Helminthiasis

Helminthiasis
Ascaris worms (one type of helminth) in the small bowel of an infected person in South Africa (X-ray image with barium as contrast medium)
Classification and external resources
ICD-10	B83.9
ICD-9-CM	128.9
DiseasesDB	28826
MeSH	D006373

Helminthiasis (alternatively spelled helminthosis; plural helminthiases), also known as helminth infection or worm infection, is any physiological damage. They remain the major cause of wildlife diseases, economic crises in the livestock industry, and human socio-economic problems in developing countries.

Some types of helminthiases are among the London Declaration on Neglected Tropical Diseases" which was launched on 30 January 2012. It aims to control or eradicate those particular diseases by 2020, by ensuring necessary supply of drugs and other intervention, and promoting sanitation and health education.^[1]

Soil-transmitted helminthiasis (STH) and schistosomiasis are the most important group of helminthiases, collectively belonging to the "neglected tropical diseases".^[2] Soil-transmitted helminthiases are responsible for parasitic infections in a quarter of the total human population.^[3] One well-known example of soil-transmitted helminthiases is ascariasis.

Signs and symptoms

Example clinical photo: Guinea worm infection (dracunculiasis), worm coming out of the foot of an infected person.

Ascaris infection: Antimesenteric splitting of the outer layers of the bowel wall due to a large amount of ascaris (South Africa)

Light infections

In cases of light infections there can be no symptoms.

Tissue damage and infections

Heavy infections directly damage tissues as the parasites can block internal organs or exert immense pressure in the gut. Infections are predominantly found in stomachache, fever, vomiting, diarrhea, loss of appetite, loss of blood, fatigue, and listlessness.

Antimesenteric splitting of the outer layers of the bowel wall can occur due to large amount of helminths, such as ascaris: The bowel can be so tightly packed with ascaris that it becomes semi-rigid and inflexible and the outer layers of the bowel wall, which are the muscle layers, split under the tension.

Abdominal distension and abdominal pain might be the symptoms together with vomiting, sometimes vomiting of worms.^[4] Patients might present with peritonitis or a gangrenous bowel.^[4] This often requires emergency surgery. Volvulus complicating ascariasis still carries a high mortality and morbidity rate.^[4] Early detection and early operative intervention is very important.^[4]

Morbidity

In humans, under chronic infections, such as those in schistosomiasis, extreme morbidity is the common symptom.^[5] Morbidity is accompanied by persistent poverty, decreased productivity, poor birth outcomes, poor school and work performance, and poor socioeconomic development.^[6] A severe case of taeniasis can occur when the brain is infected by accidental ingestion of cysts, a clinical condition called neurocysticercosis, which is the leading cause of acquired epilepsy.^[7]

Immune reactions

Indirect effects also associate with the disease. As pathogens, helminths induce immune reactions. Immune-mediated inflammatory changes occur in the skin, lung, liver, intestine, CNS, and eyes as they invade these tissues.The migration of Ascaris larvae through the respiratory passageways can also lead to temporary asthma and other respiratory symptoms.^[8] Systemic changes such as eosinophilia, edema, and joint pain reflect local allergic responses to parasites.^[9] In many cases, they can induce hypersensitivity leading to an acute allergy reaction called anaphylaxis. These immune responses can lead to increased susceptibility to other infections such as tuberculosis, HIV and malaria.^[10][11] Coinfection cases have become serious medical problems particularly in African countries.^[12] Heavy infection reduces HIV progression and viral load, most likely by improving helminth-induced immune suppression.^[13]

Malnutrition

Helminthiasis is associated with nutritional problems such as vitamin deficiencies, stunting, anemia, and protein-energy malnutrition, which in turn affect cognitive ability and intellectual development.^[14] This relationship is particularly alarming because it is gradual and often relatively asymptomatic.^[15] Worms most probably compete directly with their hosts for nutrients; but the magnitude of this effect is likely to be minimal as the nutritional requirements of worms is relatively small.^[16][17][18] In pigs and humans, Ascaris has been tied to temporarily induced lactose intolerance and vitamin A, amino acid, and fat malabsorption.^[14] Impaired nutrient uptake may result from direct damage to the intestines' mucosal walls as a result of the worms’ presence, but it may also be a consequence of more nuanced changes, such as chemical imbalances caused by the body’s reaction to the helminths.^[19] Alternatively, the worms’ release of protease inhibitors to defend against the body’s digestive process may impair the breakdown of other nutritious substances, as well.^[16][18] In some cases diarrhea due to worms can cause speed “transit time” through the intestinal system, reducing absorption of nutrient.^[14]

Malnutrition due to worms can give rise to anorexia.^[17] A study of 459 children in Zanzibar revealed spontaneous increases in appetite after deworming.^[20] This could be due to a side effect of body’s immune response to the worm and the stress of combating infection.^[18] Specifically, some of the cytokines released in the immune response have been linked to anorexic reactions in animals.^[16]

Helminths may also cause iron-deficiency anemia. This is most severe in heavy hookworm infections, as N. americanus and A. duodenale feed directly on the blood of their hosts. Although the daily consumption of an individual worm (0.02-0.07 ml and 0.14-0.26 ml respectively) is quite low, the collective consumption under heavy infection can be significantly high.^[14] One scholar estimated that "the blood loss caused by hookworm was equivalent to the daily exsanguination of 1.5 million people".^[18] Whipworm is also attributed to anemia in the small intestine.^[14][18]

Cognitive ability

Malnutrition due to helminths may directly affect cognition. This includes low educational performances, decreased ability to focus, difficulty with abstract cognitive tasks, and "lower scores...on tests of mental and motor development...[as well as] increased fearfulness, inattentiveness, and decreased social responsiveness" among very young children.^[16] Anemia has also been associated with reduced stamina for physical labor, a decline in the ability to learn new information, and "apathy, irritability, and fatigue".^[14] Study on deworming of 47 students from the Democratic Republic of the Congo, using iron supplements, showed that it produced better effects on mental cognition.^[21] Among 159 Jamaican schoolchildren, deworming led to better "auditory short-term memory" and "scanning and retrieval of long-term memory", which they achieved in nine-week period.^[22] Studies in the Philippines and Indonesia found significant negative impacts of helminthic infection on memory and fluency,^[23] and between worm infection and intellectual performance, particularly because their findings were significant in aspects of intellect that went beyond mere cognition and reaction time.^[24]

School performance

Helminthiasis is associated with absenteeism, under-enrollment, and attrition in school children.”^[16]

Causes

Ascaris life cycle: Adult worms in the lumen of the small intestine (1). The female produces eggs (approximately 200,000 per day) that are excreted with the feces (2). Unfertilized eggs are harmless, but fertilized ones are infective after 18 days to several weeks (3). Infective eggs are ingested (4), enter the gut (5), develop into larvae in the intestine, and penetrate the blood vessel to enter lungs, where they develop further (6), after 10 to 14 days, penetrate the alveolar walls, ascend the bronchial tree to the throat, and are re-swallowed (7). Upon reaching the small intestine, they develop into adult worms (8). It takes 2 to 3 months for one complete cycle. Adult worms can live 1 to 2 years.

Collage of various helminth eggs, from left to right: Trichosomoides egg, Ascaris lumbricoides with larva hatching, sample of adult roundworms, Hymenolepis nana, Schistosoma mansoni and Toxocara canis with larva hatching

Types

Helminthiases are classified as follows (the disease names end with "-sis" and the causative worms are in brackets):

Roundworm infection (nematodiasis)

• Filariasis (Wuchereria bancrofti, Brugia malayi infection)
• Onchocerciasis (Onchocerca volvulus infection)
• Soil-transmitted helminthiasis - this includes ascariasis (Ascaris lumbricoides infection, trichuriasis (Trichuris infection), and hookworm infection (includes Necatoriasis and Ancylostoma duodenale infection)
• Trichostrongyliasis (Trichostrongylus spp. infection)
• Dracunculiasis (guinea worm infection)

Tapeworm infection (cestodiasis)

• Echinococcosis (Echinococcus infection)
• Hymenolepiasis (Hymenolepis infection)
• Taeniasis/cysticercosis (Taenia infection)
• Coenurosis (T. multiceps, T. serialis, T. glomerata and T. brauni infection)

Trematode infection (trematodiasis)

• Amphistomiasis (amphistomes infection)
• Clonorchiasis (Clonorchis sinensis infection)
• Fascioliasis (Fasciola infection)
• Fasciolopsiasis (Fasciolopsis buski infection)
• Opisthorchiasis (Opisthorchis infection)
• Paragonimiasis (Paragonimus infection)
• Schistosomiasis/bilharziasis (Schistosoma infection)

Acanthocephala infection

• Moniliformis infection

Neglected tropical diseases

Among all helminthiases, the following helminth infections are classified under neglected tropical diseases:^[2][25]

1. All soil-transmitted helminthiases
2. Roundworm infections such as lymphatic filariasis, dracunculiasis and onchocerciasis
3. Trematode infections such as schistosomiasis and food-borne trematodiases (including fascioliasis, clonorchiasis, opisthorchiasis, and paragonimiasis)
4. Tapeworm infections such as cysticercosis, taeniasis, and echinococcosis

Transmission

Helminths are transmitted to the final host in several ways. The most common infection is through ingestion of contaminated vegetables, drinking water and raw or undercooked meat. Contaminated food may contain eggs of nematodes such as Ascaris, Enterobius, and Trichuris; cestodes such as Taenia, Hymenolepis, and Echinococcus; and treamtodes such as Fasciola. Raw or undercooked meats are the major sources of Taenia (pork, beef and venison), Trichinella (pork and bear), Diphyllobothrium (fish), Clonorchis (fish), and Paragonimus (crustaceans). Schistosomes and nematodes such as hookworms (Ancylostoma and Necator) and Strongyloides can directly penetrate the skin. Finally, Wuchereria, Onchocerca, and Dracunculus are transmitted by mosquitoes and flies.^[5] In the developing world contaminated water is the major risk factor of infection.^[26]

Infection can also take place by mistake when people eat soil on purpose - a practice called geophagy which is not uncommon in sub-Saharan Africa. The soil is eaten for example by pregnant women to counteract a real or perceived deficiency of minerals in the diet.

Most common

Of all the known helminth species, the most important helminths with respect to understanding their transmission pathways, their control, inactivation and enumeration in samples of human excreta origin, namely dried feces, faecal sludge, wastewater and sewage sludge are:^[27] soil-transmitted helminths (including Ascaris lumbricoides, which is the most common worldwide, Trichuris trichiura, Necator americanus, Strongyloides stercoralis and Ancylostoma duodenale), Hymenolepis nana, Taenia saginata, Enterobius, Fasciola hepatica, Schistosoma mansoni, Toxocara canis and Toxocara cati.

Mechanism

Response to worm infection in humans is a Th2 response in the majority of cases. Inflammation of the gut may also occur, resulting in cyst-like structures forming around the egg deposits throughout the body. The host's lymphatic system is also increasingly taxed the longer helminths propagate, as they excrete toxins after feeding. These toxins are released into the intestines to be absorbed by the host's bloodstream. This phenomenon makes the host susceptible to more common diseases, such as viral and bacterial infections.

Diagnosis

Identification and quantification of helminth eggs at UNAM university in Mexico City, Mexico

For basic diagnosis, specific helminths can be generally identified from the feces, and their eggs microscopically examined and enumerated using the fecal egg count method. This is particularly useful in veterinary investigations.^[28] But it fails to identify mixed infections, and on clinical practice, the technique is highly inaccurate and unreliable, such as those for schistosomes and soil-transmitted helmiths.^[29] Sophisticated tests such as serological assays, antigen tests, and molecular diagnosis are also available;^[28][30] however, they are time-consuming, expensive and not always reliable.^[31]

Prevention

Prevention of helminth infection includes the following measures:

• Use of clean water for personal and domestic uses;
• Sanitation and health education such as by promoting use of toilets therevy reducing open defecation (access to sanitation and other WASH practices have been linked to reductions in soil-transmitted helminth infections.^[32][33]);
• Awareness on personal hygiene such as hand washing with soap at critical times (before contact with food and after use of the toilet)
• Avoiding the use of untreated human excreta as fertilizer.^[3]
• Constant wearing of shoes
• Soaking vegetables with bleach and adequate washing cooking of foods^[34]
• Deworming of pets and proper disposal of their feces.^[34]

Mass deworming of children is regarded by some as a prevention method but is in actual fact more of a treatment method.

Research is underway for a vaccine against helminths, such as a hookworm vaccine.^[35]

Treatment

Medications

Broad-spectrum benzimidazoles (such as albendazole and mebendazole) are recommended for treatment of intestinal roundworm and tapeworm infections; while macrocyclic lactones (such as ivermectin) are effective against adult and migrating larval stages of nematode; and praziquantel is the drug of choice for schistosomiasis, taeniasis, and most types of food-borne trematodiases. Oxamniquine is also widely used in mass deworming programmes. Pyrantel is commonly used for veterinary nematodiasis.^[36][37] Artemisinins and derivatives are proving to be candidates as drugs of choice for trematodiasis.^[38]

Mass deworming

In

• Information at WHO
• European Commission
• Center for Disease Control and Prevention
• Global Atlas of Helminth Infections

External links

References

• Hookworm infection
• Hookworm vaccine
• Kato technique

See also

The 1990-2013 Global Burden of Disease study estimated 5,500 direct deaths due to schistosomiasis,^[67] whilst more than 200,000 people are estimated to die yearly from causes that are related to schistosomiasis.^[68] Another 20 million have severe consequences from the disease.^[69] It is the most deadly of the neglected tropical diseases.^[70]

Estimates for the annual death toll which is directly due to soil transmitted helminthiasis is as high as 135,000.^[14][65][66] The death toll due to the malnutrition link is likely to be much higher.

Deaths

It is estimated that intestinal nematode infections cause 5 million disability-adjusted life years (DALYS) to be lost, of which hookworm infections account for more than 3 million DALYS and ascaris infections more than 1 million.^[63] There are also signs of progress: The Global Burden of Disease study published in 2015 estimates a 46% (59% when age standardised) reduction in years lived with disability (YLD) for the 13-year time period from 1990 to 2013 for all intestinal/nematode infections, and even a 74% (80% when age standardised) reduction in YLD from ascariasis.^[64]

Disability-adjusted life years

Individual predisposition to helminth infection for people who have the same sanitation infrastructure and hygiene behavior is thought to result from differing immunocompetence, nutritional status and genetic factors.^[61] Due to the fact that individuals are predisposed to either a high or a low worm burden, the size of the worm burden reacquired after successful treatment is proportional with the intensity of infection before treatment.^[61]

Even in areas of high prevalence, the intensity of infection is not uniform within communities or families.^[61] A small proportion of community members usually harbors the majority of worms, and this depends on age: The maximum intensity of "worm burden" is generally at 5-10 years of age, and rapidly declines to a lower level for people older than 10 years.^[62]

Variations within communities

Because of their high mobility and lower standards of hygiene, school-age children are particularly vulnerable to these parasites.^[59] A child in a low-economy country is estimated to harbour at least one helminth, and multi-species infections are very common.^[60]

In 2014, only 148 people were estimated to have dracunculiasis thanks to a successful eradication campaign for that particular helminth, which is easier to eradicate than other helminths as it is only transmitted by drinking contaminated water.^[58]

As of 2014, the World Health Organization estimates that over 1.5 billion people (a quarter of the total population) are infected with soil-transmitted helminthiases,^[3] 249 million with schistosomiasis (which may have even surpassed malaria at ~207 million cases in 2013),^[50] 56 million people with food-borne trematodiasis (i.e. other than schistosomiasis),^[51] 120 million with filariasis,^[52] 50 million people with cysticercosis,^[53] at least 15 million people with onchocerciasis,^[54] and 1 million people with echinococcosis.^[55] This adds up to between 1.5 to 2 billion people worldwide infected with one or more types of helminths - some could have multiple infections. Another source estimates a much higher figure of 3.5 billion infected with one or more soil-transmitted helminths.^[56] Also, it is estimated that 4.5 billion people are at constant risk of STH infection.^[57]

The soil-transmitted helminths (A. lumbricoides, T. trichiura, N. americanus, A. duodenale), schistosomes, and filarial worms collectively infect more than a quarter of human population at any one time, far surpassing HIV/AIDS and malaria taken together.^[28][30] Schistosomiasis alone is the second most prevalent parasitic disease of all times in humans, next only to malaria.^[49]

Infection estimates

The most affected regions are tropical and subtropical areas. Highest incidences are in subsaharan Africa, central and east Asia, and the Americas.

Epidemiology

Surgery - even emergency surgery - might be required to remove parts of the intestine if the worm infestation has reached such a high number of worms that the worms block that piece of intestines.^[4][48] Patients who are heading for surgery, for example to extract worms from the biliary tree, can be pre-treated with albendazole to kill worms prior to the surgery. In the case of intestinal obstruction it is however an emergency and there is no time to do this so surgeons have no alternative than manually pulling the worms out.

Piece of intestine, blocked by worms, surgically removed from a 3-year-old boy in South Africa.^[48]

Example of ascariasis (ascaris infection) - Difficult surgical procedure in South Africa on a gangrenous piece of bowel that had to be cut out; live ascaris worms are emerging.

Surgery

^[47][46] Some studies have found evidence of health benefits and other reviews not.^[45][44] campaigns such as improved cognitive ability, nutritional benefits, physical growth and performance are still debated and not conclusively proven.mass deworming improves the health of an individual, wide-ranging outcomes from deworming Although ^[43] Deworming programs can improve school attendance by 25%.^[42][41]