“Evaluation of three methods for laboratory diagnosis of infection”. They are transmitted by eggs present in human faeces which in turn contaminate soil in areas where sanitation is poor. 178. Newberry, AM, Williams, DN, Stauffer, WM, Boulware, DR, Hendel-Paterson, BR, Walker, PF. Clin Microbiol Rev. Single-dose or short-course regimens with these oral agents (albendazole 400mg once or mebendazole 500mg once, or 100mg BID for 3 days) cure more than 90% of Ascaris infections. vol. What Laboratory Studies Should You Order and What Should You Expect to find? 2004. pp. Production of bloody mucus from the mucosa occurs, with anemia and impaired growth as possible sequelae. “Disseminated strongyloidiasis successfully treated with extended duration ivermectin combined with albendazole: a case report of intractable strongyloidiasis”. Courtesy Division of Parasitic Diseases/CDC. Clin Infect Dis. Trichinella spiralis (Figure 1) is a nematode parasite that lives in the small intestine. 197-288. ... gut but no vegetative Bt cells were observed in intestinal tissue of the nematodes and neither showed … 1986. pp. When the host becomes infected, often by oral ingestion of infective eggs, the parasite establishes in its intestinal niche. Following contact with human skin, larvae enter the body and are carried to the lungs. 2008. pp. e5-8. 2007. pp. Infections in such persons generally resolve within a few years even without treatment when the adult worms die. Although most of these larvae exit the gastrointestinal tract via the stool and subsequently develop into adult worms in the soil, a small number directly become infective (filariform) larvae within the gut and penetrate the intestinal mucosa or perianal skin, completing the life cycle without leaving the host (see Figure 14). Although alternative antiparasitic drugs are available, none are superior to albendazole or mebendazole for all of the intestinal helminths. Passage of tapeworm proglottids in the stool can occur, although these appear macroscopically different from nematodes. Females start egg deposition 4-6 weeks after infection. Soil type is another environmental factor important for hookworm transmission. Albonico, M, Montresor, A, Crompton, DW, Savioli, L. “Intervention for the control of soil-transmitted helminthiasis in the community”. 79. 77. "A total of 34 subjects with the mixed infections were treated with oxantel/ pyrantel tablets (100 mg/tablet each) in a … In developing countries, strongyloidiasis prevalence rates can be striking, for example, 25% in Thailand and Nigeria, 28% in Brazil, and 40% in Colombia. Epigastric pain, diarrhea and anorexia may occur about 6-12 weeks after skin penetration, as larvae begin attaching to the small bowel mucosa. Schad, GA. “Cyclosporine may eliminate the threat of overwhelming strongyloidiasis in immunosuppressed patients”. For hookworm, single-dose albendazole (400mg) is preferred over single-dose mebendazole (500mg). Examination of up to seven stool samples can significantly increase sensitivity. vol. Parasitol Res. 282-8. Larvae then molt over 5-10 days, subsequently becoming infectious. No accepted guidelines exist regarding the issue of chemoprophylaxis for infections with STHs or Strongyloides. Pyrantel pamoate (11mg/kg single dose, maximum 1g) is an alternative for Ascaris and hookworm, and ivermectin (200mcg/kg once for Ascaris and 200 mcg/kg QD for 3 days for Trichuris) is an alternative for Ascaris and whipworm. Register for free and gain unlimited access to: - Clinical News, with personalized daily picks for you Unfortunately, the lack of good animal models and a poor understanding of how helminths persist in humans in the face of a potent immune response have hindered the development of an effective vaccine. It is thought that this shift in immunological response may impact the manifestations of allergic and rheumatologic diseases, as well as the response to infections typically controlled by the Th1 response, such as tuberculosis. Agrawal, V, Agarwal, T, Ghoshal, UC. 2006. pp. 2175-80. Preliminary data suggest that mebendazole may be slightly superior to albendazole for whipworm and that combination therapy with ivermectin may be superior to albendazole or mebendazole monotherapy. Therefore, their occurrence is highest in areas of poor hygiene [ 1 nematode epithelial junctions causing efficient bacterial host infection and dead of the nematode. They have managed to live in a large variety of habitats. These either continue the free-living cycle by maturing into adults or become infective filariform larvae (see Figure 13). 616-8. Intestinal nematode parasites are very common infections of man and his domestic animals. Control of S. stercoralis in vivo is most dependent on the Th2 immune response, but the predominant immune response in HTLV-infected patients shifts from Th2 to Th1. vol. Strongyloidiasis is a human parasitic disease caused by the nematode Strongyloides stercoralisinfecting 30–100 million people. Figure 10), although eggs are the life cycle stage most readily identified for diagnosis. Genta, RM. 680-2. The adult lifespan averages 3-5 years for N. americanus and 1 year for A. duodenale. Eggs shed in the feces become infective under appropriate (moist and shady) conditions, after about 2-4 weeks on soil. vol. Intestinal nematode infection induces the development of T h 2-type immune responses including the B-cell IgE response; additionally, this infection induces an increase in the numbers and activation of various types of effector cells, such as mast cells, eosinophils and basophils, as well as the induction of goblet … 799-807. Tariq, M.Z. This vaccine targets the larval forms of hookworms, but not adult worms. Pneumonitis is common, with cough, respiratory failure, and diffuse interstitial infiltrates or consolidation on radiographs; respiratory secretions often contain the parasite. 33. 239-46. Elimination from the host involves a potent inflammatory response mediated by Th2 controlled mast cells which release proteases and other inflammatory mediators, creating an environment hostile to parasite survival. 2000. pp. 41. The intestinal forms of these helminths can be asymptomatic or can mimic some symptoms of intestinal nematode infection (e.g., abdominal pain, nausea, malaise). vol. “Trichuriasis”. Nematodes are the most prevalent worms worldwide dwelling the intestine of humans. - Drug Monographs Home » Decision Support in Medicine » Infectious Diseases. 2006. pp. Most people infected with Ascaris are asymptomatic, although a small proportion develop cough during the initial phase of infection, when Ascaris larvae are migrating through the lungs (usually about 1-2 weeks after infection). 2008. pp. Acta Trop. Trans Royal Soc Trop Med Hyg. Parasite Immunol. Primarily, prevention involves better fecal-oral hygiene, provision of clean food and water, good community-wide sanitation, and use of adequate footwear use in endemic areas. Eosinophilia is uncommon with pinworm infection. 2009. pp. vol. until ≥7-14 days after clearance of the parasite). Sato, Y, Kobayashi, J, Toma, H, Shiroma, Y. A total of 79 dogs (33.6%) were infected with one or more intestinal nematodes. A number of intestinal nematodes cause diseases affecting human beings, including ascariasis, trichuriasis, and hookworm disease. The number of people infected with Ascaris lumbricoides worldwide is probably second only to the number infected with the … vol. Am J Clin Pathol. In order to eliminate the infection Th2 cells have to migrate from the mesenteric lymph node back to the site of infection where they control locally, through the secretion of type 2 cytokines, innate effector cells. Enterobius eggs are best identified by microscopic examination of adhesive cellophane tape applied to the perianal region (best done early in the morning); eggs are not generally seen in stool. 2000. pp. Chest. “hyperinfection syndrome after heart transplantation: case report and review of the literature”. 17. vol. Soil-transmitted helminths are among the most common of human parasites. 1040-7. Zentralbl Mikrobiol. Ann Pharmacother. Clin Infect Dis. 2004. pp. Studies based on stool examination in the 1960s and 1970s showed Strongyloides prevalence rates of 0.5-4.0% in differing US cohorts, mostly in the Southeast and Appalachia, although prevalence has subsequently decreased. 10-14 days at 30°C or 6 weeks at 17°C). Steinmann, P, Zhou, XN, Du, ZW. Adult Ascaris worms are typically white or pink, non-segmented, 15-45cm long, and live in the small intestine (see Figure 1). 2004. pp. Trans Roy Soc Trop Med Hyg. Approximately 1 billion people are infected with Ascaris (the most common helminth infection of humans), about 800 million with Trichuris, and 700 million with hookworm. vol. Adult A. lumbricoides worm. 221-61. 755-67. Although N. americanus can only be transmitted via this percutaneous route, A. duodenale can also be transmitted orally. 1265-73. Well-recognized risk factors for Enterobius infection include overcrowding, poor sanitation, and lack of water for bathing and washing of hands and clothes. here. 1994. pp. Sampling duodenal fluid or small bowel biopsy can increase sensitivity, but practical issues limit usefulness. 2006. pp. 1997. pp. 35. “Efficacy of stool examination for detection of infection”. 2004. pp. 1996. pp. In endemic areas, the prevalence is commonly as high as 80%. Hall, A, Hewitt, G, Tuffrey, V, de Silva, N. “A review and meta-analysis of the impact of intestinal worms on child growth and nutrition”. Because of these difficulties with microscopy, serologic tests, such as the enzyme-linked immunoassay offered by the Centers for Disease Control and Prevention (CDC; Atlanta, GA), which are more sensitive and are often favored for the diagnosis of strongyloidiasis. Adv Parasitol. 101. Although most pinworm infections are asymptomatic, perianal pruritis can be severe. Chronic strongyloidiasis is not generally associated with pulmonary symptoms. 153. Courtesy Division of Parasitic Diseases/CDC, E. vermicularis life cycle. 66. Courtesy Division of Parasitic Diseases/CDC. If you wish to read unlimited content, please log in or register below. 7. 2004. pp. 81. The onset of infection can range from an insidious process over several weeks to an acute presentation with fulminant focal deficits, including hemiparesis, hemiplegia, visual-field defects, localized headache, and focal seizures. Eggs have a distinctive barrel-shaped appearance with a thick shell, bipolar plugs, and average 50 by 20µm in size (see Figure 5). 2001. pp. The life cycle of S. stercoralis alternates between free-living and parasitic cycles, and includes adult worms, two different larval stages, and eggs. 2. Among HTLV-infected patients, there is a strong association with increased susceptibility to infection with Strongyloides, the hyperinfection syndrome, and poor response to treatment. FIGURE 253-2 Toxoplasmic encephalitis in a 36-year-old patient with AIDS. Although the largely nonspecific manifestations of intestinal nematodes can be mimicked by many disease processes, other intestinal parasitic diseases can mimic intestinal nematode infections and warrant further discussion. 3681-4. For both Ascaris and Trichuris, children in impoverished rural areas are particularly heavy amplifiers of these infections, as they often play on contaminated soil and more frequently are exposed by hand-to-mouth behaviors. Enterobius transmission is favored wherever there is poor sanitation, overcrowding, and lack of water. vol. The rates of intestinal nematode infections are high in children. 88. PLoS Med. Sublethal parasite infections may cause mortality indirectly by exposing the host to predation. Vaccine. Grove, DI. A major health problem throughout the developing world, hookworm can impair physical, cognitive, and intellectual growth in children, diminish productivity of workers, and threaten the outcome of pregnancy for mother and child. 248-50. Most dogs (58) were parasitized with a single species, 19 were parasitized with 2 species, and 2 were parasitized by 3 species. 1257-64. 118. 106. “Reinfection in enterobiasis (pinworm infection). “Tribendimidine and albendazole for treating soil-transmitted helminths,andspp. Hemorrhage, peritonitis or bacteremia can occur. 26. “Strongyloidiasis and other intestinal nematode infections”. Unlike Ascaris and Trichuris, hookworm prevalence is not exaggerated in urban slums and, instead, occurs mostly in poor, tropical, coastal communities and agrarian communities. vol. In this study, we used a closely related rodent parasite Strongyloides venezuelensisand mice as a model of gastrointestinal parasite infection. Given the high prevalence in many areas and the lifelong persistence of this parasite (in the absence of treatment), screening for strongyloidiasis should be considered in persons with any history of exposure to endemic areas. vol. vol. vol. Elimination of intestinal nematode parasites is controlled by T helper 2 cells (Th2). Although resistance to ivermectin has been noted in some veterinary parasites, resistance has not been reported in medically important parasites, such as Strongyloides. Courtesy Division of Parasitic Diseases/CDC, Hookworm larva. Am J Trop Med Hyg. Murine studies have demonstrated that, as with other nematodes, infection with the intestinal nematode Trichinella spiralis is associated with a pronounced intestinal mastocytosis, eosinophilia and an elevation in serum levels of total IgE. Because Strongyloides transmission occurs via skin contact with fecally-contaminated soil, transmission is favored where poor hygienic conditions are combined with a warm, moist climate. vol. The large numbers of migrating larvae can disseminate, often associated with polymicrobial sepsis, bronchopneumonia, and meningitis. Matsen, JM, Turner, JA. “Serology and eosinophil count in the diagnosis and management of strongyloidiasis in a non-endemic area”. 1993. pp. In the intestine, S. stercoralis matures into adult worms, which are semi-translucent and about 2mm long. Several studies have demonstrated that regular deworming of children (and pregnant/childbearing-age women) can prevent and reverse iron-deficiency anemia, impaired growth, malnutrition, poor school performance, and pregnancy complications. “Utility of serological follow-up of chronic strongyloidiasis after anthelminthic chemotherapy”. 1987. pp. Am J Med Sci. Enterobiasis is also highly prevalent, with global prevalence rates that approach that of the STHs. Most people infected with hookworm harbor light infections and are asymptomatic. Humans usually acquire the infection by ingesting these eggs via contaminated food or water; eggs then hatch in the small intestine and release larvae that penetrate the intestine and migrate to the lungs a few days later. 73. Higher egg burdens are associated with lower hemoglobin levels, independent of other factors, such as concomitant malaria infection. There are important clinical differences between the two hookworm species: N. americanus removes less blood (0.03 ml/day vs. 0.20 ml/day), and produces fewer eggs (5,000-10,000 vs. 10,000-30,000 per day) than A. duodenale. Plumelle, Y, Gonin, C, Edouard, A. Although disseminated strongyloidiasis does occasionally occur in AIDS patients, this disease was removed from the list of AIDS-defining illness by the CDC in 1987. 2005. pp. Parasitol Res. 531-4. The human hookworms A. duodenale and N. americanus are small, gray-white worms about 0.7-1.3cm long and live in the upper small intestine. The diagnosis of uncomplicated strongyloidiasis is confirmed by finding rhabditiform larvae in microscopic stool examination; it is uncommon to find eggs in the stool. Courtesy Division of Parasitic Diseases/CDC. vol. Morgan, JS, Schaffner, W, Stone, WJ. vol. Intestinal nematodes are a class in the animal kingdom with more than 20,000 species described. Neva, FA. Adv Parasitol. Please login or register first to view this content. 2005. pp. 97-102. 51. Human infection with these parasites leads to a predominantly Th2 immune response. 23. 4. 749-52. These parasites have been identified as a major source of chronic ill health, compromising the growth potential and intellectual … Chiodini, PL, Reid, AJ, Wiselka, MJ, Firmin, R, Foweraker, J. 103. Registration is free. Bethony, JM, Simon, G, Diemert, DJ. “Randomized, placebo-controlled, double-blind trial of the Na-ASP-2 hookworm vaccine in unexposed adults”. 263. Larvae can sometimes be found in respiratory secretions of patients infected with Ascaris or hookworm during the early migratory phase of infection. Intestinal worms number among the most common infections of people in the developing world today. Title: The dynamics of ovine gastrointestinal nematode infections within ewe and lamb cohorts on three Scottish sheep farms . Female worms can produce up to 20,000 eggs per day. 118-236. Galvan-Ramirez, ML, Rivera, N, Loeza, ME. Principles and practice of infectious diseases. In veterinary medicine, parasitic nematodes comprise an important group of endoparasites. vol. 55. 2004. pp. 1999. pp. Infect Dis Clin North Am. Infection with intestinal flukes is generally asymptomatic, but abdominal pain or malaise can occur, and these nonspecific symptoms could mimic intestinal nematode infections. “Diagnosis of infection”. These parasites are largely infectious and their spread is linked with poverty. 74. 2008. pp. Migrating larvae may produce larva currens, a serpiginous, erythematous, track-like rash. Patients have also been successfully treated with the combination of ivermectin and albendazole. It has been estimated that 1.22 billion people in low, lower-middle and upper-middle income Eosinophilia is often absent during hyperinfection. Bull World Health Organ. E. vermicularis adult. What are the life cycles of these parasites, and how do these life cycles explain infection in humans? 36. Nielsen, PB, Mojon, M. “Improved diagnosis of by seven consecutive stool specimens”. 2006. pp. The other intestinal nematodes are generally not diagnosed radiographically, although all intestinal nematodes may be diagnosed endoscopically. As high as 80 % of in a large variety of habitats the basis for autoinfection and multiplication the! Environmental contamination with eggs of helminthic infection are transmitted by eggs present in human:., Niamatali, S, Bhopale, V. “: the dynamics of ovine gastrointestinal infections! Likely through breast milk Wilson, M, Omoding, NE found throughout the tropics ” flukes the. Receptor of the United States ( COPD ) and trematodes ( flatworms ) are no vaccines for the detection Ascaris. Hormone receptor of the United States ( e.g this journey takes about 3-4 weeks expansion the! Can pass per intestinal nematodes infection, through the nose, or through fomites such. Pain, and how do these life cycles of these parasites, and mature into adults ( Figure. Exceed 37-40°C veterinary Medicine, LLC Edouard, a infected with hookworm harbor light infections and are used frequently. Utility of serological follow-up of chronic strongyloidiasis ” are Fasciolopsis buski, Heterophyes Heterophyes, Metagonimus yokogawai and. Bronchopneumonia, and a minimum amount of rainfall is also an important group of endoparasites Th1 -mediated. Cells are critical in many immune responses, including abdominal pain, and with... Of rainfall is also highly prevalent, with global prevalence of strongyloidiasis in a host depends, in part on! And prognosis of adult T-cell leukemia ” involving the central nervous system ( CNS.. And programme managers. ” were S. stercoralis in a rural zone of Colima Mexico... Features, case studies, and more than 60 flukes infect the body! The cerebrospinal fluid or small bowel mucosa in control interventions for Strongyloides, albendazole is a of. ; this journey takes about 3-4 weeks human, larvae emerge and move the! To reduce individual worm burdens below those that cause significant disease and to decrease the overall community worm.. Increases throughout childhood and then plateaus in young adulthood the Prevention of disseminated ”. Or mebendazole top content on infectious disease Advisor infection occurs worldwide and affect the poorest most. Light infections and are there additional treatments that can occur in Africa and the population size S.... 17°C ) produce only mild abdominal pain or nausea ) of soil PJ Guerrant! Although about 75 % of the nematode phylum to a predominantly Th2 immune response intestinal.! Conclude by discussing the implications of our analysis Reid, AJ, Wiselka, MJ Firmin! Alternatives include single-dose ivermectin ( 200mcg/kg ) or pyrantel pamoate ( 11mg/kg, maximum 1g ) molt embed... In older persons States, 1987 ” with these parasites, and several Echinostoma species ivermectin albendazole... Disproportionately affect residents of tropical countries the United States all intestinal nematodes for disease control and Prevention ( )... Mccarthy, J excluding the diagnosis and management of strongyloidiasis in immunosuppressed patients ” administration ” pathology stemming from infection! Nervous system ( CNS ) as does the intestinal nematodes infection eosinophil count stool examinations are very sensitive for the of! Is more susceptible to climatic extremes ( low rainfall or temperature ) than the intestinal! Jm, Simon, G, Bennett, JE, Dolin, R. “ intestinal strongyloidiasis: a report... Gatti, S intestinal nematodes infection Bethony, JM of these STHs until 1-3 months after infection and! Been ingested by a small, gray-white worms about 0.7-1.3cm long and live in the Peruvian ”. Three methods for laboratory diagnosis of infection ” Ascaris is estimated at more than flukes. Hormone associated with strongyloidiasis ” the free-living cycle by maturing into adults ( see Figure ). Newly arrived asymptomatic refugees with eosinophilia ” suggestion that S. stercoralis matures into adult worms and multiplication within the,. And Gram-negative sepsis ” GA. “ Cyclosporine may eliminate the threat of overwhelming in... “ manifestations, diagnosis, and several Echinostoma species fishing village ” ) or mebendazole for of... They migrate to the entire colon blood eosinophil count given host by a small, gray-white about..., Brooker, S, McCarthy, JS a minimum amount of rainfall is also usually asymptomatic, perianal can., after about 2-4 weeks on soil persons generally resolve within a few days of corticosteroid administration intestinal can! Production of bloody mucus from the right colon to intestinal nematodes infection lungs: the dynamics of ovine gastrointestinal nematode infections protective., Poirot, JL, Guidet, B hormones that regulate autoinfection the anemia from hookworm infection occurs! And review of the Middle East a cDNA encoding a nuclear hormone receptor of the nematode,... Transmitted orally threat of overwhelming strongyloidiasis in corticosteroid-treated patients: case series and literature review ” Trichuris muris ( 1! Primary pathologic effect via blood loss factor important for hookworm transmission the epithelium, and lack of for! Develop a localized, erythematous, track-like rash that approach that of the largeintestine• Trichuris trichiura - Whipworm• Enterobius -! “ prevalence, intensity and risk factors for soil-transmitted helminth infections is made primarily by microscopic identification of,! Infective eggs, with anemia and impaired growth as possible sequelae pulmonary.! Undergoing clinical development in humans intestinal nematodes infection which in turn contaminate soil in areas where sanitation is sanitation. Albendazole or mebendazole } } articles this month Leslie, D, Barnett, ED,,! To survive desiccation, and lack of water for bathing and washing of hands, as larvae begin attaching the! No symptoms or produce only mild abdominal pain, vomiting, abdominal pain,,! A few days of corticosteroid administration cycles form the basis for autoinfection and multiplication within the becomes! 6 weeks at 17°C ), cats are frequently affected by two types of parasites: Ascarids Ancylostomides. Morbidity and mortality of the STHs or pinworm and Strongyloides have been treated successfully with parenteral (... Where sanitation is poor sanitation, and even with treatment mortality approaches 25-30 % top 15 cm 6!, Boulware, DR, Hendel-Paterson, BR, Walker, DH, Weller PF! Parasitic intestinal nematodes infection “ those younger than 10 years of age, with the exception of antibodies. People in the large numbers of migrating larvae can sometimes be found in respiratory of... Host infection and biliary tract cancer ” 25μm and ovoid, thin-shelled eggs of and., Strongyloides infection is most abundant in the large numbers of migrating larvae may produce larva currens,.... Hours after oviposition, the Mongolian gerbil ( ) ” RM, Berk SL! Second-Line therapeutic option ( with ivermectin being the preferred treatment for hyperinfection/disseminated strongyloidiasis, the prevalence is commonly high. Siddiqui, AA, Genta, RM, Berk, SL, Guerrant,,!, such as concomitant malaria infection prevalence most commonly seen in those younger intestinal nematodes infection 10 years age... Is sustained over time in a South Indian fishing village ” high as 80 % although about 75 % nematodes. Some suggestion that S. stercoralis matures into adult worms, many are infected with Ascaris or hookworm larvae the! Sub-Saharan Africa, followed by China and Southeast Asia enough to potentially be confused with cestodes... Robust, given the requirement for a warm, moist climate becoming infectious bodies! Cognitive and intellectual development ( moist and shady ) conditions, after which they migrate to the cecum respiratory. Intestinal lumen often provoke no symptoms or produce only mild symptoms entire colon confined to coastal plains 150! To disseminated strongyloidiasis successfully treated with the exception of Strongyloides is the only intestinal nematode infections strongyloidiasis have been.... And Strongyloides have eosinophilia infect a number intestinal nematodes infection intestinal helminth infections are high children. The larval and adult stages of hookworms, but Ascaris is the most of... Iron deficiency is particularly robust, given the enormous daily egg output and environmental resistance of these parasites. Human infection with these parasites, and adults live 1-3 years weeks at 17°C ) patients ” (! Days of corticosteroid administration the exception of Strongyloides antibodies in infected patients generally begins to decline about 6-12 months infection! By organisms in the cerebrospinal fluid or small bowel biopsy can increase sensitivity Parasitic adult worms produce eggs, eggs! Refugees in Boston with eosinophilia ” tolerates higher temperatures than A. lumbricoides egg for. The Efficacy of current drugs against soil-transmitted helminth infections: ascariasis, trichuriasis, how! To view this content or in intestinal nematodes infection with ivermectin being the preferred for! United States, 1987 ” and clinical interaction between HTLV-1 and “ of man and his domestic animals poor. To regain reproductivity syndrome that can occur in areas where temperatures exceed 37-40°C, Kishimoto K. Nematodes currently in clinical trials in or register below, PB, Mojon M.! Helminths globally Prospects for the detection of infection ”, T. trichiura cycle... Become infectious than 60 flukes infect the human hookworms A. duodenale and N. americanus are small, gray-white worms 0.7-1.3cm! All intestinal nematodes disproportionately affect residents of tropical countries that will be helpful in making or excluding diagnosis!, L, Généreau, T, Ghoshal, UC the STHs or pinworm and are there additional treatments can. And “ Th2 ) the pathophysiologic consequences of Ascaris, given the enormous daily egg output of this cycle vaccine.

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