SIBUGAY TECHNICAL INSTITUTE, INC.

Lower Taway, Ipil, Zamboanga Sibugay

COLLEGE OF MIDWIFERY

COURSE MODULE 3
(Midterm)

MICROBIOLOGY AND PARASITOLOGY

Prepared By:

Haridja A. Asid, RN, RM, LPT, MN

Course Facilitator

SY 2023 - 2024
STII, Lower Taway, Ipil, Zamboanga Sibugay Province
 INSTRUMENTS AND EQUIPMENT USED IN MICROBIOLOGY
The instruments used in the microbiology include different kinds of instruments required for a lot of different
processes conducted within those laboratories.

Instruments used in Microbiology Lab with Principle and Uses. Image created with biorender.com

1. Analytical Balance
 An analytical balance is a type of balance that is commonly used for the measurement of mass in the
sub-milligram range.

Working Principle

 These types of balances are made with a measuring pan enclosed

in a transparent covering that prevents small particles or air
currents from getting collected on the pan.
 An electric analytical balance uses the force necessary to
counteract the mass rather than measuring the mass itself.
 An electromagnet is used to create a force required to achieve a
balance with the mass of the substance, and the resulting force is
displayed.
Uses

 As they are highly precise and based on advanced technology, analytical balances are explicitly used in
laboratories for the effective completion of tasks like weighing test materials and sampling amounts,
formulation, density determination, purity analysis, quality control testing, and material and conformance
testing.
2. Autoclave
 An autoclave is a pressurized chamber used for the process of sterilization and disinfection by combining
three factors: time, pressure and steam

Working Principle

 Autoclaves use steam as their sterilization agent. The basic principle

of an autoclave is that all the items within the autoclave come in
direct contact with the steam for a particular period irrespective of
the nature of the material- whether it is liquid, plastic ware, or
glassware.

 The amount of time and the temperature depends on the type of

material being sterilized and the increase in temperature of the cycle
allows for shorter periods.

Uses
 Autoclaves are mostly used for the sterilization of medical or laboratory equipment with the capacity of
sterilizing a large number of materials at once.
 They are commonly used for the preparation of culture media during laboratory applications.

3. Bunsen burner
 Bunsen burner is a standard tool used in laboratories, named after Robert Bunsen.
 It is a gas-fueled single open flame.
Working Principle

 This burner is made with a metal tube on a flat base with a gas inlet at the
bottom of the tube, which may have an adjustable valve. On the sides of the tube
are openings which can be adjusted with a collar to control the amount of air
that can enter.

 Once the burner is connected to a gas source, the gas is forced by the gas
pressure so that the gas reaches the top where the flame is ignited with a match
or a lighter.
Uses

 It is commonly used for processes like sterilization, combustion, and heating. In

medical or microbiology laboratories, it is commonly used for micro-loop
sterilization.

4. Centrifuge
 A centrifuge is a device that allows the rotation of an object about a single
axis, where an outward force is applied perpendicularly to the axis.

 A laboratory centrifuge is motor-based and allows the rotation of a liquid

sample resulting in the separation of the components of the mixture.
Working Principle
  A centrifuge works on the principle of sedimentation, where the high speed of the rotation causes the
denser particles to move away from the center while smaller, less dense particles are forced towards the
center.
 Thus, the denser particles settle at the bottom while the lighter particles are collected at the top.
 In a laboratory tabletop centrifuge, the sample tubes are aligned at an angle so that the particles have to
travel a shorter distance before they hit the bottom.
Uses

 The primary application of a centrifuge is the separation of particles suspended in a suspension. It can be
used for the separation of cell organelles, nucleic acid, blood components, and separation of isotopes.

5. Colony Counter
 A colony counter is used to estimate the density of a liquid culture by counting the number of CFU (colony
forming units) on an agar or culture plates.

Working Principle

 This instrument can accommodate different sizes of

plates which are scanned on top with UV, white light
and/or fluorescent illumination.
 One can accomplish the counting either manually with
the touch pressure or with a digital counter.

Uses

 A colony counter is primarily used for counting the

number of colonies present on a culture plate to estimate the concentration of microorganisms in liquid
culture.

6. Deep Freezer

Working Principle

 Deep freezers are based on the

principle that under extremely low
temperatures, there is minimum
microbial growth which allows for
the protection and preservation of
different substances.

 Based on this principle, we can

even preserve cultures over a long period of time without any change in the concentration of the
microorganisms.
Uses
  A deep freeze can be used for the preservation of different things used in the laboratories for a very long
period of time. Deep freezers are used in laboratories to store and preserve medical equipment, food items,
blood samples, medicines, and injections, etc. for a more extended period of time.

7. Homogenizer
 Homogenizer is a device used in laboratories for the mixing of various
liquids and materials like tissue, plant, food, soil, and many others.

Working Principle

 This instrument is based on the principle that when large globules in coarse
emulsion are passed under high pressure through a narrow orifice, they
break down into smaller particles giving a more uniform and stable mixture

 A homogenizer has a metal rod with narrow parallel openings in the form of
a comb at the end which acts as the orifice for the homogenization process.

Uses

 A homogenizer is primarily used to disrupt cells to acquire cell organelles for different microbiological
processes.
 It is used in the preparation step before the extraction and purification of different macromolecules like
proteins, nucleic acids, and lipids.

8. Hot plate
 A hot plate is a stand-alone appliance used in microbiology laboratories
as a tabletop heating system.

Working Principle

 Unlike the traditional ways of producing heat through the fire, a hot plate
produces heat by the flow of electricity.
 On a hot plate, electricity runs through the coils which have a high level
of electrical resistance. The resistance in the coils converts the electrical
energy into heat energy which causes the coils to release heat.
Uses

 In a laboratory, hot plates are used to heat glassware and their

components.
 They are used over water baths as in water baths might be hazardous in case of any spills or overheat.

9. Hot air oven

 A hot air oven is an electrical device that is used for sterilization of
medical equipment or samples using dry heat.

Working Principle
  Hot air oven is a type of dry heat sterilization which is performed on dry materials and on substances that
do not melt or catch fire under high temperature.

 There are two types of hot air oven based on the working principle
 Forced air hot air oven: In this type of hot air oven, the heated air inside the oven is distributed throughout
the oven with a fan. This prevents the rising of hot air towards the top while keeping the cold air at the
bottom. This allows for the adequate heating of materials inside the oven.
 Static air hot air oven: In this type of oven, the heat is produced by coils present at the bottom of
the oven with no fan. The hot air rises and doesn’t allow the effective sterilization of the
materials.

 The equipment inside the oven acquire heat and pass the heat towards the center, one layer at a time which
allows for effective dry heat sterilization.
Uses

 Hot air oven can be used to sterilize materials like glassware, metal equipment, powders, etc.
 It allows for the destruction of microorganisms as well as bacterial spores.

10. Incubator
 An incubator is a device that is used in the laboratories for the growth and maintenance of microorganisms
and cultures.
 Incubator provides an optimal temperature, pressure, moisture, among other things required for the growth
of microorganisms.

Working Principle

 The incubator is based on the principle of

maintaining a proper atmosphere for the growth
of microorganisms.
 Incubators have a heating system that allows for
the temperature within the incubator to be
adjusted according to the type of organism
cultivated inside.
 Similarly, they are provided with adjustments
for maintaining the concentration of CO2 to
balance the pH and humidity required for the growth of the organisms.
 Variation of the incubator like a shaking incubator is also available, which allows for the continuous
movement of the culture required for cell aeration and solubility studies.

Uses
 Incubators have a wide range of applications including cell culture, pharmaceutical studies, hematological
studies, and biochemical studies.
 Incubators can also be used in the stem cell research area.
11. Laminar Air Flow/ Laminar Hood
 Laminar Hood is a closed device primarily for processes or instruments
sensitive to microbial contamination.

Working Principle

 A Laminar Hood is made up of stainless steel, avoiding joints and

corners to prevent the accumulation of bacterial spores.
 This device creates a sterile environment with the flow of sterile air
through a High-Efficiency Particulate Air (HEPA) filter and shortwave
ultraviolet germicidal lamp that sterilizes the workstation.
 Laminar Air Flow has to turn on 15 minutes before to ensure complete
sterilization and the workstation should be cleaned with ethanol before
and after use.
Uses

 Laminar Hood is commonly used to conduct processes that are sensitive

to contamination.
 It is used for experiments related to plant tissue culture and for the experiments of genetic transformation.

12. Magnetic Stirrer

 Magnetic Stirrer is a device commonly used in microbiology laboratories for the purpose of mixing
liquids.

Working Principle

 This device consists of a rotating magnetic or an electromagnet creating

a rotating magnetic field that allows the stir bar (a piece of heavy metal)
to move around in the vessel.
 It is coupled with a heating system to heat the liquid while it mixed.

Uses

 It is usually used for mixing various liquid components in a mixture in a

chemical or microbiology laboratory.
 This device is used in place of other stirrers as it is noise-free and
because the size of the stir bar is so tiny, there is less chance of
contamination.

13. Microscope
 Microscopes are devices that allow the observer to an exceedingly close view of minute particles.
Working Principle

 There are many different types of microscopes, each of which

works on their respective principles. However, there is some
commonality in them.
 The basic principle in a microscope is magnification. Based on
the relative position of the object from the lens or
electromagnets, different positions, nature, and magnification of
the image can be achieved.
 Different types of microscopes are developed to cater to the
specific needs of the observation. However, the common theme
is magnification.
Uses

 Based on the type of microscopes, different microscopes are used for different purposes.
 They are primarily used for the observation of minute particles which cannot be observed with naked eyes.

14. pH Meter
 pH meter is a device used in laboratories that measure the H-ion concentration in water-based solutions to
determine the acidity or alkalinity of the solution.
 A pH meter is often termed as “potentiometric pH meter” as it measures the difference in electric potential
between the reference and a pH electrode.

Working Principle

 In a potentiometric pH meter, single or multiple glass electrodes,

connected to a bulb selective to hydrogen ions, are attached to a
metal rod.
 When the bulb with the electrodes is dipped into a solution,
hydrogen ions in the solution exchange with positive charges on
the electrode generating an electrochemical potential which is
displayed in terms of pH units on display.
Uses

 A pH meter is primarily used to measure the acidity of

pharmaceutical chemicals, cultures, soil, and water treatment
plant.
 It can be used to measure the acidity level in wine and cheese during their production.

15. Spectrophotometer
 The spectrophotometer is an optical instrument for measuring the
intensity of light in relation to the wavelength.
 Based on the amount of light absorbed by a colored solution, a
quantitative analysis of the solution can be done.

Working Principle
  Spectrophotometry is based on the Beer-Lambert Law, which states the absorbance of light by a solution
(of a particular wavelength) is directly proportional to the concentration of the substance.
 Different wavelengths of lights are passed through a solution as different substances have better
absorbance at different wavelengths. Based on the absorbance of a particular wavelength, the quantitative
analysis of a solution can be done.
Uses

 In a microbiology laboratory, a spectrophotometer is applied for the measurement of substance

concentration of protein, nucleic acids, bacterial growth, and enzymatic reactions.

16. Vortex Mixer/ Vortexer

 A vortex mixer is one of the basic technologies used for the mixing of
samples in glass tubes or flasks in laboratories.

Working Principle

 It is based on the simple principle of causing reactions and

homogenization by agitating the mixture.
 Motorized draft shafts present on the mixer oscillates and transfers the
movement to the sample tubes causing the sample fluids to undergo
turbulent flow.
Uses

 Vortex mixer is mostly used for the mixing of various sample fluids in the sample tubes and also allows
for the homogenization of cells and cell organelles.

17. Water Bath

 Water Bath is a conventional device that is used for chemical reactions that required a controlled
environment at a constant temperature.

Working Principle

 A sensor in the device transfers water temperature to a

reference value which is then amplified and a control
system generates a signal for the heating system which
heats the water to the desired temperature.
Uses

 Water baths are primarily used for heating samples

under a controlled temperature.
 These are suitable for heating chemicals that might be
flammable under direct ignition.

18. Water Distiller

 A water distiller is a device that purifies water by the process of distillation.
  This instrument is commonly used in medical laboratories, microbiology laboratories, organic chemistry
laboratories and medical industries.

Working Principle

 A water distiller is based on the principle of distillation.

 According to this process, water is first brought to a boil and then
condensed into liquid form to obtain pure distilled water.

Uses
 It is used to obtain distilled water required for many lab tests as
well as for the preparation of culture media.

Keep in Mind:
 Microbiology equipment is a large category covering all kinds of items used in microbiology
laboratories.
 An autoclave is a pressurized chamber used for the process of sterilization and disinfection by
combining three factors: time, pressure and steam
 The spectrophotometer is an optical instrument for measuring the intensity of light in relation to the
wavelength.
 A pH meter is primarily used to measure the acidity of pharmaceutical chemicals, cultures, soil, and
water treatment plant.

Comprehension Check:
1. What are the uses of microscope?
2. What is a laminar wood? What are its uses?
3. What is a centrifuge? What are its uses?
To validate your answer, feel free to contact your course facilitator through any of the following:
 Facebook: Haridja Asid
 Contact No: 09260073732
 Email address: benhar02012018@gmail.com

THE NORMAL BACTERIAL FLORA OF HUMANS

The human body is a complex and thriving ecosystem. It contains about 1013 human cells and also about 1014
bacterial, fungal, and protozoan cells, which represent thousands of microbial species. These microbes, called
the normal flora, are usually limited to certain areas of the body, including the skin, mouth, large intestine, and
vagina. In addition, humans are always infected with viruses, most of which rarely, if ever, become
symptomatic. If it is normal for us to live in such close intimacy with a wide variety of microbes, how is it that
some of them are capable of causing us illness or death?
Pathogens are usually distinct from the normal flora. Our normal microbial inhabitants only cause trouble if our
immune systems are weakened or if they gain access to a normally sterile part of the body (for example, when a
bowel perforation enables the gut flora to enter the peritoneal cavity of the abdomen, causing peritonitis). In
contrast, dedicated pathogens do not require that the host be immunocompromised or injured. They have
developed highly specialized mechanisms for crossing cellular and biochemical barriers and for eliciting
specific responses from the host organism that contribute to the survival and multiplication of the pathogen.

In order to survive and multiply in a host, a successful pathogen must be able to colonize the host, find a
nutritionally compatible niche in the host body, avoid, subvert, or circumvent the host innate and adaptive
immune responses, replicate, using host resources; and exit and spread to a new host

Under severe selective pressure to induce only the correct host cell responses to accomplish this complex set of
tasks, pathogens have evolved mechanisms that maximally exploit the biology of their host organisms.

THE NORMAL FLORA

In a healthy animal, the internal tissues, e.g. blood, brain, muscle, etc., are normally free of microorganisms.
However, the surface tissues, i.e., skin and mucous membranes, are constantly in contact with environmental
organisms and become readily colonized by various microbial species. The mixture of organisms regularly
found at any anatomical site is referred to as the normal flora, except by researchers in the field who prefer the
term "indigenous microbiota". The normal flora of humans consists of a few eukaryotic fungi and protists, but
bacteria are the most numerous and obvious microbial components of the normal flora.

The predominant bacterial flora of humans are shown in Table 1. This table lists only a fraction of the total
bacterial species that occur as normal flora of humans. A recent experiment that used 16S RNA probes to
survey the diversity of bacteria in dental plaque revealed that only one percent of the total species found have
ever been cultivated. Similar observations have been made with the intestinal flora. Also, this table does not
indicate the relative number or concentration of bacteria at a particular site.

Table 1. Bacteria commonly found on the surfaces of the human body.

BACTERIUM Skin Con- Nose Pha Mouth Lower Ant. Vagina
junc- rynx GI Urethra
tiva
Staphylococcus epidermidis (1) ++ + ++ ++ ++ + ++ ++
Staphylococcus aureus* (2) + +/- + + + ++ +/- +
Streptococcus mitis + ++ +/- + +
Streptococcus salivarius ++ ++
Streptococcus mutans* (3) + ++
Enterococcus faecalis* (4) +/- + ++ + +
Streptococcus pneumoniae* (5) +/- +/- + + +/-
Streptococcus pyogenes* (6) +/- +/- + + +/- +/-
Neisseria sp. (7) + + ++ + + +
Neisseria meningitidis* (8) + ++ + +
Enterobacteriaceae*(Escherichi +/- +/- +/- + ++ + +
a coli) (9)
Proteus sp. +/- + + + + + +
Pseudomonas aeruginosa* (10) +/- +/- + +/-
 Haemophilus influenzae* (11) +/- + + +
Bacteroides sp.* ++ + +/-
Bifidobacterium bifidum (12) ++
Lactobacillus sp. (13) + ++ ++ ++
Clostridium sp.* (14) +/- ++
Clostridium tetani (15) +/-
Corynebacteria (16) ++ + ++ + + + + +
Mycobacteria + +/- +/- + +
Actinomycetes + +
Spirochetes + ++ ++
Mycoplasmas + + + +/- +

++ = nearly 100 percent + = common (about 25 percent) +/- = rare less than 5%) * = potential
pathogen
__________________________________________________________________________________________

Table 1 Notes

(1) The staphylococci and corynebacteria occur at every site listed. Staphylococcus epidermidis is highly
adapted to the diverse environments of its human host. S. aureus is a potential pathogen. It is a leading cause of
bacterial disease in humans. It can be transmitted from the nasal membranes of an asymptomatic carrier to a
susceptible host.

(2) Many of the normal flora are either pathogens or opportunistic pathogens. The asterisks indicate members
of the normal flora that may be considered major pathogens of humans.

(3) Streptococcus mutans is the primary bacterium involved in plaque formation and initiation of dental caries.
Viewed as an opportunistic infection, dental disease is one of the most prevalent and costly infectious diseases
in the United States.

(4) Enterococcus faecalis was formerly classified as Streptococcus faecalis. The bacterium is such a regular a
component of the intestinal flora, that many European countries use it as the standard indicator of fecal
pollution, in the same way we use E. coli in the U.S. In recent years, Enterococcus faecalis has emerged as a
significant, antibiotic-resistant, nosocomial pathogen.

(5) Streptococcus pneumoniae is present in the upper respiratory tract of about half the population. If it invades
the lower respiratory tract it can cause pneumonia. Streptococcus pneumoniae causes 95 percent of all bacterial
pneumonia.

(6) Streptococcus pyogenes refers to the Group A, Beta-hemolytic streptococci. Streptococci cause tonsillitis
(strep throat), pneumonia, endocarditis. Some streptococcal diseases can lead to rheumatic fever or nephritis
which can damage the heart and kidney.

(7) Neisseria and other Gram-negative cocci are frequent inhabitants of the upper respiratory tract, mainly the
pharynx. Neisseria meningitidis, an important cause of bacterial meningitis, can colonize as well, until the host
can develop active immunity against the pathogen.
(8) While E. coli is a consistent resident of the small intestine, many other enteric bacteria may reside here as
well, including Klebsiella, Enterobacter and Citrobacter. Some strains of E. coli are pathogens that cause
intestinal infections, urinary tract infections and neonatal meningitis.

(9) Pseudomonas aeruginosa is the quintessential opportunistic pathogen of humans that can invade virtually
any tissue. It is a leading cause of hospital-acquired (nosocomial) Gram-negative infections, but its source is
often exogenous (from outside the host). Colonies of Pseudomonas aeruginosa growing on an agar plate. The
most virulent Pseudomonas species produce mucoid colonies and green pigments such as this isolate.

(10) Haemophilus influenzae is a frequent secondary invader to viral influenza, and was named accordingly.
The bacterium was the leading cause of meningitis in infants and children until the recent development of the
Hflu type B vaccine..

(11) The greatest number of bacteria are found in the lower intestinal tract, specifically the colon and the most
prevalent bacteria are the Bacteroides, a group of Gram-negative, anaerobic, non-sporeforming bacteria. They
have been implicated in the initiation colitis and colon cancer.

(12) Bifidobacteria are Gram-positive, non-sporeforming, lactic acid bacteria. They have been described as
"friendly" bacteria in the intestine of humans. Bifidobacterium bifidum is the predominant bacterial species in
the intestine of breast-fed infants, where it presumably prevents colonization by potential pathogens. These
bacteria are sometimes used in the manufacture of yogurts and are frequently incorporated into probiotics.
(13) Lactobacilli in the oral cavity probably contribute to acid formation that leads to dental
caries. Lactobacillus acidophilus colonizes the vaginal epithelium during child-bearing years and establishes
the low pH that inhibits the growth of pathogens.

(14) There are numerous species of Clostridium that colonize the bowel. Clostridium perfringens is commonly
isolated from feces. Clostridium difficile may colonize the bowel and cause "antibiotic-induced diarrhea" or
pseudomembranous colitis.

(15) Clostridium tetani is included in the table as an example of a bacterium that is "transiently associated" with
humans as a component of the normal flora. The bacterium can be isolated from feces in 0 - 25 percent of the
population. The endospores are probably ingested with food and water, and the bacterium does not colonize the
intestine.

(16) The corynebacteria, and certain related propionic acid bacteria, are consistent skin flora. Some have been
implicated as a cause of acne. Corynebacterium diphtheriae, the agent of diphtheria, was considered a member
of the normal flora before the widespread use of the diphtheria toxoid, which is used to immunize against the
disease. Corynebacterium diphtheria is no longer a part of the normal flora.

ASSOCIATIONS BETWEEN HUMANS AND THE NORMAL FLORA

E. coli is the best-known bacterium that regularly associates itself with humans, being an invariable component
of the human intestinal tract. Even though E. coli is the most studied of all bacteria, and we know the exact
location and sequence of 4,288 genes on its chromosome, we do not fully understand its ecological relationship
with humans.

In fact, not much is known about the nature of the associations between humans and their normal flora, but they
are thought to be dynamic interactions rather than associations of mutual indifference. Both host and bacteria
are thought to derive benefit from each other, and the associations are, for the most part, mutualistic. The
normal flora derive from their host a steady supply of nutrients, a stable environment, and protection and
transport. The host obtains from the normal flora certain nutritional and digestive benefits, stimulation of the
development and activity of immune system, and protection against colonization and infection by pathogenic
microbes.

While most of the activities of the normal flora benefit their host, some of the normal flora are parasitic (live at
the expense of their host), and some are pathogenic (capable of producing disease). Diseases that are produced
by the normal flora in their host may be called endogenous diseases. Most endogenous bacterial diseases
are opportunistic infections, meaning that the the organism must be given a special opportunity of weakness or
let-down in the host defenses in order to infect. An example of an opportunistic infection is chronic bronchitis
in smokers wherein normal flora bacteria are able to invade the weakened lung.

Sometimes the relationship between a member of the normal flora and its host cannot be deciphered. Such a
relationship where there is no apparent benefit or harm to either organism during their association is referred to
as a commensal relationship. Many of the normal flora that are not predominant in their habitat, even though
always present in low numbers, are thought of as commensal bacteria. However, if a presumed commensal
relationship is studied in detail, parasitic or mutualistic characteristics often emerge.

Tissue specificity
Most members of the normal bacterial flora prefer to colonize certain tissues and not others. This "tissue
specificity" is usually due to properties of both the host and the bacterium. Usually, specific bacteria colonize
specific tissues by one or another of these mechanisms.

1. Tissue tropism is the bacterial preference or predilection for certain tissues for growth. One explanation for
tissue tropism is that the host provides essential nutrients and growth factors for the bacterium, in addition to
suitable oxygen, pH, and temperature for growth.
Lactobacillus acidophilus, informally known as "Doderlein's bacillus" colonizes the vagina because glycogen is
produced which provides the bacteria with a source of sugar that they ferment to lactic acid.

2. Specific adherence
Most bacteria can colonize a specific tissue or site because they can adhere to that tissue or site in a specific
manner that involves complementary chemical interactions between
the two surfaces. Specific adherence involves biochemical
interactions between bacterial surface components (ligands or
adhesins) and host cell molecular receptors. The bacterial
components that provide adhesins are molecular parts of their
capsules, fimbriae, or cell walls. The receptors on human cells or
tissues are usually glycoprotein molecules located on the host cell or
tissue surface

3. Biofilm formation
Some of the indigenous bacteria are able to construct biofilms on a
tissue surface, or they are able to colonize a biofilm built by another
bacterial species. Many biofilms are a mixture of microbes, although
one member is responsible for maintaining the biofilm and may
predominate.
The classic biofilm that involves components of the normal flora of the oral cavity is the formation of dental
plaque on the teeth. Plaque is a naturally-constructed biofilm, in which the groups of bacteria may reach a
thickness of 300-500 cells on the surfaces of the teeth. These accumulations subject the teeth and gingival
tissues to high concentrations of bacterial metabolites, which result in dental disease.

MICROBES AND YOU: NORMAL FLORA

Microbes are everywhere. They populate the air, the water, the soil, and have even evolved intimate
relationships with plants and animals. Without microbes, life on earth would cease. This is due mainly to the
essential roles microbes play in the systems that support life on earth, such as nutrient cycling and
photosynthesis. Further, the physiology, nutrition and protection of plants and animals (including humans) is
dependent on various relationships with microbes.
You are covered in microorganisms! In fact, there are approximately 10 times as many prokaryotic cells
(mainly bacteria) associated with your body than there are eukaryotic cells, but this is a good thing.
Microbes that colonize the human body during birth or shortly thereafter, remaining throughout life, are referred
to as normal flora. Normal flora can be found in many sites of the human body including the skin (especially the
moist areas, such as the groin and between the toes), respiratory tract (particularly the nose), urinary tract, and
the digestive tract (primarily the mouth and the colon). On the other hand, areas of the body such as the brain,
the circulatory system and the lungs are intended to remain sterile (microbe free).
THE COMPOSITION OF THE NORMAL FLORA

The normal flora of humans are exceedingly complex and consist Figure 1. Location of normal microbial flora.
of more than 200 species of bacteria. The makeup of the normal flora may be influenced by various factors,
including genetics, age, sex, stress, nutrition and diet of the individual.

Three developmental changes in humans, weaning, the eruption of the teeth, and the onset and cessation of
ovarian functions, invariably affect the composition of the normal flora in the intestinal tract, the oral cavity,
and the vagina, respectively. However, within the limits of these fluctuations, the bacterial flora of humans is
sufficiently constant to a give general description of the situation.
A human first becomes colonized by a normal flora at the moment of birth and passage through the birth canal.
In utero, the fetus is sterile, but when the mother's water breaks and the birth process begins, so does
colonization of the body surfaces. Handling and feeding of the infant after birth leads to establishment of a
stable normal flora on the skin, oral cavity and intestinal tract in about 48 hours.
It has been calculated that a human adult houses about 1012 bacteria on the skin, 1010 in the mouth, and 1014 in
the gastrointestinal tract. The latter number is far in excess of the number of eucaryotic cells in all the tissues
and organs which comprise a human. The predominant bacteria on the surfaces of the human body are listed in
Table 2. Informal names identify the bacteria in this table. Formal taxonomic names of organisms are given in
Table 1.

Table 2. Predominant bacteria at various anatomical locations in adults.

Anatomical Location Predominant bacteria

Skin staphylococci and corynebacteria
 Conjunctiva sparse, Gram-positive cocci and Gram-
negative rods
Oral cavity
teeth streptococci, lactobacilli
mucous membranes streptococci and lactic acid bacteria
Upper respiratory tract
nares (nasal membranes) staphylococci and corynebacteria
pharynx (throat) streptococci, neisseria, Gram-negative rods
and cocci
Lower respiratory tract None
Gastrointestinal tract
stomach Helicobacter pylori (up to 50%)
small intestine lactics, enterics, enterococci, bifidobacteria
colon bacteroides, lactics, enterics, enterococci,
clostridia, methanogens
Urogenital tract
anterior urethra sparse, staphylococci, corynebacteria,
enterics
vagina lactic acid bacteria during child-bearing
years; otherwise mixed

Normal Flora of the Skin

The adult human is covered with approximately 2 square meters of skin. The density and composition of the
normal flora of the skin varies with anatomical locale. The high moisture content of the axilla, groin, and areas
between the toes supports the activity and growth of relatively high densities of bacterial cells, but the density
of bacterial populations at most other sites is fairly low, generally in 100s or 1000s per square cm. Most bacteria
on the skin are sequestered in sweat glands.
The skin microbes found in the most superficial layers of the epidermis and the upper parts of the hair follicles
are Gram-positive cocci (Staphylococcus epidermidis and Micrococcus sp.) and corynebacteria such
as Propionibacterium sp. These are generally nonpathogenic and considered to be commensal, although
mutualistic and parasitic roles have been assigned to them. For example, staphylococci and propionibacteria
produce fatty acids that inhibit the growth of fungi and yeast on the skin. But, if Propionibacterium acnes, a
normal inhabitant of the skin, becomes trapped in hair follicle, it may grow rapidly and cause inflammation and
acne.

Sometimes potentially pathogenic Staphylococcus aureus is found on the face and hands in individuals who are
nasal carriers. This is because the face and hands are likely to become inoculated with the bacteria on the nasal
membranes. Such individuals may autoinoculate themselves with the pathogen or spread it to other individuals
or foods.

Normal Flora of the Conjunctiva

A variety of bacteria may be cultivated from the normal conjunctiva, but the number of organisms is usually
small. Staphylococcus epidermidis and certain coryneforms (Propionibacterium acnes) are dominant.
Staphylococcus aureus, some streptococci, Haemophilus sp. and Neisseria sp. are occasionally found.

The conjunctiva is kept moist and healthy by the continuous secretions from the lachrymal glands. Blinking
wipes the conjunctiva every few seconds mechanically washing away foreign objects including bacteria.
Lachrymal secretions (tears) also contain bactericidal substances including lysozyme. There is little or no
opportunity for microorganisms to colonize the conjunctiva without special mechanisms to attach to the
epithelial surfaces and some ability to withstand attack by lysozyme.

Pathogens which do infect the conjunctiva (e.g. Neisseria gonorrhoeae and Chlamydia trachomatis) are thought
to be able to specifically attach to the conjunctival epithelium. Newborn infants may be especially prone to
bacterial attachment. Since Chlamydia and Neisseria might be present on the cervical and vaginal epithelium of
an infected mother, silver nitrate or an antibiotic may be put into the newborn's eyes to avoid infection after
passage through the birth canal.

Normal Flora of the Respiratory Tract

A large number of bacterial species colonize the upper respiratory tract (nasopharynx). The nares (nostrils) are
always heavily colonized, predominantly with Staphylococcus epidermidis and corynebacteria, and often (in
about 20% of the general population) with Staphylococcus aureus, this being the main carrier site of this
important pathogen. The healthy sinuses, in contrast are sterile. The pharynx (throat) is normally colonized by
streptococci and various Gram-negative cocci. Sometimes pathogens such as Streptococcus pneumoniae,
Streptococcus pyogenes, Haemophilus influenzae and Neisseria meningitidis colonize the pharynx.
The lower respiratory tract (trachea, bronchi, and pulmonary tissues) is virtually free of microorganisms, mainly
because of the efficient cleansing action of the ciliated epithelium which lines the tract. Any bacteria reaching
the lower respiratory tract are swept upward by the action of the mucociliary blanket that lines the bronchi, to be
removed subsequently by coughing, sneezing, swallowing, etc. If the respiratory tract epithelium becomes
damaged, as in bronchitis or viral pneumonia, the individual may become susceptible to infection by pathogens
such as H. influenzae or S. pneumoniae descending from the nasopharynx.
Normal Flora of the Urogenital Tract
Urine is normally sterile, and since the urinary tract is flushed with urine every few hours, microorganisms have
problems gaining access and becoming established. The flora of the anterior urethra, as indicated principally by
urine cultures, suggests that the area my be inhabited by a relatively consistent normal flora consisting of
Staphylococcus epidermidis, Enterococcus faecalis and some alpha-hemolytic streptococci. Their numbers are
not plentiful, however. In addition, some enteric bacteria (e.g. E. coli, Proteus) and corynebacteria, which are
probably contaminants from the skin, vulva or rectum, may occasionally be found at the anterior urethra.
The vagina becomes colonized soon after birth with corynebacteria, staphylococci, streptococci, E. coli, and a
lactic acid bacterium historically named "Doderlein's bacillus" (Lactobacillus acidophilus). During reproductive
life, from puberty to menopause, the vaginal epithelium contains glycogen due to the actions of circulating
estrogens. Doderlein's bacillus predominates, being able to metabolize the glycogen to lactic acid. The lactic
acid and other products of metabolism inhibit colonization by all except this lactobacillus and a select number
of lactic acid bacteria. The resulting low pH of the vaginal epithelium prevents establishment by most other
bacteria as well as the potentially-pathogenic yeast, Candida albicans. This is a striking example of the
protective effect of the normal bacterial flora for their human host.
Normal Flora of the Oral Cavity
The presence of nutrients, epithelial debris, and secretions makes the mouth a favorable habitat for a great
variety of bacteria. Oral bacteria include streptococci, lactobacilli, staphylococci and corynebacteria, with a
great number of anaerobes, especially bacteroides.
The mouth presents a succession of different ecological situations with age, and this corresponds with changes
in the composition of the normal flora. At birth, the oral cavity is composed solely of the soft tissues of the lips,
cheeks, tongue and palate, which are kept moist by the secretions of the salivary glands. At birth the oral cavity
is sterile but rapidly becomes colonized from the environment, particularly from the mother in the first feeding.
Streptococcus salivarius is dominant and may make up 98% of the total oral flora until the appearance of the
teeth (6 - 9 months in humans). The eruption of the teeth during the first year leads to colonization by S.
mutans and S. sanguis. These bacteria require a nondesquamating (nonepithelial) surface in order to colonize.
They will persist as long as teeth remain. Other strains of streptococci adhere strongly to the gums and cheeks
but not to the teeth. The creation of the gingival crevice area (supporting structures of the teeth) increases the
habitat for the variety of anaerobic species found. The complexity of the oral flora continues to increase with
time, and bacteroides and spirochetes colonize around puberty.
The normal bacterial flora of the oral cavity clearly benefit from their host who provides nutrients and habitat.
There may be benefits, as well, to the host. The normal flora occupy available colonization sites which makes it
more difficult for other microorganisms (nonindigenous species) to become established. Also, the oral flora
contribute to host nutrition through the synthesis of vitamins, and they contribute to immunity by inducing low
levels of circulating and secretory antibodies that may cross react with pathogens. Finally, the oral bacteria exert
microbial antagonism against nonindigenous species by production of inhibitory substances such as fatty acids,
peroxides and bacteriocins.
On the other hand, the oral flora are the usual cause of various oral diseases in humans, including abscesses,
dental caries, gingivitis, and periodontal disease. If oral bacteria can gain entrance into deeper tissues, they may
cause abscesses of alveolar bone, lung, brain, or the extremities. Such infections usually contain mixtures of
bacteria with Bacteroides melaninogenicus often playing a dominant role. If oral streptococci are introduced
into wounds created by dental manipulation or treatment, they may adhere to heart valves and initiate subacute
bacterial endocarditis.
Normal Flora of the Gastrointestinal Tract
The bacterial flora of the gastrointestinal (GI) tract of animals has been studied more extensively than that of
any other site. The composition differs between various animal species, and within an animal species. In
humans, there are differences in the composition of the flora which are influenced by age, diet, cultural
conditions, and the use of antibiotics. The latter greatly perturbs the composition of the intestinal flora.
In the upper GI tract of adult humans, the esophagus contains only the bacteria swallowed with saliva and food.
Because of the high acidity of the gastric juice, very few bacteria (mainly acid-tolerant lactobacilli) can be
cultured from the normal stomach. However, at least half the population in the United States is colonized by a
pathogenic bacterium, Helicobacter pylori. Since the 1980s, this bacterium has been known to be the cause of
gastric ulcers, and it is probably a cause of gastric and duodenal cancer as well. The Australian microbiologist,
Barry Marshall, received the Nobel Prize in Physiology and Medicine in 2005, for demonstrating the
relationship between Helicobacter and gastric ulcers.
The proximal small intestine has a relatively sparse Gram-positive flora, consisting mainly of lactobacilli
and Enterococcus faecalis. This region has about 10 5 - 107 bacteria per ml of fluid. The distal part of the small
intestine contains greater numbers of bacteria (10 8/ml) and additional species, including coliforms (E. coli and
relatives) and Bacteroides, in addition to lactobacilli and enterococci.
The flora of the large intestine (colon) is qualitatively similar to that found in feces. Populations of bacteria in
the colon reach levels of 1011/ml feces. Coliforms become more prominent, and enterococci, clostridia and
lactobacilli can be regularly found, but the predominant species are anaerobic Bacteroides and anaerobic lactic
acid bacteria in the genus Bifidobacterium (Bifidobacterium bifidum). These organisms may outnumber E.
coli by 1,000:1 to 10,000:1. Sometimes, significant numbers of anaerobic methanogens (up to 10 10/gm) may
reside in the colon of humans. This is our only direct association with archaea as normal flora.

At birth the entire intestinal tract is sterile, but bacteria enter with the first feed. The initial colonizing bacteria
vary with the food source of the infant. In breast-fed infants, bifidobacteria account for more than 90% of the
total intestinal bacteria. Enterobacteriaceae and enterococci are regularly present, but in low proportions, while
bacteroides, staphylococci, lactobacilli and clostridia are practically absent. In bottle-fed infants, bifidobacteria
are not predominant. When breast-fed infants are switched to a diet of cow's milk or solid food, bifidobacteria
are progressively joined by enterics, bacteroides, enterococci lactobacilli and clostridia. Apparently, human
milk contains a growth factor that enriches for growth of bifidobacteria, and these bacteria play an important
role in preventing colonization of the infant intestinal tract by non-indigenous or pathogenic species.

The composition of the flora of the gastrointestinal tract varies along the tract (at longitudinal levels) and across
the tract (at horizontal levels) where certain bacteria attach to the gastrointestinal epithelium and others occur in
the lumen. There is frequently a very close association between specific bacteria in the intestinal ecosystem and
specific gut tissues or cells (evidence of tissue tropism and specific adherence). Gram-positive bacteria, such as
the streptococci and lactobacilli, are thought to adhere to the gastrointestinal epithelium using polysaccharide
capsules or cell wall teichoic acids to attach to specific receptors on the epithelial cells. Gram-negative bacteria
such as the enterics may attach by means of specific fimbriae which bind to glycoproteins on the epithelial cell
surface.

It is in the intestinal tract that we see the greatest effect of the bacterial flora on their host. This is due to their
large mass and numbers. Bacteria in the human GI tract have been shown to produce vitamins and may
otherwise contribute to nutrition and digestion. But their most important effects are in their ability to protect
their host from establishment and infection by alien microbes and their ability to stimulate the development and
the activity of the immunological tissues.
On the other hand, some of the bacteria in the colon (e.g. Bacteroides) have been shown to produce metabolites
that are carcinogenic, and there may be an increased incidence of colon cancer associated with these bacteria.
Alterations in the GI flora brought on by poor nutrition or perturbance with antibiotics can cause shifts in
populations and colonization by nonresidents that leads to gastrointestinal disease.
Beneficial Effects of the Normal Flora

The effects of the normal flora are inferred by microbiologists from experimental comparisons between "germ-
free" animals (which are not colonized by any microbes) and conventional animals (which are colonized with a
typical normal flora). Briefly, some of the characteristics of a germ-free animals that are thought to be due to
lack of exposure to a normal flora are:

1. vitamin deficiencies, especially vitamin K and vitamin B12

2. increased susceptibility to infectious disease
3. poorly developed immune system, especially in the gastrointestinal tract
4. lack of "natural antibody" or natural immunity to bacterial infection

Because these conditions in germ-free mice and hamsters do not occur in conventional animals, or are alleviated
by introduction of a bacterial flora (at the appropriate time of development), it is tempting to conclude that the
human normal flora make similar contributions to human nutrition, health and development. The overall
beneficial effects of microbes are summarized below.

1. The normal flora synthesize and excrete vitamins in excess of their own needs, which can be absorbed as
nutrients by their host. For example, in humans, enteric bacteria secrete Vitamin K and Vitamin B12, and lactic
acid bacteria produce certain B-vitamins. Germ-free animals may be deficient in Vitamin K to the extent that it
is necessary to supplement their diets.

2. The normal flora prevent colonization by pathogens by competing for attachment sites or for essential
nutrients. This is thought to be their most important beneficial effect, which has been demonstrated in the oral
cavity, the intestine, the skin, and the vaginal epithelium. In some experiments, germ-free animals can be
infected by 10 Salmonella bacteria, while the infectious dose for conventional animals is near 106 cells.
3. The normal flora may antagonize other bacteria through the production of substances which inhibit or kill
nonindigenous species. The intestinal bacteria produce a variety of substances ranging from relatively
nonspecific fatty acids and peroxides to highly specific bacteriocins, which inhibit or kill other bacteria.

4. The normal flora stimulate the development of certain tissues, i.e., the caecum and certain lymphatic
tissues (Peyer's patches) in the GI tract. The caecum of germ-free animals is enlarged, thin-walled, and fluid-
filled, compared to that organ in conventional animals. Also, based on the ability to undergo immunological
stimulation, the intestinal lymphatic tissues of germ-free animals are poorly-developed compared to
conventional animals.

5. The normal flora stimulate the production of natural antibodies. Since the normal flora behave as
antigens in an animal, they induce an immunological response, in particular, an antibody-mediated immune
(AMI) response. Low levels of antibodies produced against components of the normal flora are known to cross
react with certain related pathogens, and thereby prevent infection or invasion. Antibodies produced against
antigenic components of the normal flora are sometimes referred to as "natural" antibodies, and such antibodies
are lacking in germ-free animals.
Harmful Effects of the Normal Flora
Harmful effects of the normal flora, some of which are observed in studies with germ-free animals, can be put
in the following categories. All but the last two are fairly insignificant.

1. Bacterial synergism between a member of the normal flora and a potential pathogen. This means that one
organism is helping another to grow or survive. There are examples of a member of the normal flora supplying
a vitamin or some other growth factor that a pathogen needs in order to grow. This is called cross
feeding between microbes. Another example of synergism occurs during treatment of "staph-protected
infections" when a penicillin-resistant staphylococcus that is a component of the normal flora shares its drug
resistance with pathogens that are otherwise susceptible to the drug.

2. Competition for nutrients Bacteria in the gastrointestinal tract must absorb some of the host's nutrients for
their own needs. However, in general, they transform them into other metabolisable compounds, but some
nutrient(s) may be lost to the host. Germ-free animals are known to grow more rapidly and efficiently than
conventional animals. One explanation for incorporating antibiotics into the food of swine, cows and poultry is
that the animal grows faster and can therefore be marketed earlier. Unfortunately, this practice contributes to the
development and spread of bacterial antibiotic resistance within the farm animals, as well as humans.

3. Induction of a low grade toxemia Minute amounts of bacterial toxins (e.g. endotoxin) may be found in the
circulation. Of course, it is these small amounts of bacterial antigen that stimulate the formation of natural
antibodies.

4. The normal flora may be agents of disease. Members of the normal flora may cause endogenous disease if
they reach a site or tissue where they cannot be restricted or tolerated by the host defenses. Many of the normal
flora are potential pathogens, and if they gain access to a compromised tissue from which they can invade,
disease may result.

5. Transfer to susceptible hosts Some pathogens of humans that are members of the normal flora may also
rely on their host for transfer to other individuals where they can produce disease. This includes the pathogens
that colonize the upper respiratory tract such as Neisseria meningitidis, Streptococcus pneumoniae,
Dental Caries, Gingivitis and Periodontal Disease

The most frequent and economically-important condition in humans resulting from interactions with our normal
flora is probably dental caries. Dental plaque, dental caries, gingivitis and periodontal disease result from
actions initiated and carried out by the normal bacterial flora.

Dental plaque, which is material adhering to the teeth, consists of bacterial cells (60-70% the volume of the
plaque), salivary polymers, and bacterial extracellular products. Plaque is a naturally-constructed biofilm, in
which the consortia of bacteria may reach a thickness of 300-500 cells on the surfaces of the teeth. These
accumulations subject the teeth and gingival tissues to high concentrations of bacterial metabolites, which result
in dental disease.
The dominant bacterial species in dental plaque are Streptococcus sanguis and Streptococcus mutans, both of
which are considered responsible for plaque.
Plaque formation is initiated by a weak attachment of the streptococcal cells to salivary glycoproteins forming a
pellicle on the surface of the teeth. This is followed by a stronger attachment by means of extracellular sticky
polymers of glucose (glucans) which are synthesized by the bacteria from dietary sugars (principally sucrose).
An enzyme on the cell surface of Streptococcus mutans, glycosyl transferase, is involved in initial attachment of
the bacterial cells to the tooth surface and in the conversion of sucrose to dextran polymers (glucans) which
form plaque.
Dental Caries is the destruction of the enamel, dentin or cementum of teeth due to bacterial activities. Caries
are initiated by direct demineralization of the enamel of teeth due to lactic acid and other organic acids which
accumulate in dental plaque. Lactic acid bacteria in the plaque produce lactic acid from the fermentation of
sugars and other carbohydrates in the diet of the host. Streptococcus mutans and Streptococcus sanguis are most
consistently been associated with the initiation of dental caries, but other lactic acid bacteria are probably
involved as well. These organisms normally colonize the occlusal fissures and contact points between the teeth,
and this correlates with the incidence of decay on these surfaces.
Streptococcus mutans in particular has a number of physiological and biochemical properties which involve it
in the initiation of dental caries.
1. It is a regular component of the normal oral flora of humans which occurs in relatively large numbers.
It readily colonizes tooth surfaces: salivary components (mucins, which are glycoproteins) form a thin
film on the tooth called the enamel pellicle. The adsorbed mucins are thought to serve as molecular
receptors for ligands on the bacterial cell surface.
2. It contains a cell-bound protein, glycosyl transferase, that serves an adhesin for attachment to the
tooth, and as an enzyme that polymerizes dietary sugars into glucans that leads to the formation of
plaque.
3. It produces lactic acid from the utilization of dietary carbohydrate which demineralizes tooth
enamel. S. mutans produces more lactic acid and is more acid-tolerant than most other streptococci.
4. It stores polysaccharides made from dietary sugars which can be utilized as reserve carbon and energy
sources for production of lactic acid. The extracellular glucans formed by S. mutans are, in fact, bacterial
capsular polysaccharides that function as carbohydrate reserves. The organisms can also form
intracellular polysaccharides from sugars which are stored in cells and then metabolized to lactic acid.
Streptococcus mutans appears to be important in the initiation of dental caries because its activities lead to
colonization of the tooth surfaces, plaque formation, and localized demineralization of tooth enamel. It is not
however, the only cause of dental decay. After initial weakening of the enamel, various oral bacteria gain access
to interior regions of the tooth. Lactobacilli, Actinomyces, and various proteolytic bacteria are commonly found
in human carious dentin and cementum, which suggests that they are secondary invaders that contribute to the
progression of the lesions.
Periodontal Diseases are bacterial infections that affect the supporting structures of the teeth (gingiva,
cementum, periodontal membrane and alveolar bone). The most common form, gingivitis, is an inflammatory
condition of the gums. It is associated with accumulations of bacterial plaque in the area. Increased populations
of Actinomyces have been found, and they have been suggested as the cause.
Diseases that are confined to the gum usually do not lead to loss of teeth, but there are other more serious forms
of periodontal disease that affect periodontal membrane and alveolar bone resulting in tooth loss. Bacteria in
these lesions are very complex populations consisting of Gram-positive organisms (including Actinomyces and
streptococci) and Gram-negative organisms (including spirochetes and Bacteroides). The mechanisms of tissue
destruction in periodontal disease are not clearly defined but hydrolytic enzymes, endotoxins, and other toxic
bacterial metabolites seem to be involved.
THE NATURE OF BACTERIAL HOST-PARASITE RELATIONSHIPS IN HUMANS
Bacteria are consistently associated with the body surfaces of animals. There are many more bacterial cells on
the surface of a human (including the gastrointestinal tract) than there are human cells that make up the animal.
The bacteria and other microbes that are consistently associated with an animal are called the normal flora, or
more properly the "indigenous microbiota", of the animal. These bacteria have a full range of symbiotic
interactions with their animal hosts.
In biology, symbiosis is defined as "life together", i.e., that two organisms live in an association with one
another. Thus, there are at least three types of relationships based on the quality of the relationship for each
member of the symbiotic association.
Types of Symbiotic Associations
1. Mutualism. Both members of the association benefit. For humans, one classic mutualistic association is that
of the the lactic acid bacteria that live on the vaginal epithelium of a woman. The bacteria are provided habitat
with a constant temperature and supply of nutrients (glycogen) in exchange for the production of lactic acid,
which protects the vagina from colonization and disease caused by yeast and other potentially harmful
microbes.
2. Commensalism. There is no apparent benefit or harm to either member of the association. A problem with
commensal relationships is that if you look at one long enough and hard enough, you often discover that at least
one member is being helped or harmed during the association. Consider our relationship with Staphylococcus
epidermidis, a consistent inhabitant of the skin of humans. Probably, the bacterium produces lactic acid that
protects the skin from colonization by harmful microbes that are less acid tolerant. But it has been suggested
that other metabolites that are produced by the bacteria are an important cause of body odors (good or bad,
depending on your personal point of view) and possibly associated with certain skin cancers. "Commensalism"
best works when the relationship between two organisms is unknown and not obvious.
3. Parasitism. In biology, the term parasite refers to an organism that grows, feeds and is sheltered on or in a
different organism while contributing nothing to the survival of its host. In microbiology, the mode of existence
of a parasite implies that the parasite is capable of causing damage to the host. This type of a symbiotic
association draws our attention because a parasite may become pathogenic if the damage to the host results in
disease. Some parasitic bacteria live as normal flora of humans while waiting for an opportunity to cause
disease. Other nonindigenous parasites generally always cause disease if they associate with a nonimmune host.
Parasitology, actually a branch of microbiology, refers to the scientific study of parasitism but somehow it
developed into a discipline that deals with eucaryotic parasites exclusively.
 Key Points
Mutualism, a relationship in which both species benefit, is common in nature. In microbiology, there are
many examples of mutualistic bacteria in the gut that aid digestion in both humans and animals.
Commensalism is a relationship between species in which one benefits and the other is unaffected. Humans
are host to a variety of commensal bacteria in their bodies that do not harm them but rely on them for
survival (e.g. bacteria that consume dead skin).
Parasitic relationships, in which one species benefits and the other suffers, are very common in nature.
Most of the microorganisms studied in medical microbiology are parasitic and feed on human tissue. For
example, cholera, leishmaniasis, and Giardia are all parasitic microbes.

Bacterial Pathogenesis
A pathogen is a microorganism (or virus) that is able to produce disease. Pathogenicity is the ability of a
microorganism to cause disease in another organism, namely the host for the pathogen. As implied above,
pathogenicity may be a manifestation of a host-parasite interaction.
In humans, some of the normal bacterial flora (e.g. Staphylococcus aureus, Streptococcus pneumoniae,
Haemophilus influenzae) are potential pathogens that live in a commensal or parasitic relationship without
producing disease. They do not cause disease in their host unless they have an opportunity brought on by some
compromise or weakness in the host's anatomical barriers, tissue resistance or immunity. Furthermore, the
bacteria are in a position to be transmitted from one host to another, giving them additional opportunities to
colonize or infect.
There are some pathogens that do not associate with their host except in the case of disease. These bacteria may
be thought of as obligate pathogens, even though some may rarely occur as normal flora, in asymptomatic or
recovered carriers, or in some form where they cannot be eliminated by the host.
Opportunistic Pathogens
Bacteria which cause a disease in a compromised host which typically would not occur in a healthy
(noncompromised) host are acting as opportunistic pathogens. A member of the normal flora can such as
Staphylococcus aureus or E. coli can cause an opportunistic infection, but so can an environmental organism
such as Pseudomonas aeruginosa. When a member of the normal flora causes an infectious disease, it
sometimes referred to as an endogenous bacterial disease, referring to a disease brought on by bacteria 'from
within'. Classic opportunistic infections in humans are dental caries and periodontal disease caused by normal
flora of the oral cavity.
Pseudomonas aeruginosa, one of the most common opportunistic pathogens of humans. The bacterium causes
urinary tract infections, respiratory system infections, dermatitis, soft tissue infections, bacteremia and a variety
of systemic infections, particularly in cancer and AIDS patients who are immunosuppressed.
The normal flora, as well as any "contaminating" bacteria from the environment, are all found on the body
surfaces of the animal; the blood and internal tissues are sterile. If a bacterium, whether or not a component of
the normal flora, breaches one of these surfaces, an infection is said to have occurred. Infection does not
necessarily lead to infectious disease. In fact, infection probably rarely leads to infectious disease. Some
bacteria rarely cause disease if they do infect; some bacteria will usually cause disease if they infect. But other
factors, such as the route of entry, the number of infectious bacteria, and (most importantly) the status of the
host defenses, play a role in determining the outcome of infection.
Determinants of Virulence
Pathogenic bacteria are able to produce disease because they possess certain structural or biochemical or genetic
traits that render them pathogenic or virulent. The term virulence is best interpreted as referring to the degree of
pathogenicity. The sum of the characteristics that allow a given bacterium to produce disease are the pathogen's
determinants of virulence.
Some pathogens may rely on a single determinant of virulence, such as toxin production, to cause damage to
their host. Thus, bacteria such as Clostridium tetani and Corynebacterium diphtheriae, which have hardly any
invasive characteristics, are able to produce disease, the symptoms of which depend on a single genetic trait in
the bacteria: the ability to produce a toxin. Other pathogens, such as Staphylococcus aureus, Streptococcus
pyogenes and Pseudomonas aeruginosa, maintain a large range of virulence determinants and consequently are
able to produce a more complete range of diseases that affect different tissues in their host.
Properties of the Host
The host in a host-parasite interaction is the animal that maintains the parasite. The host and parasite are in a
dynamic interaction, the outcome of which depends upon the properties of the parasite and of the host. The
bacterial parasite has its determinants of virulence that allow it to invade and damage the host and to resist the
defenses of the host. The host has various degrees of resistance to the parasite in the form of the host defenses.
Host Defenses
A healthy animal can defend itself against pathogens at different stages in the infectious disease process. The
host defenses may be of such a degree that infection can be prevented entirely. Or, if infection does occur, the
defenses may stop the process before disease is apparent. At other times, the defenses that are necessary to
defeat a pathogen may not be effective until infectious disease is well into progress.
Typically the host defense mechanisms are divided into two groups:
1. Innate Defenses. Defenses common to all healthy animals. These defenses provide general protection against
invasion by normal flora, or colonization, infection, and infectious disease caused by pathogens. Innate defenses
include anatomical and structural barriers, inflammation, phagocytosis and the presence of a normal bacterial
flora. The innate defenses have also been referred to as "natural" or "consitutive" resistance, since they are
natural to the host.
2. Inducible Defenses. Defense mechanisms that must be induced or turned on by host exposure to a pathogen
(as during an infection). Unlike the innate defenses, they are not immediately ready to come into play until after
the host is appropriately exposed to the parasite. The inducible defenses are synonymous with acquired or
adaptive immunity and involve the immunological responses to a pathogen causing an infection.
Adaptive immunity is generally quite specifically directed against an invading pathogen. The innate defenses
are not so specific, and are directed toward general strategic defense. Innate defenses, by themselves, may not
be sufficient to protect a host against pathogens. Such pathogens that evade or overcome the relatively
nonspecific innate defenses are usually susceptible to the more specific inducible defenses, once they have
developed.
The Immune System
The inducible defenses are so-called because they are induced upon primary exposure to a pathogen or one of
its products. The inducible defenses are a function of the immunological system and the immune responses. The
innate defenses and immediately available for host defense. The inducible defenses must be triggered in a host
and initially take time to develop. The type of resistance thus developed in the host is called acquired immunity.
The term immune usually means the ability to resist infectious disease. Immunity refers to the relative state of
resistance of the host to a specific pathogen brought on by the activities of the immunological system.
Acquired or Adaptive Immunity, itself, is sometimes divided into two types, based on how it is acquired by the
host.
In active immunity, the host undergoes an immunological response and produces the cells and factors
responsible for the immunity, i.e., the host produces its own antibodies and/or immuno-reactive lymphocytes.
Active immunity can persist a long time in the host, up to many years in humans.

In passive immunity there is acquisition by a host of immune factors which were produced in another animal,
i.e., the host receives antibodies and/or immuno-reactive lymphocytes originally produced in another animal.
Passive immunity is typically short-lived and usually persists only a few weeks or months.
Antigens
Antigens are chemical substances of relatively high molecular weight that stimulate the immune response in
animals. Bacteria are composed of various macromolecular components that are antigens or " antigenic" in their
host and bacterial antigens interact with the host immunological system in a variety of ways.
Natural Antibodies
Studies on germ-free animals have confirmed that a normal bacterial flora in the gastrointestinal tract are
necessary for full development of immunological (lymphatic) tissues in the intestine. Furthermore, the
interaction between these immune tissues and intestinal bacteria results in the production of serum and secretory
antibodies that are directed against bacterial antigens. These antibodies probably help protect the host from
invasion by its own normal flora, and they can cross react with antgenically-related pathogens. For example,
antibodies against normal E. coli could react with closely-related pathogenic Shigella dysenteriae. These type of
antibodies are sometimes called natural or cross-reactive antibodies.
Bacterial Antigens made into Vaccines
In another way, bacterial antigens that are the components or products of pathogens are the substances that
induce the immune defenses of the host to defend against, and to eliminate, the pathogen or disease. In the
laboratory, these bacterial antigens can be manipulated or changed so that they will stimulate the immune
response in the absence of infection or pathology. These isolated or modified antigens are the basis for active
immunization (vaccination) against bacterial disease. Thus, a modified form of the tetanus toxin (tetanus
toxoid), which has lost its toxicity but retains its antigenicity, is used to immunize against tetanus. Or, antigenic
parts of the whooping cough bacterium, Bordetella pertussis, can be used to induce active formation of
antibodies that will react with the living organism and thereby prevent infection.
Antimicrobial Agents
One line of defense against bacterial infection is chemotherapy with antimicrobial agents such as antibiotics.
The ecological relationships between animals and bacteria in the modern world are mediated by the
omnipresence of antibiotics.
Antibiotics are defined as substances produced by a microorganism that kill or inhibit other microorganisms.
Originally, a group of soil bacteria, the Streptomyces, were the most innovative producers of antibiotics for
clinical usage. They were the source of streptomycin, tetracycline, erythromycin and chloramphenicol, to name
just a few antibiotics. Because bacteria evolve rapidly toward resistance, because bacteria can exchange genes
for antibiotic resistance, and because we have overused and misused antibiotics, many pathogens are emerging
as resistant to antibiotics. There have already been reported infections by Enterococcus, Staphylococcus aureus
and Pseudomonas aeruginosa that are persistent to all known antibiotics. Bacterial resistance to antimicrobial
agents has become part of a pathogen's determinants of virulence. These are examples of genetic means by
which bacteria exert their virulence.
The usage of antibiotics to control the growth of parasites is an artificial way to intervene in the natural process
of the host-parasite interaction. But, of course, it is done for the obvious purpose of curing the disease. The
body heals itself: most antibiotics just stop bacterial growth, and the host must rely entirely on its native
defenses to accomplish the neutralization of bacterial toxins or the elimination of bacterial cells. The judicious
use of antibiotics in the past five decades has saved millions of lives from infections caused by bacteria.
Primary Pathogens versus Opportunistic Pathogens
Pathogens can be classified as either primary pathogens or opportunistic pathogens. A primary pathogen can
cause disease in a host regardless of the host’s resident microbiota or immune system. An opportunistic
pathogen, by contrast, can only cause disease in situations that compromise the host’s defenses, such as the
body’s protective barriers, immune system, or normal microbiota. Individuals susceptible to opportunistic
infections include the very young, the elderly, women who are pregnant, patients undergoing chemotherapy,
people with immunodeficiencies (such as acquired immunodeficiency syndrome [AIDS]), patients who are
recovering from surgery, and those who have had a breach of protective barriers (such as a severe wound or
burn).
STAGES OF PATHOGENESIS (The development of a disease)
Pathogenesis refers to the development of a disease and the chain of events leading to that disease.
To cause disease, a pathogen must successfully achieve four steps or stages of pathogenesis: exposure (contact),
adhesion (colonization), invasion, and infection. The pathogen must be able to gain entry to the host, travel to
the location where it can establish an infection, evade or overcome the host’s immune response, and cause
damage (i.e., disease) to the host. In many cases, the cycle is completed when the pathogen exits the host and is
transmitted to a new host.
1. Exposure

An encounter with a potential pathogen is known as exposure or contact. The food we eat and the objects we
handle are all ways that we can come into contact with potential pathogens. Yet, not all contacts result in
infection and disease. For a pathogen to cause disease, it needs to be able to gain access into host tissue. An
anatomic site through which pathogens can pass into host tissue is called a portal of entry. These are locations
where the host cells are in direct contact with the external environment. Major portals of entry are identified in
Figure 2 and include the skin, mucous membranes, and parenteral routes. (Chain of Infection is presented in
Module 2)
 Fig.2. Shown are different portals of entry where pathogens can gain access into the body. With the exception of the
placenta, many of these locations are directly exposed to the external environment.

Mucosal surfaces are the most important portals of entry for microbes; these include the mucous membranes of
the respiratory tract, the gastrointestinal tract, and the genitourinary tract. Although most mucosal surfaces are
in the interior of the body, some are contiguous with the external skin at various body openings, including the
eyes, nose, mouth, urethra, and anus.
Most pathogens are suited to a particular portal of entry. A pathogen’s portal specificity is determined by the
organism’s environmental adaptions and by the enzymes and toxins they secrete. The respiratory and
gastrointestinal tracts are particularly vulnerable portals of entry because particles that include microorganisms
are constantly inhaled or ingested, respectively.
Pathogens can also enter through a breach in the protective barriers of the skin and mucous membranes.
Pathogens that enter the body in this way are said to enter by the parenteral route. For example, the skin is a
good natural barrier to pathogens, but breaks in the skin (e.g., wounds, insect bites, animal bites, needle pricks)
can provide a parenteral portal of entry for microorganisms.
In pregnant women, the placenta normally prevents microorganisms from passing from the mother to the fetus.
However, a few pathogens are capable of crossing the blood-placental barrier. The gram-positive bacterium
Listeria monocytogenes, which causes the foodborne disease listeriosis, is one example that poses a serious risk
to the fetus and can sometimes lead to spontaneous abortion. Other pathogens that can pass the placental barrier
to infect the fetus are known collectively by the acronym TORCH (Table 4).
Transmission of infectious diseases from mother to baby is also a concern at the time of birth when the baby
passes through the birth canal. Babies whose mothers have active chlamydia or gonorrhea infections may be
exposed to the causative pathogens in the vagina, which can result in eye infections that lead to blindness. To
prevent this, it is standard practice to administer antibiotic drops to infants’ eyes shortly after birth.
Table 4. Pathogens Capable of Crossing the Placental Barrier (TORCH Infections)
Disease Pathogen
T Toxoplasmosis Toxoplasma gondii (protozoan)
O Syphilis Treponema pallidum (bacterium)
Chickenpox Varicella-zoster virus (human herpesvirus 3)
Hepatitis B Hepatitis B virus (hepadnavirus)
HIV Retrovirus
Fifth disease (erythema Parvovirus B19
infectiosum)

R Rubella (German measles) Togavirus

C Cytomegalovirus Human herpesvirus 5
H Herpes Herpes simplex viruses (HSV) 1 and 2

2. Adhesion

Following the initial exposure, the pathogen adheres at the portal of entry. The term adhesion refers to the
capability of pathogenic microbes to attach to the cells of the body using adhesion factors, and different
pathogens use various mechanisms to adhere to the cells of host tissues.
Molecules (either proteins or carbohydrates) called adhesins are found on the surface of certain pathogens and
bind to specific receptors (glycoproteins) on host cells. Adhesins are present on the fimbriae and flagella of
bacteria, the cilia of protozoa, and the capsids or membranes of viruses. Protozoans can also use hooks and
barbs for adhesion; spike proteins on viruses also enhance viral adhesion. The production of glycocalyces (slime
layers and capsules) with their high sugar and protein content, can also allow certain bacterial pathogens to
attach to cells.
Biofilm growth can also act as an adhesion factor. A biofilm is a community of bacteria that produce a
glycocalyx, known as extrapolymeric substance (EPS), that allows the biofilm to attach to a surface. Persistent
Pseudomonas aeruginosa infections are common in patients suffering from cystic fibrosis, burn wounds, and
middle-ear infections (otitis media) because P. aeruginosa produces a biofilm. The EPS allows the bacteria to
adhere to the host cells and makes it harder for the host to physically remove the pathogen. The EPS not only
allows for attachment but provides protection against the immune system and antibiotic treatments, preventing
antibiotics from reaching the bacterial cells within the biofilm.
 3. Infection

Following invasion, successful multiplication of the pathogen leads to infection. Infections can be described as
local, focal, or systemic, depending on the extent of the infection. A local infection is confined to a small area
of the body, typically near the portal of entry. For example, a hair follicle infected by Staphylococcus aureus
infection may result in a boil around the site of infection, but the bacterium is largely contained to this small
location. Other examples of local infections that involve more extensive tissue involvement include urinary tract
infections confined to the bladder or pneumonia confined to the lungs.
In a focal infection, a localized pathogen, or the toxins it produces, can spread to a secondary location. For
example, a dental hygienist nicking the gum with a sharp tool can lead to a local infection in the gum by
Streptococcus bacteria of the normal oral microbiota. These Streptococcus spp. may then gain access to the
bloodstream and make their way to other locations in the body, resulting in a secondary infection.
When an infection becomes disseminated throughout the body, we call it a systemic infection. For example,
infection by the varicella-zoster virus typically gains entry through a mucous membrane of the upper respiratory
system. It then spreads throughout the body, resulting in the classic red skin lesions associated with chickenpox.
Since these lesions are not sites of initial infection, they are signs of a systemic infection.
Sometimes a primary infection, the initial infection caused by one pathogen, can lead to a secondary infection
by another pathogen. For example, the immune system of a patient with a primary infection by HIV becomes
compromised, making the patient more susceptible to secondary diseases like oral thrush and others caused by
opportunistic pathogens. Similarly, a primary infection by Influenzavirus damages and decreases the defense
mechanisms of the lungs, making patients more susceptible to a secondary pneumonia by a bacterial pathogen
like Haemophilus influenzae or Streptococcus pneumoniae. Some secondary infections can even develop as a
result of treatment for a primary infection. Antibiotic therapy targeting the primary pathogen can cause
collateral damage to the normal microbiota, creating an opening for opportunistic pathogens.

A SECONDARY YEAST INFECTION

Anita, a 36-year-old mother of three, goes to an urgent care center complaining of pelvic pressure, frequent
and painful urination, abdominal cramps, and occasional blood-tinged urine. Suspecting a urinary tract
infection (UTI), the physician requests a urine sample and sends it to the lab for a urinalysis. Since it will take
approximately 24 hours to get the results of the culturing, the physician immediately starts Anita on the
antibiotic ciprofloxacin. The next day, the microbiology lab confirms the presence of E. coli in Anita’s urine,
Transmission of Disease

For a pathogen to persist, it must put itself in a position to be transmitted to a new host, leaving the infected host
through a portal of exit . As with portals of entry, many pathogens are adapted to use a particular portal of exit.
Similar to portals of entry, the most common portals of exit include the skin and the respiratory, urogenital, and
gastrointestinal tracts. Coughing and sneezing can expel pathogens from the respiratory tract. A single sneeze
can send thousands of virus particles into the air. Secretions and excretions can transport pathogens out of other
portals of exit. Feces, urine, semen, vaginal secretions, tears, sweat, and shed skin cells can all serve as vehicles
for a pathogen to leave the body. Pathogens that rely on insect vectors for transmission exit the body in the
blood extracted by a biting insect. Similarly, some pathogens exit the body in blood extracted by needles.

Fig. 3. Pathogens leave the body of an infected host through various portals of exit to infect new hosts.

Keep in Mind
 The human body provides many unique environments for different bacterial communities to
live. In this context, scientists refer to the human body as the host.
 A positive host-microbe relationship is usually described as either mutualistic or
commensalistic.
 In mutualism both the host and the microbe benefit. Which is in contract to commensalisms,
where one partner of the relationship benefits (usually the microbe) and the other partner
 (usually the host) is neither benefited nor harmed.
 In a parasitic relationship the microbe benefits at the expense of the host and similarly in a
pathogenic relationship the microbe causes damage to the host. In both cases the cost to the
host can vary from slight to fatal.
 Whether a host-microbe relationship is “positive” or “negative” depends on many factors.
And in most cases the relationship will actually remain positive.
 The host provides a place and nutrition for the colonizing microbe and the microbe occupies a
space that a potential parasite or pathogen might otherwise colonize.
 Human skin is not a particularly rich place for microbes to live. The skin surface is relatively
dry, slightly acidic and the primary source of nutrition is dead cells. This is an environment
that prevents the growth of many microorganisms, but a few have adapted to life on our skin.
 Propionibacterium acnes is a Gram positive bacterium that inhabits the skin. P. acnes are
anaerobes, so they lives in pores and glands where oxygen levels are lower.
 Another prominent member of the skin flora is Staphylococcus epidermidis. This is a highly
adapted Gram positive bacterium that can survive at many sites throughout the body. S.
epidermidis can cause life threatening disease in hospital patients when invasive medical
devices such as catheters are used.
 The human nose is home to the infamous Gram positive bacterium Staphylococcus aureus,
best known for its role in hospitals where it is a major cause of surgical wound and systemic
infection.
 S. aureus is often referred to as MRSA, standing for Methicillin Resistant Staphylococcus
aureus. Infections of this bacterium are now a very serious threat to human health because it
has become resistant to all commercially available antibiotics. It is often carried in the noses
of health care workers and transmitted from patient to patient.
 It’s estimated that 500-600 different kinds of bacteria thrive on mucus and food remnants in
the mouth. A predominant member of this community is the Gram positive bacterium
Streptococcus mutans. It grows on biofilms on the surface of teeth (plaque) where it consumes
sugar and converts it to lactic acid. Lactic acid erodes the enamel on the surface of teeth,
which leads to the formation of cavities.
 Whether or not tooth decay is a disease serious enough to warrant the use of a new strain of
genetically modified bacteria is debatable.
 There aren’t many organisms that have adapted to the acidic environment of the stomach.
One organism that has been discovered living in the human stomach is the Gram negative
bacterium called Helicobacter pylori. This bacterium creates a less acidic microenvironment
by burrowing into the stomach’s mucosal lining to a depth where the pH is essentially neutral.
 H. pylori is the causative agent of gastric ulcers, something once thought to be caused by
stress, amongst other things, but which are now cured with antibiotics.
 Compared to the stomach, the small intestine is a relatively hospitable environment. However,
the small intestine presents microbes with a new challenge—high flow rates. This makes it
difficult for bacteria to colonize the small intestine because they get washed out very quickly.
As a result the concentration of bacteria in the small intestine remains relatively low (106
 bacteria per ml) and human enzymes carry out most of the digestion processes.
 The predominant bacterial species in the vaginal tract are Lactobacillus. As is the case in
other areas of the body, the presence of normal flora in the vaginal tract appears to have a
protective role since women taking antibiotics for acne or urinary tract infections who have
reduced levels of Lactobacillus often develop yeast infections. It is thought that Lactobacillus
may prevent the growth of yeast by producing hydrogen peroxide, a bi-product of bacterial
metabolism.
 The ability of a microbial agent to cause disease is called pathogenicity. The degree to which
an organism is pathogenic is called virulence.
 Bacteria perform physiological, nutritional and protective functions in the human body.
 Maintaining a balance is crucial. Normal flora consists of communities of bacteria that
function as microbial ecosystems. If these ecosystems are disrupted the consequences can be
unpredictable. Antibiotics, tissue damage, medical procedures, changes in diet, and the
introduction of new pathogens are examples of changes that can affect your normal flora.

Comprehension Check:
1. What are the stages of pathogenesis?
2. What is local infection? Focal infection? Systemic infection?
3. What is pathogenicity? How does it differ from virulence?
4. What is normal flora?
5. What are the benefits and harmful effects of normal flora?
To validate your answer, feel free to contact your course facilitator through any of the following:
 Facebook: Haridja Asid
 Contact No: 09260073732
 Email address: benhar02012018@gmail.com

SEVEN CAPABILITIES OF A PATHOGEN

A pathogen is defined as an organism causing disease to its host, with the severity of the disease symptoms
referred to as virulence. Pathogens are taxonomically widely diverse and comprise viruses and bacteria as well
as unicellular and multicellular eukaryotes.

Pathogens cause illness to their hosts through a variety of ways. The most obvious means is through direct
damage of tissues or cells during replication, generally through the production of toxins, which allows the
pathogen to reach new tissues or exit the cells inside which it replicated. A pathogen has the following
capabilities:

1. Maintain a reservoir
 human
 animal (rabies, leprosy )
 environmental (soil, water, plants, eg anthrax)
2. Leave it's reservoir and enter a host (transmission)
3. Adhere to the surface of the host
  mucus membranes (mouth, nose, urogenital tract, lungs)
4. Invade the body of the host
 be resistant to lysozyme (in tears and saliva)
 cannot be eliminated by the body's defenses
5. Invade the body's defenses
6. Multiply within the body
 needs proper nutrients e. g. iron
 some successful pathogens can break down hemoglobin and feed of the iron and lives an
multiplies in the blood stream
7. Leave the body and return to its reservoir or enter a new host.

PROTOZOAN DISEASES AND HUMANS

A parasite is an organism that lives on or in a host organism and gets its food from or at the expense of its host.
There are three main classes of parasites that can cause disease in humans: protozoa, helminths, and
ectoparasites.
A. Protozoa

Protozoa are microscopic, one-celled organisms that can be free-living or parasitic in nature. They are able to
multiply in humans, which contributes to their survival and also permits serious infections to develop from just
a single organism. Transmission of protozoa that live in a human’s intestine to another human typically occurs
through a fecal-oral route (for example, contaminated food or water or person-to-person contact). Protozoa that
live in the blood or tissue of humans are transmitted to other humans by an arthropod vector (for example,
through the bite of a mosquito or sand fly).
The protozoa that are infectious to humans can be classified into four groups based on their mode of movement:
1. Sarcodina – the ameba, e.g., Entamoeba
2. Mastigophora – the flagellates, e.g., Giardia, Leishmania
3. Ciliophora – the ciliates, e.g., Balantidium
4. Sporozoa – organisms whose adult stage is not motile e.g., Plasmodium, Cryptosporidium

B. Helminths

Helminths are large, multicellular organisms that are generally visible to the naked eye in their adult stages.
Like protozoa, helminths can be either free-living or parasitic in nature. In their adult form, helminths cannot
multiply in humans.
Helminths are parasitic worms that feed on a living host to gain nourishment and protection, while causing poor
nutrient absorption, weakness and disease in the host. These worms and larvae live in the small bowel and are
referred to as intestinal parasites.
There are three main groups of helminths (derived from the Greek word for worms) that are human parasites:
1. Flatworms (platyhelminths) – these include the trematodes (flukes) and cestodes (tapeworms).
2. Thorny-headed worms (acanthocephalins) – the adult forms of these worms reside in the gastrointestinal
tract. The acanthocephala are thought to be intermediate between the cestodes and nematodes.
3. Roundworms (nematodes) – the adult forms of these worms can reside in the gastrointestinal tract,
blood, lymphatic system or subcutaneous tissues. Alternatively, the immature (larval) states can cause
 disease through their infection of various body tissues. Some consider the helminths to also include the
segmented worms (annelids)—the only ones important medically are the leeches. Of note, these
organisms are not typically considered parasites.

C. Ectoparasites

Although the term ectoparasites can broadly include blood-sucking arthropods such as mosquitoes (because
they are dependent on a blood meal from a human host for their survival), this term is generally used more
narrowly to refer to organisms such as ticks, fleas, lice, and mites that attach or burrow into the skin and remain
there for relatively long periods of time (e.g., weeks to months). Arthropods are important in causing diseases in
their own right, but are even more important as vectors, or transmitters, of many different pathogens that in turn
cause tremendous morbidity and mortality from the diseases they cause.

Parasitic Infections
Parasitic infections cause a tremendous burden of disease in both the tropics and subtropics as well as in more
temperate climates. Of all parasitic diseases, malaria causes the most deaths globally. Malaria kills more than
400,000 people each year, most of them young children in sub-Saharan Africa.

The Neglected Tropical Diseases (NTDs), which have suffered from a lack of attention by the public health
community, include parasitic diseases such as lymphatic filariasis, onchocerciasis, and Guinea worm disease.
The NTDs affect more than 1 billion people worldwide, largely in rural areas of low-income countries. These
diseases extract a large toll on endemic populations, including lost ability to attend school or work, stunting of
growth in children, impairment of cognitive skills and development in young children, and the serious economic
burden placed on entire countries
Source: https://www.cdc.gov/parasites/sth/index.html

DISEASES OF MAN CAUSED BY PROTOZOA

AMOEBIASIS
Amoebiasis, also known as amoebic dysentery, is caused by Entamoeba histolytica. Infection generally occurs
through drinking water. The trophozoite of E. histolytica penetrates the wall of the colon, secretes histolytic
enzymes and feeds upon its cells causing ulcers.

These ulcers rupture and discharge mucus and blood into the intestine that pass along with stools and results in
amoebic dysentery. If the infection is allowed to continue the parasite may reach the liver, lungs and brain
where it causes abscesses which prove fatal.

There is no intermediate host in the life cycle of E. histolytica. Transmission of the parasite from man to man
takes place through the tetra nucleate cysts. Before the cyst formation the trophozoite changes into a smaller
minute form, which then encysts to form a tetra nucleate cyst.

These tetra nucleate cysts are voided with the fecal and contaminated water and food and are then transmitted
into new hosts. Fecal contamination of drinking water, vegetables and food are the primary causes. Eating of
uncooked vegetables and fruits which have been fertilized with infected human feces has often led to the
occurrence of disease.

Occasionally drinking water supply contaminated with infected faeces gives rise to epidemics. Houseflies may
transmit cysts while passing from faeces to unprotected foodstuffs. The cysts of E. histolytica have been found
in the droppings of cockroaches which also serve as a source of infection.
Amoebiasis is endemic in tropical countries. It can be treated with Emetine, Fumagillin, Metronidazole,
Tinidazole, Terramycin, Erythromycin, Aureomycin and Chloroquine, etc.
GIARDIASIS
Giardiasis which is characterised by loose bowels, is caused by a flagellete parasite Giardia (Lamblia)
intestinalis and a sporozoan Isopora hominis. Giardia intestinalis is a parasite in the small intestine and colon of
man.
With the help of sucking disc the parasite attaches itself on to the convex surface of the epithelial cells in the
intestine and may cause a disturbance of intestinal function leading to malabsorption of fat which causes
diarrhoea. Consequently the patient may complain of persistent looseness of bowels. The parasite is also
capable of producing epigastric pain, abdominal discomfort, loss of appetite, headache and toxic effect
(allergy).

Infection in man is brought about by ingestion of cysts. Transmission of the parasite takes place through cysts
which are voided with faeces and are transmitted to new hosts with contaminated water and food. The infection
of Giardia is more common in children than in adults.
Atebrin, Chloroquine and Acranil are effective drugs in the treatment of Giardia. Metronidazole has also been
reported to be quite effective in its treatment.

CHAGAS DISEASE (AMERICAN TRYPANOSOMIASIS)

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi and transmitted via the reduviid bug.

Chagas disease, also known as American trypanosomiasis, is caused by the parasite Trypanosoma cruzi. It is
transmitted to humans via the reduviid bug (the “kissing bugs”), and is therefore characterized as a zoonotic
disease.

Chagas disease is similar to African sleeping sickness which is caused by the African trypanosome. The risk
factors for Chagas disease include living where reduviid bugs live, including areas of Central and South
America. In addition, it is possible to obtain Chagas via blood transfusion from an individual with the active
disease.

The reduviid bug itself becomes infected by feeding on the blood of an already-infected person or animal. The
bugs are nocturnal, emerge at night and typically feed on an individual’s face. The bug then proceeds to
defecate on the person, passing Trypanosoma cruzi parasites in its feces in posterior station infection. These
parasites surround the bite wound and, when the bite is scratched, the parasites are able to pass into the host.
The reduviid bud often bites the tender skin around the eyes, leaving a swollen bump called a chagoma or
Ramona’s sign.
At this specific stage, the parasites are referred to as trypomastigotes, and these invade the host cells and
differentiate into intracellular amastigotes where they continue to multiply by binary fission. These amastigotes
then differentiate into trypomastigotes which circulate into the bloodstream. At this time, if the infected
individual is re-bitten by a reduviid bug, the cycle will start again.

Chagas disease can be characterized by two phases: acute and chronic. The acute phase is presents with mild
symptoms which include: fever, swelling of an eye and/or the area surrounding the insect bite.

The acute phase will then enter remission and, over time, additional symptoms will develop that include:
constipation, gastrointestinal issues, heart failure, abdominal pain and difficulties swallowing. It can sometime
take upwards of 20 years from the time of infection for these later heart and digestive issues to present.
American trypanosomiasis causes megacolon and megaesophagus and an enlarged heart in pediatric patients
and is very serious.

Key Points

 Chagas disease is prevalent in areas with reduviid bugs such as Central and South America.
 Chagas disease is transmitted via a vector, the reduviid bug, which becomes infected when it bites an
already-infected individual.
 The life cycle of Trypanosoma cruzi requires two hosts, the reduviid bug and the human or animal
host.

Key Terms
 zoonotic: of or relating to zoonosis, the transmission of an infectious disease between species.

LEISHMANIASIS
Leishmaniasis is caused by the protozoan parasite Leishmania and presents itself in two forms: cutaneous or
visceral leishmaniasis.
Leishmaniasis is a disease transmitted by the bite of a female sandfly. There various types of leishmaniasis that
exist including cutaneous leishmaniasis, systemic, or visceral leishmaniasis. Cutaneous leishmaniasis is
characterized by infection of the skin and mucous membranes.
The symptoms include skin sores which present at the site of the sandfly bite. In addition, cutaneous
leishmaniasis includes breathing difficulty, stuffy nose, runny nose, nose bleeds, swallowing difficulty and
ulcers in the mouth, tongue, gums, lips, nose, and inner nose. Systemic or visceral leishmaniasis present as an
infection of the entire body. There is a delay of symptoms, ranging from 2-8 months post bite, and the effects on
the immune system can result in deadly complications. The parasites damage the immune system by targeting
the disease-fighting cells.
Symptoms present much more quickly in children and include a cough, diarrhea, fever, and vomiting. In adults,
there is fatigue, weakness, loss of appetite, abdominal pain, night sweats, fever, weight loss, and changes in the
color and texture of the skin. In combination, cutaneous and visceral leishmaniasis are caused by more than 20
different leishmanial species.
Leishmaniasis is vector-borne because it is transmitted via a bite from a sandfly. The sandflies that cause
leishmaniasis are infected by an obligate intracellular protozoa of the genus Leishmania. The species of
Leishmania that can cause leishmaniasis include: L. donovani complex with 2 species (L. donovani, L.
infantum, also known as L. chagasi); the L. mexicana complex with 3 main species (L. mexicana, L.
amazonensis, and L. venezuelensis); L. tropica; L. major; L. aethiopica; and the subgenus Viannia with 4 main
species (L. (V.) braziliensis, L. (V.) guyanensis, L. (V.) panamensis, and L. (V.) peruviana). These various
species are indistinguishable via morphology but can be identified using advanced techniques such as
isoenzyme analysis.
Leishmaniasis is transmitted by the bite of infected female phlebotomine sandflies which can transmit the
infection Leishmania. The sandflies inject the infective stage, metacyclic promastigotes, during blood meals.
Metacyclic promastigotes that reach the puncture wound are phagocytized by macrophages and transform into
amastigotes. Amastigotes multiply in infected cells and affect different tissues, depending in part on which
Leishmania species is involved. These differing tissue specificities cause the differing clinical manifestations of
the various forms of leishmaniasis. Sandflies become infected during blood meals on infected hosts when they
ingest macrophages infected with amastigotes. In the sandfly’s midgut, the parasites differentiate into
promastigotes, which multiply, differentiate into metacyclic promastigotes, and migrate to the proboscis.
Key Points
 Leishmaniasis is a vector-borne disease and is transmitted by the sand fly.
 Cutaneous leishmaniasis is the most common form of leishmaniasis and symptoms include skin
sores.
 Visceral leishmaniasis is more severe and is characterized by the migration of parasites to the vital
organs and tissues.
Key Terms
 visceral: of or relating to the viscera – the internal organs of the body
 cutaneous: of, relating to, existing on, or affecting the exterior skin; especially the cutis
 phagocytosis: the process by which a cell incorporates foreign particles intracellularly.

TRICHOMONIASIS
Trichomoniasis is caused by the species of flagellate parasite, Trichomonas. Its body is pear-shaped provided
with one nucleus, an axostyle, a parabasal body, 3- 5 anterior free flagella, and one backwardly directed
flagellum along the side of the body. Trichomonas are parasites in vertebrates and many invertebrates. Three
species are found in man which are:

 Trichomonas hominis
 Trichomonas lenax and
 Trichomonas vaginalis

The most common pathogenic species is Trichomonas vaginalis. It inhabits the vagina of women and causes
vaginitis. The disease is characterized by inflammation of vaginal mucosa, burning sensation, annoying itch and
abnormal discharges.
Transmission of parasite is always during sexual intercourse by male members who act as intermediaries. T.
vaginalis is also found in urinary tract of men infecting the urethra and prostate. Arsenic and iodine drugs and
antibiotics such as Terramycin and Aureomycin have proved useful in the treatment of the disease.

MALARIA
Malaria is a mosquito-borne infectious disease that affects humans and other animals caused by various species
of the protist Plasmodium.

Malaria is a parasitic disease that is caused by the bite of an infected Anopheles mosquito. Malaria can be
transmitted from mother to baby and by blood transfusions. The Anopheles mosquito transmits the parasites,
called sporozoites, upon biting the hosts, into the bloodstream to the liver, where the parasites continue their life
cycle.

In the liver, the parasites mature and release another form called merozoites, which enter the bloodstream and
infect the red blood cells. In the red blood cells, they develop into ring forms called trophozoites and schizonts
that in turn, produce further merozoites. Upon infection of the red blood cells, the parasite is able to multiply
within the cell, break open and continue infecting additional red blood cells.

The symptoms occur in a cyclical manner every 48-72 hours. Malaria is characterized by the development of
symptoms that include high fevers, shaking chills, flu-like symptoms, and anemia. The symptoms that persist
due to parasitic infection are a result of the release of merozoites into the bloodstream, destruction of the red
blood cells and the free circulation of large amounts of hemoglobin in the red blood cells due to disruption.

The five types of malaria parasites include species of Plasmodium. The fives species include: Plasmodium
falciparum, Plasmodium vivax, Plasmodium ovale, Plasmodium malariae, and Plasmodium knowlesi.
Plasmodium falciparum is responsible for the majority of deaths caused by infection and Plasmodium vivax,
ovale and malariae cause a milder form of malaria. The species, Plasmodium knowlesi, commonly causes
malaria in macaques but can also cause severe infections in humans.

Malaria is common in temperate climates and the Centers for Disease Control and Prevention (CDC) estimates
300-500 million cases each year. In addition, it is estimated that 1 million people die from it each year as well.
Malaria is typically diagnosed by microscopic examination of blood or with antigen-based rapid diagnostic
tests.

Disease transmission can be reduced by preventing mosquito bites through the use of mosquito nets and insect
repellents. However, the mosquitoes which transmit malaria have begun to develop resistance to insecticides
and the parasite itself has developed resistance to commonly used antibiotics. As a result of increased
resistance, it is extremely difficult to contain the spread of this disease.

Key Points
 The five common species of Plasmodium that cause malaria include: Plasmodium falciparum,
Plasmodium vivax, Plasmodium ovale, Plasmodium malariae and Plasmodium knowlesi.
 Mosquitoes transmit the protists by injecting sporozoites into the bloodstream of humans.
 The sporozoites injected into the bloodstream, travel to the liver where they multiply into
merozoites, rupture the liver cells, and then return to the bloodstream.
 A mosquito, upon feeding off an already infected individual, will carry the protists and become
infectious.
 The symptoms of malaria can present in a cyclic manner.
 Key Terms
 merozoites: the organisms formed by multiple fission of a sporozoite within the body of the host.
 antigen: A substance that induces an immune response, usually foreign.
 sporozoites: Any of the minute active bodies into which a sporozoan divides just before it infects a
new host cell.

TOXOPLASMOSIS

Toxoplasmosis is a parasitic disease caused by the protozoan Toxoplasma gondii and its life cycle mandates a
definitive host which are cats.

Overview

Toxoplasmosis is an infection caused by the parasite Toxoplasma gondii. Toxoplasmosis is found in humans
worldwide, but the definitive hosts are cats. Humans may become infected as a result of infected blood
transfusions, organ transplants, ingesting contaminated soil, raw or undercooked meat, and most commonly
from the careless handling of cat litter, which can lead to accidental ingestion of the parasite. Toxoplasmosis
can also be passed from an infected mother to her baby via the placenta (transplacentally). Symptoms that may
occur from toxplasmosis include: enlarged lymph nodes, headache, fever, muscle pain, and sore throat.
Individuals with immunocompromised or weakened systems display more severe symptoms, such as:
confusion, fever, headache, blurred vision and seizures. The three categories of toxoplasmosis include acute,
latent, and cutaneous toxoplasmosis.

Symptoms

Acute toxoplasmosis is characterized by swollen lymph nodes found in the neck or under the chin, followed by
the axillae, and the groin area. Enlarged lymph nodes will occur at different times after the initial infection.
Latent toxoplasmosis is characterized by the formation of cysts in both the nervous and muscle tissue due to the
bradyzoite form of the parasite. Often times, individuals infected with latent toxoplasmosis do not present with
symptoms, as the infection enters a latent phase. In individuals with cutaneous toxoplasmosis, skin lesions will
occur due to the tachyzoite form of the parasite and its presence in the epidermis. Infection occurring in early
months of pregnancy results either in abortion or still birth of the fetus.

Hosts, Life Cycle

The known definitive hosts for Toxoplasma gondii are members of family Felidae (domestic cats and their
relatives). In the life cycle of this parasite, unsporulated oocysts are shed in the cat’s feces. The cat will shed
large numbers of these cysts over a short period of time. The oocysts will then take 1-5 days to sporulate in the
environment and become infective. The intermediate hosts in nature (including birds and rodents) become
infected after ingesting contaminated soil, water, or plant material. The oocysts, upon ingestion, will transform
into tachyzoites, which will localize in the neural and muscle tissue. After localizing to these sites, they will
develop into tissue cyst bradyzoites. Cats, can become infected after consuming intermediate hosts that are
infected with tissue cysts or by ingesting sporulated oocysts.

Key Points
  Cats are the definitive hosts for Toxoplasma gondii and are the primary source of infection to
humans.
 Toxoplasmosis can occur in either acute, latent or cutaneous forms.
 Toxoplasmosis is found worldwide and can be transmitted by eating undercooked meat of animals
which may contain cysts, ingesting contaminated food or water, transplacentally or from coming in
contact with infected cat feces.
Key Terms
 definitive host: a host in which the parasite reaches maturity and, if possible, reproduces sexually
 transplacental: Through or across the placenta

Keep in Mind:
 Amoebiasis, also known as amoebic dysentery, is caused by Entamoeba histolytica.
 Giardiasis which is characterised by loose bowels, is caused by a flagellete parasite Giardia Lamblia
intestinalis and a sporozoan Isopora hominis
 Leishmaniasis is caused by the protozoan parasite Leishmania and presents itself in two forms:
cutaneous or visceral leishmaniasis.
 Chagas disease, also known as American trypanosomiasis, is caused by the parasite Trypanosoma
cruzi. It is transmitted to humans via the reduviid bug (the “kissing bugs”), and is therefore
characterized as a zoonotic disease.
 Trichomoniasis is caused by the species of flagellate parasite, Trichomonas
 Malaria is a mosquito-borne infectious disease that affects humans and other animals caused by
various species of the protist Plasmodium.
 Toxoplasmosis is a parasitic disease caused by the protozoan Toxoplasma gondii and its life cycle
mandates a definitive host which are cats.

Comprehension Check:
1. What are parasites?
2. What are protozoa? List at least 5 diseases caused by this parasite?
3. What are the three main classifications of parasites?
4. What is Amoebiasis? What is its causative organism?
5. What are the species of Leishmaniasis known to cause parasitic infection humans?
6. What are the species of Plasmodium that can cause malaria?

To validate your answer, feel free to contact your course facilitator through any of the following:
 Facebook: Haridja Asid
 Contact No: 09260073732
 Email address: benhar02012018@gmail.com
 DISEASES IN MAN CAUSED BY HELMINTHS
Human Helminthiases, Populations at Risk, and Resulting Diseases
Helminth parasites are parasitic worms from the phyla Nematoda (roundworms) and Platyhelminthes
(flatworms). Together, they comprise the most common infectious agents of humans in developing countries.
The most common helminthiases of humans are those caused by intestinal infection with STHs, namely
Ascarias lumbricoides, Trichuris trichiura, and hookworms (Necator americanus and Ancylostoma duodenale),
followed by schistosomiasis and lymphatic filariasis

Helminth diseases (Helminthiasis) or worm infection is any macroparasitic disease of humans and other animals
in which a part of the body is infected with parasitic worms known as helminths. These worms are categorized
into three main categories: roundworms, tapeworms, and flukes. There are numerous identified helminths that
infect humans which are broadly classified into tapeworms, flukes, and roundworms.

They often live in the gastrointestinal tract of their hosts, but they may also burrow into other organs, where
they induce physiological damage. Transmission of helminths typically involves direct contact with the parasite,
or ingestion of the parasite via contaminated food or water. In some cases, the parasites can pass through human
skin from infected water or soil.

Symptoms range depending on the type of helminth causing the disease. There may be general symptoms, or
more specific symptoms as certain regions of the body are affected. Furthermore, while full recovery is possible
from some infections, death or debilitating disabilities occurs with other infections. Treatment, when possible,
usually involves administration of anti-inflammatory drugs alone or in combination with anti-helminth drugs
that kill the existing parasites in various stages of their development.

Helminths cause human disease worldwide, although climate conditions limit many species of helminths to
tropical or semi-tropical areas. However, with changes in climate, certain infections are becoming widespread.
Developing or poverty-stricken countries are heavily affected with helminth diseases, a problem compounded
by lack of education, funding, and additional problems in these countries such as HIV infection, lagging
infrastructure, political instability, and war.
Disease History, Characteristics, and Transmission
Helminths are parasitic worms, that is, they infect a host and survive by feeding off the host's nutrients, a
process that usually harms the host. The adverse effects of the helminth lead to the development of disease
within the host. There are roughly 300 recognized helminths that infect humans. Helminths are thought to have
been present in humans as far back as ancient Egyptian times, and gradually, specific disease-causing species
were identified over the centuries. The study of helminths increased in the twentieth century, which caused the
number of recognized helminths to increase from 28 to over 300.

Helminths are separated into three main categories based on morphology (structure) and mode of transmission.
These categories are roundworms or nematodes, tapeworms or cestodes, and flukes or trematodes.

Roundworms (Nematodes)

Most roundworms hatch and live in the intestines. The eggs of roundworms enter the body of the host and travel
towards the intestines, where they hatch. Depending on their subtype, they remain in the intestine or migrate to
other regions of the body.
Transmission of roundworms occurs when contaminated material enters the body. This could be via ingestion of
contaminated food or water, entry of eggs via the anal or genital tracts, or ingestion of, or contact with,
contaminated soil.

Symptoms of roundworm infection vary depending on the type of worm. Some cause general symptoms such as
abdominal pain, diarrhea, fatigue, itching, and fever, while others can be more specific and cause damage to
certain regions of the body.

Tapeworms (Cestodes)

Tapeworms generally live in the intestines. Their eggs are normally ingested when meat containing the parasites
is undercooked or raw. While symptoms may not occur, some patients will experience abdominal pain, fatigue,
and diarrhea.
Flukes (Trematodes)
Flukes are a group of helminths that live in various regions of the body including the spleen, liver, lungs, and
intestines. The lifecycle of these worms involves freshwater snails as intermediate hosts. Following the release
of larval forms of the worm from the snail into fresh water, the larval worms can enter humans via contact with
the skin.

Most cases of fluke infection do not cause initial symptoms, and the parasites pass out of the body. However,
reinfection can occur. If it occurs continuously over time, this can cause damage to body organs. In
symptomatic cases, infection usually results in a rash, itching, muscle aches, coughing, chills, and fever. Severe
infections involve flukes entering the liver, lung, or brain and spinal cord.
Scope and Distribution
Helminth diseases occur worldwide. However, different types of infections are present in different regions. One
factor that influences where an infection can occur is climate. Some helminths survive only in tropical climates,
while others require temperate conditions.

Soil-transmitted helminths and schistosomes, a type of trematode, are the cause of most of the world's helminth
disease burden. Regions that are poverty-stricken, in the midst of conflict, or have low sanitation standards have
a high prevalence of infection. Poverty-stricken countries in the developing world, located in Africa, China,
East Asia, and the Americas, account for most of the world's helminth infections.
Treatment and Prevention
As there are a large variety of helminths that cause disease in humans, there is no specific treatment. However,
most infections can be treated via the use of vermifuges, which are anti-worm drugs that effectively kill
parasitic worms. In addition, while some helminth infections can be cured within a short period of time, others
may take months or years to heal, and in some cases, patients are left with debilitating disabilities due to organ
and limb damage.

There are several ways to prevent infection from helminths. First, avoiding contact with the parasites ensures
infection does not occur. Contact can be prevented by frequent washing of hands, maintaining a clean bathroom
and kitchen, and avoiding contact with infected animals. Furthermore, thorough cooking of food, particularly
pork and beef that may potentially carry parasites, prevents ingestion of parasites. Chlorinating, filtering, or
boiling drinking water prevents parasites being ingested while drinking. To avoid parasite uptake while bathing
or swimming in infected water, a problem particularly for fluke parasites, water can be boiled prior to bathing,
or avoided completely.
Another way to prevent infection is to lower the prevalence of helminths within a community. This is achieved
through regular deworming, or administration of anti-worm treatments to infected people. This can effectively
reduce the long-term effects of the parasites on infected persons, as well as reduce the prevalence of the parasite
within a community.

In order to effectively implement prevention methods in communities affected by helminth infestations,

communities can be educated about hygiene, sanitation, and proper food preparation. Together with helminth
treatments, these methods help to reduce the prevalence and effects of helminths on communities.

Helminth diseases are most likely to strike children, especially in the developing world, causing malnutrition
and illness. Malnutrition during childhood has life-long effects on an estimated 182 million children worldwide,
from increased rates of illness and stagnated development, to disability and premature death. Thus, the World
Health Organization (WHO), in partnership with UNICEF, focuses its anti-helminth efforts on children and
schools. In areas where helminths thrive in local water or soil, efforts to curb helminth diseases include food
safety, hygiene, and sanitation education, as well at the widespread administration of anti-helminth drugs.

Keep in Mind:
 Helminth diseases are caused by parasitic worms known as helminths. These worms are categorized
into three main categories: roundworms, tapeworms, and flukes.
 Helminths infect a host and survive by feeding off the host's nutrients, a process that usually harms
the host.
 Contact can be prevented by frequent washing of hands, maintaining a clean bathroom and kitchen,
and avoiding contact with infected animals. Furthermore, thorough cooking of food, particularly pork
and beef that may potentially carry parasites, prevents ingestion of parasites. Chlorinating, filtering,
or boiling drinking water prevents parasites being ingested while drinking
 Helminth diseases are most likely to strike children, especially in the developing world, causing
malnutrition and illness. Malnutrition during childhood has life-long effects on an estimated 182
million children worldwide, from increased rates of illness and stagnated development, to disability
and premature death

Comprehension Check:
1. What are helminths?
2. What are the types of helminths that caused parasitic/worm infections?
3. How are heminths transmitted?
4. What are the likely effects of helminth diseases especially in children?
5. List ways on how to prevent helminthiasis.

To validate your answer, feel free to contact your course facilitator through any of the following:
 Facebook: Haridja Asid
 Contact No: 09260073732
 Email address: benhar02012018@gmail.com
 SOIL-TRANSMITTED HELMINTH INFECTIONS

Soil-transmitted helminth infections are among the most common infections worldwide and affect the poorest
and most deprived communities. They are transmitted by eggs present in human feces which in turn
contaminate soil in areas where sanitation is poor.

The main species that infect people are the roundworm (Ascaris lumbricoides), the whipworm (Trichuris
trichiura) and hookworms (Necator americanus and Ancylostoma duodenale). These STH species are normally
addressed as a group because they need similar diagnostic procedures and respond to the same medicines.

Strongyloides stercoralis is an intestinal helminth with peculiar characteristics: the parasite requires different
diagnostic methods than other soil-transmitted helminthiases, and for this reason is frequently not identified. In
addition, the parasite is not sensitive to albendazole or mebendazole and therefore not impacted by large-scale
preventive treatment campaigns targeting other soil-transmitted helminthiases.

Soil-transmitted helminth infection is found mainly in areas with warm and moist climates where sanitation and
hygiene are poor, including in temperate zones during warmer months. These STHs are considered Neglected
Tropical Diseases (NTDs) because they inflict tremendous disability and suffering yet can be controlled or
eliminated.
Transmission

Soil-transmitted helminths are transmitted by eggs that are passed in the faeces of infected people. Adult worms
live in the intestine where they produce thousands of eggs each day. In areas that lack adequate sanitation, these
eggs contaminate the soil. This can happen in several ways:

 eggs that are attached to vegetables are ingested when the vegetables are not carefully cooked, washed
or peeled;
 eggs are ingested from contaminated water sources;
 eggs are ingested by children who play in the contaminated soil and then put their hands in their mouths
without washing them.

In addition, hookworm eggs hatch in the soil, releasing larvae that mature into a form that can actively penetrate
the skin. People become infected with hookworm primarily by walking barefoot on the contaminated soil.
There is no direct person-to-person transmission, or infection from fresh faeces, because eggs passed in faeces
need about 3 weeks to mature in the soil before they become infective.

A. lumbricoides, T. trichiura and hookworms do not multiply in the human host, re-infection occurs only as a
result of contact with infective stages in the environment. S. stercoralis can reproduce in the host and in
immunocompromised individuals, its uncontrolled multiplication can be fatal.

Soil-transmitted helminths live in the intestine and their eggs are passed in the feces of infected persons. If an
infected person defecates outside (near bushes, in a garden, or field) or if the feces of an infected person are
used as fertilizer, eggs are deposited on soil. Ascaris and hookworm eggs become infective as they mature in
soil. People are infected with Ascaris and whipworm when eggs are ingested. This can happen when hands or
fingers that have contaminated dirt on them are put in the mouth or by consuming vegetables and fruits that
have not been carefully cooked, washed or peeled. Hookworm eggs are not infective. They hatch in soil,
releasing larvae (immature worms) that mature into a form that can penetrate the skin of humans. Hookworm
infection is transmitted primarily by walking barefoot on contaminated soil. One kind of hookworm
(Anclostoma duodenale) can also be transmitted through the ingestion of larvae.
People with light soil-transmitted helminth infections usually have no symptoms. Heavy infections can cause a
range of health problems, including abdominal pain, diarrhea, blood and protein loss, rectal prolapse, and
physical and cognitive growth retardation. Soil-transmitted helminth infections are treatable with medication
prescribed by your health care provider.

Hookworm Ascaris
Whipworm

Nutritional effects

Soil-transmitted helminths impair the nutritional status of the people they infect in multiple ways.
 The worms feed on host tissues, including blood, which leads to a loss of iron and protein.
 Hookworms in addition cause chronic intestinal blood loss that can result in anaemia.
 The worms increase malabsorption of nutrients. In addition, roundworm may possibly compete
for vitamin A in the intestine.
 Some soil-transmitted helminths also cause loss of appetite and, therefore, a reduction of
nutritional intake and physical fitness. In particular, T. trichiura can cause diarrhoea and
dysentery.

Morbidity and symptoms

Morbidity is related to the number of worms harboured. People with infections of light intensity (few worms)
usually do not suffer from the infection. Heavier infections can cause a range of symptoms including intestinal
manifestations (diarrhoea and abdominal pain), malnutrition, general malaise and weakness, and impaired
growth and physical development.

Infections of very high intensity can cause intestinal obstruction that should be treated surgically. S.
stercoralis may cause dermatological and gastro-intestinal morbidity and is also known to be associated with
chronic malnutrition in children. In case of reduced host immunity, the parasite can cause the
hyperinfection/dissemination syndrome that is invariably fatal if not promptly and properly cured and is often
fatal despite the treatment.

WHO strategy for control

In 2001, delegates at the World Health Assembly unanimously endorsed a resolution urging endemic countries
to start seriously tackling worms, specifically schistosomiasis and soil-transmitted helminths.

The strategy for control of soil-transmitted helminth infections is to control morbidity through the periodic
treatment of at-risk people living in endemic areas. People at risk are:

 preschool children
  school-age children
 women of reproductive age (including pregnant women in the second and third trimesters and
breastfeeding women)
 adults in certain high-risk occupations such as tea-pickers or miners.

WHO recommends periodic medicinal treatment (deworming) without previous individual diagnosis to all at-
risk people living in endemic areas. This intervention reduces morbidity by reducing the worm burden. In
addition:
 health and hygiene education reduces transmission and reinfection by encouraging healthy behaviours;
and
 provision of adequate sanitation is also important but not always possible in resource-poor settings.

Periodical treatment aims to reduce and maintain the intensity of infection, and to protect infected at-risk
populations from morbidity.

Deworming can be easily integrated with child health days or supplementation programmes for preschool
children, or integrated with school health programmes. In 2018, over 676 million school-aged children were
treated with anthelminthic medicines in endemic countries, corresponding to 53% of all children at risk.

Schools provide a particularly good entry point for deworming activities, as they allow the easy provision of the
health and hygiene education component, such as promotion of handwashing and improved sanitation.

WHO added the control of morbidity due to S. stercoralis as an objective for 2030. This will be possible
because of the expected availability of pre-qualified ivermectin at affordable cost. Distribution of ivermectin is
expected through the platforms used to control the other soil-transmitted helminthiases.

WHO recommended medicines

The WHO recommended medicines –albendazole (400 mg) and mebendazole (500 mg) – are effective,
inexpensive and easy to administer by non-medical personnel (e.g. teachers). They have been through extensive
safety testing and have been used in millions of people with few and minor side-effects.

Both albendazole and mebendazole are donated to national ministries of health through WHO in all endemic
countries for the treatment of all children of school age. Ivermectin for the control of S. stercoralis is expected
to be available at affordable price from 2021.

Global target

There are six 2030 global targets for soil-transmitted helminthiases:

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

Keep in Mind:
  Soil-transmitted helminth infections are caused by different species of parasitic worms.
 They are transmitted by eggs present in human faeces, which contaminate the soil in areas where
sanitation is poor.
 Infected children are nutritionally and physically impaired.
 Approximately 1.5 billion people are infected with soil-transmitted helminths worldwide.
 Control is based on periodical deworming to eliminate infecting worms, health education to prevent
re-infection, and improved sanitation to reduce soil contamination with infective eggs.
 Safe and effective medicines are available to control infection

Comprehension Check:
1. What are the main species that cause soil transmitted Helminthiasis?
2. Who are the people at risk for STH?
3. What are the two medicines/drugs recommended by WHO?
4. How do we prevent STH infections?

To validate your answer, feel free to contact your course facilitator through any of the following:
 Facebook: Haridja Asid
 Contact No: 09260073732
 Email address: benhar02012018@gmail.com

SCHISTOSOMIASIS

Schistosomiasis, also known as bilharzia, is a disease caused by parasitic worms. Infection with Schistosoma
mansoni, S. haematobium, and S. japonicum causes illness in humans; less commonly, S. mekongi and S.
intercalatum can cause disease. The worms that cause schistosomiasis infect than 200 million people
worldwide.

Transmission

Infection occurs when your skin comes in contact with contaminated freshwater in which certain types of snails
that carry schistosomes are living.

Freshwater becomes contaminated by Schistosoma eggs when infected people urinate or defecate in the water.
The eggs hatch, and if certain types of freshwater snails are present in the water, the parasites develop and
multiply inside the snails. The parasite leaves the snail and enters the water where it can survive for about 48
hours. Schistosoma parasites can penetrate the skin of persons who are wading, swimming, bathing, or washing
in contaminated water. Within several weeks, the parasites mature into adult worms and live in the blood
vessels of the body where the females produce eggs. Some of the eggs travel to the bladder or intestine and are
passed into the urine or stool.

Signs and symptoms

Within days after becoming infected, you may develop a rash or itchy skin. Fever, chills, cough, and muscle
aches can begin within 1-2 months of infection. Most people have no symptoms at this early phase of infection.
When adult worms are present, the eggs that are produced usually travel to the intestine, liver or bladder,
causing inflammation or scarring. Children who are repeatedly infected can develop anemia, malnutrition, and
learning difficulties. After years of infection, the parasite can also damage the liver, intestine, lungs, and
bladder. Rarely, eggs are found in the brain or spinal cord and can cause seizures, paralysis, or spinal cord
inflammation.

Symptoms of schistosomiasis are caused by the body’s reaction to the eggs produced by worms, not by the
worms themselves.

Diagnosis

The health care provider may ask you to provide stool or urine samples to see if you have the parasite. A blood
sample can also be tested for evidence of infection. For accurate results, you must wait 6-8 weeks after your last
exposure to contaminated water before samples are taken.

Treatment

Safe and effective drugs are available for the treatment of schistosomiasis. Praziquantel is the recommended
treatment drug. See your doctor for appropriate diagnosis and treatment.

Who are at risk?

If you live in or travel to areas where schistosomiasis occurs and your skin comes in contact with freshwater
from canals, rivers, streams, ponds, or lakes, you are at risk of getting schistosomiasis.

In what areas of the world does schistosomiasis occur?

 Africa: contact with any freshwater in southern and sub-Saharan Africa–including the great lakes and
rivers as well as smaller bodies of water– should be considered a risk for schistosomiasis transmission.
Transmission also occurs in the Mahgreb region of North Africa and the Nile River valley in Egypt and
Sudan
 South America: Brazil, Suriname, Venezuela
 Caribbean: Dominican Republic, Guadeloupe, Martinique, Saint Lucia (risk in Caribbean is very low)
 The Middle East: Iran, Iraq, Saudi Arabia, Yemen
 Southern China
 Parts of Southeast Asia and the Philippines, Laos
 A recent focus of ongoing transmission has been identified in Corsica.

Prevention

 Avoid swimming or wading in freshwater when you are in countries in which schistosomiasis occurs.
Swimming in the ocean and in chlorinated swimming pools is safe.

 Drink safe water. Although schistosomiasis is not transmitted by swallowing contaminated water, if
your mouth or lips come in contact with water containing the parasites, you could become infected.
Because water coming directly from canals, lakes, rivers, streams, or springs may be contaminated with
a variety of infectious organisms, you should either boil water for 1 minute or filter water before
drinking it. Boiling water for at least 1 minute will kill any harmful parasites, bacteria, or viruses
present.
  Bath water should be heated to a rolling boil for at least 1 minute. Water held in a storage tank for at
least 1-2 days should be safe for bathing.

 Vigorous towel drying after an accidental, very brief water exposure may help to prevent the
Schistosoma parasite from penetrating the skin. However, you should NOT rely on vigorous towel
drying to prevent schistosomiasis.
LYMPHATIC FILARIASIS
Lymphatic filariasis is a parasitic disease caused by three species of microscopic,
thread-like worms. The adult worms only live in the human lymph system. The
lymph system maintains the body’s fluid balance and fights infections.
Lymphatic filariasis affects over 120 million people in 72 countries throughout
the tropics and sub-tropics of Asia, Africa, the Western Pacific, and parts of the
Caribbean and South America.
Transmission

The disease spreads from person to person by mosquito bites. When a mosquito
bites a person who has lymphatic filariasis, microscopic worms circulating in the
person’s blood enter and infect the mosquito. When the infected mosquito bites another person, the microscopic
worms pass from the mosquito through the skin, and travel to the lymph vessels. In the lymph vessels they grow
into adults. An adult worm lives for about 5–7 years. The adult worms mate and release millions of microscopic
worms, called microfilariae, into the blood. People with the worms in their blood can give the infection to
others through mosquitoes.
Who is at risk for infection?
Repeated mosquito bites over several months to years are needed to get lymphatic filariasis. People living for a
long time in tropical or sub-tropical areas where the disease is common are at the greatest risk for infection.
Short-term tourists have a very low risk. An infection will show up on a blood test.
Signs and symptoms
Most infected people are asymptomatic and will never develop clinical symptoms, despite the fact that the
parasite damages the lymph system. A small percentage of persons will develop lymphedema or, in men, a
swelling of the scrotum called hydrocele .Lymphedema is caused by improper functioning of the lymph system
that results in fluid collection and swelling. This mostly affects the legs, but can also occur in the arms, breasts,
and genitalia. Most people develop these clinical manifestations years after being infected.

The swelling and the decreased function of the lymph system make it difficult for the body to fight germs and
infections. Affected persons will have more bacterial infections in the skin and lymph system. This causes
hardening and thickening of the skin, which is called elephantiasis. Many of these bacterial infections can be
prevented with appropriate skin hygiene and care for wounds.
Men can develop hydrocele or swelling of the scrotum due to infection with one of the species of parasites that
causes LF, specifically W. bancrofti.
Filarial infection can also cause tropical pulmonary eosinophilia syndrome. Eosinophilia is a higher than normal
level of disease-fighting white blood cells, called eosinophils. This syndrome is typically found in infected
persons in Asia. Clinical manifestations of tropical pulmonary eosinophilia syndrome include cough, shortness
of breath, and wheezing. The eosinophilia is often accompanied by high levels of Immunoglobulin E ( IgE) and
antifilarial antibodies.

Diagnosis
The standard method for diagnosing active infection is the examination of blood under the microscope to
identify the microscopic worms, called microfilariae. This is not always feasible because in most parts of the
world, microfilariae are nocturnally periodic, which means that they only circulate in the blood at night. For this
reason, the blood collection has to be done at night to coincide with the appearance of the microfilariae in the
blood.

Serologic techniques provide an alternative to microscopic detection of microfilariae for the diagnosis of
lymphatic filariasis. Because lymphedema may develop many years after infection, lab tests are often negative
with these patients.
Prevention
Avoiding mosquito bites is the best form of prevention. The mosquitoes that carry the microscopic worms
usually bite between the hours of dusk and dawn . If you live in or travel to an area with lymphatic filariasis:
 Sleep under a mosquito net.
 Wear long sleeves and trousers.
 Use mosquito repellent on exposed skin between dusk and dawn.
Treatment
People infected with adult worms can take a yearly dose of medicine, called diethylcarbamazine (DEC), that
kills the microscopic worms circulating in the blood. While this drug does not kill all of the adult worms, it does
prevent infected people from giving the disease to someone else.
People with lymphedema and elephantiasis are not likely to benefit from DEC treatment because most people
with lymphedema are not actively infected with the filarial parasite. Physicians can obtain DEC from CDC after
lab results confirm infection.
People with lymphedema and hydrocele can benefit from
lymphedema management, and in the case of hydrocele surgical
repair. Even after the adult worms die, lymphedema can
develop. You can ask your physician for a referral to see a
lymphedema therapist for specialized care. Prevent the
lymphedema from getting worse by following several basic
principles:
 Carefully wash and dry the swollen area with soap and
water every day.
 Elevate the swollen arm or leg during the day and at
night to move the fluid.
 Perform exercises to move the fluid and improve lymph Lymphedema and Elephantiasis
flow.
 Disinfect any wounds. Use antibacterial or antifungal cream if necessary.
 Wear shoes adapted to the size of the foot to protect the feet from injury.
Men with hydrocele can undergo surgery to reduce the size of the scrotum
Keep in Mind:
 Schistosomiasis, also known as bilharzia, is a disease caused by parasitic worms. Infection with
Schistosoma mansoni, S. haematobium, and S. japonicum causes illness in humans.
 Infection occurs when your skin comes in contact with contaminated freshwater in which certain
types of snails that carry schistosomes are living.
 Lymphatic filariasis is a parasitic disease caused by three species of microscopic, thread-like worms.
The adult worms only live in the human lymph system
 People with lymphedema and hydrocele can benefit from lymphedema management, and in the case
 of hydrocele surgical repair
 People infected with Filariasis can take a yearly dose of medicine, called diethylcarbamazine (DEC)
that kills the microscopic worms circulating in the blood.
 People with lymphedema and hydrocele can benefit from lymphedema management, and in the case
of hydrocele surgical repair

Comprehension Check:
1. What is the causative organisms of Schistosomiasis? Filariasis?
2. How are these parasitic infections transmitted?
3. List the principles on how to prevent lymphedema from getting worse.
4. What are the signs and symptoms of Schistosomiasis?
5. What are the signs and symptoms of Filariasis

To validate your answer, feel free to contact your course facilitator through any of the following:
 Facebook: Haridja Asid
 Contact No: 09260073732
 Email address: benhar02012018@gmail.com

SIBUGAY TECHNICAL INSTITUTE, INC.

Lower Taway, Ipil, Zamboanga City
COLLEGE OF MIDWIFERY

Microbiology and Parasitology

ACTIVITY NO. 1: PROTOZOAN DISEASES

Name: ____________________________________________ Date: _________________
Course – Year & Section: _____________________ Score: ________________

Direction: Found below are some of the common protozoan diseases in human. Complete the table by filling in
columns 2 and 3 with their causative organisms and signs and symptoms of each disease.
Protozoan Diseases Causative organism Clinical manifestations
Malaria
Trichomoniasis
Leishmaniasis
Amoebiasis
Toxoplasmosis
Giardiasis
Chagas disease

SIBUGAY TECHNICAL INSTITUTE, INC.

Lower Taway, Ipil, Zamboanga City
COLLEGE OF MIDWIFERY

Microbiology and Parasitology

ACTIVITY NO. 2: HELMINTHIASIS

Name: ____________________________________________ Date: _________________

Course – Year & Section: _____________________ Score: ________________

Direction: Found below are helminths diseases in human. Complete the table by filling in the remaining
columns with their causative organisms, signs and symptoms and preventive measures of each disease.
Helminth Causative Signs and Preventive measures
Diseases organisms symptoms
Filariasis
Schistosomiasis
Ascaris
Hookworms
Whipworms

SIBUGAY TECHNICAL INSTITUTE, INC.

Lower Taway, Ipil, Zamboanga City
COLLEGE OF MIDWIFERY
 Microbiology and Parasitology

ACTIVITY NO. 3: THINK ABOUT IT!

Name: ____________________________________________ Date: _________________

Course – Year & Section: _____________________ Score: ________________

Direction: Answer the following questions briefly in your own words. You may use extra sheet/s of paper if
needed.
1. Normal flora consists of communities of bacteria that function as microbial ecosystems. Discuss the
benefits of normal flora and its harmful effects. Explain the consequences If these ecosystems are
disrupted.
2. Compare primary pathogen and opportunistic pathogen.
3. What is pathogenicity? Virulence?
4. Compare the three types of infection: Local, focal, systemic.
5. Discuss the stages of pathogenesis.

MIDTERM EXAMINATION

NOVEMBER 16-18, 2023