Hookworm infection

Introduction

• Hookworm infection is defined as “Any infection

caused by Ancylostoma duodenale or Necator
americanus.”
• They may occur as single or mixed infections in the
same person.
Problem statement
World
• Almost eradicated from Europe and USA.
• It is still seen in warm, moist climates in tropical and
subtropical regions between 45 north and 30 south of equator. (
e.g. Asia, Africa, central and south America and south pacific)
• Geographical distribution of these two species used to be
regarded as relatively distinct however, over the past decades
both parasites no longer have rigid demarcation.

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Epidemiological determinants

Environment

Agent Host

Fig: Epidemiological triad of hookworm infection

4
 Agent factor
• Agent: Adult worms live in the small intestine, mainly jejunum where they
attach themselves to the villi.
• Measures: - male - 8 to 11 mm
female - 10 to 13 mm with dorsally curved anterior end.
• Eggs - are passed in faeces in thousands
- one female of Ancylostoma duodenale produces about 10,000 –
30,000 eggs
- one female of
Necator americanus
produces about
5000- 10,000 eggs per
day
Life cycle of hookworm

6
• Reservoir - Man is the only important reservoir of
human hookworm infection.
• Infective material
- Faeces containing the ova of hookworms.
- Immediate source of infection is soil
contaminated with infective larvae.
• Period of infectivity – As long as the person
harbours the parasite.
 Host factors
• Age : All age groups; In endemic area, highest incidence in 15-
25 years
• Sex: Both sexes
• Nutrition: Malnutrition
• Host- parasite balance:
In endemic area,
Inhabitants develop a host parasite balance
Worm load is limited
Harbours parasite without manifesting clinical signs and
symptoms
Infection rate may be 100 percent
Some may have light infection but some proportion are
heavily infected
• Occupation: agricultural workers than town workers.
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 Environmental factors
• Soil : damp, sandy or friable soil with decaying vegetation.
• Temperature: 24 to 32 °C favorable for larval development;
egg doesn’t develop below 13°C ; larva killed at 45-50°C.
• Oxygen
• Moisture and Rainfall
• Shade
• Human habits: Open field defecation, barefoot walking,
untreated sewage disposal

10
 Mode of transmission:
• Through skin penetration of feet
• Oral route(direct ingestion of infective larva), via contaminated
foods and vegetables.

Incubation period:
• Necator americanus: 7 weeks
• Ancylostoma duodenale: unpredictable; ranging from 5 weeks
to 9 months.

11
Effect of the disease
 Individual:
• Chronic blood loss and iron deficiency anemia.
• Low birth weight babies, Abortion, Still births
• Hypoalbuminemia
• Decrease exercise tolerance

Community: Three major area affected

• Nutrition, growth and development
• Work and productivity
• Medical care costs

12
 Laboratory Diagnosis
• Demonstration of the eggs in faeces by direct
microscopy or by concentration methods is the
diagnostic test.
• In stool samples examined 24 hours or more after
collection, the eggs may have hatched and
rhabditiform larvae may be present.
• These have to be differentiated from strongyloides
larvae. Egg counts give a measure of the intensity of
infection.
• Adult hookworms may sometimes be seen in feces.
• Eggs are oval or elliptical, measuring 60 μm by 40
μm, colourless, not bile stained, with a thin
transparent hyaline shell membrane.
• segmented ovum, usually with 4 or 8 blastomeres.
The eggs float in saturated salt solution.

Fig: Egg of Hookworm

Ascariasis
 An infection of intestinal tract caused by the adult,
Ascaris lumbricoides

 Clinically manifested by vague symptoms of:

 Nausea
 Abdominal Pain
 Cough

Ascariasis 16
PROBLEM STATEMENT

Ascariasis 17
 Geographic Distribution and Prevalence of
Ascariasis
 Ascariasis is the most common helminthic infection, with an
estimated worldwide prevalence of 25% (0.8-1.22 billion people).

 Ascariasis is present in at least 150 of the 218 countries in the

world. Prevalence estimates widely vary among countries and
within communities inside these countries.

 Usually asymptomatic, ascariasis is most prevalent in children of

tropical and developing countries, where they are perpetuated by
contamination of soil by human feces or use of untreated feces as
fertilizer.
Source:
1. Bethony J, Brooker S, Albonico M, Geiger SM et al. Soil- transmitted helminthic
infections: ascariasis, trichuriasis, and hookworm. Lancet. 2006 May 6. 367
2. Medscape (Emedicine) Ascariasis 18
 Problem Statement: Nepal
 As shown by various reports, A. lumbricoides has remained as the
most leading intestinal parasite in Nepal

 The reported prevalence rate ranged from less than 15.0% to over
75.0%.

 Ascaris infection was more prevalent in rural areas. However,

reports showing relatively low prevalence of ascariasis in rural
areas were also available.

 A hospital-based study with a mean number of 6,837 faecal

samples per year conducted in the capital city of Kathmandu over
a period of one decade, have revealed a static prevalence of
ascariasis with an average of approximately 35%.
Ascariasis 19
 Epidemiological Determinants
Agent: Ascaris lumbricoides

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sdf saf
Host Environment
Ascariasis 20
 Agent Factors
 Agent: Ascarias lumbricoides
 Habitat (Adult worm): Small Intestine ( 85%: Jejunum, 15%:
ileum)
 Sex: Separate
 Morphology:
 Cylindrical, with tapering ends
 Pale pink or flesh colored
 Mouth at anterior
Male end has 3 finely toothedFemale
lips
Smaller than female, 15-30 cm in length Larger than male, 20-40 cm in length
and 2-4 mm in thickness and 3-6 mm in thickness

Posterior end: Curved ventrally to form a Posterior end: Straight and conical,
hook and carries 2 copulatory spicules
Vulva is situated mid- ventrally, near the
junction of anterior and middle thirds of
body
Ascariasis 21
Figure showing Male and Female Ascarias lumbricoides

Ascariasis 22
 Lifecycle of Ascarias lumbricoides

 Involves only 1 host.

 Natural host: Man. There is no intermediate host.

 Infective form: Embryonated eggs

 Infective material: Faeces containing the fertilized egg

Ascariasis 23
 Lifecycle of Ascarias lumbricoides
Start Here

Ascariasis 24
 Host Factors

 Rate: High in children. They are the most important disseminators

of infection.

 Adults: Some resistance

Ascariasis 25
 Environmental Factors
 Soil transmitted infection.

 Eggs remain viable in soil for month or years under favourable

conditions

 Development of egg in soil depends on nature of soil and various

environmental factors. Factors that favours are:
 Location and Soil: Clayey and moist shady location
 Temperature: 20o-30o C

 Human habits: Indiscriminate open air defaecation helps in

dissemination of eggs

Ascariasis 26
 Period of communicability: Until all fertile females are destroyed
and stools are negative.

 Mode of transmission: By fecal- oral route i.e. by ingestion of

infective eggs with food or drink.

 Incubation period: About 2 months

Ascariasis 27
 Prevention and Control: Primary Prevention
 Most effective in interrupting transmission.
 These are:
 Sanitary disposal of human excreta to prevent or reduce
faecal contamination of soil
 Provision of safe drinking water, food hygiene habits
 Health education of community in use of sanitary latrines,
personal hygiene and changing behavioral patterns
 Measures of personal protection such as wearing protective
footwear and making use of health facilities for diagnosis
and treatment

 To be effective, must take into consideration:

 Life cycle of parasite
 Peculiar ecological, social and cultural circumstances that
prevail in a community.Ascariasis 28
 Prevention and Control: Secondary Prevention
 Effective drugs are available for treatment of the human reservoir.

 These are:
 Piperazine
 Mebendazole
 Levamisole
 Pyrantel Pamoate

 Albendazole:
 Dose for adults and children >2 yr.: 400 mg single dose
 Contraindicated in children <2 yr. and in pregnancy

 Mebendazole:
 Usual dose: 100 mg twice daily for 3 days for all ages
above 2 yrs. Ascariasis 29
 Prevention and Control: Secondary Prevention
(Contd.)
 Levamisole:
 Levorotatory form of Tetramisole
 More active than Tetramisole
 For many years remained as Drug of choice
 Dose: Single oral dose of 2.5 mg/kg of body weight
(maximum 150 mg recommended)
 Used successfully in mass treatment

 Pyrantel Pamoate:
 Effective dose: Single dose of 10 mg/kg of body weight
with maximum of 1 g.

Ascariasis 30
 Prevention and Control: Secondary Prevention
(Contd.)
 Mass Treatment:

 Periodic deworming at interval of 2 to 3 months may be

undertaken.
 May be needed where parasites and protein-energy
malnutrition are highly prevalent.
 Will not interrupt transmission of disease.
 But merely reduces the worm-load.
 It would be unrealistic to expect that ascariasis would be
eliminated via mass treatment unless sanitation
improvement is combined with treatment.
 In fact ascariasis is disappearing spontaneously in certain
areas as a result of improved sanitation.

Ascariasis 31
 Prevention and Control: National
 Nutrition programs implemented by CHD’s Nutrition Section
(1993–2016)

 Control of IDA: Control parasitic infestation among

nutritionally vulnerable groups through deworming
pregnant women and children aged 12-59months.

 School health and nutrition program: The biannual

distribution of deworming tablets to grade 1 to 10 school
children.

Source: Annual Health Report (2072/73), Department of Health Services, Ministry of

Health
Ascariasis 32
 Prevention and Control: National
 Safe motherhood and newborn health

 ANC: Provision of tetanus toxoid and diphtheria (Td)

immunization, iron folic acid tablets and deworming
tablets to all pregnant women, and malaria prophylaxis
where necessary.

Source: Annual Health Report (2072/73), Department of Health Services, Ministry of

Health

Ascariasis 33
 Prevention and Control: National
 Ministry of Health achievement of nutrition in emergency in 14
earthquake affected districts (2015/16): Children aged 12-59
months received deworming tablets
Target Population: 418, 544 Children not Receiving
Tablets, 12.00%
Beneficiaries reached: 368, 223
% of target reached: 88%

Children Receiving
Tablets, 88.00%

Source: Annual Health Report (2072/73), Department of Health Services, Ministry of

Ascariasis 34
Health
Students received Deworming tablet (Biannual)-
2016
1400000 1330952

1200000
1251879
1000000

800000

600000 395687
313516
249138 168799412475 124739
400000 326541
268061
189165
200000 134710

0
EDR CDR WDR MWDR FWDR National
Girls Boys
Source: Annual Health Report (2072/73), Department of Health Services, Ministry
ofAscariasis
Health 35
 <5 yr. children received Deworming tablet
(Biannual)- 2016
3500000
3246970
3000000

2500000

2000000

1500000
1175970
1000000

615716 693449
500000
463759
298076

0
EDR CDR WDR MWDR FWDR National
Source: Annual Health Report (2072/73), Department of Health Services, Ministry
ofAscariasis
Health 36
Thank you