. The least
infection rate was observed in Kukkuruk with 1(0.03%) out of 3000 persons
(Table 3).
Out of the 34 cases encountered in the study, 26 were being contained
giving a percentage containment of 76.47 (Table 2).

Table 2: Current Cases of Dracunculiasis and the Number
Contained During 2003/2004 Survey in Borno State
LGA No. of
villages
formerly
endemic
No. of
villages
still
endemic
98
No. of
HHs
Est.
Popn.
No. (%)
of cases
No. (%)
contained
Bama 92 06 131,259 264,931 17(0.01) 13(76.05)
Damboa 06 02 880 7,750 03(0.04) 3(100)
Dikwa 14 1 1,417 10,538 11(0.10) 8(72.7)
Gwoza 6 0 457 4,538 0(0) 0(0)
Konduga 13 2 1,847 12,883 2(0.02) 2(100)
Mafa 6 0 350 2,580 0(0) 0(0)
Magumeri 1 1 21 130 1(0.70) 0(0)
Marte 2 0 175 1,850 0(0) 0(0)
Monguno 3 0 486 4,860 0(0) 0(0)
Total 148 12 136,892 310,092 34(0.01) 26(76.5)
Key:
HHs = Households
Est. Popn. = Estimated population

Table 3: Dracunculiasis as Observed in Currently Endemic
Villages of Borno State (2003/2004 Survey).
Local
Government Area
99
Name of Village Estimated
population
No. (%)
Infection
Bama Walasa Kura 3,200 3,(0.09)
Bula Manzue 330 1(0.30)
Nguzoduwa 350 7(2.00)
Bula Melebe 2,008 2(0.10)
Bodimari 3,000 3(0.10)
Bugurmari 3,000 1(0.33)
Damboa Mafi 950
1(0.11)
Ngotori 1,200 2(0.17)
Dikwa Masa 3,000 11(0.03)
Konduga Kukkuruk 3,000 1(0.03)
Mianti 150 1(0.67)
Magumeri Ka‟ajiya 130 1(0.77)
Total 12 17,618 34(0.20)

100
4.4 SEX SND AGE RELATED DISTRIBUTION OF DRACUNCULIASIS
IN THE DTUDY COMMUNITIES
The distribution of the disease among the sexes was observed in the
study communities. Twenty-five (0.02%) out of the 162,972 males and
9(0.01%) out of the 147,120 females examined had guinea worm cases. This
result has demonstrated that more males than females were infected. This
was the case in most of the endemic villages studied. The chi-square (x²)
analysis of results revealed that there was no significant difference in
infection rates between the sexes (P>0.05).
In age related distribution of the disease, it was observed that
individuals within the age group 11-40 years were more infected. The lowest
infection rate was recorded in individuals that were above 40 years of age
with no cases recorded among the females (Table 4). Results of Chi square
(X 2 ) analysis showed that there was no significant difference (P>0.05) in the
infection rates among the different age groups.
4.5 PREVALENCE OF GUINEA WORM DISEASE IN RELATION TO
SOURCES OF DRINKING WATER
Table 5 shows the infection rate in relation to the different sources of
water. The result obtained has revealed that the highest number of cases
was observed among the most frequent users of pond water. Out of the
265,003 persons examined, 26(0.01%) were infected; also out of the 28,776
persons depending on both hand-dug wells and pond water, 5(0.02%) were
infected. Likewise 3(0.02) from 16,313 of those depending on borehole and
pond were infected. The one-sample T-test analysis showed that there was
no significant difference (P>0.05) in the number of infected persons in
relation to the sources of drinking water. No pipe borne water was found in
the study area. The few number of streams encountered were not made use
of by the villagers for domestic purposes.

101
Table 4: Distribution of Dracunculiasis in the Different Age
Groups of Both Sexes in 2003/2004.
Age Group
(Years)
No.
Examined
Males Females
No. (%)
Infected
No.
Examined
No. (%)
Infected
00 – 10 38,023 4(0.01) 26,302 2(0.01)
11 – 20 37,353 6(0.07) 34,201 2(0.01)
21 – 30 34,716 7(0.02) 30,522 3(0.01)
31 – 40 22,814 5(0.02) 22,641 2(0.01)
41 – 50 18,193 1(0.01) 17,001 0(0.00)
51+ 11,873 2(0.02) 16,453 0(0.00)
TOTAL 162,972 25(0.02) 147,120 9(0.01)

102
Table 5: Prevalence of Dracunculiasis in Relation to Sources of
Water in Borno State
Source of Water Number Examined Number/ (%)
Infected
Borehole/Pond 16,313 3(0.02)
Pipe Borne - -
Stream - -
Ponds 265,003 26(0.01)
Hand-dug Wells/Ponds 28,776 5(0.02)
Others - -
TOTAL 310,092 34(0.01)

103
4.6 PREVALENCE OF GUINEA WORM INFECTION IN THE
DIFFERENT OCCUPATIONAL GROUPS
The results obtained during the course of this study showed that
nomads had the highest risk of infection followed by farmers. Out of 5,123
nomads examined, 2(0.04%) were infected while 17(0.02%) out of 97,571
farmers were also infected; that is, half of the 34 cases reported were
farmers. These were followed by homemakers who had 7(0.02%) infected
persons out of the 85,426 examined; students recorded 5(0.01%) out of
40,692, traders had 2(0.01%) from 16,433 while pre-school age recorded
1(0.004%) from 23,720 persons. No case was observed in civil servants and
Almajiris. The one-sample T-test analysis showed that there was no
significant difference (P>0.05) in infection rate among the different
occupational groups (Table 6).
4.7 INDIGENOUS AND IMPORTED CASES ENCOUNTERED IN THE
STUDY AREA
Out of the 34 cases encountered during the study, only one was
imported, giving a 2.94% importation rate. The remaining 33(97.06%) were
all indigenous (Table 7).
4.8 MONTHLY VARIATION OF DRACUNCULIASIS IN BORNO STATE
The study which lasted for a period of 12 months showed that cases
were observed during the months of July through November 2003 only. From
December, 2003 to June 30, 2004, no cases were observed. The highest

104
Table 6: Prevalence of Guinea Worm Infection in the Different
Occupational Groups
Occupation
Pre-school age
Students
Civil servants
Home makers
Farmers
Traders
Nomads
Almajiris
Number Examined
23,720
40,692
16,215
85,426
97,571
16,433
5,123
24,912
No (%) infected
1(0.004)
5(0.01)
0(0.00)
7(0.01)
17(0.02)
2(0.01)
2(0.04)
0(0.00)
Total 310,092 34(0.01)

105
Table 7: Indigenous and Imported Cases of Dracunculiasis
Encountered in Borno State during 2003/2004.
LGA
No. of
endemic
villages
No. of
cases
No. of
indigeno
us cases
No. of
imported
cases
%
imported
cases
Bama 06 17 17 - 0
Danboa 02 3 3 0 0
Dikwa 01 11 10 1 9.1
Gwoza 00 - - - -
Konduga 02 2 2 0 0
Mafa 00 - - - -
Magumeri 01 1 1 0 0
Marte 00 - - - -
Monguno 00 - - - -
TOTAL 12 34 33 1 2.94

106
number of cases occurred in September 12(35.30%) followed by August with
10(29.41%); (Figure 9).
4.9 ANATOMICAL DISTRIBUTION AND DEGREE OF DISABILITY OF
THE AFFECTED INDIVIDUALS
The distribution of dracunculiasis lesions on the patients‟ different parts
of the body was also considered during the course of the study. The results
obtained showed that all (100%) the cases encountered occurred on the
lower limbs (legs and feet). There was also no case of multiple infections.
The most obvious anatomical defects caused by the disease were
damages on the tissues which caused much pain which led to disability.
Three (8.8%) persons out of the 34 cases encountered were incapacitated
(Plate 1); one each was encountered in Kashimiri, Ngozoduwa (Bama LGA)
and Masa village (Dikwa LGA). The remaining 31(91.2%) affected individuals
were still able to carry out their farm work after their ulcers were cleaned and
bandaged.
The complications of Dracunculiasis encountered during the course of
this study include prodromal and cryptic lesions, cicatrix and cellulites.
Another observation was whitish thread of a guinea worm body or its head
protruding from most of the ulcers. The only cases recorded as positive were
the ones which guinea worm actually emerged from. The duration of a lesion
ranged from 2-3 weeks.

No. of Cases
14
12
10
8
6
4
2
0
July
7
August
10
September
12
October
3
November
107
2
December
0 0 0 0 0 0 0
January
Months
February
Figure 9: Monthly Variation of Dracunculiasis in Borno State
(2003/2004)
March
April
May
June

108
Plate I: Ulcer of an Infected Leg Revealing Emerging Guinea
Worm at Masa Village (Dikwa LGA)

109
4.10 THE STATUS OF INTERVENTION STRATEGIES IN BORNO
STATE
Table 8 gives a comprehensive list of all the intervention strategies put
in place in the 9 endemic local government areas of the State.
A critical evaluation of the guinea worm eradication intervention
strategies put in place in Borno State revealed that a Borno State plan of
action which was adopted from the National Plan which also was in line with
the African regional strategy was being carefully implemented from 1988.
The procedure involved an integrated approach (Ransome-Kuti, 1991), with
emphasis on the prevention of guinea worm transmission by creating a barrier
between the worm and water sources especially the need for patients to
avoid contact with surface sources of drinking water, the provision of safe
water supply and the management of cases (NIGEP Guidelines 1993).
International, government and non-governmental and voluntary
agencies and associations which joined the fight against guinea worm disease
in the study areas included UNICEF, USAID, JICA, CIDA, DFRRI,
UNDP/WORLD BANK, EEC, ODA, and The Carter Centre (= Global 2000) as
well as the Borno State and local government task forces on guinea worm
eradication. They were able to do this through the use of posters, t-shirts,
guinea worm cloth, flip charts, educational session by local authority, radio
jingles, Television/video/cinema, schools, comic books (Yellow books),
churches, mosques, market strategy, theatre/drama, and “worm weeks”.

Table 8: Status of Interventions and Natural Sources of Water in Endemic Villages of Borno State.
LGA No. of
currently
Endemic
Villages
HE (%) VBHWs
(%)
110
FIL (%) Aba (%) No. of
HDWs
No. of
BHs
No. of
CCCs
Natural
Sources of
Water
Ponds Stream
Bama 06 100 100 100 100 49 4 2 Ponds -
Damboa 02 100 100 100 100 02 - - Ponds -
Dikwa 01 100 100 100 100 03 1 1 Ponds -
Gwoza 00 100 100 100 100 - - - Ponds -
Konduga 02 100 100 100 100 08 - 1 Ponds -
Mafa 00 100 100 100 100 02 - - Ponds -
Magumeri 01 100 100 100 100 0 - 1 Ponds -
Marte 00 100 100 100 100 01 - - Ponds -
Monguno 00 100 100 100 100 - - - Ponds -
Total 12 100 100 100 100 65 05 05
Key:
HE = Health Education BH = Borehole
VBHW = Village Based Health Worker Aba = Abate
CCC = Case Containment Centre HDW = Hand-Dug-Well
Fil = Filter

4.10.1 Health Education (HE)
111
The result from the study area showed that the level of awareness
created through Health Education was very commendable. All the affected
villages received adequate Health Education (Table 9 Plate 2). This was
carried out by NIGEP/Global 2000 field staff and the trained Village-Based-
Health-Workers (VBHWs), village heads, teachers residing in the various
endemic villages. The endemic study communities understood what the
disease was and how one got infected with the disease and also spread it.
The need for infected persons to avoid contact with surface sources of
water in order to stop their contamination with larvae was also understood.
They reported any case of guinea worm promptly to the VBHWs in order for
them to be managed and contained. Members of affected communities were
educated on the use of filter to filter all their drinking water in order to trap
infected cyclops that might be in them. There were community mobilization
activities still going on to create public awareness and enlist active community
participation and involvement in all stages of programme planning,
implementation, monitoring and education.
4.10.2 Filter Distribution and Usage
The result of this study showed that all (100%) the 136,892
households examined in the follow-up communities were provided with
functional monofilament nylon filters to enable them filter their water.
Nomads and „Almajiris‟ were equally given straw/pipe filters which have a
string at one end to enable them hang them around their necks (Plate 4).

112
Table 9: Evidence of Health Education in the Various Endemic
Villages of Borno State.
LGA No. of endemic No. of villages % of villages
villages receiving HE receiving HE
Bama 92 92 100
Damboa 06 06 100
Dikwa 14 14 100
Gwoza 06 06 100
Konduga 18 18 100
Mafa 06 06 100
Magumeri 01 01 100
Marte 02 02 100
Monguno 03 03 100
TOTAL 148 148 100
KEY:
HE= Health Education

113
Plate II: Nomads and Farmers Receiving Health Education on the
Field.

114
Damaged filters were replaced promptly with monofilament nylon
filters. Twenty four thousand five hundred and thirty nine monofilament nylon
filters and 390 straw/pipe filters were distributed/replaced to affected
communities between July 1, 2003 and June 30, 2004. The distribution list is
shown in Table 10.
Gwoza, Marte and Monguno LGAs did not receive any filters during the
said period. This was not unconnected with the fact that these LGAs had not
reported any case for the past 2 years. It was observed on close examination
that members of these communities actually made use of the filters, (Plates 3
and 4).
4.10.3 New Water Supply
Tables 11, 12 and 13 show the proportion of villages where a new
hand-dug-well or a borehole has been sunk/drilled since the beginning of the
Eradication Programme. Forty-seven point three percent (47.3%) of the 148
endemic villages had received at least one new safe water source.
Five (5) boreholes were drilled; 4 in Bama and 1 in Dikwa LGAs but only 3
were actually functional at the time of the research even though the services
were intermittent.
There were also 65 hand-dug-wells recorded by the researcher as
being provided throughout the study area although some were through
communal efforts. Out of the 65 HDWs, only 55 were functional at the time
of this study. Altogether, there were only 64 safe drinking water sources, 28
required repairs and 69 were unsafe (Table 13). The BHs and most of

115
Table 10: Use of Filter in Dracunculiasis Endemic Villages of Borno
State.
LGA
No. of
villages
No. of
current
endemic
villages
No. of
HHs
examined
No. of
HHs with
filter
No. of HHs
with
functional
filter
No. of filter dist
in 2003/2004
Mono Straw
filament filter
Bama 92 06 131,259 131,259 131,259 13,621 390
Damboa 06 02 880 880 880 1,775 0
Dikwa 14 01 1,417 1,417 1,417 4,279 0
Gwoza 06 00 457 457 457 0 0
Konduga 18 02 1,847 1,847 1,847 3,027 0
Mafa 06 00 350 350 350 1,360 0
Magumeri 01 01 21 21 21 477 0
Marte 02 00 175 175 175 0 0
Monguno 03 00 486 486 486 0 0
TOTAL 148 12 136,892 135,774 135,774 24,539 390
KEY:
HHs= Households.

116
Plate III: A Woman Using a Monofilament Cloth Filter to Filter
Water before Drinking.

117
Plate IV: Nomadic Farmers Using Straw Filters for Drinking.

118
Table 11: Proportion of Villages Receiving a New Water Supply
LGA
No. of
end.
villages
No. of
villages
with safe
water
Type/No.
of safe
water
Number
functional
Adequate
(Yes/No)
BH HDW BH HDW
Bama 92 13 4 49 02 46 NO
Damboa 06 00 - 02 00 00 NO
Dikwa 14 03 01 03 01 03 NO
Gwoza 06 00 - 00 00 00 NO
Konduga 18 03 - 08 00 06 NO
Mafa 06 02 - 02 - 00 NO
Magumeri 01 00 00 00 00 00 NO
Marte 02 01 00 01 00 00 NO
Monguno 03 00 00 00 00 00 NO
TOTAL 148 22 05 65 03 55 NO
BH = Borehole HDW = Hand-dug Well

119
Table 12: Types 0f New Water Supply Provided to Endemic Villages
LGA
No. of
end.
village
Type of new water supply Remaining
villages
PB BH HDW
Bama 92 - 04 49 39
Damboa 06 - - 02 04
Dikwa 14 - 01 03 10
Gwoza 06 - - - 06
Konduga 18 - - 08 10
Mafa 06 - - 02 04
Magumeri 01 - - - 01
Marte 02 - - 01 01
Monguno 03 - - - 03
Total 148 - 5 65 78
PB = Pipe borne BH= Borehole HDW =Hand-dug Well

120
Table 13: Status of Water Supply in the Endemic Villages of Borno
State
LGA No. of safe No. requiring No. of sources
sources water repairs
unsafe
Bama 48 14 37
Damboa 00 02 01
Dikwa 4 10 03
Gwoza - - 06
Konduga 06 02 11
Mafa 00 - 05
Magumeri - - 01
Marte - - 02
Monguno - - 03
TOTAL 58 28 69

121
the HDWs were provided by Borno State Government, a few HDWs were
provided by various Local Government Authorities and some broken down
HDWs were renovated by Global 2000 (Plate V).
The HDWs were usually very deep (several metres deep) and sometimes
required the use of animals like donkeys to draw up the water in them.
Ropes and containers for drawing water were normally donated to the
communities.
4.10.4 Village Based Health Worker Needs (VBHW)
Table 14 shows the number/proportion of villages with VBHWs in the
study area. All the 148 villages studied had VBHWs giving percentage
coverage of 100. Their kits for case management/containment were also
examined and found that 53(35.81%) out of the 148 VBHW had their kits well
equipped with bandages, cotton wool, antiseptic solutions, for cleaning and
bandaging of guinea worm ulcers in order to contain such cases. The
situation was observed in those villages still reporting cases. In some cases
VBHWs in such villages were better equipped.
4.10.5 Case Containment/Management Strategy (CCS)
During the course of this study, it was observed that 26(76.5%) out of
the 34 cases encountered were contained while 8(23.5%) were not, (Table
2); that is, the 26 cases were reported to VBHWs who in turn reported to the
supervisor for confirmation/verification of the cases within 24hours. The 26
patients did not enter any water bodies with their ulcers to contaminate them.

122
Plate V: Villagers Making Use of a Renovated Hand Pump at
Masa Village, Dikwa LGA, Borno State

123
Table 14: Number of Villages that have Village-Based Health
Workers (VBHWs) in the Study Area
LGA
No. of
endemic
villages
No. of
current
endemic
villages
No. of
villages
with
VBHWs
No. of
VBHWs
with
equip. kits
No. of
villages
requiring
VBHWs
Bama 92 06 92 20 -
Damboa 06 02 06 04 -
Dikwa 14 01 14 06 -
Gwoza 06 - 06 04 -
Konduga 18 02 18 10 -
Mafa 06 - 06 05 -
Magumeri 01 01 01 01 -
Marte 02 - 02 01 -
Monguno 03 - 03 02 -
TOTAL 148 12 148 53 -

124
All the cases were treated and no Tetanus toxoid was administered to any of
the patients (Table 15). The medical treatment was in the form of cleaning
the ulcers with water or antiseptic solutions and bandaging them. Analgesics
and sometimes malaria drugs were given to alleviate the pains and fever
caused by emerging worms. The 26 patients did not enter any water body to
contaminate it until the worm(s) completed emergence.
There were altogether 5 Case Containment Centres (CCC) present throughout
the study area. These were in the form of temporary tents with a mattress, a
table, a lantern and other items the patients might need. Food was brought
to the patient by his/her family members. There were 2 of these CCCs in
Bama LGA and 1 each in Dikwa, Konduga and Magumeri LGAs, (Table 8;
Plates VI and VII).
4.10.6 Abate (Temephos) Treatment/Application
Table 16 shows the number of ponds in the various endemic villages
that were treated with Temephos during the study period. Ninety three
ponds were ideally eligible (=having ≤500m³ of water) for treatment but 104
in all were treated, giving percentage coverage of 111.8. The ponds in
Gwoza, Marte and Monguno LGAs were not treated. The reason for this was
that these LGAs had not reported cases for the past 2 years and therefore
were not eligible for abate application.
4.10.7 The Cash Reward Strategy
This was also observed to be in operation in all the endemic villages of
Borno State. All the people that reported the 34 cases encountered during

125
Table 15: Villages in Borno State Where Infected People Received
Treatment During the 2003/2004 Survey
LGA
No. of villages
currently
endemic
No. of endemic
villages
receiving
treatment
% of endemic
villages
receiving
treatment
Bama 06 06 100
Damboa 02 02 100
Dikwa 01 01 100
Gwoza 00 00 00
Konduga 02 02 100
Mafa 00 00 100
Magumeri 00 00 00
Marte 01 01 100
Monguno 00 00 00
TOTAL 12 12 100

126
Plate VI: A Sign Post to a Case Containment Centre

127
Plate VII: A Typical Case Containment Centre with Patients at
Ngozoduwa Village (Bama LGA, Borno State)

128
Table 16: Number of Ponds in the Various Endemic Villages that
Were Treated With Abate During 2003/2004 Survey
No. of ponds No. of ponds % of ponds
LGA No. of eligible for treated treated
villages treatment
Bama 92 52 52 100
Damboa 06 06 06 100
Dikwa 14 23 23 100
Gwoza 06 00 00 00
Konduga 18 00 11 1100
Mafa 06 05 05 100
Magumeri 02 07 07 100
Marte 01 00 00 00
Monguno 03 03 00 00
TOTAL 148 93 104 111.8

129
the course of this study were given cash rewards of N500 each. This gave a
total amount of N17, 000 being the amount spent on Cash Reward Strategy
during 2003/2004 epidemiological year. Anybody who first reported the case
to the VBHWs be it the victim himself/herself, a relation to the victim or any
other person was the one the reward was given to. The case was first of all
verified and confirmed to be a case of guinea worm before the amount was
handed over to him/her. There were posters all over the endemic villages
that read “Report a case of Guinea worm and get N500 reward”.
4.11 IMPACT OF KNOWLEDGE, ATTITUDE, PRACTICES AND BELIEFS
OF THE SAMPLED INDIVIDUALS ON DRACUNCULIASIS AND
THE INTERVENTION STRATEGIES PUT IN PLACE
The impact of knowledge, attitude, practices and beliefs (KAP) of the
individuals in the study communities was also considered. The sources of
information and data for these evaluations have been given in Chapter three.
The result is presented on table 17.
4.11.1 Knowledge
Studies on the knowledge of the sampled communities showed that all
the respondents (5, 000;100%) including some from non-endemic
neighbouring LGAs of Borno State had good knowledge about the disease.
The awareness of the presence of the disease was well known and
widespread even among neighbours to endemic LGAs. Within the endemic
LGAs, the disease was well known as a public health problem. The Kanuris
referred to the disease as “Ngudi”, the Shuwa called it “Irk”, the Fulani

130
Table 17: Knowledge, Attitudes, Practices and Beliefs (KAP) of the
Sampled Communities on the Disease and Interventions
in Borno State.
KAP Before/Early Part Of The
Knowledge of the
disease
Attitudes towards
sufferers/of
sufferers
Attitudes towards
interventions
Eradication Proggramme
Knew the Local names of disease
– “kurkunu” (Hausa); “Ngudi”
(Kanuri), “Irk” (Shuwa), “Burutu”
(Fulani), “Tije” (Germagu), but
not the cause and prevention of
the disease.
People with Guinea worm
infection were stigmatized by
others so they were shy and did
not let others know they had the
disease.
Rejected water that was
untreated with Abate for fear that
it was poison to kill. Did not like
the odour in water either.
Rejected the idea of being
confined at the C.C.Cs
Practices Used hot iron rod to pierce
Beliefs about the
cause of the disease
through the point of worm
emergence and applied local
herbs to burns/ulcers. Entered
water bodies with their ulcers
thereby contaminating the water
bodies
They used to believe it was
caused by bad blood.
During 2003/2004
Survey
Had full knowledge about its
cause, that is, by drinking
contaminated water;
prevention by filtering,
boiling and avoiding
contamination of domestic
water after being infected.
People with the infection
were well cared for by
others and cases were
reported to the VBHWs.
Had no constraint in the
adoption of any of the
interventions.
Reported cases to VBHWs
for proper management and
containment/treatment and
bandaging.
They learned through HE
that it was caused by
drinking water
contaminated with larvae of
D. medinensis.

131
“Burutu”, in Hausa it was known as “Kurukunu, while in Gemargu it was
referred to as “Tije”. Health education posters on the transmission and
prevention of “Ngudi” in the different languages were conspicuously displayed
all over the endemic villages. The occurrence of the disease was well known
by the different tribes including those of unaffected areas. All the 5,000
(100%) respondents in the study communities had knowledge about the
source of the disease. This was attributable to the introduction of Global
2000 Health Education Campaigns. Asked if they knew what to do in case of
infection, with guinea worm; all the respondents answered that they were to
report promptly to the VBHW and not to enter any drinking water body in
order not to contaminate it with guinea worm larvae. They also knew how to
treat a disease victim, that is, to clean with water or antiseptic solution and to
bandage the ulcer. The victim was to be confined at the Case Containment
Centre until the whole worm(s) was extracted.
Use of Filter
All the 5000 (100%) respondents in the various endemic communities
knew what a monofilament nylon filter and straw/pipe filter were. They also
knew how to make use of them and admitted using them both at home (in
case of the monofilament nylon filter) and on their farms (in case of the
straw/pipe filters). Asked when they started using the filters some
respondents replied that they had been filtering their water for the past 10-12
years but the straw/pipe filters were only introduced three years back.

132
Water Treatment With Abate (Temephos)
All the 5000 (100%) respondents had knowledge on what Abate was
and its function – to kill/destroy the cyclops in the water and therefore break
the transmission cycle of the disease. They also knew how long it would take
before the water would be safe to drink after its application.
Safe Water Supply
All the 5000 people interviewed knew what safe water sources were –
pipe borne, borehole, hand-dug-wells and rain water. They also saw the
need for it. They understood that these sources of water do not normally
have cyclops breeding in them.
Case Containment/Management Strategy
All the 5000 respondents in the study communities knew what a CCS
was and how it was performed that is, reporting a case of dracunculiasis
within 24 hours of worm emergence to the VBHW who in turn will clean and
bandage the ulcer and give HE to the infected person not to enter any water
body in order not to contaminate it with guinea worm larvae. Asked if they
knew what a case containment centre was, all the respondents knew what it
was, a place reserved for patients with emerging guinea worm to be managed
and contained by the VBHW. The patients were confined here for as long as
it took the worm(s) to completely emerge.

4.11.2 Attitudes
133
The 5000 (100%) respondents admitted having a different attitude
about dracunculiasis with the awareness created by Global 2000 through
Health Education about the cause of the disease. They now understood the
cause, management and prevention of the disease so were no longer shy
about it. The affected persons attended all social gatherings and community-
based functions; and even when they were unable to attend any it was purely
because of incapacitation and not because of any local belief that the disease
was contagious. Infected people were no longer stigmatized or treated with
contempt. Almost all the respondents had hope that within a short time the
disease would be eradicated if Global 2000/NIGEP do not relent in their effort
to eradicate the disease.
Use of Filter
Their attitudes towards use of filter to filter drinking water were good.
They accepted making use of them always. None of the respondents had any
constraints in the use of filter. They actually requested for replacements any
time the ones they already had were torn or became old.
Abate Application
All the 5000 respondents had expressed fears about the safety of
Abate to humans when it was first introduced. They were scared about the
colour and taste of the chemical on application and so had a negative attitude
towards it. With the intensification of public awareness campaign and Health
Education they now knew that the treated water would taste better after 12

134
hours of treatment and that it was safe for human consumption when applied
at the correct dosage and so their negative attitude changed completely.
Safe Water Supply
Most of the villages sampled had no safe water supply and so the
respondents did not directly feel the impact. Almost all the respondents
expressed disappointment with the government for not supplying them with
“good” water. The idea of provision of safe water they thought was the
responsibility of government alone. Some had come to realize that it was
wise for them to contribute towards their own health too. The constraint they
had with safe water supply was lack of finance. With money available, they
would gladly contribute to the digging of wells. In some of the villages there
were actually efforts made by community members to dig some wells.
Case Containment/Management/Strategy
This was a welcome idea of the respondents but the only fear
expressed was the idea of being confined at the CCC for an indefinite number
of days/weeks since nobody knew when the worms would completely
emerge. They expressed the fear of not having people to work for them on
their farms while they were at the CCCs. This made some patients to hide
their cases for fear of being confined especially at the first introduction of this
strategy.

The Cash Reward Strategy
135
All the 5000 (100%) respondents had a positive attitude towards this
strategy since it involved money. Every member of the sampled communities
went out to actively search for cases in order to report to the VBHWs and
collect the cash reward of N500 (at the time of the study) on verification of
the case.
4.11.3 Practices
A number of guinea worm disease management practices were in
existence in the study area before the introduction of Eradication
interventions by NIGEP/Global 2000. According to the respondents, one of
the popularly known practices involved the use of a hot iron rod to pierce
through the swelling suspected to contain pre-emergent worm in order to
destroy the “bad blood” that caused it (so the respondents believed at that
time). At the time of this study this was no longer practised. Global 2000
team actually punctured some swellings that were located especially around
joints to bring relief to the affected individuals. Application of “Tamele” oil to
guinea worm swellings or ulcers to dry them up faster and therefore enable
the worms to emerge faster was also done by the Team. The respondents
admitted using other methods before contact with NIGEP/Global 2000 team
which changed their perception about the disease.
There was one practice by the respondents as regards interventions
that was detrimental to the success of the eradication programme. Some
members of the communities still preferred pond water to hand-dug-wells in

136
villages where these were made available. Their reasons were that the wells
were too deep for them to draw water from especially after a hard day‟s work
and also that some of the wells were located very far from their houses. The
introduction of straw/pipe filters made things very easy for those who used to
drink filtered water while at home but once away from home drank water
from any source.
4.11.4 Beliefs
The general belief about the cause of the disease among members of
endemic communities of Borno State was that it was caused by “bad blood”.
All the 5000 (100%) respondents admitted to the fact that Health Education
Campaign had changed all that. They used to have the notion that Abate was
a dangerous chemical donated by their enemies to kill them but they had at
this time realized that it was very safe chemical to humans when
administered correctly.
4.12 DENSITY AND INFECTIVITY RATES OF THE CYCLOPS IN THE
VILLAGES STUDIED
A total of 7,052 cyclops were collected from 15 ponds from July-
December 2003.The water samples collected and examined from these ponds
which were located in different parts of the state all harboured cyclops while
none of the five (5) wells which served as the control harboured any. The
mean number of cyclops recovered was 16 while the density per litre of water
was 3. The density per litre was highest in Bama,Dikwa,mafa and Magumeri
Local Government Areas each recording 4 cyclops, (Table 18).

137
Table 18: Density and Infectivity Pattern of Cyclopoid Copepods
Collected in Various Ponds in the Study Areas
LGA Villages
(Ponds)
No.
Examined
X D/L No. (%)
Infection
Bama Ngozoduwa 537 18 4 4(0.74)
Walasa kura 572 19 4 3(0.52)
Bodimari 531 18 4 0(00)
Damboa Ngotori 467 16 3 00(00)
Dikwa Masa 1 528 18 4 6(1.10)
Masa 2 549 18 4 4(0.73)
Gwoza Kushekushe 359 12 2 0(00)
Konduga Kurkkuruk 532 18 4 0(00)
Mianti 383 13 3 0(00)
Mafa Azangoro 1 556 19 4 0(00)
Azangoro 2 336 11 2 0(00)
Magumeri Ka‟ajiya 1 598 20 4 5(0.84)
Ka‟ajiya 2 297 10 2 3(1.00)
Marte Allajidari 302 10 2 0(00)
Monguno Ali Ngotamari 505 17 3 0(00)
TOTAL 15 7,052 16 3 25(0.35)
Control
(Deep Wells)
Well 1 Wulasa kura - - - -
Well 2 Ngozoduwa - - - -
Well 3 Ngotori - - - -
Well 4 Mianti - - - -
Well 5 Masa - - - -
GRAND
TOTAL
20 7,052 16 3 25(0.35)
Key:
x = Mean number of Cyclops
D/L = Density of Cyclops per litre of water

138
The infectivity pattern of the cyclops collected from the various ponds
is also summarized in table 18 and figure 10. Twenty five (0.35%) of the
7,052 cyclops sampled were infected with the larvae of Dracunculus
medinensis. These were recorded from 6(40%) of the ponds sampled while
the remaining 9(60%) ponds did not harbour any infected cyclops. Infection
rates of the cyclops were highest in Masa 1(1.1%) and Ka‟ajiya 2, 3 (1.0%)
while the least infection rates were observed in Wulasa Kura 3 (0.52%). The
water samples in the remaining villages of Bodimari, Ngotori, Kushekushe,
Kukkuruk, Mianti, Azangoro, and Allajiddari and Ali ngotamari did not harbour
any infected cyclops.
4.13 MONTHLY VARIATION OF INFECTIVITY OF CYCLOPS
Figure 10 shows the monthly variation of infected cyclops in the study
area. The result revealed that infections were recorded between July and
November 2003 with December (2003) and January, 2004 recording no
infections of cyclopoid copepods. The month of September recorded
11(5.30%) cyclopoid infections which was the highest while October and
November recorded the least infection rates of 2(0.07%) each.
4.14 EFFECT OF ABATE LARVICIDE ON CYCLOPOID DENSITY IN
BORNO STATE (JULY – OCTOBER 2003)
The results obtained on the impact of Abate larvicide application on
cyclopoid copepod densities in Borno State during the 4 months of study are
presented on Table 19. The result showed that the cyclopoid densities
obtained before application of Abate were twice higher than the ones

No. of Cyclops
12
10
8
6
4
2
0
July
3
August
7
September
11
October
2 2
November
139
December
0 0 0 0 0 0 0
January
Months
February
Figure 10: Monthly Variation of Cyclops Infectivity (2003-
2004)
March
April
May
June

140
Table 19: Mean Cyclopoid Density (Md/L) in Water Bodies Before
and After Treatment with Abate Larvicide from Sampling
Stations (Borno State, Nigeria)
Treatment Month/Mean Density/Litre Total
Stations Periods July August September October X
Ngozoduwa Before 3.0 3.0 3.0 4.0 13.0
2 weeks 2.0 1.0 2.0 3.0 8.0
4 weeks 3.0 3.0 3.0 3.0 12.0
8.0 7.0 8.0 10.0 33.0
Mafi Before - - 4.0 - 4.0
2 weeks - - 2.0 - 2.0
4 weeks - - 4.0 - 4.0
- - 10.00 - 10.00
Masa Before 8.0 3.0 3.0 4.0 18.0
2 weeks 2.0 1.0 2.0 3.0 8.0
4 weeks 3.0 3.0 3.0 3.0 12.0
13.0 7.0 8.0 10.0 38.0
Kukkuruk Before 4.0 - - - 4.0
2 weeks 2.0 - - - 2.0
4 weeks 3.0 - - - 3.0
9.0 - - - 9.0
Azangoro Before - - 4.0 4.0 8.0
2 weeks - - 2.0 2.0 4.0
4 weeks - - 3.0 4.0 7.0
- - 9.0 10.0 19.0
Ka‟ajiya Before - - 4.0 5.0 9.0
2 weeks - - 2.0 3.0 5.0
4 weeks - - 4.0 4.0 8.0
- - 10.0 12.0 22.0
TOTAL 30 14 45 42 131
Key
X - Mean
- Summation

141
obtained 2 weeks after application and just slightly higher than or equal to
the figures obtained 4 weeks after application of the larvicide. This was the
case in all the ponds sampled. In a pond where only one or two months were
used for the experiment, the trend observed was the same. Two way Analysis
of Variance (ANOVA) showed that there was no significant difference
(p>0.05) in the treatment periods but a significant difference (p0.05)
between the months and the treatment periods.
4.15 THE COST IMPLICATION OF INTERVENTIONS IN BORNO
STATE, 1996 – JUNE 2004
The estimated amount spent on the eradication programme in Borno State
from 1996 – June 2004 is presented in table 20. A total of N74, 902,755.00
was spent on the programme in Borno State during the said period. The
figures obtained showed that N5,000,000 was spent on the purchase of
Jeeps; N3,390,110.00 on Motorcycles, N980,600 on bicycles while N7,482,925
was used on fuel. Others included N3, 760,000 spent on purchase of Abate
larvicide; N5, 129,400 was paid as allowances to VBHWs; N27,016,290 on
both straw and cloth filters; N1,667,120 on HE materials while N250,000 was
used in the construction of Case Containment Centres (CCC). The remaining
N30, 000 was spent on cash reward to the infected persons who reported
their cases to the eradication team or to their relations or any other person
who reported that somebody else had an infection.

Table 20: Cost Implication of Intervention Strategies in Borno State (1995-2004)
Activity Est.
No./Vol/Qty.
142
Est. Amount (N) Source
LGA S. Govt. Fed.
Govt.
Allowances of VBHWs 148 5,129,400 - - - Yes
*Boreholes *5 - Yes Yes - Yes
Hand-dug-wells 10 100,000 Yes Yes - Yes
Purchase of Abate 188 drums 3,760,000 - - Yes Yes
Filters and Straw filters 211,751 27,016,290 - - - Yes
Drugs 96,310 - Yes - Yes
Bicycles 203 980,600 - - Yes Yes
Motorcycles 59 3,390,110 - - - Yes
Jeeps 5 25,000,000 - - - Yes
Reward (Cash) 60 30,000 - - - Yes
H.E. Materials 1,666,120 - - Yes Yes
Fuel 185,285L 7,482,925 Yes - Yes Yes
Case Containment Centres (CCC) 5 250,000 - - Yes Yes
Total N74,902,755
Key:
LGA = Local Government Area
S. Govt = State Government
Fed. Govt. = Federal Government
WHO = World Health Organization
UNICEF = United Nations Children‟s Fund
WHO/UNICEF/
Carter Centre

143
CHAPTER FIVE
DISCUSSION AND CONCLUSION
5.1 TREND OF DRACUNCULIASIS CASES IN BORNO STATE FROM
1995 - 2003
The eradication effort of the Nigeria Guinea worm Eradication
Programme (NIGEP) and global 2000 of The Carter Centre has resulted in a
gradual but steady decline in incidence of dracunculiasis in Borno State from
527 cases in 1995 to 34 in 2003. This gives a 94.2% reduction rate. This
reduction in incidence is very significant but still worrisome because of the
epidemiology of the disease on one hand and the goal of the eradication
programme which was set to eradicate the disease by 1995 and later 2000
and 2005but these three deadlines could not be met. The current deadline,
set for 2009(Hopkins,2005) can only be achieved if NIGEP and global 2000
will intensify their efforts. Eradication of the disease in Borno State may seem
possible in 2005 if extra effort is put in the area of case containment as to be
able to achieve 100% case containment. The study demonstrated evidence of
accurate reporting of the cases as shown in the results of the house to house
visits (Table 2).
5.2 DISTRIBUTION OF DRACUNCULIASIS IN BORNO STATE
This study has re-established that dracunculiasis is still endemic in
some communities in Borno State, occurring at fairly high proportions of
endemicity in Magumeri (0.70%) and Dikwa LGA and low proportions in
Damboa (0.04%), Konduga (0.02%) and Bama (0.006%) LGAs of the State.

144
The occurrence of the disease during the course of this study was confined to
only 5 LGAs; Gwoza, Mafa; Marte and Monguno LGAs which were also
formerly endemic for this disease reported zero cases. The disease has been
variously described as occurring in scattered locations (Muller, 1971), foci
areas (Edungbola et al. 1986), cluster of communities, isolated cases in
provinces (Watts, 1987) and highly localized pockets of infection within the
areas where the disease is found (Muller, 1971; Watts, 1987). Some cases
reported in the Sudan had occurred in areas designated as unaffected
because of widespread population mobility (Watts, 1987). In Borno State, the
population indulged in activities which involved lots of movement, as in
agricultural workers, transportation of farm produce to markets which
sometimes were located in other LGAs, towns and villages. Some were
nomads moving to and from across these areas seeking pasture for their
cattle and thereby exporting and importing some of these cases. Some were
„Almajiris‟ who spend one year in one town/village/LGA and another in a
different village/town/LGA. It has been proposed by Watts, (1987), that the
areas affected by the disease in Africa extend right across the northern part
of the continent south of 18 o N including all ecological zones from the forest
through the savannah to the semi desert Sahel to the desert. He also stated
that savannah vegetation in particular dominated by grasses, scattered trees
and shrubs and associated with a tropical wet and dry climate predominates
where dracunculiasis is present. The description fits that of the study area
perfectly and it is therefore not a surprise that the disease is endemic. The
prevalence of the disease showed that there were only 34 cases in the 9 LGAs

145
of Borno State during 2003/2004 epidemiological year. In any case, in
considering data on prevalence it should be borne in mind that figures based
only on patent guinea worm infections probably under-estimate the true
position of the disease to some extent since in a certain proportion of cases
the infection may only be detected when calcified worms are revealed by X-
ray examinations (Reddy et al. 1968). This was not carried out during the
course of this study.
5.3 AGE AND SEX RELATED DISTRIBUTION OF DRACUNCULIASIS
IN BORNO STATE
The result of this study showed that the disease affected all age
category in the males, but in the females only persons from 0-40 years were
infected. The highest prevalence rates were recorded in males 11-4- years old
but in the females, persons from 0-40 years old were equally infected
(0.01%) although no significant difference(p>0.050) was observed. This
finding is in line with those of Nwosu et al. (1982) who reported 14-40 (20%)
years old as the most affected. It is also similar to those of Adeiyongo and
Onwuliri (2004), who observed that the 11-40 years old (24.6%) in a rural
community in North Central Nigeria were mostly affected.
Studies carried out by various researchers present diverse observations
reflective of peculiar epidemiological circumstances. Scott (1960) in Ghana
found a significantly higher incidence of the disease in children than in adults
whereas Belcher et al. (1975) and Edungbola (1983) found low incidence
rates of the infection in children and infants. Although Kale (1977) reported
highest prevalence rates in the 40-49 year age group, Sahba et al. (1973) in

146
Iran and Onwuliri et al. (1988-90b) in Nigeria did not find any differences
between the various age groups.
The low prevalence rates observed in the older age groups in this
study were attributed to the increased awareness created through Health
Education which the older individuals are supposed to benefit from more than
the younger ones. The 11-40 year age group was the productive workforce;
participating in almost all household and farm activities like fetching of water,
firewood and tilling the land which exposes them more to the disease. This
explains why the group was most hit by the disease.
According to Edungbola (1983), every body in an endemic area is at
risk of infection. He has opined that the chance of contracting the infection is
the same for all who drink from polluted sources in an endemic area. Scott
(1960) suggested that the level of gastric acidity may protect some people
from dracunculiais but this has been strongly challenged by Gilles and Ball
(1964) and Sita-Davis et al. (1969).
Braide (1991) had cited a KAP study carried out in parts of South
Eastern Nigeria which showed that 49.9% of household water was collected
by women; 37.75% by children below 15 years and 12.4% by adult males.
This pattern is likely to be true for other parts of Nigeria as a similar result
was also obtained in Borno State with 54% of water collection done by
women, 38% by children below 15 years and only 8% by adult males. It was
therefore concluded that since women and children among other household
responsibilities fetched, stored and dispensed household water, they formed
the prime target for Health Education in guinea worm eradication.

147
Sex-related prevalence of dracunculuasis in this study showed that
there was no significant difference (P>0.05) in infection rate between males
(0.02%) and females (0.01%). This result agrees with similar other studies in
similar geographical areas in Dukku, Gombe State (Fabiyi 1991); and Oju and
Okpokwu LGA in Benue State (Onwuliri et al. 1988-90b). Nwobi et al. (1996)
also found that males (63%) had higher attack rates than females (37%).
Lyons (1972) in Ghana; Adeiyongo and Onwuliri (2004) in Nigeria found
significantly higher rates in women than men. Results obtained by Lyons
(1972) showed that females had prevalence rate of 28.9% as against 23.2%,
while those of Adeiyongo and Onwuliri (2004) showed that 21.4% of the
females were infected as against 16.3% males. This had been attributed to
more exposure of the affected females to infection. The higher infection
rates (0.02%) recorded for males as against 0.01% in females in the present
study was attributed to more exposure of the males to the infection. There
were some duties designated for only women (like fetching of water,
firewood) and others designated for only men (like clearing of the land and
making of new ridges for agricultural use, occasionally fetching of water
especially by younger males and less frequently by the adult males). The
men therefore stayed away longer on the farm activities and required greater
water consumption from any nearby ponds that might possibly be
contaminated by infected persons. Secondly, females in the present study
formed the prime target for Health Education as regards filter usage in
filtering household water and therefore might have been more cautious about
drinking water that was not filtered. According to Kale (1977) individuals who

148
spent most of their time on the farms have greater exposure and show higher
disease prevalence since they would want to quench their thirst directly from
small water holes in the vicinity of the farm.
5.4 DIFFERENT LEVELS OF INFECTION IN RELATION TO SOURCES
OF DRINKING WATER
The one sample T-test analysis of the infection rates in the different
groups of people that depended on the different sources of drinking water
showed there was no significant difference (P>0.05) among them. These
included those depending on boreholes and ponds, ponds, hand-dug-wells
and ponds. These results obtained showed that 3(0.02%) out of 16,313 who
depended on both borehole and pond water were infected, 26(0.01%) out of
265,003 depending on ponds only and 5(0.02%) out of 28,776 of those
depending on both hand-dug-wells and ponds were infected. This agrees
with the findings of Onabamiro (1952) and Onwuliri et al. (1988-90b).
Onabamiro (1952) had stated that whenever people depended on stagnant
water, several cases of guinea worm were to be found but where people got
their water from rivers and streams which flowed all year round, very few
cases of drcunculiasis were to be found. Edungbola et al. (1988) had
observed the inseparable link between water source and prevalence of guinea
worm infection. This relationship implicates the vector habitat and human
contact (Onabamiro, 1954; Onwuliri et al. 1988-90a).
The prevalence of the disease in the present study area was a clear
reflection of the source and type of water. Twenty-six (76.5%) of the 34
infected persons depended solely on pond water. Sources of water varied

149
during the dry and rainy seasons. Ponds were the main source of water in all
the villages especially during the rainy season which is the transmission
period hence the high number of cases recorded in pond users. Twenty-nine
(85.3%) out of the 34 cases encountered occurred during the rainy season
(July – September) (Figure 10). Hand-dug-wells and boreholes were made
use of mostly in the dry seasons when most of the ponds dried up and this
explains why persons who depended on these two in combination with ponds
recorded only 5(14.7%) of the 34 cases encountered. The boreholes required
the use of generators and these used diesel which was very expensive and
had to be provided by LGA when money was available. It therefore became
very difficult to maintain them in order to use them all year round. The water
level in the soil in this area too was observed to be very low reaching 200 feet
typical of the geographical region. The inadequate hand-dug-wells were very
deep therefore it was very tiring drawing water from them especially by
elderly people. In some instances animals like donkeys were used to draw
water from these wells. There was no pipe borne water and the very few
streams present were far from homes and not used for housework. All these
have made the individuals prefer pond water. One of the intervention
strategies in the Guinea worm Eradication Programme was the treatment of
ponds with Abate (Temephos) to kill the cyclops. With this it is hoped that
the disease will be eradicated from these communities entirely.

150
5.5 PREVALENCE OF INFECTION IN RELATION TO THE
OCCUPATIONAL STATUS OF THE SAMPLED POPULATION
Occupational disposition placed nomads (0.04%) and farmers (0.02%)
at the highest risk of infection in the study communities. Analysis of data
however showed that there existed no statistical difference (P>0.05) among
pre-school age, students, civil servants, home makers, farmers, traders,
nomads and Almajiris. Nwobi et al. (1996) and Onwuliri et al. (1988-90a)
found infection to be more in farmers only (13.8% and 59.7% respectively).
Farmers and nomads spent most of their time away from homes, making
them more vulnerable to use of drinking water from unsafe sources. These
two categories of individuals travelled long distances to their farms and
grazing of cattle without their filtered water. The higher consumption of
unfiltered water by these groups away from home resulting from physical
dispensation of energy during work may account for the higher infection rates
(Onabamiro, 1954; Ukoli, 1990). It had been observed in the past that
intervention measures did not take care of farmers and others whose
occupational requirements make daily use of water sources that are unlikely
to be safe inevitable (Kale, 1977). During the course of this study it was
observed that Nomads and farmers had been provided with straw filters for
use while away from their homes.
5.6 SEASONAL VARIATION OF DRACUNCULIASIS CASES
In the current study, dracunculiasis was observed to occur during the
months of July (20.59%), August (29.41%), September (35.29%), October
(8.82%) and November (5.88%) only. This was a period of peak rainfall and

151
the beginning of the dry season in the area. This period coincided with the
period of cultivation of such stable crops as guinea corn, millet and beans.
The seasonal and periodic increase in the incidence and prevalence of
dracunculiasis as a major feature of the impact of the disease has been
widely studied among various workers. In particular the disease has been
frequently connected with monthly rainfall pattern and peak agricultural
activity (Onabamiro, 1952; Lyons, 1972; Belcher et al. 1975; Kale, 1977;
Muller, 1979; Nwosu et al. 1982; Ugwu and Nwaorgu 1988-90). Most of the
patients examined were not incapacitated and so could still carry out their
farm work. However 3 persons were incapacitated and could not carry out
their farm work. No case of school absenteeism was observed during the
course of the study. The students infected had their ulcers cleaned and
bandaged by the VBHWs and after that were able to attend school.
The seasonality of the incidence of dracunculiasis in Nigeria has been
studied by many investigators. According to Ramsay (1935); Muller, (1979);
Edungbola and Parakoyi (1991) the peak incidence of the infection occurs
during and immediately after the end of the rainy season in the semi and sub-
Saharan and Sahel savannah regions of the country. This is mainly between
the months of May and October of spatial or few concentrated seasonal
rainfall in this area (Ramsay, 1935; Ola Daniel and Osisanya, 1985; Osisanya
1986; Onwuliri et al. 1988-90a; Suleiman and Abdullahi, 1988-90). The
findings in this study agree with those of the aforementioned authors.
Ramsay (1935); Muller (1979) and Edungbola (1984) on the other hand
observed that most cases become apparent during the dry season extending

152
mainly to the planting season in the humid-climate savannah and forest areas
of the country. This is mainly as from the month of November to April
(Onabamiro, 1952; Kale, 1977; Nwosu et al. 1982). Onabamiro (1951) had
correlated guinea worm transmission and infection rate to the infective
density which was in turn obviously determined by the amount of rainfall.
According to him, large numbers of guinea worm larvae were ingested by
pond water drinkers in the dry season when the cyclops density was high.
However the transmission and infection rate were greatly reduced at the close
of wet season when the density of cyclops had fallen. Onwuliri et al. (1989)
had also observed that the density of the cyclops increased greatly during the
dry season but decreased drastically with the onset of rainfall. This,
according to him, was because increased salinity and low level of dissolved
oxygen during the dry months of scanty rainfall in the guinea savannah and
forest areas of the country favour higher cyclops density and infectivity.
Muller (1979) had observed that all running water in the desert area of
Southern Iran was saline. It is therefore possible that the surface water
sources of guinea worm transmission in the semi-arid habitat of Northern
Nigeria such as that of Borno State may have the required salinity to sustain
infective cyclops density in the rainy months.
5.7 DEGREE OF DISABILITY, ANATOMICAL SITES AND DURATION
OF INCAPACITATION
In the course of this study, only 3(0.82%) of the 34 cases encountered
were severely infected and the individuals affected incapacitated. The

153
disease caused damages on the tissues and led to ulcers which caused pain
and led to disability.
The lower limbs were the preferred sites of worm emergence in this
study. The pronounced propensity for the most dependent parts of the body
is believed to be a biological phenomenon that ensures the survival and
perpetuation of D. medinensis as the sites of predilection coincide with these
most frequently in contact with water where the obligatory intermediate host,
the cyclops, is likely to be encountered by the embryos that are discharged on
immersion in water (Muller, 1971; Kale, 1977). The distribution of lesion
observed in this study (100% on the lower limbs) corresponds with that of
Kale (1977) who observed the highest number (77.30%) on the lower limbs.
The site of predilection for the body where gravid female guinea worm
eventually emerges through the skin is of public health importance in terms of
the clinico-pathology, the illness effect and the transmission of the disease.
The first sign of active infection is the formation of a blister (induced by
emerging gravid female worms) which ordinarily causes relatively mild
discomfort of limited duration (Edungbola and Parakoyi, 1991). However the
most serious pathological consequences of the disease is the severity of
disabling pains and morbidity due largely to host-tissue reactions to the worm
presence or migration or repeated and multiple infection (Lyons, 1972),
secondary bacterial complications of infection, anatomical location of
emerging worm, and the occasional rupturing of the adult female worm in the
body (Edungbola and Parakoyi, 1991). All the patients in this study had only
one point of worm emergence which was the lower limbs.

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Investigations have revealed that irrespective of geographical
differences, most worms emerge from the lower limbs, although occasionally
they may be found almost anywhere on the body (Muller, 1971; Belcher et al.
1975, Kale, 1977; Nwosu et al. 1982). The emergence of guinea worm on
the lower limbs has been found to be of high proportion, reaching up to
87.9% (Rao and Reddy, 1965) and 92% (Lyons 1972). These occur usually
with over 50% of these lesions preferring the feet and ankles (Muller 1971;
Kale 1977). The emergence of the worms on the lower limbs (100%) only in
this study could be linked with the water sources available in the area
(ponds). These were collected by first entering the water body sometimes up
to the knee level and this could stimulate the worms under the skin to
emerge.
The current study did not encounter any case of secondary infection
leading to tetanus. This is in contrast to the findings of Lauckner et al. (1961)
and Primae and Becquet, (1963) who identified guinea worm ulcers as the
major entry point for tetanus spores in Western Nigeria and Burkina Faso
respectively. The high correlation between guinea worm ulcers and tetanus
infection was also reported in Upper Volta (Primae and Becquet, 1963) led
the authors to advise the government of Burkina Faso to administer tetanus
vaccine to dracunculiasis patients. Wurapa et al. (1975), in Ghana and Nwosu
et al. (1982) in Nigeria observed tetanus infection in roughly half the cases.
The absence of any tetanus case in the current study was attributed to case
containment/management strategy employed in the area by NIGEP/Global
2000. Open ulcers were cleaned with water or antiseptic solutions and

155
properly dressed to prevent contamination of water bodies by the larvae from
them and secondarily to prevent any bacteria from getting in. The patients
were in some cases confined at the case containment centre so that there
was no opportunity for their ulcers to be infected by tetanus bacteria.
Based on Muller‟s 1971 comprehensive review of the clinico- pathology
of dracunculiasis complications, Edungbola and Parakoyi (1991) concluded
that the health status, personal hygiene, nutritional condition and the physical
activities of a patient influence the severity of dracunculiasis morbidity.
5.8 THE IMPACT OF THE INTERVENTION STRATEGIES ON
DRACUNCULIASIS IN BORNO STATE
The intervention strategies used in the eradication of dracunculiasis in
Borno State were an integrated approach. Health education created a lot of
awareness about the disease, its cause, prevention and also the need to filter
all drinking water using monofilament nylon filters. The filters were
distributed free by Global 2000 staff. Recently, straw or pipe filters have
been introduced by the Carter Centre for use by farmers while on the farms,
nomads, students and Almajiris. These have proved to be very effective as
the children especially took pleasure in hanging them around their necks
wherever they went. Akpovi (1981) noted that filters were cheap, feasible
and acceptable. The combination of filter usage and health education has
been employed in the eradication of the disease in Burkina Faso (WHO 2003).
It was observed during the cause of this research that the use of filters did
not pose any constraint in the study communities. They had sufficient supply

156
of filters and even to households in communities that currently were not
endemic. This was to screen out any possibility of accidental cases of
contamination of water bodies by immigrants who were infected with the
disease. Damaged or old filters were replaced promptly and the Global 2000
field staff usually went round from time to time checking on households in
endemic communities to ensure that they were actually making use of the
filters. With the introduction of the straw or pipe filters to other family
members who do not stay at home always due to occupational demands, all
the safe water needs of a family had been satisfied. Water filters, though
widely acclaimed cheap and most simple intervention strategy, had to be
distributed (Brieger et al. 1991). This was satisfactorily achieved in the study
area. Yekutiel (1981) had also noted that even when all criteria for disease
elimination are met, there is always the extra need for continuous monitoring
and preservation. As far as the endemic communities in Borno State under
study are concerned, the use of filters was more desirable than even the
provision of hand dug wells. It was observed that households from both
formerly and currently endemic villages were supplied with filters. The zeal
for the use of filter can be viewed from the high number of filters distributed
or replaced in 2001 (29,093 filters); 2002 (87,849 filters) and 2003 (24,690
filters), (NIGEP, 2001/2002). Abate is an organophosphocyanamid which was
used in the treatment of contaminated water sources. This intervention was
observed to be very ideal in the study area since they depended largely on
pond water. Skilled man power was used in the application of the chemical to
water sources; (Nigeria Guinea worm Eradication Programme Annual

157
Statistical Summary, 2001, 2002). The supply of the chemical too was
adequate. Ideally the number of ponds eligible for treatment (ponds with
volumes of water less than or equal 500m 3 ) during 2003/2004 epidemiological
year was 93, but 104 (111.8%) ponds were treated in all. This was to rule
out the possibility of any contamination of ponds close to endemic villages.
The results of this study showed that the months of June through November
were most ideal for the cost-effective treatment of ponds because they
correspond to the beginning of the rainy season and the beginning of the dry
season with the highest potentials of disease transmission in the study area.
However, the application actually started in July 2003. Some ponds treated
had volumes of water above or below the recommended volume but careful
calculations were done before application in order not to over or under apply
the chemical. This was necessary so as to avoid leaving out some ponds that
might be harbouring infective cyclops. Single applications of chemical to
ponds were not carried out as this is against WHO recommendation (WHO,
1989). The difficulty encountered with the use of Abate in the eradication
programme was the time it took to treat one pond and the number of ponds
present in a single village. A minimum of two hours was required depending
on the size and shape of the pond. The series of activities leading to the
application were tedious – measurement of the length, width and depth at
different points; the calculation to get the volume and lastly the measurement
and application of the chemical. Another danger in Abate application is the
risk of entering water bodies without knowing what was inside in order to
take measurements. The ponds which most of the inhabitants depended

158
upon for their domestic water supply were normally selected for Abate
application.
Socio-ecological and cultural preconditions (example cultural habits and
beliefs) have been observed to cause people to reject control measures
(Yekutiel, 1981; Oguniyi and Amole, 1990). This was not observed in the
study area. Members of the communities complied with every intervention
employed in the eradication of dracunculiasis in their area. With the
elaborate health education (HE) given, they understood that Abate was not
poison and that it would not kill them. They understood that after abate
application; a time lapse of 6 hours (WHO 1989) was required for the colour
and taste of the water to normalise.
New water supply was not a very popular intervention in Borno State.
This was confirmed from the total number of hand-dug-wells and boreholes in
the area. In the 9 LGAs formerly endemic and 5 currently endemic for
dracunculiasis, there were only 3 functional boreholes and 55 functional hand-
dug-wells. This was grossly inadequate considering the WHO standards of
250 inhabitants per borehole and 100 inhabitants per hand-dug-well (WHO,
1998b). There were many factors responsible for the non-popularity of new
water supply. The first was the problem of finance for the programme
coordinators to sink wells and drill boreholes. The second was the problem of
the geology of the study area. The water table in the study area was very
deep (up to 200 feet) and this required very deep wells and boreholes to be
able to get water that will last all year round. This had also its problems, for
example, a lot of money would be required to sink a single borehole or dig a

159
hand-dug-well. Secondly, the wells, where available, were too deep so this
posed a problem for the users for it was tiring especially after a hard day‟s
work to start drawing water from such a deep well when one could just walk
a few metres away and get water from a pond. Some were so deep that it
required the services of animals for example donkeys, which not everybody
could afford, to draw water. Thirdly, these HDWs or BHs (where available)
were sited very far away from residential areas of some members of the
community so they preferred making use of filters to filter pond water which
was located near their houses to walking long distances to get water from
Hand-dug wells or Boreholes. The few Boreholes available needed to be
operated using generators. The diesel used to run these generators
sometimes was not available and the inhabitants were left with no choice
than to make use of treated or filtered pond water. In some instances the
BHs were reserved strictly for use during the dry season when most of the
ponds dried up in order to save cost.
The case containment strategy (CCS) was aimed at making sure cases
were reported promptly (within 24 hours of worm emergence) to enable the
VBHWs confine such a patient at the CCC in order to stop the contamination
of water sources with the larvae of guinea worm. The patients were confined
at the CCCs until the worm completed emergence. It was observed that the
patients did not like the idea of being confined for an indefinite number of
days or weeks and therefore missed farm work. The strategy had other
impediments too. There was limited number of CCCs (only 5 in the 9 LGAs).
Recently the North-East zone of Nigeria modified this strategy into a mobile

160
CCC where the patient was confined in his own house by the Global 2000
Team. The patient‟s farm work, feeding and all his other needs were paid for
by the team. Some members of the team stayed behind with the patient until
the worm had completely emerged. This method was very effective but it
could only be employed where there are very few cases left as in Borno State.
The CCC itself had to be in a conducive environment and the community had
to comply with it before it was effective. The allowances due to the patients
were to be paid and on time while they were at the CCC. If there was
enough cash, the mobile case containment strategy might be employed in all
zones when the cases are below ten (10). The impediments in the
implementation of this strategy may be responsible for the eight cases that
were not contained during the study period.
The cash reward strategy was also welcome because of the instant
gain involved. Members of the communities could have resorted to faking
cases in order to get money but for the fact that any case reported must be
confirmed and verified before the cash was given to the reporter (not
necessarily the patient). The method was feasible in endemic areas where
cases are remaining few in number to enable the eradication team fish out
the last cases. The strategy was very appropriate in the study area which
reported only 34 cases during the study period. It can be employed in other
areas too where there are few cases remaining.

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5.8.1 THE SUCCESSES OF THE ERADICATION PROGRAMME IN
BORNO STATE
The combination of multiple strategies in Borno State have been able
to reduce the number of cases from 2,053 in 1998 to only 34 in 2003/2004
epidemiological year and also reporting zero cases from 2005 to
2007(NIGEP,2005-2007. This huge success has been largely due to the
following reasons:
The involvement of former Nigerian head of State, General Yakubu
Gowon, and former head of State, now President Amodou Toumani Toure of
Mali, with their sustained, passionate advocacy throughout Nigeria and
francophone disease-endemic countries, are major factors in recent successes
of the programs.
The generous funding provided by a grant from the Bill and Melinda
Gates Foundation in 2000 (Hopkins et al. 2005) and both the political and
financial advantages have come to fuller realization during the most recent
years of the programme.
The commitment and dedication of Global 2000 team; both office and
field staff who have left no stone unturned to ensure that the eradication
programme was a success.
The commitment and dedication of Village-Based-Health Workers and
supervisors located in the various endemic villages. These volunteers ensured
that cases were detected on time and also made sure that they were
contained and managed to prevent water contamination, collected and
distributed filters.

162
The level of acceptability of the interventions by the community
members also gave a boost to the eradication programme. It would have
been a useless venture, for example, providing filters for the populace who
would not agree to filter their water, or applying Abate to waters and then the
villagers refusing to drink water from such sources. The various communities
had no constraint in the use of any of the intervention strategies.
The adoption of health education campaign on the use of filters to filter
all drinking waters and the restriction of infected people from entering and
contaminating water sources together with Abate application to destroy
cyclops have proved to be the most effective measures in Borno State. These
are also recommended for use in other areas where dracunculiasis is
endemic.
Health Education has also improved the level of awareness at the
village level against superstitious practices and beliefs.
The successful use of village volunteers can also be applied to other
public health control programmes like onchocerciasis, malaria, loasis and
Tuberculosis.
5.9 THE IMPACT OF KNOWLEDGE, ATTITUDES, BELIEFS AND
PRACTICES ON THE DISEASE AND ON THE INTERVENTIONS
PUT IN PLACE
Guinea worm intercommunity spread, endemicity and intensity of
transmission has been attributable to the year after year prevalence and
continuous yearly incidence of the disease has in turn been blamed on the
limited knowledge, certain attitudes, practices and beliefs of the affected local

163
communities (Ameh, 1995). Edungbola (1983) and Muller (1979) have
maintained that the disease also influences the performance and observation
of local celebration and religious festivals, politic, and aids malnutrition among
children. Onwuliri et al. (1988-90) and Adeiyongo (2004) in Benue and
Nasarawa states of Nigeria respectively, observed that infected persons still
believed it was a spell cast on them by their enemies and therefore refused to
comply to the interventions. Adeiyongo and Onwuliri in Central Nigeria
observed that infected persons used hot iron to press at the point of worm
emergence and in addition rubbed local herbs like Pergularia extensa on the
wounds and this created more problems. The Intensive Health Education
Campaign by Global 2000 Team has created enough awareness in the study
area to such a level that there were no more superstitious beliefs, practices
and habits that constituted any hindrance to guinea worm eradication.
Members of the sampled communities had knowledge about the cause,
treatment/management and prevention of the disease. They complied very
well with the interventions and there were no constraints in either the use of
filters or of water treated with Abate. Ameh (1995) reported in Benue State,
of Nigeria that some rituals required a lot of eating and drinking and only
surface water was recommended by the priests. Such habits, he further
stressed, rendered useless many prophylactic, therapeutic and control
measures. Few respondents in the present study still engaged in practices
which were detrimental to the success of the eradication programme for
example the preference of pond water to water from hand-dug-wells even
where these were available for the simple reason that some or almost all the

164
wells are very deep and therefore extra effort was needed in drawing the
water. Muller (1971) had observed that provision of draw wells did not solve
the problem of lack of water and cited cases where surface water supply was
preferred partly because it tastes brackish for religious reasons and the extra
effort involved in drawing water from the well.
In Borno State therefore, it requires the combination of filter usage and
Abate application/treatment of ponds to eradicate the disease. This has
already been seen to prove very effective as it has been observed in this
study, the drastic reduction in the number of cases from 2,053 in 1998 to only
34 in 2003/2004 epidemiological year.
5.10 THE DENSITY AND INFECTIVITY RATES OF THE CYCLOPOID
COPEPODS IN THE VARIOUS VILLAGES SAMPLED IN BORNO
STATE
The infectivity of cyclopoid copepods with D. medinensis larvae was
established in this study. Similar reports of infectivity of cyclops have been
documented by other research workers in other parts of the country although
of higher rates than the present study (0.35%). The works by Onwuliri et al.
(1991) in Plateau State reported 12 – 14%; Onabamiro (1951) in Southern
Nigeria recorded 5.1% infection rates, while Nwobi et al. (1996) in Plateau
State reported 4.9%. The low rates of 0.35% recorded in the present study
could be as a result of the massive and integrated eradication programme
embarked upon by Global 2000 in collaboration with NIGEP towards the
eradication of the disease. The objective of the eradication programme is to
exterminate the pathogen, D. medinensis and not the copepoid vectors. The

165
villages in which infected cyclops were observed coincided with the ones
which did not achieve 100% case containment during the epidemiological
year under study. These villages also coincided with the ones in which human
infections were observed during the study period.
5.10.1 Seasonal Variation of the Density and Infectivity of the
Cyclops
The results obtained from this study showed that seasonal variation
existed in the density and infection rates of the cyclops. Cyclops densities
and infectivity were highest during the rainy season (June-October) while no
cyclops were recovered from any of the ponds as they all dried up as from
January 2004. This coincided with the period when residence in guinea worm
endemic villages in these areas usually came more in contact with surface
water bodies and since it has been established that transmission in these
areas takes place during the rainy season, it has been observed that the
transmission potentials of the vectors depend solely on the density and levels
of infectivity of the cyclops especially in stagnant ponds (Udonsi 1987, Watts
et al. 1989; Nwobi et al. 1996).
This study indicated that in Borno State the evidence of cyclops
infection assured a very wide dimension being much more serious than
perceived. This was intimately associated with shortfalls in some of the
interventions for example, the non achievement of the 100% case
containment (Adeiyongo, 2006) leading to the re-contamination of water
bodies by infected individuals. Also the breakdown of the very few available
sources of portable water supply or the lack of diesel to run the generators

166
used in pumping water from such sources which in turn were very
inadequate. This presents a classical situation of the strong potential of
formerly guinea worm free communities becoming endemic should there be
continuous inadequate supply of potable drinking water. This is in line with
earlier observations by Nwobi et al. (1996).
The measures adopted for the eradication of guinea worm disease
include among others the prohibition of infected persons from wadding into
pond water as observed by Fabiyi (1991) in Bauchi State; but this is normally
not adhered to by the infected individuals. If guinea worm eradication
machinery puts in more efforts towards achieving 100% case containment in
all the endemic villages, the infectivity rate of the cyclops will be reduced to
zero and thus the link between D. medinensis larvae and the vector will be
broken. Also if application of Abate in these affected communities
commences at the beginning of the rainy season, (June) (Adeiyongo 2006),
the density of the cyclops will be reduced before the beginning of
transmission period sets in (July), and infected cyclops gotten rid of and thus
the transmission cycle would be broken down and eradication of guinea worm
in Borno State ensured.
5.11 EFFECTS OF ABATE (TEMEPHOS) APPLICATION ON THE
CYCLOPOID COPEPOD DENSITIES IN BORNO STATE
The result obtained from this study revealed that the density of cyclops
reduced drastically by half after two weeks of application and thereafter
increased to about ¾ or 1 by the 4 th week after Abate application. There was
scanty or no reports from other authors with which to compare our findings.

167
However, the results obtained were in agreement with the expectations of
WHO (1989) that a reduction of 80 – 90% in the density of cyclops compared
to the estimated density before treatment indicated that the application of
Abate was appropriate and successful, and also that if the Abate larvicide
treatment had been successful, the relative number of copepods should be
greatly reduced and these should be smaller in size than before treatment.
The results in this study have given us the conclusion that the application of
Abate in the study area was done according to WHO set guidelines and that it
was one of the effective ways of controlling guinea worm disease.
5.12 THE COST IMPLICATION OF GUINEA WORM PROGRAMME IN
BORNO STATE
A total amount of N74, 902,755.00 was spent on guinea worm
eradication programme in Borno State between 1996 and June 2004. Certain
shortfalls were observed from the findings. The amount spent on allowances
to VBHWs was very small (N500 per VBHW per month) and this might have
brought lack of commitment on the part of the VBHWs. Few hand-dug wells
were rehabilitated and no new ones were dug. No single borehole was sunk
by the eradication team; one or two were maintained and this was not good
enough. However, N27, 0162,290.00 was spent on filters alone and that
explained the success of the programme in the area, since this was able to
get to every household in the endemic villages. More effort should be geared
towards the area of Health Education and case containment on the need to

168
filter all drinking water and not to contaminate water bodies in order to
render the State and the Nation at large free of the menace.
5.13 IMPEDIMENTS OF THE ERADICATION PROGRAMME IN
BORNO STATE
Despite the series of successes recorded by the eradication programme
in Borno State, there were some impediments as well.
The first and most important of the impediments was lack of finance.
This caused a lot of problems in carrying out all the necessary surveillance,
field work and interventions. There were few vehicles available for use
compared to the large area (69,436square kilometres) that had to be
covered. Allowances paid to Village-Based-Health-Workers was extremely
small (N500 per person) considering the very important role they were
playing in the eradication programme at the village level. This might lead to
laxity on their part in constantly checking on the individuals for possible cases
of the disease. The motorcycles and bicycles given to field staff and VBHWs
respectively were not maintained properly due to lack of funds and this might
have led to poor supervision. The very few boreholes available in the study
area had to be run by generators that use diesel. This was not, in most
cases, easily available due to lack of funds and the people had no other
choice but to return to pond water usage from time to time.
Secondly, the area was highly inaccessible. A distance of just 20kms
could take up to 2hours or more by road depending on the season.
Movement in this area also needs special vehicles like the 4-wheel drive being
currently used by Global 2000 staff. This sometimes hindered movement of

169
field staff to various villages for supervision (especially during the rainy
season) considering the large land mass (69436square kilometres) of Borno
State.
Thirdly, the geology of the study area posed a serious challenge in the
area of safe water provision (Hand-dug-wells and Bore-holes). The water
table in this area is very deep (up to 200 feet deep) and therefore creates a
lot of problems when wells are to be dug. Some have water only during the
rainy season but dry up during the dry season. The very few that have water
all the year round are so deep that the depth itself creates problems for the
users.
Fourthly, the new strategy of confining guinea worm patients at the
case containment centres was initially slowed down by unacceptability, which
however improved consequently with improved awareness.
The fifth is the early withdrawal of Global 2000 field staff from areas
reporting zero cases for just one or two years. This poses a serious threat to
maintaining surveillance and to the certification of elimination of the disease.
Early withdrawal could also lead to indifference on the part of both the
VBHWs and Global 2000 field staff who do not have any other means of
sustenance, and therefore would prefer the disease to continue to linger on
so they could have some means to live on. This could definitely lead to a
resurgence of cases and therefore serious set back in the eradication
programme may result.
The sixth is the non containment of all cases. Cases that are not
contained go back to contaminate water sources where other people get

170
infected or re-infected. During the course of this study eight out of the 34
cases encountered were not contained, one case is enough to infect a whole
state not to talk of eight.
The seventh is the series of armed bandits operations in the area
which have also hindered surveillance activities in the area.
Globally, we have reports of insecurity hindering operations in some
important areas in Ethiopia, Cote d‟Ivoire, and Sudan, even though in Sudan,
the main impediment of Sudan‟s civil war is now over, significant insecurity
still remains in parts of Southern Sudan (Hopkins et al. 2002). Complacency
and apathy are still important concerns in some quarters and among some
health personnel, but this is most often manifest now by lack of urgency in
responding to suspected cases of dracunculiasis, and by inadequacy of
surveillance for dracunculiasis in formerly disease-endemic areas or areas not
disease-endemic in most African countries concerned, including many that
have reduced or apparently eliminated the disease at great cost. One final
factor that has become more evident in recent years is the existence of
neglected marginalized populations such as the Black Tuaregs of Mali and
Niger, and the Konkomba ethnic group in Ghana and Togo, who dominate
some of the pockets of disease remaining but who were previously
overlooked and/or their significance unrecognized, by the respective
Dracunculiasis Eradication Programmes (Hopkins et al. 2005).

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5.14 RECOMMENDATIONS AND CONCLUSIONS
Although the successes and impediments of the Guinea worm
Eradication Programme in Borno State have been enumerated, it is obvious
that some measures have to be taken in order to be able to sustain the
programme at the state level and globally.
The first recommendation is for the Federal Government to increase its
budgetary allocation to the Eradication Programme through the Ministry of
Health. Government at all levels in Nigeria should assume the leadership role
in NIGEP partnership with a view to meeting certification criteria for guinea
worm disease eradication. The former Head of State, General Yakubu Gowon,
through the Gowon Centre, has already done a great deal in this direction of
mobilizing State Governors, Local Government, Chairmen and other able
citizens of this country to support this programme. The support could be in
kind or cash for example donating vehicles for use on the field or buying
pipe/straw filters and donating to the programme. The provision of safe
water could be supported not necessarily by sinking wells or drilling boreholes
but by sponsoring the construction of cisterns and reservoirs to collect rain
water during the rainy season to be used during the dry season.
The second recommendation is for the State Governors together with
the various Local Government Chairmen of these areas to come together and
open up roads to ease up surveillance activities, and set up clinics for these
suffering citizens.
The third recommendation is for the Global 2000 field staff and VBHWs
in areas certified free of the disease to be absorbed into other Control/Health

172
Programmes like Malaria, Polio, Onchocerciasis, Lymphatic filariasis. The
knowledge/skills they have acquired from guinea worm eradication
programme will become very useful in these other programmes as well.
Communities should come together and dig wells in order to
compliment Government efforts. They should also take other measures like
guarding of ponds in turns to prevent infected people from contaminating
water bodies; infected people caught violating the laws to pay a fine and
other such measures.
Sudan, Ghana and Nigeria still reported 5,074, 3,190 and 73 cases
respectively in 2007 (Ruiz-Tiben, 2007). The certification criteria states that
there should be Certification Standard Surveillance System for at least three
(3) consecutive years of zero guinea worm indigenous case reporting. It is
therefore impossible for global eradication of guinea worm to be achieved by
2009.

5.15 SUMMARY OF RESULTS
173
Review of guinea worm cases from 1995-2007 by passive surveillance;
house to house case search by active surveillance; taking stock of
intervention strategies put in place and their functional state, and KAP studies
through questionnaire and interviews revealed that, guinea worm cases were
on the decline in Borno State. Five (55.55%) out of the 9 Local Government
Areas and 12(8.1%) out of the 148 villages sampled were still reporting
cases. Thirty-four (0.01%) out of 310,092 (162,972 males and 147,120
females) examined had guinea worm cases. More males (25; 0.02%) than
females (9; 0.01%) were infected but no significant difference (p>0.05) was
observed. All age groups in the male category were equally infected while
ages 11-40 were more infected in the female category. Twenty-six (76.5%)
of the 34 cases encountered were people still depending on pond water for
drinking and other domestic purposes. Farmers (17; 0.02%) and Nomads (5;
0.04%) had higher infection rates than the other occupational groups
although T-test analysis did not show any statistical difference (p>0.05).
Twenty-six (76.5%) of the 34 cases were contained while 8(23.5%) were not.
All the 34(100%) cases occurred on the lower limbs. Cases were recorded
between July and November with the peak (12; 35.29%) in September and
the least (2; 2.94%) in November.
The intervention strategies put in place included Health Education,
filter usage, Abate application/treatment, case containment centres, safe
water supply, Cash reward and Village-Based-Health-Workers. The preferred
intervention strategies were filter usage, Abate application and there was one

174
Village-Based-Health Worker in each village. Safe water supply sources and
case containment centres were grossly inadequate as there were only 55
functional Hand-dug wells, three boreholes and only 5 case containment
centres in the study area.
KAP studies showed that individuals had good knowledge about the
disease; its cause, prevention and treatment. Superstitious beliefs were no
longer associated with the disease and traditional methods of treatment were
no longer employed. Sampled communities had no constraint in the
compliance to any of the intervention strategies. This was attributed to the
awareness created by the Eradication programme through Health Education.
A total of 7,052 cyclops were collected from 15 ponds and 25(0.35%)
out of these were infected with the larvae of D. medinensis. Infection of
cyclops were observed between July and November 2003 while December
2003 and the early part of 2004 recorded no infected cyclops. The month of
September 2003 recorded the highest number of infected cyclops (11;
5.30%) which coincided with the peak period for guinea worm cases in the
same year. The result of impact of Temephos on cyclopoid density showed
that the cyclopoid densities obtained before application of the larvicide were
twice higher than the ones obtained two weeks after application and just
slightly higher than or equal to the figures obtained 4 weeks after.
The cost of the eradication programme in Borno State was
N74,902,755.00.

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5.16 CONTRIBUTION TO KNOWLEDGE
An evaluation of Guinea worm Eradication Programme in Borno State
revealed that:
1. Guinea worm cases can be reduced by the use of Health Education,
filter usage and temephos (Abate) application to water much more
than by the provision of potable water as widely acclaimed. Provision
of potable water was not a popular intervention measure due to the
low water table of the state.
2. The successful use of Village-Based-Health Workers (VBHWs) in Guinea
worm Eradication Programme is necessary in the control programmes
of other diseases such as Onchocerciasis, lymphatic filariasis,
schistosomiasis and malaria.
3. The actual period that Temephos (Abate) application to water bodies
to kill cyclops was determined in the sahalian region as June. This
coincided with the month before the peak of transmission period in
order to reduce the density of the cyclops. The time interval between
one application and the other is 4 weeks.
4. The successes and impediments of the Guinea worm Eradication
Programme revealed in this study will be used to improve on planning
and implementation of other future community programmes.
5. This study has contributed to the determination of the actual date of
certification of eradication which has been missed several times.

176
5.17 RECOMMENDATION FOR FURTHER STUDIES
This study has pointed out the successes and impediments in the
implementation of the Eradication Programme. It is therefore recommended
that similar studies be carried out in other parts of the country and even in
other countries where guinea worm has been endemic.
Vector studies in this research was only limited to density and
infectivity of cyclops and impact of Abate (Temephos) on their density. It is
therefore suggested that further research be carried out in the area of
identification of cyclops species present in the water bodies of the endemic
communities.

177
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L.G.A.
198
APPENDIX A1
LOCAL GOVERNMENT AREAS AND VILLAGES OF BORNO
STATE SURVEYED DURING 2003/2004
NAME OF
VILLAGE
NO. OF
HOUSEHOLDS
ESTIMATED
POPULATION
NO. OF
CASES
BAMA Abuja 450 3,000 -
Bama town 15,000 100,000 -
Walasa kura 340 3,200 3
Bula Manzue 55 330 1
Nguzoduwa 143 350 7
Adawa 250 1,500 -
Bogoro 26 130 -
Bula Melebe 300 2,008 2
Mbaga-Eali 150 500 -
Yerwa Baktaba 180 650 -
Mallam Kari 350 1,300 -
Bula Jokoye 50 250 -
Mafi 200 950 -
Banki Town 4,000 50,000 -
Jelta 16 100 -
Kashimiri 448 4,000 -
Bodimari 95 3,000 3
Malarire 130 260 -
Bula Gao 21 150 -
Nguzuaa 270 600 -
Salasa Dakari 28 80 -
Goni Alliri 40 200 -
Rija‟a 43 260 -
Jimcyte 60 600 -
Magarin (Yemut) 55 120 -
Jabbari 65 650 -

199
NAME OF
NO. OF ESTIMATED NO. OF
L.G.A.
VILLAGE HOUSEHOLDS POPULATION CASES
BAMA Bula Umar (Abarim) 20 200 -
Dussua 250 4,000 -
Chur-chur 30 300 -
Marsamari 15 150 -
Durbe Ngobdori 70 700 -
Zenda 50 105 -
Gulumba 2,682 6,800 -
Mbaga Eali 150 500 -
Bornisu 25 221 -
Bula Karaye 27 270 -
Landartar/yermati 95 500 -
Morodo 18 1,800 -
Aurasiri 48 487 -
Ngermari 176 1760 -
Zumbula 350 3,000 -
Kagalmari 85 350 -
Raffa B. Goni 45 250 -
Abarram 163 200 -
Ali Karimari 107 500 -
Digra Pompormati 26 250 -
Bugurmari 30 300 1
Ajirubulajo 60 200 -
Tafana kura 25 250 -
Borjino 38 380 -
Zarmari 53 450 -
Jongomari 18 50 -
Yerwa kalukutu 400 4,000 -
Bula Bulin 200 2,000 -
Chinna 135 600 -
Andara I & II 400 2,000 -

L.G.A.
NAME OF
VILLAGE
200
NO. OF
HOUSEHOLDS
ESTIMATED
POPULATION
NO. OF
CASES
BAMA Bula Morube 55 500 -
Kalamudor 60 400 -
Suwa Bara 18 180 -
Terigi 140 1,400 -
Walasa kusuluwa 64 270 -
Warafaya 200 2,000 -
Zetelenge 300 1,200 -
Borwashe 60 1600 -
Mallamuri 35 350 -
Bula Buylin Gulumba 80 500 -
Chingori 200 1,000 -
Fala 38 180 -
Modumajiri 40 180 -
Bem-Bem 350 3,800 -
Bula
Umarbellambabe
400
4,000
Cha-chile 45 452 -
Jada‟a 320 3,200 -
Kumshe 650 6,500 -
Wdizuzu 35 100 -
Bishiri 50 170 -
Falatari 120 650 -
Grema-kasalri 80 200 -
Leno-Abunaye 70 350 -
Alagorno 60 350 -
Bula Boyoye 15 130 -
Bula Gonikidda 15 130 -
Bula kursobe 33 332 -
Bula mangaye 100 1,000 -
Bula Mastaphabe 100 1,050 -
-

L.G.A.
NAME OF
VILLAGE
BAMA Bula Ngambe
(Umaruwa)
201
NO. OF
HOUSEHOLDS
ESTIMATED
POPULATION
NO. OF
CASES
400 2,200 -
Bula Sheriwuye 150 750 -
Kaji Bere Aji 67 400 -
Kardule 141 846 -
Kote kura 160 1600 -
Mulu Buta 350 2,100 -
Mungule 117 700 -
31,259 264,931 17
DAMBOA Mafi 200 950 1
Wgotori 120 1,200 2
Kingarwa 175 1,750 -
Ngirinalawanti 95 950 -
Ngow Njaba 90 900 -
Yerwa II 200 2,000 -
880 7,750 3
KONDUGA Lawanti Umarti 25 150 -
Mianti 25 150 1
Ngublori 44 245 -
Abukarti 45 450 -
Kukkuruk 300 3,000 1
Adamti 99 250 -
Abulam “A & “B 400 1,700 -
Diwaranti 83 180 -
Saitti 30 300 -

L.G.A.
NAME OF
VILLAGE
202
NO. OF
HOUSEHOLDS
ESTIMATED
POPULATION
NO. OF
CASES
KONDUGA Makunta (Mallamari) 55 300 -
Yauri 60 250 -
Nyaleri 300 3,000 -
Yajiwa 133 800 -
Gumsuri 35 210 -
Followane 35 350 -
Kommolla 28 168 -
Gurzum 30 180 -
1,847 12,883 2
DIKWA Masa 450 3,000 11
Isari 108 750 -
Wulamashe 250 1,200 -
Metene 53 580 -
Bulatura 8 80 -
Fulatari 9 90 -
Warajama 52 450 -
Durbe 350 3,000 -
Gumulde 30 300 -
Ajiri Gwanga 70 700 -
Bura Burabe 21 218 -
Sholoba 6 60 -
Dugula Hamed 6 65 -
Dugula hammer 4 45 -
1,417 10,538 11
GWOZA Kushe kushe 50 500 -
Kirawa A & B 50 500 -
Jimini A & B 21 210 -

L.G.A.
NAME OF
VILLAGE
203
NO. OF
HOUSEHOLDS
ESTIMATED
POPULATION
NO. OF
CASES
Mbala Vale 19 190 -
GWOZA Mbituku A 17 170 -
Kirawa Town 300 3,000 -
457 4,570 -
MAFA Azangoro 100 360 -
Munyeri 75 450 -
Dogumba B.-
Zanawa 8 95 -
Burari 9 90 -
Dogumba B.-
Aldawa 8 85 -
Mafa Town 150 1,500 -
350 2,580 0
MARTE Allah Jiddari 150 1,600 -
Runde 25 250 -
175 1,850 0
MAGUMERI Ka‟ajiya 21 130 1
MONGUNO Ali Ngodomari 350 3,500 -
Kalmari 74 740 -
Guza 62 620 -
486 4,860 0

204
APPENDIX A2: NIGERIAN GUINEA WORM ERADICATION
PROGRAMME FORM 2 – VILLAGE REPORT

205
APPENDIX A3: QUESTIONNAIRE
AN EVALUATION OF GUINEA WORM ERADICATION INTERVENTION
STRATEGIES IN BORNO STATE, NIGERIA
Health Education
1. Do you know what guinea worm disease is? (Yes/No). Explanation
needed.
_______________________________________________________
2. How does one contact the disease? _________________________
3. How does one spread the disease? __________________________
4. When did you know about the cause and spread of the disease –
(Year)
5. How can you stop the spread of the disease? _________________
6. How can you treat the disease victim? _______________________
7. Are there superstitions/taboos on the disease in your village (Yes/No)
8. If yes what are they? _____________________________________
Filter
1. Do you know what a nylon filter is? __________________ (Yes/No
2. Do you know how to use it? _______________________ (Yes/No).
How? _________________________________________________
3. Do you have a nylon filter material___________________ (Yes/No)
4. Do you use it? (Yes/No). If yes how often?
(Always/Sometimes/Never.
5. How long have you been using filters? _______________________
6. Do you have any constraint in the use of filters? (Yes/No). What are
they?
Abate
1. Do you know what abate is? (Yes/No). What is it? ____________

206
2. Has abate ever been applied in your village? __________ (Yes/No)
3. When was abate first applied in your village? ____________ (Year)
4. When last was abate applied in your village? _______ (Month/year)
5. Do you know why abate is applied in your village pond? (Yes/No)
Why __________________________________________________
6. Does your community accept abate treatment of your pond? (Yes/No)
Why __________________________________
Water Supply:
1. What is your source of water supply? ______ (Pond/well/Bore-hole)
2. Is it serviceable throughout the year? ________________ (Yes/No)
3. Is it functional now? ______________________________ (Yes/No)
4. How far is it from your villages? _______________ (Distance/Time)
5. What is your village doing about improving water source(s)?
______________________________________________________
6. Is there a new water supply in your village?_____ (Yes/No). If yes,
who provided it? ________________ when? __________________
Case Containment Strategy (CCS):
1. Do you know what CCS is? ____________ (Yes/No).
What is it? ___________________________________________
2. How is CCS done? _______________________________________
3. What do you think of CCS? ________________________________
4. Have you ever had Guinea worm disease before? _______ (Yes/No)
5. How were you treated? _______________________ i.e. impression
6. How long did the Guinea worm take to complete emerging?
_______ (Months)
7. When last did you or members of your family have Guinea worm
disease? ___________ (Year)

207
Appendix B1: Chi-Square of the Prevalence of Dracunculiasis in
Borno State in Relation to Ages and Sexes of the
Individuals Sampled
Age Group
(Years)
No.
Examined
MALE FEMALE
No. (%)
Infected
No.
Examined
No. (%)
Infected
00 – 10 38,023 4(0.01) 26,302 2(0.01)
11 – 20 37,353 6(0.07) 34,201 2(0.01)
21 – 30 34,716 7(0.02) 30,522 3(0.01)
31 – 40 22,814 5(0.02) 22,641 2(0.01)
41 – 50 18,193 1(0.01) 17,001 0(0.00)
51+ 11,873 2(0.02) 16,453 0(0.00)
TOTAL 162,972 25(0.02) 147,120 9(0.01)
Df 5
Chi-Square 1.314
P-Value 0.9335
Chi-square analysis shows that there is no significant difference (p>0.05) in
the number of infected persons in relation to age and sex.

208
Appendix B2: T-test Analysis of the Prevalence of Dracunculiasis
According to Their Sources of Drinking Water
Source of
Water
Number
Examined
Number (%)
Infected
Borehole/Pond 16,313 3(0.02)
Pipe Borne - -
Stream - -
Ponds 265,003 26(0.01)
Hand-dug Wells/Ponds 28,776 5(0.02)
Others - -
TOTAL 310,092 34(0.01)
Mean 5.007
Df 5
t-value 1.365
P-Value 0.2306
T-test analysis shows that there is no statistical difference (p>0.05) in the
number of infected persons in relation to the source of drinking water.

209
Appendix B3: T-test Analysis of the Distribution of Guinea Worm
Cases in Relation to the Occupational Status of the
Individuals
Occupation Number
Examined
Number
Infected
Pre-school age 23,720 1
Students 40,692 5
Civil Servants 16,215 0
Home Makers 85,426 7
Farmers 97,571 17
Traders 16,433 2
Nomads 5,123 2
Almagiris 24,912 0
TOTAL 310,092 34
Mean 4.250
Df 7
t-value 1.998
P-Value 0.0859
T-test analysis shows that there is no statistical difference (p>0.05) in the
number of infected persons in relation to the occupational status of the
individuals.

210
APPENDIX B4: Two Way Analysis of Variance of the Effect of
Abate on Cyclopoid Densities in the Sampled
Communities of Borno State.
Between-Subjects Factors
Value
Label
N
1 Before 24
Treatment (Period) 2 2 weeks 24
3 4 weeks 24
1 July 18
2 August 18
Months
3
Septemb
er 18
4 October 18
Tests of Between-Subjects Effects
Dependent Variable: Content
Source
Type III Sum
of Squares
Df
Mean
Square
F Sig.
Corrected Model 51.153(a) 11 4.65 1.59 0.125
Intercept
238.347 1
238.34
7 81.486 0
v2 15.528 2 7.764 2.654 0.079
v3 33.042 3 11.014 3.765 0.015
v2 * v3 2.583 6 0.431 0.147 0.989
Error 175.5 60 2.925
Total 465 72
Corrected Total 226.653 71
a R Squared = .226 (Adjusted R Squared = .084)
The result of the two way analysis of variance shows that:
1. there is no significant difference (P>0.05) between treatment periods
(V2).
2. there is a significant difference (P0.05) between the treatment periods and
the months (V2V3).