Case guesses:

Sophia writes:

Dear Twipsters!

I think you’ll be reading this in 2020, so Happy New Year and all the best! Thank you for another year of twip episodes and thank you for taking the time to further explain things for me. I really appreciate this. Let me venture a guess: I looked for the picture the boy was shown in the 6th ed. but after a while I gave up as most of the worms look the same to me. Did I miss a picture showing worms in stools? Anyhow, I would say that the baby is suffering from Ascariasis among other things. The protuberant belly could be partly due to the worms and partly due to kwashiorkor given a diet based on carbohydrates. In addition, given the dysentery outbreaks I wonder if and how these boys restore their gut microbiome to a healthy level. Given the older boy’s stunting I wanna say kwashiorkor might be the main cause for it since it inhibits growth in the first years of life to a point that a child can never catch up with expected height even if given proper diet after year 3 in life. What to do? 

1. treat the patients

2. educate children and adults on hygienic practices

3. explore ways to introduce protein in their diet

4. explore possibilities for clean water in the area (or cholera etc will come back)

It seems so hard. I saw the pics on the facebook page (good job! nice page! please keep us posted). I am assuming the kids above were not affected by HIV as well (Vincent didn’t ask this question last time)

Safe trips this year and all the best!

Greetings from Greece (current temp 8 degrees C. Yes, we do get winter and snow and subzero temperatures in Greece ; we just got lucky this year with warm temperatures due to anticyclones from the Sahara. I won’t complain about that!)

Alida writes:


If you asc me, this sounds like ascaris!

A lumbering fan, 

George writes:

Dear Doctors, 

I have been listening to your podcast for a while now and finally decided to write my guess on the case. 

I am PGY3 in Internal Medicine and just matched to Infection disease fellowship, I am very thrilled about my future career path!

I believe that the boy may have Ascaris lumbricoides infection since the description of the worm is round, pink and 8 inches long. Also, patient appearance suggests this infection too, protuberant round abdomen and delay in physical development – all could be from malnutrition due to the heavy burden of infection.

Treatment would be a single dose of albendazole or mebendazole.

I want to thank you for what you do. Keep up the great work!


George Zarkua, MD

Courtney writes:

Dear Doctors, 

I thought this case would be relatively straightforward, but after spending quite some time on it, I now know better. I originally started my journey in PD 7 in appendix c’s photos..  Unfortunately I didn’t find any photos of an 8 inch (or ~20 cm) pinkish worm.. So, looking at the “Diagnostics and Laboratory Abnormalities” table for “distended stomach” I started my search amongst the “hepatomegaly” worms. I narrowed it down between  Ascariasis and Schistosomiasis. Both match the location, both cause a distended stomach, both can be spread via contaminated water, and both can cause a short stature. However, Schistosomiasis worms are about 15 mm long.. A far cry from an 8 inch worm (~200 mm).   Ascariasis seems like the best match, but PD 7 doesn’t mention anything about worms being passed in the stool and I couldn’t find a length for it. 

I then went on an internet jaunt/ scrolling through PD 7 and saw a few other things, but none of them quite matched. Most were too small or need to be transmitted via animals/ undercooked meat. I revisited Ascariasis and even though it’s lacking a few things, I decided it is the best choice. 

My official guess is Ascariasis.  Diagnostics would be looking at the eggs stool sample for eggs.  Treatment is usually Albendazole or Mebendazole. Unfortunately, if the infection is severe enough surgery may be required to remove the worm.   

I am curious, what happens after treatment? Isn’t there a strong chance the child (and it sounds like his brother) can become reinfected with worms? Also, is there ever any intraspecific/ interspecific competition that happens? Or are the worms (and this just isn’t for Ascariasis, but all internal parasites) derived from a singular infection or are there hundreds of worms that come from being repeatedly infected as they continue to drink the contaminated water? Does having all these worms impact if they can get other parasites like hookworm? 

One last question: Dr. Griffin, what are the logistics like for your travel? Do you pick where you go or are you assigned? Does each clinic have different specialists or are you all general practitioners who know a little bit of everything? Are there doctors continuously at this clinic or do the doctors come for say, 10 days, every few months? Are the clinics able to have things like MRI’S/ CAT scans/ etc? What happens if someone needs major surgery? 

Stay Curious,


Raychel writes:

I suspect it was Babesia microti

Jim writes:

Greetings Brave Slayers of the Worm Internal:

Based on the information you provided, I would guess that the two patients have Ascaris Roundworm infection. 

These patients live in a community where the soil and the water is contaminated by poorly contained human waste which is spread further by its use in the local agriculture.  

Since the local climate favours several species of waste-friendly worms, we should consider the prospects of a co-infection with fellow travellers such as Whipworm or Hookworm. Moreover, if water conditions in the nearby stream support the right species of snail, Schistosomiasis might be endemic. 

Respecting the symptoms in this case, both patients have distended bellies. This could be an indication that intestinal worms are taking significant nutrients away from them.  In the case of the older sibling, the evident degree of developmental delay is consistent with a longterm worm infection. 

Microscopic inspection of fecal assays is probably the best available way to determine which parasites are present and in what numbers.   If Ascaris is the only parasite found, it can be treated with a single dose of Albendizole. Unfortunately, unless community conditions change, eventual reinfection is likely.  

Happy New Year and welcome to the Roiling ‘20s!

Take care,

Jim in Vancouver

James writes:

Ascaris lumbricoides, a parasitic roundworm that often resides in the duodenum.

Somebody poops the eggs out into food/water supply. Then on what one of my Peds Infectious Disease docs called “The fecal oral highway”, we eat ‘em. Then comes what some of my medical students think is pretty gross, the egg hatches, the larva penetrates the duodenum and ends up in the lung. Then in the grand circle of life, we swallow it and it ends up, again, in the duodenum. Doesn’t seem all that efficient to me. Works for them, though.

Is it true that all 40K species of nematodes have 4 molts? Anyway, the adults develop, know each other (in the biblical sense), and produce knobby often biliously stained eggs. Then the circle is complete, Obi-Wan.

Differential Diagnosis: I think it’s too big and wrong syndrome for Pinworm (Enterobius.) I also doubt Hookworms or Whipworms. I guess Strongyloides belongs on the list too, but again I don’t like that so much.

Hard for me to believe the time of day matters all that much. The eggs are said to be pretty durable. Would the water in the tropics be less motile in the AM, allowing some settling? Can’t really think of why. Here in Colorado in the glacier fed streams, perhaps the flow is a little greater later in the day?

One of the Immunology professors at Duke when I was in Grad School told me that he had first worked with Ascaris, but became so violently allergic to it that he could not even walk into the lab any more and had to switch projects. Since I am violently allergic to another invasive “parasite”, grass pollens in the spring, I can relate.

Enjoying the podcast. I also enjoyed the StemTalk episode and will be stealing/pirating/citing (your pick) the stories about Toxoplasma, Trichinella, and Necator for my medical students!

James M. Small, MD PhD, FCAPAssociate Professor of PathologyAchieving New Heights in MedicalEducation
Rocky Vista University • Parker, CO 80134

Andrew writes:

Meri Kihirimete  (Merry Ki-hi-ri-met-e) from Pongaroa,

As you might have guessed the greeting is Māori for Merry Christmas.

The weather here is showery, 24°C and cloudy.

Book not yet won – desperately trying not to fall into the gambler’s fallacy.

My guess is Ascaris lumbricoides.

My train of thought:

Intestinal worms endemic in the Uganda-Kenya border region; hookworm, Trichuris trichiura, Schistosoma mansoni, Ascaris lumbricoides, Entamoeba histolytica / E. dispar

The twip-team discussed toilets, water and diets quite a bit. OK I am thinking fecal-oral route with maybe some sort of water-borne vector in between.

A lot to unpack here – hopefully an omen for me on Christmas day 🙂
I start to look through my PDF of Parasitic Diseases 7th Edition looking for pink worms but the all look pinkish and brown so I start working on the size aspect. I change to the Parasitic Diseases Youtube channel and quickly find lecture #24 “Giant Intestinal Worms” and soon all the puzzle pieces fit the pattern for geo-helminths and Dixon’s unholy trinity. The salient points that lead me to deciding on ascaris is its earthworm-like appearance, the failure to thrive syndrome, and the distended abdomens. The idea that there is a waterborne vector can be dismissed and the eggs are being deposited in the soil by children afraid to use the long-drop toilet and the use of feces as manure.

I had learned, years ago, that the distended abdomen in children was due to ‘malnutrition’ and that piqued my interest to find out more. Learning that the distention derives from kwashiorkor – a severe protein-energy malnutrition that leads to edema. The name means ‘the sickness a baby gets when the new baby comes’ as the weaned child loses access to protein.  Ascarius inhibits protein absorption, by the host, through the release of trypsin – a very sneaky trick. With a protein poor, carbohydrate rich diet the children are going to get very little protein at all.

I check the other possible worms but am sure a stool examination will show the presence of ascaris eggs.

Treatment: Ascaris should be treated before any other helminths found to be present as an irritation might lead  to aberrant migration within the body leading to complications. Also the village needs to be treated with access to proper sanitation and a diet with adequate protein sources, but that is beyond the scope of the case.

Two postscripts:

1. Sophie from Greece is my hero. My knowledge retention was better with the explanations and the podcast was even more entertaining that its usual high standard.

2. As far as I am concerned, flights by scientists and educators should be subsided. I don’t fly anymore and I will happily donate my saved carbon.

ngā mihi o te tau hou  [pronounced: na me-he oh teh tau hoe] (happy new year in Māori)

Ben writes:

To the TWiP DVD (Dickson, Vincent, and Daniel),

Firstly, congratulations to Vincent on starting up a new podcast in TWiN! The small amount of neuroscience I got in my undergraduate degree was too dense and so I tended to switch off, but I’m finding TWiN very appealing and easily digestible!

For this week’s case guess, I would say it is likely that 1 year old boy is infected with Ascaris lumbricoides. No other worms come to mind of that size and shape, and it would fit the setting well. Having said this, infection with A. lumbricoides would the boy has come into contact with human faeces and it may be the case that he is also infected with other soil-transmitted helminths. It is likely that his older brother is also infected with A. lumbricoides, given the protuberant abdomen. It seems most likely that both boys are infected with A. lumbricoides, and also likely Trichuris  and possible hookworm, and that these soil-transmitted helminths are acting combinatorially to cause the delayed growth seen in both children. It is possible that this could be compounded by malnutrition, but I wouldn’t think based on the description of diet given by Daniel that this would be sufficient to cause such significant growth stunting. Albendazole and mabendazole treatment would likely be effective for all three of the soil-transmitted helminths mentioned. Without improved sanitary conditions or continued routine deworming, unfortunately these children will probably become reinfected again in the future.

It is currently a sweltering 42 degrees celsius in Adelaide, South Australia and we are set for a week of days above 40 degrees, which is not very good news as an area larger than Maryland has been completely destroyed by bushfires already this year, just in the state of New South Wales, in what will likely go down as by far our worst bushfire season in history.

Thank you all for another great year of Podcasting, and wishing you all the best over the holiday period



Cecelia writes:

Dear Doctors, 

   Thanks again for your podcast. 

   I think the 2 boys, the fifteen year old and the one year old, are infected with Ascaris lumbricoides. The younger brother is known to be passing worms that fit the description of Ascaris. The older brother is not able to visualize the worms due to the type of toilets used in that part of the country.

   As stated in PD7,in some regions of Africa up to 95% of the population can be infected by Ascaris. This can be due to poor hygiene and the  ability for Ascaris eggs to survive in the environment for long periods. 

   Ascaris is spread by ingesting the  eggs that have been passed in the feces of an infected person.

  Both boys show signs of infection as well. The youngest having a distended abdomen and the older by his short stature appearing younger than he is.

   As stated in PD7, a 400 mg dose of Albendazole or 500 mg of Mebendazole is effective for de-worming. 

   There is so much information on Ascaris infection that I’m sure your other responders will include. I look forward to your next podcast!



St. Petersburg

(Yes, the west coast of Florida!)

Peter writes:

Dear Drs of TWIP

The description in TWIP 178 really had me scratching my head.  Let’s review the facts:

1) A 1 year old with evidence of slowed physical development accompanied by their 15 year old brother with the same problem.

2) Enlarged belly in the 1 year old, and similar sign in the 15 year old.

3) Two descriptions were given: firstly the 15 year old boy mentioned a long, flat, white worm. Daniel described the picture in the Parasitic Diseases 7 as showing a pinkish, almost fleshy coloured worm that is 8 inches (about 20 cm) in length, and round.

The description of a large, round worm and a distended abdomen immediately brings Ascaris lumbricoides to mind. None of the images in PD 7, however, show a pinkish worm, unless one counts the illustration on page 206 and a few of the individuals in Figure 18.7. The predominant colour seems to be yellow or beige. (The trematodes Fasciola and  Clonorchis *are* pink but neither round nor large enough.) This colour does align with the boy’s description of the worm as white though. 

The enlarged belly could be due to Ascaris lumbricoides as a bolus from a heavy infestation of Ascaris worms (roundworms) could cause both the enlarged abdomen and impaired growth reported. Then again Schistosoma mansoni can cause hepatosplenomegaly (enlarged liver and spleen), which might explain this symptom in the young boy or his older brother. 

S. mansoni could also cause slowed physical development (stunting) as could hookworm (most commonly Necator americanus).. In addition, PD 7 notes that the STH Trichuris trichiura (whipworm) is often found together with A. lumbricoides and that “[c]hildren suffering from heavy trichuriasis develop chronic malnutrition, short stature, anemia, and finger clubbing.”

The symptoms are thus non-specific, so I will consider epidemiology. Moses Adriko et al note that mass deworming campaigns have reduced the incidence of STH infection from over 60% in most districts to just less than 9% in 2016. Of the remaining cases of STH, hookworm is the most prevalent infection (~7.7% of children), followed by whipworm (~1.3%) and roundworm (~0.5%). Schistosomiasis impacts some 13% of children. 

Perhaps the details of which STH is plaguing the children is less important than what to do about it. Albendazole and mebendazole are recommended for treating helminthic infections, although the correct choice of drug and treatment regime will depend on what is practical in the setting. For schistosomiasis, praziquantel is recommended. I realise that I have digressed quite far from the original description of a worm in this discussion, but given the lack of opportunity for detailed diagnostics it seems prudent to pay attention to the parasites unseen as much as to the parasite that was seen by the 15 year old. While re-infection is always possible (even likely), the Adriko paper gives me hope that public health interventions in the country are gaining ground.


Moses Adrio et al “Impact of a national deworming campaign on the prevalence of soil-transmitted helminthiasis in Uganda (2004-2016)”, PLOS Neglected Tropical Diseases, July 5 2018:


writing from my home base, a rather rainy Cape Town, for once

P.S. Vincent asked about feeding mosquitoes. I enclose below a photo taken in the insectary of the University Clinical Research Center (UCRC) at the University of Science, Techniques And Technologies in Bamako, Mali. The glass vessel is fed with warm water to keep the apparatus at human body temperature. Infected blood is inserted into the central tube (which is closed at the bottom with parafilm) and mosquitoes are in the box attached at the bottom (the similar facility that I visited at CERMEL in Lambaréné, Gabon had a simple cup full of mosquitoes). One challenge at UCRC is acquiring the blood: it is unethical to entice one’s students to donate blood (given the student/supervisor relationship) so the university is forced to compete with other users of the local blood bank for human blood.

By the way, my host in Bamako, Prof Abdoulaye Djimdé ( is a good candidate for a future hero of parasitology profile.

and thank you *so* much! Winning a copy of PD 7 has been a highlight of my month.

(my eldest kid has already informed me that they will steal the book from me – they share my interest in infectious diseases while also having a much more artistic bent – perhaps science communication is in their future!)

Kevin writes:

Manson’s Tropical Diseases (1923) in the chapter on ascaris, describes them as “verminous visitors” and “troublesome guests.” This has an almost a holiday flavor. 

The two brothers in this case are infected with Ascaris. A large pinkish intestinal worm could really be nothing else. They may be co-infected with Trichuris and hookworm as well, a trifecta of soil transmitted helminths (STH). The differential diagnosis in this case spills over into the social and economic realms. The protuberant abdomens and stunted growth suggest chronic protein-calorie malnutrition. Poverty and unbalanced nutrition are likely the principle culprits in the poor condition of these children. Though not innocent bystanders, the ascarids are probably just adding insult to injury. It is likely that the majority of children in their village are infected, but our patients may be at the low-end of the social strata with a more precarious existence (? orphans being raised by a grandmother). Treating these boys with albendazole will likely remove the infection temporarily, but re-infection is inevitable. If their worm burdens are extremely high perhaps their overall condition will show some improvement. 

On initially hearing Case 178, I thought that individual treatment and mass deworming were equally ‘intuitively obvious’, a ‘case of common-sense;’ something that ‘just stands to reason.’ The picture became much murkier when I read some of the literature on STH, MDA (mass drug administration) and their effect on nutrition, cognition, and growth. The Cochrane review of MDA (recently updated September 2019 and summarizing 50 trials involving over 84,000 children) concluded that deworming programs “do not appear to improve height, haemoglobin, cognition, school performance, or mortality.” The Cochrane also states that there is very little evidence that body weight, physical fitness and school attendance is improved after deworming. Added to the disappointing effect of deworming on multiple outcome measures is the possibility that deworming could increase susceptibility to malaria infection in children. The consensus opinion is that MDA for STH does not increase malaria infection. However, complex inter-relationships of chronic helminth infection and immune function leaves open the possibility of unexpected consequences of mass treatment. 

In a 2014 review, Hawdon argues that mass drug administration for STH is an unsustainable strategy and instead advocates for the use of bio-gas latrines. But this ‘solution’ brings up the entire topic of the sociology of defecation and the acceptance of latrine use among traditional people. Flies again appear in the ointment regarding the ‘uptake’ of latrine use in traditional rural societies. This curious topic is briefly discussed in the endnotes. 

In summary: of course the two boys should be dewormed, if only to prevent the more uncommon consequences of intestinal obstruction, biliary invasion or extra-intestinal migration. The effect of one-time treatment however is unlikely to have dramatic or long-term benefits without the addition of more diffuse remedies such as widespread sanitation, mitigation of poverty and improved nutrition. 

Wishing the trio of worm mentors a very auspicious New Year.


Miscellaneous thoughts stimulated by the case:

Nematodes are usually quite bland in color, generally whitish or greyish or even slightly translucent. This is in contrast to the turbellarians, which can be positively psychedelic in coloration. In order to prematurely doom this letter to obsolescence, I want to mention the ‘Game of Thrones’ leader of the army of the ‘Unsullied’: Grey Worm. One of the rare times that a cinema/TV hero is named after a pigmented worm. Some good photos of pink ascarids can be seen at the Korean web-site: Web Atlas of Medical Parasitology:

Regarding ‘growth stunting.’ This term, which I haven’t heard in quite a long time, was used in several of the reviews that I read. It reminded me of a common admonition given to kids in the 60s and 70s: “Don’t smoke, it’ll stunt your growth.” In the 2000s this should be changed to: “Don’t vape, it’ll give you bronchiolocentric organizing pneumonia.”

Latin: parasitus, which Lewis & Short defines as (in particular) –in a bad sense: one who, by flattery and buffoonery, manages to live at another’s expense, a sponger, toad-eater, parasite (syn. scurra). The original Greek also has this negative connotation despite the literal meaning of one who sits at table with. Maybe it’s a bit trite to lead off with a definition, even worse, one with classical pretentions. But it is relevant to the question that lies in the shadow of the ascarids that populate this case. Why ascaris? What other intestinal worm is so large and pinkish (though some authors say they can be cream colored.) It’s intuitive: worms are bad. 

Ascaris and nutrition:

Effects of intestinal parasitic infections on nutritional status of primary children in Imo State Nigeria. Ihejirika OC, et al, Pan Afr Med J. 2019 May 16;33:34

Total prevalence of stunting was 26.0% and it was not associated with intestinal parasitic infections in the study area Stunting is mostly due long-term poor nutritional intake and is the best indicator of growth retardation in children over long period of time. ….

Ascariasis: nutritional implications. Schultz MG. Rev Infect Dis. 1982 Jul-Aug;4(4):815-9.

didnt find a signif. improvement in nutritional status post-tx for ascariasis

Ascariasis and childhood malnutrition. Hlaing T, Parasitology. 1993;107 Suppl:S125-36.

“Reasons for failures to detect improved growth in some studies are provided. This review strongly indicates that A. lumbricoides infection definitely retards childhood growth.”

Prevalence and intensity of Ascaris lumbricoides infections in relation to undernutrition among children in a tea plantation community, Sri Lanka: a cross-sectional study. Galgamuwa LS,et al BMC Pediatr. 2018 Jan


RESULTS Of the study sample (almost 500 Sri Lankan children), 38.4% showed Ascaris lumbricoides infections. Light intensity infections (51%) were common in the infected children, followed by moderate (30%) and heavy (19%) infections. Prevalence of Ascaris infections was significantly associated with de-worming more than six months prior to the study. Prevalence of undernutrition among children was 61.7%. Forty-five per cent were underweight, while 24.1% and 21.5% of children were stunted and wasted respectively. However, no significant association was found between Ascaris infections status and undernutrition. Meanwhile, heavy intensity infections were associated with decreased values of WHZ (p = 0.020).

Mass drug administration for STH:

The effect of three-monthly albendazole treatment on malarial parasitemia and allergy: a household-based cluster-randomized, double-blind, placebo-controlled trial Wiria AE, et al.[published correction appears in PLoS One. 2013;8(9).  PLoS One. 2013;8(3)

double-blinded prospective placebo controlled trial 4000 subjects, 21 month follow up….no significant effect of deworming on malaria infection…

Impact of a national deworming campaign on the prevalence of soil-transmitted helminthiasis in Uganda (2004-2016): Implications for national control programs Moses Adriko et al, PLoS Negl Trop Dis 12(7): e0006520

Soil-transmitted Helminths and Anemia potentially reduce and retard cognitive and physical growth in school-age children with great implications for national control programs in Africa.4,285 children were assessed one study area Mbale showed great reductions in STH infection over the 12 years of the study and mass drug administraton. (54.1% vs. 6.9%)   This study is a prevalence study. It contains no anthropometric data or analysis of effect of mass deworming on nutritional, educational or cognitive status of children.

Effects of treatment for intestinal helminth infection on growth and cognitive performance in children: systematic review of randomised trials, Rumona Dickson,et al, BMJ 2000;320:1697 open access

Authors’ conclusions: Public health programmes to regularly treat all children with deworming drugs do not appear to improve height, haemoglobin, cognition, school performance, or mortality. We do not know if there is an effect on school attendance, since the evidence is inconsistent and at risk of bias, and there is insufficient data on physical fitness. Studies conducted in two settings over 20 years ago showed large effects on weight gain, but this is not a finding in more recent, larger studies. We would caution against selecting only the evidence from these older studies as a rationale for contemporary mass treatment programmes as this ignores the recent studies that have not shown benefit. The conclusions of the 2015 edition have not changed in this update.

CONTROLLING SOIL-TRANSMITTED HELMINTHS: TIME TO THINK INSIDE THE BOX? John M. Hawdon, J. Parasitol., 100(2), 2014, pp. 166–188 

Hawdon argues that mass drug administration for STH is an unsustainable strategy and instead advocates for the use of bio-gas latrines. 

Deworming and malaria infection:

Effect of Repeated Anthelminthic Treatment on Malaria in School Children in Kenya: A Randomized, Open-Label, Equivalence Trial, Kepha S, et al. J Infect Dis. 2016;213(2):266–275. 

This 13 month follow-up study of 2400 children concluded that “repeated deworming does not alter risks of clinical malaria or malaria parasitemia among school children and that school-based deworming in Africa may have no adverse consequences for malaria.”  And it has been hypothesized that this may influence, either positively or negatively, human immunity to malaria parasites and hence susceptibility to clinical malaria. However, previous studies have been typically cross-sectional and performed in single populations, and they have produced conflicting results.

The effect of three-monthly albendazole treatment on malarial parasitemia and allergy: a household-based cluster-randomized, double-blind, placebo-controlled trial Wiria AE, et al.[published correction appears in PLoS One. 2013;8(9).  PLoS One. 2013;8(3) double-blinded prospective placebo controlled trial 4000 subjects, 21 month follow up….no significant effect of deworming on malaria infection…


For people (of the non-epidemiologist persuasion) in high resource nations, excretory practices are fairly standardized and not subject to a great deal of discussion. The idea that open defecation would be preferable to a latrine or outhouse seemed unimaginable before I read a few papers on the subject. I have also appended a few notes on the intersection of religion and defecation as well as the the role of superstition in toileting.

Routray P, Schmidt WP, Boisson S, Clasen T, Jenkins MW. Socio-cultural and behavioural factors constraining latrine adoption in rural coastal Odisha: an exploratory qualitative study. BMC Public Health. 2015;15:880. Published 2015 Sep 10. doi:10.1186/s12889-015-2206-3

cultural defecation habits and rituals. Determinants of non-latrine use. Very interesting examination of the complex sociological factors involved in latrine use versus open defecation in rural India. 

What motivates open defecation? A qualitative study from a rural setting in Nepal. Bhatt N, et al. PLoS One. 2019;14(7):e0219246. 

Looks at factors involving socializing, women’s safety, privacy, and using the latrine as a storage area. Long discussion section with descriptions of toileting practices in many different cultures. Comprehensive web site with strong references, and well researched information about historical toileting practices. 

Fishermen from various Lake Victoria islands think that using a latrine prior to a fishing expedition will bring bad luck and a poor catch. See this bizarre news account from an 2013 African source:

NEPAD (New Partners for Africa’s Development)  2013: mentions Lake Victoria Island residents and the latrine/toilet defecation superstition:

Note that some authors discount the superstition theories regarding non-use of latrines. Instead they blame poor availability of toilets, poverty, soil conditions unfavorable to latrine construction and semi-nomadic fishing practices.

Muslim toilet traditions: 

Step into the toilet left leg first while entering and exit using the right leg. (According to Hadith of prophet Mohammed). The toilet is known as the devil’s lair. Therefore entering must be with the left foot and going out with the right foot. Prayer to be uttered upon exiting the toilet: “Praise be to Allah who relieved me of the filth and gave me relief.” A Hebrew prayer, the Asher Yatzar is similarly uttered after exiting the toilet among devout Jews. It is a prayer of thanksgiving. References at

Dept of Parasitic Haberdashery:

Parasitic nematode worm (Ascaris sp.) under the microscope Mini Skirt Designed by Zosimus $30.77

WesternU Global Health Track Students: Dana, Steven, and Chris write:

Hello TWiP professors, 

Thank you for providing such interesting cases. We believe that for this months episode, Ascaris Lumbricoides is most likely the parasite.  We came to this conclusion mainly because the worm described was about 8 inches long, round (not actually flat), and pink and this directed us towards a large roundworm.   For treatment albendazole/mebendazole could be used. 


WesternU Global Health Track Students: Dana, Steven, and Chris