Helminthiasis, also known as worm infection, is any macroparasitic disease of humans and other animals in which a part of the body is infected with parasitic worms, known as helminths. There are numerous species of these parasites, which are broadly classified into tapeworms, flukes, and roundworms. They often live in the gastrointestinal tract of their hosts, but they may also burrow into other organs, where they induce physiological damage.
Soil-transmitted helminthiasis and schistosomiasis are the most important helminthiases, and are among the neglected tropical diseases. These group of helminthiases have been targeted under the joint action of the world's leading pharmaceutical companies and non-governmental organizations through a project launched in 2012 called the London Declaration on Neglected Tropical Diseases, which aimed to control or eradicate certain neglected tropical diseases by 2020.
Helminthiasis has been found to result in poor birth outcome, poor cognitive development, poor school and work performance, poor socioeconomic development, and poverty.Report of a WHO Expert Committee (1987). Prevention and Control of Intestinal Parasitic Infections. World Health Organization, Technical Report Series 749.Del Rosso, Joy Miller and Tonia Marek (1996). Class Action: Improving School Performance in the Developing World through Better Health and Nutrition. The World Bank, Directions in Development. Chronic illness, malnutrition, and anemia are further examples of secondary effects.
Soil-transmitted helminthiases are responsible for parasitic infections in as much as a quarter of the human population worldwide. One well-known example of soil-transmitted helminthiases is ascariasis.
Types of parasitic helminths
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 from dried feces, faecal sludge, wastewater, and sewage sludge are: soil-transmitted helminths, including Ascaris lumbricoides (the most common worldwide), Trichuris trichiura, Necator americanus, Strongyloides stercoralis and Ancylostoma duodenale Hymenolepis nana Taenia saginata Enterobius Fasciola hepatica Schistosoma mansoni Toxocara canis Toxocara cati
Helminthiases are classified as follows (the disease names end with "-sis" and the causative worms are in brackets):
Roundworm infection (nematodiasis) Filariasis (filarial worms: 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) Baylisascaris (raccoon roundworm, may be transmitted to pets, livestock, and humans)
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
Signs and symptoms
The signs and symptoms of helminthiasis depend on a number of factors including: the site of the infestation within the body; the type of worm involved; the number of worms and their volume; the type of damage the infesting worms cause; and, the immunological response of the body. Where the burden of parasites in the body is light, there may be no symptoms.
Certain worms may cause particular constellations of symptoms. For instance, taeniasis can lead to seizures due to neurocysticercosis.
Mass and volume In extreme cases of intestinal infestation, the mass and volume of the worms may cause the outer layers of the intestinal wall, such as the muscular layer, to tear. This may lead to peritonitis, volvulus, and gangrene of the intestine.
Immunological response As pathogens in the body, helminths induce an immune response. Immune-mediated inflammatory changes occur in the skin, lung, liver, intestine, central nervous system, and eyes. Signs of the body's immune response may include eosinophilia, edema, and arthritis. An example of the immune response is the hypersensitivity reaction that may lead to anaphylaxis. Another example is the migration of Ascaris larvae through the bronchi of the lungs causing asthma.
Secondary effects
Immune changes
In humans, T helper cells and eosinophils respond to helminth infestation. It is well established that T helper 2 cells are the central players of protective immunity to helminths, while the roles for B cells and antibodies are context-dependent. Inflammation leads to encapsulation of egg deposits throughout the body. Helminths excrete into the intestine toxic substances after they feed. These substances then enter the circulatory and lymphatic systems of the host body.
Chronic immune responses to helminthiasis may lead to increased susceptibility to other infections such as tuberculosis, HIV, and malaria. There is conflicting information about whether deworming reduces HIV progression and viral load and increases CD4 counts in antiretroviral naive and experienced individuals, although the most recent Cochrane review found some evidence that this approach might have favorable effects. Helminth infection also lowers the immune responses to vaccination for other diseases such as BCG, measles, and Hepatitis B.
Chronic illness Chronic helminthiasis may cause severe morbidity. Helminthiasis has been found to result in poor birth outcome, poor cognitive development, poor school and work performance, decreased productivity, poor socioeconomic development, and poverty.
Malnutrition Helminthiasis may cause chronic illness through malnutrition including vitamin deficiencies, stunted growth, anemia, and protein-energy malnutrition. Worms compete directly with their hosts for nutrients, but the magnitude of this effect is likely minimal as the nutritional requirements of worms is relatively small. In pigs and humans, Ascaris has been linked to lactose intolerance and vitamin A, amino acid, and fat malabsorption. Impaired nutrient uptake may result from direct damage to the intestinal mucosal wall or from more subtle changes such as chemical imbalances and changes in gut flora.Crompton, D. W. T. (1993). Human Nutrition and Parasitic Infection. Cambridge University Press. Alternatively, the worms' release of protease inhibitors to defend against the body's digestive processes may impair the breakdown of other nutrients. In addition, worm induced diarrhoea may shorten gut transit time, thus reducing absorption of nutrients.
Malnutrition due to worms can give rise to anorexia. A study of 459 children in Zanzibar revealed spontaneous increases in appetite after deworming. Anorexia might be a result of the body's immune response and the stress of combating infection. Specifically, some of the cytokines released in the immune response to worm infestation have been linked to anorexia in animals.
Anemia Helminths may cause iron-deficiency anemia. This is most severe in heavy hookworm infections, as Necator americanus and Ancylostoma 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 small, the collective consumption under heavy infection can be clinically significant. Intestinal whipworm may also cause anemia. 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. A study of the effect of deworming and iron supplementation in 47 students from the Democratic Republic of the Congo found that the intervention improved cognitive function. Another study found that in 159 Jamaican schoolchildren, deworming led to better auditory short-term memory and scanning and retrieval of long-term memory over a period of nine-weeks.
Cognitive changes Malnutrition due to helminths may affect cognitive function leading to low educational performance, decreased concentration and difficulty with abstract cognitive tasks. Iron deficiency in infants and preschoolers is associated with "lower scores ... on tests of mental and motor development ... [as well as] increased fearfulness, inattentiveness, and decreased social responsiveness". Studies in the Philippines and Indonesia found a significant correlation between helminthiasis and decreased memory and fluency. Large parasite burdens, particularly severe hookworm infections, are also associated with absenteeism, under-enrollment, and attrition in school children.
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 trematodes 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 penetrate the skin directly.
The roundworm, Dracunculus has a complex mode of transmission: it is acquired from drinking infested water or eating frogs and fish that contain (had eaten) infected crustaceans (copepods); and can also be transmitted from infected pets (cats and dogs). Roundworms such as Brugia, Wuchereria and Onchocerca are directly transmitted by mosquitoes. In the developing world, the use of contaminated water is a major risk factor for infection. Infection can also take place through the practice of geophagy, which is not uncommon in parts of sub-Saharan Africa. Soil is eaten, for example, by children or pregnant women to counteract a real or perceived deficiency of minerals in their diet.
Diagnosis
Specific helminths can be identified through microscopic examination of their eggs (ova) found in faecal samples. The number of eggs is measured in units of eggs per gram. However, it does not quantify mixed infections, and in practice, is inaccurate for quantifying the eggs of schistosomes and soil-transmitted helminths. Sophisticated tests such as serological assays, antigen tests, and molecular diagnosis are also available; however, they are time-consuming, expensive and not always reliable.
Prevention Disrupting the cycle of the worm will prevent infestation and re-infestation. Prevention of infection can largely be achieved by addressing the issues of WASH—water, sanitation and hygiene. The reduction of open defecation is particularly called for, as is stopping the use of human waste as fertilizer.
Further preventive measures include adherence to appropriate food hygiene, wearing of shoes, regular deworming of pets, and the proper disposal of their feces.
Scientists are also searching for a vaccine against helminths, such as a hookworm vaccine.
Treatment
Medications