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Worm Infestations. Medical term- “ Helminthiasis ” Most common infection worldwide >2000 million people affected worldwide Includes different worms like Hookworm ( Ancylostoma duodenale ) Roundworm ( Ascaris lumbricodes ) Pin worms ( Enterobium vermicularis )
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Medical term- “Helminthiasis” • Most common infection worldwide • >2000 million people affected worldwide • Includes different worms like • Hookworm (Ancylostomaduodenale) • Roundworm (Ascarislumbricodes) • Pin worms (Enterobiumvermicularis) • Tape worms(Taeniasaginata/ Taeniasolum)
Incidence in India • Round worm- most common • Widely prevalent • Heavily infected areas – Assam, W Bengal, Bihar, Orissa, A.P., Tamil Nadu, Kerala, Maharashtra • 60-80% population of certain areas of W.B., UP, Bihar, Orissa, Punjab, TN & AP affected
How are Helminths Transmitted • Contaminated food • Contaminated water • Through piercing the skin (Hookworms) • Habits like eating mud in children (“Pica”)
Predisposing Factors • Unsanitary conditions • Malnutrition • Improperly cooked meals • Improper hygiene
VULNERABLE GROUPS • Pre-school • School going children • Adolescent girls • Women of child-bearing age
WORM INFESTATION- SYMPTOMS • Abdominal pain • Nausea/vomiting • Diarrhea • General malaise & weakness • Anemia • Retarded physical growth & development in children • Intestinal obstruction
BEST STRATEGY “Deworming school-aged children is probably the most economically efficient public health activity that can be implemented in any low-income country were soil-transmitted helminths are endemic”
CONTROL & PREVENTION OF WORM INFESTATION Maximum risk – In children 5 - 14 years of age • Treat following groups once or twice per year • Pre-school & school age children • Women of child-bearing age (including 2nd & 3rd trimester of pregnancy) • Workers in high risk profession- Miners, tea-pickers, etc
Ideal Time for Deworming • For children, ideally done every 6 months after 1 year of age • Dosing intervals of 2-3 months if protein-energy malnutrition is prevalent
BENEFITS OF DEWORMING Beneficial effects on growth Better nutrition- shown to improve iron & Vitamin A status Improves school performance Reduces morbidity DEWORM INDIA 11
Drugs used for Deworming • Albendazole • Mebendazole • Levamisole • Pyrantelpamoate • Ivermectin
ALBENDAZOLE- ADVANTAGES Highly effective Safe Single dose Dose: 400 mg (>10 kg body weight) 200 mg (< 10 kg body weight) Relatively inexpensive Easy to administer DEWORM INDIA 13
Drugs for Deworming 14 DEWORM INDIA
Ascariasis/Round worm infection • Ascariasis is a disease of humans caused by the parasitic roundworm Ascarislumbricoides.
Infection occurs by swallowing food contaminated with Ascariseggs from feces. • The larvae hatch in the intestine, burrow through the gut wall, and migrate to the lungs through the blood system. • There they break into the alveoli and pass up the trachea where they are coughed up and swallowed. • The larvae pass through the stomach for a second time into the intestine where they mature into adult worms. • They maintain their position by swimming against the intestinal flow caused by peristalsis. • Adult worms have a life-span of 1-2 years which means that individuals may be infected all their lives as worms die and new worms are acquired
CLINICAL MANIFESTATIONS • Infections are usually asymptomatic. • The clinical presentation depends upon the worm-load, the location and migration of larvae and deprivation of nutrition of the host • Common features are pain abdomen, abdominal distension, nausea, cough, loss of weight, growth failure, anemia, vitamin deficiencies, bruxism, voracious appetite
Associated problems are pica, sleeplessness, irritability, urticaria, fever, eosinophilia and diarrhoea. • It can produce intestinal obstruction by worm mass or gangrene or perforation, obstructive jaundice, appendicitis, pancreatitis, ascaris encephalopathy, liver abscess and peritonitis • Migration of larvae through lungs may result in ascaris pneumonia(LOEFFLER’S SYNDROME) • Larvae in the circulation may cause convulsion.
Diagnosis • Passing a worm in the stool or vomit. • Clinical examination and stool examination of round worm eggs • X-ray
Management: • Single dose Albendazole or Mebendazole twice daily for 3 days irrespective of patient’s age • Pyrantelpamoate single dose or Levamisole single dose • Piperazine citrate is ideal for eradication of round worm infestation. It is given 100-150 mg/ Kg for one or two days at nightbefore sleep in the form of syrup or tablets or granules
Prevention • use of toilet facilities; • safe excreta disposal; • protection of food from dirt and soil; • hand washing. • Food dropped on the floor should never be eaten without washing or cooking, particularly in endemic areas. • Fruits and vegetables should always be washed thoroughly before consumption.
This is a very common which occurs throughout the world. • It is also known as pinworm or enterobiasis, as it is caused by infection with Enterobiusvermicularis. • The male threadworm is about 4 mm long and is rarely seen. • The female is bigger at 1 cm long and a little under 1 mm in diameter. It is white and pointed at each end. • It may be seen at night emerging from the anus to lay eggs. • It does not appear to have any natural host other than humans.
Female threadworms lay an average of 11,000 tiny eggs, which are invisible to the naked eye. • Eggs are laid outside the anus, or, in girls, around the vagina and urethra. • Eggs are usually laid at night whilst the child sleeps. • The eggs are accompanied by an irritant mucus, which causes intense pruritus and scratching • The eggs get on to the hands and from there to the mouth to reinfect.
Following ingestion of the eggs, the larvae hatch in the small intestine and establish themselves in the colon, reaching maturity in approximately 2 weeks. Adult worms live for up to 6 weeks.
Clinical Presentation • Majority of children have no complaints • The infected child may present with vague general symptoms like poor appetite, loss of weight, teeth grinding, abdominal pain, nausea, vomiting and diarrhoea. • Pruritus ani is important feature. It occurs due to crowding of gravid females at anus. • Scratching may cause secondary infection • In female child vulvovaginitis may be found • Child may have irritability, restlessness, sleep disturbance, enuresis.
Investigations • Often the diagnosis is clear and no investigation is required. If there is a report of something like a tiny piece of cotton moving, there is no need for further investigation. • A simple and useful test is the adhesive tape test for eggs. Transparent wide hypo-allergenic adhesive tape is applied to the perianal skin first thing in the morning, before wiping or bathing. The tape is then placed on a slide or put in a specimen container for later examination. Microscopy may be performed. Many tiny eggs are seen adherent to the tape. • Stool examination for eggs is positive in only 5% of cases.
Management: • Albendazole 10-14mg/Kg single dose or Mebendazole 100mg once only. • Other useful drugs are piperazine or pyrivinium. • Re-infection may occur and need repeated courses of treatment for complete eradication • All members of family are investigated and treated to prevent cross infection • Crotamitone cream should be applied to perianal region to prevent irritation and scratching
Hygiene measures include: • Wear tight underwear at night. • Have a bath or shower each morning and wash around the anus. • Change and wash underwear, nightwear, and, if feasible, bedlinen and towels each day. Do not shake them as this spreads eggs. Do not share towels. • Keep fingernails short and clean. Wash hands and scrub under the nails first thing in the morning, after using the toilet or changing nappies, and before eating or preparing food. • Put toothbrushes in a closed cupboard, and rinse them well before use.
Prevention • Good hygiene, especially washing of hands before eating or preparing food. • Sucking fingers or biting nails is to be discouraged. • Treatment should be effective and it should be repeated to assure complete eradication.
The hookworm is a parasitic nematode that lives in the small intestine of its host, which may be a mammal such as a dog, cat, or human. Two species of hookworms commonly infect humans, Ancylostomaduodenale and Necatoamericanus.
Ancylostomaduodenale produces 30,000 eggs and Necatoamericanus produces 9,000 eggs per day. • Eggs are passed in the faeces and on warm, moist soil they hatch larvae after 1-2 days. • Newly hatched larva becomes infective and able to penetrate skin within 5-10 days • Infection occurs when the larva enters the body through the skin of bare footed individual • Larav of A. duodenale are infective also through the mouth.
In the human body Larva migrates via lymphatics and blood stream to the lungsand from there up the trachea, and coughed and are swallowed. • They then pass down the esophagus and enter the digestive system, finishing their journey in the intestine, where the larvae mature into adult worms and may survive for 1-4 years
Clinical manifestations • There are no specific symptoms or signs of hookworm infection. • they give rise to a combination of intestinal inflammation and progressive iron/protein-deficiency anaemia. • Larval invasion of the skin might give rise to intense, local itching, usually on the foot or lower leg, which can be followed by lesions that look like insect bites, can blister ("ground itch"), and last for a week or more.
Coughing, chest pain, wheezing, and fever will sometimes be experienced by people who have been exposed to very large numbers of larvae. • Epigastric pains, indigestion, nausea, vomiting, constipation, and diarrhea • Signs of advanced severe infection are those of anemia and protein deficiency, including emaciation, cardiac failure and abdominal distension with ascites.
DIGNOSIS: • Stool examination for hook worm ova and occult blood • Blood examination: Eosinophilia
TREATMENT: • Albendazole 10mg/Kg single dose or 5mg/kg daily for 3 days • Other drugs can be used are mebendazole, levamisole or pyrantelpamoate • Correction of anemia should be done with iron therapy and blood transfusion in severe cases • Nutritios diet, Iron rich food and prevention of complications
Prevention • Sanitary disposal of faeces • Periodic case finding • Treatmrnt of all infected persons • Treatment of anemia and health education • Good personal hygiene • Use of foot wear • Donot use untreated sewage as fertilizer.
Tapeworm Infestation is the infection of the digestive tract by adult tapeworms. • Live tapeworm (larvae) are sometimes ingested by consuming undercooked food. • Once inside the digestive tract, a larva can grow into a very large adult tapeworm. • Among the most common tapeworms in humans are the faeces tapeworm (T. solium), the beef tapeworm (T. saginata), the fish tapeworm (Diphyllobothrium spp.), and the dwarf tapeworm (Hymenolepis spp.).
Pathophysiology • Typically, a cestode requires one or more intermediate hosts in their life cycle. The life cycle is as follows: • The eggs are passed into the environment from the primary host. • The eggs are ingested by an intermediate host in which they hatch. • The larvae enter the tissues of the intermediate host and encyst. • The primary host ingests the cysts in the flesh of the intermediate host • When humans are the primary hosts, the adult cestode is limited to the intestinal tract. When humans are the intermediate hosts, the larvae are within the tissues, migrating through the different organ systems.
Clinical presentation • Although tapeworms in the intestine usually cause no symptoms, some people experience upper abdominal discomfort, diarrhea, and loss of appetite. • Anemia may develop in people with the fish tapeworm. • Infection is generally recognized when the infected person passes segments of proglottids in the stool (looks like white worms). • Rarely, worms may cause obstruction of the intestine. • And very rarely, T. solium larvae can migrate to the brain causing severe headaches, seizures and other neurological problems. This condition is called neurocysticercosis.
Diagnosis: • Stool examination for eggs, proglottides or motile segments • Neurocysticercosis diagnosed by CT scan or MRI. • CSF examination
MANAGEMENT • Tapeworms are treated with medications taken by mouth, usually in a single dose. The drug of choice for tapeworm infections is praziquantel. • Other drugs include Niclosamide, mepacrine, albendazole or mebendazole. • Symptomatic and supportive treatment
Prevention • Wash hands with soap and water before eating or handling food and after using the toilet. • When traveling in areas where tapeworm is more common, wash and cook all fruits and vegetables with safe water before eating. • properly disposing of animal and human feces. • Thoroughly cook meat at temperatures of at least 125 F (52 C) to kill tapeworm eggs or larvae. • Freeze meat for at least 12 hours and fish for at least 24 hours to kill tapeworm eggs and larvae. • Avoid eating raw or undercooked pork, beef and fish. • Promptly treat dogs infected with tapeworm.
Reference • Hockenberry, Wilson, Judie. Wong’s essentials of pediatric Nursing. South India Edition. Elsevier publication. • Dorothy R Marlow, Barbara A Redding, Raman Kalia. Marlow’s textbook of pediatric Nursing. Harcourt Brace & Company Asia Pte Ltd. • ParulDatta. Pediatric Nursing. 4th edition. Jaypee Publishers. New Delhi.
