STH
 
Significant portion of the population is at risk
 30.07% of population of Kaunlaran (6977 children ages 1-14)
 Main source of income is agriculture which puts them in greater risk for STH infections

The municipality of Kaunlaran suffers from poor sanitation

 a significant proportion of 15%  of households still employ closed pit, open put and pail
system for their sanitary toilet facilities.
 Significant percentage of the municipality don’t have access to safe water at 20% of all
households
 5.2% of households still get water from lake, river, rain, and others.
 only a proportion of 52.4% (98/187) of food establishments granted with a sanitary
permit
 only 49.6% of food handlers (82/165) were given health certificates
 only 59.6% of households (2656/4427) have complete basic sanitation facilities

Poor child care programs

 Vitamin supplementation with Vitamin A, iron, and micronutrients

o Vitamin A
 60% were only given to children age 12months to 59 months
 Iron
 2% among 12to 59 months
 Micronutrient
 42% among children age 12 months to 23 months

WHO strategy for control

The WHA endorsed a resolution WHA54.19 suggesting the immediate control of morbidity
against soil-transmitted helminths through periodic deworming in high risk populations
including
 Preschool children
 School-age children
 Women of reproductive age (including pregnant at 2 nd and 3rd trimesters and
breastfeeding mothers)
 Adults in certain high-risk occupations (tea-pickers or miners)

WHO recommends
 deworming even without prior screening of at risk individuals (esp children at school).
Through this morbidity is reduced by decreasing worm burden in the community.
o Deworming through WHO recommended medicines – albendazole (400mg) and
mebendazole (500mg)
 Effective
 Inexpensive
 Easy to administer, even by non-medical personnel such as teachers
  Chewable tablets single dose
 Safe
o WHO also added control for S. Stercoralis morbidity as an objective for 2030.
 Ivermectin – prequalified at affordable cost. Although availability may be
affected due to use as a possible treatment for the current disease pandemic of
COVID-19
 Health and hygiene education reduces transmission and reinfection by encouraging healthy
behaviours
o Schools provide a good entry point for promotion of proper hand washing and
improved sanitation.

WHO also proposed a global target for 2030 against STH

1. Achieve and maintain elimination of STH morbidity in pre-school and school age children
2. Reduce the number of tablets needed in preventive chemotherapy for STH
3. Increase domestic financial support to preventive chemotherapy for STH
4. Establish an efficient STH control programme in adolescent, pregnant and lactating women
5. Establish an efficient strongyloidiasis control programme in school age children
6. Ensure universal access to at least basic sanitation and hygiene by 2030 in STH-endemic areas

Department of Health
 continues its drive to eliminate intestinal parasitism in our country
 School based deworming in coordination with DepED and community based deworming in
various health centers and RHUs
 Target of 85% deworming coverage
 Goal to reduce the prevalence of STH in the country by 20% by 2022 to prevent its detrimental
impact on children’s health and education

Impact of the new normal to STH

 Despite the evident threat of COVID-19 in the community, we should not lay our eyes off from
other diseases, especially the ones that are already considered neglected diseases, such as STH.
Its prevention, control, and management are relatively simple and accessible; however its
effects to the vulnerable populations (which include mostly school-age children) can be severely
detrimental not only to their health but also their education.
 Due to implementation of online classes and prohibition of face-to-face learning, school-based
deworming strategy is not feasible currently in the new normal; hence, deworming program
shall rely mostly on community based deworming through the various health centers and RHUs.
 Possibly a relative decrease in incidence due to the constant promotion of hand hygiene or
proper hand washing
 Decrease in incidence may also be due to control of food establishments and limitation of
movements during the community quarantine, hence children are less likely to get infected from
 unsanitary food establishments, and are limited only to home-cooked foods which are relatively
safer and healthier.
 Although there is also a possibility that the new normal may indirectly affect the incidence of
STH as the unemployment rate will increase, therefore poverty rate will also increase in the
country, which is usually attributed to STH risk especially in lower socioeconomic groups.

Hookworms
Another significant group of parasitic worm causing STH are hookworms. This comprise
of two main species which are known to infect humans, namely Ancylostoma
duodenale and Necator americanus [1]. However some species are also known for their
lesser role in hookworm-related diseases. Ancylostoma ceylanicum and A. caninum which
are primarily a canine hookworm is known for its capability to cause zoonotic disease
leading to enteritis and ileitis. And lastly, A. braziliense, A. caninum, and Uncinaria stenoce
are considerably known to cause cutaneous larva migrans among hookworms [2][3].

Epidemiology
Approximately 470 million individuals are known to have hookworm infections
globally. Its distribution is widely spread particularly in warm and moist regions including
Asia, Africa, Central and South America, and the South Pacific. N. americanus serves as the
leading cause of hookworm infections worldwide, whereas A. duodenale is more prevalent in
the Mediterranean region and South-western Asia [2].
Common factors that increases the risk for hookworm infection include warm and
moist environment, low socioeconomic status, poor sanitation and hygiene, and high
exposure to soil particularly in agricultural jobs which can all be deemed in the community
of Kaunlaran [1][4].

Pathophysiology and Life Cycle

Hookworm eggs are initially passed in the stool of an infected individual. During
favorable conditions including warm, moist and shaded setting, first-stage larvae or
rhabditiform larvae hatch in 1 to 2 days and become free-living in soil. They eventually molt
twice to become infective filariform (third-stage) which can survive 3 to 4 weeks in suitable
environmental conditions. Infection starts once it comes into contact with the human skin
which is typically on bare feet. The larvae penetrate the skin through their buccal mucosa,
invading the host which sometimes presented as ground itch. In N. americanus, cutaneous
penetration occurs through production of proteases to break down collagen and elastin
which are components of connective tissues; whereas in Ancylostoma larvae, hyaluronidase
enzyme is produce to penetrate the dermal integrity of the host. The larvae will eventually
make their way to the blood vessels to the right side of the heart and then to the lungs.
Their migration to the pulmonary vasculature causes a type-1 hypersensitivity reaction
causing Loeffler syndrome. As they migrate into the pulmonary alveoli, they eventually
ascend through the bronchial tree then into the pharynx, and are swallowed into the
intestinal tract. As they reach the duodenum, they actually molt twice to become immature
worms that have cutting plates to attach on the intestinal mucosa of the host. They reside
in the small intestine to become mature which may take several years. Hookworm
maturation and sexual differentiation for mating usually occurs in 4 to 6 weeks; a mature
female usually lays 3000 eggs per day in the intestinal lumen which exits the host through
the feces. The chronic consumption of the parasite and leakage of blood from their
attachment in the intestinal wall causes significant blood loss especially in heavily infected
hosts that could reach up to 9.0 mL/day. Accompanying factors such as deprived nutrition
of the hosts may lead to iron-deficiency anemia. In addition to this, concurrent protein loss
may result to hypoproteinemia and hypoalbuminemia, which can cause anasarca and
aggravate host malnutrition [5].

Signs and symptoms

Hookworm infections predominantly present asymptomatically, although clinical
features and symptoms are usually nonspecific and relate to agent stage and site of agent
invasion.
Upon cutaneous penetration, infection typically presents as ground itch
characterized by localized erythematous reaction. As the hookworm infection progresses to
the lungs, it usually demonstrates as coughing episodes, sneezing, bronchitis, hemoptysis,
and even eoisinophilic pneumonia known as Loeffler syndrome. Rare cases might also
present Wakana syndrome which is distinguished by peroral infection, nausea accompanied
by vomiting, throat itchiness and irritation, as well as dyspnea and cough. And finally, once
infection reaches the small intestine, abdominal symptoms arise which include pain,
distension, diarrhea, occult fecal blood, and, even melena [1][5].
However, hookworm infection is known for its nutritional burden mainly through iron
deficiency anemia due to blood loss via mechanisms of direct parasitic consumption and/or
leakage caused by attachment of parasites on the intestinal mucosa. Concurrent
hypoalbuminemia caused by the chronic protein loss, may even lead to symptoms of edema
and anasarca[6]. There are rare instances that individuals with severe infection may also
present with geophagia wherein they crave soil and even ingest dirt [1][7].

what can be deduced in the community of Kaunlaran based from their poorly managed
nutritional program puts them in a greater risk for iron deficiency anemia.

[1] Albonico M, Savioli L. Hookworm: a neglected resurgent infection. BMJ. 2017 Oct 24;359:j4813
[2] Ghodeif AO, Jain H. Hookworm. [Updated 2021 Jan 27]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546648/
[3] Cdc.gov. 2021. CDC - Hookworm - Biology. [online] Available at:
<https://www.cdc.gov/parasites/hookworm/biology.html> [Accessed 24 April 2021].
[4] Parija SC, Chidambaram M, Mandal J. Epidemiology and clinical features of soil-transmitted
helminths. Trop Parasitol. 2017 Jul-Dec;7(2):81-85. [PMC free article] [PubMed] [Reference list]
[5] Jourdan PM, Lamberton PHL, Fenwick A, Addiss DG. Soil-transmitted helminth infections. Lancet.
2018 Jan 20;391(10117):252-265.
[6] Loukas A, Prociv P. Immune responses in hookworm infections. Clin Microbiol Rev. 2001
Oct;14(4):689-703, table of contents.
[7] Hotez PJ, Brooker S, Bethony JM, Bottazzi ME, Loukas A, Xiao S. Hookworm infection. N Engl J Med.
2004 Aug 19;351(8):799-807.