Hookworm (Photo: CDC)

By Katherine Kahn, Contributing Writer
Health Behavior News Service

Purposely infecting patients with hookworms or whipworms to treat hay fever and other immune-related diseases has been experimented with since the 1970s.

A new review by The Cochrane Library concludes that current evidence doesn’t yet support the use of this therapy.

However, worm therapy does appear to be safe, the review’s lead author says.

“Allergic diseases affect hundreds of millions of people worldwide, especially in industrialized countries,” says review author Ashley Croft, M.D., a public health physician at the headquarters of the Surgeon General, Whittington Barracks, in Lichfield, UK. “Existing treatments for allergies, which mostly involve pharmacotherapy, are often expensive, dangerous, or ineffective. If worm therapy can be shown to be effective and safe, it will represent an important new clinical option for treatment.”

Croft theorizes that worm therapy might work if having intestinal worms “‘tones up’ the immune system of their human hosts, so that the host stops being over-responsive to common allergens. This helps the worms avoid detection and destruction by the host’s immune system.”

“It’s generally appreciated that in the 20th century a whole series of immunological diseases have emerged out of nowhere,” Weinstock explains, including hay fever, asthma, inflammatory bowel diseases, and multiple sclerosis. “Why did these diseases emerge? If you look around the world, these diseases are fairly common in industrialized countries, but in less developed countries, they are relatively rare.”

 Key Points

• Since the 1970s, worm therapy has been used as an alternative treatment for hay fever under the assumption that it might calm overactive immune systems.

• No long-term studies have been conducted to demonstrate that worm therapy relieves hay fever symptoms.

• An evidence review of available studies of worm therapy shows no benefit for hay fever sufferers, and that while safe it may cause minor digestive problems.

The cause, Weinstock believes, is the tremendous improvement in hygiene—and that includes lack of exposure to intestinal worms, such as hookworms and whipworms. “Up until the 20th century, everybody had worms,” Weinstock says.

The lack of worm infections in modern societies, Weinstock conjectures, has led to over-reactive immune systems and an increase in immune-related diseases.

Croft’s review examined evidence from two placebo-controlled, double blinded studies that enrolled a total of 130 adults who had either intermittent or persistent allergic rhinitis.

One study used hookworm larvae, which enter through the skin and travel to the intestines and the other study used pig whipworm eggs that participants swallowed.

Participants who used worm therapy had no reduction in hay fever symptoms or percentage of days when symptoms were minimal. They also had no changes in lung function or quality of life scores.

Croft cautions that these studies are too small to truly evaluate effectiveness. “It did come as a surprise, therefore, that we found that people with allergic rhinitis who took worms were less likely to have to take tablets as rescue medication during the grass pollen season.”

Weinstock also says that the studies to date haven’t been designed very well and says it was surprising researchers found any response at all since the study follow-up times were too short.

“To treat an allergy, you probably have to have a treatment strategy that’s at least six months long,” before evaluating effectiveness, he says. The studies ran for only three months and six months, respectively, after initiating worm therapy.

“Our main finding was that worm therapy is safe,” says Croft. “In participants who took worms there were some gastrointestinal side effects, such as abdominal pain and diarrhea, but these were transient and were not so severe as to cause people to drop out of the trials.”

Croft says that there is enough evidence to support continued research in worm therapy. “Clinical trials in worm therapy are not expensive to run and the potential benefits from this new form of therapy are very great,” he says.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

Pertussis, the whooping cough bacteria -- CDC photo

The number of cases of whooping cough in Washington state increased by more than 50 percent between 2010 and 2011, the State Department of Health reported Wednesday.

Last year there were 912 cases in the state — the highest in six years — up from 608 cases reported in 2010.

In recent years, adolescents and adults have accounted for an increasing proportion of cases, health officials said.

“The number of reported cases is just the tip of the iceberg,” State Health Officer and pediatrician Dr. Maxine Hayes said. “Many young people and adults who get pertussis may not know they have it and don’t seek medical attention.

Whooping cough, also known as pertussis, is a highly contagious respiratory illness spread by coughing and sneezing.

Initially, an infection may seem like a cold, but patients then go on to develop a severe, persistent–often wracking–cough that can last for weeks.

The coughing fits can be prolonged and are often followed by a long inhalation that causes the “whooping” sound that gives the disease its name.

The bouts of coughing can leave victims breathless and unable to eat, drink or sleep. Complications of the infection include pneumonia, seizures and death.

Whooping cough can affect people of all ages — but is most serious in infants, especially those too young to get vaccinated or who aren’t fully protected.

Adolescents and adults often get a much milder case of whooping cough, but they can still spread it, the Department of Health warned.

There is a vaccine that can prevent infection, but it is not effective in newborns or infants. Health officials therefore recommend that anyone who has contact with newborns and infants be vaccinated or, if they have been vaccinated, to make sure their vaccination is up-to-date.

Who should get the vaccine?

The U.S. Advisory Committee on Immunization Practices has issued new pertussis vaccination recommendations:

• Pregnant women to get pertussis vaccine (Tdap) later in pregnancy (after 20 weeks’ gestation). Women who get Tdap vaccine before or during pregnancy pass on extra protection against pertussis to their babies.

• Anyone who takes care of or has close contact with babies to get pertussis vaccine, ideally at least two weeks before beginning close contact with the infant. This includes siblings of infants who should be up-to-date on DTaP and other recommended immunizations.

• Tdap vaccine is available for adolescents and adults through age 64. But adults 65 and older who expect to have close contact with babies younger than 12 months should get a dose of Tdap to help protect the baby from pertussis.

• Health care workers of all ages who have contact with infants should get vaccinated too.

Protection wears off so you may need a booster

Most people get a series of pertussis vaccines when they’re kids, but protection wears off over time. The Department of Health recommends people substitute a Tdap vaccine for one routine tetanus (Td) booster, which is needed every 10 years; people should get it sooner if they’re in close contact with young kids or live in an area where there are pertussis cases. There’s no minimum time period between getting Td and Tdap vaccines. Only one Tdap vaccine is recommended in a person’s lifetime.

Vaccines available for free for kids under 19

All recommended vaccines are offered to all kids under 19 at no cost through health care provider offices participating in the state’s Childhood Vaccine Program.

Health care providers may charge an office visit fee and a fee to give the vaccine, called an administration fee.

People who cannot afford the administration fee can ask their regular health care provider to waive the cost.

Adults should talk to their insurance carriers about coverage for pertussis vaccine.

To learn more:

• Visit the PKIDS Online pertussis information page.

• Contact your local health agency  or the Department of Health’s Office of Immunization and Child Profile at 360-236-3595.

Dhan Biswakarma and his wife, Bee Biswakarma, who live in Kent, are among several deaf Bhutanese refugees who have been learning American Sign Language at Highline Community College. Photo Allison Barrett

By Allison Barrett

Nancy Allen, an American Sign Language (ASL) teacher at Highline Community College, goes through a stack of name cards, holding up each one and looking quizzically at the students.

“Whose is this?” she signs.

A short man in his 50s smiles hesitantly and raises his hand slowly as he sees the card with his name.

“What is your name?” Allen signs.

The man points to his chest, crosses his fingers in the sign for “name” and then slowly shapes his stout, weathered fingers to form: “D-H-A-N. My name is Dhan.”

Sitting next to him, his wife laughs out loud as her turn comes. She stumbles over the signing sequence, but she follows Allen’s lead and carefully signs her name.

“My name is B-E-E. Bee.”

For Bee and Dhan Biswakarma, Bhutanese refugees restarting their lives in Kent, the struggles of resettlement are intensified by the fact that the deaf couple has few means of communicating with the speaking world.

The Biswakarmas are among a number of deaf or hard-of-hearing Bhutanese refugees who have been resettled in King County in the past several years. Last spring’s class at Highline represented the Biswakarmas’ first exposure to a developed language.

“They have gone their whole lives with no formal language, getting by without a lot of communication,” said David Van Hofwegen, the couple’s caseworker from the World Relief Organization.

They have a repertoire of gestures to communicate with family members. But when it comes to sharing their thoughts with the hearing world, they are limited to signing the basics: eat, sleep, sick, house, wife, child.

And family.

In class, Bee has difficulty remembering how to sign her name, but she immediately grasped the expression for family. At home, she makes the sign after pointing to each relative seated on the mismatched jumble of couches and wooden chairs.

Sher Pandey (in baseball cap), his wife, Basu Pandey (to his left), and Man Budhathoki (at right) practice signing at Highline's American Sign Language class last spring. Photo Allison Barrett

Bee, 47, and Dhan, 55, met in a refugee camp along Nepal’s eastern border after each fled Bhutan by foot in 1991.

They were driven out of their home country by policies implemented in the mid-1980s to forcefully integrate the ethnic Nepali inhabitants of southern Bhutan into the monarchy’s vision of a unified national identity.

Southern Bhutanese were required to go to impossible ends to prove citizenship, ordered to stop teaching Nepali in schools and to abandon traditional dress and customs.

They protested and the military cracked down.

Homes were raided at night and dissidents were jailed, said Bal Biswa, a relative who helps to take care of Bee and Dhan.

Dhan and his extended family, including his relatives and caretakers Bal and Pabita Biswa, joined 23 other families to walk out of Bhutan, sleeping in the forest by day and traveling at night.

According to the United Nations High Commission on Refugees, since 1990 almost 100,000 southern Bhutanese have fled the tiny Himalayan kingdom that is often hailed as the “happiest country in the world” and celebrated for its measurement of Gross National Happiness.

Sitting in the Kent apartment that he and Bee share with Bal and Pabitra, Dhan points at Pabitra and then brings his hand above the ground in a gesture that looks like he’s placing it on the head of an invisible child. He pantomimes that he is carrying something.

Pabitra explains that Dahn helped her carry her kids out of Bhutan. She and her husband, Bal, lost two of those young children to a fever that broke out in the squalor of the early encampments.

Bhutan. Map by Shahid Parvez under Creative Commons license.

Little preparation

Bee and Dhan arrived in Seattle early this year, part of the more than 1,800 Bhutanese who have been resettled in Washington state since 2008. They came with their son, 12-year-old Golpal, who is able to hear and lives with other relatives.

The couple had little preparation for life here.

Bee and Dhan were both born deaf, leaving limited options for employment or education. Bhutan had no established sign language until 2003, when the monarchy opened its first school for deaf children.

“You are considered backwater in society,” said Mitra Dhital, a Bhutanese refugee who works as a medical social worker for the Asian Counseling and Referral Services.

In many ways, they are even less independent in America.

Bee and Dhan don’t like to walk the five blocks to a grocery store alone, for fear of getting lost. Sometimes they stroll around the perimeter of the building, but never leave the grounds.

At first they were fearful of going to their ASL class. They were daunted by many things, including the bus ride there, until the World Relief organization provided a volunteer-driven van ride.

Among the eight Bhutanese class members, there is a range of hearing impairment, from Bee, who lives in complete silence, to a man in his mid-30s who has no hearing in one ear and is slowly going deaf in the other.

The number of those who are deaf or hard-of-hearing represent only a small percentage of the Bhutanese refugees here. But caseworkers say it is an unusually large number compared to other refugee groups. No one is certain why.

It is unclear whether that is the result of policies that give the deaf resettlement priority because of their lack of opportunities in the camps, or if the number reflects a high occurrence of deafness within Bhutan.

The World Health Organization estimates that of the 278 million people in the world living with moderate to profound hearing loss, 80 percent live in developing countries. And about half of all cases are preventable, caused in part by illnesses like measles, mumps and rubella that have readily available vaccinations in the developed world.

Ear infections, exacerbated by poor sanitation and hygiene, often went untreated in the refugee camps for Bhutanese, said Dhital.

Allen is adamant that even without a formal language, Bee and Dhan understand each other just fine. “All deaf people have a language,” said Allen.

The challenge for Bee, Dhan and the others in the class is finding a way to interact with the hearing world.

Allen, director of interpretive services at Highline, was approached about starting an ASL class for deaf Bhutanese about a year ago. She had never taught a class tailored to refugees.

Around the same time, Allen ran into a Bhutanese couple in the college’s parking lot, a hearing woman with her deaf husband. The wife, enrolled in English classes at Highline, was in search of a class for her husband.

“The light bulbs started going off,” said Allen. “There are other deaf refugees here. There is a need that is not being met.”

She says her deaf co-teacher, Ricardo Velilla, is the key to the class.

Extremely animated, he can model abstract concepts with ease. He acts out a jaunty stroll down the road, a runaway vehicle and narrowly averted catastrophe. He then runs the palm of one hand up the back of the other in a smooth motion. This is the sign for “almost.”

For a short time, Allen and Velilla had a deaf man from Somalia in their class.

“One day he came in very agitated, making all these wild motions,” said Allen. “Ricardo took one look at him and explained to me, ‘He used to have a driver’s license in his home country but he’s frustrated because he can’t get one here.’ ”

Allen knows lots of other deaf refugees and immigrants could benefit from access to ASL. But for now, the class is only offered once a week.

Until Bee and Dhan acquire enough ASL to communicate ideas to the hearing world, their prospects for employment are dismal.

Van Hofwegen is assisting them with the lengthy and very difficult process of qualifying for federal disability benefits.

The program doesn’t accept international evidence. You have to visit a primary physician for a referral and get screened by certified audiologists and other specialists, a procedure that requires Bee and Dhan, accompanied, to run to appointments all over the county.

Evening sets in, and the Kent apartment is filled with the scent of Nepali dumplings. Golpal and some neighbor boys are engaged in a cutthroat game of marbles on the floor. Bal and Pabitra’s sons are using the bulky computer in the corner, browsing Facebook and watching Bollywood videos on YouTube.

Dhan retreats to the bedroom and returns, carrying a sheet of paper. He takes a seat next to Bee on the couch.

They both lean over the manuscript that is covered in a scrawling alphabet, written in Dhan’s shaky hand, and start to shape their fingers into signs, beginning with the letters of their names.

Allison Barrett, a UW senior, wrote this piece for Health Intersections, the UW Communications Department’s class on global health reporting. She can be reached at allisondbarrett@gmail.com

Manufacturers of the nonprescription cough and cold remedies agreed to make the change in labeling after long negotiations with federal regulators.

Earlier this year, the US Food and Drug Administration (FDA) issued a warning that infants and children under 2 years of age should not be given cough and cold medicines, including decongestants for a stuffy nose, expectorants for loosening mucus, antihistamines for sneezing and runny nose and antitussives for quieting cough.

The FDA issued the warning after an expert advisory panel said there was insufficient evidence the drugs were safe and effective in treating children.

The drugs have been linked to serious side effects, including convulsions, rapid heart rates and death.

The FDA has been pressed to ban the use of the drugs for children under the age of 12. 

In its Consumer Update issued earlier this year warning against the use of over-the-counter cough and cold medicines for treating a colds in infants and children under 2 years of age, FDA advises: 

A cold is a respiratory illness that is usually self-limited and lasts about a week. Cold symptoms typically include sneezing, coughing, runny or stuffy nose, and sore throat. Children may also experience a fever. Most of the time, a cold will go away by itself. If you are concerned about making your child feel more comfortable, talk with your doctor about what approaches to take. Your doctor may recommend drinking plenty of fluids to help loosen mucus and keep children hydrated, and using saline nasal drops and gently suctioning mucus from the nose with a bulb syringe. Your doctor may also recommend fever reducers such as acetaminophen or ibuprofen. If your child’s cold symptoms do not improve or get worse, contact your doctor. A persistent cough may signal a more serious condition such as bronchitis or asthma.

To learn more:

• Read the FDA’s Consumer Update.
• Go to the National Library of Medicine’s information page on the common cold.
• Visit Seattle Children’s Health Advice webpage.