Hookworm dosing and response

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This page discusses the therapeutic use of the human hookworm, Necator americanus (NA) [1]. The other species of human hookworm, Ancylostoma duodenale, [2] is not suitable for use in therapy because it takes an estimated nine times more blood than Necator, can infect a foetus by crossing the placenta, and is able to migrate via breast milk. [3]

Therapeutic response[edit]

The success of hookworm therapy cannot be predicted[edit]

At the present time, it is not possible to predict who will benefit from hookworm therapy, nor to what extent a condition might respond, but factors that favour a better outcome include:

  • being young
  • having been ill for a shorter period of time
  • having a less severe form of a disease

The severity of skin response to the initial inoculation is not a reliable guide to the likely extent of success with the therapy.

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My first dose I had quite a severe reaction at the site, blisters & marks that lasted for ever (but, in three years) I have had no benefits to my allergies at all. [4]

Early benefits are possible but not common, and they may fluctuate[edit]

A few people may begin to see benefits at an early stage, but these don't become consistent until at least 12 weeks.

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… within less than a day, I felt almost giddy and stronger and was breathing so much better. I started eating foods that I had so sorely missed and had very minimal reactions. [5]
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I had significant relief from chronic nasal congestion on the day after I first inoculated with NA. [6]
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I felt incredible the first days, like I didn't in years. [7]
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At 19 days it was like a miracle for me. I felt better than I had in years. But it took a lot longer (and additional inoculations) before I got to 95% better.” [8]
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Six weeks for me. [9]
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I saw results for asthma relief at 8 weeks after my first dose of NA. [10]
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I started getting improvement at around 8 - 10 weeks.” [11]

Disease symptoms may worsen before improving[edit]

Disease symptoms frequently worsen during the first few months before beginning to improve. One individual, who had had daily headaches and frequent migraines for many years, saw his symptoms worsen slightly in the first 4 months after his first dose. [12]

Consistent improvement can begin anytime from 3 to 24 months[edit]

For the majority of those who do eventually respond, significant benefits do not usually materialise until at least 3 months after the first inoculation, with most people only seeing improvement in their condition between 3 and 6 months.

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I had no benefit at all until about 14 or 15 weeks, and it took until 23 weeks for anything significant to improve. [13]
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I had chronic idiopathic urticaria and it took 5 and a half months from first NA dose until I was able to come off all meds. [14]

Some may only start to improve between 6 and 12 months.

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It took nine months before I saw improvement of my eczema. [15]
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I have food intolerances IBS and Graves' disease. Inoculated 9 months ago and am now starting to see an improvement with IBS and food intolerance. (Link expired)
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Did not see positive results until 9th or 10th month. [16]

Others have had to wait until beyond 12 months and, in a few cases, for as long as 18-24 months.

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I got improvement in about 3 months but my eczema wasn't gone until I'd had NA for a couple years or so. [17]
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At 16½ months, I think my hookworms and whipworms are really starting to work! Since (two weeks ago), I have had only 3 loose stools… I have more periods of relief than periods of exacerbation from my nasal inflammation and asthma. [18]
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It took a good 12-18 months to be able to say, yep, **definitely** much better and staying better. [19]
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18 month update. After hitting the one year mark with no improvement I was starting to get discouraged… Finally, a couple weeks ago, everything changed. I was able to eat regular foods again. [20]
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I was about 20 months into treatment before seeing really significant gains. [21]
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I was a year and a half into HT and flaring. My GI wouldn't do my colonoscopy because I was so inflamed he thought I would perf. He thought I should be admitted for IV steroids and started on Remicade. But (at almost 2 years) I have been in complete remission for the past two months and have never felt as good. [22]
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I was close to giving up on my little worms, since I saw no discernible improvement for a year and a half (but) I’m glad I stuck with it. One of my most burdensome allergies was oral allergy syndrome and (at nearly 2 years) I can now eat raw food with NO reaction! Blueberries, strawberries, spinach, broccoli... Delicious! I'm the healthiest I've ever been. (A private message, Sept 2013.)

The long wait can be a challenge, but the eventual rewards can make it worth while.

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My daughter was under a year when we started and it took 10 months to see consistent results. In between that there were improvements on and off. Though it felt like forever at the time, the 10 months really isn’t much time for the amazing quality of her life now. 2½ years later, she improves more and more. [23]

Diseases may continue to flare occasionally up to 18 months[edit]

Even when benefits appear early in the process, diseases can continue to flare periodically for no apparent reason until around 18 months.

The emergence of benefits can be a gradual process[edit]

The appearance of benefits can be a very gradual process in some people, and follows a natural progression in which the amount of time that worms have been hosted can be more important than the number of worms inoculated.

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It happened slowly (from 3-6 months post inoculation) and just kind of snuck up on her. [24]
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I have Hashimoto’s… My thyroid antibodies started slowly decreasing two years ago, when I started HT, first with TSO and then about a year ago with NA. Every time I measured, they were lower. Today for the first time, they are normal. [25]
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It was like day by day I felt better and stopped even thinking about it. Later I looked back and couldn't remember feeling sick. It was just being normal. [26]

In another example, someone who had been unable to eat any normal foods for more than a decade began to tolerate a few foods for the first time at 12 weeks, but tolerance to other foods was only regained very gradually, over a period of 18 months. [27]

Provided that an adequate colony is maintained, improvements often continue to appear into the third year, and even beyond that, albeit at a gradually diminishing rate. The first comment below was written by someone with MS and food sensitivities after hosting hookworms for over 2½ years.

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Of all my food sensitivities, the loss of butter in my life was the most difficult. The last time I tried it was about 6 months ago, and within an hour had a crushing headache, brain fog and fatigue. But last night while I was baking for my dad I just couldn't resist and tried a little butter. And... I was fine! So I tried some more - still ok! And a bit more at breakfast - still no reaction! Yay!!! It looks like butter is back on the menu! In the past few months I was also able to start eating eggs again, and I finally am noticing diminished nerve pain in my fingers - there's still some, but it's noticeably better. [28] [29]
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It took 2.5 years before I could eat eggs (which I’d been sensitive to before hookworms). [30]
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I am in 3rd year of therapy now … the improvements are still adding on in terms of overall benefits. (A patient with Crohn's disease.)
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I also think I've recently seen improvements in my reaction to gluten almost 3 years since my first dose of NA. [31] [32]

Different conditions in the same host may respond at different times[edit]

Where someone has more than one condition, these may take different lengths of time to respond. One subject experienced an unusually early response when his nasal congestion began to ease on the day after his first inoculation, but his Restless Leg Syndrome only began to reduce during week 5, and took 19 weeks to resolve completely. And, while a few of his food intolerances began to ease at 12 weeks, it was 18 months before he was able to eat all foods again.

A child with “terrible contact dermatitis and severe eczema from multiple food allergies” had mostly clear skin by 9 months after her first inoculation with hookworms, but her food allergies only began to disappear at 19 months. [33]

People with several conditions may not see improvement in all of them[edit]

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I do HT for severe food intolerance and I achieved almost full remission, although it didn't do anything for my runny nose and only a little for the CFS. [34]

Response may vary from one inoculation to another[edit]

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I have found my response to each inoculation to be different. Some caused few symptoms, some caused a complete melt down. And some resulted in little or no improvement, some brought immediate improvement, some brought very slow incremental change. I’m on my 9th dose and it’s been rough, while the 8th was easy. [35]

The self-treater who reported this, added that, in her case, new symptoms which appear after an inoculation can last anywhere from a couple of days to 6 months. [36]

For benefits to last, a hookworm colony needs regular maintenance[edit]

Although it appears that a few individuals may be able to enjoy a continuation of some benefits after hookworms are lost, [37] benefits will only continue in the vast majority of cases for as long as the colony is actively maintained by adding periodic top-up doses.

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Needing to stay topped up with the worms is a lesson I have had to learn the hard way… I had taken 3 doses over a period of 9 months. Then no new worms for 5-6 months… Nearly all of my old symptoms have returned fairly quickly. At first, I thought I had killed them off. But they are aging. [38]

See also[edit]

For more detail about what to expect at each stage of hookworm therapy, see the following page.

Introduction to hookworm dosing[edit]

Hookworm dosing cannot be reduced to a formula because everyone is different in how they respond to helminths.

It is not necessary to use the large doses that were advocated by the early pioneers of this therapy, typically starting with a dose of 25 or 35 hookworm larvae, followed in some cases by even larger supplementary doses.

A dose of 5 larvae has proved to be an effective introduction, and this number minimises the side effects that are a common feature of the early experience of hookworm therapy.

For more detail about the possible side effects, see the following page.

If starting with 5 larvae, most hookworm hosts should be free from side effects by 12 weeks, so would be able to add a further dose at this point. However, more worms should not be added until all the side effects caused by the first dose have completely subsided, along with any exacerbation of symptoms of the disease being treated. Otherwise, there could be an aggregation, or "stacking", of side effects from both doses. Apart from the host having to endure these side effects, along with any disease exacerbations caused by the introduction of hookworms, the increased inflammation caused by adding too many worms too quickly may be sufficient to prevent at least some of the new worms from attaching to the gut lining.

For someone who is very sick, it can be tempting to try to speed up the therapy process in the early stages by adding more worms as quickly as possible, but this can be counterproductive, possibly causing such severe side effects that it would be necessary to terminate the colony and start over.

Disease remission is brought about not so much by the number of worms being hosted as by the length of time that worms have been present. There is nothing to be gained by attempting to reach a notional maximum number of worms in any particular time frame. All that is required is that the colony is refreshed by periodic top-ups.

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Time is your best friend when it comes to autoimmune disease and HT. [39]

Once disease remission is achieved, the size and frequency of doses can be determined more accurately by observing how long it takes for signs of one’s disease to return after a dose, and using this information to establish a dosing regimen that will maintain uninterrupted remission. A period of experimentation is usually required, and hookworm hosts should keep a record of the size and dates of all their doses.

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I now realise that the dosage, intervals and maintenance of HT is ongoing and requires lots of attention, which if I’m being honest I wasn’t expecting.
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I'm still figuring out the number of worms best for me, 5 years into this. For some of us, it's much more complicated than ‘take worms, get better'.

Hookworm dosing in a nutshell

1. Start with 5 NA larvae. (For children, see Hookworm dosing in children below.)

If the self-treater is hypersensitive or has one of several specific conditions, they should start with just 3 larvae.
Doses larger than these are not necessary and may cause undue side effects which, in some cases, can require termination and a fresh start.

2. Add supplementary doses at intervals of at least 12 weeks.

The number of larvae in each successive dose can be increased gradually, while being careful to avoid overdosing, which can cause side effects.
There is no need to aim for any particular colony size. All that is necessary is to regularly add fresh doses to ensure that there are always young adult worms present in the gut.

3. Once benefits have appeared, experiment to find the number of worms per dose, and the interval between doses, that will optimise those benefits.

The ideal number of larvae per dose and the optimum dosing frequency vary considerably between self-treaters.

4. Keep dosing under review indefinitely because the need for worms can change over time, requiring re-optimisation of the dosing regimen.

See the rest of this page for full details about each of the above steps.

The evolution of hookworm dosing[edit]

The early providers had limited evidence on which to base dosing

When the first company to sell hookworms online was established in 2007, researchers working with hookworms were still at the stage of carrying out preliminary experiments, including on themselves, in an attempt to establish what number of larvae might be suitable for use in reintroducing this species into helminth-naive subjects for therapeutic purposes. [40] [41] Beyond these experiments, there was little information to help the commercial hookworm providers in deciding what doses they should recommend to their customers.

The individuals behind the first online hookworm vendor separated early in their association to form two companies - Autoimmune Therapies (AIT) and Worm Therapy - which recommended different doses for those commencing hookworm therapy. In the case of AIT, a first dose of 35 larvae was followed by two doses of 50 larvae at 12 week intervals. Worm Therapy started their new clients with a dose of 25 larvae, and based the size and timing of subsequent doses on the recipient’s response to their first dose.

Numerous early hookworm self-treaters who used these two regimens reported significant side effects from the doses they were supplied, especially clients of AIT. One self-treater had to contend with 19 weeks of intermittent diarrhoea from weeks 5 to 24 following an initial dose of 35 larvae, and someone who used AIT’s full 35/50/50 sequence was hospitalised with organ damage, which was fortunately reversed by medical treatment. [42]

For the first few years after hookworms became available commercially, the only online discussion about helminthic therapy was in a Yahoo forum created and run by AIT, where this company’s approach to dosing was accepted, largely without question.

The online community refined dosing based on collective experience

After the creation, in 2012, of the independent Helminthic Therapy Support group on Facebook, reports began to emerge of members who appeared to have inoculated with too many hookworms, causing a loss of benefits and a decline in health that necessitated termination of their hookworm colonies. In some cases, the resulting destabilisation of health caused ramifications that lasted for many months, and even several years for a few individuals.

As more reports began to emerge of adverse side effects following the dosing protocols that were still in use, particularly by AIT, warnings were issued to Support group members about the risks of inoculating with too many hookworms, especially for those who have one of the conditions that are now listed as requiring a modified approach to helminth dosing.

When this Helminthic Therapy Wiki was founded, in January 2017, this Hookworm Dosing and Response page became the repository for all the details about hookworm dosing that had been collected from posts to the Support group and elsewhere. This material showed very clearly that the previous approach to hookworm dosing had been flawed, and that not only are much smaller introductory doses preferable from the point of view of causing less side effects, but that they also produce the same level of efficacy as larger introductory doses, and provide a solid foundation for longterm dosing which might, for some self-treaters, eventually include much larger supplementary doses.

New providers embraced the new approach to dosing

In 2014, a new breed of hookworm provider began to emerge, beginning with Wormswell (2014-2018), and followed by Symmbio (2016), YourSymbionts (2018) and Au NAturel (2019). These companies not only introduced a more user-friendly, pay-per-dose business model, but also worked more closely with the online community of helminth self-treaters than previous companies had done.

Once this wiki was available, the newer providers all recognised the site as the definitive database of information about all aspects of helminthic therapy, and contributed to the site's development. As the knowledge about hookworm dosing evolved, these companies adopted an increasingly more conservative approach in line with the evidence presented on this page.

AIT continued to apply their introductory 35/50/50 dosing protocol until 2017, except in the case of clients with fibromyalgia, whom they had come to realise require much lower doses. But, after the company’s attention was drawn to this page, they adopted a new dosing regimen and, by late 2017, had begun to introduce newcomers to the therapy with a dose sequence of 5/5/10/10/20/20 larvae. Worm Therapy, meanwhile, continued to start most of their new clients on a dose of 25 larvae, and persisted with this practice into at least the early part of 2019, even after their attention had been drawn to the data on this page, which they rejected as being merely anecdotal.

Reports received by this wiki in 2020 and 2021 revealed that AIT had reverted to recommending, and supplying, doses of 50 NA larvae, even though dosing at this level had previously put at least one of their clients in hospital with potentially fatal side effects. [43] AIT have apparently even suggested that some of their clients take supplementary doses of up to 100 larvae.

Obsolete dosing practice is perpetuated outside the online community

Medical practitioners with an interest in helminthic therapy who follow the conversation in the Helminthic Therapy Support group had mostly modified their approach to hookworm dosing by the start of 2019, and the majority were starting new patients on a dose of 5 larvae. A few, however, continued to operate in isolation from the online community, and were not keeping up to date via this wiki. Consequently unaware of the reports of severe side effects experienced by some self-treaters, these doctors continued to use a variety of idiosyncratic dosing protocols that often involved excessively large doses, for example, introducing new patients to the therapy with between one and three doses of 25 larvae.

In late 2018, one naturopathic doctor was still starting most of his patients on an initial dose of 25-35 larvae, followed by 2 or 3 doses of 20 larvae at three month intervals and then 5-10 larvae at 2 month intervals, a schedule that is diametrically opposed to what is suggested by user experience, as reported on this page.

In late 2020, another naturopathic doctor who was obviously aware of the need to start with much smaller doses, was nevertheless introducing too many doses in the first 12 weeks. Starting her patients with a single larva, she was adding a second one a week later, then following these with a further 5 larvae every two weeks until a colony of 20 was reached in the tenth week.

There are some self-treaters who are not working with a doctor and who fail to find, or decide to overlook, the advice available on this page, and turn instead to obsolete information found on assorted sites across the internet, which leads them to seek larger hookworm doses than are advisable. Unfortunately, these individuals sometimes even turn a deaf ear to attempts by providers to encourage them to be more conservative in their dosing choices.

Hookworm dosing in research centres

The hookworm self-treaters who are members of the online community far outnumber the subjects who have taken part in the few formal clinical trials that have been mounted to investigate the therapeutic potential of hookworms, and the researchers involved in these studies have consequently had access to far less data to inform their understanding of the effects of different dose sizes.

Prior to 2006, researchers at Nottingham University had carried out a small dose-ranging study to identify a suitable dose size for their trials of therapeutic infection with NA in humans. [44] They concluded from this study that a dose of 10 NA larvae is well tolerated, elicits a modest eosinophilic and antibody response, and was potentially suitable for use in preliminary clinical therapeutic trials. However, after trials using single doses of 10 NA, the team at Nottingham then employed a single dose of 25 NA in their Worms in Relapsing Remitting Multiple Sclerosis (WiRMS) trial that ran from 2011 to 2016. [45] Other centres investigating the therapeutic effects of hookworms have used doses ranging from 10 to 40 larvae. [46] [47] [48]

The information on this page, condensed from the experience of thousands of citizen scientists in the online community, could be invaluable to medical researchers, if they chose to utilise it. For example, they would discover the importance of maintaining a hookworm colony by continuing to add supplementary doses at appropriate intervals. Unfortunately, however, medical research has largely ignored the experience of helminth self-treaters and the data presented here.

The first dose[edit]

The first dose of NA is best restricted to a maximum of 5 larvae[edit]

In the first decade of self-treatment with hookworms (2007-2017), introductory doses of up to 35 larvae were recommended by providers, but this quantity often causes severe side effects. Even a dose of 5 NA can produce some side effects, but these are usually manageable at this dosage.

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I chose to start low and slow, with two doses of 5 NA three months apart (and) I’m so glad I did, because even a small number of NA have caused quite a bit of discomfort, mainly a worsening of autoimmune symptoms. [49]

Not only do very small doses keep any side effects to a minimum, but 5, or even 3, NA, are also effective, and start the process of bringing the host's immune system back into balance.

Individuals who are hypersensitive, or have at least one of these conditions, are advised to commence with just 3 NA.

Those who began with a dose of 50 or more NA have usually regretted it![edit]

Early pioneers who inoculated with 50 larvae eventually wished they hadn’t! Prof David Pritchard of Nottingham University School of Pharmacy could not cope with a single inoculation of 50 hookworm larvae, [50] and Dr James Logan from the London School of Hygiene and Tropical Medicine, who inoculated with 50 hookworm larvae for a UK TV documentary, had to abort the experiment after 60 days, saying, "I just can't live with the symptoms and the stomach pains.” [51]

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I let myself be convinced, without doing my homework, it was OK to inoculate 50 NA at first dose... At 5½ weeks, the asthma-like symptoms and cough are going away, but to be replaced by a dull but unrelenting belly pain and diarrhea that get pretty bad for a while after meals, and waves of mild nausea and unbelievable gas. Day 45, about 6½ weeks... belly ache is nearly gone, but the diarrhea and gas remain... uncomfortable and embarrassing (I can't remember smelling such awful gas or soiling underpants three times in a week before). [52] [53] [54]
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I inoculated with 50 NA 15 weeks ago. Side effects have been really rough... [55]
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I did 50 my first dose too. Not the smartest thing I've ever done... Gut pain until around 12 weeks... ended up killing off my colony and starting over. I did 6, then 6 more after 18 weeks. I'm doing much better now... [56] [57]
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I started with 70, and that was a big mistake. Had to take steroids for 2 months just to tolerate the epigastric pain and increase in immune response. [58]

Doses of 30 or 35 larvae can cause severe side effects[edit]

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After inoculation (with 30 HW), the joint pain worsened so severely that at some points I could hardly walk or move.” [59]
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I started with an initial dose of 30, which gave me horrible side effects and put me out of commission for 3 months. Would not recommend. [60]
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I had to kill my first dose of 35 HW because the GI symptoms were unbearable.
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I received a dose of 35 HW about 3 weeks ago and last night I awoke gasping for air because my throat had closed up. It was a harrowing experience that lasted about a minute as I was unable to breathe.” [61]
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I am 6 weeks post first inoculation (with 35 hookworms) and experiencing extreme exacerbation of my RA symptoms. It's hard to deal with while wondering if this will actually be worth it. [62]
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Inoculated with (35) HW 6 weeks ago... I've been getting my ass kicked by worm flu! Week 4 assorted gastric issues, week 5- radical nausea, stomach aches & fatigue. My naturopath prescribed me prednisone (10 days reducing), 3 days left. Not getting better… (Link expired)

Doses of 20 or 25 larvae can cause very unpleasant effects[edit]

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I inoculated myself 2 months ago with 25 NA... I am having serious side effect since 2 weeks. Mainly stomach/upper belly pain to the point I am barely able to work. Today I bought mebendazole as I am considering terminating my NA. [63]
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I dosed with 25 NA. I only had a reaction for about 24 hours. Then at 3-4 weeks all hell broke loose and it was horrible for the next 10-12 weeks. I reacted to almost all food. [64]
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I was out of work - unpaid - for 3 weeks (after a dose of 25 NA) because of unbearable agonising stomach pains... I was taking them for allergies, and am otherwise quite healthy (no IBD or anything), so I wasn't expecting serious side effects... As it was I nearly had to terminate them. [65] [66]
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My husband is on day 63 with 25 NA. For the last two weeks he's had intermittent achy body/joint pain, daily diarrhea with stomach pain and last night a low grade fever. It has been getting progressively worse. This morning, for the first time, he said that he was close to his breaking point. [67]
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Exactly 5 days post inoculation (with 25 NA), I awoke in the middle of the night thinking someone was choking me. My throat was burning and closing up fast, causing my breath to rasp in my chest. [68]
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I inoculated with 20 NA (to treat seasonal allergies) and found weeks 5-12 incredibly hard. The stomach pain never resolved itself. I had to up my Prednisone dose and take it almost every day. It's hard to function with that pain. I finally had to take Albenazole (and) my body is now pain free again. I will start again w 5 and go from there… [69] [70]
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My colony was about 30. Then I did 25 thinking I would be fine. Well not the case. I went down hill very fast and eventually had to terminate. [71]

Prolonged side effects can mask other developing conditions[edit]

Apart from having to cope with the side effects of larger doses of hookworms, there is also a risk that these symptoms could mask other conditions that might develop during a prolonged side effect period, as happened in the following case.

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... the eosinophilia from the worms totally masked my diabetes symptoms for 6 months and would have done so for much longer if i had not aborted them. The extreme thirst, pain in the muscles of the lower leg and lower arm, malaise, overheating, brain fog, etc., are all symptoms of both conditions. Aborting the hookworms got rid of about 80% of the symptoms and I was just about to take a second dose of worming tablets because i thought the remaining symptoms were due to some survivors, when in fact this is what the diabetes was causing. There was no way i could have noticed the diabetes while suffering the extreme reaction I had from HWs.

Patients with some conditions need to start with just 3 larvae[edit]

Anyone with an increased level of sensitivity should start with just 3 larvae, especially if they have one of the conditions listed in the following page section.

Here are just two examples of the difficulties experienced by people with hypersensitivities who inoculate with too many hookworms.

Someone with mastocytosis who inoculated with 30 NA ended up in hospital after increasingly high doses of prednisone failed to relieve muscle spasms that were so severe and constant she was literally screaming. She could not even roll over in bed. [72]

And someone with narcolepsy reported as follows.

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I had 10 HW to start and thought I was going to die. But I could do 3. And then another 3. And then I could stand 5.

Even 3-5 larvae can cause significant side effects in some people[edit]

A first dose of 5 larvae can cause significant side effects in some people, and not only those who are hypersensitive.

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On the evening of day 3 post inoculation with 5 NA (my first) i started feeling a bit of a headache as I went to bed. I woke up after sleeping about 2 hours with a searing headache and growing nausea. This lasted all night and all the next day. It was very intense and I couldn’t function all day. Around 8pm, however, the headache and nausea suddenly subsided and I was able to eat again and feel pretty normal. [73]
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I started with a five hw dose four days ago. Wasn't sure about starting that low… But joint pain and muscle fatigue started to kick in yesterday and then today with a vengeance… I'm so glad now it was just five I started with. [74]
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I had huge side effects from my first dose of 5 NA. I had to take a few days off at the worst moment... [75]
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After 3 weeks of 5 NA I had an intense reaction. My depression flared, got really sick, had a huge rash break out on my face, lost my appetite and developed hypersomnia. [76]
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I inoculated about 4 weeks ago with 5 NA. The last ten days have been rough. I've been experiencing cold/flu symptoms for the past ten days that started to clear up and then came back with a vengeance, plus some other symptoms more in line with a flare. Fatigue, deep and persistent coughing, insomnia, post nasal drip, congestion, constant acid reflux, random itching all over my body/skin sensitivity, swelling, worsening of my existing skin problems, trouble regulating my body temperature, neuropathy in hands, and food cravings. I also had a migraine last week for the first time since I started treating my autoimmune disease with plaquenil. I'm going to a clinic tomorrow to ask for prednisone. (Link expired)
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I also took 5 NA and started getting HORRIBLE stomach pains at Day 28. Like my insides were shredding. I am at Day 41 now, still having intense pain, but taking Benadryl (antihistamine in US) has helped a lot... [77]
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Horrible fatigue today… (at 2 days). [78] Too much fatigue, can't stand any more. This is simply unbearable… I should have taken just 3... (at 4.5 weeks). [79] [80] (Reported by a patient with CFS/ME, after inoculating with 5 NA.)
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Since week five (with 5 NA) I've had some pretty rough side effects. Constant fatigue, brain fog, and some depression... I can't eat much of anything right now. [81]
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I had painful tingling in my fingers, legs, arms and feet (almost like thousands of piranha’s nibbling under my skin.) I also noted "a jumpiness that feels cellular". Along with... severe joint pain. Lower back, ankles, neck and one knee. The worst of all of this started around week 8 after my first ever inoculation with 5 NA.[82]
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This is Day 61 (with 5 NA). Having a hard time with the stomach pains, nausea, and now very strong muscle pains. All of my muscles are so tight. Feels like EVERY single muscle. [83]
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I am about 14 weeks post innoculating with 5 NA. I had quite a lot of difficult symptoms from weeks 3-10 post innoculation:, stomach pain, bloating, feeling feverish & really tired. I got through it just, but since I was ill anyway, holding down a job with all that was hard. [84]
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After my first dose of 5HW I experienced extreme fatigue. It wasn't until my third dose that things began to make a big shift. [85]

Even a first dose of 3 NA can be a challenge for a few self-treaters, including some who are not on the hypersensitive spectrum.

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I am treating mainly neuropsychiatric issues, but 3NA was almost unbearable at points, in the mental effects it had. There was about a week and a half where I was so depressed it was hard to function. I think even 5 would have been too much for me! (Link expired.)

Just 3-5 larvae can be surprisingly effective[edit]

It can be difficult to imagine that very small numbers of tiny hookworms would be capable of producing much benefit in a host many times their size, but it is clear that they are.

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3 little (hook)worms can have a huge impact on a 91kg guy! I used only 3 HW end 2015 and again 3 a month ago (Feb 2017). I can tell you that they can have incredible impact on me. Both times I had a bounce. [86]
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At 10 weeks post inoculation with 5 NA for CFS/ME and chronic migraine, in the past two days I suddenly have many times more energy than usual for winter. Vastly more. Last winter a weekly trip to the grocery store would wipe me out to the point of being able to do NOTHING (no work, no housework, no cooking, nothing but resting) the entire rest of the week and I struggled to stay awake past 7 pm no matter how much I rested during the day. Yesterday, I cleaned the kitchen, batch cooked for half of the day, vacuumed, changed the bed linens and stayed up until 10 pm. Today I'm mopping, cleaning the bathrooms, doing laundry and cooking a bit more. This energy is in addition to the early improvements I've had in brain fog, joint pain, plantar fasciitis and increased tolerance to high FODMAP foods. [87]
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My 11 year old son developed a bad dog dander allergy - he couldn’t be near our dogs without wheezing and getting skin blotches. He was inoculated with 5 HW. He is now (6 months later) free from his allergy, he can roll around with the dogs and rub his face on them with no issues!! [88]
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I started using hookworm in 2011 (for Rheumatoid Arthritis). I only had one dose of 5. I was symptom free within 4 months and stayed symptom free for 5 years. (Edited from two posts in this thread.)
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My daughter (age 16) suffers from terrible allergies. She gets asthmatic symptoms and needs an inhaler. Eight weeks ago she inoculated with 5NA. She is at this time much relieved. I would estimate by about 70% or more. She has a clear nose and has not needed her inhaler for over a month. Last night she spent the night at a friends house who had a cat. She was fine. I am surprised that only 5 seemed to provide such relief. [89]
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My first dose was only 11 weeks ago with 5 HW. Even though it is very early in my HW treatment I have had great success. Right now I have only a few patches of eczema, which is a vast improvement. The psoriasis around my ankles is slowly clearing up. Who knew 5 worms could do so much?! [90]

This individual then increased the size of her next two doses, but this brought no additional benefit.

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I did fine at 5HWs so went to 10 and then 25. My best benefit was at 5 so went back down. [91]

The absence of a rash may not indicate a failed inoculation[edit]

For full details, see the following page.

Other helminth species should not be added alongside a first dose of NA[edit]

Beginning helminthic therapy with more than one species of worm presents an increased challenge to the host’s immune system, resulting in a greater risk of side effects.

Once a host's immune system has become accustomed to the presence of one species, the addition of further species may provide extra benefits.

Supplementary doses[edit]

Helminthic therapy is not a one-dose fix. To reap the benefits offered by helminths, self-treaters need to maintain exposure to them indefinitely. The first dose is just the starter.

A supplementary dose can usually be added 12 weeks after the first dose, but only if all side effects from the first dose have ceased. In a few cases, side effects can persist beyond 12 weeks.

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Took my initial dose of 5 NA near six months to fully settle, pretty sure I'd have had to terminate if I’d introduced another 5 after 3 months. [92]

Once side effects have settled, and the first cohort of worms has been in place for at least 12 weeks, these mature worms will help to modulate the immune system’s response to the second dose. This will result in less side effects unless there is a large increase in the size of the second dose which would make side effects more likely, in a dose-dependent manner. It is therefore recommended that all self-treaters who are using NA should proceed cautiously and only increase the size of supplementary doses gradually, selecting the number of larvae in each new dose based on their experience with the previous dose.

If the first dose was 5, and side effects were absent or minimal, the second dose might be 10. However, if a first dose of 5 larvae causes significant side effects, this should be followed by a further dose of 5, and this should only be added once the side effects from the first dose have subsided. The response to the second dose should then be assessed during the following 12 weeks before deciding on the size of the third dose, and so on until side effects are no longer being experienced.

The amount of time that worms have been hosted is more important for the treatment than the number of worms that have been inoculated, and there is therefore no urgency to reach any particular total number.

After a few doses have been added, side effects should cease to appear altogether, if they have appeared at all beyond the first dose. However, supplementary doses may occasionally continue to trigger a recurrence of the disease being treated, as happened in the following case after each of the first four doses.

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Whenever I add more NA, my asthma comes back... not as bad as before I started NA. But then after 8 weeks, the asthma goes away entirely. [93] [94]

Once supplementary doses are no longer causing side effects or exacerbating the disease being treated, the size of doses can be gradually and cautiously increased, while remaining vigilant for any return of adverse effects.

A few NA hosts may eventually tolerate doses of between 35 and 50 larvae[edit]

After the first few doses, a few hosts do best with larger supplementary doses in the long term, and tolerate them well.

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I've done 35 with no issues multiple times. [95]
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I am now certain that a smaller dose does nothing for my SIBO. The effect of dosing with 40 HW... is so remarkable and so quick that my friends and family are quick to tell me that my worms are alive. lol. I take 40 NA every 3 months. [96] [97]
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I need to take 50 every 6 months.

Supplementary doses of 35 or more larvae may cause side effects[edit]

Even subjects who have been hosting hookworms for many years may continue to experience significant and quite long-lasting side effects following supplementary doses of 35 or more larvae.

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I find that every time I inoculate (always with 35 HW) I get a bad round of gas. This normally starts around 2 weeks after inoculating, but it settles down after a while if I don't reinoculate, and is gone by around 4½ months. (Edited from two posts: [98] [99])
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My reaction to HW is about the same now as it was when I began. Hookworms, in my case, cause a strong, long lasting negative response once I inoculate (with doses of between 35 and 50). I don't get the “bounce.” My mood plummets, brain fog occurs, my IBD related arthritis flares and I have general tiredness. I need to get sleep. Smaller dosing lessen my response. This lasts for 4 to 6 weeks then I start feeling better. (Edited from two posts: [100][101])
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I give myself 50 once a year and have some mild side effects. These are actually worse than my initial dose gave me.
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I had diarrhoea for 2.5 months once when my dose was too high. Didn't realise what it was until it cleared up almost exactly 3 months after inoculation. [102]

Too many hookworms may cause Löffler’s (Loeffler's) syndrome[edit]

The side effects caused by large supplementary doses mostly affect the gastrointestinal tract, causing the typical diarrhoea, cramping and gas, etc., but, sometimes, they may involve the chest, and possibly result in Löffler’s (Loeffler's) syndrome, a type of eosinophilic pneumonia (inflammation of the lung) that is caused by the immune system attacking the larvae during their transit through the lungs. This reaction is similar to those that occur at the site of inoculation on the skin, and in the gut.

Löffler’s Syndrome is most likely to be seen in those with a history of asthma or allergy, and it can manifest as a productive cough and shortness of breath, but possibly also as sinus and other upper respiratory issues. These may last for several weeks, but not necessarily continuously, and, while they do not usually require treatment, they can be very unpleasant, so it may be wise to avoid the use of supplementary doses of 35 or more in order to obviate the risk of inducing Löffler’s Syndrome.

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I have asthma, and my first inoculation (10 HW) went fine. I inoculated a second time with 35 and kicked off Loffler's Syndrome - the worst bout of respiratory distress I've ever had. My difficulty breathing began around 2 weeks after inoculation, and continued for about 8 weeks. It then subsided, and recently came back again. I have been using inhaled steroids twice a day for the last few months. [103]

It is also possible to experience Loffler’s syndrome following inoculation with much smaller doses of NA, especially in those with certain pre-existing conditions - particularly those affecting the lungs - or with certain genetic profiles.

Someone with pulmonary hypertension and interstitial lung disease associated with scleroderma, in addition to a pre-existing Strongyloides infection, developed Loffler’s syndrome after taking a dose of 15 NA following previous doses of 5 and 10, both of which had been side effect-free and produced some improvements in health. All three doses were taken at 12 week intervals. Following the third dose, this individual became so ill that she was hospitalised and required high dose prednisone, even after termination of her NA colony. [104] [105]

Someone else who developed Loffler’s syndrome following inoculation with NA subsequently discovered, as a result of extensive genetic testing, that she is essentially defenceless against most parasites, so needs to restrict the number of helminths she hosts. [106] (She has an adverse variation of the LTF gene [107] amongst other genetic anomalies. Her testing was carried out by GeneSavvy and reviewed by a doctor experienced in interpreting such tests.)

The latter individual was unaware of her genetic predisposition when she began helminthic therapy, and there will inevitably be others with similar genetic variations who may face severe effects from adding just a few too many NA. Her case is further evidence for why everyone who starts therapy with hookworms should commence with no more than the recommended 3-5 larvae, and should proceed thereafter with caution, only increasing the size of supplementary doses very gradually.

Larger doses may potentially cause organ damage in rare cases[edit]

There has been a single report in the scientific literature of a case of reversible damage to the heart myocardium (in addition to Loeffler’s syndrome affecting the lungs) as a result of hypereosinophilia following inoculation over 7 months with three large doses (35/50/50) of NA. [108](Abstract) [109](Full text)

Supplementary doses may be best kept under 20 or 25[edit]

For most of those who are not in the higher risk category, keeping supplementary doses below 25 larvae will reduce the risk of significant side effects.

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Started with 25 HW, then 50 for the next batch which sent my immune system mad, needed prednisone...
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Anything more than 25 (hookworms) and I suffer from brain fog and lethargy, achy joints that could last a few weeks. [110]
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In my experience, taking larger doses (over 25 hookworms) can cause symptoms (similar to those) of an anaphylactic reaction. Scratchy itchy throat, sensation of tingling of mouth and tongue, effort to swallow. From armpit to elbow was very swollen and hot (around the inoculation site), more so than any other previous inoculation. Also, I can't prove this, but my shingles began following this bad reaction to 25 hookworms. [111] [112]
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Started with 15, then 30, then 30, and most recently 20 because I experienced symptoms that were too much to handle. [113]
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In my experience, taking smaller doses (under 20) of hookworm is best. [114]
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I dropped from 25 to 15 worms and the side effects were significantly less! [115]
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I used to top up with 25-30 NA's but my provider suggested topping up with fewer. I used around 10 on my last 2 dosing and it worked great! [116]
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I can never tolerate more than 10-15 at a time and I mitigated one dose of 20 (bad decision) with low dose prednisone.[117]
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I've inoculated with doses of 5, 5, 10, 25, and then a final 25 about 9 weeks ago, with each dose at least 12 weeks apart. The last two doses of 25 each have caused significant side effects without much added benefit. And the benefit I did get from the 25 was no greater than that of the dose of 5 or 10. [118]

Some people need to restrict supplementary doses to 5 larvae or less[edit]

Some self-treaters have found that they need to continue to use very small doses, and that these provide them with all the benefits they require. This is particularly true for those on the hypersensitivity spectrum, who should continue to inoculate with very low numbers for at least the first few doses, and possibly indefinitely. It is also true for a small number of self-treaters who are helminth permissive. These individuals have a reduced ability to control helminths, probably due to their genetic profile, so they accumulate worms rather than losing them to the relentless attrition that limits worm numbers in most people.

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I did 5 and did well for 5 months then did 10 and caused massive CFS/ME flare. [119]
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I had 3 inoculations - 5/15/10. All was well after the first 2, then all hell broke loose after the third one. It has been 9 weeks now and there is no reprieve. (Link expired)
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I started out with a dose of 5 HWS, then went to 10, a couple dose of 25, then back down to 10 before realizing the optimal dose is only 5. At the higher doses I actually had an increase of some symptoms for a while. [120]
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5 or less will be my goto dose from now on. [121]
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Going from 5-10 caused a HOST of problems including an extreme sensitivity to just about every food imaginable. It’s been a few years and the effects did eventually go away, but definitely always dose with the lowest dose possible. [122]

A few people may need to pause treatment after just one or two doses[edit]

Not everyone needs to add supplementary doses routinely every 12 weeks, and doing this can prove counter-productive for some hypersensitive, or helminth-permissive, individuals.

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I did three NA and did relatively ok. After three months, I did three more, but this second dose made my symptoms about 10 times worse. I was sicker then ever before, with even more symptoms that I’d never had previously. So I terminated. (Via private message.)
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I had 3 inoculations - 5/15/10. All was well after the first 2, then all hell broke loose after the third one. It has been 9 weeks now and there is no reprieve. (Link expired)
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My body seems extraordinarily sensitive to hw, so it’s very easy for me to overdose... When I started over (after termination) it was with doses of mostly 5-6 at a time, usually 6 months apart. [123] [124]

Dosing in the long term[edit]

Hookworm survival[edit]

The length of time that hookworm hosts can go between doses in the long term depends on three factors.

  1. The rate of attrition, which is dependent on the strength of the host’s unique immune response to helminths. This is greatest in people with IBD and other intestinal disorders involving inflammation, and is partly determined by host genetics. [125] [126]. (The authors of one very small study that was reported in 2001 hypothesised that the longevity of adult hookworms is probably determined more by parasite genetics than by host immunity. [127] However, this opinion was based on research carried out in a far smaller sample than that available in the helminthic therapy community, where many hundreds of NA self-treaters have inoculated with larvae from the same stock, but reported losing their worms after widely differing lengths of time. This strongly suggests that host immunity is the major determinant of hookworm longevity.)
  2. The extent of any use of substances that impact the health of the worms. For details of these, see the Human helminth care manual.
  3. The number of hookworms that were previously inoculated may also affect the length of time before symptoms begin to return.

Hookworms are reported to survive for 3-10 years [128] but to be capable of living for up to 15 years, [129] and possibly even 18 years. [130] A few hookworm self-treaters have been able to enjoy remission from their diseases for more than 5 years after a single inoculation.

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I started using hookworm in 2011. I only had one dose of 5. I was symptom free within 4 months and stayed symptom free for 5 years. (Edited from two posts: [131] [132])

However, the experience of most self-treaters suggests that hookworms typically only survive for between 1 and 3 years.

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I inoculated with 10 NA a year and a half ago and had about 14 months of amazing relief. [133]

Some hosts, especially those with digestive diseases, can lose their hookworms in as little as 2 or 3 months.

Long-term dosing is based on individual user experience[edit]

The frequency with which NA hosts need to reinoculate varies widely between individuals.

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It appears I lose my worms every three months. My relative went about five months before her symptoms returned. [134]

The size of doses required also varies considerably between individual users.

In order for hookworm hosts to establish the ideal dose size and dosing frequency for them, they should keep a record of the size and dates of all their doses while they are gradually introducing larvae within their individual tolerance. Once they have achieved remission, they should pause dosing and note the length of time that it takes between their last inoculation and the reappearance of symptoms of their disease. This will provide the best guide to the frequency with which they will need to re-inoculate in the long term in order to maintain uninterrupted remission.

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I can tell when the NA die off and I need to take another dose because my gluten sensitivity flares up, my headaches are worse and my aches and pains are worse. [135]
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My previous dose (10 NA) was 5.5 months ago, and some of the baseline symptoms of my so-far "benign MS" were reoccurring… [136]
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One of the symptoms we watch to tell us when the colony is not working at 100% is arthritic knees. Another is dry eye. [137]
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… one of the first ways I knew my old colony was dying off was that I was having stomach issues on Monday mornings, after we had our usual Sunday roast dinner and wine etc. [138]

People who have several conditions may find that, when their colony begins to need reinforcements, symptoms of these conditions may begin to return at different stages. As soon as there is an indication that one condition is returning, and it is clear that the symptoms are not being caused by something else, a top-up dose is likely to be required.

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I know my body well and now know the subtle symptoms of my autoimmunity. When this happens I need to top-up on helminths because my colony is too small to suppress my autoimmune response. [139]

Waiting until disease symptoms begin to return is not usually a problem with hookworms because attrition is a gradual process, and a proportion of the colony should still be alive when symptoms begin to reappear. These existing residents will usually maintain a degree of immune modulation while a new cohort becomes established, and will themselves be perked up by the arrival of the newcomers, with the result that most people see a fairly rapid return of full benefits.

Once it has been established how long a dose will last (this may vary somewhat according to the size of the dose), future top-up doses should be added in time to prevent a recurrence of symptoms, and a reminder to do this should be set in a diary or phone. Otherwise, mild symptoms may not be recognised as an indication of the need to top up one's colony and could be overlooked, with the result that the self-treater might find themselves in desperate need of a dose.

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The benefits wore off exactly 12 months after first inoculation. I panicked because flare ups came back stronger than ever. Talked to her doctor and we decided to innoculate 20 more immediately, 3 months later she was back to base, we needed azithro during those months to protect her until the helminths were able to kick back in. [140]

Long-term dosing in practice[edit]

After a period of personal experimentation, the majority of hookworm hosts settle on a long-term re-inoculation rate equivalent to 1 or 2 larvae per week, added at intervals ranging from weekly to twice each year, e.g., 1 or 2 weekly, 2-4 fortnightly, 4-8 monthly, 12-25 quarterly, or 25-50 every six months. A few outliers at either end of the spectrum find that they need to add the equivalent of only 1 larva every 2 weeks, or as many as 5 larvae each week, but with a maximum of 50 larvae per dose.

The following comments illustrate the range of dose sizes and dosing frequency being used, and show that many self-treaters top up at least every 3-6 months.

12 months

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Unless I take something that kills them, I probably only need 3 or so, once a year. [141]

5-6 months

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I inoculate with 15 each 5 months, because I swear my baseline symptoms start to return at about 6 months post-inoculation. [142]
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I need to re-dose every 20 weeks. If I wait longer, symptoms return and I go through worm flu again (though diminished). If I re-dose every 20 weeks, results are more consistent. [143]
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I need 25 every six months.
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I inoculate with 30 about every 6 months. [144]
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I need to take 50 every 6 months.

3-4 months

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I find 1-3 NA ok. Five is ok if (my colony is) low. But more than that I have symptoms... I will probably do 2 every 3 months as a topup. [145]
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I dose 20 NA at about 3 month Intervals. [146]
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I need 25 every 3 months. [147]
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I have to redose every three months also. 35 is my magic number. [148]
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I take 40 NA every 3 months. [149]
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I now take about 7-10 hookworms every 3-4 months. [150]

2-3 months

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I tried 20 NA every 3 months - it gave me worm flu. Now i've gone to 10 NA every 2 months, and it seems to work better for me personally. [151]
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I need 40 NA every 8 weeks, for now. [152]
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I do best at 2-3 month redoses. If I wait longer, I wish I hadn't. [153]
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I now dose with 40 every 2.5 months. I need a frequent high dose to keep my Crohn's under control. [154]

1-2 months

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My brother is now doing 3 NA every 4 weeks and that seems to be good for him as at 10-12 weeks he has return of symptoms. [155]
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I do 5 NA every 7 weeks. If I do it more often, I feel sick and flared up. If I space it out more, my autoimmune symptoms return. I listen to my body and this is what it needs at this point. I journal my symptoms so I’m able to see the patterns. [156]

1-2 weeks

Several people who began to increase the frequency of doses, while reducing the number of larvae in each dose, have continued this process until they were dosing every one or two weeks. Someone who is treating ankylosing spondylitis went first from dosing quarterly to adding 10-15 NA every other month. [157] Then, finally, he changed to adding 6 NA every two weeks. [158]

Another self-treater, who had begun dosing with 30 NA every 6 months, changed to 5 every month.

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I've found that this new schedule is much better at keeping my sinuses clear. I'm beginning to think that the number of larva is much less important than the frequency of inoculation. [159]

After noting the improvements gained from more frequent dosing, he adopted a fortnightly regimen.

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I've recently started 2-3 hookworm every 2 weeks and am getting much better results than I did with 30 every 6 months. [160] [161]

And he has since changed to weekly dosing with just one larva.

The additional exposure to migrating larvae facilitated by more frequent inoculations may provide increased immune stimulation.

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… the larval phase of infection rather than the persisting egg-laying adult worms may be largely responsible for the cytokine production and so responders may be the more frequently/more recently exposed individuals. [162]

Trickle dosing, and sensitisation to NA[edit]

In his book, An Epidemic of Absence, Moises Velasquez-Manoff mentions that light, transitory, hookworm infections may prime allergic disease, and some other commentators have suggested that trickle dosing with hookworms (adding one or two larvae every week or fortnight) could present a potential risk of increased sensitisation to them, perhaps reducing the maximum number that can successfully colonise. However, feedback from self-treaters suggests that frequent dosing does not cause sensitisation, but that the addition of too many worms too quickly can do, especially in hypersensitive individuals.

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My wife lost her colony due to an 8 days treatment of antibiotics. As we were in a hurry to replenish her colony, and so inoculating 20 every 20 days, she became sensitized to them. [163]

The individual whose experience is described in this last quote has also found that inoculating with 8-10 NA larvae every 6-8 weeks also results in sensitisation to the worms, and foods begin to cause the symptoms that she experienced prior to first using NA, and which she associates with allergy: brain fog, blurry vision, tiredness, grumpyness and lack of motivation. If she is tested at that point with a vial of NA larvae, using Applied Kinesiology [164], her muscles will invariably be found to be weak, suggesting that she has become allergic to the hookworms. Treatment using NAET [165] [166][167] will usually restore normal muscle function, but, if retesting 24 hours later finds that her muscles are still weak, a second NAET treatment will be undertaken, and this invariably restores the benefits she usually enjoys as a result of hosting hookworms.

The risk of sensitisation to hookworms is likely to be highest in hypersensitive subjects and those with allergies, and this is one reason why it is important to start hookworm therapy with no more than 5 larvae (just 3 for the hypersensitive and those with certain other conditions), and then to increase the size of supplementary doses very gradually so that any side effects that do develop will appear at a manageable rate rather than become suddenly so severe that termination is needed, or NAET treatment is required by those with access to this modality.

It might be assumed that those who choose to dose every week or fortnight would have an almost continuous rash, but the rash caused by 1-3 larvae is usually minimal. [168]

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I currently inoculate with 1 hookworm larva every week, so my initial itch is muted enough that it doesn't tell me for sure if the larva made it. But the bounce that night does. And I get a small itchy rash a couple days later that confirms it. [169]

Dose size and frequency may need adjustment over time[edit]

Reactions to helminths may change over time, requiring some adjustment to dosing.

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After 10 years of using helminths my body has changed and reactions to helminths have changed. I find hookworms cause more symptoms at smaller doses (so) my treatment requires tweaking of dosage, timing, amounts. [170]

Some people may even experience seasonal changes in their response that also require adjustments to dosing.

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Time of year also makes a difference for me. My autoimmunity is stronger in the winter months. [171]

Colony size[edit]

It is impossible to determine how many hookworms are being hosted at any given time because there is no reliable test for this. Neither can the size of a colony be ascertained by adding up the doses that have been inoculated previously, because attrition is constantly taking its toll on intestinal worms, killing them at widely varying rates in different individuals. So, rather than aiming for any notional colony size, the best approach is for individuals to observe their response to each of the doses they add over time and to use this knowledge to determine what size and frequency of top-up doses will enable them to keep their disease in remission.

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Don't worry too much about colony size. I take 10 NA every 3 to 4 months and TTO every 2 weeks. The first year, my symptoms returned after I waited too long to take more NA, so I think the key is to just get that regular influx every few months. [172]

Since a few hookworm hosts may not achieve remission for up to 2 years, it may not be possible for them to see any obvious connection during this time between the number of worms inoculated and their effects, so a lack of benefits within this period may not necessarily indicate a need to add more worms. However, people with a higher attrition rate may lose their worms long before they reach 2 years, so it is essential during this period to maintain the colony by adding supplementary doses as discussed above.

Some people do extremely well with a relatively small number of hookworms.

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For the last 2 weeks my son has been able to stroke and even hug the dogs without getting a severe allergic reaction. Plus he hasn’t needed to use anti-histamines for weeks now - by just hosting 5 hookworms!! [173]
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I took one batch of 25 NA last year because I was experiencing pain and swelling every day from Graves and Hashimoto's diseases. I had a dramatic reduction in swelling and pain (and) lost about 15lbs of water weight. A few months later, I got pregnant, and did not have a miscarriage (I had 3 earlier that might have had something to do with the thyroid diseases). My TSH, T3 & T4 levels stabilized right before the pregnancy, they followed the "textbook" levels through the pregnancy and stabilized right after as well. My antibody levels for both diseases dropped. My Endo ... said - ‘the improvements are real - and they are unexpected.’ [174]
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I am 7 months in to treatment for dermatomyositis and other autoimmune problems. I have 35 hookworms and have recovered almost completely. I had sun sensitivity, food allergies and skin problems which are all gone. [175]

Others have claimed they needed to establish a colony of between 100 and 150, and even as many as 200 hookworms. However, since there is no reliable way to establish how many worms are being hosted, and since attrition rates very widely between individuals, it cannot be assumed that someone who has inoculated with 4 doses of 25 NA over a year will have a colony of 100 at the end of that period. Any improvement in such cases may actually have been the result of the gradually increasing period of time that these individuals had been hosting worms, rather than their number. It is known that, in some cases, benefits can continue to accrue during the first two years, even after starting with only a small dose and without any supplementary doses.

Overdosing on hookworms[edit]

There is a risk that attempting to increase the size of a colony without an obvious need to do so may cause a loss of benefits.

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I tried NA for many years but after initial success I crashed completely due to overdosing and never got back on track. [176]
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I dosed up to around 100 hookworms (for total food intolerance) and lost all my tolerance to foods again. We killed the hookworms off and I've had 3 new doses so I now have 35 hookworms. It took a while but I am back to eating a lot broader range of foods. So when it comes to hookworm dosing, It seems (for me anyway) that a smaller amount of worms works better. [177]
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I have lost 80% of benefits in the 14 weeks since (my third) dose. [178]

This loss of benefits as a result of exceeding a personal dosing limit is seen particularly, but not exclusively, in those on the hypersensitivity spectrum.

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For me too many worms causes exactly the same symptoms as no worms at all! After being able to eat everything I wanted for 2 amazing years, cracks started to appear and eventually I crashed and was back to just 10 foods. It took a long time to work out that this was the result of too many worms rather than too few. After killing my previous colony I started afresh. About 4 weeks after the second inoculation I could again eat everything I wanted! (Post now deleted.)

In addition to a loss of benefits caused by overdosing on hookworms, there can also be excessive side effects.

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I definitely had an aggravation from too many hookworms (at six months into my treatment, and after a dose of 50) and I think that I may have been able to get into a much better place by knocking the hookworms back. I had felt so good on them at their best I was very hesitant to eliminate them. I did the abendazole 100mg caps twice per day for three days but doubt I killed them all… now my aggravation symptoms (anxiety and diarrhea) are greatly diminished. [179]

In some cases, side effects - especially diarrhoea - can persist for some time after a colony has been terminated.

Reducing the size of a hookworm colony[edit]

If too many worms have been added, resulting in unmanageable side effects, it may not be necessary to terminate the entire colony. Carrying out a partial cull should reduce the severity of the side effects while leaving some worms to continue the therapy.

A partial cull can be achieved by using any of the substances categorised in the Human helminth care manual as being potentially lethal to human helminths (marked with an ❌), although the effects of these substances will not be as predictable as those of an anthelminthic drug. The details on the Terminating a helminth infection page can be used to tailor a cull to meet the individual self-treater’s particular needs. For example, a single 500mg dose of mebendazole may kill approximately 30% of a colony of NA and, if this doesn't provide sufficient relief from the side effects, further doses of the drug can be taken as required.

Is there a constitutive limit on colony size?[edit]

Croese, et al., observed that the size of hookworm colony returned to the pre-inoculation level by week 21 and, even though this study using capsule endoscopy had involved only two subjects, it’s authors opined that there is a colony size status quo that is constitutively set by the host.

This assertion by Croese, et al., appears to be contradicted by the findings of a more recent study in which a colony of NA observed in a patient was described as "massive".

There may also be different degrees of predisposition to hookworm infection in different groups, e.g., young/old, male/female, [180] and other influences on colony size may include blood group. [181]

Before these more recent studies were published, the earlier paper by Croese, et al., had prompted the following discussion in one of the helminthic therapy support groups.

Read the full discussion... 

DD

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It has recently come to my attention that two Australian researchers, Drs Croese and Speare, inoculated with hookworm and then did capsule endoscopy (swallowed a pill camera). It seems that no matter how many they inoculated with (50-100), Dr. Croese always ended up with 6-9 living adult worms and Dr. Speare always ended up with about 16.

TC

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this doesn't quite made sense to me. we already know many people in countries where hookworm are endemic have too many of them, to the point of becoming anemic.

LE

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It doesn't really make sense to me either, but OTOH, anecdotally, I've read similar things, that maybe the established worms have a way of preventing new ones from doing well. There is a lot of contradictory information. The other issue is that people in the developing world can be getting inoculated on a daily basis. It doesn't seem to me that a pill camera would necessarily image every square millimeter of intestine, though.

DD

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I understand that most people 'in the wild' have a small number too. It is only a few who can't seem to control the number and have enough for anemia. This could also explain why nobody is reporting anemia among us users even though several have inoculated with relatively large doses. I agree LE, that perhaps some could be missed by pill cam. But I wouldn't think it would be many.

LE

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Then the issue, too, if you start out low and slow is what is the carrying capacity going to be? If you only got 7, maybe your carrying capacity is 15. Or is it going to lock at 7 because that's what you started with? My daughter definitely seems better after a significant top off, the rest of us, it's hard to see much difference yet.

DD

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I suspect that if your carrying capacity was 15 then it wouldn't change if you started with 7. I imagine it could change though based on other factors. For instance, I suspect it might grow with age as our immune systems become less robust.

KK

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since it was only two guys who did the pill cam, that is not a very big representation of any population. u all have seen so many variables amongst us all, and wherein, for example, some seem to only be able to carry their worms for a relatively short time period and then they die, repeatedly, that this could just be an individual thing that these two men happened to share.

BS

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It is a fascinating thing to speculate on how many we actually have and whether our immune systems or the worms themselves regulate our worm carrying capacity.

If this is the rule for hookworm, though, such that a dose of 15 or 50 or 100 or repeated top up doses all result in the same worm load, I wonder how to account for a few things from the historical record.

1) The Italians building the Gotthard tunnel in the late 19th century - they not only got very sick, but many of them died of congestive heart failure. If the worm load is independent of repeated doses and only depends on the individual's predetermined load based on genetics or whatever, what would explain such an epidemic? The tunnel workers likely mostly already had hookworm (how else would it have got into the tunnel in the first place?), so if repeated doses did not increase their loads, why did they go from asymptomatic as a group to sick enough to lead to the discovery of AD?

2) I have the same question for the history of the southern US and NA. Hookworm overloading due to repeated dosing was supposed to be significant enough to cause anemia in enough people to decimate the economy and motivate founding of the rockefeller commission to combat it. Moreover, if repeated dosing does not increase the worm load for most of the population, why was the rockefeller solution, which primarily involved latrines to limit re-infection, so effective that the whole economy was successfully recovered. They did not give everyone multiple doses of mebendazole, so it's not like hookworm was being eliminated. The effect could only be due to reduced worm loads. If the ultimate equilibrium load is not affected by repeated dosing, how can it then go down so profoundly merely be stopping the repeat dosing?

If either hookworm species really behaves in such a benign way, it would also be unique among parasitic eukaryotes.

I suppose it's also possible that even if the adult equilibrium population is independent of dosing magnitude and frequency, that the therapeutic effect may still depend more on how many helminths you are dosed with than how many survive.

Then the situation with NA would be more analogous to TSO - in TSO it the immune response to the attempted infestation that must be doing the trick as there is no persistent infection with adult TS? The effects we get with NA may be similarly be related to the transit of larvae

So it does not follow that even if equilibrium worm load remains the same that it is useless to top up or that larger doses are not more effective.

But I still am skeptical that worm load is a zero order function with respect to dose magnitude and frequency. I'm sure it's not perfectly linear, but there is no other way to account for populations being devastated by poor sanitation than that there is some increase in load with increasing area under the curve for dose....

There is a way that I might trust to actually count worms and it would not be that hard to do. One could make a monoclonal antibody to NA and then bind it to radioactive technetium. Lay down under a gamma camera and you might be able to resolve the number of worms if they were somewhat spread out.

I am a bit skeptical that a pill cam will see them all, given the size of colonic lesions I've seen missed by colonoscopy.

And then there is the Pritchard dose ranging study. Although the numbers were small, the people getting larger doses were pretty reliably sicker and had larger immune responses to match. One would have to believe that the worms were having attrition well after the establishment of enteritis-causing adults in the gut - an attrition that is proportional to the initial dose. More than proportional to the initial dose, actually.

IOW, the immune response is more than proportional to the initial dose, but does not prevent adults attaching to the mucosa long enough to cause eosinophilic enteritis.

And then one would have to further believe that most of the adults attached to the mucosa are then later successfully eliminated, and that the higher the initial dose, the higher fraction of worms are killed by the immune system. Otherwise, the higher the initial dose, the higher the ultimate worm load and we are back to square one.

JL

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Whether new worms displace old ones has been documented in those with Crohn's taking very large doses (50 at a shot), but I doubt it occurs in anyone without either Crohn's, Coeliac or UC. Or intestinal allergies and perhaps IBS, too.

MD

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I did read the Croese paper quite a long time ago but really did not take much notice of it for the following reasons. I can not see how HW could pose any sort of risk to health in environments where infection is uncontrolled if there were some mechanism which allowed the body to keep numbers so low.

So if we are capable of limiting HW number it is clear that even in someone who was malnourished the presence of approx 20 HW is going to have almost no effect, therefore either the observation that HW have historically been a major cause of morbidity and mortality is incorrect, and people were developing anaemia and other health problems attributed to HW but actually due to other causes.

Or final HW numbers are a direct result of the number of exposures and there is no limiting factor to the final population, allowing numbers that are large enough to cause or contribute to pathology. If this is the case, which I believe it is, there must simply be some factor or variable in Croese's experiments that resulted in numbers being limited. Just because something gets into print does not mean that it is not open to mistakes (experimental) and misinterpretation of experimental data.

Colony collapse[edit]

Occasionally, hookworm hosts may experience the total loss of their colony, possibly as a result of taking certain antibiotics or consuming one of the other substances that are capable of harming hookworms. (For more details, see the Human Helminth Care Manual.) Colony collapse is uncommon, as is the need to deliberately terminate a colony and start over, but, if it does occur, disease symptoms may return rapidly.

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When I took antibiotics, my symptoms returned within 2 days. It was incredibly eye opening and scary. I forgot how much they were helping. [182]
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When I lost mine, it was apparent the next day. [183] I felt as though I had been hit by a truck ... and it didn't go away. [184]
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When they (NA) died off, and I didn’t reinoculate for a month because the shipment was late, I completely relapsed. [185]

Some subjects have reported a more gradual loss of benefits after a colony collapse, this difference perhaps being due to these individuals having hosted worms for a longer period.

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During about 5 weeks after the Albendazole, she felt OK but little by little allergy symptoms started to appear. [186]
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I gradually began to notice increased brain fog, my lips became drier than usual and my skin slightly more itchy. Then, at around three weeks after the severe diarrhoea (induced by excessive binging on sauerkraut), I began to experience a return of nasal congestion... Daily headaches also returned around this time, my appetite was non-existent, and food tolerance was somewhat reduced... My concentration got worse and I was needing more sleep again... Then, I noticed definite hints of Restless Leg Syndrome when I took a nap, and my gut began to become sore after eating. [187]

When a colony is lost before any benefits have been experienced, the host may not know that their worms have succumbed. This is one reason why it's important to continue to add supplementary doses at 12 week intervals until benefits have become obvious.

In the absence of any existing worms to modulate the immune response to a replacement dose following a colony collapse, this dose should be of an appropriately limited size, perhaps similar to the dose that was used at the very beginning of treatment, if this proved to be effective without causing undue side effects.

A full return of benefits may take a while, and the length of time varies between individuals.

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It’s now 10 weeks after my new colony was started and my legs (Restless Legs syndrome) have been mostly calm for about 2 weeks. [188]
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The benefits returned 12 weeks after my first inoculation after this (colony collapse) happened, even though it took about 8 months to get benefits the first time. [189]
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It took a solid 20 weeks to recover and see most of the symptoms go away, and another 4-8 weeks after that to eat some gluten and nightshades. [190]
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It has taken easily 6 months to get back to where I was. [191]

Some benefits may return more quickly than others.

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I experienced small but noticeable benefit within 10 days. However it took another year to approach the benefits that I had just begun to experience before my third dose. [192]
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Almost two weeks after the new team of worms went in, I was again enjoying a degree of relief, though I still had some way to go before I was back to my usual wormy bliss. I was still getting a little nasal congestion, some brain fog and a lot of headaches, but I was once again free from the Restless Leg Syndrome. The last symptom to go was nasal congestion, which continued to be a problem until 12 weeks, when it became significantly easier, though it didn't go completely until almost week 20, at which point I was pretty much back to how I had been before the explosive diarrhoea (induced by excessive binging on sauerkraut) that had flushed out my worms. [193]

Hookworm dosing in children[edit]

Children are usually introduced to hookworms with a first dose of 3, or possibly 5, larvae, but no more than 3 if they have one of the conditions that require a modified approach to helminth dosing.

Based on the child’s experience with the first dose, subsequent doses can be increased gradually, if required, using the approach described above in the Supplementary doses section.

Some children may eventually be able to tolerate doses of up to 25 larvae, and might benefit from being given these larger numbers, once they have an established hookworm colony.

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We gave him 5, 5, 10, and 25, over 18 months. He would flare up after a while so we always figured the worms had stopped working. And sure enough once he’d had another dose, three months later he’d be perfect skin again. So the final dose of 25 has lasted us much longer and seems like he just needed higher numbers. [194]

Also see the following page.

See also[edit]

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