Order Strongylida

THE HOOKWORMS
Necator americanus

American hookworm, American murderer

Necatoriasis, uncinariasis.
Tropical Anaemia, the Germ of laziness.
Geographical distribution
New World
South America, Southern Africa, Southern
India,Northern Australia, Southern States of
USA.
Habitat: Jejunum, upper ileum
Attached to mucosa, but may attach to new
sites during feeding
 Morphology of N.americanus
Adult
Males
7 - 9mm x 0.3mm, Wide long bursa,
Copulatory spicules fused terminally into a
barb.

Females
9 - 11mm x 0.4mm
Eggs- ovoid multinucleate, thin hyaline
shelled, produces 6000-20000 per day
--

Bursa (A) and head (B) of Necator americanus.

 (a) (b)
Diagram showing the dorsally bent anterior extremities of
(a) Ancylostoma duodenale and (b) Necator americanus.
 Both male & female worms
1. Pinkish or creamy gray
2. Buccal capsule
Ventral and dorsal, semilunar cutting plates
instead of teeth
4. 1pr subventral lancets deep in buccal cavity
5. Amphidial excretory and oesophageal glands for
exodigestion, excretes anticoagulant
6. Contraction of oesophageal muscles draws blood
and anchors worms to the intestinal wall
Transmission - Necator americanus
Cutaneous – L3 filariform larvae penetrate
through skin folicles

ESSENTIAL PULMONARY
DEVELOPMENT BEFORE
DEVELOPING TO ADULT STAGE
- 15 years longevity ( 1-20)
Rhabditiform larvae in stool
The Hookworms

Ancylostoma duodenale
Old World hookworm, Ancylostomiasis,
Miner’s anaemia
 Morpholoy of Ancylostoma duodenale
Worms flexed at neck like a hook -Adult
MALE;
· 8-11 mm X 0.4 - 0.5mm
· caudal bursa campanulate and supported by
fleshy rays
· 7prs rays: 2 ventral, 2 dorsal, 3 lateral
· 1 pr copulatory spicules
FEMALE:
· 10 -13 mm X 0.6mm
· eggs: prod. 25000-35000 per day and are
indistinguishable from Necator’s
BOTH Male & female worm
· Pinkish or creamy gray
· Buccal capsule large subglobular,
Chitinised Oesophagus lined with cuticle
DENTITION
· Ventral (upper) two 2prs fused teeth
· Outer tooth larger, inner tooth with small
inconspicuous processes
· Dorsal ( lower) - dental plate with a Median
cleft
· 1pr inconspicuous teeth deep in capsule
· Dorsal oesophageal gland opens through dorsal
dental plates
• Rhabditiform larvae – actively feed, has a
long buccal cavity and small genital
primordium.
• Filariform larvae – nonfeeding – shorter
esophagus than strongyloides stercoralis.
Has pointed tail.
• Larvae eggs of N. americanus & A.
duodenale basically indistinguishable
.
Transmission of Ancylostoma duodenale
1. Cutaneous – L3 filariform larvae penetrate
through skin folicles ( the unshod status )
2. Oral route – swallowed filariform larvae become
infective without lung passage
3. larvae sequestered inside muscle fibre
migrate to intestine via lungs or go to
mammary glands and via the colostrum
to pups.
• Galactogenic hookworm infection not
demonstrated in human hookworm.
• only suggested by high neonatal hookworm
incidence
• worm Longevity 1 year - 9 years (5 - 7)
 Pathogenesis
• Blood feeding (hematophagous) habit- primary pathogenic
mechanism.
• Worm attach with month parts to wall of small intestine
• Feed on blood frm ruptured capillaries
• Blood loss estimated at 0.03 ml/day per worm in N A and
0.15 ml/day per worm in A D infection
• Parasite secretes anti-coagulants to maintain continuous
oozing of blood at the hookworm attachment and free flow
of blood through the parasite’s alimentary canal.
• Anaemia in Hookworm – Iron Deficiency Anaemia
• Children & pregnant women – most susceptible of IDA
• Children IDA – impaired neurological dev & cognitive
function, in pregn low infant birth wght or infant death
HOOKWORM INFECTION AND
HOOKWORM DISEASE

1. Cutaneous lesions:
itching sensation by penetrating larvae cause
severe unrelieved pruritus, allergic reaction
erythmatous papular rash - vescicular
known as “ Ground itch”
2. Creeping eruption ( cutaneous larva migrans Other
species of hookworm are known to accidental infect humans,
as they primarly parasites for dogs and cats - A.braziliense
and dogs only- A. Caninum. When they infect humans, they
are unable to complete life cycle, infecting subcutaneous or
skeletal tissue and may produce a condition known as
“cutaneous larva migrans” (lessions resemble creeping
worms through th skin)
(Uncinaria - European dog hookworm)
- larvae evoke severe reaction forming serpiginous
tunnels in the dermis, (travel several/mm/day), itchy
scratching several weeks or months
· - Deep skin eruption
Pneumonitis - CLCs in sputum
· associated with moist, wet soil and vagrant dogs and cats feces
3.Pulmonary lesions
(a) A. duodenale - oral route transmission
WAKANA disease in Japan
· Nausea, vomiting, salivating, itching of the
pharynx, hoarseness of voice.
· Several days later - cough dyspnea,
hyperesinophilia, nausea.
· Allergic reaction to larvae even when boiled
Pneumonitis
· Migrating hookworm larvae break out
of broncho alveoli and cause focal
hemorrhages
· Pneumonitis - more severe cough than in
Ascaris pneumonitis or Strongyloides
infections
4. Intestinal Infection and Hookworm Disease
(a) Worm attachment, (digest mucosa.)
(b) Blood lost at attachment sites.
Anticoagulant in Ancylostoma caninum
Previous attachment sites - small open ulcers
(c) Acute heavy infection:-
Fatigue, nausea, vomiting, burning
cramping abdominal pain
(d) massive infection - massive intestinal
hemorrhage - CLCs in feces
Eosinophilic infiltration
(e) Chronic hookworm infections
· Iron deficiency symptoms, pallor, facial
and pedal oedema, apathy,
vacant dull expression, listlessness
Hb 5g/dl, enlarged heart, heart murmurs
· Mental and physical development
retarded
5.Hookworm disease refers to: (essential
symptoms)
· Microcytic, hypochromic anaemia due to
hookworm
· Chronic blood loss with inadequate
replacement of iron and protein
· Related to worm burden
5 eggs/mg feces - not clinical grade
20 egg/mg feces - significant Anaemia
50 eggs/mg feces - hookworm disease,
from over crowding by the worms
 DIAGNOSIS OF HOOKWORM
1. Demonstration of eggs in faeces:
2. Charcot-Leyden crystals in faeces – in prepatent
period
3. Free larvae in stored faeces – to be differentiated
from other larvae
4. Culture of eggs – Harada-Mori test,(adult worms
buccal apparatus can be examined and
Coproculture
5. In light infection concentration methods could
be used- zinic sulphate concentration, formol
ether, Kato-Katz
6. PCR
 TREATMENT OF HOOKWORM
Treatment for worm infection and treatment for
anaemia. Priority treatment is for the anaemia
1. Adult Parasites: to reduce worm load
a. Albendazole –200mg daily for 3 days
b. Mebendazole
c. Levamisole
d. Pyrantel Pamoate (Combatrin)
Treatment for Hookworm Cont.
2.Cutaneous Larva Migrans
a. oral Thiabendazole
b. Topical Thiabendazole
c. Mebendazole
d. 10% Metriphonate in petroleum
jelly - topically
Treatment for Hookworm Cont.
3. Hookworm anaemia
a. Iron therapy
b. Folic acid
c. Parenteral iron – iron-dextran
when patients cannot tolerate iron by
mouth or when compliance is poor.
 Epidemiology
• One quarter of worlds population is infected.
• Main reservoir is man
• Transt. depends on adequate source of infection in human population
• Deposition of eggs in favourable environment for extrinsic develop of
parasite.
• Appropriate conditions of soil (moisture and warmth) for larva to dev
• Suitable conditions for infective larva to penetrate skin
• Cultural and agricultural practices – use of human faeces for fertilizer
provide good opportunities for infection
• Hookworms larva ve ability to migrate downward into soil, avoiding
desiccation
• Hookworms ve longer adult lifespan and can find refuge frm external
temperatures for longer than other geohelminth species, increasing
chances of HW transmission stages being deposited and develop in
suitable thermal conditions.
• Can infect children – 6mths- infection rises with increasing age to a
plateau in adult hood
Endemicity of hookworms depends on
1. Continuous infection in the human
population
2. Promiscuous defecation ensuring that ova
are deposited in favorable soil for extrinsic
development
3. Appropriate conditions – sandy and humus
soil
4. Opportunity for the infective larvae to
come in contact with bare skin.
5. Prolonged dry and cold seasons are
unsatisfactory for the extrinsic
development
6. Defecation habits and use of night soil in
agriculture ensures inoculation of soils for
human exposure.
7. Temperature is major factor in determining
geographical distribution
- Necator eggs and larvae tolerates higher
temperatures than those of Ancylostoma
- Necator is warm climate hookworm
- Ancylostoma is cooler climate
hookworm
8. How patterns of rainfall influence distribution
a. Hookworm infective larvae are hygrophilic, they
migrate with rising rain moisture or dew.
b. Infective larvae migrate to the soil surface, and
on to grass blades, migrate as high as moisture
permits.
c. During periods of drying, the larvae retreat with
the receding water film below the surface- many
perish
d. Alternating drying and wetting conditions lead
to destruction of larvae by desiccation.
8. Cont.
e. In absence of fecal contamination, the soil
becomes non infective.
f. Flushing rains = concentrate in lower areas.
g. During periods of drought and low temperature,
infective larvae can remain viable in the soil for
several months.
h. Infective larvae migrat against the capillary flow
of moisture – basis for the Harada-Mori fecal
culture. Beaver, P.C. 1975. Biology of
soil-transmitted helminths. The massive
infection. Health. Lab. Sci. 12. 116-125
9. Role of dung beetles in hookworm
distribution
a. Dung beetle break up and bury feces in
soil
b. This action produces soil-feces mixture
suitable for development of larvae.
10. Prevalence and intensity determined by
cross sectional surveys and egg counts.
 Control
• Chemotherapy- three strategies can be used
(i) Mass chemotherapy, i.e. tx of all persons if prevalence of infection is
50% or over.
(ii) Selective population chemotherapy , i.e. tx of all infected persons at
time of survey.
(iii) Targeted chemotherapy, i.e. tx of specific groups likely to suffer the
greatest morbidity e.g. Sch-age, Pre-sch children, Pregnant women
Primary goal of chemotherapy is to reduce transmission and hence worm
burden and morbidity in community.
• Sanitation- improvements in environmental hygiene are the ultimate
answer to the control and elimination of geohelminths infections. This
is expense for developing countries, however many varieties of
affordable latrines are available e.g. Ventilated improved latrines and
double-vault latrine these allow for adequate composting of human
excretion as fertilizer. Sanitation is slow to develop, therefore periodic
tx should be maintained until sanitation has had impact on
transmission
• Health education- success or failure of control programmes often
hinges on the modification of behavioural patterns.

• Community participation- crucial for success of any programme.

Active participation in planning and execution of any intervention is
mandatory.

• Monitoring and evaluation- are essential and should be used to

review or revise any control programme
Ancylostoma ceylanicum
1. Males 8mm. Females 10mm
2. Two large teeth, each with a small on each
side of the middle line.
3. In cats and wild cats, dogs and man to a
lesser extent in SE Asia, Phillipines,
Taiwan, India
4. Does not cause larva migrans in man
5. Causes intestinal infection in man and
needs to be distinguished from N.
americanus and A.duodenale
Ancylostoma ceylanicum Cont.
6. Small bursa , as wide as it is long supported
by short lateral rays
7. Causes creeping eruption
(Cutaneous Larva Migrans)
Ancylostoma brazilliense
1. Wild and domestic Cats and dogs in Brazil
Phillipines, India, Thailand, Ceylon,
Indonesia, New Guinea
2. Males – 8mm, Females – 10mm with
distinct angular bend at level of vulva
3. Bucal capsule with pair of inconspicuous
median teeth and a pair of outer larger
teeth.
Ancylostoma caninum
1. Dog parasite
2. Human parasite in the Phillipines, L3found
in skeletal muscle of man in Louisiana-
Paratenesis common
3. Males – 10mm, Females – 14mm
4. Large buccal capsule – 3prs ventral teeth
5. Bursa supported by slender rays
6. Eggs slightly larger than A.duodenale
7. Oesophageal ( amphidial) glands with
proteolytic enzymes
EPIDEMIOLOGY OF HOOKWORM

Geographical distribution:
One quarter of worlds population is infected.
Limited by climate. One species predominates