When we were kids, we used to sing this song, which annoyed my mother…LINK

Nobody likes me, everybody hates me,
Guess I’ll go eat worms,
Long, thin, slimy ones; Short, fat, juicy ones,
Itsy, bitsy, fuzzy wuzzy worms.

But actually, worms are a health problem, not because they kill you (they rarely do) but not because you eat them, but because they make you tired and weak, and your body has trouble fighting off other infections.

So it is good news that a drug company and a private NGO, the Taskforce for Child Survival and Development, are teaming up to start deworming children in poor countries:

“Johnson & Johnson is committed to donating 50 million doses of mebendazole in 2007 to treat 25 million children in several countries, the largest pharmaceutical donation to treat intestinal worms to date. After Cameroon, doses will go to Bangladesh and Uganda”

The medicine they will give out is Mebendazole. It is not the cheapest, but it is the easiest medicine to use, since you don’t have to calculate the dosage as when you give out piperazine and it kills several different types of worms.

Essentially, it kills three worms: Pinworms, hookworms, and roundworms.

Most moms know about Pinworms. They are the ones that make your kid itch and scratch their bottoms. To diagnose them, we give moms a piece of scotch tape or a special sticky slide with instructions to pat it around the anus early in the morning. Often the mom sees the tiny wiggly threads there when she does it, and if not, you find the eggs on the slide. If you find them, you have to treat the entire family to keep it from bouncing from one person to another. They spread via dirty fingers, so they can spread through families and schools. However, pinworms are essentially only annoying, not a threat to health.

Then you have roundworms or Ascaris.LINK2.

These are long tan pencil sized worms that look like earthworms without wrinkles. Usually when a kid passes them, the mom calls us in panic (sometimes at night), but unless you have a lot of them, they rarely cause problems. Usually we treat the kid and that’s the end of it.

But in countries where kids are already poorly nourished, the worms can absorb nutrition that the kid needs. And some kids have hundreds of worms: You feel their bloated stomachs, and feel firm wormy intestines. Sometimes the child has so many they actually block the intestines, and if you don’t operate they die. But the most terrible thing about the ascaris is that when you are sick with vomiting and diarrhea, the worms, who are anchored onto the wall of the intestine, get unstuck, and migrate. Not only do you pass the worm with the diarrhea, sometimes they come up when you vomit and stick in the thoat and the child chokes to death.

Finally, if you eat something with a lot of worm eggs, you can get a cough. They travel into the blood, through the lungs, you cough them up and then swallow them again before you are infected. If you eat a lot of eggs, you can actually get pneumonia type symptoms.

Ascaris is also spread through the “finger feces food” route, but since the kids are less likely to be scratching down below fifty times a day, they don’t usually spread through families like Pinworms.

Usually the worm is spread through food that had dirt on it, or from eating dirt. Since we have toilets in the USA and don’t usually use human dung for fertilizer, it’s not a major problem

However, in the third world villages, often they don’t have privies, and a lot of people won’t use them because they are dirty. So often they go to a specified area outside , make a small hole, and do their business. When I was in Africa, the phrase was not “go to the bathroom” but “go to the forest”. Also, children often just go where and when they want. No pampers, just moss or cloth diapers or open bottoms. (Remember: In the heat, dirty diapers cause terrible rashes. So it is actually cleaner to use nothing).

When you have to walk a mile to fetch water, the hands might not be washed as thoroughly as in countries with running water. That is probably why many religions (the Bible, Hinduism, Islam) have washing rituals as part of their religious practices: The Lord God, or the Holymen who took his dictation, tried to keep people healthy, not just holy, and many of the rules about eating, clothing, hygiene etc. make sense to a doctor. And the tradition of religion promoting health continues to this day. That’s why Ghandi used to carry a toilet with him, teaching about priveys along with holiness, and why church organizations run much of the rural hospitals and clinics in Africa.

But it is the last worm, hookworm,LINK2 LINK3the is the real danger to life.

The other two worms “eat” by absorbing partially digested food. Hookworms hook into the wall of the intestine, and drink your blood. The worms are small, but you might have of thousands of them.

If you have a few, you might not be bothered at all. If you have more, you end up anemic, lacking blood, and tired all the time. You know the old stereotype in the USA of the “Lazy white Southerner”? Well, that lazy southerner was probably anemic from hookworm.

In areas where there is hookworm, you often see the kid for another reason and he is pale. In epidemic areas, we just treat every kid we see, and often if you can get the money, give out the medicine with baby clinics or in schools. Sometimes we see these kids when they are terribly anemic, with swollen abdomens and trouble breathing with a hemoglobin of 3 or 4 (normal is 12). So we have to transfuse them with blood, even though the transfusion has a risk of giving the child HIV or hepatitis. If they aren’t at death’s door, another treatment is to give an iron infusion. This can cause major allergic reactions, but usually within a day or two the kid starts to improve.

Now, hookworms are also spread in a cycle that includes feces, so one way to treat them is to build priveys and try to get people to use them

But unlike the previous two germs, you don’t get the worm from eating wormeggs with food. Instead, the hookworm hatch into little worms and when you walk over contaminated soil, they enter your skin and can cause an itch. This is why the usual village hygiene of having a toilet area outside of the village might not work if the hole isn’t dug deep enough. You need a deep hole privey, and if you don’t want kids and animals to fall into the holes, you need a cover for it. But since everyone goes to the same small area, if you want privacy, you need a curtain or wall. But then the wall hold in smells and flies. So many people won’t go in such a dirty area, prefering a “clean” area behind a tree. But of course, when you go to your area, you are walking over where others have gone before, and can pick up hookworm if you aren’t wearing expensive shoes.

When the worm enters the skin, it goes up through the lungs and can cause pneumonia. Then you cough it up, swallow the phelgm, and voila, when it hits the small intestine, it hooks in and sucks blood.

The public health treatment of this also is to have kids wear shoes, rather than bare feet and sandals, since the worm enters the skin of the feet. But shoes are expensive…and hot…and have to be replaced and resoled all the time.

Having enough water to properly clean also helps. But this often means either deep wells or having an easy way to purify shallow well water. And, of course, it means making the water near the village so that it is available even in the dry season when the streams and shallow wells are dry.

So the good news: these worms can be prevented by building priveys, good water supplies (making it easier to wash hands and food) and shoes. The bad news is that doing these things takes time, so in the meanwhile, the treatment of those who have the worms is a good idea.

So three cheers for those who actually are trying to help

———–Nancy Reyes is a retired physician living in the rural Philippines with her husband. Her webpage is Finest Kind Clinic and Fishmarket and she writes medical essays on Hey Doc Xanga Blog

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