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Souvce TIe JouvnaI oJ FavasiloIog, VoI. 85, No. 3 |Jun., 1999), pp. 392-396
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The Journal of Parasitology.
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J. Parasitol., 85(3), 1999
p.
392-396
? American
Society
of
Parasitologists
1999
THIS WORMY WORLD*
Norman R. Stoll
Rockefeller Institute for Medical Research, Princeton, New
Jersey
One cannot have
experienced
the war without
having
been
impressed
anew,
and
depressed, by
the amount of
parasitism
in the world.
Speak-
ing helminthologically,
it
may
be referred to as the
grave
host r6le
which the lives of men
play
in the lives of worms. Or, think of it the
other
way about, for there is likewise the
great parasitic
role the lives
of worms
play
in the lives of men. Back from the Pacific come a thou-
sand-odd Americans with schistosomiasis, and a few times that
many
with filariasis, and several
multiples
more with
ancylostomiasis
(sensu
strictu).
To homes
widely dispersed throughout
the land
go
these ex-
service men, to live a lifetime in
familiarity
with the
strangely sounding
names of their
distantly-acquired
helminthiases.
These observations
suggest
familiar
concepts
to the
parasitologist.
The One World of Wendell Wilkie that struck with the force of a new
idea at the
politicoeconomic level, is, of course, decades, and in some
respects
centuries old, to the student of
disease-producing agents.
How-
ever, each
parasitologist
is wont to live in his
thinking
in One World
with the
species
which
particularly
interests him. There have been,
therefore, only
a few
attempts
to
bring
all
species
of
major
human
concern into the short focus of a brief
presentation.
In the belief that
there
might
flow from such renewed consideration certain
emphasis
useful to world citizens and in our science,
this
attempt
at such a suc-
cinct statement has been made.
Just how much human helminthiasis is there in the world?
The bare mention of the
question
will make those of
you
with noso-
geographical interests-or, better, helminthogeographical
interests-
warily
scratch a mental ear and mull over a remark that ends "where
angels
fear to tread." If so
you
are
doing furtively
what I did
openly
and
frequently
in these last weeks, as the difficulties in the
accomplish-
ment of such a combined
analysis
and
synthesis presented
themselves.
I need
scarcely
remind
you
of what some of those hurdles are: so
many
parasitological surveys
of but small numbers of
people, frequently
of
other
design
than to
represent
fair
samples
of an area,
done
by
workers
of
varying
aims and
by techniques
of even more variable
efficiency
in
relation to the task at hand. Worse,
at first
sight,
from a true census
standpoint,
is the fact that in order to
gain
a
comprehensive perspective,
examination results made at intervals over
years
have needed to be
compressed
as if made at a
single
recent
point
on the time scale, some-
times without full
knowledge
of what
complicating
or ameliorative fac-
tors had been
interposed
in the meantime.
One cannot
change
this state of affairs at the moment. Instead, one
takes the data as
they
are and does the best one can. One remembers
that whatever
legitimate objection
there
may
be to their
projected
use
inheres also in all
generalizations
made in this field. The information
presented
this
morning
is from the same kind of data we all have had,
of
necessity,
to
employ
in
piecing
out the
impressions
we
currently
possess,
of the extensiveness of the
problems
to be discussed. In sub-
stance, the net difference in the use made of them here
by me, is that
I have restated such
adjectival generalizations
of the reference book as
"rare," "common," "prevalent,"
into the best
quantitative
terms which
searching
of the records and
epidemiological insight
have
permitted.
One needs to be reminded, of course, that even the statement of 2166
million human
beings
on the
planet
in 1940 includes estimates rather
than
uniformly precise
census
figures.
White and
Jacoby (1946)
have
noted that the estimates for China,
which run from 400 to 550 millions,
represent
a
discrepancy,
itself
greater
than the
population
of the United
States. For
my purposes
I have relied
primarily
on data furnished or
approved by
the Office of
Population Research, Princeton
University,
including
the recent
League
of Nations
publication by
Lorimer
covering
the U.S.S.R. The Statistical Yearbook of the
League,
which could
equal-
ly
well have been
employed,
would have modified certain sub-totals,
but it comes out with a like
global
total of 2170 million.
The censuses or estimates
vary
in date from 1920 to 1942, more than
*
Address of the President,
American
Society
of
Parasitologists,
De-
cember 27, 1946, Boston.
half of them
occurring
in the 1935-1940
period.
An
approximately
sim-
ilar statement as to dates
applies
to the helminthic infection
figures,
although publications
into 1946 have been consulted.
Some of the details of the
analysis
can be visualized best
by
exam-
ining
the status of
specific
infections. Let's start with Trichinella spir-
alis. Here is a
parasite
whose life
history,
one of the first worked out
for a helminth of man, has been known for
nearly
a
century.
It is an
infection about which, in this
country,
we have
developed good epi-
demiologic
information in the last decade or so, an infection which
should have
special
interest for a Boston audience, in view of
Augus-
tine's
(1942)
evaluation of it as the "most serious
parasitic
disease in
New
England."
Trichinella is almost
completely
absent in man in a
major portion
of
the world. East of Suez
(more specifically Syria)
all the
way
to San
Francisco, as well as in
Australia,
in
Africa,
and
generally throughout
the torrid zone, it is
substantially
nonexistent as a human infection. In
these
regions
live about 2/3 of the earth's inhabitants, but the few cases
of record
suggest
an infection rate there of the order, say,
of one hun-
dredth of one
per
cent in man.
The classic zones of infection have been instead in central
Europe,
and those
parts
of
temperate
America to which its
emigrants
and their
eating
habits for
pig
have
gone.
In
Europe,
the
reports
in the
pre-war
years concerning man, as well as
officially inspected pork,
have
sug-
gested exceedingly
low rates. The war
years themselves, however, have
furnished outbreaks in
nearly
all
European countries, and recurrent
ep-
isodes in German
troops during
the
campaigns, especially
in Poland and
Russia. Results of
surveys
there on a
comprehensive scale, by
direct
microscopic
examination
supplemented by digestive techniques applied
to muscle obtained at human
necropsies,
are not
yet
available.
Europe,
including Russia, contains above 500 million
people.
If we assume the
diaphragm
infection rate
throughout Europe
to be as low now as one
per
cent (and this is much
higher
than
pre-war indices),
that would mean
about 5 million cases.
In South America, recent rates
reported
from Chile, (Neghme, 1944)
slightly
exceed 10
per cent, and from
Uruguay
3
per
cent
(Talice
and
Fiandra, 1943),
with the
probability
that the latter
may
reflect the situ-
ation in
Argentina.
Mazzotti
(1944)
believes 12
per
cent the
likely figure
for Mexico
City.
These four areas of Middle and South America
possess
then, by extrapolation,
about one million cases. In Canada, according
to the examinations of Cameron
(1943),
and Kuitenen-Ekbaum
(1941),
there is an
apparently trifling
infection rate of about 1
per cent, perhaps
100,000 in all Canada-which is not so
trifling
but that clinical out-
breaks
occasionally develop.
This low rate, and trichinosis outbreaks
nonetheless
occurring
in Canada without the
exigencies
of famine, may
be taken as a
pointer
toward how low the index must become before
complete
control of trichina is
accomplished.
In the U.S.A. we have trichinosis in a
bigger way.
Thanks to the
nearly 12,000 necropsy
examinations in recent
years, nearly
half of
them
by
the National Institute of Health workers, who combined mi-
croscopic
and
digestive techniques,
we have now what must be consid-
ered a rather
good perspective
of the situation
throughout
this
country.
It's over-all
finding
is about 1 in 6 Americans infected. On the basis of
the 1940 census of 131 million
people,
there are then 21 million Amer-
icans who have
ingested
Trichinella spiralis. Proportionately,
in certain
parts
of the
country
it would be
higher.
Trichinella incidence obtained at
necropsies
has the
advantage
of
being
a
figure
which indicates total
exposure,
inasmuch as most infected
individuals would
appear
to retain evidence of calcified larvae
through-
out life. It is further of interest, therefore, that the NIH data show 41/2
per
cent of
positives
with counts of 50 or more larvae
per gram
of
muscle, infections of an order
"capable
of
causing pronounced
clinical
symptoms."
These individuals, if adults, would, I calculate, be
carrying
muscle loads in excess of one million trichina larvae.
Hall and Collins
(1937) emphasized
that the United States "has the
greatest problem
of trichinosis of
any country
in the world." The
figures
392
STOLL-THIS WORMY WORLD 393
adduced indicate that also it should be said: we have in this
country
more than 3 times as much trichinosis as is known in all the rest of the
world
put together.
Because the
problem
is thus
predominantly
our own, one is
tempted
to
digress
and to muse a little about such a record, which, of course, is
a
preventable one, and maintained
primarily through allowing hogs
to
be fed uncooked
garbage containing
meat
scraps harboring
live Trich-
inella. Those of
you
who travel the
Pennsylvania
R. R. into New York
become aware that we maintain in the
Jersey
meadows at Secaucus a
malodorous demonstration for
every
traveller to observe how it is done.
When we Americans manifest an
unbecoming impatience
at how sloth-
ful other
peoples are, in
undertaking
the
necessary
and obvious
steps
to free themselves from this, that or the other endemic helminthiasis,
let us
pause
a moment with ourselves. We can ruminate with
profit
on
the
extraordinary
slowness demonstrated
by
a
supposedly widely
edu-
cated
people,
in
failing
to
protect
itself
against trichinosis,
when it can
do so
by
the
simple
device of
eating pork only
when the trichinae in it
have been cooked, say,
to the
consistency
of medium-boiled
eggs.
Such
a
simple protective
measure has been
propagandized
in this
country
widely
for
well-nigh
a
half-century.
We can also ruminate on the ex-
traordinary
inertia of
public officials, legislative
and other, in their odd
failure to
adequately
control the
feeding
of uncooked trichinae in raw
garbage
to
hogs.
One is
given
to wonder, considering
that our scientific
analysis
of the
subject
is now
competent,
and the road to control thus clear, whether
we are
dealing
here not with a
mercenary,
but with a
psychological,
block
against
effective action.
Perhaps
"trichinosis" is a word of too
little odium. Would Americans be
equally
comfortable in
realizing
that
each 6th
among
them is
harboring garbage
worms? And that one in 150
persons dying
from other causes takes to the
grave
a million or more
garbage
worm larvae? What wasted
"blind-alley"
effort from the stand-
point
of Trichinella
demography!
If time
permitted considering
the helminths of man, species by spe-
cies, in relation to their incidence and the
populations
of individual
countries or other
geographical units, it would be as
illuminating
an
experience
to
you,
I
think,
as it has been to me. It is a sort of new
perspective
in
helminthology,
or at least a new
emphasis-this
view of
the worms man lives with,
not
primarily
in their taxonomic relations,
nor in the accident of historical or local interest, but in terms of the
over-all number of his fellows that are burdened with them.
Omitting
many
of the
steps by
which the factual statements are made, we come
out like this at the world level for some familiar forms:
Taenia
saginata,
the beef
tapeworm,
39 million infections, most as-
cribed to Africa and to the U.S.S.R., but Taenia solium, the
pork tape-
worm, less than 3 million,
with
nearly
a half in Asia.
Cysticercosis
manifestly
makes
up only
a small
part
of these. Further, one is
surprised
to discover that the best estimate for
hydatid infection, which, according
to Barnett
(1937),
stimulates about a hundred titles a
year
in the liter-
ature, appears
to come to less than 100,000 cases,
with South America
leading.
For
Hymenolepis
nana there are about 20 million
currently
indicated infections, 2/3 of them in Asia. This
species
seems rare in
Oceania. On Guam we did not encounter it or
any
other
tapeworm
in
natives, although
infections were found in 0.5
per
cent of service men,
which
they
had
evidently brought
to the area from homeside.
Diphyl-
lobothrium latum, the broad or fish
tapeworm,
shows about 3 million
cases each in the Baltic littoral,
northern Russia, and U.S.S.R. in Asia,
and a world total of 10 million. Thus, the cestodes
altogether represent
72 million infected individuals.
Of fish-transmitted trematodes, Clonorchis sinensis, the human liver
fluke, confined to Asia, seems not to be in excess of 19 million infec-
tions. The related
Opisthorchis felineus,
confined to fisher folk in East
Prussia, the
Dneiper
river basin, and northern Sverdlovsk in Asiatic
U.S.S.R., has indications of one million.
Of the fishborne small intestinal flukes, Metagonimus
and Hetero-
phyes,
I have been unable to find evidence of more than a few hundred
thousand
probable
infections. A similar statement holds for Echinosto-
ma and Gastrodiscoides.
The
large
intestinal fluke, Fasciolopsis buski, again
a form confined
to Asia, totals 10 million infections, about a half of which are in the
Chekiang
endemic center. The related form, Fasciola
hepatica
of the
ruminant liver
passages,
has been
reported
with
increasing frequency
in
man and from all continents, but there is no indication that more than
100,000 cases are involved. Dicrocoelium dendriticum, also
normally
in ruminants, has been found
(including
confirmations at
necropsy)
es-
pecially
in the
Stalingrad
and Transcaucasus
regions,
where it occurs in
sufficient
degree
to indicate several hundred thousand cases.
Paragonimus
westermani incidence has not been
easy
to define, but
with the aid of some
relatively
recent
surveys
it is
possible
to
place
the
limiting
value of about 3 million cases of
lung
fluke infection in Asia
and a few thousand in West Africa.
The several trematode infections of man
just
mentioned account for
about 34 million infected individuals. The schistosomes
represent
more
than three times as
many
additional trematode infections, with S.
ja-
ponicum
the most numerous. For the six
major
centers of S.
japonicum
endemicity
in the
Yangtze valley,
an
average
incidence is
given
of about
7
per
cent
microscopic positives, barring
some
heavily
infected
villages
(Faust
and
Meleney, 1924).
If for
present purposes
and to include non-
egg-passing cases, one takes 20
per
cent of the entire
populations
of
the
provinces
in which such foci are described, adds to it 10
per
cent
of the entire
populations
of such other Chinese
provinces
and
Japanese
prefectures
as are known to have foci, and includes for the
Philippines
30
per
cent of the
population
of the islands of
Leyte, Samar, Mindoro,
and Mindinao-the total infected with S.
japonicum represents
46 mil-
lion
people.
The anomalous Dutch East Indies focus in the Celebes
(Bonne
and
Sandground, 1940), presumably
contains
only
a few thou-
sand infections.
For S. haematobium, some
regions
as in East Africa
suggest
a 50
per
cent incidence, others
grade
down to 10
per
cent as in North Africa,
and for
Egypt
we have the estimate of Scott
(1936, 1937a)
of 6 million
infected. The African areas free of infection are in
general
of low
pop-
ulation. To the millions
carrying
S. haematobium in Africa are to be
added
only
an
approximate 200,000 in the Near East and a few thou-
sands in
Europe,
for a world total of 39 million bilharzia-infected in-
dividuals. A small
outlying
infective center on the southern end of Por-
tugal (Bettencourt.and Borges, 1927) may
have now a new and
oppo-
sitely placed
focus in western India
(Andreasen
and Suri, 1945),
both
at the moment
inconsequential numerically.
S. mansoni is the most
dispersed
of the three schistosomes of man
(if
we include intercalatum with
haematobium).
Besides the
equatorial
zone in Africa, there is a band of infection from northern
Nigeria
west-
ward. These with Scott's 3 million cases in
Egypt
total 23 million for
Africa. Whether establishment of our western
hemisphere
endemic areas
is to be ascribed
exclusively
to the slave trade, seems to be a matter to
question (Magalhaes
and Dias, 1944).
But foci on this side the Atlantic
appear
to account for about a third of a million cases in the West Indies,
30,000 in Venezuela
according
to Scott, and
nearly
6 million in the
spreading
infective zone in northeastern Brazil. All told this
gives
29
million
persons
infected with S. mansoni, and 114 million for the 3
schistosome
species
combined.
In the absence of
comprehensive surveys
for
parasites
such as
guinea
worm and the filarids, a device of
limiting
values has been
employed.
The areas in India from which Dracunculus medinensis has been re-
ported-which having
small rainfall are in
general
the low hookworm
zones in India-have about 110 million inhabitants. If as
high
as 25
per
cent is used for the
guinea
worm incidence, there are 271/2 million
infections indicated. A similar tactic
applied
to
Afghan, Iran, Arabia,
and southwestern U.S.S.R. in Asia, yields slightly
over 5 million more
cases of "the
fiery serpent." Similarly
the African endemic areas would
contribute another 15 million infected, but the
single
focus on this con-
tinent, in northern Bahia, Brazil, involves
only
a few thousand.
Figured
by
this method, which
may
be too
generous,
the world has 48 million
guinea
worm cases.
Onchocerca in Central America is localized on the Pacific
slopes
of
3 states in Guatemala, and 2
(not 3) departments
of Mexico.
(Both
Dampf (1942),
and Bartter
(1945)
have taken occasion to insist that the
department
of Guerrero is free from the
disease.)
These 5
political
sub-
divisions have a combined
population
of 2/3 million. In Africa, the zone
from Sierra Leone eastward
through
the infected
regions
contains 57
million inhabitants. If a third of all these are involved with the infection,
the world total for Onchocerca would not exceed 20 million.
Mansonella ozzardi is confined to
regions
of Middle and South
America with a
population
of 21 million. If a third are infected there
are 7 million with Mansonella.
Acanthocheilonema
perstans occupies
the Onchocerca
regions
in Af-
rica, supplemented by
foci in North Africa; and in South America over-
laps,
in
part,
the Mansonella areas. It is also found in Dutch New Guin-
394 THE JOURNAL OF PARASITOLOGY, VOL. 85, NO. 3, JUNE 1999
ea in the Pacific. These
regions
have a combined
population
of about
81 million, and if a third are infected, there are 27 million Acantho-
cheilonema cases.
Loa loa is
strictly
an African form of the west and west central
regions
where dwell 39 million
people.
If a third of these have loaiasis,
there are 13 million.
These four filarid forms, conveyed respectively by Simulium, by
Cu-
licoides, and
by Chrysops, parasitize
then 67 million
people. Despite
the
simplified
method of
approximating
this
total,
it
may
have consid-
erable
validity, although
the estimate for Onchocerca is
possibly
too
high,
and that for Acanthocheilonema too low.
The same
general
method can be used for orientation of Wuchereria,
although
it cannot be
applied
so
simply.
In the
following analysis
W.
bancrofti
and W.
malayi
have not been
distinguished. One, the other,
or both, are at home in human
beings
and
appropriate mosquitoes pretty
much
throughout
the
tropical part
of the world. Wuchereria is endemic
in
Oceania,
with the notable
exception
of New Zealand, most of Aus-
tralia, and some of the lesser islands;
it is in the Dutch East Indies, with
Java's 40 millions
surprisingly free, however;
it is in the
Philippines,
Formosa, and southern
Japan;
in the coastal area of
Asia-broadly
in-
terpreted-from
northern
Kiangsu province
in China clear around the
eastern, southeastern,
and southern
fringe
of the continent, almost to
Suez; it is in the broad
equatorial
belt across Africa, together
with Mad-
agascar
off the southeast coast, and North Africa; it is in South America,
especially
in an area around
Belem,
Brazil
(Causey
et al, 1945),
and a
coastal belt from the Guianas to Colombia;
and in the West Indies.
How
many
in this broad
tropical territory
shall we define as
having
filariasis?
Only
those who show microfilariae in the blood? If so the
marines
garrisoned
near Samoan
villages
and later invalided home with
tell-tale
symptoms
could not be said to have had this infection, for the
number
showing microfilaremia, even
up
to now, is of the order of much
less than one
per
cent. But if these service men were
properly diagnosed
as
having
filariasis after endemic residence measured in
months, is there
reasonable
probability
that
anyone
fails to receive infection who
grows
up
from
babyhood
in a filariated area
(Dickson, Huntington
and Eic-
hold, 1943; Franks, Chenoweth and Stoll, 1947)?
The
simplest assump-
tion then would be to
say
that all the
population
in endemic
regions
is
filariated, and
put
the
responsibility
on
any disputant
to
prove
how
many
were not. That would mean 758 million
people,
about 1/3 the
population
of the
globe.
Actually
not all filarial foci are as
hyperendemic
as
Samoa, with
year-
round
mosquito breeding.
In
regions
where the
vector, through drought
or
cold, gives
the inhabitants an annual
respite,
it seems
probable
that
variable
proportions
of the
population escape.
Determined
country by
country
on this basis there are 157 million cases of wuchereriasis in
Asia, 22 million in Africa, 9 million in Middle and South America,
one
million in Oceania, with a world total of 189 million, about half of
them
showing
microfilaremia.
Perhaps
the over-all
figure
thus stated is
too low, but I do not believe it is too
high.
Let us turn
briefly
to-shall I
say-more homely findings?
which in
the last decade or so have
surprised
even
parasitologists, namely,
those
on enterobiasis. In the
period following
World War I,
a number of work-
ers in the Baltic countries and the U.S.S.R.
explored
various more direct
procedures
than fecal
diagnosis
for
determining
the
presence
of Ente-
robius
(Cram
et al VI, 1937).
For a time their results were somewhat
unnoticed
generally,
but
beginning
with the
reports
of Headlee
(1935)
and Hall
(1937b),
the information accrued has been in some
respects
startling. Perhaps
we were
thinking
what was true in
Europe
could not
happen
here.
You recall Stiles'
generalization
that with hookworms found in Texas,
in Florida, and in
Virginia,
the
triangle
so defined demonstrated wide
distribution of the disease in our Southern States. Now one
may
draw
a
polygon
for Enterobius with vertices at
Washington,
D. C.
(41 per
cent incidence, "considered as
representing
a fair cross section" of the
white
population,
Cram XXVIII, 1943);
Boston
(boys 15, girls
23
per
cent, Weller and Sorenson, 1941); Toronto, Canada
(adults 52, children
60
per cent, Kuitenen-Ekbaum, 1943);
South Dakota
(39 per
cent in
school children, Mauss, 1945);
San Francisco
(boys 29, girls
34
per
cent, Jacobs, 1942);
New Orleans
(30 per
cent in removed vermiform
appendices,
Schenken and Moss, 1942).
These data are not of institu-
tionalized
persons, where, even in the South, we have come to be ac-
customed to much
higher percentages
than those noted
(Evans
and
Moore, 1942; Sawitz et al, 1940).
The over-all results obtained
during
the last decade, by examining
for Enterobius material taken
directly
from where the worms have been,
suggest
that there are factors, still not
precisely defined, which are es-
pecially
favorable for
pinworm
dissemination in our modem
way
of
living.
This
applies
to families not
only
at low but at
very high
social
levels, I assure
you-and
so could some of
my friends; it
applies
to
rural as well as to urban life;
it
appears
to
apply
more the farther north
one
goes;
it
applies particularly
to institutionalized
persons (Cram,
1941)
both north and south, here and abroad, whether of the
aged,
the
children, or the
psychopathic;
and
up
to now has been demonstrated to
apply geographically
to
Europe (Young, 1942)
both in and out of Russia
(Schiiffner, 1944, says
100
per
cent of the children of Amsterdam, are
infected),
to the
Argentine (Bacigalupo, 1941),
to Mexico
City (Maz-
zotti and
Quintanar, 1943),
and to Manila (Chanco and Soriano, 1939),
as well as to the United States and Canada.
It
appears
to
apply
in lessened
degree
the closer
you approach
the
humid
tropics,
as
increasing
evidence in Middle America
(Mazzotti,
1945; Sutliff and Echandi, 1946)
and elsewhere attests. On Guam,
where the natives were full of intestinal
parasites,
we found
only
one
per
cent of the children
positive by
scotch
tape (Stoll,
Chenoweth and
Peck, 1947),
and
except
for Manila, it has not been
reported
in
high
incidence in the Pacific.
Only
in Northern America and
Europe, including U.S.S.R., can the
over-all number of infected be
extrapolated
with confidence, and the
totals reach 18 and 87 million. This is about
equivalent
to the number
indicated in the balance of the world
by
the
application
of a cautious
but reasonable increase in the incidence data from other
types
of
survey.
Altogether
in the world this
brings
a tentative total of 209 million in-
fected with
pinworm.
Let us turn now to certain other nematodes that alone contribute over
half of the helminthiases of man.
It is just over a hundred
years
since hookworms were first observed
as human
infections, and named A. duodenale. It is
slightly
less than a
half hundred
years
since the
endemicity
and
gravity
of hookworm in-
fection on this side of the Atlantic were
recognized,
and Stiles
(1902)
described N. americanus. The realization of the
damage
caused
by
these
forms
eventually brought
into
play,
first in this
country
and later in
many
of the endemic areas of the world, the most formidable
campaign-
ing
ever undertaken
against
human helminths. This considered and con-
siderable attack did not eventuate in
ridding
hookworm
completely
from
much
territory. Except
for certain
mines, I have found
only
one
specific
reference to such a result-date 1941
(Spitzer),
in re St. Martin of the
Netherlands West Indies of a few thousand inhabitants.
It should be said
immediately
that the anti-hookworm
goal
did not
for
long
envision eradication. Instead it evolved, and
campaigning
ex-
erted itself
mostly
in
blunting
the curse in areas which
appeared
to have
the
greatest
hookworm burdens. The
making
of
permanent gains against
this infection has come
up against
the
changing
of
deep-seated, long-
established customs that are not to be
easily disestablished, and
against
nutritional and economic
problems
not to be
quickly
resolved. As
Bailey
K. Ashford wrote
(1934)
near the end of his life: hookworm
"parasites
plus poorly
balanced food
bring
fatalities and serious
grades
of anemia
which would not occur from
parasites
alone....
Only
when the funda-
mental
thing
is done will the disease as a disease
disappear
from Puerto
Rico. And that funda-mental
thing
is the
provision
of better food for
Puerto Ricans.... It is, therefore, no
longer
a medical
problem,
but a
sociologic
one of the
very
first water."
Nowhere in the world has
grappling
with the infection been so
per-
sistent
(barring recessions)
as in our own South, and
Ceylon.
I have
found no record of decreased incidence in
Ceylon,
but the
resurveys
in
this
country
made
during
the 1930s and summarized
by Keller, Leathers
and Densen
(1940) point
out a 2/3 decrease in incidence since 1910-
14. About one-fourth of the
remaining positives
still show more than
21/2
eggs per milligram, indicating
worm burdens
"sufficiently
severe to
produce
clinical
symptoms."
If one studies the incidence data of 11 southern states at the earlier
and later
periods,
in relation to white and
negro
rural
populations
of the
1910 census and the 1935 census
approximation,
it would
appear
that
the number of hookworm-infected Americans has decreased from about
4/2 million to 13/ million in the interval. This would be a decrease of
61
per
cent in the number of infected individuals, to match the decrease
in incidence of 68 per cent. What is equally of interest is that geograph-
STOLL-THIS WORMY WORLD 395
ically
the infected
region
of the 1930s is still co-extensive with that of
the earlier
period.
For the
purposes
of
my present discussion, one of the results of the
anti-hookworm
campaigns,
and the residual interest
they engendered,
has been the
accruing
of information on incidence
throughout
the world,
not
only concerning
hookworm but associated intestinal helminths as
well. With no sizeable dents known to have been made in the incidence
of infection
anywhere
but here, it has been
possible
to
employ
data of
several
years ago
to
supplement recently gathered facts, and thus
help
piece
out the
picture
of the number of infected
persons.
Without at this
moment
presenting
an
analysis
in detail, it summarizes as follows:
For hookworm. From one to a few million in Oceania, Europe,
North-
ern America, and the U.S.S.R.; up
to 359 million in Asia, inclusive of
Japan,
the
Philippines,
and Dutch East Indies. Of the Asiatic total, 205
million are
assigned
to India, broadly speaking-a country
whose hook-
worm burden is
increasing.
The total for the world is
put
at 457 million,
a numerical measure of the
weight
of mankind's worst helminthic
path-
ogen.
For Ascaris. In Northern America, 3 million; in Middle and South
America,
14 times as much; in Africa, nearly
60 million,
in some areas
there, ascaris
being
said to cause more
disability
than
any
other hel-
minth
(you
will remember that in our own South while incidence of
Enterobius and hookworm is less in
negroes
than in whites, the reverse
is true of
ascaris).
For the world, 644 million ascaris infections-these,
with hookworms, representing
about half of man's helminthiases.
I have
adopted
Winfield's estimate, which is based both on his own
work and that of the China Hookworm Commission, of 335 million
infected Chinese. You
may
remember the
graphic analysis
from which
Winfield
(I, 1937)
concludes that the Chinese harbor 6 x 109 adult
ascarids; capable
of
producing
22 X 1016
eggs annually. Further, that
this mass of adult ascarids is
equivalent
to the
weight
of 442,000 men.
Winfield could have continued with a further
interesting computation.
If the
daily egg-laying capacity
of a well-fed
pair
of A. lumbricoides is
put
at 200,000, such
fecundity
is at the rate of about 5
grams
of
eggs
per year.
Winfield's
average
Chinese infections of 18 worms would thus
yield
over 1/10 of a
pound,
and his whole infected Chinese
population
about 18,000 tons of ascaris
eggs annually.
There is a
huge
nutritional
beneficence bestowed
upon
ascaris
by
the human host in China alone.
For Trichuris. About a half million infections each in Oceania and
in Northern America; roughly
25 to 35 million each in the U.S.S.R.,
Africa, Europe,
and Middle and South America; but 227 million in Asia.
The world total comes to 355 million trichuris-infected individuals.
For
Strongyloides
we must
accept any
estimate based on
present
data
as
inadequate.
The usual
surveys report very little, much less than is
probably present,
and the
high
incidence
figures
in occasional
special
reports
have
usually
been on small numbers of individuals.
Using
avail-
able data, only
Africa with about 31/3 million, Middle and South America
with 8/2 million, and Asia with 21 million contribute
significantly
to a
tentative world total of 35 million infections.
Of recent
years
another
small-intestine-inhabiting
nematode has ob-
truded itself more and more in
surveys
for human helminths, namely
Trichostrongylus. Usually thought
of as a
parasite
of ruminants, or
per-
haps
better of herbivores, a half-dozen
species
have now been
reported
from man. The data
suggest
about 3 million infections in
Japan
and
Korea, and an additional 11/2 million in India, with a million more in
the
U.S.S.R., mostly
in Transcaucasus and the Ural
region.
The foci in
Africa
appear
to involve no more than a few thousand cases, but even
so the world total is 5/2 million.
All told we have noted
just
over 2200 million helminthic infections
assigned
to
just
under 2200 million
people
on the
planet.
If
you
have
gained
the
impression
that it must be
scientifically
labelled a "tentative"
statement, you may
also have
gained
the
impression
that it was
by
no
means
lightly
arrived at. Both
impressions
are correct.
The Chinese have a
saying,
"If
you
do not scale the
mountain, you
cannot view the
plain."
Once
population
totals of the
helminthically
infected are available, certain
generalizations immediately emerge.
First,
a host view. Some
people
in the U.S.A. and Canada-Northern
America in our classification-have a
way
of
feeling
that we are a
relatively
helminth-free
people-it
is the rest of the world that is
really
parasitized. Well, part
of such a statement is
partly
true.
Actually
North-
ern America shares with Oceania and
Europe,
exclusive of the U.S.S.R.,
a status of about 1/3 as many helminthiases as people; for the U.S.S.R.
in both
Europe
and Asia this rises to 2/3 for Asia and Middle and South
America it is not far from 4/3; for Africa over 6/3.
Second, a worm view. The relative survival
ability
of different
par-
asitic
groups
is thrown into
sharp
relief in terms of the number of
parasitized
human hosts. There are
only
72 million cestode and 148
million trematode infections in our totals, but over 2000 million nem-
atode infections. This is doubtless a tribute to the
variety
and
compar-
ative
biological efficiency
of nematode life
cycles.
All cestodes reach
man
by
the host's own act, albeit at times not
consciously; through
ingestion by
man of
egg
or larval forms; trematodes
similarly
reach him
passively, through ingestion
of larval forms, but in addition
actively
through
the
parasites'
own efforts, as witness schistosome cercariae. It
is, however, the nematodes that exhibit the most varied methods.
They
reach man
by
his own act of
ingesting
ova that have been
recently
passed,
and ova that have had to
ripen externally
for
days
or weeks; by
his own act of
ingesting
larval forms in water, and larval forms in food.
They
also reach him not
through
his own act but on the initiative of
the
parasites themselves, infective larvae
actively penetrating
his bare
skin in contact with moist soil, and
actively penetrating
his skin in
contact with the
mouthparts
of
blood-sucking
insects which reached him
by
air-borne tactics. Each of five helminthic
species, illustrating
four of
these nemic
life-history styles, registers
more human infections than
either all the cestodiases or all the trematodiases.
Only
two in the clas-
sification, namely
Dracunculus and Trichinella, which come in
by
water
and food, show so few
parasitisms
as do the
food-transported
flatworm
species.
Third, a sanative view
(which might,
less
provocatively,
be called a
sanitary view).
If we bar
hydatid
and
garbage
worms from consideration
(recall they represent only
one
per
cent of the
total),
all these helmin-
thiases
depend solely,
or
mainly,
on man as the definitive host, not on
the maintenance of reservoir hosts. In their ultimate
cycle
of man back
to man, and
cutting
across the taxonomic fences, these helminthiases
fall into two
great categories.
One in sevent of the total helminthic
infections of man can he classified as due to his ineffective insulation
from transfer hosts. The other 6/7 of man's helminthiases are due to
ineffective insulation from his own
excretory products.
The one-seventh
reach him via
cyclops,
or
they
reach him via
mosquitoes (sensu latu).
The other six-sevenths reach him, immediately
or
eventually, by
the
method of H. nana and Enterobius, or
by
the method of Ascaris and
Trichuris, or
by
the method of T.
saginata
and Clonorchis, or
by
the
method of
Ancylostoma
and Necator, or
by
the method of the schisto-
somes. In all of these 6 out of 7 cases what comes back to him or to
his fellows is, in fashion
appropriate
to each
specific organism,
some-
thing biologically
nursed
along
a return
journey,
that
began
the moment
a
relaxing sphincter permitted
the
passing
of waste
products
from an
infected
person.
Somewhere
along
the line between the time when an
egg
was lost from that human host and the time the
specifically appro-
priate
infective
agent
was
ripe
to return to him, somewhere
along
that
line a different brand of sanitation, broadly interpreted,
would have
broken the
biological
chain and
spared
new human hosts.
My analysis
has concerned itself with helminthic infections over-all,
not alone those with the most serious worm burdens, for it is the whole
pattern
of infection of helminths in the world of man we are
aiming
to
grasp. Tactically
it
may
be
required
that we concentrate attack for ame-
lioration and control on
persons
and communities most
severely
affect-
ed.
Strategically,
at the world level, we need to know of the
enemy
wherever he rears his head, in order that over-all
planning
omit no
favorable
opportunity
for
neutralizing
him. Helminthiases do not have
the
journalistic
value of
great pandemics
like flu or
plague, although
they may
have an as
yet unrecognized
relation to them; they
do not,
for the most
part, present
dramatic clinical cases, but to make
up
for
their lack of drama, they
are
unremittingly
corrosive. If
you
were
aroused
by
the
sufferings of, say,
ten thousand service men with fila-
riasis and schistosomiasis, what can
your imagination
do with ten thou-
sand
upon
ten thousand natives in endemic areas-who have no ho-
meside relatives to write letters to their
congressmen?
The world
population, according
to informed
prediction, may
reach
3300 million
by
the end of the
century,
an increase of 50
per
cent
(Notestein, 1945).
The
parasitoses, by extrapolation, may grow
even
t This was
given
at Boston as "one in
eight." My
work sheets which
showed 1 in 7 had been mis-read as 1:7.
396 THE JOURNAL OF PARASITOLOGY, VOL. 85, NO. 3, JUNE 1999
more, for some of the areas marked for most
population growth
are
among
those with
higher
helminthic indices.
Are there
ways parasitologists
can
help
reduce the
prospect
of
having
the world
forge
ahead to more than 3000 million human helminthiases
by
the
year
2000?
It seems to me there are
possibilities.
I.
Certainly
we can
widely uphold,
and
strengthen
the
teaching of,
the nuclear
principles
that
apply
in our field.
They obviously
should be
known
by intelligent
world citizens,
and we should make it
popular
that
they
are.
Certainly
we should assist the firm establishment of
compe-
tently taught parasitology
in medical schools, which the war has fos-
tered.
There are some red entries in our own
ledger
of the war because such
knowledge
was not more
freely dispensed
earlier. For instance,
soon
after Pearl Harbor, training
centers for marines were established in the
South Pacific, including
Samoa where American forces had been for
decades. Somewhere in the
higher
echelons there must have been a
medical officer in a
position
of advice,
or decision,
as to how close to
native huts and
villages
it was
prudent
to barrack the men.
Evidently
that medical officer never heard of bancroftian filariasis
being present
where men in uniform saw it with
dismay,
or else he did not know that
filariasis is transmitted
by mosquitoes.
In the name of Manson, it is for
us all to blush at that hiatus.
II. We can
encourage by precept
and
example
a
shortening
of the
usual
lag period
there is in
getting acceptable improvements
in ideas
through
to where
they
will do the most
good,
and be less tolerant when
the
lag
seems
unnecessarily long.
I have two illustrations.
The Health Section of the
League
of Nations
recently published
a
valuable "Handbook of Infectious Diseases"
(1945
III 1, CH
1454),
up-to-date enough
to include "new
chapters
on the
sulphonamides, pen-
icillin, etc.," but with serious omissions
concerning
anti-helminth
drugs.
For instance, the recommended treatment for ascaris is
merely
santonin
and
chenopodium,
and for hookworm
thymol, chenopodium,
or carbon
tetrachloride. This handbook had the admirable aim of
noting "every
recent addition to scientific
knowledge concerning
methods of combat-
ing
these diseases."
Why,
under a
League imprint,
should it miss
being
up-to-date
about such anthelmintics as
tetrachlorethylene
and
hexylres-
orcinol which have been valuable and
accepted
for more than a decade
and a half?
Or take the case of Guam. This little island of 200
square
miles has
been in our hands since the
Spanish-American
war, administered
by
a
naval
governor continuously
until December 1941, and re-established
so since. As
early
as the
published sanitary report
for 1905
Surgeon
R.
P. Crandall, wrote, "Extraordinary prevalence
of Ascaris lumbricoides
in
nearly every
individual member of the
community
has been
forcibly
represented
as a veritable curse." The native
population
then was evi-
dently
about 10,000. By
1913
Surgeon
C. P.
Kindleberger
was
saying:
"Practically every
native adult, all native children over 2
years
of
age,
and some as
young
as 6 months,
are infected with one or more intestinal
parasites."
In 1914 the U. S. Naval Medical Bulletin
reproduced,
for
Passed Asst.
Surgeon
E.
O.
J.
Eytinge,
a classic
picture (which
most of
you
have seen in
textbooks)
of a
3-year-old
Guamanian child with fatal
hookworm infection. In 1924, E. U. Reed, Lt.-Comdr., M.C., published
the results of
nearly 2,000
fecal examinations made
throughout
the is-
land. These showed that less than one
per
cent of the natives were
uninfected with hookworm, whipworm,
or roundworm; other exami-
nations showed that of
navy
and marine
personnel
and their families on
the island more than 6 months, 13
per
cent of the adults and 76
per
cent of the children were
positive
for one or more of these three
para-
sites, while those there less than 6 months were all
negative. McKinley's
Geography
of Disease
(1935), quoting
the
Surgeon-General
of the
Navy, placed
ascariasis and hookworm next
only
to
leprosy
and
yaws,
in
public
health
importance
on the island in 1933. Should it have caused
surprise, therefore, that 8 months after the American
re-occupation,
of
a fair
sample
of natives examined,
as
many
as 9 in 10 were infected
with hookworm and trichuris,
and 6 in 10 with ascaris, with
egg
counts
in all three infections
among
the world's
highest? During
the
period
26
January-9 August 1945, Zimmerman
(1946) performed
50
post-mortem
examinations of Guamanian children 4
years
of
age
and under, and
found "in 21 instances the
primary
cause of death was hookworm dis-
ease with its attendant
complications."
The
friendly
and
gracious
inhabitants of this little island, whose Cha-
morro chromosomes have
strong
admixtures from
European
and Amer-
ican sources, through
natural causes have no malaria, no filariasis, no
fluke or cestode infections, and
only
a little enterobiasis. It is true the
harshness of the helminthic assault in
early
1945 with hookworm, tri-
churis, and ascaris must have been accentuated because of the inevitable
dislocation that occurs in the lives of native
peoples
in battle areas. It
is true that over the
years
conscientious and devoted medical officers
had been stirred to alleviate the
parasitisms by instigating
sanitation and
prescribing
anthelmintic treatment. Then
why
such a result on an island
about 1/3 the size of an
average
Massachusetts
county,
and where most
of its 24,000 natives live in less than half its area? It seems to me the
answer is
obvious-enough
was not done, and what was done was not
done well
enough.
Thousands of anthelmintic treatments have been ad-
ministered, case
by
case in
hospital
and
dispensary.
But treatment of
individual cases was
promptly
nullified
by
a
parasite-infested
environ-
ment. Here was an instance,
if ever, where the treatment
approach
to
control would
profit only
if of the whole
community.
The success Lam-
bert was
having only
a little
way off,
as Pacific distances
go,
seems not
to have filtered
through
to Guam. So in
place
of a model American
tropical colony
there comes to
light
instead an
ancylostomized,
trichur-
ized, and ascarized
community
of
long standing.
There are
fortunately signs
that
postwar
this
gloomy picture
will be
brightened.
If
they
materialize Americans homeside will be
glad
to hear
that their
friendly
Guamanian wards, who
aspire
to American citizen-
ship,
have been assisted to
gain
a desirable Pacific freedom-freedom
from worms.
Perhaps
the
neighboring Saipanese
could be included.
Why,
at
long last, should we not look forward to a demonstration of
some
perfection
in the
deworming
of Guam-24,000 persons
on an
island of 200
square
miles?
III. Besides the
possibilities mentioned, of
encouraging
wider dissem-
ination of the central ideas in our field, and their
application,
there is
another side of the
problem
which is a
challenge specifically
to us. The
question
is
legitimately
raised whether the tools furnished for
attacking
the helminthiases of man are not in need of
sharpening. Against
the
intestinal helminths we think of them as education, sanitation, and treat-
ment. Stiles
(1932) wisely
observed in an article on hookworm disease,
that
among important
factors in
public
health advancement of the South
were "the automobile
filling
stations with the
practical
demonstration
in
public
health connected with their comfort rooms."
Perhaps
he was
saying obliquely
what is all too true.
Logically necessary
as is the
pit
latrine to combat soil
pollution,
the esthetic affront it
gives
to those
who are
supposed
to use it, vitiates its virtues and drives adults as well
as children back to the out-of-doors where the air is free. That is true
even in this latitude,
and the closer to the
tropics
the truer it is. No
wonder latrine construction and use is hard to establish there.
Yeager's
bored hole substitute is
praiseworthy,
but makes slow advances. What
we need is to find a "convenience of civilization," an excusado, as
attractive in its
way
as is the
filling
station comfort room.
In another direction, methods of soil sterilization,
in which
progress
is
being
made
against plant parasitic nematodes, could be
profitably
exploited
to determine whether
they might
not
protect
man
against
the
consequences
of his
using
unconfined defecation sites. Have we too
easily shrugged
off
improvements here, continuing
to make and rec-
ommend Model T ideas,
when the demand is for less
bumpy riding?
New
chemo-therapeutic preparations
are desirable,
to
encourage
more
widely
the
breaking
of
parasitic
life
cycles
within man himself.
Against
hookworm our best
present
bet is
tetrachlorethylene, against
ascaris in
children
hexylresorcinol, against pinworm gentian
violet. But all these
leave
something
to be desired, and
against
trichuris and other forms we
are in worse case. What we need are worm treatments as effective and
well-tolerated as
phenothiazine
in
sheep;
and from the
greatness
of the
need, we
ought
to have a hundred workers
seeking them,
instead of a
handful in
desultory
effort. For our familiar intestinal fauna, as well as
parenteral forms, one of the
goals
could well be
something
of less
drastic action in individual dose, but
potent cumulatively,
and thus
ap-
plicable
to
population groups,
as are vitamins in bread, iodine in salt,
and fluorides in water.
And here, deliberately
on a note of unfinished business, I
prefer
to
interrupt
consideration of the
problem
of human helminthiases at the
world level. We need to leave it in a mood of work still to be done.
In March, with the
Society becoming
of
age, my distinguished pre-
decessor told
you
of the
making
of a
parasitologist.
If
by
chance he had
ended with the line, "Bring
me men to match
my mountains," it would
have been allowed me to
say:
"Here are some of the mountains."