HOOKWORMS

Introduction
• The common species of hookworms
commonly infect humans are:
– Ancylostoma duodenale
– Necator americanus

• The disease caused by hookworms is

known as:
– Hookworm disease (Ancylostomiasis,
necatoriasis)
• The second most common human helmithic
infection (after ascariasis)
 Geographical distribution and Epidemiology
• Hookworms are of worldwide distribution; mostly in areas with moist
and warm climate
• A. duodenale and N. americanus are chronic infections and are
estimated to affect 740M people in areas of rural poverty in the
tropics and subtropics.
• Both Ancylostoma duodenale and Necator americanus are found in
Africa, Asia Americas and Australia
• Only Necator americanus is found in south India and predominates
in the Americas, while only A. duodenale is found in the Middle East,
North Africa, northern India and southern Europe
• Children are especially vulnerable to this kind of infection. These
roundworms infect about 25% of the world's population.
• An estimate of 44 million pregnant women are infected with
hookworm worldwide, with 7.5 million in sub-Saharan Africa alone
• Determinant factors: moist and warm temperature are essential for
larvae development in soil, poverty, poor sanitations, over
population and water supplies
• Intensity of hookworm infection increases with age. Infection rise in
the intensity of infection during childhood, with either a peak or a
plateau in adulthood
 Habitat
• The adult worm resides in small
intestine of man particularly in
jejunum
 Morphology
Ancylostoma duodenale
• A. duodenale is a cylindrical white, grey or
reddish – brown from ingested blood thread
like worm
• Adult females measures 10 to 13 mm and
males measures 8 to 11 mm
• The male is smaller than female and has
corpulatory bursa at the rear end consisting of
an umbrella-like expansion of the cuticle
• Both male and female worms have a buccal
capsule containing 2 pair of teeth for
attaching to the small intestinal mucosa.
Scanned electron micrograph of the mouth capsule of
Ancylostoma duodenale, note the presence of four "teeth,"
two on each side (two pair of teeth)
Necator americanus
• Closely resembles A. duodenale but it is
shorter and slender

• Adult females measures 9 to 11 mm and

males measures 7 to 9 mm

• The buccal capsule is smaller than that

of A. duodenale and has cutting plates
(1 pair) instead of teeth.
Scanned electron micrograph of the mouth capsule of
Necator americanus, Note the presence of two cutting
“plates“.
 The Morphological differences between two
species of Hookworms
A. duodenale N. americanus
Size Larger Shorter and more
slender
Buccal capsule Two pair of teeth Has cutting plates

Eggs Lay about 25,000 – Slightly larger and

35,000 eggs each lays about 6000-
day 20,000 eggs daily
 Egg:
 Hookworm eggs examined on wet mount cannot be
distinguished morphologically; differing only slightly in
size:
 Necator americanus : 64 – 76 by 36 – 40 µm
 Ancylostoma duodenale: 56 – 60 by 36 – 40 µm
 Oval or ellipsoidal shape
 Thin shell
 The embryo has begun cellular division and is at an early
(gastrula) developmental stage.
 The egg has blunt rounded ends and a single thin
transparent hyaline shell (appears microscopically as a
black line around the ovum).
 It is unsegmented at oviposition and in 2 – 8 cell
stages of division in fresh feces.
Hookworm rhabditiform larva. note long mouth opening (Left side). S.
stercoralis rhabditiform larva. Note the mouth is short (Right side)
Hookworm filariform larva (wet preparation)
 Transmission
• Penetration of the infective filariform larvae
through the host skin
• A. duodenale larvae are also orally infective
(by direct ingestion of infective larvae
contaminated fruits and vegetables) and
transmammary route (lactogenic transmission
during breastfeeding may occur).
• Highest transmission occurs in the coastal
regions and Lake shores, where infective 3rd-
stage larvae can migrate freely in sandy soils
and where temperatures and moistures are
optimal for viability of larvae.
 Life cycle
• Adult worms inhabits the small intestine
• Eggs are passed in the stool, and under
favourable conditions (moisture, warmth,
shade), larvae hatch in 1 to 2 days.
• The released rhabditiform larvae grow in the
faeces and/or the soil, and after 5 to 10 days
(and two moults) they become filariform
(third-stage) larvae that are infective.
• These infective larvae can survive 3 to 4 weeks
in favourable environmental conditions.
• On contact with the human host, the larvae
penetrate the skin and are carried through the
veins to the heart and then to the lungs.
• They penetrate into the pulmonary alveoli, ascend
the bronchial tree to the pharynx, and are
swallowed.
• The larvae reach the small intestine, where they
reside and mature into adult.
• Adult worms live in the lumen of the small
intestine, where they attach to the intestinal wall
with resultant blood loss by the host.
• Most adult worms are eliminated in 1 to 2 years,
but longevity records can reach several years.
 Some A. duodenale larvae, following
penetration of the host skin, can become
dormant (in the intestine or muscle)
 In addition, infection by A. duodenale
may probably also occur by the oral and
transmammary route
 N. americanus, however, requires a
transpulmonary migration phase.
Life cycle
Pathogenesis/ clinical features
Cutaneous or invasive stage
• Dermatitis, known as "ground itch“. The
larvae penetrating the skin causing
allergic reaction, petechiae or papule
with itching and burning sensation.
Scratching leads to secondary infection
• Most common between the toes and on
the back of the feet
Wakana disease
• A. duodenale may be transmitted through
ingestion of larvae. They can develop into
mature worms directly in the intestine
without migrating through the lungs.
• Is characterized by nausea, vomiting,
pharyngeal irritation, cough, dyspnea, and
hoarseness. Increased circulating levels of
IgE occur in response to migrations of third-
stage larvae in the lungs and intestines.
Pulmonary phase
• Occurs when larvae are breaking out of
capillaries in lungs

• Pneumonitis: cough, asthma, low fever,

blood-tinged sputum or hemoptysis,
chest-pain, inflammation shadows in
lungs and high degree of eosinophilia.
• These manifestations go on about 2
weeks.
Intestinal phase
• Abdominal pain and loss of appetite,
mucosal inflammation

• In heavy infection
Loss of protein resulting to
Hypoproteinaemia leading to oedema,
anasarca, stunted grow and mental
retardation (malnutrition)
Hookworm anaemia
• Blood loss occurs when worm use their cutting
apparatus to attach themselves to the
intestinal mucosa and submucosa and contract
their muscular esophagi to create negative
pressure, which sucks a plug of tissue into
their buccal capsules.
• Adult hookworms release anticlotting agents
such as factor VIIa/tissue inhibitor to ensure
continuous blood flow
• The hookworm ingested a portion of the
extravasted blood, some RBC undergo lysis,
releasing Hb which is digested by a cascade of
hemoglobinases in the gut of parasites.
• Chronic loss of blood leading to
Hookworm anaemia
The anaemia is typically iron deficiency
anaemia (microcytic hypochromic anemia)
and respond very well to iron therapy

• An estimated blood loss

A.duodenale daily blood loss
0.15mL/d per worm
N. americanus 0.03mL/d per worm
 Other clinical manifestations
• A moderate or heavy hookworm burden results in
recurrent epigastric pain and tenderness, nausea,
exertional dyspnea, pain in the lower extremities,
palpitations, joint and sternal pain, headache,
fatigue and impotence.
• Stools may contain blood and frank melaena may
occur in children.
• Some patients crave bulky substances and ingest
dire (pica)
– Taste my be perverted and some patients may
exhibiting unnatural craving for such things as
earth, mud or lime (pica or geophagy).
 Hookworm disease in mothers and children
• Overall prevalence and intensity of hookworm infection are
higher in males than in females, b’se males have greater
exposure to infection
• Women and young children have the lowest iron stores and are
most vulnerable to chronic blood loss as a result of hookworm
infections
• In children hookworm infections affects memory, reasoning
ability and reading comprehension in childhood
• Hookworm infection in children may reduce school attendance,
with subsequent effects on productivity and wage-earning
potential in adulthood
• In pregnancy-hookworm related iron-deficiency anaemia is
linked to increased maternal mortality, impaired lactation,
prematurity and low birth weight
• The association between hookworm infection and anaemia is
greatest in multigravidas
 Diagnosis
• Stool examination to detect characteristics
eggs using concentration technique (formol-
ether, Zinc sulphate concentration) , Kato
Katz technique
• Hb level
• Culture
• PCR – specie differentiation in faecal
sample
 Prevention and control
• Improve standard of hygiene and sanitation
• Public health education focusing on
wearing shoes and use of toilets.
• Mass chemotherapy through school-based
deworming:- Single dose of ALB (400mg) or
MEB (500mg)
• Deworming programs to pregnant mothers
at 2nd trimester and women of
childbearing ages.
 Management
• Anaemia is treated with Iron orally
(Ferrous sulphate)
• A high protein diet is necessary to replace
protein loss dietary supplements
• Albendazole and Mebendazole and
pyrantel pamoate are drugs of choice