Hookworm timeline

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This page is a general guide to what might be expected after inoculationThe introduction of an infectious agent into an organism. [http://helminthictherapywiki.org/wiki/index.php/Helminth_inoculation Helminth inoculation] with NAthe human hookworm, Necator americanus, and should be read in conjunction with the page, Hookworm side effects, and the page section, Therapeutic response. Individual experience can vary considerably.

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I had all side effects described in the timeline but they all came 1-2 days earlier than described. [1]
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My body never followed that timeline. I get bounce first day, next 3-5 days chaos and after 1 week normalcy and relief. [2]


Timeline overview

Day 1

Localised skin reaction may occur (see The hookworm inoculation rash) and can continue, often intermittently, until 21 days. [3]

Days 2-5

The larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. travel, via the lungs and oesophagus, to the intestines. [4] [5] Side effects can occur on or after the 4th day (or, rarely, from day 2) and may include coughing, respiratory symptoms, fatigue, diarrhoea, cramping, gas, nausea and vomiting. Symptoms of the disease being treated may also flare. The severity of side effects is dose-dependent, varies widely between individuals and is to some extent determined by the subject’s disease. Side effects are not a reliable indication of a successful outcome from the therapy.

Days 6-14

The worms mature in the intestines, and this may cause a 'bounce' - a sudden improvement in symptoms, causing subjects to feel unusually well. Starting about three or four days after infection with hookwormsA helminth that lives in the small intestine. Necator americanus (NA) is the only hookworm species used in helminthic therapy. Its microscopic larvae are applied periodically to the skin., and lasting for up to two weeks, there may be a profound remission of symptoms (Crohn's, allergies, etc.) and also an experience of a strong sense of calm, focus, happiness and lightheartedness, (see The helminthic therapy 'bounce') but this won't last, so don’t stop taking any medications at this point! (See Combining helminthic therapy with drug treatments.)

Weeks 3-11

The worms complete their maturation by 21-22 days and start to attach to the inner wall of the intestine for the first time from day 21. There may be fatigue and gastrointestinal symptoms [6] continuing - often intermittently - from 29-70 days. Due to an increased inflammatory reaction, allergies may get somewhat worse in the first 4-5 weeks, before improving. The worms begin producing eggs between weeks 6 and 8, and some hosts have reported that they experienced the start of long-lasting improvement at 7 or 8 weeks.

Months 3-6

The worms only really begin to 'work', and the reduction in symptoms begins to become consistent, at around 12 weeks. Allergies and asthma, in particular, generally (but not always) resolve between the 11th and 13th weeks. By week 20, the worms are usually in their stride. Where required, a supplementary dose may be added between weeks 12 and 20, but not before week 12.

Months 6-12

By now, the immune system has adjusted to the presence of the hookwormsA helminth that lives in the small intestine. Necator americanus (NA) is the only hookworm species used in helminthic therapy. Its microscopic larvae are applied periodically to the skin. to the point where the good that they do may diminish somewhat, an effect that is usually offset by the addition of supplementary doses.

Months 12-24

A few may not see any benefit until after 12 months, or even as late as 2 years, and there is always a possibility of encountering minor setbacks until 2 years.

Year 2 and beyond

As long as a hookwormA helminth that lives in the small intestine. Necator americanus (NA) is the only hookworm species used in helminthic therapy. Its microscopic larvae are applied periodically to the skin. colony is maintained, benefits may continue to develop beyond two years, although to an increasingly lesser extent.

The timeline in detail

Day 1: Inoculation

For information about the inoculationThe introduction of an infectious agent into an organism. [http://helminthictherapywiki.org/wiki/index.php/Helminth_inoculation Helminth inoculation] process, see the following page.

Some people experience an itch and/or a pink rash that can be raised but is limited to the site of inoculationThe introduction of an infectious agent into an organism. [http://helminthictherapywiki.org/wiki/index.php/Helminth_inoculation Helminth inoculation]. For more detail about this, see the following page.

For information about how to treat an inoculationThe introduction of an infectious agent into an organism. [http://helminthictherapywiki.org/wiki/index.php/Helminth_inoculation Helminth inoculation] rash, see this page:

In a few cases, a lack of any skin response may indicate that the larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. failed to survive the rigours of the journey, particularly if exposed to extreme cold which is alway possible during even a short period at altitude during flight. In this event, the host should contact their provider.

When trying helminthic therapyThe reintroduction to the digestive tract of a controlled number of specially domesticated, mutualistic helminths (intestinal worms) in the form of microscopic eggs or larvae to reconstitute a depleted biome to treat and prevent chronic inflammation, autoimmune disease and other immunological disorders including allergy. for the first time, it is easy to obsess about the process, to wonder whether the treatment has 'taken', and to ascribe every tick and sniffle that develops in the first few days, post inoculationThe introduction of an infectious agent into an organism. [http://helminthictherapywiki.org/wiki/index.php/Helminth_inoculation Helminth inoculation], to the helminthsAn intestinal worm which grows large enough to be seen with the naked eye when mature but which is microscopic when administered in helminthic therapy. [https://en.wikipedia.org/wiki/Helminths Wikipedia:Helminths]. This obsession is natural, but it is important to remember that one's body continues to operate largely as usual in the early stages of a helminthic infection. One still gets colds and food poisoning, etc., and any physical changes experienced by new helminth hosts are far more likely to be manifestations of normal bodily functions than the action of the helminthsAn intestinal worm which grows large enough to be seen with the naked eye when mature but which is microscopic when administered in helminthic therapy. [https://en.wikipedia.org/wiki/Helminths Wikipedia:Helminths]. The latter follow a natural progression determined by evolution over millions of years, which is largely hidden from immediate experience.

Days 2-5: Migration

During the first two days, the larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. migrate from the skin, via the bloodstream, to the lungs, and, once they are in the bloodstream, they commence feeding on protein within the blood. [7] [8].

The still-invisible larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. then burrow through the lining of the lungs to join all the particulate matter - dust, smoke particles, pollen, etc. - being swept up along the 'escalator' of hairs that lines the inside surface of the lungs. This ciliary conveyor belt eventually transports the larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. to the throat, where they transfer from the airway to the gullet before continuing on their journey down to the stomach and on to the small intestine, where they will spend the remainder of their lives. (See Hookworm lifespan.)

Occasionally, the migration of the larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. through the lungs may make some people cough, although this dose-related effect is actually quite rare.

Coughing up phlegm and spitting this out should be resisted from days 2-5 to avoid expelling larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. that might be passing through the throat at the time, on their way from the lungs to the gastrointestinal tract. The transfer from airway to oesophagus/esophagus occurs quite low in the throat (beneath the epiglottis) so, while coughing up phlegm from the throat might cause a loss of larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state., blowing one's nose or sneezing should not. However, using a neti pot for nasal irrigation may wash away larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. if this is done by drawing saline in through a nostril and expelling it from the mouth. A more worm-friendly method for use in the first few days after inoculationThe introduction of an infectious agent into an organism. [http://helminthictherapywiki.org/wiki/index.php/Helminth_inoculation Helminth inoculation] is to draw in saline through one nostril and immediately expel this via the other nostril without involving the throat.

Common side effects at this stage are, in descending order of occurrence: a flare of the skin rash at the site of inoculationThe introduction of an infectious agent into an organism. [http://helminthictherapywiki.org/wiki/index.php/Helminth_inoculation Helminth inoculation], fatigue, diarrhoea, cramping and gas, nausea and vomiting. (For more detail about the side effects, see Hookworm side effects.) Children may display behavioral changes akin to those seen in a child with flu or allergies - lethargy, crankiness, etc.. Symptoms of the disease being treated may flare, and there may be a recapitulation of long-forgotten injuries and illnesses. (See: Recapitulation of old injuries, illnesses.)

Days 6-14: The 'bounce'

Typically, not much happens during this period, unless it is a continuation of symptoms that started within the first few days. The only change that may occur is a possible 'bounce'. This is a fairly unusual phenomenon observed in some subjects but not described in the literature.

The ‘bounce’ is a period in which all the subject's usual symptoms (Crohn's, asthma, allergies, etc.) disappear, sometimes completely. It typically occurs around the end of week one, perhaps as early as day five and even as late as week two. It can last about a week, but may appear for only 3-4 days, or, rarely, last for almost two weeks. Often this cessation of symptoms is accompanied by a wonderful feeling of calm, serenity, well-being and happiness.

It is easy to take a ‘bounce’ as evidence that the worms have 'worked' and that all will be well form this point on. Unfortunately, the ‘bounce’ never lasts, so one should not suddenly abandon whatever medications one is taking, or the diet one is following! This phenomenon is only temporary and not an indication that one has achieved remission in record time.

The appearance of a ‘bounce’ may be due to the fact that the body suddenly finds it has an appropriate target at which to aim its immune artillery. Alternatively, it may be due to something that the larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. are doing that elicits a strong response that quells inflammation. Either way, the 'bounce' is something to be enjoyed... while it lasts.

For more detail, see the following page.

Weeks 3-11: Side effects

After reaching the small intestine, the larvaeThe active immature form of an insect, or an animal such as a helminth, which develops from an egg and eventually transforms again into its adult state. moult, complete their maturation by 21-22 days and start to attach to the inner wall of the intestine for the first time from day 21. Initially, the hookwormsA helminth that lives in the small intestine. Necator americanus (NA) is the only hookworm species used in helminthic therapy. Its microscopic larvae are applied periodically to the skin. distribute themselves along the length of the jejunum, unless this has been surgically removed or an individual has hundreds of worms.

There may be fatigue and gastrointestinal symptoms [9] continuing - often intermittently - from 29-70 days. These side effects correlate with the period of elevated eosinophilEosinophils are a specialised type of white blood cell with a variety of both harmful and beneficial functions. Their numbers rise temporarily following inoculation with helminths. counts (see the graphic below) which can result in eosinophilic gastroenteritis. The side effects peak at about 50 days, before gradually diminishing and returning to baseline at approximately 100 days.

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Graphic taken from: Dose-ranging study for trials of therapeutic infection with Necator americanus in humans (PDF)

Side effects at this stage can include, in order of occurrence: fatigue, cramping, bloating, gas, epigastric pain (stomach ache all over the abdomen) or sometimes pain concentrated on the left side, [10] diarrhoea, nausea, and a recurrence of the skin rash, especially on day twenty-one when the worms begin to attach to the intestines. A few people have reported the appearance of constipation between the 3rd and 10th weeks, and some have noticed a heightened sense of smell from around 5 or 6 weeks. While the latter change is usually welcome, it was linked with nausea in one case. Very rarely, someone may report feeling depressed.

For those individuals who get gastrointestinal side effects, these are most likely to occur around day 21, as a result of the body's attempt to expel the worms by deploying eosinophilsEosinophils are a specialised type of white blood cell with a variety of both harmful and beneficial functions. Their numbers rise temporarily following inoculation with helminths. - white blood cells that attack helminthsAn intestinal worm which grows large enough to be seen with the naked eye when mature but which is microscopic when administered in helminthic therapy. [https://en.wikipedia.org/wiki/Helminths Wikipedia:Helminths] - to cause eosinophilic enteritis. However, some only see the start of gastrointestinal symptoms from day 30 onwards.

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Other than the initial rash and a flareup of the inoculationThe introduction of an infectious agent into an organism. [http://helminthictherapywiki.org/wiki/index.php/Helminth_inoculation Helminth inoculation] site again on day 12, I had no other signs until about day 31 or 32 when I began with gastroenteritis symptoms. [11]

In most people, this inflammatory response translates to a few days of loose bowel movements or diarrhoea, perhaps accompanied by fatigue. However, a few people may get prolonged gastrointestinal symptoms continuing for many weeks, even beyond week 20, and they may occasionally only start between 10 and 12 weeks.

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I am just at the end of my 10th week and there has been a massive increase in diarrhoea. [12]
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I often see my worst digestive upset starting as late as 12 weeks. [13]

These side effects always resolves eventually, without treatment.

The severity of the side effects varies enormously from person to person and is dose-dependent. Only a small percentage experience stronger side effects, including pronounced diarrhoea and cramping due to gas, which can be spectacularly bad and has been described as 'toxic', 'industrial' or 'otherworldly'.

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She had some pretty noxious-smelling emanations about the three week mark. [14]

Rarer still are fever, night sweats and joint pain. For those suffering the worst side effects, even if it is only a few percent of those who try the therapy, the effect is such that study or work would be very difficult. Therefore care should be taken in optimising dosing, right from the outset. For guidance on this, see the Hookworm dosing and response page.

All the side effects except the skin rash normally reduce sequentially with successive doses. One individual, who had many weeks of diarrhoea following the first hookwormA helminth that lives in the small intestine. Necator americanus (NA) is the only hookworm species used in helminthic therapy. Its microscopic larvae are applied periodically to the skin. dose, found his symptoms greatly reduced the second time around and, after the third dose, there was no liquid diarrhoea at all during the side effect period, just very soft stools with a 'cow pat' consistency. After the fourth dose, his stools were virtually as normal, but remained slightly softer than they had been prior to infection.

The skin rash at the inoculationThe introduction of an infectious agent into an organism. [http://helminthictherapywiki.org/wiki/index.php/Helminth_inoculation Helminth inoculation] site may also recur during the gastrointestinal side effect phase, perhaps because the worms shed cells and debris from their skin as they migrate through the host's skin, and, when the worms attach and put the same kind of material (their skin) into contact with the host's immune system in the intestines, the host's immune system releases antibodies to those types of cells or proteins wherever they occur, whether in the intestine or in the skin.

Apart from the skin rash, which tends to ease after a few days, all the other side effects typically come and go, and the experience can be very much like riding a roller-coaster.

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I experienced about a week of near total remission of psoriasis, followed by the worst flare of my life. 46 days in and I'm nearly clear again. [15]

There is also enormous variation between individuals, with some people getting no symptoms at all, and others - especially those using higher doses - experiencing relentless fatigue, disabling abdominal pain and geysers of diarrhoea.

It is worth remembering that hosting worms does not stop one succumbing to all the usual infections, stomach upsets, etc., to which man is heir. So, when symptoms emerge, these may not be due to the helminthsAn intestinal worm which grows large enough to be seen with the naked eye when mature but which is microscopic when administered in helminthic therapy. [https://en.wikipedia.org/wiki/Helminths Wikipedia:Helminths].

For more detail about some of the possible side effects and how to treat them, see the following page.

Months 3-6: Maturity

The worms usually start to work - if they are going to work at all - between week 12 and 20, although this varies between individuals and depends on the disease being treated. By week 20, the worms are usually in their stride and, where required, a supplementary dose may be added between weeks 12 and 20, but not before week 12. See Hookworm dosing and response.

Months 6-12

Between six and twelve months, the immune system adjusts to the presence of the hookwormsA helminth that lives in the small intestine. Necator americanus (NA) is the only hookworm species used in helminthic therapy. Its microscopic larvae are applied periodically to the skin. to the point where the good they do may diminish somewhat. For some people, this means that they may fall out of full remission or require continued medication to maintain it, albeit at a lower level than pre-hookwormsA helminth that lives in the small intestine. Necator americanus (NA) is the only hookworm species used in helminthic therapy. Its microscopic larvae are applied periodically to the skin.. The addition of supplementary doses will usually reverse this trend.

Beyond this period of possible drop-off, things get better again, until a final equilibrium is achieved. For some, this may be reached at 11 months, while, for a few, it may take longer.

Months 12-24

A few may not see any benefit until after 12 months, or even as late as 2 years, and those who have seen earlier benefits should continue to note gradual improvement beyond 12 months, while still possibly encountering minor setbacks until 2 years.

Year 2 and beyond

As long as a hookwormA helminth that lives in the small intestine. Necator americanus (NA) is the only hookworm species used in helminthic therapy. Its microscopic larvae are applied periodically to the skin. colony is maintained, benefits may continue to develop beyond two years, although to an increasingly lesser extent.

Eventually, efficacy will decline as the worms age. This may not be for 3, 4, 5, or even more years, (see Hookworm lifespan) but it is possible for efficacy to decline earlier than this, especially in a small sub-group of individuals with Crohn's diseaseAlso known as regional enteritis, this is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms. It primarily causes abdominal pain, diarrhea (which may be bloody if inflammation is severe), vomiting or weight loss, but may also cause complications outside the gastrointestinal tract such as skin rashes, arthritis, inflammation of the eye, tiredness and lack of concentration. or one of a few other specific conditions. For these few, efficacy can decline as early as three months, while, for others, it may happen when the egg output of their hookwormsA helminth that lives in the small intestine. Necator americanus (NA) is the only hookworm species used in helminthic therapy. Its microscopic larvae are applied periodically to the skin. declines substantially at about the 12-month mark. Whenever there is a loss of benefit, subjects should immediately arrange to receive a supplementary dose, which will usually quickly restore efficacy.

A few people may continue to experience side effects following supplementary doses. See the following page section.

See also

SimpleHTLogo(18x18).gif Helminthic Therapy Wiki: documenting the science, management, experience and results of helminth replacement therapy.