Soil-Transmitted Helminths and
Other Intestinal Roundworms
Elaine C. Jong
ABSTRACT
Infections with soil-transmitted helminths (STHs) affect the
health of millions of people around the world. Individuals of all
ages may be infected with the common roundworm (Ascaris
lumbricoides), whipworm (Trichuris trichiura), and hookworm
(Ancylostoma duodenale and Necator americanus), although school-
aged children living in resource-poor endemic areas are more
likely to be infected with heavy worm burdens that contribute
to significant malnutrition, delayed physical growth, cognitive
impairment, serious illness, and even death. Chronic infections
with hookworm and whipworm are associated with the develop-
ment of iron-deficiency anemia owing to daily blood loss in the
stools. Light worm infections are usually asymptomatic;
however, when such infections are diagnosed among returning
travelers and immigrants from endemic areas, there is usually a
strong personal desire to be free from worms whether symp-
tomatic or asymptomatic.
Two other nematode (roundworm) infections also are con-
sidered in this chapter: those caused by pinworm and Strongy-
loides stercoralis. Pinworm (Enterobius vermicularis) infections are
a ubiquitous scourge among children and the households that
they live in, usually causing perianal itching but occasionally
producing more serious pathology. S. stercoralis can cause
chronic infections in humans that last decades because of para-
site autoinfection, and may be associated with skin rashes and
hypereosinophilia as well as fatal hyperinfections in immune-
compromised hosts—for example, persons on immunosuppres-
sive drugs, persons infected with human immunodeficiency
virus (HIV), and persons with cancer or various other immune-
compromising conditions.
There are many geographic areas where a high risk of STH
transmission overlaps with high rates of HIV infections and
acquired immunodeficiency syndrome (AIDS) among resident
populations. Some studies have postulated that helminthic
infections in persons co-infected with HIV may adversely affect
HIV-1 progression, as measured by changes in CD4 count, viral
load (measured by HIV-1 ribonucleic acid [RNA]), and/or clini-
cal disease progression. Diagnosis of latent worm infections and
appropriate treatment of HIV-1 co-infected persons and others
with immunocompromised status are strongly recommended
for those who live or have lived in high-risk geographic areas
for STH transmission.
GEOGRAPHIC DISTRIBUTION
Ascaris is probably the most common helminthic infection, with
a global prevalence of approximately 1.3 billion persons infected.
The majority (over 70%) of Ascaris infections occur in China,
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78
India, and Southeast Asia, followed by countries in Latin
America and the Caribbean region (approximately 13%), and in
sub-Saharan Africa (approximately 8%). It is estimated that
whipworm and hookworm each are responsible for 500 to 900
million infections worldwide. Whipworm has a similar geo-
graphic distribution as Ascaris, whereas hookworm is highly
prevalent in sub-Saharan Africa and south Asia. Transmission of
STHs also occurs in developed countries; it has been reported
in persons living or working in resource-poor rural farming
communities in the southern United States and southern
Europe. Transmission of Strongyloides and pinworm occurs in
urban as well as rural locales, because there is not an obligatory
life-cycle developmental stage in soil.
RISK FACTORS
STHs are transmitted in human populations in tropical and
temperate climates where poverty and poor sanitation result in
fecal contamination of the environment. Parasite eggs of Ascaris,
whipworm, and hookworm have an obligatory developmental
period of several weeks in the soil before the larvae contained
in the eggs become mature and infective for humans. Humans
usually acquire worm infections by fecal-oral transmission from
contaminated fingers and food (Ascaris, whipworm, pinworm) or
by direct skin contact with fecally contaminated soil (hook-
worm, Strongyloides). In addition, direct person-to-person trans-
mission of Strongyloides and pinworm is possible among those
having close personal contact with infected persons, and auto-
infections are also possible (see later).
CLINICAL FEATURES
Clinical signs and symptoms reflect the life-cycle stages of each
parasite within the human host (Table 78-1). Larval penetration
of intact skin often elicits a pruritic skin rash (hookworm, Stron-
gyloides). When immature larval parasite forms are migrating
through the lungs and other host tissues during natural life-
cycle stages, elevated peripheral blood eosinophils may occur.
As the larvae of Ascaris, hookworm, and Strongyloides migrate
through the lungs as a part of their life cycle in the human host,
a cough may develop and transient infiltrates may be seen on
chest radiographs. During Strongyloides hyperinfection, larvae
may be found in specimens of the blood-tinged sputum. Persons
with light STH infections may have few specific signs or symp-
toms, and many are undiagnosed. Because worm infections do
not elicit a protective immune response, persons (especially chil-
dren) residing in areas of transmission can acquire heavy worm
burdens over time and manifest serious consequences of
infection.
 CHAPTER 78  •  Soil-Transmitted Helminths and Other Intestinal Roundworms 467

Table 78-1  Summary of Parasite Life Cycles

PARASITE TRANSMISSION INCUBATION ADULT HABITAT LIFESPAN CLINICAL FEATURES

Ascaris Ingestion of eggs 2-3 months Small intestine 1-2 years Pulmonary larval migration
lumbricoides (cough and eosinophilia)
(common Intestinal discomfort
roundworm) Obstruction of a viscus, or
intestinal perforation
Ova in stools
Spontaneous passage of adult
worms per rectum, mouth,
or nose
Trichuris trichiuris Ingestion of eggs 1-3 months Large intestine in 3-8 years Diarrhea, cramps
(whipworm) the cecum; Blood in stools
gravid females Anemia
migrate to the Tenesmus, rectal prolapse
rectum Ova and occasional adults in
stools
Ancylostoma Skin penetration 2 or more Small intestine in 1 year Skin rash at site of infection
duodenale, by infective weeks the duodenum (“ground itch”)
Necator larvae after and upper Pulmonary larval migration
americanus contact with jejunum (cough and eosinophilia)
(hookworm) contaminated Diarrhea, abdominal
soil discomfort
Anemia
Hypoproteinemia
Occult blood and ova in stools
Strongyloides Skin penetration 3 weeks Small intestine May persist up Skin rash at site of infection
stercoralis by infective to 35 years Pulmonary larval migration
larvae after through (cough and eosinophilia)
contact with autoinfections Diarrhea, abdominal
contaminated discomfort
soil; Persistent eosinophilia
autoinfection; Larvae in stools
skin-to-skin Autoinfective cycle
contact Hyperinfection syndrome
Enterobius Ingestion of eggs 2-4 weeks Large intestine in Gravid females, Anal and/or vulvar pruritus
vermicularis the cecum 3-6 weeks; Rare cause of appendicitis
(pinworm) males, 1-2 Self-infection from fecal-oral
weeks contamination

Common Roundworm: Ascaris lumbricoides Whipworm: Trichuris trichiura

Infected persons may be asymptomatic or complain of vague
abdominal symptoms. Ascaris worms become hyperactive when
irritated by fever, starvation, or medications in the human host:
a worm may ascend from normal residence in the lumen of the
small intestine through the stomach and esophagus, exiting
through the mouth or nose; or a worm may pass without symp-
toms per rectum, shocking the host who finds a spontaneously
expelled gross specimen. Infection with only a single Ascaris
worm can cause morbidity owing to their relatively large size: a
worm may migrate to ectopic locations such as the appendix or
common bile duct, causing obstruction and inflammation.
Ascaris is capable of perforating the intestines, resulting in fecal
spillage and the development of peritonitis. In heavily infected
children, small bowel obstruction may result from a bolus of
worms and may necessitate emergency laparotomy. Taking all
these possible scenarios into account, Ascaris infections should
be treated when detected (Figure 78-1).
Whipworm is a parasite infection with worldwide distribution,
and although persons of any age may be infected, children
account for the majority of reported cases. Whipworm infec-
tions are chronic and relatively silent, but moderate to severe
infections (from around 200 to 1000 adult worms or more) are
associated with iron-deficiency anemia, growth retardation, and
chronic bloody mucoid diarrhea. The adult worms inhabit the
human colon, from the cecum to the rectum, with the mouth-
part of each worm firmly embedded in the bowel epithelium,
and the thicker posterior bodies of the worms moving freely in
the bowel lumen. In heavy whipworm infections, rectal prolapse
is thought to be associated with both physical factors and inflam-
matory changes caused by infection in the bowel wall: peristaltic
contractions of the bowel push the worm bodies in the rectum
toward the anus while the anterior ends remain firmly attached
to the chronically inflamed bowel wall, and rectal prolapse may
occur (Figure 78-2).

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468 SECTION VIII  •  Parasitic Diseases

1. Ova contaminate food and

are ingested with it.

5. Larvae ascend trachea to

larynx and are swallowed. Intestinal obstruction due
4. Larvae reach lung by to Ascaris lumbricoides
way of pulmonary (chiefly in children)
artery, penetrate
8. Fertilized eggs
20 to 35 cm

alveoli, and enter

become
bronchi.
embryonated
3. Larvae penetrate in 2 to 3 weeks.
15 to 25 cm

gut wall and pass

to heart via portal 2. Larvae Ascaris
vein, liver, and emerge from lumbricoides
inferior vena cava. eggs in in vermiform
small intestine. appendix

Fertilized
(Outer covering
7. Ova are lost owing
expelled to pressure
Male Female in feces. of cover glass)
6. Larvae molt and develop into adult
worms in small intestine. Worms are
harbored here, may pass to other organs
(biliary tract, appendix), or emerge from
anus, mouth, nose. Unfertilized

Figure 78-1  Ascaris infection.

Hookworm: Ancylostoma duodenale and Strongyloidiasis: Strongyloides stercoralis

Necator americanus
A. duodenale and N. americanus were commonly known as “Old
World” and “New World” hookworm, respectively. However,
after recognition that infections with both species are transmit-
ted in both the Eastern and Western hemispheres, the geo-
graphic designations have decreased in usage. Infections with A.
duodenale are potentially more harmful than infections with N.
americanus; A. duodenale worms attach to the intestinal mucosa
and suck blood at a rate of 0.15 to 0.26 mL/day per worm com-
pared with N. americanus with a rate of 0.03 mL/day per worm.
Thus blood loss is greater with A. duodenale for a comparable
level of infection. Additional blood loss occurs from the multiple
points of attachment and detachment of the adult hookworms
in the duodenum and jejunum. When the worms bite into the
mucosa to attach and feed, an anticoagulant is released into the
local tissue, and bleeding from these sites into the lumen of
the small intestine persists after the worms detach and move on
to fresh areas of mucosa. Although the two species can be dis-
tinguished by the morphology of the mouth parts and the
copulatory bursae of the adult worms, the eggs of the two
are indistinguishable. Once the diagnosis of hookworm is
made, drug treatment is the same regardless of species (Figure
78-3).
In the soil-transmitted cycle of Strongyloides, adult female worms
developing in the submucosa of the small intestine lay eggs that
mature within in a few hours to produce rhabditiform larvae
that enter the fecal stream in the lumen of the bowel. Strongy-
loides rhabditiform larvae exiting the body in feces that are
deposited in moist soil develop into infective stage filariform
larvae (through asexual or sexual free-living cycles). Filariform
larvae are capable of penetrating intact human skin, and new
infections occur when skin comes into direct contact with the
contaminated soil.
Alternatively, the immature rhabditiform larvae in the fecal
stream may rapidly develop into infective filariform larvae while
still in the intestines. The filariform larvae in the fecal stream
may penetrate either the intestinal mucosa or the perianal skin
and migrate to blood vessels, completing their life cycle without
leaving the human host through a process of autoinfection. The
pruritic, serpiginous erythematous skin rash on the buttocks
elicited by this autoinfection is called cutaneous larva currens,
because the tracklike rash caused by the migrating subcutaneous
larvae can extend at a rate of 5 to 10 cm an hour. Strongyloidia-
sis is a sexually transmitted infection when intimate skin-to-skin
contact occurs while infective filariform larvae are present in the
rectum and on the perianal skin.

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 CHAPTER 78  •  Soil-Transmitted Helminths and Other Intestinal Roundworms 469

Embryonated eggs contaminate food and water and are ingested

Embryo escapes from egg

in small intestine by
forcing out albuminous
plug at one end. Free larvae
then develop into adult male
and female forms

Adult worms migrate to cecum

and appendix, where they initially
live and copulate; over time,
they may populate the large
intestine from cecum to rectum
1 cm

Eggs become embryonated

in soil (3 to 4 weeks under
favorable conditions;
6 months to 1 year at low
temperatures)

Rectal prolapse may

Fertilized egg is occur in some heavily
expelled in feces infected persons

Figure 78-2 Whipworm infection.

Pinworm: Enterobius vermicularis

Chronic Strongyloides infections are often silent, although
some patients complain of transient skin rashes and itching
associated with the autoinfective cycle. Elevation of the periph-
eral blood eosinophils may be noted as an incidental finding on
routine laboratory studies and may trigger a clinical investiga-
tion for occult parasite infection. Serious disease results if the
infected host becomes immunocompromised; then, Strongyloides
hyperinfection with dissemination of the parasites to all internal
organs precipitates local inflammatory changes and severe
enteritis, pneumonitis, and microabscesses as well as other life-
threatening secondary complications (Figure 78-4).
Perianal itching in children is the hallmark of pinworm infec-
tions. However, there are rare reports of appendicitis, peritoni-
tis, and salpingitis in which ectopic pinworms or ova were
associated with inflammatory reactions in the tissue. Usually,
adult pinworms inhabit the cecum, and gravid females migrate
to the rectal area at night to deposit eggs on the perianal skin.
The embryonated eggs mature after 4 to 6 hours of oxygenation
outside the intestine. Fingers and fingernails touching or
scratching the perianal area are easily contaminated and may
reinfect the original host when the contaminated fingers or

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470 SECTION VIII  •  Parasitic Diseases

Secondary anemia

Larvae ascend trachea to

pharynx and are swallowed
Necator americanus
Larvae reach lung via pulmonary (adult worms)
artery, then penetrate alveoli
and enter bronchi

1 mm

9 mm
9 to 1

7 to
Larvae enter bloodstream Mature worms develop in
and are carried to heart duodenum and jejunum,
bite into mucosa, and
suck blood, causing
variable degree of anemia

Fertilized ova are Necator Ancylostoma

discharged americanus duodenale
in feces

Mouth parts
Rhabditiform
larvae develop
in ova in
Infection takes place when 24 hours
filariform larvae penetrate human
skin, causing “ground itch”
Copulatory bursae

Rhabditiform
larvae escape
Larvae molt twice developing from egg
into filariform larvae

Figure 78-3  Hookworm infection.

objects touched by the fingers are put in the mouth. Contamina-
tion of the household environment (e.g., blankets, sheets, cloth-
ing, dust) results from eggs shed from the skin, and infections
are easily spread to other persons as a consequence of close
household or personal contact (Figure 78-5).
DIAGNOSTIC APPROACH
Definitive diagnosis of helminthic infection depends on mor-
phologic identification of the characteristic eggs (ova), larvae,
and/or even adult forms in fecal samples, tissue biopsy speci-
mens, or sputum. Identifying unique parasite ova and larval
forms in submitted stool specimens by microscopic examination
is the most common way of making the diagnosis. However,
microscopic diagnosis and estimation of the worm burden by
quantitative egg counts in the stool are challenging, because
parasite eggs may not be shed uniformly into the fecal stream
on a daily basis and may be unevenly dispersed within a given
stool specimen. Therefore when resources allow, the examina-
tion of three stool specimens from the given individual, each
collected on a different day, yields a more comprehensive profile
of potential parasite infections and allows a more accurate
estimation of the parasite burden compared with examination
of a single stool specimen. Owing to their relatively large size,
diagnosis of Ascaris infections can be made by visual inspection
of adult worms that are spontaneously passed through one of
the body orifices (per rectum, mouth, or nose), contained in
surgical specimens, or observed during radiologic imaging
studies. Pinworm eggs can be recovered from suspected cases
by pressing the sticky side of clear adhesive tape on the perianal
skin first thing in the morning. Strongyloides eggs are rarely seen
in stool specimens, and special laboratory techniques are usually
required to visualize the larval forms. Serologic tests for diag-
nosis of Strongyloides are available from state public health and
commercial reference laboratories.
CLINICAL MANAGEMENT AND
DRUG TREATMENT
Drug therapy is usually directed by the parasite diagnosis. The
therapeutic goal of anthelmintic parasitic drug treatment is to
eradicate or significantly lower the worm burden in infected
individuals—except for Strongyloides-infected individuals, who

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 CHAPTER 78  •  Soil-Transmitted Helminths and Other Intestinal Roundworms 471

In lungs larvae may cause hemorrhage or infiltration

Larvae ascend trachea to

pharynx and are swallowed
Parasitic adult females develop
Larvae penetrate alveoli in duodenum, penetrate duodenal
and enter bronchi or jejunal mucosa, and deposit
embryonated eggs

Rhabditiform larvae are hatched from

eggs, find way to intestinal lumen,
and are expelled in feces

Filariform larvae migrate via

bloodstream, passing through
heart and pulmonary artery Rhabditiform larvae
to lungs discharged in feces
Indirect
(long,
Direct (shor

sexua
Rh l) cycle
la ab
in rvae ditif
fec d or
es isch m
ar
t, asexua

ge In soil
d larvae
develop
(within
l) c y

Filariform (infective) 36 hours)

c le

larvae develop and into

sexually
le a

penetrate skin
mature,
di

A serpiginous skin rash

ng

to free-living
au caused by filariform larvae
to- rhabditiform

te
Filariform (infective) larvae develop infec migrating subcutaneously

ntia
and penetrate skin ti o n males and

rat tedly
may develop on the buttocks
females
g d re ffere

s
or thighs

ion
a
ge pe
iv an n di
After fertilization
embryonated eggs
i

ne
al aga

are laid a
y
es

m
in

Second rhabditiform a e m l
v fe -
larvae hatched lar nd free
or m sa w
bditif male e ne
Rha into inat
orig

Figure 78-4  Strongyloides infection.

should be treated until a total cure is achieved. The parasites
have varying degrees of susceptibility to the anthelmintic drugs,
and some of the drugs have a broad spectrum, a useful property
for treating mixed infections. Single-dose drug treatment pro-
tocols (Tables 78-2 and 78-3) have been studied because of their
utility in mass treatment programs. Published studies conducted
in Africa, South America, and Asia have demonstrated that peri-
odic mass treatment programs conducted with broad-spectrum
anthelmintic drugs in school-aged children in endemic areas
resulted in catch-up and accelerated physical growth, as well as
improved cognitive performance measurable in the months fol-
lowing treatment.
Recommended drug treatment may feature a single-dose
regimen or a longer duration of treatment with a given drug to
ensure optimal cure rates for a given parasite. Pyrantel pamoate
is widely used and relatively inexpensive in developing coun-
tries. The drug is a tetrahydropyrimidine derivative, which is
thought to inhibit neuromuscular transmission in the helminth,
causing spastic paralysis of the worm that promotes subsequent
expulsion of the worm from the host’s intestine. Pyrantel
pamoate is poorly absorbed from the gastrointestinal tract, is
generally well tolerated with few reported adverse side effects,
and is not efficacious in the treatment of Trichuris and
Strongyloides.
The anthelmintic drugs albendazole, mebendazole, and
thiabendazole were developed as the result of research on the
benzimidazole ring, an integral part of the chemical structure
of vitamin B12. Anthelmintic benzimidazole drugs are thought
to preferentially bind with the cytoskeletal protein tubulin in
parasite cells, impairing microtubule formation, and also appear

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472 SECTION VIII  •  Parasitic Diseases

Infestation by ingestion of contaminated food and water

Self re-infection
by contaminated
fingers

Embryos escape from

eggs in stomach and
duodenum, molt twice,
develop into male
and female worms

After copulation, males and

females migrate to cecum
and appendix. Males remain
here and eventually die.
9 to 11 mm

Females migrate to rectum

and anal canal.
2 to 5 mm

Rarely gravid female worms Females migrate (at night) to anal and perianal
may migrate to vagina regions where they deposit eggs and cause
and fallopian tubes. intense itching; eggs mature within few hours

Fingers (particularly fingernails) become contaminated

through scratching (or handling clothing)
Eggs and adult female worms are discharged in feces

Figure 78-5  Pinworm infection.

Table 78-2  Summary of Overall Cure Rate (%) in Studies Reporting the Use of Single-Dose Oral Albendazole,
Mebendazole, and Pyrantel Pamoate

Treatment Regimen

PARASITE ALBENDAZOLE (400 mg) MEBENDAZOLE (500 mg) PYRANTEL PAMOATE (10 g/kg)

Ascaris lumbricoides 93.9% 96.5% 87.9%

Trichuris trichiura 43.6% 23.0% 28.1%
Hookworm 78.4% 22.9% 87.9%

Data from Keiser J, Utzinger J: Efficacy of current drugs against soil-transmitted helminth infections. Systemic review and meta-analysis, JAMA
299:1937-1948, 2008.

to interfere with parasitic glucose uptake. The benzimidazole
drugs are not efficiently absorbed from the gastrointestinal tract,
although the amounts absorbed during oral treatment appear
sufficient to affect some tissue-phase parasites.
Thiabendazole was discovered in 1961 and was the first
anthelmintic benzimidazole drug introduced into clinical
medicine. Although highly effective against several helminths,
its usage has been limited by predictable unpleasant side
effects (including anorexia, nausea, vomiting, vertigo, and head-
ache) and toxicity, notably erythema multiforme. Thiabendazole
remains the drug of choice for treatment of serious Strongyloides
and Trichinella infections (Chapter 83).
Mebendazole became widely used in clinical medicine in the
1970s and is a highly efficacious drug against several intestinal
parasite infections. In the United States the drug is indicated
for treatment of Ascaris, whipworm, hookworm, and pinworm
infections. Mebendazole has few adverse side effects (infre-
quently reported mild nausea, vomiting, abdominal discomfort)
when used in the low-dose, short-term treatment schedules rec-
ommended for intestinal nematode infections.
Albendazole was introduced into clinical medicine in 1979,
although it was not licensed in the United States until the
mid-1990s. Albendazole’s broad spectrum of activity and low
profile of adverse reactions make it invaluable for the treatment

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 CHAPTER 78  •  Soil-Transmitted Helminths and Other Intestinal Roundworms 473

Table 78-3 Drugs and Treatment Regimens for Selected Helminths

Treatment Regimens

THIABENDAZOLE
ALBENDAZOLE MEBENDAZOLE (500-MG CHEWABLE
(200-mg TABLET; (100-mg PYRANTEL PAMOATE TABLET OR 500-
100-mg/5-mL ORAL CHEWABLE (50-mg/mL ORAL mg/5-mL ORAL
SUSPENSION) TABLET) SUSPENSION) SUSPENSION)

Ascaris lumbricoides 400 mg as a single dose 100 mg twice daily 11 mg/kg in a single oral Not recommended
for adults and children × 3 days for adults dose not to exceed a (drug toxicity
over 2 years of age; and children over maximum dose of 1 g concerns)
200 mg as a single dose 2 years of age for adults and children
in children 1-2 years old over 2 years of age
Whipworm (Trichuris 400 mg daily × 1 or 2 days 100 mg twice daily Not recommended (low Not recommended
trichiura) × 3 or 4 days cure rates) (drug toxicity
concerns)
Hookworm 400 mg daily × 1 or 2 days 100 mg twice daily 11 mg/kg in a single oral Not recommended
(Ancylostoma × 3 or 4 days dose not to exceed a (drug toxicity
duodenale and maximum dose of 1 g concerns)
Necator for adults and children
americanus) over 2 years of age × 3
days
Pinworm (Enterobius 400 mg as a single dose 100 mg as a single 11 mg/kg in a single oral Not recommended
vermicularis) for adults and children dose for adults dose not to exceed a (drug toxicity
over 2 years of age; and children over maximum dose of 1 g concerns)
200 mg as a single dose 2 years of age; for adults and children
in children 1-2 years old; repeat the dose over 2 years of age;
repeat the dose after 2 after 2 weeks repeat the dose after 2
weeks weeks
Strongyloides 400 mg daily × 3 days for Not recommended Not recommended (low 25 mg/kg twice daily
stercoralis— adults and children over (low cure rates) cure rates) (not to exceed
intestinal infection 2 years of age* 1.5 g twice daily) ×
2 or 3 days
Strongyloides 400 mg daily × 15 days for Not recommended Not recommended (low 25 mg/kg twice daily
stercoralis— adults and children over (low cure rates) cure rates) (not to exceed
hyperinfection 2 years of age 1.5 g twice daily) ×
syndrome 10-15 days

*See text for use of ivermectin drug therapy for treatment of intestinal strongyloidiasis.

of individuals as well as a favored drug in mass treatment
programs.
Ivermectin, a semisynthetic anthelmintic drug derived from
the avermectins, antiparasitic agents isolated from the fermenta-
tion products of Streptomyces avermitilis, is indicated for the
treatment of uncomplicated (intestinal) S. stercoralis infections.
The drug acts by binding selectively to glutamate-gated chloride
ion channels present in nerve and muscle cells of the parasite.
Subsequent hyperpolarization of these cells owing to chloride
ion influx leads to paralysis and death of the parasite. The drug
is active only against intestinal larval stages of Strongyloides and
is not indicated for treatment of disseminated tissue infections
(hyperinfection syndrome). The test of cure for intestinal Stron-
gyloides infections is the absence of larvae in three or more
follow-up stool samples collected over the period beginning 3
or 4 weeks after completion of therapy to 3 months afterward.
Clinical studies suggest that ivermectin administered as a single
oral dose of 170 to 200 mcg/kg may be more effective
than albendazole therapy (200 mg twice a day for 3 days)
against intestinal strongyloidiasis. Other studies show that
ivermectin (200 mcg/kg given once daily for 1 or 2 days) had
a comparable cure rate with fewer reported side effects than
thiabendazole (25 mg/kg twice a day for 3 days) against intesti-
nal strongyloidiasis.
PREVENTION AND CONTROL
Prevention and control of STH requires a multipronged
approach involving public health measures, personal hygiene,
and drug treatment of infected persons. Improved levels of sani-
tation, especially implementation of programs for collection and
decontamination of human fecal wastes, are essential in regions
with high rates of STH transmission, but such improvements
require administrative infrastructure and resources over the
course of years. Mass drug treatment programs targeting school-
aged children and other high-risk groups have been shown to
yield short-term improvements in affected populations, but
these also depend on administrative infrastructure and contin-
ued availability of affordable, efficacious drugs. Personal preven-
tion measures include wearing shoes and avoiding direct skin

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474 SECTION VIII  •  Parasitic Diseases
contact with moist ground in areas where there is known trans-
mission of hookworm and Strongyloides; school-aged children
should be taught good personal hygiene practices. Challenges
to current control efforts include varying degrees of inherent
EVIDENCE
Igual-Adell R, Oltra-Alcaraz C, Soler-Company E, et al: Efficacy
and safety of ivermectin and thiabendazole in the treatment of
strongyloidiasis, Expert Opin Pharamacother 5:2615-2619, 2004.
A retrospective review of 88 adult cases of chronic strongyloidiasis treated
with either thiabendazole or ivermectin, from 1999 to 2002, in
Valencia, Spain. Noncure after drug treatment was associated with
continued eosinophilia.
Kirwan P, Asaolu SO, Molloy SF, et al: Patterns of soil-
transmitted helminth infection and impact of four-monthly
albendazole treatments in preschool children from semi-urban
communities in Nigeria: a double-blind placebo-controlled
randomised trial, BMC Infect Dis 9:20, 2009. This placebo-controlled
field study among Nigerian preschool children aged 1 to 4 years found
that more than 50% of the preschool children were infected by one or
more helminths. A. lumbricoides was the most prevalent infection
(47.6%). Results of the study suggest that systematic treatment
programs using a broad-spectrum anthelmintic drug are necessary to
reduce the prevalence and intensity of STH infection among preschool
children in a population characterized by moderate prevalence and low
intensity.
ADDITIONAL RESOURCES
Keiser J, Utzinger J: Efficacy of current drugs against soil-transmitted hel-
minth infections: systemic review and meta-analysis, JAMA 299:1937-
1948, 2008. A comprehensive review and meta-analysis of published studies
assessing the efficacy of single-dose albendazole, mebendazole, levamisole, and
pyrantel pamoate against A. lumbricoides, hookworm, and T. trichiura infec-
tions. The authors conclude that additional data from “well-designed, adequately
powered and rigorously implemented trials” are needed regarding efficacy of
current drugs with regard to both cure and egg reduction rates, and that bench-
marks are needed for monitoring subsequent drug resistance.
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parasite susceptibility to the commonly used anthelmintic drugs
and the possibility of accelerated emergence of drug-resistance
as a consequence of repeated mass chemotherapy programs in
endemic areas.
Sasaki J, Seidel JS: Ascariasis mimicking an acute abdomen, Ann
Emerg Med 21:217-219, 1992. Ascariasis is a common childhood
infection worldwide. Whereas most Ascaris infections are benign, the
two pediatric cases presented in this report illustrate that such infections
are in the differential diagnosis of pediatric acute abdomen. Children at
risk include immigrants and those with a history of travel to foreign
countries, but cases of ascariasis have been reported in children who have
not traveled outside the United States.
Stephenson LS, Latham MC, Kurz KM, et al: Treatment with a
single dose of albendazole improves growth of Kenyan
schoolchildren with hookworm, Trichuris trichiura, and Ascaris
lumbricoides infections, Am J Trop Med Hyg 41:78-87, 1989. This
placebo-controlled field study of Kenyan schoolchildren studied the
association between infections with one or more intestinal helminths and
poor child growth. The study reports that measurable improvements in
growth could be seen on reexamination 6 months after a single oral dose
of albendazole, despite the children’s continued exposure to reinfection.
Watson JL, Herrin BR, John-Stewart G: Deworming helminth co-infected
individuals for delaying HIV disease progression, Cochrane Database Syst
Rev 3:CD006419, 2009. A review and meta-analysis of published studies
evaluating the effects of deworming on markers of HIV-1 disease progression in
helminth and HIV-1 co-infected individuals. They conclude that there is evidence
of significant benefit in attenuating or reducing plasma viral load and/or increas-
ing CD4 counts after deworming. Further trials are necessary to further evalu-
ate species-specific effects and to document long-term clinical outcomes.