It’s worm inside

Moving cooked spaghetti! A five-year-old girl had just spewed up a bolus of worms.

My eldest sister who was manning the registration table, being non-medically oriented struggled to keep her composure and bland expression, but her eyes, at least to me, gave her away. We had happily tagged along with our brother, a then medical student, whose professor had fielded him in to help out an underprivileged community. We had all grown up being exposed to such situations. My grandfather, a Protestant minister, and my grandmother had made it a point to regularly involve the members of the clan, regardless of age, in medical missions in our province long before we realized what they were trying to teach us. Poverty and its consequences were familiar faces.

Who wouldn’t be moved by data that one out of three children under 5 years old in the Philippines are stunted, coupled with a recent report by the Programme for International Student Assessment among 15-year-olds that we are underperforming in reading comprehension, mathematics, and science. According to poverty statistics for the first quarter of 2023 by the Philippine Statistics Authority, 22 percent of the population was unable to meet their basic food and nonfood needs. An average Filipino would need P2,759 a month to survive, an amount which, to some, would just be the cost of a meal in a restaurant. One need not be a genius to connect the dots. Nutrition plays a major part in a child’s development.

“Mag-tsinelas ka, bubulatihin ka.” “Ang payat po ng anak ko, malakas naman kumain, may bulate kaya po siya, Dok?” These questions have a basis. There are worms, or in medical terms, soil-transmitted helminths which may be acquired through ingestion of fertilized eggs from contaminated hands, water, or improperly washed fruits or vegetables wherein human waste was used as fertilizer, or penetration of skin via larvae. These infections are more prevalent among preschool and school-aged children because of their propensity to play outdoors. Incidence however is greater in impoverished areas where there is a lack of handwashing facilities and latrines which encourages open defecation. In the Philippines, studies done from 2007-2018 included roundworms and hookworms as causative agents. While there are many causes of malnutrition, there are few studies to my knowledge that deal with how much of an impact intestinal parasitic infections have on nutritional indices such as wasting or stunting.

The little girl described above had played host to the roundworm called Ascaris. She must have ingested more than a fair share of fertilized eggs that caused such a heavy infection. To give you an idea of its life cycle, eggs hatch in the small intestine and turn into larvae that penetrate intestinal walls and subsequently are carried hematogenous or through lymphatics to organs such as the liver and the lungs. In the intestines, these larvae grow into adult worms and from readings, if both males and females are present, a female worm is said to be capable of producing 200,000 fertilized eggs per day. Once passed out into the stool, it takes around two to four weeks to become infective. If you have come across horrific reports of Ascaris being found in the brains or kidneys, it is not an impossibility as worms may also migrate to such ectopic sites.

While this may not sound like an urgent public health concern, let me tell you it is. For one, most infections are asymptomatic and infection is not limited to preschool or school-age children. For as long as hygienic practices and facilities for proper human waste disposal are wanting, anyone can get an infection. Second, while treatment is available, reinfection is possible and there is no such thing as lasting immunity.

This coming Tuesday, I have been tasked to lecture on intestinal parasitism and provide insights to the pediatric community on why, as one professor of mine in public health had said, we remain a wormy country. Poring through the literature, multiple reasons have been stated. Poverty and lack of sanitation have been repeatedly mentioned. Others include a notable lack of knowledge and awareness of soil-transmitted helminthic diseases, their mode of transmission, and preventive measures, aside from a lack of political will. Even though there is a national program in place and there are initiatives such as regular school-based mass deworming programs, implementation is dependent on how the local government units see the problem and make it a priority. Mere knowledge does not necessarily translate into action. In a sea of health problems, it would take years for us to eradicate or provide lasting solutions for dengue, tuberculosis, or vaccine-preventable diseases. For this problem at least, we have a chance of wriggling our way out if we seriously put our minds to it.

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