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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 neglected tropical diseases (NTDs) are the most common infections of the world’s poorest people, and the soil-transmitted helminth (STH) infections are the most common NTDs. The three most important STH infections of humans, based on their prevalence and global disease burden, are: (i) infection (also known as roundworm infection or ascariasis); (ii) hookworm infection (hookworm); and (iii) infection (whipworm infection or trichuriasis). Together, these helminth infections afflict more than 1 billion people in developing countries. The intestines of hundreds of millions of children living in Africa, Asia, and the Americas harbor a menagerie of worms. Harold Brown, the late former parasitology professor at Columbia University College of Physicians and Surgeons, frequently referred to , , and hookworms as “the unholy trinity” to indicate that it was extremely common for a child to be infected with all three parasites simultaneously. In addition to their enormous global prevalence and their intimate link with rural poverty, another important feature of STH infections is their predilection for affecting children more than adults. The unholy trinity adversely affects the neuropsychiatric activities of children, in turn damaging school performance and reducing school attendance. Currently, the most effective approach to the control of STH infections is through deworming of large populations through mass drug administration of anthelmintic drugs belonging to the benzimidazole class (sometimes referred to as benzimidazole anthelmintics or BZAs).

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2

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Parasitic Diseases
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Typhoid Fever
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Large Intestine
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Small Intestine
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Necator americanus
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Figures

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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 hookworm. The effects of the disease—malnutrition and anemia—are worse in children. (Photos of the children courtesy of Brigid McCarthy of National Public Radio [© 2005 NPR].)

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Image of Figure 2.2
Figure 2.2

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

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.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 from de ; later modified for )

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Image of Figure 2.4
Figure 2.4

(Left) Little girl from Paraguay with severe worm infection. (Right) Worms expelled after anthelmintic treatment. (Photos courtesy of Nora Labiano; reproduced from .)

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Image of Figure 2.5
Figure 2.5

Global distribution of human hookworm infection. (From .)

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Image of Figure 2.6
Figure 2.6

Distribution of human hookworm infection in the American South at the turn of the 20th century. The map displays the rates of hookworm 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 P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Image of Figure 2.7
Figure 2.7

Life cycle of the hookworm . (From .)

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Image of Figure 2.8
Figure 2.8

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

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Image of Figure 2.9
Figure 2.9

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

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Image of Figure 2.10
Figure 2.10

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

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Image of Figure 2.11
Figure 2.11

Proportion of children (1 to 14 years of age) by country requiring preventive chemotherapy for soil-transmitted helminthiases, worldwide, 2010. (See http://gamapserver.who.int/mapLibrary/Files/Maps/Global_STH_2010.PNG [© 2011 WHO].)

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2
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Tables

Generic image for table
Table 2.1

The “unholy trinity”

Citation: Hotez P. 2013. “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection, p 17-40. In Forgotten People Forgotten Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555818753.ch2

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