worm infestation its types, risk factors, etiology, pathophysiology, clinical manifestation, management

1. WORM INFESTATION
Ms Alisha Talwar

2. Worm Infestation
• Worm infestations are long-term diseases that produce
few symptoms in their early stages and sometimes serious
effects at well-developed stages or may be quite fatal at
times.

3. Causative Agent
Worms can be generally classified as
• ROUND WORMS: pin worms, hook worms
• FLAT WORMS: tape worm
• FLUKES: liver fluke

4. Flatworms
• Flatworms include Tapeworms and Flukes.
• Flatworms breathe and eat through their skin.
• They have no separate organs for digestion or circulation.
• Flatworms feed on the blood, tissue fluids, or pieces of cells
inside the bodies of their hosts.
• Flatworms live in humans that infect the blood and organs.
• Flatworms range in size from being microscopic to some
over 20 metres long for example in the whale tapeworm.
This causes
fasciola
hepatica
Fasciolosis

5. Roundworms
• Some of the most common types of Roundworms include
Pinworms or Threadworms, Hookworms and Ascaris.
• Roundworms have hollow bodies and openings at either
end and generally grow between 2-5 inches long.
• Roundworms are very commonly found in pets and animals
such as dogs and cats and can be easily passed on to
humans.

6. Roundworms
• Roundworms live in salt water, fresh water and the soil.
• Eating contaminated foods or getting worms from
contaminated pets is the most usual way to get
roundworms.
• Hookworms and pinworms are often the most common
types of roundworms found in humans.
Pinworm infestation
Hookworm Infestation

8. Etiology
• Fecal contamination of water
• Unsanitary conditions
• Eating raw or undercooked meats or fish
• Keeping animals in close unsanitary conditions
• Rat or insect infestations
• Malnourished or diseased persons

9. Etiology
• Heavy mosquito or fly infestations
• Playgrounds where children can eat or come in contact with
soil
• Raw fish and meat
• Contaminated food
• Contaminated water
• Unhygienic life style

10. Symptoms
Based on the place of stay of the worms, the
symptoms are produced
• No symptoms or very few
• Symptoms may occur immediately or take more than 20
years.
• At times worms can be passed whole or in segments in the
stool.

11. Symptoms
• Digestive tract with intestinal worms causes abdominal
pain, weakness, Diarrhea, loss of appetite, weight loss,
vomiting, anemia, Malnutrition with deficiencies of vitamins
(B 12) minerals (iron), fats, and protein.
• Itching around anus and vagina, inability to sleep, urinating
in bed, and abdominal pain seen in pinworm infections.

12. Symptoms
• Skin - Eruptions, Fluid-filled sacs called vesicles, Intense
facial swelling, especially around the eyes.
• Allergic reactions- Skin rash , Skin itchiness and itchiness
around the anus
• Liver flukes- Enlarged tender liver , Fever , Abdominal
pain , Diarrhea, Yellowish skin
• Lymphatic involvement - Swollen elephant-like legs or
testicles

13. Harms associated with having
worms
Effect of STH on the nutritional status of children
Worms impair the nutritional status of people they infect in
multiple ways
• Worms feed on host tissues, including blood, which leads to a
loss of iron and protein and often contributes to anaemia.
• Worms can increase the malabsorption of nutrients; roundworm
may compete for Vitamin A in the intestine.
• Some worms can cause a loss of appetite, reducing nutritional
intake and physical fitness.
• Some worms can cause diarrhea and dysentery.

14. Development and educational
consequences of worms in children
• Worms have negative effects on the mental and physical
development of children.
• Children with worms are often underweight and have
stunted growth.
• Heavy infections often make children too sick or too tired to
concentrate at or even attend school.
• Long term, children not treated for worms are shown to
earn less as adults.

15. Effect of worms on child mortality
• Intestinal worm infections affect child morbidity, not
mortality.
• There is not rigorous evidence that suggests that worms
affect child mortality but there is ample evidence that
worms fundamentally affect the quality of children’s lives
and negatively impact their access to health, education and
livelihoods.

16. Prophylaxis
• Avoid uncooked meat and raw fish
• Thoroughly cook meat to temperatures of at least 145
degrees Fahrenheit for whole cuts of meat and to at least
160 degrees F for ground meat. Then let it rest for at least
3 minutes before carving or eating. Safe temperatures for
poultry are different.
• Freeze meat to -4 degrees F for at least 24 hours to kill
tapeworm eggs.
• Wash hands with soap and hot water before preparing or
eating foods.

17. Management
• There are several medicines that may be used to treat
worm infections - they are sometimes called anti-helmintics.
• Mebendazole is the most commonly prescribed medicine for
worms.

18. Management
• Other medicines that may be prescribed for the various types of
worm infections include:
• Levamisole
• Niclosamide
• Praziquantel
• Albendazole
• Diethylcarbamazi
• Ivermectin
• Tiabendazole

19. Deworming the children
• Albendazole and Mebendazole are the names of the
deworming drugs used by the Government of India and is a
safe treatment for intestinal worms. The recommended
dosage is as follows
• For children of 2 years and upwards - : 1 tablet
Albendazole (400 mg) or 1 tablet Mebendazole (500 mg)
• For children of age 1 – 2 years - ½ tablet of
Albendazole (400 mg) or 1 tablet of Mebendazole (500 mg)

20. Contd….
• Appropriate administration of tablets to children between
the ages of 1 and 3 years is important.
• The tablet should be broken and crushed between 2
spoons, then water added to help administer the drug.
• The older children should chew the tablet and if required
should consume some water.

21. Side-effects of deworming
• Mild side effects like dizziness, nausea, headache, and
vomiting, all likely due to the worms being passed through
the child’s body.
• These side effects disappear after some time.
• Side effects are usually experienced by children with high
infections.
• If symptoms do not go away within 24 hours, or if they are
very severe, the child is probably experiencing something
unrelated to the treatment and should be taken to the
nearest health facility

22. Benefits of treatment
• Rigorous studies have shown that deworming has a
significant impact on the health, education and livelihoods
of treated children. Outcomes of deworming can include:
• Decreases anaemia and improves nutrition
• Increases growth and weight gain
• Improves cognition and mental and physical development
• Increases resistance to other infections

23. Contd…
• Supports more frequent school attendance
• Improves children’s ability to learn better and be more active in
school
• Increase hours worked and wages earned in the long-run in
adulthood
• Deworming also has important spillover effects, meaning that
other members of the community who do not receive treatment
benefit, as there are fewer worms in the environment.
• This is especially important for children who are too young to be
treated but for whom worms can greatly impair cognitive
development.

24. National Deworming Day-2019
• Aim- to intensify efforts towards STH control among
children in India, the Ministry of Health & Family Welfare,
Government of India (GoI) observes the National
Deworming Day (NDD) bi-annually on 10th February and
10th August in all states and UTs followed by mop-up
activities.
• This year the NDD is being conducted on 8th February and
mop up day on the 14th February. The eighth round of
National Deworming Day (NDD) campaign was initiated
from 8 February 2019.

25. Contd…
• Currently largest single day public health program in the
world, the National Deworming Day this year is set to
reach 24.44 crore children and adolescents in 30
states/UTs, in the age group of 1-19 years.
• The National Deworming Day will be followed by a Mop-Up
Day (MUD) on 14th February 2019 with the intent of
deworming children who missed the dose on February 10th.
All Government and Government aided schools and
anganwadi centers will be the sites for implementation of
National Deworming Day across the country.

26. Target audience
• All children (both boys and girls) in the age group of 1-19
years.
• The NDD is being implemented through the combined
efforts of Department of School Education and Literacy
under Ministry of Human Resource and Development,
Ministry of Women and Child Development and Ministry of
Drinking Water and Sanitation

27. HOOKWORM
INFESTATIONS

28. Hookworm infestations
• Historically, hookworm infection has disproportionately
affected the poorest among the least-developed nations,
largely as a consequence of inadequate access to clean
water, sanitation, and health education.
Ancylostoma
caninum, a
type of
hookworm,
attached to
the intestinal
mucosa

29. Hookworm Infestation
• Human hookworm disease is a common helminth
infection that is predominantly caused by the nematode
parasites Necator americanus and Ancylostoma duodenale;
organisms that play a lesser role include Ancylostoma
ceylonicum, Ancylostoma braziliense, and Ancylostoma
caninum.
• Hookworm infection is acquired through skin exposure to
larvae in soil contaminated by human feces.
• Soil becomes infectious about 9 days after contamination
and remains so for weeks, depending on conditions.

30. Pathophysiology
• The life cycle of hookworms begins with the passing of
hookworm eggs in human feces and their deposition into
the soil.
Ancylostoma braziliense mouth parts. Hookworm, parasite.

31. Pathophysiology
• Each day in the intestine, a mature female A duodenale
worm produces about 10,000-30,000 eggs, and a mature
female N americanus worm produces 5000-10,000 eggs.
• After deposition onto soil and under appropriate conditions,
each egg develops into an infective larva.

32. Contd…
• These larvae are developmentally arrested and nonfeeding;
if they are unable to infect a new host, they die when their
metabolic reserves are exhausted, usually in about 6
weeks.
• Larval growth is most proliferative in favorable soil that is
sandy and moist, with an optimal temperature of 20-30°C;
under these conditions, the larvae hatch in 1 or 2 days to
become rhabditiform larvae, also known as L1.

33. Contd…
• The rhabditiform larvae feed on the feces and undergo 2
successive molts; after 5-10 days, they become infective
filariform larvae or L3.
• These L3 go through developmental arrest and can survive
in damp soil for as long as 2 years; however, they quickly
become desiccated if exposed to direct sunlight, drying, or
salt water. L3 live in the top 2.5 cm of soil and move
vertically toward moisture and oxygen.

34. Contd…
• The larvae migrate through the dermis, entering the
bloodstream and moving to the lungs within 10 days; once
in the lungs, they break into alveoli, causing a mild and
usually asymptomatic alveolitis with eosinophilia.
• In 3-5 weeks, the adults become sexually mature, and the
female worms begin to produce eggs that appear in the
feces of the host.

35. Lifecycle of Hookworm

36. Statistics and Incidences
• Worldwide, hookworms infect an estimated 472 million people.
• Hookworm infection and disease are now most likely to be found
in immigrants, refugees, and adoptees from tropical countries.
• Cutaneous larva migrans is endemic in the southeastern states
and Puerto Rico; the canine hookworm A caninum has
reportedly caused eosinophilic enteritis in Australia and the
United States.
• Human infection with A duodenale or N americanus is estimated
to affect approximately 472 million people worldwide.

37. Contd…
• Infection is most prevalent in tropical and subtropical zones,
roughly between the latitudes of 45°N and 30°S; in some
communities, prevalence may be as high as 90%.
• In 2010, it was estimated that 117 million individuals in
sub-Saharan Africa were infected with hookworms, as well
as 64 million in East Asia, 140 million in South Asia, 77
million in Southeast Asia, 30 million in Latin America and
the Caribbean, 10 million in Oceania, and 4.6 million in the
Middle East and North Africa.

38. Contd…
• In endemic areas, the highest prevalences are reported
among school-aged children and adolescents, possibly
because of age-related changes in exposure and the
acquisition of immunity.
• Studies from China and Brazil indicate a consistently
increasing prevalence, from 15% at age 10 years to 60% at
age 70 years and older; egg counts in stool also increase in
a similar pattern.
• Males and females are equally susceptible to hookworm
infection.

39. Causes
• Hookworms may persist for many years in the host and
impair the physical and intellectual development of children
and the economic development of communities.
• Necator americanus. N americanus is the globally
predominant human hookworm and is the only member of
its genus known to infect human; it is a small, cylindrical,
off-white worm; adult males measure 7-9 mm, and adult
females measure 9-11 mm.

40. Contd….
• Poor sanitation. Poor hygiene habits and sanitation
contribute to the development of hookworm infestations as
they thrive in dirty, unkempt surroundings.
• Limited access to clean water. Ingestion of water
infested with eggs of hookworms leads to the development
of hookworm in humans.

41. Infected foot of female patient

42. Clinical Manifestations
• Hookworms causing lumps and streaks beneath the skin.
• Ground or dew itch- An erythematous, pruritic,
papulovesicular rash develops at the site of initial infection
on the palms or soles and may persist for 1-2 weeks after
initial infection; intense scratching may lead to a secondary
bacterial infection, which is quite common.
• Pulmonary symptoms- When the worms break through
from the venous circulation into the pulmonary air
spaces, cough, fever, and a reactive bronchoconstriction
may be observed, with wheezing heard on auscultation.

43. Contd….
• GI symptoms. Migration of the worms into the
gastrointestinal (GI) tract may cause GI discomfort
secondary to irritation; as the worms mature in the
jejunum, patients may experience diarrhea, vague
abdominal pain, colic, flatulence, nausea, or anorexia.

44. Contd…
• Symptoms of anemia- Signs of iron-
deficiency anemia are often insensitive.; patients may
exhibit pallor, chlorosis (greenish-yellow skin
discoloration), hypothermia, spooning nails, tachycardia, or
signs of high-output cardiac failure.

45. Contd…..
• Cutaneous larva migrans. Cutaneous larva migrans
manifests as pathognomonic, raised serpiginous tracts
(creeping eruptions) with surrounding erythema that may
last as long as 1 month if untreated; lesions are most
commonly seen on lower extremities but may be limited to
the trunk or upper extremities, depending on the site at
which the infective larvae entered the body.

46. Hookworms causing lumps and
streaks beneath the skin

47. Assessment & Diagnostic findings
• Blood studies- Anemia is confirmed by CBC and peripheral
blood smear results that demonstrate signs typical of iron-
deficiency anemia; microscopy reveals hypochromic,
microcytic red blood cells (RBCs); eosinophilia is surprisingly
persistent and may be due to attachment of the adult
worms to the intestinal mucosa.
• Stool examination- The diagnosis is confirmed with direct
microscopic analysis of fecal samples to verify the presence
of hookworm eggs; the specimen is fixed in formalin and
prepared as a wet mount.

48. Medical management
• Most cases of classic hookworm disease can be managed
on an outpatient basis with anthelmintic and iron therapy,
complemented by an appropriate diet.
• Iron therapy. Patients with anemia and malnutrition may
require both iron supplements and nutritional support
(including folate supplementation).
• Antihelmintics. For patients with cutaneous larva migrans
who have minimal symptoms, specific anthelmintic
treatment may be unnecessary.

49. Contd…
• Blood transfusions. Blood transfusion is indicated in rare
cases of acute severe gastrointestinal (GI) hemorrhage; in
patients with chronic anemia, blood transfusions (ie, packed
red blood cells [RBCs]) should be administered slowly and
are usually followed by a diuretic to prevent rapid fluid
overload.

50. Pharmacological Mangement
• Antihelmintics are the drug of choice for hookworm
infections.
• Antihelmintics- Anthelmintic drugs effective against
hookworms include benzimidazoles
• The Centers for Disease Control and Prevention (CDC)
continues to recommend a 400-mg single dose of
albendazole on its Website (July 26, 2018), but notes that
albendazole is still not FDA approved for the treatment of
hookworm infection.

51. NURSING
MANAGEMENT

52. Nursing Assessment
• History- The majority of individuals who develop
hookworm infection are from known endemic areas; they
frequently have a history of wearing open footwear or
walking barefoot in such areas.
• Physical exam- Skin and pulmonary findings are minimal;
physical findings in the early (larval migration) stage of the
disease differ from those in the late (established GI
infection) stage.

53. Nursing Diagnosis
• Acute pain related to mucosal irritation.
• Ineffective tissue perfusion related to blood loss.
• Impaired skin integrity related to persistent scratching
of the affected area.
• Deficient knowledge related to the disease process and
treatment.

54. Nursing Interventions
• Reduce or diminish pain- Provide rest periods to
promote relief, sleep, and relaxation; acknowledge reports
of pain immediately; get rid of additional sources of
discomfort, and determine the appropriate pain relief
method.
• Improve tissue perfusion- Submit patient to diagnostic
tests as indicated; administer blood transfusion as
indicated.

55. Contd…
• Protect skin integrity- Monitor site of impaired tissue
integrity at least once daily for color changes, redness,
swelling, warmth, pain, or other signs of infection; provide
skin care as needed; keep a sterile dressing technique
during wound care; clip the patient’s nails as necessary;
and teach patient and significant others about
proper handwashing, wound cleansing, dressing changes,
and application of topical medications.

56. Contd…
• Enforce knowledge about the disease and its
treatment- Determine priority of learning needs within the
overall care plan; render physical comfort for the patient;
grant a calm and peaceful environment without
interruption; include the patient in creating the teaching
plan; help the patient in integrating information into daily
life; and provide clear, thorough, and understandable
explanations and demonstrations.

57. PINWORM
INFESTATIONS

58. Pinworm Infestations
• Enterobiasis (also called pinworm, seatworm, or
threadworm infection) is a benign intestinal disease caused
by the nematode Enterobius vermicularis. It is the most
prevalent helminthic infection in the United States.
eggs of the human parasite Enterobius vermicularis

59. Contd….
• Enterobius vermicularis is a small nematode.
• This common helminthic infestation has an estimated
prevalence of 40 million infected individuals in the United
States.
• The pinworm is a white threadlike worm that invades the
cecum and may enter the appendix.

60. Contd…
• The female nematode averages 10 mm X 0.7 mm, whereas
males are smaller.
• Article contaminated with pinworm eggs spread pinworms
from person to person.
• All socioeconomic levels are affected; infestation often
occurs in family clusters. Infestation does not equate with
poor home sanitary measures (an important point when
discussing therapy).

61. Pathophysiology
• The life cycle of these
worms is 6 to 8 weeks,
after which reinfestation
commonly occurs
without treatment.

62. Contd…
• Two types of adult of Enterobius vermicularis of which one is
male and the other is female
• E. vermicularis is an obligate parasite; humans are the only
natural host.
• Fecal-oral contamination via hand-mouth contact or via fomites
(toys, clothes) are common methods of infestation.
• After ingestion, eggs usually hatch in the duodenum within 6
hours.
• Worms mature in as little as 2 weeks and have a lifespan of
approximately 2 months.

63. Contd..
• Adult worms normally inhabit the terminal ileum, cecum,
vermiform appendix, and proximal ascending colon; the
worms live free in the intestinal lumen.
• The female worm migrates to the rectum after copulation
and, if not expelled during defecation, migrates to the
perineum (often at night) where an average of 11,000 eggs
are released.
• Eggs become infectious within 6-8 hours and, under
optimum conditions, remain infectious in the environment
for as long as 3 weeks.

64. Life cycle of Enterobius
vermicularis

65. Contd…
• Prevalence is approximately 5-15% in the general
population; however, this rate has declined in recent years;
prevalence rates are probably higher in institutionalized
individuals; humans are the only known host.
• Infestation rate increases with increased population density,
and with personal habits such as thumb sucking.
• E. vermicularis infestation occurs worldwide. Prevalence
data vary by country.

66. Contd…
• A study that aimed to determine the extent of enterobiasis,
strongyloidiasis, and other helminth infections in infants,
preschool-aged, and school-aged children from rural coastal
Tanzania reported that Enterobius vermicularis infections were
found in 4.2% of infants, 16.7%, of preschool-aged children,
and 26.3% of school-aged children.
• Secondary bacterial skin infection may develop from vigorous
scratching to relieve pruritus.
• The people most likely to be infected with pinworms are children
younger than 18 years, people who take care of infected
children, and people who are institutionalized; in these groups,
the prevalence can reach 50%.

67. Statistics and Incidences
• The incidence of enterobiasis are highest in school-age
children and next highest in preschoolers.

68. Clinical Manifestations
• Perianal itching. Intense perianal itching is the primary
symptom of pinworms. This occurs especially at night when the
female worm leaves the anus to deposit ova.
• Erythema. Patients often have excoriation or erythema of the
perineum, vulvae, or both, but infestation can occur without
these signs.
• Abdominal pain. Abdominal pain may sometimes be severe
and can mimic acute appendicitis.
• Visual worm sighting. Visual sighting of a worm by a reliable
source (e.g., a parent) is usually accepted as evidence of
infestation and grounds for treatment.

69. Assessment and Diagnostic
Findings
• The usual method of diagnosis is to
use cellophane tape to capture the
eggs from around the anus.
• Cellophane tape test The
cellophane tape test for identifying
worms is performed in the early
morning, just before or as soon as
the child wakens; the tape is then
examined microscopically for eggs
in the laboratory.
“Enterobius vermicularis”
or pinworm parasite

70. Medical Management
• Handwashing- Thorough and regular handwashing is
effective in preventing disease transmission.
• Personal hygiene- Changing personal habits such as
thumb-sucking or nail-biting may reduce re-infection; The
child should also be encouraged to observe other hygiene
measures, such as regular bathing and daily change of
underclothing; the nurse should teach caregivers to keep
the child’s fingernails short and clean.

71. Pharmacological Management
• Drug therapy with pyrantel, mebendazole, or albendazole is
the current standard in treating enterobiasis
• Anal albendazole. Anal albendazole may help with
symptoms of pruritus ani.

72. NURSING
MANAGEMENT

73. Nursing Assessment
• History-Patients with enterobiasis are often asymptomatic.
Worms may be incidentally discovered when they are seen
in the perineal region; if patients are symptomatic, pruritus
ani and pruritus vulvae are common presenting symptoms.
• Physical exam- Worms can be found in stools or on the
patient’s perineum before bathing in the morning.

74. Nursing Diagnosis
• Risk for impaired skin integrity related to intense
perianal scratching.
• Acute pain related to smooth muscle spasm secondary to
migration of parasites in the stomach.
• Imbalanced Nutrition: less than body
requirements related to anorexia and vomiting.
• Hyperthermia related to decrease in circulation secondary
to dehydration.

75. Nursing Interventions
• Administer medications as ordered. Drug therapy with
pyrantel, mebendazole, or albendazole to destroy the causative
parasites. Effective eradication requires treatment of the
patient’s family or members of the household.
• Inform patient of the side effects of pyrantel. Stool may
be bright red and may cause vomiting. The tablet form of this
drug is coated with aspirin and shouldn’t be given to aspirin-
sensitive patients.
• Improve skin integrity. Application of an antipruritic ointment
or albendazole may help control scratching; keeping the
patient’s fingernails trimmed to prevent excoriations is helpful.

76. Contd…
• Diminish pain. An antihelminthic medication should be
prescribed to patients with enterobiasis.
• Improve hygienic status. Avoid scratching the area and
nail-biting because this is a cause of autoinfection;
thorough handwashing should be done before and after
meals. Tell family not to shake bed linens to avoid
aerosolization of eggs that may be found on linens.
• Diminish increase in temperature. Administer
antipyretics as prescribed; tepid sponge baths may also be
given

77. Research Article
A study of prevalence of intestinal worm infestation and
efficacy of antihelminthic drugs
Kumar, H., Jain, K., & Jain, R. (2014)
Background
• Intestinal worm infestation is a global health problem. Soil-
transmitted helminth (STH) infections form the most important
group of intestinal worms affecting two billion people worldwide,
causing considerable morbidity and suffering, though entirely
preventable. The present study was undertaken to measure the
parasite load in the target population and evaluate the efficacy
of anthelminthic drugs.

78. Methods
• Current study was undertaken from 01 July 2012 to 30 June 2013. All
outdoor as well as indoor patients advised stool examination formed the
study population and it included 2656 males and 76 females (including 6
children). Investigations included stool examination and blood counts. A
single-oral dose of anthelminthic drug was given to all positive cases. Stool
tests were repeated after 14–21 days to evaluate cure rate.
Results
• Overall prevalence of intestinal worm infection was found to be 49.38%.
Ascaris was the most common parasite (46.88%), followed by Taenia
(2.1%) and Hymenolepis nana (0.21%). Cure rate was found to be 66% for
Ascaris and 100% in other cases.
Conclusion
• The study reveals high prevalence of intestinal helminths in our subject
population and calls for immediate control measures, including preventive
chemotherapy and treatment of entire ‘at risk’ population and improvement
of their living conditions including provision of potable water.

79. NURSING
MANAGEMENT

81. References
• Dutta, P. (2018). Paediatric nursing. (4th ed.). Jaypee Publications Pvt Ltd. India
• Study Guide for Wong's Essential of Pediatric Nursing - Elsevier eBook on VitalSource , 10th
Edition
• https://nurseslabs.com/hookworms/
• https://nurseslabs.com/enterobiasis/
• https://www.cdc.gov/parasites/liver_flukes/index.html
• https://www.dairyknowledge.in/content/management-worm-infestation
• https://www.who.int/intestinal_worms/more/en/
• Kumar, H., Jain, K., & Jain, R. (2014). A study of prevalence of intestinal worm infestation
and efficacy of antihelminthic drugs. Med J Armed Forces. 70(2). 144-148
• http://vikaspedia.in/health/sanitation-and-hygiene/importance-of-deworming-in-children
• http://vikaspedia.in/health/diseases/common-problems-1/common-problems