HOOKWORMS

KALOLI
 Hookworms
Intestinal nematodes adults SI (jejunum), attach
to SI mucosa by mouth parts. Important spps:
• Necator americanus (New World) &
Ancylostoma duodenale (Old World) infn of man.
• Ancylostoma braziliense  cats
• Ancylostoma caninum  dogs
• Ternidens deminutus  monkeys & baboon
A.braziliense & A.caninum infn in man 
arrested in skin  cutaneous larval migrans.
 Hookworms contd..
• Widespread & clinically important infn in
tropics & sub-tropics. A. duodenale &
N.americanus affect > 1 billion people &
cause anaemia in > 96 million people.
• A.d  Southern Europe (north coast of
Africa, northern India, north China &
Japan).
• N.a  Central & Southern Africa & South
Asia.
 Hookworms: morphology
• Adults: Small, < 1.5 cm, adults curved
anteriorly (hook like) but do not have
hooks. N.a closely resembles A.d, but
there are features that distinguish them.
• Eggs: Oval or elliptical in shape,
colourless, transparent shell & segmented
ovum
• Eggs of N.a & A.d are indistinguishable
Adult female & male hookworms
Necator & Ancylostoma mouth
parts
Male Ancylostoma & Necator
copulatory bursae
Hookworm Egg
 Hookworm: Life cycle
• Eggs (2, 4 or 8 blastomeres) faeces
(A.duodenale 25 – 35000 eggs/day;
N.americanus 6000 – 20000 eggs/day).
• In moist shaded soil L1 (free living in faecal
matter, have a bulbous oesophagus i.e
rhabditiform larva).
• L1 larva feeds on bacteria, moults on day3 to L2
& on day5 oesophagus disappears elongated
larva, move from faeces to soil & moult L3
(filariform larva) infective stage.
 Hookworm life cycle contd…
• Under favourable conditions (shade, moist soil &
warmth 250C – 350C), L3 can survive for 3 – 6
weeks.
• Protected from drying, L3 survive for 2 years.
• L3 ascend vertically 60 – 90 cm & laterally about
30 cm in sandy loamy soils  implications for
transmission: wet type earthen floor pit latrines
or shallow pits for defaecation L3 to the top.
 Hookworm life cycle contd…
• L3  human skin blood Rt side of heart 
lungs day3 (HLM)  3rd moult.
• In lungs, L3  alveoli  bronchioles  up the
trachea.
• In trachea cough L3 swallowed
oesophagus stomach & SI (jejunum) on day7,
4th moult adults (buccal capsule) attach to SI
mucosa.
• Mature males & females copulate, in 3 – 5
weeks females lay eggs.
 Hookworm life cycle contd...
The life cycle of N.americanus &
A.duodenale are similar except:
• A.duodenale placental, mucous
membrane (mouth) & skin.
• N.americanus ONLY skin
• Migrating larvae of N.americanus
adults; those of A.duodenale may
undergo an arrested development (aridity
/ drought).
 Hookworms life cycle contd..
• Hypobiosis  arrested development of
migrating larvae of A.duodenale under arid
and hostile environment.
• Larvae do not develop directly into adults so
as to avoid release of eggs in an
unfavourable environment.
• The arrested worms mature as the environment
becomes favourable (increased humidity /
moisture).
 Hookworms pathology
• Pathology occurs at 3 stages of the
infection
• Site of entry into skin: Get vesiculation
and pustulation (“Ground itch”).
• During HLM: Get bronchitic & asthma
like attacks
• Adults in SI: Hookworm anaemia &
hookworm disease.
 Hookworms pathology contd..
Hookworm anaemia:
• Fe2+ deficiency (hypochromic microcytic
anaemia) blood loss, depletion of iron stores &
poor dietary Fe2+ intake.
• Hkws suck blood & cause bleeding, about 0.03
mls lost /day/worm in N.americanus & 0.15 –
0.26 mls /day/worm in A.duodenale.
• Thus, with poor Fe2+ stores, poor dietary Fe2+
& heavy infn likelihood of anaemia.
 Hookworms pathology contd..
Hookworm disease:
• Hypoproteinaemia (hypoalbuminaemia)
important feature of hookworm anaemia.
• Patients look oedematous (as in
kwashiorkor).
• The oedema does not respond to
diuretics.
 Hookworms: clinical features
Larval hookworms:
• Site of entry ground itch (irritating
vesicular rash in the soles of feet or
hands).
• In HLM bronchitic attacks (dry cough) &
asthma like attacks (wheezes)
accompanied with fever and high
eosinophilia.
 Hookworms: clinical features
Adult worms in SI:
• Light infn with adequate Fe2+ stores &
adequate dietary Fe2+  no symptoms.
• In heavy infns significant blood loss
chronic Fe2+ deficiency anaemia (pallor of
conjuctiva, nail beds and palms;
• Advanced cases: generalised oedema
with CCF.
 Hookworms: diagnosis
• Clinical: Pallor & “facies of hookworm
disease”
• Lab: Demonstration of adults & eggs in
faeces.
• Stool culture by Harada-Mori technique
 L3 to distinguish N.americanus from
A.duodenale (DX of hookworm eggs to
species level).
 Hookworms: treatment
Available treatments:
• Pyrantel pamoate, more effective in
Ancylostoma than Necator.
• Ketrax, more effective in Necator than
Ancylostoma
• Mebendazole, effective for all (3 doses)
• Albendazole, effective for all (1 dose)
drug of first choice
 Hookworms: epidemiology
• Hookworm widespread & clinically important
disease in tropics & sub-tropics.
• A. duodenale & N. americanus affect > 1 billion
people & cause anaemia morbidity in > 96
million people.
• A.duodenale parasite of Southern Europe
(noarth coast of Africa, northern India, north
China & Japan).
• N.americanus parasite of central & southern
Africa & South Asia.
 H/w Epidemiology contd..
• Both N.a & A.d occur in Tanzania, N.a the
predominant species.
• Man only reservoir of hookworm infn,
transmission depends on moist and warm
environment to allow larvae to develop to
L3.
• Poor faecal disposal & use of human
faeces as fertilizer facilitate transmission.
 H/w Epidemiology contd..
• L3 can ascend vertically 60 – 90 cm in
sandy loamy soils, & laterally for about 30
cm
• This has implications for transmission:
wet type earthen floor pit latrines or
disposal of adult & children faeces in
shallow pitsL3 will found their way to the
top.
Level of hookworm infn in a community:
Assessed by:
• Stool surveys  presence of eggs & egg counts
(Kato-Katz technique)  get prevalence,
intensity & worm burden.
• Soil pollution demonstration of L3 by the
Baermann method or culture by Harada – Mori
technique.
• Supplemented by Hb levels to establish the
prevalence and the degree of hookworm
anaemia.
These data provide the basis for the choice of
approaches to control.
 Control of hookworms
• Sanitary disposal of human faeces in pit
latrine. This requires adequate coverage of pit
latrines, which should be used properly by all
household members.
• Health education: Information and education on
transmission, disease burden & appropriate
control measures with the aim to induce
behavioural changes towards community
participation and adoption of appropriate control
measures.
 Control of hookworms contd..
Antiheminthic treatments & Fe2+
supplementation
• In areas with high prevalence and intensity of
infection with low haemoglobin levels mass
treatment with antihelminthics with iron
supplementation are indicated. The drug of
choice is Albendazole because in a single dose.
• The goal is to reduce to reduce morbidity and
transmission.
 Control of hookworms contd..
Available approaches:
• Blanket (mass) Rx: all individuals in the
community are treated
• Selective mass Rx: a selected group of
individuals eg schoolchildren is treated.
A successful control programme requires an
integrated approach combining mass
deworming, health education & sanitation.