PARASITOLOGY LECTURE

INTESTINAL NEMATODES
Ascaris lumbricoides
Hookworm
Strongyloides stercoralis
Trichuris trichiura
Enterobius vermicularis
Capillaria philippinensis
NEMATODES (Roundworms) 2. Tissue
1. Intestinal Trichinella spiralis
Ascaris lumbricoides Visceral Larva Migrans
Trichuris trichiura (Toxocara canis or Toxocara cati)
Strongyloides stercoralis Cutaneous Larva Migrans
(Ancylostoma braziliense or Ancylostoma
Hookworms caninum)
- Ancylostoma duodenale Dracunculus medinensis
- Necator americanus Angiostrongylus cantonensis
Enterobius vermicularis 3. Blood and Tissues
Capillaria philippinensis Wuchereria bancrofti
Brugia malayi, Brugia timori
Loa loa
Onchocerca volvulus
Mansonella species
PHYLUM NEMATODA (THE TRUE
ROUNDWORMS)
Morphology and general characteristics
The adult nematode is unsegmented, elongated, cylindrical
worm.
The sexes are separate (dioecious). The male is smaller than
female and the posterior portion of male is curved or coiled.
 The supporting body wall consists of the following
1. an outer, hyaline, non-cellular cuticle with three main layers
cortical layer, which is the outermost layer composed of collagen and
cuticulin
homogenous matrix, the middle layer
the fibrous layer
2. a subcuticular epithelium or hypodermis which is responsible
for secretion of the cuticle
3. layer of muscle cell or somatic musculature, wherein there
are two types of muscle cells (a) platymyarian muscle cells
and (2) coelomyarian muscle cells
 All of the viscera including the digestive system, excretory
system and the reproductive system are suspended in a body
cavity known as pseudocele or pseudocoelum.
The fluid of pseudocele known as hemolymph contains
hemoglobin, glucose, proteins, salts and vitamins and fulfills
the function of the blood.
 Digestive System
The adult worm has a complete digestive tract

Mouth - located at the anterior end; maybe equipped with

hooks,teeth, plates and other structures for the purpose of abrasion,
attachment and sensory response
Buccal cavity - tubular or funnel-shaped, which in some species is
expanded for sucking purposes
Esophagus - a muscular tube that pumps food posteriorly into the
intestine; characteristically varies in size, shape and structures which are
useful for species identification
Types of esophagus:
Filariform - simple, long and slender; seen in Strongyloides
Rhabditiform - divided into distal corpus, an isthmus and
and esophageal bulb; seen in Enterobius
Spiruroid - anterior portion muscular, posterior glandular;
seen in Filarial worms
Strongyliform - short, muscular with a waist, seen in
Ancylostoma
Stichosoma - long, thin, capillary-like lined with
esophageal glands cells known as stichocytes or stichosomes
seen in Trichuris, Capillaria and Trichinella
4. Intestine/Midgut a flattened tube with a wide lumen that
follows a straight course from the esophagus to the rectum.
This absorbs nutrients and probably plays a role in the excretion
of nitrogenous waste products.
5. Rectum
Nervous system
The most important commissure is the CIRCUM-
ESOPHAGEAL RING COMMISSURE, which constitutes the
nerve center.
PAPILLAE are minute inflations of the cuticle, which function as
tactile receptors.
The paired minute chemoreceptor organs located in the cephalic
or cervical region of all nematodes are known as AMPHIDS.
Pair of minute lateral post anal or caudal chemoreceptor organ
present in some specie of nematodes without caudal glands is
known as PHASMIDS.
Reproductive system
The male reproductive organs are situated in the posterior
third of the body as a single coiled or convoluted tube
Accessory copulatory apparatus consists of one or two
unsheathed copulatory spicules which are sclerotizations of
the cuticle arising from the dorsal wall of cloaca. This
spicules maybe short or long and use for attachment of the
male to the female during copulation.
In some species, a wing-like appendage or copulatory
bursa/bursa copulatrix maybe present. Nematodes
spermatozoa are stored in the seminal vesicle.
 The female reproductive system may either be a single or
bifurcated tube, differentiated into ovary, oviduct, seminal
receptacle, uterus, ovijector, vagina and a vulva that opens to
the exterior. The ovum passes from the ovary into the
oviduct (fallopian tube) where it is fertilized.
The female adult maybe classified into
oviparous, in which eggs are oviposited and the embryo develops
outside the maternal body as in Ascaris, Trichuris
viviparous or larviparous, where the adult female gives birth to a
larva as in Trichinella spiralis and Filarial worms
parthenogenetic where the female can produce viable eggs
without being fertilized by the male worms as in Strongyloides
stercoralis.
Ovum
The daily output of a gravid female may range from 20 to
200,000 eggs.
The egg consists of a multinucleated mass of protoplasm
usually containing yolk granules. The egg shell may consist of
three layers:
vitelline membrane - formed immediately after sperm
penetration;waxy colorless and lipoidal in nature
chorionic or true shell - a secretory product of the egg; chitinous in
nature and synthesized from glycogen and ovarian nitrogen
albuminous layer - outermost layer;has a tanning action
Ascaris lumbricoides
The most common intestinal nematode in man
Giant Round worm
Soil-transmitted helminth (which means that the soil
plays a major role in the development and transmission
of the parasite.
It causes varying degrees of pathology:
Tissue infection to the invading larvae
Intestinal irritation to the adult
Other complications due to extraintestinal migration
Parasite Biology
This worm is so-called polymyarian type of somatic muscle
arrangement in which cells are numerous and project well into
the body cavity.
 Male adult Ascaris:
Measures 10 to 31 cm in
length
They have ventrally curved
posterior end with two
spicules
Single and long tubule
Female adult Ascaris:
Measures 22 to 35 cm in
length, with smooth
striated muscles
They have paired
reproductive organs in the
posterior two-thirds
 Infertile eggs: Fertile eggs:
Measures 88 to 94um by Measures 45 to 70um by
39 to 44um 35 to 50um
Longer and narrower than There is an outer, coarsely
fertile eggs mammilated albuminous
have a thin shell and covering
irregular mammilated Has a thick, transparent,
coating filled with hyaline shell with thick
refractile granules outer layer of supporting
structure and a delicate
(vitelline, lipoidal, inner
membrane)
 The infective stage is the fully embryonated egg.
When these eggs are ingested, the larvae hatch in the lumen
of the small intestine and penetrate to the intestinal wall. The
larvae then enters the venules to go to the liver through the
portal vein, on to the heart through the pulmonary vessels .
In the lungs, the larvae undergo molting before migrating
to the larynx and oropharynx to be swallowed in the
digestive tract.
The migration phase and molting takes about 7 to 10 days
 The prepatent period takes about 60 to 70 days.
The eggs are deposited in the soil when a person with Ascaris
infection defacates indiscriminately.
In the soil, it takes about 2 to 3 weeks to develop into
infective stage.
The larvae reach their third stage when they molt within the
egg and become embryonated.
Only when this infective egg is swallowed can humans
become infected with Ascaris.
Pathogenesis and Clinical
Manifestations
During lung migration, the larvae may cause host
sensitization resulting in allergic manifestations such as:
Lung infiltration
Asthmatic attacks
Edema of the lips
Symptoms similar to pneumonia may result due to the
penetration of lung capillaries by several larvae as they enter
through the air sacs.
Eosinophilia is present during larval migration
Pathogenesis and Clinical
Manifestations
Serious effects are due to the erratic migration of adult worms
The worms may be vomited and may escape through the nostrils
They may invade bile ducts through the ampulla of Vater and enter the
gallbladder or liver
Patients with biliary ascariasis experience severe abdominal pain
this is brought about by the movement of the worms inside the
biliary tract.
Worms may also lodge in the appendix or occlude the pancreatic
duct and cause acute appendicitis or pancreatitis, respectively.
A single Ascaris adult, during its extraintestinal migration may
obstruct the pancreatic duct and produce acute pancreatitis.
Diagnosis
Direct Fecal Smear (DFS)
Kato Thick Technique
Kato-Katz Technique

The DFS is less sensitive compared to the Kato Thick and

Kato-Katz techniques. The last two methods are useful for
both individual and mass screening in schools or in the
community.
Treatment
Single dose of any broad spectrum antihelminthics:
Albendazole (400 mg single dose [200mg for children less than
2 years old]) drug of choice
Mebendazole (500 mg)
Pyrantel pamoate (1 gm)
Epidemiology
Important factor contributing to the transmission of
ascariasis:
Poor health education on personal, family, and community
hygiene
Prevention and Control
1. Sanitary disposal of human feces
2. Health education (personal, family, and community
hygiene)
3. Mass chemotherapy done periodically, once, twice, or
thrice a year with children as the target population, thus
decreasing the number of potential source of infection.
HOOKWORMS: Necator americanus
and Ancylostoma duodenale
Parasite Biology
All hookworms have the meromyarian type of somatic
muscle arrangement (cells are few in number)

Common names:
Necator americanus New world hookworm
Ancylostoma duodenale Old world hookworm
Ancylostoma caninum Dog hookworm
Ancylostoma braziliense Cat hookworm
Necator americanus adult Ancylostoma duodenale adult
Small, cylindrical, fusiform, Slightly larger than N. americanus
grayish-white nematodes There are single-paired male and
Females (9 to 11 mm by 0.35 mm) female reproductive organs
are larger than males. The head is continuous as the
Posterior end of the male has a curvature of the body
broad, membranous caudal bursa The buccal capsule has two pairs
with rib-like rays, used for of curved ventral teeth
copulation.
The buccal capsule has a ventral
pair of semilunar cutting
plates.
The head is curved opposite to the
curvature of the body, which is like
a hook at the anterior end.
Rhaditiform larva
Rhabditiform larvae of N. americanus and A. duodenale are
indistinguishable.
They resemble those of the Strongyloides stercoralis (but the
larva of the hookworms are larger, more attenuated
posteriorly and have a longer buccal cavity).
The genital primordium is smaller in hookworms and larger
in Strongyloides stercoralis.
Filariform larva
The buccal spears of the N. americanus filariform larva are
conspicuous and parallel thoughout their lengths.
In contrast, the filariform larva of A. duodenale has
inconspicuous buccal psears and transverse striations on the
sheath in the tail region.
The filariform larva is the infective stage to humans.
Infection is penetrated through the exposed skin.
Eggs
The eggs have bluntuly rounded ends and a single thin transparent
hyaline shell.

The hookworm lifecycle is direct

It begins with the adult worms copulating while attached to the mucosa
of the small intestines
Female worms oviposit into the intestinal lumen and the eggs are passed
out with human feces
In the soil, the embryo within the egg develops rapidly and hatches after
1 to 2 days into rhabditiform larva and the larva is transformed to
non-feeding filariform larva which is now the infective stage to
humans.
 Filariform larva penetrates the skin.
Then they enter venules and migrate to the heart and lungs
then into the alveoli. The larvae ascends to the trachea and
are finally swallowed passing down to the small intestine.
After one month, the worms become sexually mature and
start laying eggs.
Pathogenesis and Clinical
Manifestation
The pathology involves:
1. The skin at the site of entry of the filariform larvae
2. The lung during the larval migration
3. The small intestine (the habitat of the adult worms)
Pathogenesis and Clinical
Manifestation
Penetration of the filariform larvae through the skin
produces maculopapular lesions and localized
erythema.
Itching is always severe and it is known as ground itch or
dew itch as I is related to contact with soil specially on
a dewy morning.
Bronchitis and pneumonitis if the larvae is migrating to the
lungs
Abdominal pain, steatorrhea, or sometimes diarrhea with
blood and mucus, and blood eosinophilia of 30% to 60% -
maturation of the worm in the intestine
Pathogenesis and Clinical
Manifestation
Hookworm infection is chronic hence the patients do not
exhibit acute symptoms
Chronic moderate or heavy hookworm infection may result
to progressive, secondary, microcytic, hypochromic anemia
of iron deficiency type (due to the loss of blood)
Hypoalbuminemia (low level of albumin due to combined
loss of blood, lymph, and protein)
Diagnosis
1. Direct Fecal Smear
2. Kato Thick or Kato-Katz technique
3. Concentration methods like Zinc Sulfate method, Formalin-
ether, and Centrifugal floatation
4. Culture methods- Harada Mori (allows hatching of larvae from
eggs on strips of filter paper with one end immersed in water)

Concentration method used for determining whether the stool

is positive or negative for eggs of hokworms
Culture method recommended for the identification of the
filariform larvae
Treatment
Albendazole (400 mg single dose) drug of choice
Mebendazole (500 mg single dose)
Epidemiology
Both species have become widely distributed throughout the
tropics and subtropics
The local distribution of human hookworm infection is greater in
agricultural areas.
Farmers are more prone to the infection (because they work in
ricefields and vegetable gardens, and they are not properly
protected from contact with infective soil).
Factors that contribute to the transmission of hookworms:
1. Suitability of the environment for eggs or larvae
2. Mode of extent of fecal pollution of the soil
3. Mode and extent of contact between infected soil and skin or
mouth
Prevention and Control
1. Sanitary disposal of human feces
2. Wearing of shoes, slippers, and boots so that skin contact
with infective larvae in contaminated soil is avoided
3. Health education on personal, family, and community
hygiene
4. Treatment of infected individuals
5. Mass chemotherapy when prevalence is greater than 50%
6. Protection of susceptible individuals by improving
household income
Strongyloides stercoralis
This group of nematode is characterized by free-living
rhabditiform and parasitic filariform stages
This is the only species naturally pathogenic to humans.
Several species have been reported in mammals and in birds.
The parasitic form of this worm uses the intestine as its
habitat.
Parasite Biology
The filariform female (2.2mm by 0.04mm) is colorless,
semi-transparent, with a finely striated cuticle.
It has a slender tapering anterior end
A short conical pointed tail
The short buccal cavity has four indistinct lips
The long slender esophagus extends to the anterior fourth of
the body
The intestine is continuous to the subterminal anus
The vulva is located one-third the length of the body from
the posterior end
The uteri contain a single file of eight thin-shelled,
transparent, segmented ova
 Free-living female
Larger than free-living
male
It has muscular double
bulbed esophagus
The intestine is a straight
cylindrical tube
Free-living male
Smaller than free-living
female
Ventrally curved tail
Two copulatory spicules
Rhabditiform larva
Measures 225um by 16um
It has elongated esophagus
with a pyriform posterior
bulb
It is slightly smaller
compared with the
hookworm
It has a short buccal capsule
and a large genital
primordium
Infective Filariform larva
Non-feeding
Slender
About 550um in length
Smaller to the hookworm
filariform larva but with a
distinct cleft at the tip of
the tail
 Eggs
Clear thin shell
Similar to those of hookworms except they measure only about
50 to 58um by 30 to 34um
 Free living forms of Strongyloides stercoralis are found in the
soil.
The female worm lays embryonated eggs which develop into
rhabditiform larvae after a few hours
These larvae feed on organic matter and transforms into
free-living adults.
When conditions in the soil become unfavorable, rhabditiform
larvae develop into filariform larvae, which are infective to
humans.
 The parasitic life cycle begins when filariform larvae infect
human through the skin.
The parasites enter the circulation, pass through the lungs,
and migrate to the larynx where they are subsequently
swallowed.
Larvae develop into adults after one month while it is in the
duodenum
Females reproduce by parthenogenesis (theyinvade the
intestinal mucosa where they deposit their eggs)
Eggs hatch into rhabditiform larvae, migrate into lumen,
and pass out in the feces.
Autoinfection
Occurs when rhabditiform larvae pass down the large
intestine and develop into filariform larvae.
Being the infective stage, these filariform larvae may invade
the mucosa and enter the circulation t start another
parasitic life cycle without leaving the body of the host.
Pathogenesis and Clinical
Manifestations
Three phases of Strongylodiasis:
1. Invasion of the skin by filariform larvae
2. Migration of the larvae to the body
3. Penetration of the intestinal mucosa by adult female worms
 First phase produces erythema of the skin and hemorrhagic
papules
Second phase lobar pneumonia with hemorrhage
Third phase adult worms may be found in the intestinal
mucosa from the pylorus to the rectum, but the greatest
numbers are found in the duodenal and upper jejunal
regions.

Heavy infection produces Cochin China diarrhea

(numerous episodes of watery and bloody stools).
Diagnosis
1. Concentration techniques
2. Beales string test
3. Duodenal aspiration
4. Small bowel biopsy
Treatment
1. Albendazole (400 mg) drug of choice
2. Thiabendazole (maximum of 3 grams per day)
Epidemiology
Strongyloides is more of a fecally-transmitted worm than a
soil-transmitted helminth because it is infective shortly after
the passage with the feces.
The factors that affect transmission include poor sanitation
and indiscriminate disposal of human feces, which contain
Strongyloides larvae.
Prevention and Control
Health education on personal, family and community hygiene
Infected individuals should be treated in order to prevent
mortality and morbidity
RHABDITIFORM Buccal Cavity Genital Primordium
Hookworm Longer Shorter and inconspiscuous
Strongyloides stercoralis Shorter Larger and prominent

FILARIFORM Esophagus Tail

Hookworm Extremely about of Pointed
the body
Strongyloides Extremely about of Notched
stercoralis the body
Trichuris trichiura
whipworm
Soil-transmitted helminth
Ascaris and Trichuris are frequently observed as occurring
together (this can be explained by the similarities in their
distribution and mode of transmission
This helminth is classified as holomyarian (based on the
arrangement of the somatic muscles in cross-section where
the cells are small, numerous, and closely packed in a narrow
zone.
Parasite Biology
The male worm measures 35 to 45 mm (slightly shorter than the
female; it has a coiled posterior with single spicule and refractile
sheath)
The female worm measures 35 to 50 mm (it has a bluntly rounded
posterior end)
The worms have an attenuated anterior three-fifths traversed by a
narrow esophagus resembling a string of beads
The robust posterior two-fifths contains the intestine and a
single set of reproductive organs
A female lays approximately 3,000 to 10,000 eggs per day.
Larvae are not usually described (because soon after the
embryonated eggs are ingested, the larvae escape and penetrate
intestinal villi where they remain for three to ten days.
Eggs
The approximate measurements of the egg are 50 to 54 by 23
um.
Eggs are lemon-shaped with plug-like transluscent
polar prominences
They have a yellowish outer and a transparent inner shell.
Fertilized eggs are unsegmented and embryonic development
takes place outside the host when eggs are deposited on
clayish soil
Compared to Ascaris eggs, Trichuris eggs in soil are more
susceptible to dessication
Adult worm
Trichuris worms inhabit the large intestine
Their whip-like portion is deeply embedded into the intestinal
wall of the cecum
After copulation, the female worm lays eggs, which are passed out
with feces and deposited in the soil
Under favorable conditions, the eggs develop and become
embryonated within 2 to 3 weeks
If swallowed, the infected embryonated eggs go to the small
intestine and undergo four larval stages to become adult
worms.
Unlike Ascaris, there is no heart-lung migration
Pathogenesis and Clinical
Manifestations
The anterior portion of the worms, which are embedded in
the mucosa, cause petechial hemorrhages (which may
predispose to amebic dysentery presumably because the
ulcers provide a suitable site for tissue invasion by Entamoeba
histolytica).
The mucosa is hyperemic and edematous
Rectal prolapse (because of enterorrhagia)
Diagnosis
Direct Fecal Smear
Kato-Thick technique
Kato-Katz technique
Acid-ether and Formalin Ether methods (Concentration
methods)
Treatment
Mebendazole (500 mg single dose) drug of choice
Albendazole (400 mg) used as an alternative drug
Epidemiology
Trichuriasis occurs in both temperate and tropical countries
but is more widely distributed in warm, moist areas of the
world
In school surveys conducted in 2001 in the Philippines,
Trichuris trichiura has been found to have higher infection
rates than Ascaris lumbricoides.
Prevention and Control
1. Mass treatment (if infection rates are greater than 50%)
2. Periodic mass may be necessary
3. Treatment of infected individuals
4. Sanitary disposal of human feces by construction of toilets
and their proper use
5. Washing of hands with soap and water before and after
meals
6. Health education on sanitation and personal hygiene
7. Thorough washing and scalding of uncooked vegetables
especially in areas where night soil is used as a fertilizer.
Enterobius vermicularis
pinworm
Enterobiassis or Oxyuriasis (characterized by perianal itching
or pruritus ani)
This intestinal nematode is classified as meromyarian based
on the arrangement of somatic muscles (two to five cells per
dorsal or ventral half).
Parasite Biology
Adult worms have cuticular alar expansions at the anterior
end and a prominent posterior esophageal bulb
The female adult worm (8 to 13mm by 0.4mm) has a long
pointed tail
The uteri of gravid females are distended with eggs
The male adult worm (2 to 5mm by 0.1 to 0.2mm) has a
curved tail and a single spicule.
 Rhabditiform larva
Measures 140 to 150um by 10um
Has a characteristic esophageal bulb
 Eggs
Assymetrical
One side flattened and other side convex
The transluscent shell consists of an outer, triple, albuminous
covering (for mechanical protection)
It has inner lipoidal membrane (for chemical protection)
Outside the host, the eggs become infective in four to six hours
The ovum develops into a tadpole-like embryo
 Adult worms
Found on the lower ileum and cecum
Gravid female worms migrate down the intestinal tract and exit
through the anus to deposit eggs on the perianal skin.
After deposition, the female dies
Eggs on the perianal region become fully embryonated within 6
hours
When ingested, eggs containing the third stage larvae hatch
in the duodenum, pass down to the small intestine to the
cecum, and develop into adults.
Eggs are resistant to disinfectants
Pathogenesis and Clinical
Manifestations
Mild catarrhal inflammation results from attachment of
worms
Mechanical irritation and secondary bacterial invasion lead
to inflammation of the deeper layer of the intestines
Intense itching leads to scratching and eventually secondary
bacterial infection.
Insomnia children infected with this parasite (due to
pruritus)
Other signs of infection: poor appetite, weight loss,
irritability, grinding of teeth, and abdominal pain.
Diagnosis
Grahams scotch adhesive tape swab (perianal
cellulose tape swab)
Treatment
Pyrantel pamoate (10mg/kg) drug of choice
Albendazole (400 mg)
Mebendazole (500 mg)
Epidemiology
It is the only intestinal nematode that cannot be controlled
through sanitary disposal of human feces (because eggs are
deposited in the perianal region instead of intestinal lumen)
The route of infection: mouth, respiratory system (by
inhalation), and through the anus
Prevention and Control
Personal cleanliness and personal hygiene
Handwashing
Fingernails should be cut short
Infected patients should sleep alone
The use of showers than bathtubs is suggested
Capillaria philippinensis
Intestinal capillariasis is characterized by abdominal pain,
chronic diarrhea, and gurgling stomach.
It was described in the Philippines in 1963 after the death of
the first human case
Parasite Biology
Tiny nematode residing in the small intestine of humans
The male spicule has an unspined sheath
The parasites are members of the Family Trichuroidea (which
characteristically have a thin filamentous anterior end and a
slightly thicker and shorter posterior end.
The esophagus has rows of secretory cells called
stichocytes and the entire esophageal structure is called
a stichosome.
The anus is subterminal and the vulva in females is located at
the junction of anterior and middle thirds.
Parasite Biology
Female worms produce characteristic egg which are peanut
shaped with striated shells and flattened bipolar plugs.
Eggs are passed in the feces and embryonate in the soil or water.
The eggs must reach the water in order to be ingested by small
species of freshwater or brackish water fish.
The eggs hatch in the small intestines of the fish and grow into the
infective larvae.
When the fish is eaten uncooked, the larvae escape from the fish
intestines and develop into adult worms in human intestine.
The first generation of female worms produces larvae to build up
the population.
Pathogenesis and Clinical
Manifestations
Abdominal pain Vomiting
Gurgling stomach Edema
(borborygmus) Severe protein-losing
Diarrhea enteropathy
Weight loss Malabsorption of fats and
Malaise sugars
Anorexia Decreased excretion of
xylose
Low electrolyte levels
(especially Potassium)
High levels of
Immunoglobulin E
Diagnosis
Based on finding the characteristic eggs in the feces by:
Direct Fecal Smear
Concentration methods
Treatment
In severe cases with electrolyte and protein loss, patients
should be given electrolyte replacement and high protein
diet
Antidiarrheal an anthelminthics:
Albendazole (400 mg) drug of choice
Mebendazole (200 mg)
Epidemiology
Intestinal capillariasis was first recorded in Northern
Luzon in the Philippines.
In the Philippines, cases have been documented from the
Northern Luzon provinces, Zambales, and Southern Leyte.
Infections are acquired by eating uncooked small
freshwater/brackish water fish.
Ilocano people enjoy eating bagsit and other fishes found
in the lagoons.
In Monkayo, CompostelaValley Province, an outbreak
describes as a mystery disease in 1998 resulted in the
death of villagers due to misdiagnosis
Prevention and Control
Infections can be prevented by:
Discouraging people in endemic areas from eating raw fish
Good sanitary practices should be followed
Educational programs should be implemented