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Comment by rybosworld | Hacker News Reader

Stuff like this makes me wonder if I should deworm once a year just to be safe. In the U.S., the recommendation is that "healthy individuals do not need to deworm".

But then I see stats from the CDC on infection rates. https://www.cdc.gov/media/releases/2014/p0508-npi.html

- More than 300,000 people living in the United States are infected with Trypanosoma cruzi, the parasite that causes Chagas disease

- At least 14 percent of the U.S. population has been exposed to Toxocara, the parasite that causes toxocariasis

- 60 million U.S. citizens are infected with Toxoplasma Gondii

- The Trichomonas parasite is extremely common, affecting 3.7 million people in the United States

A healthy individual is far more likely to be asymptomatic if they do have a parasite infection. That makes me question the recommendation for healthy individuals to avoid deworming.

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There is no single “deworming” medicine, and the treatments to cover actual infections of some of those come with significant side effects and risks. Even treating an (unlikely) real acute infection can cause a cascade of inflammatory responses that can kill a person if not monitored by medical professionals.

The idea of deworming in healthy individuals in developed countries is the domain of alternative medicine, where people tend to use questionable supplements or under dosed pharmaceuticals for peace of mind.

However, even antibiotics aren’t as safe as some of these people think. One of my acquaintances died following complications of antibiotics that he purchased over the internet and self-administered. It was a rare outcome of using the antibiotic, but statistically it was several orders of magnitude more likely to cause problems than the condition he thought he was self-treating.

It’s the ingrained thought that one can preemptively control outside forces on one’s health. That because there’s more than 1, the statistic must mean, me too.

My recommendation is if you feel like you want piece of mind, to talk to your doctor about it. If your doctor recommends a treatment, follow it. Don’t just buy deworming medication because you fear you might have worms.

> My recommendation is if you feel like you want piece of mind, to talk to your doctor about it. If your doctor recommends a treatment, follow it.

I don't know anything about worms, but I'm very certain that I could choose a doctor that would recommend treatment or one that would not, depending on what I've already decided I want.

Most advice is given in the spirit of good faith, that you are not actually trying to hurt yourself.

Further, if you do pick your doctor based on the fact that they will give you the treatment you want, at least someone other than you knows that you are taking medications with potentially bad side effects.

> Further, if you do pick your doctor based on the fact that they will give you the treatment you want…

Isn’t this how the opioid epidemic started? Going to doctors that would prescribe you OxyContin because you hurt your finger? Or back? Or knee? Or ego?

It's the same effect.

If you want pain meds, I'm sure it's easy at any of those "pain management clinics" I see advertised.

If you call a few doctors and ask "Does your practice handle worms? I'm worried I might have worms," you'll have at least some of them say "absolutely, all the time, come right in".

If they want a happy customer and they know your expectations and they know the risk of dewormer is low, then they'll probably go along with it to make you a recurring ~~customer~~ patient.

You might not even know you've accidentally guided the doctor in that direction.

> The idea of deworming in healthy individuals in developed countries is the domain of alternative medicine

30% of Danes have pinworm. Developed countries aren’t immune from parasites. Especially such parasites.

It still hasn't been determined whether that is or isn't a healthy thing: https://en.wikipedia.org/wiki/Helminthic_therapy

This might be true, but I’ve determined personally that they’re absolutely disgusting. I honestly might take action against them if they were known to be good for my health

why don't they get treated for it if it's so common? I understand it's not that hard to get rid of the infestation.

It’s pretty hard! Or at least killing them is easy, not getting infected again immediately isn’t so easy.

Drugs are effective against the worms, but not the eggs. So you have to deworm once, wait for the eggs to hatch, then deworm again 2 weeks later.

The eggs are small enough to blow around in the wind. And will be all over the bedding and kids clothes if they’re infected (and probably their school environment). So the chances of reinfection, and family wide infection are high.

This is 30% of Danish children not adults.

> The idea of deworming in healthy individuals in developed countries is the domain of alternative medicine

It used to be the domain of every farm kid in flyover country. Deworming was a once-a-month thing because you're working with animals, animal poop, and generally around things that might have parasites in them.

I'd imagine you don't want to use anything that would kill a parasitic worm in your brain for the same reason heartworm treatment is so dangerous. Dead parasites have to go somewhere.

Intestinal parasites aren't as big of a concern as far as the danger of treating yourself at home. You do want to know what you're dealing with and the appropriate handling of the parasite though.

That doesn't mean it was correct.

What deworming procedure are you referring to?

My mom says she took ivermectin frequently as a child, and we’re in the disparagingly named named “flyover country.”

Looking at Wikipedia it seems she was taking it after it was approved for animals, but before it was for humans. I don’t know if she’s mistaken it for another medication or if that’s just what was done then. I know when a friend of mine thought he had worms she suggested he take the dog form of it, and this was well before all of the recent press, so I’m inclined to think it’s the latter.

I did not mean the term "flyover country" disparagingly. I used it because it accurately reflects how the coastal peoples think of the silent majority.

It's fine, no worries.

We really should come up with something in reverse. "The arrogant coasts," perhaps ;)

"coasties" was the word that popped into my head.

That's a dangerous game.

Yup, and in general, the more benign the parasite, the more benign the treatment.

Usually the recommendation to not undergo unnecessary medical action is because the action itself can be not great for you. Killing parasites can be difficult because, unlike most bacteria and viruses, parasites are eukaryotic (same as us). This means drugs designed to target parasites may also be likely to target our cells to some degree.

Most of the time treatment is fine, but in some people the side effects can be quite severe. This is the root of the recommendation to not do so unless you know you have a reason to.

Other countries recommend routine deworming. So it must be a fairly close call.

And honestly I am very pro-science but the “do no harm” bias in medicine makes me fundamentally question a lot of the recommendations. If it was just slightly better to deworm, do you think they’d recommend it? And then face accusations after any side effects (even if it was statistically the right call to do).

> And honestly I am very pro-science but the “do no harm” bias in medicine makes me fundamentally question a lot of the recommendations.

It's really not that - people have a fundamental desire to take action to mitigate tail risk even when that action poses more actual risk. You have to look at risk-reward tradeoff across the population. Treating the entire population for a disease very few of them have will almost certainly yield more (and potentially more harmful) realized side-effects than the actual primary effects being caused by the disease itself. Especially when patients aren't seeking treatment, so are most likely asymptomatic.

Ditto testing low-risk populations for all sorts of conditions they mostly don't have. Even a test that is 99% accurate in a high-incidence population is going to be utterly ineffective when applied to the general population. Bayes theorem tells us this. The side effects up to and including death of investigating or treating these false positives adds up to a real net-negative situation.

If it was even an eency weency bit better to treat in the US I would say they would overwhelmingly do so because they'd be sued into the ground otherwise.

tl;dr: especially when it comes to treatments, action is not always better than inaction. Generally, the US medical system tends towards action.

> Even a test that is 99% accurate in a high-incidence population is going to be utterly ineffective when applied to the general population.

I read that sentence a few times. 99% accurate seems quite high. WSJ recently opined about the 1-in-5 cancer misdiagnosis rate.

https://www.wsj.com/articles/are-you-sure-you-have-cancer-di...

"Are You Sure You Have Cancer?"

The point is that a test that has a guarantee like "out of 100 people who test positive, only one will turn out to be negative" (99% specificity) can have an arbitrarily high false-positive rate when applied to the whole population: if a condition affects 1 in 10k individuals, then out of 10k individuals that take that test, 100 will be positive, but only 1 will be a true positive. The rarer the condition, the more specificity you need in your test to have a low false positive rate.

The WSJ article is behind a paywall so I can't double check this, but you can have a 99% accurate test with a 20% misdiagnosis rate. The difference is that 99% is per-person, and 20% is per-positive-result. A rare condition will have more false-positives relative to true-positives than the test accuracy would indicate.

It's a bit easier to understand if you think of the extreme case: if the disease is completely eliminated than all positives are false-positives.

Firstly, not all worms are created equal. The most common worms in NA and Western Europe (like pinworm) just aren’t that serious.

Second, absent actual testing, the risk/reward of deworming is very much a function of the likelihood that you actually have one or more of these worms. That probability is too low in, say, the US to give routing deworming positive expected value. It’s telling that even routine testing isn’t worth the time/cost.

Thirdly, it’s not like… _exactly_ clear that all of these parasites are a problem in the first place. Many of them are frequently asymptomatic with negligible long term consequences. There are even those who believe that the near eradication of hookworm and its minor gut immunosuppressive effect in the developed world is the explanation for much higher rates of inflammatory bowel disease. I that one, but the general idea is that a lot of these worms just don’t actually cause much harm.

And lastly, deworming medications aren’t exactly a joke. They can have serious risks associated with them. Overall it just doesn’t make any sense to routinely deworm in the developed world.

Those countries have very different risk factors. How many people in your community would you say do not have access to a plumbed toilet? clean water?

Not trolling, but in certain cities the amount of human waste in the streets suggests the answer could be far from zero. These unsanitary conditions seem to me to be an additional risk factor that probably wasn't taken into account when the risk factors for 'wealthy countries' were being calculated.

IDK whether this is significant to the original question (de-worm or not) because I'm not qualified to speculate, but I think it certainly suggests that at least for some cities, the evidence should be re-evaluated with realistic sanitation conditions in mind.

it actually has nothing to do with individual patient health. The reason why 'we' don't recommend it is because we want to spend money and resources on others. Its about cost. providing the cheapest treatment for everyone so that you 'maximize coverage'.

Except ironically there's a theory that a lack of parasitic infections may contribute to autoimmune diseases:

https://focus.science.ubc.ca/worms-ae3a1579c58c

Humanity evolved with parasites. Like gut bacteria, excessive focus on hygeine may be more harmful than helpful.

As someone who grew up in mud and all kinds of filth while playing in a (stereo)typical Indian city, I have to say this makes sense. We kids were just left to play by themselves for hours at a time while we made merry in the dirtiest streets. Nobody was “clean”. There were open drains everywhere and let’s just say that a ball going into those drains never stopped an exciting game of gully cricket.

And, this was most of India not just us.

The medicine iirc is quite harsh on your kidney.

And worms aren’t all bad. Your body’s immune system likely welcomes its presence. Our th1-th2 balance is supposed to have evolved with an assumption of helminth infections happening over the course of your life, so having a worm or two is likely a good thing. Supposedly. Don’t go around barefoot in feces to get hook worms. Not anymore than trying to deworm once a week destroying kidneys I suppose.

> Don’t go around barefoot in feces to get hook worms.

You say that, but I've heard at least one story where someone did exactly that (and claimed that it cured their allergies and asthma): https://www.thisamericanlife.org/404/enemy-camp-2010/act-thr...

I'll personally stick to allergy shots, though.

I did years of allergy shots (environmental), it helped a middling amount. When it came to dog and cat allergy, I could have gone for several more years of inconvenient shots. Instead, I got a self-applied treatment of Necator americanus that I found through the helminth therapy wiki. I found a marked improvement in my pet allergies, which is great since I live with a cat and two dogs now.

It's not a cure but a marked reduction in symptoms. I used to have to take fexofenadine basically daily. Now I only need it under extreme conditions.

I'm sure the worms have long since died off and I may need to re-up.

I've wanted a Goa'uld for years.

>And worms aren’t all bad. Your body’s immune system likely welcomes its presence. Our th1-th2 balance is supposed to have evolved with an assumption of helminth infections happening over the course of your life, so having a worm or two is likely a good thing. Supposedly

What is the point of making a claim and then walking it back?

As the article says on deworming, it’s not so simple: “Some medications for example could trigger inflammation as the larvae died off. An inflammation can be harmful to organs such as the brain, so they also needed to administer medications to counteract any dangerous side-effects.”

If you’ve got kids in a daycare, then there’s a good chance your family may end up with pinworms at some point, which can stick around for months due to their lifecycles. If you get it though, you’ll know.

That got me to google pinworms and related symptoms.

Firstly, gross.

Secondly, I'm surprised I've never heard about it before as we raised two kids through daycares, then pre-schools, and elementary school seemingly without ever getting it and not ever even hearing about it.

rybosworld says >"In the U.S., the recommendation is that "healthy individuals do not need to deworm"."<

You quote something but provide no source. I believe the quote is at least not wise and probably is incorrect. People should periodically be checked for parasites. Otherwise they may be writing posts to YC under the influence of a worm!8-)

Butt seriously, many individuals in the USA have worms. When I was a child in the southwest USA we were tested at least once a year for parasites including worms. That was decades ago. Yet today the topsoil is the same, the plants and animals are the same and the parasites remain. Children still put their hands into dirt, eat dirt and sand, and touch everything. Gardeners are just as bad. I had worms as a child and I likely catch them now and again. I take care of it.

Some people "deworm" themselves in their work: e.g., ivermectin products are often applied to animals' skin. That ivermectin clears many parasites from the cowboy as well as from the cow.

That is pretty sketchy data. However, deworming once a year might be an overkill. What is the health cost of deworming to individual? What is the cost to the environment?

'60 million U.S. citizens are infected with Toxoplasma Gondii'

US 2023 pop >> 340M .. so about 1 in 4 people you randomly interact with are allied beings.

Yeah, this seems like a fairly reasonable precaution. Yet most doctors will think you are crazy and not entertain the idea.

Are you looking to have a dead worm in your brain? Because this is how people end up with dead worms in their brain.

Is an alive worm in one's brain better?

possibly? a dead worm will start decaying. a rotting worm in your brain could easily lead to a sepsis state in one of the organs least able to deal with it.

The worm won't live forever -- eventually it will die and your body will have to deal with it.

Maybe it will try to make an escape before it dies? Honest question. Like for reproductive purposes?

I had the same thought!

Probably safer to get a cheap CT scan done in Mexico if you are worried about parasites inside your skull than to take dewormers. That said, Ivermectin is a very safe medication that you can try with minimal side effects.

Getting on an airplane, flying to a foreign country, getting a dose of radiation, then flying back is significantly more risky than your risk of having adverse parasitic infections in a developed country. This is a good example of how logic can completely break down in the face of a little bit of medical knowledge about obscure edge case stories.

But it is a) a nice vacation and b) saver for ypur health (assuming you take a MRT, but then CTs are very low radiation now). All in all better than taking medication without proper indication to do so.

You’re getting a dose of radiation for the airplane flight anyway might as well pitch an umbrella and a lounger on the beach in Mazatlán while you’re at it

All depends on how desperate you are to find out based on your own risk assessment.

You're probably right - however I've recently found a number of papers indicating a heightened risk of parasitic infection post cdiff which I had earlier this year.

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