Potential Impact of a Diagnostic Test for Detecting Prepatent Guinea Worm Infections in Dogs

Chad has seen a considerable reduction in cases of Guinea worm disease (or dracunculiasis) in domestic dogs in recent years. Tethering of dogs and application of Abate® larvicide to water sources appear to have contributed to this progress, but with 767 reported dog cases in 2021, accelerating elimination of the disease in Chad may require additional tools. We investigate the potential benefits of a hypothetical diagnostic test that could be capable of detecting prepatent infections in dogs. We adapt an agent-based simulation model for forecasting the impact of interventions on guinea worm disease in dogs to examine the interaction of multiple test factors including test accuracy, when the test can detect infection, dog selection, and dog-owner compliance with tethering recommendations. We find that a diagnostic test could be successful if used in conjunction with existing interventions, and elimination can be achieved within 2 years with 80% or higher test sensitivity, 90% or higher specificity, systematic testing of each dog twice per year, and more than 90% long-term tethering compliance when a dog tests positive or a worm is emerging. Because of the long incubation period of Guinea worm disease (10-14 months) and the fact that no treatment exists, the benefits of the test rely on the testing rollout and response of dog owners. If the test could estimate the timing of worm emergence, long-term tethering could be eliminated and infected dogs could be tethered only when the worms are expected, minimizing the related resources (human and financial) to support the intervention.

Progress Toward Eradication of Dracunculiasis - Worldwide, January 2022-June 2023

The effort to eradicate Dracunculus medinensis, the etiologic agent of dracunculiasis, or Guinea worm disease, commenced at CDC in 1980. In 1986, with an estimated 3.5 million cases worldwide in 20 African and Asian countries, the World Health Assembly called for dracunculiasis elimination. The Guinea Worm Eradication Program (GWEP) was established to help countries with endemic dracunculiasis reach this goal. GWEP is led by The Carter Center and supported by partners that include the World Health Organization, UNICEF, and CDC. In 2012, D. medinensis infections were unexpectedly confirmed in Chadian dogs, and since then, infections in dogs, cats, and baboons have posed a new challenge for GWEP, as have ongoing civil unrest and insecurity in some areas. By 2022, dracunculiasis was endemic in five countries (Angola, Chad, Ethiopia, Mali, and South Sudan), with only 13 human cases identified, the lowest yearly total ever reported. Animal infections, however, were not declining at the same rate: 686 animal infections were reported in 2022, including 606 (88%) in dogs in Chad. Despite these unanticipated challenges as well as the COVID-19 pandemic, countries appear close to reaching the eradication goal. GWEP will continue working with country programs to address animal infections, civil unrest, and insecurity, that challenge the eradication of Guinea worm.

Progress Toward Global Eradication of Dracunculiasis - Worldwide, January 2021-June 2022

Dracunculiasis (Guinea worm disease), caused by the parasite Dracunculus medinensis, is acquired by drinking water containing small crustacean copepods (water fleas) infected with D. medinensis larvae. Recent evidence suggests that the parasite also appears to be transmitted by eating fish or other aquatic animals. About 1 year after infection, the worm typically emerges through the skin on a lower limb of the host, causing pain and disability (1). No vaccine or medicine is available to prevent or treat dracunculiasis. Eradication relies on case containment* to prevent water contamination and other interventions to prevent infection, including health education, water filtration, treatment of unsafe water with temephos (an organophosphate larvicide), and provision of safe drinking water (1,2). CDC began worldwide eradication efforts in October 1980, and in 1984 was designated by the World Health Organization (WHO) as the technical monitor of the Dracunculiasis Eradication Program (1). In 1986, with an estimated 3.5 million cases† occurring annually in 20 African and Asian countries§ (3), the World Health Assembly called for dracunculiasis elimination. The Guinea Worm Eradication Program (GWEP),¶ led by The Carter Center and supported by partners that include WHO, UNICEF, and CDC, began assisting ministries of health in countries with endemic disease. In 2021, a total of 15 human cases were identified and three were identified during January-June 2022. As of November 2022, dracunculiasis remained endemic in five countries (Angola, Chad, Ethiopia, Mali, and South Sudan); cases reported in Cameroon were likely imported from Chad. Eradication efforts in these countries are challenged by infection in animals, the COVID-19 pandemic, civil unrest, and insecurity. Animal infections, mostly in domestic dogs, some domestic cats, and in Ethiopia, a few baboons, have now surpassed human cases, with 863 reported animal infections in 2021 and 296 during January-June 2022. During the COVID-19 pandemic all national GWEPs remained fully operational, implementing precautions to ensure safety of program staff members and community members. In addition, the progress toward eradication and effectiveness of interventions were reviewed at the 2021 and 2022 annual meetings of GWEP program managers, and the 2021 meeting of WHO's International Commission for the Certification of Dracunculiasis Eradication. With only 15 human cases identified in 2021 and three during January-June 2022, program efforts appear to be closer to reaching the goal of eradication. However, dog infections and impeded access because of civil unrest and insecurity in Mali and South Sudan continue to be the greatest challenges for the program. This report describes progress during January 2021-June 2022 and updates previous reports (2,4).

Development and validation of a quantitative PCR for the detection of Guinea worm (Dracunculus medinensis)

Dracunculus medinensis (Guinea worm) is a parasitic nematode that can cause the debilitating disease dracunculiasis (Guinea worm disease) in humans. The global Guinea Worm Eradication Program has led intervention and eradication efforts since the 1980s, and Guinea worm infections in people have decreased >99.99%. With the final goal of eradication drawing nearer, reports of animal infections from some remaining endemic countries pose unique challenges. Currently, confirmation of suspected Guinea worm infection relies on conventional molecular techniques such as polymerase chain reaction (PCR), which is not specific to Guinea worm and, therefore, requires sequencing of the PCR products to confirm the identity of suspect samples, a process that often takes a few weeks. To decrease the time required for species confirmation, we developed a quantitative PCR assay targeting the mitochondrial cytochrome b (cytb) gene of Guinea worm. Our assay has a limit of detection of 10 copies per reaction. The mean analytical parameters (± SE) were as follows: efficiency = 93.4 ± 7.7%, y-intercept = 40.93 ± 1.11, slope = -3.4896 ± 0.12, and the R² = 0.999 ± 0.004. The assay did not amplify other nematodes found in Guinea worm-endemic regions and demonstrated 100% diagnostic sensitivity and specificity. Implementation of this quantitative PCR assay for Guinea worm identification could eliminate the need for DNA sequencing to confirm species. Thus, this approach can be implemented to provide more rapid confirmation of Guinea worm infections, leading to faster execution of Guinea worm interventions while increasing our understanding of infection patterns.

Guinea worm (Dracunculus medinensis) is a parasitic nematode that causes debilitating disease in humans. The Guinea Worm Eradication Program would benefit from having a rapid molecular test that can confirm species identification without time-consuming DNA sequencing. We developed a qPCR protocol targeting the mitochondrial cytochrome b (cytb) gene of Guinea worm. The assay was validated analytically over 12 experiments using a standard serial dilution as well as diagnostically on DNA samples from non-target host species and other parasites (n = 180) and Guinea worm samples (n = 200) from a diversity of hosts and geographic regions. This assay could reliably detect 10 copies of the target DNA sequence and had a mean efficiency of 93.4% with 100% diagnostic sensitivity and specificity.

Assessment of the Chad guinea worm surveillance information system: A pivotal foundation for eradication

Background

In the absence of a vaccine or pharmacological treatment, prevention and control of Guinea worm disease is dependent on timely identification and containment of cases to interrupt transmission. The Chad Guinea Worm Eradication Program (CGWEP) surveillance system detects and monitors Guinea worm disease in both humans and animals. Although Guinea worm cases in humans has declined, the discovery of canine infections in dogs in Chad has posed a significant challenge to eradication efforts. A foundational information system that supports the surveillance activities with modern data management practices is needed to support continued program efficacy.

Methods

We sought to assess the current CGWEP surveillance and information system to identify gaps and redundancies and propose system improvements. We reviewed documentation, consulted with subject matter experts and stakeholders, inventoried datasets to map data elements and information flow, and mapped data management processes. We used the Information Value Cycle (IVC) and Data-Information System-Context (DISC) frameworks to help understand the information generated and identify gaps.

Results

Findings from this study identified areas for improvement, including the need for consolidation of forms that capture the same demographic variables, which could be accomplished with an electronic data capture system. Further, the mental models (conceptual frameworks) IVC and DISC highlighted the need for more detailed, standardized workflows specifically related to information management.

Conclusions

Based on these findings, we proposed a four-phased roadmap for centralizing data systems and transitioning to an electronic data capture system. These included: development of a data governance plan, transition to electronic data entry and centralized data storage, transition to a relational database, and cloud-based integration. The method and outcome of this assessment could be used by other neglected tropical disease programs looking to transition to modern electronic data capture systems.

Guinea worm disease has no pharmacological treatment or vaccines, and therefore existing prevention and control strategies (e.g., case containment, health education, chemical treatment of water bodies) are critically dependent on timely, accurate, and actionable data. We conducted informant interviews, used conceptual frameworks, and mapped data flow to evaluate the Chad Guinea Worm Eradication Program’s current information system. We identified areas for improvement including the need to consolidate variables across data collection forms and the need to develop streamlined workflows. We proposed a four-phased roadmap for transitioning to an electronic data capture system and centralizing data storage. Our approach and proposed roadmap could be adopted by other neglected tropical disease control programs looking to modernize data collection and storage procedures.

Correlates of Variation in Guinea Worm Burden among Infected Domestic Dogs

The Guinea Worm Eradication Program has been extraordinarily successful-in 2019, there were 53 human cases reported, down from the estimated 3.5 million in 1986. Yet the occurrence of Guinea worm in dogs is a challenge to eradication efforts, and underlying questions about transmission dynamics remain. We used routine surveillance data to run negative binomial regressions predicting worm burden among infected dogs in Chad. Of 3,371 infected dogs reported during 2015-2018, 38.5% had multiple worms. A multivariable model showed that the number of dogs in the household was negatively associated with worm burden (adjusted incidence rate ratio [AIRR] = 0.95, 95% CI: 0.93-0.97, P < 0.0001) after adjusting for dog age (AIRR = 0.99, 95% CI: 0.96-1.01, P > 0.1). This could relate to the amount of infective inocula (e.g., contaminated food or water) shared by multiple dogs in a household. Other significant univariable associations with worm burden included dog history of Guinea worm infection (IRR = 1.30, 95% CI: 1.18-1.45) and dog owners who were hunters (IRR = 0.78, 95% CI: 0.62-0.99, P < 0.05) or farmers (IRR = 0.83, 95% CI: 0.77-0.90, P < 0.0001). Further analysis showed that the number of dogs in the household was significantly and positively correlated with nearly all other independent variables (e.g., owner occupation: farmer, fisherman, or hunter; dog age, sex, and history of Guinea worm). The associations we identified between worm burden and dogs per household, and dogs per household and owner characteristics should be further investigated with more targeted studies.

Setback for campaign to eradicate Guinea worm disease

Arabella Gray discusses new research investigating the role of domestic dogs in sustaining Guinea worm disease in Africa.

Identifying correlates of Guinea worm (Dracunculus medinensis) infection in domestic dog populations

Few human infectious diseases have been driven as close to eradication as dracunculiasis, caused by the Guinea worm parasite (Dracunculus medinensis). The number of human cases of Guinea worm decreased from an estimated 3.5 million in 1986 to mere hundreds by the 2010s. In Chad, domestic dogs were diagnosed with Guinea worm for the first time in 2012, and the numbers of infected dogs have increased annually. The presence of the parasite in a non-human host now challenges efforts to eradicate D. medinensis, making it critical to understand the factors that correlate with infection in dogs. In this study, we evaluated anthropogenic and environmental factors most predictive of detection of D. medinensis infection in domestic dog populations in Chad. Using boosted regression tree models to identify covariates of importance for predicting D. medinensis infection at the village and spatial hotspot levels, while controlling for surveillance intensity, we found that the presence of infection in a village was predicted by a combination of demographic (e.g. fishing village identity, dog population size), geographic (e.g. local variation in elevation), and climatic (e.g. precipitation and temperature) factors, which differed between northern and southern villages. In contrast, the presence of a village in a spatial infection hotspot, was primarily predicted by geography and climate. Our findings suggest that factors intrinsic to individual villages are highly predictive of the detection of Guinea worm parasite presence, whereas village membership in a spatial infection hotspot is largely determined by location and climate. This study provides new insight into the landscape-scale epidemiology of a debilitating parasite and can be used to more effectively target ongoing research and possibly eradication and control efforts.

Guinea worm in domestic dogs in Chad: A description and analysis of surveillance data

After a ten-year absence of reported Guinea worm disease in Chad, human cases were rediscovered in 2010, and canine cases were first recorded in 2012. In response, active surveillance for Guinea worm in both humans and animals was re-initiated in 2012. As of 2018, the Chad Guinea Worm Eradication Program (CGWEP) maintains an extensive surveillance system that operates in 1,895 villages, and collects information about worms, hosts (animals and humans), and animal owners. This report describes in detail the CGWEP surveillance system and explores epidemiological trends in canine Guinea worm cases during 2015-2018. Our results showed an increased in the number of canine cases detected by the system during the period of interest. The proportion of worms that were contained (i.e., water contamination was prevented) improved significantly over time, from 72.8% in 2015 to 85.7% in 2018 (Mantel-Haenszel chi-square = 253.3, P < 0.0001). Additionally, approximately 5% of owners of infected dogs reported that the dog had a Guinea worm-like infection earlier that year; 12.6% had a similar worm in a previous year. The proportion of dogs with a history of infection in a previous year increased over time (Mantel-Haenszel chi-square = 18.8, P < 0.0001). Canine cases were clustered in space and time: most infected dogs (80%) were from the Chari Baguirmi (38.1%) and Moyen Chari Regions (41.9%), and for each year the peak month of identified canine cases was June, with 78.5% occurring during March through August. Findings from this report evoke additional questions about why some dogs are repeatedly infected. Our results may help to target interventions and surveillance efforts in terms of space, time, and dogs susceptible to recurrent infection, with the ultimate goal of Guinea worm eradication.

Ecology of domestic dogs Canis familiaris as an emerging reservoir of Guinea worm Dracunculus medinensis infection

Global eradication of human Guinea worm disease (dracunculiasis) has been set back by the emergence of infections in animals, particularly domestic dogs Canis familiaris. The ecology and epidemiology of this reservoir is unknown. We tracked dogs using GPS, inferred diets using stable isotope analysis and analysed correlates of infection in Chad, where numbers of Guinea worm infections are greatest. Dogs had small ranges that varied markedly among villages. Diets consisted largely of human staples and human faeces. A minority of ponds, mostly <200 m from dog-owning households, accounted for most dog exposure to potentially unsafe water. The risk of a dog having had Guinea worm was reduced in dogs living in households providing water for animals but increased with increasing fish consumption by dogs. Provision of safe water might reduce dog exposure to unsafe water, while prioritisation of proactive temephos (Abate) application to the small number of ponds to which dogs have most access is recommended. Fish might have an additional role as transport hosts for Guinea worm, by concentrating copepods infected with worm larvae.

Guinea worm is a parasite that causes profoundly debilitating disease in humans. An eradication program has been successful in nearly eliminating the disease from people. However, the same worm has now been found in domestic dogs and the frequency of detecting Guinea worm in dogs has been increasing. This means that to eradicate Guinea worm, the infection must be eliminated in dogs as well as in people. However, not much is known about the disease in dogs. This study is the first to investigate dog ecology in relation to Guinea worm infection. We worked in the worst-affected country, Chad. We attached GPS collars to dogs to track their ranging and use of water bodies and analysed their diets using a forensic technique, based on analysing stable isotope compostion of their whiskers and potential food items. We showed that dogs living in households that provided water to their animals had a lower risk of having had Guinea worm and that dogs that ate more fish had an increased risk. These findings suggest there is a classical route for worm transmission in dogs, via drinking contaminated water, as well as a novel route, potentially by eating fish carrying a source of infection.

Population genetic analysis of Chadian Guinea worms reveals that human and non-human hosts share common parasite populations

Following almost 10 years of no reported cases, Guinea worm disease (GWD or dracunculiasis) reemerged in Chad in 2010 with peculiar epidemiological patterns and unprecedented prevalence of infection among non-human hosts, particularly domestic dogs. Since 2014, animal infections with Guinea worms have also been observed in the other three countries with endemic transmission (Ethiopia, Mali, and South Sudan), causing concern and generating interest in the parasites' true taxonomic identity and population genetics. We present the first extensive population genetic data for Guinea worm, investigating mitochondrial and microsatellite variation in adult female worms from both human and non-human hosts in the four endemic countries to elucidate the origins of Chad's current outbreak and possible host-specific differences between parasites. Genetic diversity of Chadian Guinea worms was considerably higher than that of the other three countries, even after controlling for sample size through rarefaction, and demographic analyses are consistent with a large, stable parasite population. Genealogical analyses eliminate the other three countries as possible sources of parasite reintroduction into Chad, and sequence divergence and distribution of genetic variation provide no evidence that parasites in human and non-human hosts are separate species or maintain isolated transmission cycles. Both among and within countries, geographic origin appears to have more influence on parasite population structure than host species. Guinea worm infection in non-human hosts has been occasionally reported throughout the history of the disease, particularly when elimination programs appear to be reaching their end goals. However, no previous reports have evaluated molecular support of the parasite species identity. Our data confirm that Guinea worms collected from non-human hosts in the remaining endemic countries of Africa are Dracunculus medinensis and that the same population of worms infects both humans and dogs in Chad. Our genetic data and the epidemiological evidence suggest that transmission in the Chadian context is currently being maintained by canine hosts.

Guinea Worm (Dracunculus medinensis) Infection in a Wild-Caught Frog, Chad

A third-stage (infective) larva of Dracunculus medinensis, the causative agent of Guinea worm disease, was recovered from a wild-caught Phrynobatrachus francisci frog in Chad. Although green frogs (Lithobates clamitans) have been experimentally infected with D. medinensis worms, our findings prove that frogs can serve as natural paratenic hosts.

The peculiar epidemiology of dracunculiasis in Chad

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

Massive Dracunculus insignis infection in a dog

An 11-year-old 13-kg (28.6-lb) spayed female Cocker Spaniel was examined because of subcutaneous nodules on the hind limbs and ventral aspects of the thorax and abdomen. Focal areas of erythema and pyoderma were associated with the nodules, and purulent exudate could be expressed from a fistula in the nodules. A nematode approximately 20.5 cm in length was isolated from a draining fistula in 1 nodule and identified as Dracunculus insignis. The dog was treated with ivermectin, fenbendazole, and metronidazole, but the owner was still able to recover worms from multiple nodules for the next year.

[Report of a case of dracunculosis in a dog in the Province of Formosa--Argentina]

It is reported Dracunculus sp. in a dog from Fontana city, department of Patiño, in the Formosa Province, Argentina. This is the fourth report of Dracunculosis occurred in animals all from the same geographic area of Formosa.

Inoculation of ferrets with ten third-stage larvae of Dracunculus insignis

Infection with Dracunculus insignis was established in 7 of 10 ferrets experimentally inoculated intraperitoneally with 10 third-stage larvae (L3's). Worm recovery and infection rate were comparable to animals inoculated with 50 L3's. This study demonstrates that once infective larvae traverse the gut and pass into the peritoneal cavity, very few larvae are required to establish infection.

Dracunculus insignis in ferrets: comparison of inoculation routes

Three routes of inoculation were compared to determine the best method to infect ferrets with Dracunculus insignis. The traditional method of administering infected cyclops containing L3s through gavage was compared to intraperitoneal (i.p.) and subcutaneous (s.c.) inoculation of L3s. Ten of 18 (56%) gavaged ferrets became infected after receiving copepods containing approximately 100 L3s each; 44 adult worms were recovered from these 10 animals. Twenty-one of 28 (75%) animals inoculated with 50 L3s each became infected i.p.; 92 adult worms were recovered from the positive animals. Four of 5 (80%) ferrets given subcutaneous inoculations of 50 L3s became infected; only 6 worms were recovered from these 4 animals. Inoculation of larvae via the i.p. or s.c. route greatly simplifies the infection procedure and produces more consistent results. A simple procedure is described, which permits rapid recovery of L3s to be used in the i.p. or s.c. inoculations.

Dracunculus insignis infection in a dog

Painful, fluctuant subcutaneous swellings on the limbs of a dog were attributed to infection with Dracunculus insignis. The diagnosis was obtained by finding larvae in fluid aspirated from the swellings and by identification of the adult female nematodes after they were surgically removed. Six weeks after initial examination, another adult nematode was removed from the subcutaneous tissues of the thorax. Although uncommon, D insignis infection should be considered in the differential diagnosis of subcutaneous swellings.

Vegetative endocarditis with generalized bacterial embolism in association with phlegmon induced by Dracunculus insignis in a raccoon

Lesions of streptococcal vegetative endocarditis and subsequent embolic disease are described in a raccoon (Procyon lotor). A phlegmon of the animal's forelimb associated with Dracunculus insignis infestation was believed to be the primary site of bacterial invasion.

Observations on the seasonal prevalence, pathology and transmission of Dracunculus insignis (Nematoda: Dracunculoidea) in the raccoon (Procyon lotor (L.) in Ontario

Lesions due to Dracunculus insignis in the legs of raccoons (Procyon lotor) in southern Ontario occur seasonally as most larvigerous females emerge in the spring and early summer (April-June). The pathology of dracunculiasis in the raccoon is described and the transmission of the parasite in the wild is discussed with respect to seasonality and local agricultural practices. Crayfish, fishes and frogs (including tadpoles) were given infective third-stage larvae of D. insignis to test their suitability as paratenic hosts. Most of the larvae fed to adult Rana pipiens and R. clamitans were recovered from the somatic musculature. Larvae had increased in size and were highly infective to raccoons.

[Dracunculus insignis (Leidy, 1858) in a German shepherd]

Images

Dracunculus lutrae n. sp. (Nematoda: dracunculoidea) from the otter, Lutra canadensis, in Ontario, Canada

Over the interval 1969–1971, carcasses of 1147 mammals taken in Ontario, Canada, were examined for guinea worm. Dracunculus lutrae n. sp., was recovered from otter Lutra canadensis (Schreber). Dracunculus insignis (Leidy 1858) Chandler 1942, was found in raccoon Procyon lotor (L.), mink (Mustela vison Schreber), and fisher (Martes pennanti (Erxleben)). Female worms identified, in the absence of males, as Dracunculus sp. were found in muskrat (Ondatra zibethicus (L.), opossum (Didelphis marsupialis L.), and short-tailed weasel (Mustela erminea L.) from Ontario and a single badger (Taxidea taxus (Schreber)) from Manitoba.Dracunculus lutrae n, sp. is distinguished from other species of Dracunculus which parasitize mammals (namely D. medinensis (Linnaeus 1758), D. insignis, and D. fuelleborni Travassos 1934), by the greater length of males, greater length of spicules and gubernaculum, presence of three pairs of preanal papillae, and the arrangement in two transverse rows of papillae immediately posterior to the anus. A brief redescription of D. insignis from raccoon and mink is given. The taxonomic status of the species of Dracunculus parasitizing mammals is briefly discussed.

Dracunculus insignis (Leidy, 1858) and larval Eustrongylides sp. in a muskrat from Ontario, Canada

A muskrat, Ondatra zibethica, from northcentral Ontario harbored Dracunculus insignis (Leidy, 1858) Chandler, 1942 subcutaneously. This is the fifth report of Dracunculus sp. in muskrat and the first record of D. insignis males in this host; they are described briefly. The occurrence of Eustrongylides sp. larvae intramuscularly in this muskrat is the first reported natural infection of a mammal by nematodes of this genus.