CHAPTER ONE

INTRODUCTION

1. Introduction
1.1. History and Development of Anthelmintic drugs:

1.1.1. Benzimidazoles

The first of this class, thiabendazole, was discovered in 1961 and subsequently a number of further
benzamidazoles were introduced as broad spectrum anthelmintics. There is an extensive literature on
these compounds reporting a number of different biochemical effectsn [1]. Nonetheless, it is clear that
their anthelmintic efficacy is due to their ability to compromise the cytoskeleton through a selective
interaction with β-tubulin (1975). The effects of benzimidazoles on C. elegans, which include
impaired locomotion, reproduction and a detrimental effect on oocytes, are consistent with disruption
of processes requiring integral microtubules. The sensitivity of C. elegans to benzimidazoles is
mediated by a single gene, ben-1, which encodes β-tubulin (1989). This has provided a platform to
investigate the molecular basis of benzimidazole resistance in parasitic nematodes. It has been noted
that benzimidazole resistance in Haemonchus contortus seems to be associated with the presence of
specific alleles for β-tubulin in the drug resistant isolates (1994). Whether or not a specific β-tubulin
isoform could confer resistance to the drug was tested by experiments which showed that the
sensitivity of C. elegans ben-1 mutants to benzimidazole can be rescued by expressing a H.
contortus allele of β-tubulin from benzimidazole susceptible isolates but cannot be rescued by the
allele present in the resistant isolates (1995). This unequivocally demonstrated that a single amino
acid sustitution, Y for F, in β-tubulin, can confer anthelmintic resistance. This is the first elegant
example of a 'model hopping' approach in which the genetic tractability of C. elegans is directly
exploited to define gene function in a parasitic worm [2], [3].

Albendazole: Albendazole, patented in 1975, was invented by Robert J. Gyurik and Vassilios J.
Theodorides and assigned to SmithKline Corporation. It was introduced in 1977 as an antihelminthic
for sheep in Australia, and was registered for human use in 1982.

Mebendazole: Mebendazole came into use in 1971, after it was developed by Janssen
Pharmaceutica in Belgium. It is on the World Health Organization's List of Essential Medicines, the
most effective and safe medicines needed in a health system. Mebendazole is available as a generic
medication. The wholesale cost in the developing world is between USD 0.004 and 0.04 per dose. In
the United States a single dose is about USD 440.00 as of 2016, while in Australia and the UK it costs
about USD 5.00.

1.1.2. Piperazine

Piperazine was first used as an anthelmintic in the 1950s and it is still the active constituent of over
the counter remedies for thread worm infection in children. Its mode of action has primarily been
studied in A. suum. There is surprisingly no literature on its action in C. elegans though there is no
indication that it acts differently from its effects in A. suum. In A. suum it acts as a weak GABA-
mimetic and causes a flaccid, reversible paralysis of body wall muscle. Single channel recordings
provide evidence that it is a low efficacy, partial agonist at GABA-gated chloride channels (1985) [4].

1.1.3.   Levamisole, pyrantel and morantel

These anthelmintics are nicotinic receptor agonists (1970, 1970) and elicit spastic muscle paralysis
due to prolonged activation of the excitatory nicotinic acetylcholine (nACh) receptors on body wall
muscle. Their precise mode of action has been carefully studied at the single-channel level on the
body wall muscle preparation of A. suum ( 2005) [5], [6]. Pharmacological analysis has provided
evidence for subtypes of nACh receptor (2006), an N-type (preferentially activated by nicotine), a B-
type (preferentially activated by bephenium) and an L-type (preferentially activated by levamisole and
associated with levamisole resistance). Levamisole, and related compounds, also cause spastic
paralysis and egg-laying in C. elegans. Indeed, recordings from C. elegans body wall muscle using
levamisole and nicotine as agonists have provided further evidence that there are muscle subtypes of
nACh receptor and that these subtypes have different nACh receptor subunit compositions. At least
four subunits, unc-38, unc-29, unc-63 and lev-1 contribute to the levamisole receptor (2004, 2007).
Thus, these anthelmintics are providing pharmacological tools to dissect subtypes and stoichiometries
of native nematode nicotinic receptors [7].

Perhaps more importantly, levamisole has been extremely productive in forward genetic screens. In
the earliest studies tetramisole was used (1974) and later this was replaced by the more active isomer,
levamisole (1980). These screens have provided a resource of mutants that have been used over the
last two decades to assign function to genes expressed at the neuromuscular junction. Some of these
are nACh receptor subunits, but others interestingly are not and serve to either regulate nicotinic
receptors or muscle function 

1.1.4. Paraherquamide

Paraherquamide A and marcfortine A are both members of the oxindole alkaloid family, originally
isolated from Penicillium paraherquei and Penicillium roqueforti, respectively ( 2002). Marcfortine A
was found to be active against C. elegans in a high throughput screen ( 2002) [8]. A specific, high
affinity binding site for paraherquamide has been identified in a membrane preparation isolated
from C. elegans, with an apparent Kd of 263nM (1992). Paraherquamide and its derivative, 2-deoxy-
paraherquamide, induce flaccid paralysis in parasitic nematodes, in vitro. Pharmacological analysis of
the effects of these drugs on acetylcholine-stimulated body wall muscle contractions in A.
suummuscle strips in vitro has shown that they act as typical competitive antagonists, shifting the
concentration-response curves to the right in a parallel fashion (2002). These drugs have no apparent
direct effect on A. suum body wall muscle tension or membrane potential ( 2002) [9]. Paraherquamide
also blocks the actions of other nicotinic agonists, but not equipotently (2002;  2002). Interestingly,
this antagonist seems to distinguish nicotinic receptor subtypes on the muscle and has a greater
affinity for the receptors mediating the response to levamisole and pyrantel, than the receptors that
mediate the response to nicotine. One might therefore expect that paraherquamide would be an
effective antagonist of the levamisole-selective receptor on C. elegans body wall muscle. Importantly,
the mode of action of this class of anthelmintics differs from the more established drugs that interfere
with cholinergic transmission, e.g., levamisole, in that they act as competitive antagonists rather than
cholinomimetics. The use of paraherquamide in forward genetic screens has not yet been reported but
could potentially generate interesting new mutants. As it is a competitive inhibitor of the body wall
nACh receptor it would be predicted that mutations that increase transmitter release should confer
resistance. Thus a forward genetic screen might reveal further negative regulators of neurotransmitter
release [10].

1.1.5.  Ivermectin (macrocylic lactones and milbemycins)

Ivermectin was introduced as an anthelmintic in the 1980s by Merck. It is a semi-synthetic derivative

of avermectin which is a large macrocyclic lactone fermentation product of the micro-
organism Streptomyces avermitilis. It is remarkably potent (~1nM) and persistent in its effect and its
discovery enthused other companies to invest in the development of ivermectin analogues which
include moxidectin, milbemycin oxime, doramectin, selamectin, abamectin and eprinomectin. Here C.
elegans played a role as it was employed in a screen for further macrocyclic lactones with ivermectin-
like activity ( 1991) [11].

Ivermectin elicits a potent and persistent paralysis of nematode pharyngeal (1997; 2001) and body
wall musculature (1980; 1982). It has been shown to interact with a range of ligand-gated ion
channels including α7 nACh receptors (1998), acetylcholine-gated chloride channels (1986), GABA-
gated chloride channels (1989;  1990), histamine-gated chloride channels ( 2002), glycine receptors
( 2001) and P2X4 receptors (1999). However, it is its high affinity for nematode glutamate-gated
chloride channels (GluCl) that correlates with its potent anthelmintic activity. This was defined by the
team at Merck which succeeded in expression cloning GluClα and GluClβ ion channel subunits
from C. elegans ( 1994). Both subunits were expressed either singly, or together, inXenopus oocytes.
GluClα responds to micromolar ivermectin, but not to glutamate whilst GluClβ responds to glutamate
but not ivermectin. Co-expression of GluClα and GluClβ yields a channel which responds to
glutamate and is positively allosterically modulated by nanomolar ivermectin [12], [13]. Subsequently
a small family of nematode genes encoding GluCl channels has been identified (  2003). The
nomenclature is confusing as the same genes have been discovered by both homology screening
approaches and from forward genetic screens for ivermectin resistance genes. Essentially there are
four C. elegans genes encoding GluClα subunits, two of which are alternately spliced yielding the
GluCl channels: GluClα1 encoded by glc-1; GluClα2A and B encoded by avr-15; GluClα3A and B
encoded by avr-14; GluClα4 encoded by glc-3. There is just one GluClβ subunit encoded by glc-2 and
a further gene, glc-4, which is divergent from the genes encoding α and β subunits. Although the
pharmacology of channels assembled from these GluCl subunits has been defined in heterologous
expression systems, the important question of the subunit stoichiometry and pharmacology of the
native channels is much more poorly defined. Further studies on C. elegans are providing a better
understanding of this by delineating the expression pattern for GluCl subunits in the nervous system.
For example, the pharyngeal muscle expresses avr-15 and glc-2, (1997;  1997). Thus it might be
expected that GluClα2 and GluClβ subunits co-assemble to form a native ivermectin sensitive
channel. Whether or not other subunits contribute to the functional receptor is not yet clear. However,
the pharyngeal muscle of avr-15 mutants does not respond to ivermectin (1997;  2001) clearly
indicating an involvement of GluClα2. An important point to note in terms of the site of anthelmintic
action of ivermectin is that although the pharynxes of avr-15 mutants are not inhibited by ivermectin,
populations of avr-15 mutants exposed to ivermectin are still paralyzed. Thus GluCl channels in the
pharynx are not required for the paralytic effect. This may also be true for parasitic nematodes. For
example, ivermectin has anthelmintic activity against Ascaridia galli and yet the pharynx of this
species is not inhibited by the drug ( 2006). In order to obtain a better understanding of the role of
GluCl channels in mediating the paralytic actions of ivermectin it is probably more informative to
consider their role in the motornervous system. Currently most information is available for avr-
14 and avr-15. These genes are expressed in the motor nervous system of C. elegans (1997;  2000)
and there is immunostaining for GluClα3A and B in motorneurones of the parasitic nematode H.
contortus, (2003). One role of these GluCl channels in C. elegans involves regulation of the duration
of forward movement, a well established glutamatergic-regulated behaviour ( 2006). This function
may be conserved between C. elegans and H. contortus as H. contortus GluClα3 subunits expressed
in C. elegans avr-14 mutants restore the wild type pattern of movement ( 2006). It is most likely that
the paralytic action of ivermectin derives from its potent activation of GluCl in the motornervous
system of nematodes. However, the precise role of individual GluCl channels in mediating the effects
of ivermectin on these circuits is yet to be established. The mechanism of resistance to ivermectin has
also been studied in C. elegans. High level resistance is a complex phenomenon which requires
mutations in at least three genes, namely in glc-1, avr-14 and avr-15. Further genes, regulating
membrane permeability (osm-1) and gap junctions (unc-7 and unc-9), are also involved (2000). [14],
[15] Defining the role of GluCl mutations in conferring ivermectin resistance to parasitic nematodes
in the field is a less tractable and more controversial problem (2004).

1.1.6. Emodepside (cyclodepsipeptides, PF1022A)

The cyclodepsipeptide molecule, emodepside, is a semi-synthetic derivative of PF1022A, a
fermentation product obtained from the fungus, Mycelia sterilia, of Camelia japonica. Its discovery
and anthelmintic activity has recently been reviewed ( 2002). It is effective against isolates of
parasites that are resistant to benzimidazole, levamisole and ivermectin indicating, importantly, that it
has a novel mode of action. The molecule has pore-forming properties in planar lipids, however, this
does not appear to be important in conferring its anthelmintic potency as an optical isomer of
emodepside, with similar pore forming properties, does not have anthelmintic action. Thus it would
appear that it may act through stereospecific binding to a receptor. Studies in A. suum have
highlighted muscle paralysis and point to a calcium- and potassium-dependent mechanism of action
(2003). A candidate receptor for the cyclodepsipeptides has been cloned from a H. contortus cDNA
library by immunoscreening with an antibody to PF1022 A. This receptor, designated HC110R, has
been expressed in HEK293 cells and shown to gate calcium flux in a PF1022 A-dependent manner
(2001) [16], [17]. It has homology to mammalian latrophilins, a class of G protein-coupled receptors
which bind the neurotoxin, latrotoxin. Latrotoxin paralyses mammals by triggering neurotransmitter
release, and thus the identification of latrophilin as an emodepside receptor raised the intriguing
possibility that emodepside may cause paralysis of nematodes by stimulating excessive
neurotransmitter release at neuromuscular sites.

C. elegans is very susceptible to the effects of emodepside at nanomolar concentrations ( 2007). The
effects include slowed development, inhibition of pharyngeal pumping, decreased locomotion
(forward movement is most affected at low concentrations), and inhibition of egg-laying leading to
‘bagging’ in adult hermaphrodites. Thus C. elegans has provided an excellent model in which to
define the molecular target, or targets, through which emodepside exerts its pleiotropic actions and
indeed, to test whether latrophilins are involved.

There are two genes encoding candidate latrophilins in C. elegans, lat-1 and lat-2. The role of these
latrophilins in mediating the inhibitory effects of emodepside on feeding and locomotion has been
investigated using RNAi and gene knockouts (2004; 2007;  2007). The pharyngeal system of lat-
1 mutants show a reduced sensitivity to emodepside but their locomotor activity is inhibited in a
similar fashion to wild-type animals ( 2007). Emodepside does not exert its inhibitory effect on
locomotion through the other latrophilin, LAT-2, as lat-2mutants respond just like wild-type animals.
Nor is there redundancy of function between LAT-1 and LAT-2 in terms of the effect of emodepside
on locomotion, as the double mutant lat-2,lat-1 responds to emodepside in a similar fashion to the
single mutant, lat-1 ( 2007). Clearly, emodepside has latrophilin-independent actions.

Recently, forward genetic screens have provided further insight into the mechanism through which
emodepside exerts its inhibitory action on C. elegans muscle. A chemical mutagenesis screen of
twenty thousand genomes for mutants that could move and propagate on micromolar emodepside
recovered nine alleles of a single gene, slo-1. Strains carrying functional null alleles of slo-1 are
highly resistant to the inhibitory effects of emodepside on locomotion and feeding. Furthermore,
strains carrying gain-of-function alleles of slo-1 behave in a similar manner to emodepside-treated
animals but are not themselves emodepside hypersensitive. These data strongly support the contention
that emodepside activates a SLO-1-dependent pathway to bring about neuromuscular inhibition.

SLO-1 is a calcium-activated potassium channel (Wang et al. 2001) homologous to the mammalian
BK channels. Thus the discovery of SLO-1 as an important effector for emodepside resonates with
earlier work on Ascaris muscle which showed a calcium and potassium-dependent hyperpolarisation
(Willson et al., 2003). This channel is highly conserved throughout the animal phyla and plays a
pivotal role in regulating neuronal and muscle cell excitability (for review, Salkoff et al., 2006). InC.
elegans it is widely expressed in the nervous system and body wall muscle, but not in pharyngeal
muscle. By expressing a wild-type copy of slo-1 in specific subsets of cells in a slo-1 null background
it has been shown that emodepside can inhibit locomotor activity when SLO-1 is present in neurones
or body wall muscle but it can only inhibit feeding if SLO-1 is present in neurones (2007). Earlier
studies showed that mutations in a number of genes encoding synaptic proteins confer altered
sensitivity to the effect of emodepside on feeding consistent with the idea that it acts in the neuronal
network to disrupt rhythmic feeding behaviour (2004).

The discovery of SLO-1 as a mediator of the inhibitory effects of emodepside on C. elegans is an
important development in this field which in the light of ivermectin resistance has an urgent need for
such breakthroughs. In the broader context, there is an emerging body of evidence indicating that BK
channels such as SLO-1 may play a pivotal role in conferring sensitivity to neuroactive drugs,
including ethanol and local anaesthetics ( 2003,  2004) and in regulating the pattern of activity of
neural networks (2006). Thus, an additional and valuable facet of these studies is that emodepside
provides a new tool to dissect the functional role of SLO-1 in neural networks using the power of
molecular genetics in C. elegans [18], [19].

1.1.7. Nitazoxanide

Nitazoxanide, a pyruvate ferredoxin oxidoreductase inhibitor, acts against a broad spectrum of

protozoa and helminths that occur in the intestinal tract. It is currently used for the treatment of
protozoal infections . The site of action of this compound has not been established in nematodes
although anaerobic electron transport enzymes may be a potential target ( 2002) [20], [21]. The effect
of nitazoxanide has been examined on growth and development of C. elegans (2003). After seven
days culture, nitazoxanide 100 μM, only reduced population growth by 33%. In contrast
mebendazole, 5μM, and albendazole, 1 μM, reduced growth by over 90%. Nitazoxanide, 100 μM, had
no effect on either embryonation or hatching in Heligmosomoides polygyrus. Therefore the efficacy
of this compound is relatively low compared to other anthelmintic agents.

1.2. Importance of Anthelmintic Drug:

Anthelmintics are drugs that are used to treat infections with parasitic worms. This includes both flat
worms, e.g., flukes and tapeworms and round worms, i.e., nematodes. They are of
huge importance for human tropical medicine and for veterinary medicine. Also of importance is the
infection of domestic pets.

Mebendazole, albendazole and tiabendazole work by preventing the worms from absorbing the sugars
they need for survival. Praziquantel and ivermectin work by paralysing the worms in the gut
(intestine).

1.3. Descriptions and Activities of Anthelmintic Drugs:

Anthelminthic Drugs:

1. Benzimidazoles (Albendazole, Mebendazole, Thiabendazole)

2. Piperazine (Diethylcarbamazine citrate, Piperazine citrate)

3. Levamisole, pyrantel and morantel

4. Paraherquamide

5. Ivermectin (macrocylic lactones and milbemycins)

6. Emodepside (cyclodepsipeptides, PF1022A)

7. Nitazoxan

1.3.1. Albendazole: Albendazole is a broad-spectrum antihelminthic agent of

the benzimidazole type. It is useful for giardiasis, trichuriasis, filariasis, neurocysticercosis, hydatid
disease, pinworm disease, and ascariasis It has good activity in multiple dosesagainst cutaneous larva
migrans and strongyloidiasis, but single-dose therapy with ivermectin is more effective for these two
helminthic infections. Successful treatment with albendazole of visceral larva migrans has been
reported, although ivermectin is the drug of choice. Efficacy against the microfilarial stage of
Wuchereria bancrofti, Brugia malayi, and Loa loa is well documented,
although diethylcarbamazine(DEC) remains the parasite adulticidal drug of choice for the treatment of
patients with thesefilarial infections.DEC plus albendazole in combination has superior activity
against adult W. bancrofti compared with either drug alone.Albendazole may be of benefit in patients
with gnathostomiasis, baylisascariasis, trichinellosis, toxociariasis, capillariasis,
and angiostrongyliasis [22].

Prolonged high-dose regimens of albendazole constitute the most effective medical treatment of larval
cestode disease caused by Echinococcusgranulosus, E. multilocularis, and E. vogelii.Dosage is not
defined for children younger than 6 years of age. Treatment is tailored to response and normally is
required for a minimum of several weeks or months. Albendazole should be started several days
before surgery to minimize the effect of intraoperative spillage of cyst contents. Albendazole also is
used in the treatment of patients withcysticercosis, often with concomitant steroids. Albendazole
binds irreversibly to the nematodal isoform of β-tubulin, blocking microtubule assembly, disrupting
tegumental integrity, inhibiting motility, and impeding glucose uptake by the worm. Detectable levels
are achieved in serum,cerebrospinal fluid, cyst fluid, and bile, with aserum half-life of 8 to 15 hours
depending on the dose. Rapid, extensive hepatic biotransformation to the active
metabolite, albendazole sulfoxide, occurs, but the major route of excretion is not clear [23].
Side effects of low-dose albendazole therapy are minimal, consisting of diarrhea, abdominal pain,
migration of Ascaris through the mouth or nose, and rare hypersensitivity. With high-dose or
prolonged therapy, elevated levels of hepatic transaminases, dizziness, neutropenia, and alopecia are
most common.Serum hepatic enzyme levels and the blood count should be monitored every 2 weeks
during high-dose therapy.

Figure 1.1: Albendazole

Lack of data for children younger than 2 years of age has precluded specific US labeling for or
establishment of dosage for this age group, although the label leaves the physician discretion in
electing to treat children younger than 2 years of age. The pediatric dosage is identical to the adult
dosage [24]. Embryotoxic potential usually precludes the use of albendazole during pregnancy.

Albendazole is manufactured as a suspension and as tablets that can be crushed with food, chewed, or
taken whole. Albendazole is poorly absorbed and should be ingested with food, preferably a fatty
meal, to maximize absorption.

` 1.3.2: Mebendazole: Mebendazole is a broad-spectrum antihelmintic drug indicated for the

treatment of  nematode infestations, including roundworm, hookworm, whipworm, threadworm,
pinworm, and the intestinal form of trichinosis prior to its spread into the tissues beyond the digestive
tract. Other drugs are used to treat worm infections outside the digestive tract, as mebendazole is
poorly absorbed into the bloodstream. Mebendazole is used alone in those with mild to moderate
infestations. It kills parasites relatively slowly, and in those with very heavy infestations, it can cause
some parasites to migrate out of the digestive system, leading to appendicitis, bile duct problems, or
intestinal perforation. To avoid this, heavily infested patients may be treated with piperazine, either
before or instead of mebendazole [25].

Mebendazole and other benzimidazole antithelmetics are active against both larval and adult stages of
nematodes, and in the cases of roundworm and whipworm, kill the eggs, as well. Paralysis and death
of the parasites occurs slowly, and elimination in the feces may require several days.

Mebendazole works by selectively inhibiting the synthesis of microtubules via binding

to colchicine binding site of β-tubulin, thereby blocking polymeration of tubulin dimers in intestinal
cells of parasites [26]. Disruption of cytoplasmic microtubules leads to blocking the uptake
of glucose and other nutrients, resulting in the gradual immobilization and eventual death of the
helminths.
 Figure1.2: Mebendazole

Poor absorption in digestive tract makes mebendazole an efficient drug for treating intestinal parasitic
infections with limited adverse effects. However mebendazole has impact on mammalian cells
mostly by inhibiting polymeration of tubulin dimers, thereby disrupting essential microtubule
structures such as mitotic spindle. Disassembly of mitotic spindle then leads to apoptosis mediated via
dephosphorylation of  Bcl-2 which allows pro-apoptotic protein  Bax to dimerize and initiate
programmed cell death.

1.3.3. Piperazine: Piperazine belongs to the family of medicines called anthelmintics.

Anthelmintics are used in the treatment of worm infections.

Piperazine is used to treat:

 common roundworms (ascariasis) and

 pinworms (enterobiasis; oxyuriasis).

Piperazine works by paralyzing the worms. They are then passed in the stool [27], [28].

1.3.4. Ivermectin: Ivermectin is a broad-spectrum anti-parasite medication. It is a medication

used to treat many types of parasite infestations. This includes head lice, scabies, river blindness
(onchocerciasis), strongyloidiasis, trichuriasis, and lymphatic filariasis. It can be taken by mouth or
applied to the skin for external infestations.
Ivermectin causes an influx of Cl- ions through the cell membrane of invertebrates by activation of
specific ivermectin-sensitive ion channels. The resultant hyperpolarization leads to muscle paralysis
[29].

Ivermectin stimulates excessive release of neurotransmitters in the peripheral nervous system of

parasites. It is thought to work by paralyzing the parasite or inactivating the parasite gut. A protective
barrier, called the blood-brain barrier, blocks ivermectin from reaching the human brain [30].

1.3.5. Pyrantel: Pyrantel is a pyrimidine-derivative anthelmintic agent for the oral treatment of
various parasitic worm infections including ascariasis, hookworm infections, enterobiasis (pinworm
infection), trichostrongyliasis, and trichinellosis [31], [32].

1.3.6. Nitazoxanide: Nitazoxanide is a broad-spectrum antiparasitic and broad-spectrum

antiviral drug that is used in medicine for the treatment of various helminthic, protozoal, and viral
infections.

The antiprotozoal activity of nitazoxanide is believed to be due to interference with the

pyruvate:ferredoxin oxidoreductase (PFOR) enzyme-dependent electron transfer reaction which is
essential to anaerobic energy metabolism [33], [34].

1.3.7. Paraherquamide: Paraherquamide is a novel natural anthelmintic product with a mode

of action that is incompletely characterized. Nicotine and cholinergic-anthelmintic agonists of
different chemical classes were used to produce contraction in Ascaris muscle strips [35].
Paraherquamide and a semisynthetic derivative, 2-deoxy-paraherquamide, antagonized these
responses.

1.3.8. Emodepside: Emodepside is the only drug in this class currently prescribed to dogs or
cats. It has been evaluated for oral (dogs) or topical (cat) administration and is considered safe and
effective for use in the management of several nematode infections in dogs or cat. Emodepside is
combined with praziquantel.
The emodepside mechanism of action is considered unique to the drugs with anthelmintic activity.
The drug binds to the latrophilin receptor presynaptically, which activates a complex signal
transmission cascade that eventually results in the release of inhibitory neuropeptides into the synaptic
gap. The resulting ion influx that occurs post synaptically results in the inhibition of pharyngeal pump
function that leads to paralysis and death of susceptible nematodes [36].

1.4. Combination of Albendazole and Mebendazole:

Albendazole is used to treat such conditions,

 Ascariasis
 Capillariasis
 Cutaneous Larva Migrans
 Cysticercus cellulosae
 Echinococcus
 Enterocolitis
 Filariasis, Elephantiasis
 Giardiasis
 Gnathostomiasis
 Hookworm Infection (Necator or Ancylostoma)
 Hydatid Disease
 Liver Fluke
 Loiasis
 Microsporidiosis
 Neurocysticercosis
 Pinworm Infection (Enterobius vermicularis)
 Strongyloidiasis
 Trichinosis
 Trichostrongylosis
 Visceral Larva Migrans, Toxicariasis
 Whipworm Infection

Mebendazole is used to treat following conditions,

 Capillariasis
  Dracunculiasis
 Echinococcus
 Filariasis, Elephantiasis
 Hookworm Infection (Necator or Ancylostoma)
 Ascariasis Hydatid Disease
 Pinworm Infection (Enterobius vermicularis)
 Trichinosis
 Trichostrongylosis
 Visceral Larva Migrans, Toxicariasis
 Whipworm Infection
 Angiostrongylosis

The combination of Albendazole and Mebendazole can treat all the condions above. So the
combination is highly efficient than a single drug and can provide a full coverage against soil
transmitted helminth and some other infections.

1.5. Helminthes in human body:

Different types of worm can cause problems in humans

1.5.1. Threadworms: Sometimes called pinworms, are the only common worm infects human. They
usually occur in children and large number of children may be infected at some time. Signs of an
infestation include an itchy bottom, disturbed sleep, irritability, tiredness and a lack of interest in
eating.

Threadworms are small parasites that live in the intestines of humans. They are particularly common
in children under the age of 10. The worms are white, about 8mm long, with a blunt head and a
pointed tail. They can live for up to 6 weeks.

The female worm lays many tiny eggs around the anus. This usually happens at night while the person
is asleep since the female worms only come out at night. While laying the eggs, the worm also
produces a chemical that creates an itchiness and causes the person to scratch the area.

Eggs then stick under the fingernails and on fingertips and can be transferred to the mouth. They may
then be swallowed and cause a re-infestation.
The swallowed eggs hatch in the intestine. After a couple of weeks, the worms reach adult size and
begin to reproduction.

Threadworms can’t be catched from animals with worms. The only way animals may be responsible
for spreading human threadworms is by transporting them on their fur after human contact.

Treatment for threadworms is designed to get rid of the parasites and prevent re-infestation. To
successfully treat threadworms, you can see your doctor or pharmacist who will be able to advice on
medication for you or your child. It is commonly advised to treat the entire family at the same time to
successfully get rid of the infection [37].

When taking medicine, strict hygiene practices should be followed to prevent re-infestation.

1.5.2. Roundworms: Roundworms can live in human and can cause many problems. They are
usually found in soil and stool. They can enter the body through the mouth or direct contact with the
skin.

They can live in the human intestine for a very long time. There are several types of roundworms and
they can all be quite harmful.

Roundworms are able to pose a significant risk to humans. Contact with contaminated soil or dog
feces can result in human ingestion and infection. Roundworm eggs may accumulate in significant
numbers in the soil where pets deposit feces. Once infected, the worms can cause eye, lung, heart and
neurologic signs in people [38].

Medications orally are recommended for treating roundworm infections in adults and children over
the age of one. It works by stopping the roundworms using glucose (sugar). Without glucose, the cells
of the roundworms lose their energy supply and quickly die.

1.5.3. Tapeworms: Tapeworms are flat, segmented worms that live in the intestines of some animals
Eating undercooked meat from infected animals is the main cause of  tapeworm infection in people.
Although tapeworms in humans usually cause few symptoms and are easily treated, they can
sometimes cause serious, life-threatening problems.

Tapeworms are usually treated with a medicine taken by mouth [39]. The medications paralyze

the tapeworms, which let go of the intestine, dissolve, and pass from your body with bowel
movements.
1.5.4. Hookworm: Hookworms are parasites. This means they live off other living
things. Hookworms affect lungs, skin, and small intestine. Humans
contract hookworms through hookworm larvae found in dirt contaminated by feces [40].

As their name suggests, hookworms have hooks on their mouth that help them attach better to the
intestines of their host. Humans affected can also develop a skin condition called cutaneous larva
migrans.

Anthelminthic medications orally are the drugs of choice for treatment of hookworm infections.
Infections are generally treated for 1-3 days. The recommended medications are effective and appear
to have few side effects. Iron supplements may also be prescribed if the infected person has anemia.

1.5.2.5. Whipworm: Whipworm (Trichuris trichiura) is an intestinal parasite of humans. The larvae

and adult worms live in the intestine of humans and can cause intestinal disease. The name is derived
from the worm's distinctive whip-like shape.

Trichuriasis is infection with the parasite whipworm, is a very common intestinal helminthic

infection worldwide. About one quarter of the world's population is thought to carry the parasite.
Principally a problem in tropical Asia and, to a lesser degree, in Africa and South America, a lack of a
tissue migration phase and a relative lack of symptoms characterize whipworm infection. Trichuris is
also notable for its small size. Only individuals with heavy parasite burden become symptomatic.
Vitamin A deficiency has been seen in patients with trichuriasis [41].

Poor hygiene is associated with whipworm transmission and children are especially vulnerable
because of their high exposure risk. This is especially true in developing countries, where sanitary
conditions are poor.

The most common and effective treatment for a whipworm infection is an antiparasitic medication.

This type of medication gets rid of any whipworms and whipworm eggs in the body. The medication
usually needs to be taken for one to three days orally.

1.6. Recent Research on Helminthiasis

1.6.1. Formative research to inform development of a new diagnostic for soil-transmitted

helminths: Going beyond the laboratory to ensure access to a needed product.

Soil-transmitted helminths affect more than 1.5 billion people, mostly in very poor regions without
proper sanitation [42]. To control infections, countries periodically give deworming drugs to
populations at risk, such as school-age children, based on the results of diagnostic testing to determine
the prevalence of infection. The current method to detect infection works when infections are
prevalent, but is less useful after repeated deworming, when disease prevalence is lower. We
conducted formative research—including user and market research—to inform development of a new
diagnostic tool with improved sensitivity. Findings from this research highlight pain points with
current methods and processes, which are also opportunities for innovation. Access to new STH
diagnostics may improve program decision-making and eventually contribute to elimination of these
infections.

1.6.2. Current epidemiological evidence for predisposition to high or low intensity human helminth
infection.

The human helminth infections include ascariasis, trichuriasis, hookworm infections, schistosomiasis,
lymphatic filariasis (LF) and onchocerciasis. It is estimated that almost 2 billion people worldwide are
infected with helminths. Whilst the WHO treatment guidelines for helminth infections are mostly
aimed at controlling morbidity, there has been a recent shift with some countries moving towards
goals of disease elimination through mass drug administration, especially for LF and onchocerciasis.
However, as prevalence is driven lower, treating entire populations may no longer be the most
efficient or cost-effective strategy. Instead, it may be beneficial to identify individuals or demographic
groups who are persistently infected, often termed as being “predisposed” to infection, and target

treatment at them [43].

1.6.3. Controlling Soil-Transmitted Helminthiasis in Pre-School-Age Children through

Preventive Chemotherapy.

Pre-school age children account for 10%–20% of the 2 billion people worldwide who are infected
with soil-transmitted helminths (STHs): Ascaris lumbricoides (roundworm), Trichuris
trichiura (whipworm), and Ancylostoma duodenale/Necator americanus (hookworms). Through a
systematic review of the published literature and using information collated at World Health
Organization headquarters, this paper summarizes the available evidence to support the
recommendation that pre-school children should be included in regular deworming programmes [44].
The first section describes the burden of STH disease in this age group, followed by a summary of
how infection impacts iron status, growth, vitamin A status, and cognitive development and how
STHs may exacerbate other high mortality infections. The second section explores the safety of the
drugs themselves, given alone or co-administered, drug efficacy, and the importance of safe
administration. The third section provides country-based evidence to demonstrate improved health
outcomes after STH treatment. The final section provides country experiences in scaling up coverage
of pre-school children by using other large scale public health interventions, including vitamin A
programmes, immunization campaigns, and Child Health days. The paper concludes with a number of
open research questions and a summary of some of the operational challenges that still need to be
addressed.

1.6.4. Effect of Sanitation on Soil-Transmitted Helminth Infection

In countries of high endemicity of the soil-transmitted helminth parasites Ascaris

lumbricoides,Trichuris trichiura, and hookworm, preventive chemotherapy (i.e., repeated
administration of anthelmintic drugs to at-risk populations) is the main strategy to control morbidity.
However, rapid reinfection of humans occurs after successful deworming, and therefore effective
preventive measures are required to achieve public health goals with optimal efficiency and
sustainability [45].

1.6.5.  Preventive chemotherapy in human helminthiasis: coordinated use of anthelminthic drugs in

control interventions: a manual for health professionals and programme managers. Helminth
infections impose a great burden on poor populations in the developing world – yet robust, low-cost
and effective public health interventions are available to relieve that burden and provide a better
quality of life for people in poor settings. Control of disease due to helminth infections, as well as to
other agents, aims to alleviate suffering, reduce poverty, and support equal opportunities for men and
women. Preventive chemotherapy uses the available anthelminthic drugs – either alone or in
combination – as a public health tool for preventing morbidity due to infection usually with more than
one helminth at a time; in certain epidemiological conditions contributes also to sustained reduction of
transmission. Since many of these drugs are broad-spectrum, allowing several diseases to be tackled
simultaneously, preventive chemotherapy interventions should be conceived as drug-based rather than
disease-based: emphasis should be on the best, coordinated use of the available drugs rather than on
specific forms of helminthiasis. Although chemotherapy of human helminthiasis is the focus of this
manual, there is huge potential for its integration with the treatment of other diseases. For example,
trachoma1 control through the SAFE strategy – combining drug treatment with hygiene and
environmental management – can be linked to helminth control interventions to improve the overall
health of affected communities. The greatest challenge is to extend regular anthelminthic drug
coverage as a public health intervention to reach all individuals at risk of the morbidity caused by
helminthic infections. Preventive chemotherapy should therefore begin early in life, and every
opportunity should be taken to reach at-risk populations. This manual advocates much greater
coordination among disease control interventions than has hitherto been seen as specific – and
therefore implemented separately. Because such large numbers of people are affected, and are often
difficult to reach, it also stresses the need to make the best use of all existing drug distribution
channels to deliver anthelminthic drugs, and aims at encouraging programme managers to find other
innovative means of reaching those in need in a sustainable manner [46]. The result will be gains in
the health, education, economic status and social well-being of entire populations. Such advances will
help to build a solid foundation for improvements in maternal health and the development of children
into adults free of the burden of disabling disease. Reducing the burden of morbidity and impaired
development that characterizes human helminthiasis depends on policy decisions taken by ministers
of health, ministers of education and their advisers. Critically, it will depend also on the dedication of
health professionals and the support of partners who have committed time, money and resources to
helminth control and the involvement of communities.

1.6.6. A Research Agenda for Helminth Diseases of Humans: Intervention for Control and
Elimination.

Recognising the burden helminth infections impose on human populations, and particularly the poor,
major intervention programmes have been launched to control onchocerciasis, lymphatic filariasis,
soil-transmitted helminthiases, schistosomiasis, and cysticercosis. The Disease Reference Group on
Helminth Infections (DRG4), established in 2009 by the Special Programme for Research and
Training in Tropical Diseases (TDR), was given the mandate to review helminthiases research and
identify research priorities and gaps. A summary of current helminth control initiatives is presented
and available tools are described. Most of these programmes are highly dependent on mass drug
administration (MDA) of anthelmintic drugs (donated or available at low cost) and require annual or
biannual treatment of large numbers of at-risk populations, over prolonged periods of time. The
continuation of prolonged MDA with a limited number of anthelmintics greatly increases the
probability that drug resistance will develop, which would raise serious problems for continuation of
control and the achievement of elimination [47]. Most initiatives have focussed on a single type of
helminth infection, but recognition of co-endemicity and polyparasitism is leading to more integration
of control. An understanding of the implications of control integration for implementation, treatment
coverage, combination of pharmaceuticals, and monitoring is needed. To achieve the goals of
morbidity reduction or elimination of infection, novel tools need to be developed, including more
efficacious drugs, vaccines, and/or antivectorial agents, new diagnostics for infection and assessment
of drug efficacy, and markers for possible anthelmintic resistance. In addition, there is a need for the
development of new formulations of some existing anthelmintics (e.g., paediatric formulations). To
achieve ultimate elimination of helminth parasites, treatments for the above mentioned helminthiases,
and for taeniasis and food-borne trematodiases, will need to be integrated with monitoring, education,
sanitation, access to health services, and where appropriate, vector control or reduction of the parasite
reservoir in alternative hosts. Based on an analysis of current knowledge gaps and identification of
priorities, a research and development agenda for intervention tools considered necessary for control
and elimination of human helminthiases is presented, and the challenges to be confronted are
discussed.
1.6.7. A Research Agenda for Helminth Diseases of Humans: The Problem of Helminthiases

A disproportionate burden of helminthiases in human populations occurs in marginalised, low-

income, and resource-constrained regions of the world, with over 1 billion people in developing areas
of sub-Saharan Africa, Asia, and the Americas infected with one or more helminth species. The
morbidity caused by such infections imposes a substantial burden of disease, contributing to a vicious
circle of infection, poverty, decreased productivity, and inadequate socioeconomic development.
Furthermore, helminth infection accentuates the morbidity of malaria and HIV/AIDS, and impairs
vaccine efficacy. Polyparasitism is the norm in these populations, and infections tend to be persistent.
Hence, there is a great need to reduce morbidity caused by helminth infections. However, major
deficiencies exist in diagnostics and interventions, including vector control, drugs, and vaccines.
Overcoming these deficiencies is hampered by major gaps in knowledge of helminth biology and
transmission dynamics, platforms from which to help develop such tools. The Disease Reference
Group on Helminths Infections (DRG4), established in 2009 by the Special Programme for Research
and Training in Tropical Diseases (TDR), was given the mandate to review helminthiases research
and identify research priorities and gaps [48]. In this review, we provide an overview of the forces
driving the persistence of helminthiases as a public health problem despite the many control initiatives
that have been put in place; identify the main obstacles that impede progress towards their control and
elimination; and discuss recent advances, opportunities, and challenges for the understanding of the
biology, epidemiology, and control of these infections. The helminth infections that will be discussed
include: onchocerciasis, lymphatic filariasis, soil-transmitted helminthiases, schistosomiasis, food-
borne trematodiases, and taeniasis/cysticercosis.