eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Hookworm Infection: Follow-up

Author: Christopher M Watson, MD, Pediatric Critical Care Fellow, Johns Hopkins Hospital; Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences
Coauthor(s): Patrick W Hickey, MD, FAAP, Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences; Consulting Staff, Department of Pediatrics, Division of Pediatric Infectious Disease, Walter Reed Army Medical Center
Contributor Information and Disclosures

Updated: Oct 7, 2008

Follow-up

Further Inpatient Care

  • Repeat the stool examination 2 weeks after treatment is started.
  • If the results remain positive, the course of therapy should be repeated.

Further Outpatient Care

  • Iron supplements and nutritional support to include folate supplementation may be necessary in patients with anemia and malnutrition.

Deterrence/Prevention

  • Although walking barefoot outdoors in endemic areas should be discouraged, the effect of wearing proper footwear on hookworm transmission is likely to be overestimated.
  • Public health education about proper hygiene and sanitation considerably reduces the risk of infection.
  • In 2001, the World Health Assembly passed a resolution to encourage antihelmintic treatment in at least 75% of at-risk school-aged children by 2010 to control morbidity.2
  • School-based deworming programs are unlikely to adequately control the prevalence of hookworm infection. However, they are likely to substantially affect children's nutritional status, cognitive development, and productivity. Children with hookworm anemia have notably decreased scores on cognitive function tests and delayed acquisition of language and motor skills. With treatment of the infection and anemia, their educational performance and productivity improve.16,17,19
  • As the understanding of the immunoepidemiology and the molecular pathogenesis of hookworm infection improves, the identification of a safe and effective vaccine remains a high priority. The development of an efficacious vaccine requires molecular targeting of both larval and adult stages in order to break the reproductive cycle. In this regard, the Ancylostoma -secreted proteins (ASPs) are one group of potentially promising targets.20,21,22
  • In 2006, a phase I clinical trial was conducted on a N americanus ASP-2 (Na -ASP-2) vaccine that demonstrated the vaccine was both safe and well-tolerated.23 In addition, the vaccine evoked sustained cellular immune responses and elevated immunoglobulin titers. Other larval and adult stage targets have been identified and additional preclinical studies are being conducted. With additional investigation and further trials, these vaccines will offer an appealing novel strategy to prevent hookworm infections globally. 

Prognosis

  • With proper treatment, the prognosis is excellent.
  • In endemic areas, reinfection is common.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize, diagnosis, and properly treat hookworm disease in any patient having traveled from or through endemic regions is a pitfall.

Special Concerns

  • Severe anemia disproportionately affects pregnant women and children because of their low preexisting iron stores.
  • Significant correlation between maternal anemia (nutritional or parasitic) and increased risk of premature and low-birth weight (LBW) infants is observed.24  LBW infants subsequently have elevated overall morbidity and mortality rates compared with neonates of average weight. As a result, one strategy to reduce LBW is prenatally treating mothers for presumptive parasitic infections. A clinical trial of prenatal treatment with mebendazole in addition to iron supplementation conducted among pregnant mothers in Peru, where the prevalence of hookworm infection is high, demonstrated a small but significant reduction in the incidence of very-LBW neonates.25 . Given the potential benefits for both mother and child, this avenue of treatment warrants further investigation.
  • Commonly, children with chronic infection perform worsen in school and have decreased productivity.16,26  The etiology of this cognitive impairment is likely multifactorial, secondary to both chronic iron-deficiency anemia and missed learning opportunities.
  • In physical terms, children with chronic infection also have linear growth retardation or "stunting."13
  • Although rare, neonatal infection with A duodenale contracted by means of breastfeeding may lead to fulminant GI hemorrhage.
 
Acknowledgments

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the National Naval Medical Center, Walter Reed Army Medical Center, Uniformed Services University of Health Sciences, Department of the Navy, Department of the Army, or the Department of Defense.



More on Hookworm Infection

Overview: Hookworm Infection
Differential Diagnoses & Workup: Hookworm Infection
Treatment & Medication: Hookworm Infection
Follow-up: Hookworm Infection
Multimedia: Hookworm Infection
References
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References

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  2. World Health Organization. Parasitic Diseases. WHO. Available at http://www.who.int/vaccine_research/diseases/soa_parasitic/en/index2.html. Accessed September 6, 2008.

  3. Capello M, Hotez PJ. Chapter 276: Intestinal Nematodes. In: Long SS, ed-in-chief; Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Philadelphia, PA: Churchill Livingstone, an imprint of Elsevier Science; 2008:1298-1300.

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  12. AAP. Hookworm infections. In: Red Book 2006: Report of the Committee on Infectious Diseases. 27th ed. American Academy of Pediatrics; 2006:374-5.

  13. Stoltzfus RJ, Albonico M, Tielsch JM, Chwaya HM, Savioli L. Linear growth retardation in Zanzibari school children. J Nutr. Jun 1997;127(6):1099-105. [Medline].

  14. Bethony J, Brooker S, Albonico M, Geiger SM, Loukas A, Diemert D, et al. Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm. Lancet. May 6 2006;367(9521):1521-32. [Medline].

  15. Stoltzfus RJ, Chway HM, Montresor A, et al. Low dose daily iron supplementation improves iron status and appetite but not anemia, whereas quarterly anthelminthic treatment improves growth, appetite and anemia in Zanzibari preschool children. J Nutr. Feb 2004;134(2):348-56. [Medline].

  16. Stoltzfus RJ, Kvalsvig JD, Chwaya HM, et al. Effects of iron supplementation and anthelmintic treatment on motor and language development of preschool children in Zanzibar: double blind, placebo controlled study. BMJ. Dec 15 2001;323(7326):1389-93. [Medline].

  17. Le Huong T, Brouwer ID, Nguyen KC, Burema J, Kok FJ. The effect of iron fortification and de-worming on anaemia and iron status of Vietnamese schoolchildren. Br J Nutr. May 2007;97(5):955-62. [Medline].

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  23. Bethony JM, Simon G, Diemert DJ, et al. Randomized, placebo-controlled, double-blind trial of the Na-ASP-2 hookworm vaccine in unexposed adults. Vaccine. May 2 2008;26(19):2408-17. [Medline].

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  25. Larocque R, Casapia M, Gotuzzo E, et al. A double-blind randomized controlled trial of antenatal mebendazole to reduce low birthweight in a hookworm-endemic area of Peru. Trop Med Int Health. Oct 2006;11(10):1485-95. [Medline].

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Further Reading

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Keywords

hookworm infection, Ancylostomatidae, ancylostomiasis, Necator americanus, N americanus, A duodenale, Ancylostoma duodenale, ground itch, anemia, malnutrition, eosinophilic enteritis, hypoproteinemia, pruritic dermatitis, Wakana syndrome, Loeffler syndrome, pulmonary infection, pica, syncope

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Contributor Information and Disclosures

Author

Christopher M Watson, MD, Pediatric Critical Care Fellow, Johns Hopkins Hospital; Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences
Christopher M Watson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Patrick W Hickey, MD, FAAP, Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences; Consulting Staff, Department of Pediatrics, Division of Pediatric Infectious Disease, Walter Reed Army Medical Center
Patrick W Hickey, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Martin Weisse, MD, Program Director, Associate Professor, Department of Pediatrics, West Virginia University
Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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