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Chapter 2 : “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection

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“The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, Page 1 of 2

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Abstract:

The soil-transmitted helminth (STH) are nematodes, a type of parasitic worm distinguished by their elongate and cylindroidal shape. The three most important STH infections of humans, based on their prevalence and global disease burden, are: ascaris infection (also known as roundworm infection or ascariasis), trichuris infection (whipworm infection or trichuriasis), and hookworm infection (hookworm). Together, these helminth infections afflict over 1 billion people in developing countries. Humans have been infected with STHs since ancient times. The results were impressive and demonstrated that, if we extrapolate for the entire Chinese population, approximately 531 million cases of ascariasis, 212 million cases of trichuriasis, and 194 million cases of hookworm infection had occurred in that country. Urbanization and economic development represent two of the most powerful forces responsible for the control of hookworm infection and other neglected tropical diseases (NTDs). Humans become infected with hookworm through contact with infective larvae that live in the soil. The disease resulting from chronic hookworm infection (sometimes referred to as hookworm disease) is long-standing iron deficiency anemia, which in children is responsible for growth retardation and intellectual and cognitive impairments. Global control of STH infections presently focuses on morbidity reductions through frequent and periodic deworming with benzimidazole anthelmintics (BZAs). There are both theoretical and actual concerns about BZA drug resistance; a human hookworm vaccine is under development.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2

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Parasitic Diseases
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Large Intestine
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Small Intestine
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Ascaris lumbricoides
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Typhoid Fever
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Figures

Image of Figure 2.1
Figure 2.1

Children (left) living outside the Brazilian village of Americaninhas, Minas Gerais State (right). About 75% of people living in the area are infected with hook-worm. The effects of the disease—malnutrition and anemia—are worse in children. Pictures of the children are courtesy of Brigid McCarthy of National Public Radio (© 2005 NPR).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Figure 2.2
Figure 2.2

Prevalence of STH infections among school-age children in Americanin-has, Brazil (data courtesy of Jeff Bethony and David Diemert, Human Hookworm Vaccine Initiative; modified from graph prepared by Sophia Raff).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Figure 2.3
Figure 2.3

The relationship between prevalence of hookworm and poverty. The socioeconomic status of 94 countries was assessed according to a number of commonly used indicators, with poverty measures divided into quartiles including the poorest (first quartile), very poor (second quartile), poor (third quartile), and least poor (fourth quartile). Original comes from de Silva et al., 2003. Figure was later modified for Hotez et al., 2005.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Figure 2.4
Figure 2.4

(Left) Little girl from Paraguay with severe worm infection. Picture is courtesy of Nora Labiano and reproduced from Despommier et al., 2006. (Right) Worms expelled after anthelmintic treatment.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Figure 2.5

Life cycle of the hookworm (from Hotez et al., 2005).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Figure 2.6
Figure 2.6

Severe hookworm disease. The child is both pale and edematous, thus reflecting severe loss of both iron and protein (Public Health Image Library, CDC [http://phil.cdc.gov.]).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Figure 2.7
Figure 2.7

(Left) A Brazilian worker with , chronic hookworm infection (from Klintowitz, 1989). (Right) Jeca Tatu.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 1
Color Plate 1

Developing countries with five or more NTDs. Of the 56 nations with five or more coendemic NTDs, 40 are found in Africa, nine in Asia, five in the Americas, and two in the Middle East (map prepared by Sophia Raff).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 2
Color Plate 2

Global distribution of human hookworm infection. (From Hotez et al., 2005.)

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 3
Color Plate 3

Distribution of human hookworm infection in the American South at the turn of the 20th century. The map displays the rates of hook-worm infection among children by county groups. Red areas indicate the highest infection rates followed by orange, yellow, and green. Data from Bleakley, 2006.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 4
Color Plate 4

Picture of an adult hookworm (courtesy of David Sharf [http://www.electronmicro.com]).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 5
Color Plate 5

The global distribution of schistosomiasis (in red) (http://geo.arc.nasa.gov/sge/health/sensor/diseases/images/schisto.gif).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 6
Color Plate 6

Children in Niger with hematuria (photo courtesy of Juerg Utzinger, Swiss Tropical Institute).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 7
Color Plate 7

Geographic distribution of LF (see http://www.filariasis.org/resources/countries_map_list.htm). Green indicates countries of endemicity in which MDA is implemented; blue indicates countries unlikely to require MDA; red indicates countries and territories where LF is endemic. (Source: ©2008, World Health Organization.)

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 8
Color Plate 8

Map of Southern Sudan showing the Mankien study site.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 9
Color Plate 9

Distribution of onchocerciasis showing current status of global control efforts. Red areas represent areas under ivermectin coverage, yellow areas represent areas requiring further surveillance information, green areas are those covered previously by the OCP in West Africa, and pink areas indicate special intervention zones, i.e., previous OCP areas still receiving ivermectin and some vector control. From Basanez et al., 2006.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 10
Color Plate 10

The global distribution of trachoma (http://gamapserver.who.int/mapLibrary). Green indicates areas with no active trachoma; red indicates areas with data-confirmed endemic active trachoma; in yellow areas, trachoma is believed to be active and endemic, but data are not available.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 11
Color Plate 11

Geographic distribution of Buruli ulcer. Original data source is the WHO/Global Buruli Ulcer Initiative (http://www.who.int).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 12
Color Plate 12

Case of Buruli ulcer from Benin, West Africa (Public Image Library, CDC [http://phil.cdc.gov]).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 13
Color Plate 13

Drawing of under the microscope and following staining. From Rinaldi, 2005.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 14
Color Plate 14

Photomicrograph of stained trypanosomes in the bloodstream (Public Health Image Library, CDC [http://phil.cdc.gov]).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 15
Color Plate 15

Reproduction of J. E. Dutton’s original watercolor drawing of from the blood of an infected patient. Image is from the archives of the University of Liverpool (courtesy of David H. Molyneux).

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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Image of Color Plate 16
Color Plate 16

Geographic overlap of moderate to high hookworm infection prevalence (>20% prevalence of infection among school-age children) and transmission of falciparum malaria (based on a map of climatic suitability for malaria transmission adjusted for urbanization). From Brooker et al., 2004.

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2
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References

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Tables

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Table 2.1

The “unholy trinity”

Citation: Hotez, M.D., Ph.D. P. 2008. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 13-27. In Forgotten People, Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555816339.ch2

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