List of Abbreviations
ALT – alanine aminotransferase
AST – aspartate aminotransferase
WHO – World Health Organization
DNA – deoxyribonucleic acid
GI – gastrointestinal tract
EIA – enzyme immunoassay
ICD-10 – International Classification of Diseases 10th Revision
PCR – Polymerase chain reaction
ESR – erythrocyte sedimentation rate
US – ultrasound examination
FL – Federal Law
CNS – central nervous system
Terms and Definitions
Primary disease – a disease that, by itself or due to complications, creates an urgent need for medical care due to the greatest threat to working capacity, life, and health, or leads to disability, or becomes the cause of death.
Severity of the disease or condition – a criterion that determines the degree of damage to organs and (or) human body systems or impairment of their functions caused by the disease or condition or their complication.
Outcomes Consequences (results) – disease outcomes, social and economic results of applying medical technologies.
Complication of the disease – addition of a physiological process disturbance syndrome to the disease; violation of the integrity of an organ or its wall; hemorrhage; development of acute or chronic failure of an organ or organ system function.
Condition — changes in the body resulting from the impact of pathogenic and/or physiological factors that require medical care.
Clinical situation – a case requiring the regulation of medical care regardless of the disease or syndrome.
Syndrome – a condition developing as a consequence of a disease and defined by a set of clinical, laboratory, and instrumental diagnostic signs that allow it to be identified and classified into a group of conditions with different etiologies but common pathogenesis, clinical manifestations, and general approaches to treatment, which, at the same time, depend on the underlying diseases.
Symptom – any sign of a disease available for determination regardless of the method used for this purpose.
Patient – an individual to whom medical care is provided or who has applied for medical care regardless of whether they have a disease and regardless of their condition.
Drug formularies – a fragment of patient treatment protocols containing information on medicinal products used for a specific disease (syndrome), regimens, and specific features of their prescription.
Invasion – 1) penetration of parasites into the host organism, i.e., infection, usually by worms or other animal parasites (in a narrower sense, penetration of parasites through the host's epithelial barriers); 2) diseases caused by pathogens: a) animals (e.g., helminthic infestations); b) protists (protozoan infections).
Löffler syndrome – eosinophilic transient infiltrate, characterized by the formation in the lungs and intestines of transient infiltrates containing a large number of eosinophils, and an increase in the number of these cells in the blood.
Anthroponosis – a disease (parasitosis) occurring exclusively in humans.
Geohelminthiasis – transmission pathway via contaminated (seeded) soil.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Ascariasis is an anthroponotic geohelminthiasis caused by Ascaris lumbricoides, characterized by respiratory tract involvement and allergic reactions in the larval migration phase, and upon parasitization by mature helminths – chronic gastrointestinal tract (GIT) involvement with potential severe complications [1, 21-23].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Etiology. The causative agent of ascariasis, Ascaris lumbricoides, belongs to the phylum of roundworms Nemathelmintes, class Nematoda, order Ascaridia, family Ascaridae. The pig roundworm, Ascaris suum, can also cause ascariasis in humans [2]. Roundworms are dioecious helminths; mature individuals are spindle-shaped, and their body is covered with a thick, transversely striated cuticle. The male is smaller than the female, 15-25 cm in length, 2-4 mm in diameter, with the posterior end of the body hooked toward the ventral side. The female has a spindle-shaped body 25-40 cm long and 3-6 mm in diameter. The lifespan of an adult roundworm is about one year. Egg laying by the female begins no earlier than three months from the moment of infection and ends by 7-8 months of its life. A mature female lays up to 245,000 eggs per day [3]. In the absence of males, females lay unfertilized eggs. Fertilized roundworm eggs are yellow or yellowish-brown, oval or round in shape, and covered on top with a bumpy protein shell. Egg maturation occurs at a temperature not lower than 12°C, soil humidity of at least 8% with free access to oxygen. A larva forms inside the egg, and the egg becomes infective [1, 4, 5]. Currently, data have been accumulated indicating that humans can also be infected with the pig roundworm (Ascaris suum) [6,7].
Pathogenesis. From swallowed eggs in the upper parts of the small intestine, larvae emerge, which penetrate the intestinal wall, enter blood capillaries, and migrate via the portal vein system through the liver into the inferior vena cava, reach the right heart, then the pulmonary artery and pulmonary capillaries, from where they migrate to the lung parenchyma, where they undergo their first molt. When pulmonary capillaries are damaged, hemorrhages occur. In massive infestation, pulmonary hemorrhage and hemoptysis may be observed. Eosinophilic infiltrates form in the lung parenchyma around the larvae, which over time change their location along with the larvae (Löffler's "transient" infiltrates). During the migration period, sensitization of the macroorganism is most pronounced, and antibodies are produced against molting and metabolic products, surface antigens of the larvae, and their breakdown products.
With free access to oxygen, larvae grow, increasing in size 10-fold (from 0.1 to 1 mm), molt a second time, and ascend via the alveolar and bronchiolar epithelium, then through small and large bronchi to the oropharynx, and are swallowed with saliva, re-entering the gastrointestinal tract. This entire process takes about 14 days.
In the jejunum, helminths grow and transform into mature males and females within 70–75 days. Parasitization of adult roundworms in the intestine leads to mechanical irritation of the nerve endings of the small intestine; impairment of digestive processes due to anti-enzyme substances secreted by parasites and impairment of intestinal motor function. In case of human malnutrition, particularly in childhood, nitrogen metabolism disorders and polyhypovitaminosis may be observed. In rare cases, atypical migration of adult roundworms into the stomach, pharynx, lungs, or paranasal sinuses (maxillary, frontal) can occur, where they cause sinusitis; if the helminth enters the liver (via the common bile duct), a bacterial infection may join, leading to purulent complications (liver abscesses, purulent cholangitis) or obstructive jaundice and pancreatitis. Accumulation of roundworms in the intestine can lead to the development of obturation intestinal obstruction [8-13].
The peculiarities of the pathological process in ascariasis are determined by the sensitization of the macroorganism by metabolic products, larval molting, and their migration to the lungs. This is often manifested by the development of allergic reactions, as well as the formation of eosinophilic infiltrates in the lungs [1, 4, 11].
In the pathogenesis of the intestinal phase, the primary factors are the mechanical impact of helminths on the intestinal wall and impaired digestive processes. After ascariasis, an unstable immunity is formed, which does not protect a person from reinfection. However, with frequent reinfections, protective immunity may develop, leading to the destruction of migrating larvae in the bloodstream and lungs [1, 4, 11].
1.3 Epidemiology of the Disease or Condition
Epidemiology. Humans are the only host of Ascaris lumbricoides. In the migratory phase of ascariasis, a human serves as an intermediate host, while in the intestinal phase, as a definitive host. An infected individual releases immature eggs into the external environment via feces, where larvae form and mature under favorable conditions (optimal soil temperature and moisture, sufficient aeration). In the temperate climate zone, ascarid eggs can survive under a snow cover in winter and withstand frosts down to -20–25 °C. In the soil, in the absence of severe environmental factors, helminth eggs can remain viable for up to 10 years, and in fresh water bodies, for up to one year. The degree of patient contact with soil containing infective ascarid eggs determines the risk of infection. The transmission mechanism is fecal-oral. Transmission routes are foodborne (primary) and waterborne. Infection occurs by swallowing helminth eggs containing the infective larva. Factors of transmission include vegetables, fruits, herbs, and berries with mature ascarid eggs on their surface, as well as contaminated water and hands. In the temperate climate zone, the season of ascariasis infection lasts from April to October, and in the warm, humid climate zone, year-round. It should be noted that the mechanisms and routes of infection are similar for many soil-transmitted helminths and intestinal protozoa; therefore, mixed infections involving other intestinal helminths (whipworm, hookworm, etc.) and protozoa (Giardia, Balantidium, etc.) can be observed in ascariasis. Well-developed urban areas are not foci of ascariasis; transmission of the infection does not occur there due to the presence of sewage and water supply systems, asphalted streets and courtyards, and the absence of kitchen gardens fertilized with human waste [4, 11].
Morbidity structure. Ascariasis is a common helminthiasis, distributed in all climatic zones of the globe, except for permafrost, high-altitude, and desert regions. According to WHO data, about one billion people are infected with ascariasis worldwide, with preschool and school-aged children making up the majority [14, 26]. In Russia, ascariasis is the third most frequently registered helminthiasis after enterobiasis and opisthorchiasis. According to the Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing (Rospotrebnadzor), the maximum human infection rate in the Russian Federation was 68 cases per 100,000 population, registered in 1995. According to Rospotrebnadzor, 10,353 cases of ascariasis were detected in 2023 (7.06 per 100,000 population), which is 12.6% higher than the incidence in 2022 (6.27 per 100,000 population), but 2.4 times lower than the long-term average incidence (16.67 per 100,000 population). Among the pediatric population of all age groups, 6,742 cases were detected (22.29 per 100,000 children of the corresponding age) [27]. However, official incidence data do not reflect the true epidemiological situation regarding ascariasis, as part of the population does not seek medical care for infection and uses anthelmintic drugs independently [11, 15].
1.4 Features of Coding the Disease or Condition
B77 Ascariasis
B77.0 – Ascariasis with intestinal complications;
B77.8 – Ascariasis with other complications;
B77.9 – Ascariasis, unspecified.
1.5 Classification of the disease or condition
Clinical classification of ascariasis [13, 14, 16]
By type:
- typical (manifest)
- atypical (subclinical, asymptomatic)
By disease phase:
- early
- late
By severity:
- mild form
- moderate form
- severe form
By presence of complications:
- uncomplicated
- with intestinal complications (intestinal obstruction, peritonitis, appendicitis);
- with extraintestinal complications (purulent cholangitis, liver abscesses, purulent pleurisy, sinusitis, abdominal abscesses, asphyxia, etc.)
Table 1. Clinical classification of ascariasis [6, 16]
By severity of clinical manifestations | By disease phase | By severity | By presence of complications | |
Manifest form Subclinical form Asymptomatic form | Early phase Late phase | Mild form Moderate form Severe form | Uncomplicated | With intestinal complications With extraintestinal complications |
1.6 Clinical presentation of the disease or condition
Clinical manifestations of ascariasis depend on the intensity of infection and the phase of disease development. Two phases are distinguished: early (migratory, larval) and late (intestinal, phase of adult ascarid parasitism).
Early phase of ascariasis is caused by the migration of helminth larvae. At low infection intensity, the early phase of ascariasis may be subclinical or asymptomatic. At high infection intensity, an acute onset of the disease is observed. Patients experience weakness, malaise, and low-grade fever. Occasionally, high fever and chills, urticarial exanthema, angioedema, abdominal pain, and dyspeptic symptoms (nausea, diarrhea) are noted. Respiratory symptoms appear: dry or wet cough (with a small amount of mucous or bloody sputum), and asthma attacks are possible. In the lungs, shortening of percussion sound is detected, with dry and moist rales auscultated, which is associated with the development of transient eosinophilic infiltrates around ascarid larvae—Löffler syndrome, which is visually detected on chest X-rays. In the migratory phase with high infection intensity, granulomatous hepatitis with pigment metabolism disorders and hepatomegaly may develop, as well as pneumonia (rarely). The peripheral blood shows moderate leukocytosis and high eosinophil count (20% or more) [1, 4, 11, 26].
Lack of adequate treatment for severe forms of ascariasis in infants can lead to a fatal outcome.
Late phase of ascariasis is associated with the localization of helminths in the intestine, manifested by abdominal pain syndrome (most often cramping abdominal pain, which may present as "umbilical colic") and dyspeptic symptoms [11]. At low infection intensity, this phase is often subclinical or asymptomatic. Patients with high infection intensity, especially children, may experience functional disorders of the central nervous system (CNS): headaches, dizziness, fatigue, sleep disturbances, etc., which resolve rapidly after adequate treatment. Peripheral blood generally shows no pathological deviations in cellular elements [11, 26].
Table 2. Clinical signs and severity criteria of ascariasis
Sign | Characteristic of the sign | ||
|---|---|---|---|
Mild severity | Moderate severity | Severe severity | |
Severity and duration of intoxication syndrome | Absent or minimally expressed | Moderate severity | Pronounced |
Nature and severity of allergic manifestations | Absent or present as a short-lived allergic rash | Urticarial exanthema, skin pruritus; angioedema | Urticarial exanthema, persistent skin pruritus; recurrent angioedema |
Severity of abdominal pain syndrome | Absent or minimally expressed, short-lived | Intermittent aching abdominal pain localized in the epigastrium, around the umbilicus, in the mesogastrium; episodes of "umbilical colic" | Spasmodic, intense, and repeated abdominal pain localized in the epigastrium, around the umbilicus, in the mesogastrium; frequent episodes of "umbilical colic" |
Severity of dyspeptic syndrome | Absent or minimally expressed | Intermittent nausea, belching, flatulence, unstable stool | Frequent and pronounced dyspeptic disorders |
Severity of eosinophilia | Normal eosinophil count or slight elevation up to 20% | Moderate increase in peripheral blood eosinophils (above 20%) | Significant increase in peripheral blood eosinophils (above 20%) |
Intestinal or extraintestinal complications | Absent | No intestinal complications or intestinal complications are present | Severe intestinal and/or extraintestinal complications are present |
Complicated ascariasis determines the severity of the pathological process and is caused by various factors: secondary infection, mechanical action of adult worms, or their migration into the respiratory tract and other organs [4, 6, 13].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition: The diagnosis of "ascariasis" is established solely on the basis of positive results of direct parasitological examination methods (detection of helminth eggs, their larvae, or adult worms). Positive results of indirect methods (serological, etc.) do not serve as a basis for confirming the diagnosis of "ascariasis" and prescribing anthelmintic therapy.
2.1 Complaints and Anamnesis
It is recommended that all patients with suspected ascariasis undergo an epidemiological history assessment to identify potential routes of infection [1, 4, 11].
GCR CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Infection can occur through contact with soil, consumption of unwashed vegetables, fruits, herbs, and berries (contaminated with Ascaris eggs), or less commonly, by drinking contaminated water containing Ascaris eggs.
It is recommended to check for complaints of general malaise (loss of appetite, sleep disturbances, fatigue) in patients with suspected ascariasis to diagnose intoxication syndrome [1, 4, 11].
GCR CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Impairment of general well-being (appetite and sleep disturbances, fatigue, weakness) reflects intoxication syndrome in patients with ascariasis
It is recommended to clarify the occurrence of allergic rash episodes and skin pruritus within the past two weeks in patients with suspected ascariasis, in order to diagnose the migratory phase of ascariasis [1, 4].
GCR CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Sudden appearance of urticarial exanthema, skin pruritus, and allergic subcutaneous edema (angioedema) may indicate the migratory phase of ascariasis. It is necessary to establish the onset and assess the duration of these complaints, which should be approximately 2 weeks.
It is recommended to check for complaints of cough, sputum production, and asthma attacks in patients with suspected ascariasis to diagnose the migratory phase of ascariasis [1, 4].
GCR CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: respiratory symptoms are characteristic of the migratory phase of ascariasis; it is necessary to determine the onset of these complaints and assess their duration, which should not exceed 2–3 weeks.
It is recommended to inquire about episodes of abdominal pain or concerns regarding abdominal pain of various locations and intensities in patients with suspected ascariasis to diagnose the intestinal phase of ascariasis [1, 11].
GCR CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Abdominal pain in ascariasis is uncommon and may indicate the intestinal phase of the disease, corresponding to the parasitic phase of adult helminths.
It is recommended to assess the presence of dyspeptic symptoms (nausea, vomiting, stool disorders, etc.) in patients with suspected ascariasis to diagnose the intestinal phase of ascariasis [1, 11].
GCR CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Dyspeptic symptoms (nausea, stool disorders, flatulence) may indicate the intestinal phase of the disease, corresponding to the parasitic phase of adult helminths.
2.2 Physical Examination
It is recommended for patients with suspected ascariasis to undergo an evaluation (examination, consultation) by a general practitioner, pediatrician, family physician, infectious disease specialist, or gastroenterologist to identify objective signs of the disease [1, 4].
GCP CLoE 5Grade of recommendation – C (level of evidence – 5).
Comments: Physical examination allows for the identification of objective signs of the disease as well as any concomitant pathology.
It is recommended to perform general thermometry in children with suspected ascariasis in the morning and throughout the day to assess the clinical course of the disease (uncomplicated or complicated) [1].
GCP CLoE 5Grade of recommendation – C (level of evidence – 5).
Comments: The uncomplicated course of the disease is characterized by a normal body temperature. Elevated body temperature above 38°C in ascariasis may be observed with the development of complications or concomitant pathology.
It is recommended to examine the skin of patients with suspected ascariasis to detect allergic rashes and skin pruritus [1, 11].
GCR CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Urticarial exanthema, skin pruritus, and allergic subcutaneous edema (angioedema) may indicate a recent Ascaris infection.
It is recommended to examine and assess the patient's respiratory system (measuring respiratory rate, percussion, and auscultation findings) to diagnose pulmonary involvement in ascariasis [1, 11].
GCR CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Local dullness on percussion over the lungs, harsh or weakened breath sounds on auscultation, and the presence of dry and moist rales may be due to the migratory phase of ascariasis and the development of "transient" eosinophilic infiltrates in the lungs.
It is recommended to perform an abdominal examination in patients with suspected ascariasis to detect symptoms of intestinal involvement [1, 11].
GCR CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: painful areas may be detected upon superficial and deep palpation of the abdomen in the umbilical region during intestinal parasitism by Ascaris.
It is recommended that in the event of posthepatic jaundice or mechanical intestinal obstruction developing in a patient with ascariasis, a consultation (examination) by a surgeon (pediatric surgeon) be conducted to address the issue of surgical treatment [8, 9, 12].
GCR CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
Comments: these pathological conditions are identified by the surgeon based on clinical, laboratory, and instrumental examination data.
2.3 Laboratory Diagnostics
It is recommended that patients with suspected ascariasis undergo a complete blood count (CBC) [1, 4, 11].
GCR CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Detection of eosinophilia may indicate systemic sensitization during the migratory phase of ascariasis.
It is recommended that patients with clinical and epidemiological signs of ascariasis undergo screening for ascariasis by determining antibodies to Ascaris lumbricoides in the blood using enzyme-linked immunosorbent assay (ELISA) tests [1, 4, 11, 23].
GCP CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Serological testing can yield both false-positive and false-negative results. IMPORTANT! A positive serological test result is not a basis for confirming the diagnosis of "ascariasis" and prescribing anthelmintic therapy. It must be confirmed microscopically by detecting helminth eggs in feces [25].
It is recommended that patients with suspected ascariasis undergo microscopic examination of feces for helminth eggs and larvae using concentration methods: formalin-ethyl acetate sedimentation or flotation [1, 4, 11, 24].
GCR CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Both fertilized and unfertilized Ascaris eggs can be found in the feces of a patient with ascariasis. This method of examination is the most informative and, if positive, does not require additional tests.
Patients who have received treatment for ascariasis are recommended to undergo a follow-up microscopic stool examination for helminth eggs and larvae using concentration methods one month after the completion of therapy to evaluate its efficacy [1, 4].
GCR CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
It is recommended that patients with suspected ascariasis in the early phase of the disease with pronounced symptoms of respiratory tract involvement (cough with sputum), as well as for differential diagnosis with other respiratory system diseases, undergo microscopic examination of native and stained sputum smears [4, 11].
GCR CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: microscopic examination of native and stained sputum smears very rarely reveals isolated Ascaris larvae. This test is effective only in the early phase of ascariasis development (in the first 2 weeks) in patients with pronounced symptoms of respiratory system involvement.
It is recommended that when a patient presents with spontaneously passed Ascaris worms, an examination of the biological objects found in the feces be performed to determine their biological species in a parasitological/clinical/bacteriological laboratory [4, 11, 24].
GPP CLoE 5Level of Recommendation – C (Level of Evidence – 5).
Comments: In the final months of their lifecycle, Ascaris worms are unable to actively resist peristalsis, and upon reaching the distal parts of the intestine and subsequently the colon, they may pass spontaneously during defecation. Their detection in feces serves as the basis for establishing a diagnosis of ascariasis and administering anthelmintic therapy.
2.4 Instrumental Diagnostics
Instrumental diagnostic examinations are performed according to indications for the diagnosis of complications in patients with ascariasis or for differential diagnosis with other diseases.
In patients with ascariasis presenting with pronounced clinical signs of pulmonary involvement, it is recommended to perform a chest X-ray to detect transient pulmonary infiltrates and other lesions [1, 11, 17].
GCP CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: The examination is informative in patients with clinical symptoms of ascariasis in the early phase of the disease (the first 2 weeks from the moment of infection) for detecting eosinophilic pulmonary infiltrates (Löffler syndrome).
In patients with ascariasis presenting with severe abdominal pain, it is recommended to perform a comprehensive ultrasound examination (ultrasound) of the abdominal cavity to diagnose complications of ascariasis and identify concomitant pathology [9, 18].
GCR CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: The examination is performed for the purpose of differential diagnosis with other abdominal diseases in cases of severe abdominal pain and dyspeptic syndromes.
2.5 Other Procedures
Molecular biological methods for stool testing based on PCR have high specificity and sensitivity; however, they are performed solely for research purposes as they have not yet been standardized. Stool tests using this method may yield false-positive results due to the presence of transient helminth eggs or their fragments in the test material. Technical difficulties in the sample preparation of the initial material can lead to false-negative results. Thus, the PCR method is preliminary and must be confirmed by the results of microscopic examination [20, 24, 25].
Other diagnostic examinations are performed during differential diagnosis with tuberculosis, oncological diseases, inflammatory bowel diseases, and other pathologies.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
In the early (migratory) phase of ascariasis development, treatment principles have not been established, because in this phase a definitive diagnosis is often impossible due to its short duration (about 2 weeks) and the absence of specific symptoms. Treatment of ascariasis is carried out in the late (intestinal) phase of the disease.
3.1 Conservative Treatment
It is recommended to prescribe anthelmintic drugs: albendazole, mebendazole**, or pyrantel** to patients with ascariasis for the purpose of helminth eradication [1, 4, 11, 16].
GCP CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
Comments:
Albendazole is prescribed: for children aged 1–2 years, 200 mg (10 ml of suspension) once; for children over 2 years and adults, 400 mg (20 ml of suspension) once; as tablets, Albendazole is prescribed to patients with a body weight of 60 kg or more – 400 mg once daily; for adults and children with a body weight of less than 60 kg – 15 mg/kg of body weight once or in 2 divided doses with a small amount of easily digestible food.
Mebendazole** is prescribed to adults and children over 3 years of age at 100 mg every 12 hours for 3 days.
Pyrantel**: the drug is prescribed (in the evening during or after a meal) once (at a dose of 10 mg/kg) in the form of a suspension for adults and children: from 6 months to 2 years at a dose of 2.5 ml (125 mg), from 2 to 6 years at a dose of 5 ml (250 mg); the drug is also prescribed in tablet form for children from 3 to 6 years at a dose of 250 mg, from 6 to 12 years at a dose of 500 mg, for children over 12 years and adults weighing up to 75 kg at a dose of 750 mg; for adults weighing over 75 kg at a dose of 1000 mg.
Evaluation of treatment efficacy is carried out one month after deworming [4, 11].
It is recommended for patients with ascariasis in the absence of a positive treatment outcome (in the absence of eradication of adult Ascaris or upon repeated detection of eggs in follow-up tests) to repeat the course of antiparasitic therapy [1, 11, 16].
GCP CLOE 5Grade of Recommendation – C (Level of Evidence – 5).
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Medical rehabilitation for patients with ascariasis has not been developed.
Ascariasis is not an indication for spa-resort treatment.
5. Prevention and Dispensary Observation
It is not recommended to isolate a patient with ascariasis, since the risk of spreading ascariasis is completely absent [1, 4, 11].
Level of Evidence CLevel of Evidence Validity 5Level of Recommendation Confidence – C (Level of Evidence Validity – 5)
Comments: the patient sheds immature (non-infective) Ascaris eggs that are incapable of causing disease, and their maturation requires a prolonged period of time and specific conditions.
It is recommended to observe personal hygiene skills at home, in public places, as well as during contact with soil, sand, and plant produce for the prevention of ascariasis infection [1, 4, 11].
Level of Evidence CLevel of Evidence Validity 5Level of Recommendation Confidence – C (Level of Evidence Validity – 5)
It is recommended that medical workers conduct health education and training for children and adolescents in families and educational institutions for the prevention of ascariasis [1, 4, 11, 19, 20].
Level of Evidence CLevel of Evidence Validity 5Level of Recommendation Confidence – C (Level of Evidence Validity – 5)
6. Organization of Medical Care
Medical care for patients with ascariasis can be provided in the following settings:
outpatient (in settings not providing round-the-clock medical observation and treatment);
in a day hospital setting (in conditions not providing round-the-clock medical monitoring and treatment);
Patients are subject to hospitalization in the presence of complications [21]
Discharge from the hospital is carried out when there is no need for round-the-clock medical observation of the patient.
7. Additional Information
The following factors negatively affect the outcome of the disease, the severity of the disease, and the development of ascariasis complications:
- late presentation of patients;
- lack of treatment with antiparasitic drugs;
- inadequate doses of antiparasitic drugs;
- incorrect regimens of antiparasitic therapy;
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment Yes/No |
1. | An admission (examination, consultation) by a general practitioner/pediatrician/general practitioner (family doctor)/infectious disease specialist/gastroenterologist was performed for a patient with suspected ascariasis to identify objective signs of the disease | Yes/no |
2. | Microscopic examination of feces for helminth eggs and larvae using concentration methods was performed | Yes/no |
3. | In case of spontaneous expulsion of Ascaris, an examination of biological objects found in feces was performed to determine their biological species in a parasitological/clinical/bacteriological laboratory | Yes/no |
4. | Microscopic examination of native and stained sputum samples was performed upon suspicion of ascariasis in patients with symptoms of respiratory tract involvement (cough with sputum) | Yes/no |
5. | Chest radiography was performed in patients with ascariasis who had pronounced clinical signs of pulmonary involvement | Yes/no |
6. | Ultrasound examination (ultrasound) of the abdominal organs (complex) was performed in the presence of pronounced abdominal pain syndrome | Yes/no |
7. | Treatment with anthelmintic drugs was performed after confirmation of the diagnosis of ascariasis | Yes/no |
8. | A follow-up microscopic examination of feces for helminth eggs and larvae using concentration methods was performed a month after the end of treatment | Yes/no |
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De Meeûs T., McCoy K.D., Prugnolle F., et al. Population genetics and molecular epidemiology or how to “debusquer la bete”. Infect. Genet. Evol. 2007; 7: 308–332.
Narayan A., Gangaboraiah D.H. Randomized controlled trial comparing the safetyand efficacy of single dose albendazol and mebendazoleon ascaris, hookworm and trichuris infections. Indian commun Helth. 2001; 199 (5): 35 – 40.
Naralenkova N.V., Murashkevich T.G. Ascariasis: manifestations of the epidemic process and prevention in the Gomel Region. – Nauchnye stremleniya. – 2014. – No. 4. – P. 67 – 76.
Lynser D., Handique A., Daniala C., et al. Sonographic images of hepato-pancreatico-biliary and intestinal ascariasis: A pictorial review. Insight Imaging. 2015; 6: 641 – 646.
Das AK. Hepatic and biliary ascariasis. J. Global. Infect. Dis. 2014; 6: 65 – 72
Criscione C.D., Anderson J.D., Sudimack D, et al. Human Ascariasis: Diagnostics Update. Curr. Trop. Med. Rep. 2015; 2: 189 – 200.
Moskina O.V., Guzeeva T.M., Moskina T.S. Transmission factors of geohelminthiases (ascariasis) in the Khanty-Mansi Autonomous Okrug. – Auditorium. – 2015. – Vol. 3. – No. 7. – P. 38 – 43.
Nejsum P., Parker E.D., Frydenberg J., et al. Ascariasis is a zoonosis in Denmark. J Clin Microbiol. 2005; 43: 1142–8.
Infectious Diseases: National Guidelines / ed. by N.D. Yushchuk, Yu.Ya. Vengerov. - 3rd ed., revised and enlarged. - Moscow: GEOTAR-Media, 2023. - pp. 1065-1069
Pediatrics Guide. Vol. 8. Childhood Infectious Diseases / D.O. Ivanov, V.N. Tischenko, N.V. Skripchenko et al. - St. Petersburg: St. Petersburg State Pediatric Medical University, 2023. - pp. 726-732
Kozlov S.S., Turitsin V.S., Laskin A.V. Diagnosis of parasitoses: Modern myths. Journal of Infectology. 2011;3(11):64-68
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Kozlov S.S. Diagnostic methods for intestinal parasitoses: Pros and cons.
Clinical Laboratory Diagnostics. 2016;61(9):264-265
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Appendix A1. Working Group Composition
Clinical Guidelines by members of the International Public Organization "Euro-Asian Society of Infectious Diseases" (EASID) and the Interregional Public Organization "Association of Infectious Disease Doctors of St. Petersburg and Leningrad Region" (AIDD SPb&LR).
Full names of the authors | Place of work indicating position, academic degree, and academic title | Professional Community | Conflict of interest |
Lobzin Yuri Vladimirovich | President of the Federal Scientific and Clinical Center for Infectious Diseases of the Federal Medical-Biological Agency of Russia, Academician of the RAS, D.Sc. in Medicine, Professor, Head of the Department of Infectious Diseases at the North-Western State Medical University named after I.I. Mechnikov, Chief Freelance Pediatric Infectious Disease Specialist of the Russian Ministry of Health | "Euro-Asian Society of Infectious Diseases" (EASID), "Association of Infectious Disease Doctors of St. Petersburg and Leningrad Region" (AIDD SPb&LR) | none |
Kozlov Sergey Sergeevich | S.M. Kirov Military Medical Academy of the Ministry of Defense of the Russian Federation, Professor of the Department of Infectious Diseases (with a course in medical parasitology and tropical diseases). Professor of the Department of Adult Infectious Diseases and Epidemiology, St. Petersburg State Pediatric Medical University, Professor, D.Sc. in Medicine. | "Euro-Asian Society of Infectious Diseases" (EASID), National Association of Infectious Disease Specialists named after Academician V.I. Pokrovsky (NAIS) | none |
Bekhtereva Maria Konstantinovna | Federal Scientific and Clinical Center for Infectious Diseases of the Federal Medical-Biological Agency of Russia. Researcher at the Department of Intestinal Infections, Ph.D. in Medicine. | "Euro-Asian Society of Infectious Diseases" (EASID) | none |
Rychkova Svetlana Vladislavovna | Federal Scientific and Clinical Center for Infectious Diseases of the Federal Medical-Biological Agency of Russia Head of the Department of Pediatric Medical Care Organization | "Euro-Asian Society of Infectious Diseases" (EASID) | none |
Uskov, Alexander Nikolaevich | Federal Scientific and Clinical Center for Infectious Diseases of the Federal Medical-Biological Agency, Head of the Department of Adult Medical Care Organization, D.Sc. in Medicine, Associate Professor | "Euro-Asian Society of Infectious Diseases" (EASID), "Association of Infectious Disease Doctors of St. Petersburg and Leningrad Region" (AIDD SPb&LR) | |
Gonchar Natalia Vasilievna | Federal Scientific and Clinical Center for Infectious Diseases of the Federal Medical-Biological Agency of Russia. Senior Researcher, Head of the Department of Intestinal Infections, D.Sc. in Medicine, Professor | "Euro-Asian Society of Infectious Diseases" (EASID) | none |
Esaulenko Elena Vladimirovna | Head of the Department of Adult Infectious Diseases and Epidemiology, St. Petersburg State Pediatric Medical University of the Russian Ministry of Health, D.Sc. in Medicine, Professor, | National Association of Infectious Disease Specialists named after Academician V.I. Pokrovsky (NAIS) | none |
Usenko Denis Valerievich | Head of the Educational Center, Leading Researcher at the Clinical Department of Infectious Pathology, Central Research Institute of Epidemiology of Rospotrebnadzor, D.Sc. in Medicine | Academician V.I. Pokrovsky National Association of Infectious Diseases Specialists (NASID) | none |
Larisa A. Ermakova | Head of the Clinic of Infectious and Parasitic Diseases, Rostov Research Institute of Microbiology and Parasitology of Rospotrebnadzor Associate Professor of the Department of Infectious Diseases, Russian Medical Academy of Continuous Professional Education (RMAPO) of the Russian Ministry of Health, Candidate of Medical Sciences | Academician V.I. Pokrovsky National Association of Infectious Diseases Specialists (NASID) | none |
Appendix A2. Methodology for Developing Clinical Guidelines
Methodology
Methods used for evidence collection/selection:
- search in electronic databases.
Description of methods used for evidence collection/selection:
- the evidence base for the recommendations includes publications from the Cochrane Library, EMBASE, MEDLINE, ClinicalKey ELSEVIER, and the electronic library (www.elibrary.ru). The search depth was 10 years
Methods used to assess the quality and strength of evidence:
- expert consensus;
- assessment of significance in accordance with the levels of evidence reliability and levels of recommendation conviction.
Target audience for these clinical guidelines:
health station physician;
infectious disease physician;
clinical laboratory diagnostics physician;
general practitioner (family physician);
pediatrician;
municipal (district) pediatrician;
primary care pediatrician;
medical prevention physician;
admitting department physician;
internist;
district general practitioner;
epidemiologist.
parasitologist
Clinical guidelines "Ascariasis" are intended for use in medical organizations of the Russian Federation.
Table 3. Levels of Evidence (LE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 4. Scale for assessing the Levels of Evidence (LE) for methods of prevention, treatment, and medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 5. Scale for assessing the Grades of Recommendation (GR) for methods of prevention, diagnosis, treatment, and medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Federal Law No. 323-FZ of November 21, 2011, "On the Fundamentals of Protecting Public Health in the Russian Federation";
Federal Law of the Russian Federation No. 326-FZ dated November 29, 2010, "On Compulsory Medical Insurance in the Russian Federation";
Federal Law of the Russian Federation No. 52-FZ dated March 30, 1999, "On the Sanitary and Epidemiological Welfare of the Population"
Order of the Ministry of Health and Social Development of Russia No. 521n dated May 5, 2012, "On Approval of the Procedure for Providing Medical Care to Children with Infectious Diseases";
Order of the Russian Ministry of Health No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services";
Order of the Ministry of Health and Social Development of Russia No. 541n dated July 23, 2010, "On Approval of the Unified Qualification Handbook of Positions of Managers, Specialists, and Employees", section "Qualification Characteristics of Healthcare Worker Positions";
Resolution of the Chief State Sanitary Doctor of the Russian Federation No. 4 dated January 28, 2021, "On Approval of Sanitary Rules and Norms SanPiN 3.3686-21 'Sanitary and Epidemiological Requirements for the Prevention of Infectious Diseases'" (together with "SanPiN 3.3686-21. Sanitary Rules and Norms...")
State Report "On the State of Sanitary and Epidemiological Welfare of the Population in the Russian Federation in 2023". Moscow: Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, 2024. – 364 p.
State Register of Medicines. Available from: https://grls.rosminzdrav.ru/
Therapeutic nutrition standards. Methodological guide. 2017. Access: http://cr.rosminzdrav.ru/
Control Methods. Biological and Microbiological Factors. Methodological Guidelines MUK 4.2.3145-13.
Resolution of the Chief State Sanitary Doctor of the Russian Federation No. 24 dated February 8, 2018, "On Prevention of the Spread of Ascariasis and Toxocariasis in the Russian Federation".
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Ascariasis is an anthroponotic geohelminthiasis caused by Ascaris lumbricoides, characterized by respiratory tract involvement and allergic reactions during the larval migration phase, and by chronic gastrointestinal disorders and complications when adult Ascaris worms parasitize.
Adult specimens are spindle-shaped, and their body is covered with a thick transversely striated cuticle. The male is smaller than the female, and the posterior end of its body is hooked toward the ventral side. A mature female lays up to 245,000 eggs per day. Egg maturation takes place in the soil. The degree of patient contact with soil determines the risk of infection. Modes of transmission of ascariasis include foodborne, waterborne, and contact-household. Factors of transmission are vegetables, fruits, greens, and berries with soil particles on their surface, as well as contaminated water and hands.
After ingestion, mature Ascaris eggs enter the small intestine, larvae emerge from them and penetrate the intestinal wall. The larvae enter blood capillaries and migrate via the portal vein system through the liver into the inferior vena cava, reach the right chambers of the heart, then the pulmonary artery and pulmonary capillaries, and enter the lung parenchyma. After 14 days, they ascend to the oropharynx, are swallowed, and enter the gastrointestinal tract. The main life cycle of the parasite takes place in the human intestine. The helminth obtains nutrients by absorption through the surface of its body (causing deficiency states in the host), and the metabolic products of the helminth enter the human intestine, are absorbed into the blood, leading to the development of intoxication.
In the lung parenchyma during the larval migration phase, "transient" eosinophilic infiltrates may form. Larvae can enter the liver, brain, eyes, and other organs. Migration of Ascaris into the stomach, pharynx, respiratory tract, and paranasal sinuses is possible, followed by secondary bacterial infection and the development of complications.
The diagnosis is confirmed by laboratory tests. Treatment of ascariasis is carried out with anthelmintic drugs. The patient does not require isolation. Prevention of ascariasis: compliance with personal hygiene rules.
Quarantine and isolation measures for contacts are not carried out.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not used