Imported Dracunculiasis -- United States, 1995 and 1997

Dracunculiasis is a parasitic infection caused by a filarial worm (Dracunculus medinensis {i.e., Guinea worm}) that is transmitted through contaminated drinking water. Approximately 1 year after a person is infected, one or more meter-long adult female worms begin to emerge through the skin, often incapacitating the patient for greater than or equal to 2 months. Despite a dramatic decrease in cases worldwide, dracunculiasis is still occasionally imported into the United States. Since 1995, two cases of dracunculiasis have been reported in the United States, both imported from Sudan. This report summarizes the investigation of these cases.

Patient 1. A 9-year-old girl residing in Tennessee had emigrated from Sudan in September 1995 (1). Before the girl left Sudan, a Guinea worm had emerged and had been extracted from her right lower leg. The lesion had healed when she arrived in the United States. After she had been in the United States for 3 weeks, another Guinea worm began to emerge from her left leg. Medical examination at a local health clinic revealed a string-like worm dangling from a lesion on her left leg, and she was referred to an infectious disease specialist. The leg was secondarily infected and swollen, and the girl was unable to walk. Despite antibiotic treatment, her cellulitis did not improve, and the lesion was surgically opened, drained, and debrided of pus, necrotic debris, and fragments of the Guinea worm. The patient was hospitalized for 2 weeks, requiring surgery to stretch a contracture of her ankle and to apply a skin graft to the wound. After outpatient physical therapy, she was able to walk without crutches.

Patient 2. A 31-year-old woman residing in Connecticut had emigrated from Sudan in January 1997. In April 1997, she was evaluated at a university clinic for possible tuberculosis (TB). A radiograph revealed lung lesions consistent with TB and a worm-like calcification in her left chest. Physical examination revealed multiple, indurated, oval lesions 4-8 cm in diameter on both lower legs. The patient reported the lesions had been present for 1 year and were intermittently painful. She recalled that a long string-like worm had emerged from her leg during the previous year. Biopsy of the leg lesions revealed erythema induratum, consistent with Bazin disease, a cutaneous manifestation of TB. The patient had evidence of a dead and calcified Guinea worm in her chest and a history suggesting a live Guinea worm had emerged from her leg before she arrived in the United States. She also had pulmonary TB with a cutaneous tuberculid skin manifestation. Treatment with isoniazid, rifampin, and pyrazinomide resulted in elimination of acid-fast bacilli from sputum and resolution of cutaneous manifestations.

Reported by: P Spearman, MD, M Spring, Vanderbilt Univ School of Medicine, Nashville; W Moore, Jr, MD, State Epidemiologist, Tennessee Dept of Health. M Barry, MD, T Minichiello, MD, Yale Univ School of Medicine, New Haven; J Hadler, MD, State Epidemiologist, Connecticut Dept of Public Health. WHO Collaborating Center for Research, Training and Eradication of Dracunculiasis, Div of Parasitic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: No case of dracunculiasis transmitted in the United States has ever been reported, and importations of dracunculiasis to the United States are infrequent. Although both cases in this report involved refugees from Sudan, they differ in clinical manifestations and epidemiologic significance.

The risk for transmission of dracunculiasis from active cases imported to the United States is low; transmission would require a person with an emerging worm to enter a stagnant, freshwater pond containing copepods, and persons to drink directly from the source greater than or equal to 1 week after contamination. The disease can be completely prevented by keeping infected persons from entering and contaminating the water supply or by providing drinking water free of Dracunculus larvae. Humans are the only vertebrate host for D. medinensis. Only the worm that emerged from patient 1 could have posed any risk for contaminating a source of water in the United States. The calcified worm and the history of an emerging worm in patient 2 reflected previous infections without any possibility of transmission in the United States.

Although no drug aborts dracunculiasis infection or hastens expulsion of the adult worm, compounds that reduce inflammation and antibiotics to treat secondary infection facilitate extraction. Dracunculiasis treatment has included cleaning of the lesion and gentle traction to draw the long worm through the skin; the process may take several weeks. Care must be taken to avoid breaking the worm under the skin and subsequent allergic reaction to the internal components of the worm. Physicians who treat patients who have imported dracunculiasis can obtain treatment advice from CDC.

The global campaign to eradicate dracunculiasis began in 1986; the number of cases worldwide decreased by greater than 95% (from approximately 3.2 million cases in 1986 to 152,805 in 1996). Ongoing transmission of dracunculiasis is limited to 16 countries in Africa (2). In Asia, the disease is still occurring in Yemen. In India, the only other Asian country not yet declared free of dracunculiasis, no cases have been reported since July 1996. Pakistan, which reported its last case in October 1993, was certified free of dracunculiasis by the World Health Organization in 1997 (3).

In comparison with the dramatic decrease in cases and in villages with endemic disease globally, the numbers of reported cases and villages with endemic disease in Sudan increased sharply from 1993 to 1996. The areas with the highest prevalence of dracunculiasis are in southern Sudan, where war hampered surveillance for cases and interventions. In 1996, the 64,608 cases reported from areas in Sudan where surveillance was possible accounted for 78% of all cases worldwide (4).

The detection and investigation of every active case brought to the United States enables identification of places where dracunculiasis may still be present and prevents establishment of a focus of transmission in the United States. CDC requests that medical practitioners report any cases of dracunculiasis in the United States since 1990. A brief description of the case, including where the patient may have acquired dracunculiasis, location of treatment, approximate date of worm emergence, and clinical outcome should be reported to Guinea Worm Cases, Division of Parasitic Diseases, National Center for Infectious Diseases, CDC, Atlanta, GA 30333; telephone (770) 488-4531; or by e-mail: kdk1@cdc.gov.

References

1. Spring M, Spearman P. Dracunculiasis: report of an imported case in the United States. Clin Infect Dis 1997;25:749-50.

2. Anonymous. Dracunculiasis: global surveillance summary, 1996. Wkly Epidemiol Rec 1997; 72:133-9.

3. Hopkins DR, Azam M, Ruiz-Tiben E, Kappus KD. Eradication of dracunculiasis from Pakistan. Lancet 1995;346:621-4.

4. Anonymous. Dracunculiasis and onchocerciasis. Wkly Epidemiol Rec 1997;72:297-301.

   
   

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