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Latest revision as of 23:29, 17 April 2021

Home>Using helminths>Self-treating with NA

Necator americanus (NA) is a member of the phylum Nematoda. Commonly known as the New World hookworm, it is one of two hookworms that are adapted to living in humans, and the only one used in helminthic therapy.

Dosing with hookworms[edit]

See the following page.

Hookworm larvae storage and survival[edit]

Ideally, L3 NA larvae should be used as soon as possible after cultivation because, at this stage in their development, the larvae do not feed and therefore rely on their fat stores for nourishment, and they become increasingly weaker as these stores are used up.

Home-grown larvae have been known to survive for as long as 3-5 months if kept in ideal conditions, i.e., out of light, at a temperature of 60-65°F (15-18°C), in a minimal amount of distilled, demineralised or dechlorinated water. [1] [2] (Researchers working with NA larvae have reported that the pressure from too large a volume of water will shorten their life.) Survival time is also partly determined by the temperature at which the larvae were incubated, with those grown at a lower temperature having greater longevity.

Larvae purchased from the helminth providers may not last as long as home-grown larvae because the providers put them through a cleaning process which reduces their longevity. Variations between the cleaning protocols used by different providers result in differing lengths of shelf life. For example, one hookworm provider (Wormswell [2014-2018]) said that their larvae had a shelf life of 3 to 4 weeks after rinsing, whereas larvae purchased from a different provider (Worm Therapy) only have a stated shelf life of 2 weeks.

Purchased hookworm larvae should therefore be used as soon as possible after receipt. If there is an unavoidable delay in inoculating with the larvae, the provider should be consulted, and, in the meantime, the larvae should be stored in their original packaging at room temperature and out of direct sunlight.

If L3 larvae encounter extreme temperatures during transit, they may be dead on arrival. Freezing will kill them, and the cargo hold in an aeroplane can fall well below zero during flight, so worms in packages placed at the edges of pallets will likely succumb, but the further the package is from the edge of a pallet, the better insulated it will be and the greater the chances of the larvae surviving. Sitting in an outdoor mailbox in sub-zero temperatures will also be fatal for the larvae, so delivery should be arranged to an address where the package can be received indoors.

Worm growers have reported a 50% loss of larvae at 50ºF (10ºC) and a 90% loss if the temperature drops to 43ºF (6ºC) for several hours. Hookworm larvae are also susceptible to drying and heat, for example from direct sunlight. [3] (PDF) Temperatures above 113ºF (45ºC) will kill them, and they may only last for a week or two at 90ºF (32ºC).

Hookworm inoculation[edit]

See the following page section.

Hookworm lifecycle[edit]

Hookworm LifeCycle.gif

Source: US Centers for Disease Control [4]

The developmental stages, migration and diet of Necator americanus[edit]

Egg - Hookworms start their life as unembryonated eggs in faeces deposited in soil, and initially gain nutrients from the faeces. When there is adequate warmth, shade and moisture, the eggs embryonate and, within 1-2 days, hatch into first stage L1 larvae.

L1 - In this first, non-infective, juvenile rhabditiform (free-living) stage, the larvae feed on bacteria living in the feces in which they were deposited [5] and on bacteria and organic debris in the soil until they molt, after approximately 3 days, into second stage larvae, L2s.

L2 - During this second rhabditoform (free-living) stage, the L2 larvae will feed for 6 or 7 days and then molt again into third stage larvae, or L3s.

L3 - In this infective, filariform stage, characterized by a closed mouth, the L3 larva does not feed in its natural environment and will only survive for a few weeks until it exhausts its lipid metabolic reserves, or it finds a host, at which point it will commence feeding on protein in the bloodstream. [6] [7]. The lifespan of L3 larvae supplied by commercial helminth providers may be further shortened by their exposure to the antibacterial rinse used by these companies to clean them.

Once the L3 larvae enter the skin, they travel via the circulatory system and the heart to the lungs which the literature claims they reach at around 4-7 days. However, the subjective experience of NA self-treaters suggests a much earlier migration through the lungs, with the L3s already ascending the bronchioles to the trachea - during which part of the journey they molt into the L4 stage - between days 2 and 4.

Serum and gluthatione provide the signals for L3 larvae to continue their development to the L4 adult stage.

In experimental conditions, exposure to serum has been shown to stimulate about 50% of hookworm L3s to feed and undergo development, and this response can be increased to 90-100% by adding glutathione to the serum. [8] Starting this process in a petri dish in larvae that are to be used in therapy would make infection impossible, but the serum experiment might indicate that L3 larvae are in fact able to feed once they enter the bloodstream, which might explain successful inoculations with old batches. [9]

L4 - The L4 larvae transfer from the trachea to the oesophagus by slipping under the epiglottis. They are not coughed up into the mouth - as is sometimes claimed - unless they have become attached to mucus which is then coughed up. Once in the oesophagus, the larvae continue down to the intestines, which they reach, according to the literature, between days 8 and 14, but possibly much earlier, and perhaps by days 4 to 7. They then molt into the pre-adult stage around days 17–21 and commence feeding on blood drawn from the intestinal mucosa. Contrary to the impression created in many scientific texts, the amount of blood drawn by Necator americanus is minuscule. When discussing the amount of blood lost to hookworms, researchers will often have in mind the Old World hookworm, Ancylostoma duodenale, which draws 9 times more blood than Necator americanus.

L5 - At about 5-9 weeks, the larvae attain their adult form (L5) and the females begin producing eggs.

Note. Many of the details above were recorded from observations in a hamster model [10]

Once it has reached the intestine, Necator never migrates to other parts of the body, so remains within the gut for the rest of its life, the length of which varies widely depending on the immune response of the individual host. (See Hookworm lifespan.)

For more detail about the developmental stages and migration of NA in humans, see Immune responses following experimental human hookworm infection.

Where hookworms live[edit]

According to Wikipedia, mature Necator americanus live at the distal (lower) end of the jejunum and the proximal (upper) end of the ileum, while the other species of human hookworm, Ancylostoma duodenale - which is not used in therapy - resides in the duodenum/jejunum. [11]

Croese, et al, used capsule endoscopy to determine that the distribution of NA was influenced by the parasite’s maturity, and that, early in infestation with NA, the worms were distributed along the length of the jejunum but that, by 20 weeks, the predominant location of surviving worms was the proximal jejunum - the upper end of the jejunum, just below the duodenum. [12] It could be argued that this latter observation is more likely to be correct than the opinion expressed in Wikipedia and, if it is, mature NA are most likely to be found where the red text appears in the following representation.

mouth ➤ oesophagus ➤ stomach ➤ duodenumjejunumileumcaecum ➤ colon ➤ rectum

Rarely, NA have been observed in the stomach. This exceptional localisation might be caused by one of three factors:

1. the removal of the jejunum and/or duodenum
2. jejuno-duodeno-gastric reflux [13]
3. an excessively large hookworm colony that has forced some of its members to spread out from their usual localisation site. [14]

A short video clip of a hookworm in situ.

While it is theoretically possible that NA might be seen during a colonoscopy, this would only happen if the colonoscope were advanced into the lower end of the ileum, and only if some hookworms had taken up residence there, which is unlikely unless the jejunum has been removed or very large numbers of NA - i.e., hundreds - are being hosted, forcing some NA to occupy the ileum. It is very unlikely that any would take up residence in the colon, which they normally only pass through after they die.

Hookworms are not adversely affected by the laxatives used in preparation for a colonoscopy. While it is possible to lose hookworms to very severe diarrhoea/diarrhea, they can withstand the effects of normal, recommended quantities of laxative, including the standard colonoscopy prep.

An upper endoscopy (i.e. via the mouth) will not reach past the second of the four parts of the duodenum, so will not usually reveal, or disturb, any hookworms unless these have been forced to spread beyond their usual location as a result of one of the three factors mentioned above.

Confirming hookworm infection[edit]

There are three practical options for determining the presence of hookworms in the gut.

1. Stool test

From about six weeks post inoculation with hookworms, eggs will be detectable in the host's stool. Checking a stool sample for these eggs is the best way to establish whether hookworms are present. Unfortunately, while most pathology labs will have a faecal (stool) test called something like "Ova, Cysts, and Parasites" or "Ova and Parasite", they typically do not have sufficient experience to accurately identify hookworm eggs, a problem that is exacerbated by the relatively low numbers of worms used in helminthic therapy. Testing is therefore best carried out by a helminth provider who offers a stool testing service, a laboratory associated with a school of tropical medicine, a veterinarian (who will have experience with helminth eggs), or at home using a microscope and fecalyzer. For more details about these options, see the following page.

2. Incubation

Some hookworm hosts find it easier to check for the presence of worms by incubating a stool sample rather than attempting to count the eggs via a fecal float.

3. Blood test for eosinophils

Another way to determine whether or not you are hosting helminths is to have a blood draw to see if your eosinophil level is elevated. Although this is not a foolproof test for the presence of helminths, it is fairly reliable. It is also quick, and is a method that a medical insurer might pay for.

Caring for hookworms[edit]

See the following page.

Hookworm side effects[edit]

See the following page.

Hookworm lifespan[edit]

Once inside a host, NA are reported to survive for 3-10 years [15] [16] but to be capable of living for up to 15 years, [17] and possibly even 18 years. [18] However, the experience of hookworm self-treaters suggests that they typically only survive for approximately 1-3 years, and sometimes for as little as 2-3 months, depending on the strength of the individual host’s immune response. For more detail about this, see the following page section.

Hookworm respiration[edit]

Hookworms, like other nematodes, have digestive, nervous and reproductive systems but no circulatory or respiratory system. They pick up oxygen and give off carbon dioxide via the surface of their bodies using diffusion, which occurs whether they are in water or air. They are also able to extract oxygen from their host's blood. [19]

Is there genetic degradation in laboratory-reared hookworms?[edit]

Concern is sometimes expressed about the possibility that the hookworm larvae being sold by the commercial helminth providers may have become weakened as a result of genetic degradation in the domesticated hookworm stock.

It is probable that all the NA on sale today would have originated in the same cohort gathered from the wild by the helminthic therapy pioneers who founded the first two companies to sell NA - Worm Therapy and Autoimmune Therapies. In view of this, there is unlikely to be much, if any, advantage to be gained by sharing NA larvae with other members of the helminthic therapy community in an attempt to increase diversity.

So far as is known, there is only one other stock of safe NA that might be available to helminth self-treaters, and this is the Nottingham cohort, collected by David Pritchard and colleagues from Papua, New Guinea, and shared with research departments working with this species in other countries. Although the genetic diversity of this research stock may theoretically also be limited, obtaining a sample from this stock might arguably somewhat increase the gene pool in the worms hosted by someone who obtained their NA from commercial providers.

While a genetic bottleneck in the commercial stock may be a theoretical concern, there is no evidence of any diminution of therapeutic effect in the NA obtained from the helminth providers, therefore the possibility of genetic degradation is arguably nothing that today’s self-treaters need be concerned about in their lifetime.

Genetic degradation is not an automatic sequel to the restriction of a colony. Some insect species are able to withstand the effects on their gene pool of high levels of inbreeding, and still produce healthy offspring, a feature also seen in cockroaches and bed bugs. [20]

A study comparing mitochondrial cytochrome oxidase 1 DNA sequences from NA that had been maintained for 100 generations in laboratory-reared golden hamsters with those from natural human infections, concluded that:

The genetic differences between the laboratory, hamster maintained strain of N. americanus and field isolates from throughout China and Togo are very small (nucleotide diversity 0.0337). [21]

Any attempt to obtain new stock from the wild would introduce a significant level of risk for anyone who was to host worms obtained in this way. Walking barefoot in open-air latrines is not a good idea, as is explained by someone who did this. There is a risk of inadvertently acquiring a different type of helminth, such as the less desirable species of hookworm, Ancylostoma duodenale, which causes nine times more blood loss than NA, can be passed in a mother’s milk and can even cross the placenta to infect a foetus. Even more risky is the roundworm, Strongyloides stercoralis, which is autoinfective and potentially hyperinfective, with a risk of fatality. [22] [23]

Since the eggs of both these species are virtually identical to those of NA, anyone attempting to obtain “wild” NA would need a considerable level of expertise in species identification in order to be certain that they were not harbouring something much less desirable. They would also need to undertake multiple terminations of their hookworm colony, followed by re-inoculation with individually selected larvae that had been definitively determined to be NA.

Hookworm incubation[edit]

See the following page.

See also[edit]