Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil: IV. Clinical and histopathology

Developing low-cost house floors to control tungiasis in Kenya - a feasibility study

CONTEXT

Tungiasis is a neglected tropical skin disease endemic in resource-poor communities. It is caused by the penetration of the female sand flea, Tunga penetrans, into the skin causing immense pain, itching, difficulty walking, sleeping and concentrating on school or work. Infection is associated with living in a house with unsealed earthen house floors.

METHODS

This feasibility study used a community-based co-creation approach to develop and test simple, locally appropriate, and affordable flooring solutions to create a sealed, washable floor for the prevention of tungiasis. Locally used techniques were explored and compared in small slab trials. The floor with best strength and lowest cost was pilot trialed in 12 households with tungiasis cases to assess its durability and costs, feasibility of installation in existing local houses using local masons and explore community perceptions. Disease outcomes were measured to estimate potential impact.

RESULTS

It was feasible to build the capacity of a community-based organization to conduct research, develop a low-cost floor and conduct a pilot trial. The optimal low-cost floor was stabilized local subsoil with cement at a 1:9 ratio, installed as a 5 cm depth slab. A sealed floor was associated with a lower mean infection intensity among infected children than in control households (aIRR 0.53, 95%CI 0.29-0.97) when adjusted for covariates. The cost of the new floor was US$3/m2 compared to $10 for a concrete floor. Beneficiaries reported the floor made their lives much easier, enabled them to keep clean and children to do their schoolwork and eat while sitting on the floor. Challenges encountered indicate future studies would need intensive mentoring of masons to ensure the floor is properly installed and households supervised to ensure the floor is properly cured.

CONCLUSION

This study provided promising evidence that retrofitting simple cement-stabilised soil floors with locally available materials is a feasible option for tungiasis control and can be implemented through training of community-based organisations. Disease outcome data is promising and suggests that a definitive trial is warranted. Data generated will inform the design of a fully powered randomized trial combined with behaviour change communications.

TRIAL REGISTRATION

ISRCTN 62801024 (retrospective 07.07.2023).

Tungiasis: Participation of Cats and Chickens in the Dispersion and Maintenance of the Disease in an Endemic Tourist Area in Brazil

Tunga spp. are fleas commonly found in impoverished tropical regions. In Vila Juerana, a tourist community in Ilheus, Bahia, Brazil, where tungiasis is endemic, dogs are the main host of fleas during their life cycle. However, there is no information about the role of cats and chickens in tungiasis in the village. Of the 272 households investigated, 112 had domestic animals, 48 had only dogs, 28 had only cats, and nine had only chickens. Of the 27 households with cohabitation among species, 16 had cats and dogs, eight had chickens and dogs, and three had dogs, cats, and chickens. The injuries due to tungiasis were ranked according to the Fortaleza classification, considering stages I, II, and III as viable lesions. The paws/feet of 71/111 (63.9%) cats and 173/439 (39.4%) chickens were inspected. Dogs that lived with positive cats and chickens also were inspected. Among the 38% (27/7; 95% IC 26.74-49.32) positive cats, 16 cohabited houses with infected dogs but none lived with positive chickens. Of the chickens, 2.3% (4/173; 95% IC 0.07-4.5) had lesions caused by tungiasis. In each household where a cat was infected, the dog was also positive. Two chickens cohabited with an infected dog and the other two did not coexist with other species. Cohabitation with infected dogs and the absence of house confinement restrictions in Vila Juerana make cats important carriers that spread tungiasis in this community. Chickens had a low frequency of tungiasis lesions despite living in proximity to infected dogs and cats.

Prevalence and Infection Intensity of Human and Animal Tungiasis in Napak District, Karamoja, Northeastern Uganda

Tungiasis is an important but highly neglected cause of morbidity in resource-poor communities in Latin America and sub-Saharan Africa. Data upon which implementation of control measures can be based are scarce. Before piloting an integrated tungiasis control program in three parishes of Napak district, Uganda, a cross-sectional survey involving the systematic examination of humans and domestic mammals was implemented to establish the occurrence patterns of tungiasis. The study population was 5482 residents, of which 4035 (73.6%) participated in the study. The prevalence of tungiasis in humans was 62.8% (95% CI: 61.3-64.3%), with slightly more males than females affected (p = 0.01). Age-specific prevalence and intensity of human tungiasis followed an S-curve pattern, with children of 5-14 years and the elderly (≥60 years) being the most affected. Half of all lesions (50%) had been manipulated by sharp objects. The prevalence of tungiasis in animals was lower (14.2%, 95% CI: 10.9-18.0) than that of humans (p < 0.001). Animal tungiasis occurred in decreasing order of frequency in pigs (80%), dogs (24%), goats (16.3%), cats (8.1%) and sheep (4.9%). In conclusion, human tungiasis was highly prevalent but animal infections were comparatively few in the study area. Nevertheless, effective control measures should be based on One Health principles.

Clinical and epidemiological survey of tungiasis in Madagascar

BACKGROUND

Tungiasis is a dermal parasitic infection, classified as a neglected tropical disease. Madagascar is one of endemic countries which have been committed for decades to control the tungiasis as a public health issue. Despite this medical importance, little is known about the prevalence and epidemiology of the disease in this country.

METHODS

A descriptive cross-sectional survey was performed in two endemic foci of Antananarivo and Toamasina.

RESULTS

In total, 2971 suspected individuals were surveyed. Of them, 643 individuals were excluded due to absence or refusing clinical examinations. Therefore, 2328 individuals with aforementioned criteria were clinically examined, 320 cases (13.7%) were found infected by Tunga penetrans. Of these 320 infected cases, 241 individuals came from rural regions against 79 from urban areas. The sex ratio of infected cases was 1.15 with an age average of 34.7 years old. Most of them were illiterate (185/320, 57.8%) with no habit of feet washing (210/320, 65.6%). The majority (198/320, 61.9%) inhabited in the houses constructed by falafa providing a suitable breeding location for Tunga ectoparasites. Based on clinical examination, most of the patients (298/320, 93.1%) had the lesions on their toes followed by those possessed the lesions on the plantar (140/320, 43.7%). The lesion stages of IV and V were observed in 49.1% (157/320) of visited patients which were more common in rural regions (86%) than in urban areas (14%). For treatment, removing the fleas using needle (122/320, 38.1%), followed by the application of petroleum (100/320, 31.2%) were among the most traditional remedies used by our patients.

CONCLUSION

This investigation highlights a high burden of tungiasis in studied endemic foci in particular in rural regions. These results can be helpful in control management strategies against this parasitosis in Madagascar.

Current and future strategies against cutaneous parasites

Cutaneous parasites are identified by their specific cutaneous symptoms which are elicited based on the parasite's interactions with the host. Standard anti-parasitic treatments primarily focus on the use of specific drugs to disrupt the regular function of the target parasite. In cases where secondary infections are induced by the parasite itself, antibiotics may also be used in tandem with the primary treatment to deal with the infection. Whilst drug-based treatments are highly effective, the development of resistance by bacteria and parasites, is increasingly prevalent in the modern day, thus requiring the development of non-drug based anti-parasitic strategies. Cutaneous parasites vary significantly in terms of the non-systemic methods that are required to deal with them. The main factors that need to be considered are the specifically elicited cutaneous symptoms and the relative cutaneous depth in which the parasites typically reside in. Due to the various differences in their migratory nature, certain cutaneous strategies are only viable for specific parasites, which then leads to the idea of developing an all-encompassing anti-parasitic strategy that works specifically against cutaneous parasites. The main benefit of this would be the overall time saved in regards to the period that is needed for accurate diagnosis of parasite, coupled with the prescription and application of the appropriate treatment based on the diagnosis. This review will assess the currently identified cutaneous parasites, detailing their life cycles which will allow for the identification of certain areas that could be exploited for the facilitation of cutaneous anti-parasitic treatment.

Evaluating the potentials of randomised integrated control trial on tungiasis in a South-western Nigerian community

Considering the fact that new, safe and incorporable treatment alternatives to therapeutic prophylaxis for tungiasis are lacking and sometimes proving difficult, this present study evaluated the potentials of integrating control approach involving focal premise treatment using 5% emulsifiable concentrate of cypermethrin, and topical application of Piper guineense oil with personal protection. Of the 90 houses selected, their floors were classified into paved rooms & unpaved verandas, paved verandas & unpaved rooms, paved rooms & verandas, and unpaved rooms & verandas, and tested for the presence of sand fleas using the sweeping and beating as well as soil collection and extraction by tullgren funnel method before fumigation. A total of 100 individuals partitioned into four groups of 25 individuals each were assigned 3%, 5%, 10% and 15% of P. guineense oil irrespective of stages of embedded fleas. The mean of sand fleas decreased from 1.14, 0.07, 0.21, and 1.66 to 0.37, 0.02, 0.09 and 1.08 after two weeks of single spray compared to the untreated location (p <  0.001). Furthermore, the mean lesions of stage I reduced to 0 after 2 to 6 days of 3%, 5%, 10% and 15% ointment application, and stage II and III after 10 to 12 days of 10% and 15% application respectively. The difference between tungiasis stages and exposure time for P. guineense ointment was highly significant p = 0.007 and p = 0.0002. Notable reduction in severity score of acute and chronic tungiasis was observed thus indicating effectiveness of the topical ointment. Hexanolic oil extracts of P. guineense in 10% and 15% concentration would kill embedded sand flea and ameliorate the sufferings in endemic settings.

Therapeutic Potential of Tea Tree Oil for Tungiasis

Tungiasis (sand flea disease) is a neglected tropical disease caused by penetration of female sand fleas, Tunga penetrans, into a person's skin usually in their feet. The disease inflicts immense pain and suffering on millions of people, particularly children. The condition is most prevalent in Latin America, the Caribbean, and sub-Saharan Africa. Currently, there is no standard drug treatment for tungiasis. The available treatment options are fairly limited and unrealistic to use in endemic areas; as a result, in desperation, the affected people do more harm to themselves by extracting the fleas with non-sterile instruments, further exposing themselves to secondary bacterial infections and/or transmission of diseases such as hepatitis B virus, hepatitis C virus, or HIV. This highlights the urgent need for simpler, safer, and effective treatment options for tungiasis. Tea tree oil (TTO) has long been used as an antiseptic with extensive safety and efficacy data. The evidence on parasiticidal properties of TTO against ectoparasites such as head lice, mites, and fleas is also compelling. The purpose of this review is to discuss the current tungiasis treatment challenges in endemic settings and highlight the potential role of TTO in the treatment of tungiasis.

The efficacy of topical, oral and surgical interventions for the treatment of tungiasis: A systematic review of the literature

Background

Tungiasis is a neglected disease caused by Tunga penetrans that can be complicated by secondary infections and local tissue destruction. Adequate treatment is important, especially in vulnerable populations; potential treatment options proposed range from surgical extraction to the use of oral and topical medications. We aimed to perform a systematic review to assess the efficacy of topical, oral and surgical interventions for the treatment of tungiasis.

Methodology/Principal findings

The present review is registered in PROSPERO (CRD42021234741). On September 1, 2020, we searched PubMed, EMBASE, Scopus, Web of Science, Science Direct, Scielo and LILACS BVS. We included clinical trials and longitudinal observational studies that evaluated any topical, systemic or mechanical treatment for tungiasis. We used the Revised Cochrane Risk of Bias (RoB) Tool for Randomized Trials for clinical trial analysis. Qualitative and quantitative descriptive syntheses were performed. Our search strategy resulted in 3376 references. Subsequently, 2568 titles/abstracts and 114 full texts were screened. We finally included 19 articles; 9 were classified as clinical trials. Two and 3 articles presented low and some RoB, respectively, according to the tool. Only two articles tested the efficacy of oral medications (niridazole, ivermectin), with discouraging results. Six clinical trials evaluated topical products for the treatment of tungiasis; 2 evaluated dimeticone-based compounds and reported positive results in lesion reduction and cure. None reported significant adverse reactions. Surgical extraction was evaluated only in observational studies.

Conclusions/Significance

We conclude that, although surgical extraction is the most commonly used treatment, there is sufficient evidence supporting the use of occlusive agents, especially manufactured dimeticone-based products.

Tungiasis is a disease caused by Tunga penetrans that affects regions with low socioeconomic status and a lack of proper sanitation. The disease usually has a self-limiting course or can be cured by simple extraction, but complications are not uncommon. In vulnerable populations, such as indigenous communities, children and people with disseminated tungiasis, the development of new treatment strategies is essential for the prevention of undesirable secondary outcomes. We performed a comprehensive systematic review of the literature by searching the most important scientific databases: PubMed, EMBASE, Scopus, Web of Science, Science Direct, Scielo and LILACS BVS. We aimed to assess the efficacy of topical, oral and surgical interventions for the treatment of tungiasis. We included 19 articles, 9 of which were classified as clinical trials. Six clinical trials evaluated topical products for the treatment of tungiasis; 2 evaluated dimeticone-based compounds and reported positive results in lesion reduction and cure. None reported significant adverse reactions. We concluded that, although mechanical extraction is the most commonly used treatment, there is sufficient evidence supporting the use of occlusive agents, especially manufactured dimeticone-based products.

Treatment of tungiasis using a tea tree oil-based gel formulation: protocol for a randomised controlled proof-of-principle trial

INTRODUCTION

Tungiasis (sand flea disease or jigger infestation) is a neglected tropical disease caused by penetration of female sand fleas, Tunga penetrans, in the skin. The disease inflicts immense pain and suffering on millions of people, particularly children, in Latin America, the Caribbean and sub-Saharan Africa. Currently, there is no standard treatment for tungiasis, and a simple, safe and effective tungiasis treatment option is required. Tea tree oil (TTO) has long been used as a parasiticidal agent against ectoparasites such as headlice, mites and fleas with proven safety and efficacy data. However, current data are insufficient to warrant a recommendation for its use in tungiasis. This trial aims to generate these data by comparing the safety and efficacy of a 5% (v/w) TTO proprietary gel formulation with 0.05% (w/v) potassium permanganate (KMnO₄) solution for tungiasis treatment.

METHODS AND ANALYSIS

This trial is a randomised controlled trial (RCT) in primary schools (n=8) in South-Western Kenya. The study will include school children (n=88) aged 6-15 years with a confirmed diagnosis of tungiasis. The participants will be randomised in a 1:1 ratio to receive a 3-day two times a day treatment of either 5% TTO gel or 0.05% KMnO₄ solution. Two viable embedded sandflea lesions per participant will be targeted and the viability of these lesions will be followed throughout the study using a digital handheld microscope. The primary outcome is the proportion of observed viable embedded sand fleas that have lost viability (non-viable lesions) by day 10 (9 days after first treatment). Secondary outcomes include improvement in acute tungiasis morbidities assessed using a validated severity score for tungiasis, safety assessed through adverse events and product acceptability assessed by interviewing the participants to rate the treatment in terms of effectiveness, side effects, convenience, suitability and overall satisfaction.

ETHICS AND DISSEMINATION

The trial protocol has been reviewed and approved by the University of Canberra Human Research Ethics Committee (HREC-2019-2114). The findings of the study will be presented at scientific conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBERS

Australian New Zealand Clinical Trials Registry (ACTRN12619001610123); PACTR202003651095100 and U1111-1243-2294.

Clinical interventions for tungiasis (sand flea disease): a systematic review

Tungiasis (sand flea disease) is an epidermal parasitic skin disease occurring in resource-limited communities. There is no standard treatment for tungiasis, and available treatment options are scarce. To our knowledge, this is the first systematic review aimed to assess randomised controlled trials (RCTs) investigating interventions for tungiasis. We systematically searched databases including MEDLINE (EBSCOhost), CENTRAL, CINAHL, PubMed, Web of Science, SciELO, LILACS and Embase (Scopus) for RCTs in any language, from inception of the databases until June 12, 2021. RCTs exploring preventive and therapeutic interventions for tungiasis were eligible. We used the revised Cochrane Collaboration's risk of bias tool to assess the risk of bias and Jadad scale to quantify the methodological quality of the RCTs. Of the 1839 identified records, only eight RCTs involving 808 participants were included, and several methodological deficiencies were identified in most of the trials. Trial interventions included: oral drugs niridazole and ivermectin and topical interventions of ivermectin lotion, metrifonate lotion, thiabendazole lotion, thiabendazole ointment, dimeticones (NYDA), and a neem seed and coconut oils-based mixture for treatment and coconut oil-based lotion (Zanzarin) for prevention. The coconut oil-based lotion for prevention and dimeticones for treatment of tungiasis have displayed the most promise. Most of the RCTs included in this study had low methodological quality. There is a clear unmet need for high-quality RCTs examining safe and effective prevention and treatment alternatives of tungiasis in endemic settings.

Clinical implications and treatment options of tungiasis in domestic animals

Tunga penetrans, Tunga trimamillata and Tunga hexalobulata are the three species of sand fleas which cause tungiasis in domestic animals. Tunga penetrans and T. trimamillata are zoonotic in the tropical and sub-tropical endemic communities of Latin America and Africa. Tungiasis in animals frequently occurs alongside human tungiasis. Currently, most of the attention given to tungiasis is focusing on the human disease, and animal tungiasis is extremely neglected despite its public health and animal health significance. This review highlights recent findings concerning the clinical implications and treatment options but also summarises the occurrence, major features, public health and economic significance of tungiasis in domestic animals. Pigs, dogs, cats and domestic ruminants have been reported to harbour high intensities of sand fleas in endemic communities. High infection intensities cause significant animal morbidity which is often exacerbated by excoriations and secondary bacterial infections which are potentially fatal. In addition to the potential economic losses accruing from tungiasis-related morbidity, infected domestic animals contribute to transmission and persistence of sand fleas and eventually also to severe human disease. Although control of animal tungiasis is possible by adoption of proper husbandry practices, affected communities may not afford the resources required to implement them. Also, there are no widely acceptable and affordable insecticides for treatment of tungiasis in animals. Extension services aiming at increasing awareness on tungiasis and its control should be intensified. Also, available commercial insecticides should be evaluated for therapeutic and prophylactic properties against animal tungiasis.

Clinical and pathological aspects of first report of Tunga penetrans infestation on southern brown howler monkey (Alouatta guariba clamitans) in Rio Grande do Sul, Brazil

BACKGROUND

Tungiasis is a neglected neotropical disease caused by penetration of Tunga spp. into the skin of the host.

METHODS

Two primates were rescued from nearby different indigenous villages, and the clinical, pathological, and parasitological features of tungiasis were described. Flea identification occurred through their morphometry and was confirmed with the use of a dichotomous key.

RESULTS

Monkey 1 was parasitized by 23 sand fleas and, after treatment, was assigned to the animal rehabilitation center. Monkey 2 was in poor body condition and died shortly after clinical examination. At necropsy, this primate was parasitized by 26 specimens of sand fleas.

CONCLUSIONS

Both animals altered their tree behavior by staying on the ground for long periods. This parasitic relationship implies the possibility of enlargement of the sand flea dispersion. Thus, this is the first record of Tunga penetrans occurrence in wild Alouatta guariba clamitans.

Epidemiology of tungiasis in sub-saharan Africa: a systematic review and meta-analysis

Tungiasis is a public health disease in many rural and urban slums in sub-Saharan Africa (SSA), primarily affecting children and the elderly. Yet, this disease has received little attention in many sub-Saharan African countries. We conducted a systematic review and meta-analysis to estimate the pooled prevalence of tungiasis and associated risk factors in SSA. We searched AJOL, Google Scholar, Web of Science, and PubMed for population-based studies that reported the prevalence of tungiasis and risk factors in SSA between January 1980 and July 2020. The study employed a random-effects model and heterogeneity to estimate the pooled prevalence and evaluate the Cochran's Q-test respectively across studies that met the inclusion criteria. We screened 104 articles and retrieved 42 full-text articles to evaluate for inclusion in the review. Twenty-seven studies involving 16,303 individuals in seven SSA countries were analyzed. The pooled prevalence of tungiasis in SSA was 33.4% (95% CI: 27.6-39.8), while tungiasis prevalence was 46.5%, 44.9%, 42.0%, 37.2%, 28.1%, 22.7% and 20.1% for Ethiopia, Cameroon, Tanzania, Kenya, Nigeria, Rwanda, and Uganda, respectively. The risk of tungiasis was associated with gender, participants' age groups (4-15 years and ≥60 years), earthen floor, non-regular use of footwear, contact with animals, and residence in rural areas. An integrated approach addressing significant factors in tungiasis prevalence in SSA needs to be designed and implemented by a trans-disciplinary composition of community leaders, health professionals, non-governmental institutions, and policymakers.

Assessing the potentials of two local topical ointments as affordable treatment against tungiasis infestation: A self-experimentation in Igbokoda, Nigeria

Infestations caused by penetration of Tunga penetrans (Siphonaptera: Hectopsyllidae) in cutaneous sub-layers present morbidities and resulting mortalities if surgical treatment remains the obtainable. Considering the neglected nature of this infestation and the absence of marketable product, we report an observation on the use of grounded naphthalene in kerosene ointment, and powder of Piper guineense in coconut oil ointment as affordable treatment of embedded tungiasis flea in Igbokoda. A total of 80 individuals partitioned into two groups of 40 individuals each were assigned the locally made topical ointment irrespective of stages of tungiasis lesions. The mean of stage I, II and III tungiasis lesions treated with grounded naphthalene in kerosene ointment respectively decreased from 1.83, 3.42 and 3.89 to 0 after 5–6 days (p < .05). Also, the mean of stage I, II and III tungiasis lesions treated with grounded P. guineense ointment respectively decreased from 1.52, 3.10 and 5.00 to 0 after 6 to 7 days of treatment exposure (p < .05). Very high significant difference between stages and exposure days of participants assigned the two topical ointment was recorded p < .0001 and p = .0005 respectively. Naphthalene ointment and to a lesser extent P. guineense ointment is best to control and hinder development cycle of embedded fleas irrespective of infested part and stage of infection.

Prevalence, intensity and risk factors of tungiasis in Kilifi County, Kenya II: Results from a school-based observational study

Introduction

Awareness of the public health importance of tungiasis has been growing in East Africa in recent years, but data on epidemiological characteristics necessary for the planning and implementation of control measures do not exist. The work presented here was part of a larger cross-sectional study on the epidemiology of tungiasis in coastal Kenya and aims at identifying risk factors of tungiasis and severe disease in school children.

Methods

A total of 1,829 students of all age groups from five schools and 56 classes were clinically examined for tungiasis on their feet based on standardized procedures and observations made about the school infrastructure. To investigate the impact of school holidays, observations were repeated after school holidays in a subset of children in one school. In an embedded case-control study, structured interviews were conducted with 707 students in the five schools to investigate associations between tungiasis and household infrastructure, behaviour and socio-economic status.

Results

The overall prevalence of tungiasis was 48%; children below the age of 15 years were the most affected, and boys were twice as likely as girls to be infected. The highest risk of disease was associated with the socio-economic circumstances of the individual student at home. The study indicated that mild to moderate tungiasis could be reduced by a third, and severe tungiasis by over half, if sleeping places of children had hardened floors, whilst approximately a seventh of the cases could be prevented by sealing classroom floors in schools, and another fifth by using soap for daily feet washing.

Conclusion

There is a clear role for public health workers to expand the WASH policy to include washing of feet with soap in school-aged children to fight tungiasis and to raise awareness of the importance of sealed floors.

Tungiasis is a neglected tropical skin disease caused by penetrated sand fleas, the adult female of which burrows into the skin of the feet. The parasite rapidly expands its body size by a factor of 2000. The growth causes immense itching, inflammation, pain and debilitation. The current lack of good treatment methods means people attempt to remove the fleas themselves with non-sterile instruments causing more damage. Control efforts focus on prevention but there is little data to guide this in East Africa. The current study reinforces our previously published results on the household level from the same communities, indicating that prevention needs to focus on hardening the floors of resource-poor families and integrating daily foot washing with soap into water, hygiene and sanitation programs.

Tungiasis-related life quality impairment in children living in rural Kenya

BACKGROUND

Tungiasis (sand flea disease) is a neglected tropical skin disease caused by female sand fleas (Tunga spp.) embedded in the skin of the host. The disease is common in sub-Saharan Africa and predominantly affects children living in impoverished rural communities. In these settings tungiasis is associated with important morbidity. Whether tungiasis impairs life quality has never been studied.

METHODS

The study was performed in 50 children with tungiasis, living in resource-poor communities in coastal Kenya. Based on the Dermatology Life Quality Index (DLQI) a tool was developed to determine life quality impairment associated with tungiasis in children, the tungiasis-related Dermatology of Life Quality Index (tungiasis-related-DLQI). Pain and itching were assessed using visual scales ranging from 0-3 points. The intensity of infection and the acute and chronic severity of tungiasis were determined using standard methods.

RESULTS

Seventy eight percent of the patients reported a moderate to very large effect of tungiasis on life quality at the time of the diagnosis. The degree of impairment correlated with the number of viable sand fleas present in the skin (rho = 0.64, p < 0.001), the severity score of acute clinical pathology (rho = 0.74, p < 0.001), and the intensity of pain (rho = 0.82, p < 0.001). Disturbance of sleep and concentration difficulties were the most frequent restriction categories (86% and 84%, respectively). Four weeks after curative treatment, life quality had improved significantly. On the individual level the amelioration of life quality correlated closely with the regression of clinical pathology (rho = 0.61, p < 0.001).

CONCLUSION

The parasitic skin disease tungiasis considerably impairs life quality in children in rural Kenya. After effective treatment, life quality improves rapidly.

Animal and human tungiasis-related knowledge and treatment practices among animal keeping households in Bugiri District, South-Eastern Uganda

BACKGROUND

Zoonotic tungiasis caused by Tunga penetrans remains a serious public and animal health problem among endemic villages in Uganda and many sub Saharan African countries. Studies on human and animal tungiasis-related knowledge and treatment practices in endemic communities have never been undertaken, a limitation to development of sustainable control measures.

METHODS

A cross sectional study using semi-structured questionnaires (Supplementary file S1) was conducted among 236 animal rearing households in 10 endemic villages in Bugiri District, South-Eastern Uganda. Focus group discussions and observation checklists were used to validate and clarify the findings.

RESULTS

Most respondents knew the aetiology (89.4%), clinical signs (98%) and the ecology of T. penetrans as well as the major risk factors of human tungiasis (65.2%). In contrast, very few respondents were aware of animal tungiasis. Only 4.8% of those with infected animals on the compound knew that some of their animals were infected and 13.6% of the respondents had ever seen tungiasis-affected animals. Pigs (13.1%, n=31) and dogs (0.85%, n=2) were the only T. penetrans animal hosts known to animal owners. Affected humans were treated by extraction of embedded sand fleas using non-sterile sharp instruments in all households that reported occurrence of human tungiasis at least once (n=227). Also, affected animals were mainly treated by mechanical removal of embedded sand fleas in households that have ever experienced animal tungiasis (four out of 12; 33.3%). In a few instances, plant and animal pesticides (n=3) and other chemicals such as grease, paraffin and wood preservative (n=3) were also used to treat animal tungiasis.

CONCLUSION

The study revealed a high level of knowledge on human tungiasis but inadequate knowledge on the zoonotic nature of tungiasis. Commonly applied methods for treatment of human and animal tungiasis are a health hazard by themselves. Concerted i.e. One Health-based efforts aiming at promoting appropriate treatment of tungiasis, adequate living conditions and increased awareness on tungiasis in the communities are indicated in order to eliminate tungiasis-associated disease.

Prevalence, intensity and risk factors of tungiasis in Kilifi County, Kenya: I. Results from a community-based study

BACKGROUND

Tungiasis is a neglected tropical disease caused by female sand fleas (Tunga penetrans) embedded in the skin. The disease is associated with important morbidity. Tungiasis is endemic along the Coast of Kenya with a prevalence ranging from 11% to 50% in school-age children. Hitherto, studies on epidemiological characteristics of tungiasis in Africa are scanty.

METHODS

In a cross-sectional study 1,086 individuals from 233 households in eight villages located in Kakuyuni and Malanga Sub-locations, Kilifi County, on the Kenyan Coast, were investigated. Study participants were examined systematically and the presence and severity of tungiasis were determined using standard methods. Demographic, socio-economic, environmental and behavioral risk factors of tungiasis were assessed using a structured questionnaire. Data were analyzed using bivariate and multivariate regression analysis.

RESULTS

The overall prevalence of tungiasis was 25.0% (95% CI 22.4-27.5%). Age-specific prevalence followed an S-shaped curve, peaking in the under-15 year old group. In 42.5% of the households at least one individual had tungiasis. 15.1% of patients were severely infected (≥ 30 lesions). In the bivariate analysis no specific animal species was identified as a risk factor for tungiasis. Multivariate analysis showed that the occurrence of tungiasis was related to living in a house with poor construction characteristics, such as mud walls (OR 3.35; 95% CI 1.71-6.58), sleeping directly on the floor (OR 1.68; 95% CI 1.03-2.74), the number of people per sleeping room (OR = 1.77; 95% CI 1.07-2.93) and washing the body without soap (OR = 7.36; 95% CI 3.08-17.62). The odds of having severe tungiasis were high in males (OR 2.29; 95% CI 1.18-44.6) and were very high when only mud puddles were available as a water source and lack of water permitted washing only once a day (OR 25.48 (95% CI 3.50-185.67) and OR 2.23 (95% CI 1.11-4.51), respectively).

CONCLUSIONS

The results of this study show that in rural Kenya characteristics of poverty determine the occurrence and the severity of tungiasis. Intra-domiciliary transmission seems to occur regularly.

Secondary bacterial infections and antibiotic resistance among tungiasis patients in Western, Kenya

Tungiasis or jigger infestation is a parasitic disease caused by the female sand flea Tunga penetrans. Secondary infection of the lesions caused by this flea is common in endemic communities. This study sought to shed light on the bacterial pathogens causing secondary infections in tungiasis lesions and their susceptibility profiles to commonly prescribed antibiotics. Participants were recruited with the help of Community Health Workers. Swabs were taken from lesions which showed signs of secondary infection. Identification of suspected bacteria colonies was done by colony morphology, Gram staining, and biochemical tests. The Kirby Bauer disc diffusion test was used to determine the drug susceptibility profiles. Out of 37 participants, from whom swabs were collected, specimen were positive in 29 and 8 had no growth. From these, 10 different strains of bacteria were isolated. Two were Gram positive bacteria and they were, Staphylococcus epidermidis (38.3%) and Staphylococcus aureus (21.3%). Eight were Gram negative namely Enterobacter cloacae (8.5%), Proteus species (8.5%), Klebsiellla species (6.4%), Aeromonas sobria (4.3%), Citrobacter species (4.3%), Proteus mirabillis(4.3%), Enterobacter amnigenus (2.1%) and Klebsiella pneumoniae (2.1%). The methicillin resistant S. aureus (MRSA) isolated were also resistant to clindamycin, kanamycin, erythromycin, nalidixic acid, trimethorprim sulfamethoxazole and tetracycline. All the Gram negative and Gram positive bacteria isolates were sensitive to gentamicin and norfloxacin drugs. Results from this study confirms the presence of resistant bacteria in tungiasis lesions hence highlighting the significance of secondary infection of the lesions in endemic communties. This therefore suggests that antimicrobial susceptibility testing may be considered to guide in identification of appropriate antibiotics and treatment therapy among tungiasis patients.

Successful Treatment of Severe Tungiasis in Pigs Using a Topical Aerosol Containing Chlorfenvinphos, Dichlorphos and Gentian Violet

Background

In endemic communities, zoonotic tungiasis, a severe skin disease caused by penetrating female sand fleas, is a public health hazard causing significant human and animal morbidity. No validated drugs are currently available for treatment of animal tungiasis. Due to the reservoir in domestic animals, integrated management of human and animal tungiasis is required to avert its negative effects.

Methods and principal findings

A topical aerosol containing chlorfenvinphos 4.8%, dichlorphos 0.75% and gentian violet 0.145% licensed to treat tick infestations, myiasis and wound sepsis in animals in the study area, was tested for its potential tungicidal effects in a randomized controlled field trial against pig tungiasis in rural Uganda. Animals with at least one embedded flea were randomized in a treatment (n = 29) and a control (n = 26) group. One week after treatment, 58.6% of the treated pigs did not show any viable flea lesion whereas all control pigs had at least one viable lesion. After treatment the number of viable lesions (treated median = 0, overall range = 0–18 vs. control median = 11.5, range = 1–180) and the severity score for estimating acute pathology in pig tungiasis (treated median = 1, range = 0–3.5 vs. control median = 7, range = 0–25) were significantly lower in treated than in control pigs (p < 0.001). In the treatment group the median number of viable flea lesions decreased from 8.5 to 0 (p < 0.001). Similarly, the median acute severity score dropped from 6 to 1 (p < 0.001). Every pig in the treatment group showed a decrease in the number of viable fleas and tungiasis-associated acute morbidity while medians for both increased in the control group.

Conclusions

The study demonstrates that a topical treatment based on chlorfenvinphos, dichlorphos and gentian violet is highly effective against pig tungiasis. Due to its simplicity, the new approach can be used for the treatment of individual animals as well as in mass campaigns.

Infection with the sand flea Tunga penetrans causes severe disease in humans and animals. There are no validated drugs for treatment of animal tungiasis preventing implementation of integrated tungiasis control interventions targeting human and animal infections. A field trial was conducted to evaluate the effects of a commercial insecticidal aerosol containing chlorfenvinphos 4.8%, dichlorphos 0.75%, and gentian violet 0.145%, which is licensed to treat tick infestations, myiasis and wound sepsis, on tungiasis in pigs, the major animal reservoir in rural hyperendemic villages in Uganda. Infected pigs were recruited and randomly assigned to treatment (n = 29) and control (n = 26) groups. Seven days after a single application of the aerosol onto the affected body parts, almost 60% of the treated pigs were cured while all control pigs had at least one penetrated sand flea. The number of viable sand fleas and the severity of the tungiasis were significantly lower in the treated pigs than in the controls. This demonstrates for the first time that a simple and effective topical treatment for animal tungiasis based on two organophosphate insecticides and an antibacterial agent can be used to cure individual animals and can be integrated in tungiasis control campaigns.

Prevalence and risk factors associated with tungiasis in Mayuge district, Eastern Uganda

Introduction

Tungiasis is an endemic but neglected health problem in Uganda especially in resource poor communities. It is largely affecting rural communities in the Eastern, West Nile and Central regions. This study assessed prevalence and risk factors associated with tungiasis in Mayuge district, Eastern Uganda.

Methods

This was a cross sectional study that used a semi-structured questionnaire and observational checklist to collect quantitative data from 422 households in 12 villages. Prevalence of tungiasis was defined as presence of Tunga penetrans in the skin of any household member at the time of data collection.

Results

The prevalence of tungiasis was 22.5%. However, a big percentage 41.5% of households were reported to have had T. penetrans in the previous month while 49.5% had T. penetrans for more than one month. Majority (90.5%)of the participants used a pin, needle, or thorn to remove sand flea from infected body parts. Having dirty feet (AOR 3.86, CI (1.76-8.34)), dirty clothes (AOR 3.46, CI (2.00-5.97)), cracked house floor (AOR =6.28, CI (3.28-12.03)), dirty floor (AOR 3.21, CI (1.38-7.46)), littered compounds (AOR= 2.95, CI (1.66-5.26)) and rearing cattle (AOR 2.38, CI (1.28-4.45)) were associated with tungiasis. However, practicing preventive measures (AOR 0.51, CI (0.29-0.90)) was found protective for disease.

Conclusion

Tungiasis is still a prevalent health problem in rural communities in Eastern Uganda due to a number of individual (host) and environmental factors. There is need to increase awareness regarding improvement in sanitation and hygiene to enable communities’ implements interventions for prevention of T. penetrans.

Two Severe Cases of Tungiasis in Goat Kids in Uganda

Tungiasis ensues from the penetration and burrowing of female sand fleas (Tunga spp.; Siphonaptera: Tungidae) in the skin of mammals. There are few case reports of severe tungiasis in goats and in these cases the Tunga species were not in most cases clearly identified. Two cases of severe tungiasis caused by Tunga penetrans in goat kids from tungiasis-endemic rural Uganda are reported. These are the first severe cases of tungiasis in goats reported from outside South America.

Tungiasis-associated morbidity in pigs and dogs in endemic villages of Uganda

BACKGROUND

Tunga penetrans (Insecta, Siphonaptera, Tungidae) causes severe morbidity among heavily infected humans and animals in Latin America and sub-Saharan Africa. The clinical pathology of tungiasis in animals has never been studied systematically.

METHODS

This was a cross-sectional study conducted between January to March 2015, aimed at describing tungiasis-associated clinical pathology in 121 and 20 T. penetrans-infected pigs and dogs, living in nine and five endemic rural villages respectively located in Bugiri District, Busoga, Uganda.

RESULTS

The parasite load of infected animals ranged from one to 246 (median 8) and one to eight (median 2) in pigs and dogs, respectively. In pigs 99.3% and in dogs 100% of the lesions were located on feet. In pigs, hind legs were significantly more affected than front legs (90.9% vs. 57.9%; p = 0.002) and also had more lesions than the front legs (median 5 vs. 1; p = 0.0001). However, in dogs localization of lesions between front and hind legs never differed significantly (front, 50% vs. hind, 65%; p = 0.51) and so were the number of lesions (median front = 0.5 vs. median hind = 2; p = 0.7). Acute and chronic clinical pathology coexisted. The most common disease manifestations in pigs were hoof wall erosions (68.6%), tissue necrosis of hoof wall and skin (66.1), pain at infection sites (47.9%), hoof deformity (45.5%), fissures (44.6%) and edema (44.6%). In dogs, tungiasis mainly presented with pain at attachment site (80%), ulcers (55%), necrosis (30%) as well as hyperemia and edema (both 15%). One pig had lost dew claws while two had loose detaching claws. Despite a lower number of sand fleas, a higher proportion of infected dogs (20%) than pigs (5.8%) exhibited functional limb use difficulties (p = 0.05).

CONCLUSIONS

The pattern of clinical manifestations in pigs and dogs were very similar to those reported from affected humans and rats. The important morbidity associated with animal tungiasis makes the disease a serious veterinary health problem in sub-Saharan Africa warranting treatment and control for optimal animal production.

Characterization of Tunga penetrans antigens in selected epidemic areas in Murang'a county in Kenya

Tunga penetrans are fleas that cause tungiasis, a condition characterized by high transmission rate due to poor housing conditions, social neglect and inadequate health care in economically disadvantaged communities in developing countries. This study therefore aimed at characterizing jiggers antigens to identify immunodominant ones to help understand immunological behavior of the parasite that would otherwise be important in future control of the parasite. Samples were gravid fleas and blood samples from infested individuals in Kahuro and Murang'a East district in Murang'a County. Freeze and thaw was used to extract soluble proteins from the fleas. Ouchterlony Double immunodiffusion was used to assess antigen-antibody reactions between extracted soluble protein and the serum from immunized rats, Rattus norvegicus prior to analysis of human sera. These results were comparable to results of immunoelectrphoresis. Jigger protein isolates were analyzed in Sodium Dodecyl Sulfate Polyacrylamide Gel Electrophoresis technique (SDS-PAGE), against Pharmacia standard protein markers. Further analysis of jigger antigens against pooled human sera from infested victims in Western blot revealed three immunodominant antigens. Using simple regression analysis molecular weights of the three immunodominant antigens were estimated as 51.795, 23.395 and 15.38 kDa respectively. These results are important since they would help understand immunological behavior of the parasites. This would help to create basis for designing and improving approaches against jiggers such as development of immune prophylaxis to complement social science approaches that is mainly concerned with maintenance of high standards of hygiene.

Neosomes of tungid fleas on wild and domestic animals

Tunga is the most specialized genus among the Siphonaptera because adult females penetrate into the skin of their hosts and, after mating and fertilization, undergo hypertrophy, forming an enlarged structure known as the neosome. In humans and other warm-blooded animals, neosomes cause tungiasis, which arises due to the action of opportunistic agents. Although its effects on humans and domestic animals are well described in the literature, little is known about the impact of tungiasis on wild animals. This review focuses on the morphology, taxonomy, geographical distribution, hosts, prevalence, sites of attachment, and impact of tungid neosomes on wild and domestic animals. Because neosomes are the most characteristic form of the genus Tunga and also the form most frequently found in hosts, they are here differentiated and illustrated to aid in the identification of the 13 currently known species. Perspectives for future studies regarding the possibility of discovering other sand flea species, adaptation to new hosts, and the transfer of tungids between hosts in natural and modified habitats are also presented.

Treatment of Tungiasis with dimeticone: a proof-of-principle study in rural Kenya

Tungiasis (sand flea disease) is a neglected tropical disease, prevalent in resource-poor communities in South America and sub-Saharan Africa. It is caused by an inflammatory response against penetrated female sand fleas (Tunga penetrans) embedded in the skin of the host. Although associated with debilitating acute and chronic morbidity, there is no proven effective drug treatment. By consequence patients attempt to remove embedded sand fleas with non-sterile sharp instruments, such as safety pins, a procedure that represents a health threat by itself. In this proof-of-principle study we compared the topical application of a mixture of two dimeticones of low viscosity (NYDA) to the topical application of a 0.05% solution of KMnO4 in 47 school children in an endemic area in rural Kenya. The efficacy of the treatment was assessed during a follow up period of seven days using viability signs of the embedded parasites, alterations in the natural development of lesion morphology and the degree of local inflammation as outcome measures. Seven days after treatment, in the dimeticone group 78% (95% CI 67–86%) of the parasites had lost all signs of viability as compared to 39% (95% CI 28–52%) in the KMnO4 group (p<0.001). In the dimeticone group 90% (95% CI 80–95%) of the penetrated sand fleas showed an abnormal development already after 5 days, compared to 53% (95% CI 40–66%; p<0.001) in the KMnO4 group. Seven days after treatment, signs of local skin inflammation had significantly decreased in the dimeticone group (p<0.001). This study identified the topical application of dimeticones of low viscosity (NYDA) as an effective means to kill embedded sand fleas. In view of the efficacy and safety of the topical treatment with dimeticone, the mechanical extraction of embedded sand fleas using hazardous instruments is no longer warranted.

Tungiasis (sand flea disease), a parasitic skin disease, causes important morbidity, and eventually leads to mutilation of the feet. Hitherto, the only effective treatment is the surgical extraction of embedded sand fleas. In the endemic areas this is done using inappropriate sharp instruments and causes more harm than good. We identified the three last abdominal segments of Tunga penetrans which protrude through the skin and through which the parasite breathes, defecates, and expels eggs - as an Achilles heel of embedded sand fleas. In a proof-of-principle study we investigated whether this Achilles heel is vulnerable to dimeticone with a low viscosity and a high creeping property. We randomized the left and the right feet to either receive a topical application of KMnO4 (the standard treatment in Kenya) or of dimeticone. The major outcome measure was the absence of viability signs of the treated sand fleas. The study shows that the topical application of a mixture of two dimeticones (NYDA) effectively kills embedded sand fleas within seven days. Since dimeticones are considered to be wholly non-toxic and are not expensive the new treatment could become a means to control tungiasis-associated morbidity on the population level.

Revision on tungiasis: treatment options and prevention

The parasitic skin disease tungiasis occurs in many resource-poor communities in Latin America, the Caribbean and sub-Saharan Africa. The sand flea, Tunga penetrans, most commonly penetrates into the skin of the feet. Many individuals harbor a large number of embedded parasites and show significant morbidity. Standard treatment consists of surgical extraction of the flea and application of a topical antibiotic. There are no drugs available with proven effectiveness. Clinical trials performed in the last few years did not show very promising results. Thus, surgical extraction still remains the treatment of choice in patients with a low parasite load, such as tourists returning from endemic areas. Probably the best approach to reduce tungiasis-associated morbidity in heavily affected individuals is the application of a repellent to prevent the penetration of sand fleas. In the future, we should see new exciting data on the biology, epidemiology, therapy and control of tungiasis.

Prevention of tungiasis and tungiasis-associated morbidity using the plant-based repellent Zanzarin: a randomized, controlled field study in rural Madagascar

Background

Tungiasis, a parasitic skin disease caused by the female sand flea Tunga penetrans, is a prevalent condition in impoverished communities in the tropics. In this setting, the ectoparasitosis is associated with important morbidity. It causes disfigurement and mutilation of the feet. Feasible and effective treatment is not available. So far prevention is the only means to control tungiasis-associated morbidity.

Methodology

In two villages in Central Madagascar, we assessed the efficacy of the availability of closed shoes and the twice-daily application of a plant-based repellent active against sand fleas (Zanzarin) in comparison to a control group without intervention. The study population was randomized into three groups: shoe group, repellent group and control group and monitored for ten weeks. The intensity of infestation, the attack rate and the severity of tungiasis-associated morbidity were assessed every two weeks.

Findings

In the repellent group, the median attack rate became zero already after two weeks. The intensity of the infestation decreased constantly during the observation period and tungiasis-associated morbidity was lowered to an insignificant level. In the shoe group, only a marginal decrease in the intensity of infestation and in the attack rate was observed. At week 10, the intensity of infestation, the attack rate and the severity score for acute tungiasis remained significantly higher in the shoe group than in the repellent group. Per protocol analysis showed that the protective effect of shoes was closely related to the regularity with which shoes were worn.

Conclusions

Although shoes were requested by the villagers and wearing shoes was encouraged by the investigators at the beginning of the study, the availability of shoes only marginally influenced the attack rate of female sand fleas. The twice-daily application of a plant-based repellent active against sand fleas reduced the attack to zero and lowered tungiasis-associated morbidity to an insignificant level.

Tungiasis (sand flea disease) is a parasitic skin disease present in many resource-poor communities in South America, the Caribbean and sub-Saharan Africa. In this setting tungiasis is associated with important morbidity. Hitherto, the only effective treatment is the surgical extraction of embedded sand fleas. In the endemic areas this is done using inappropriate sharp instruments and causes more harm than good. The prevention of the infestation is the only option to control morbidity. In this study we show that the twice daily application of a herbal repellent based on coconut-oil (Zanzarin), is highly effective in preventing sand flea disease in a heavily affected community in Madagascar. The attack rate became zero immediately after starting the application of the repellent. The degree of tungiasis associated morbidity approached zero within 10 weeks. In contrast, the availability of closed solid shoes had only a marginal protective effect; although shoes were requested by the villagers and wearing shoes was encouraged by the investigators at the beginning of the study. In a control group from the same village the attack rate, the intensity of infestation and of tungiasis-associated morbidity remained unchanged. Our study in rural Madagascar shows that effective und sustainable morbidity control is possible using a repellent derived from coconut oil.

Histopathological features of tungiasis in Peru

Tungiasis is an ectoparasitic skin disease caused by Tunga penetrans and Tunga trimamillata. There is a lack of histopathological studies that evaluate the recognition of this flea in tissues. We describe the ex vivo dermoscopic and the histopathological patterns of six cases and relate the findings to the developmental stage of the parasite as defined by the Fortaleza classification: two were classified as Fortaleza 3b, 3 as 4a, and 1 as 4b. Two dermoscopic patterns were observed: a brown pigmented ring and a radial crown with a central pore. The most common histopathological findings were an eosinophilic cuticle, eggs in different stages of development, tracheal rings (parasite), and basal hyperplasia (host). The eosinophilic cuticle, eggs in different stages of evolution, and tracheal rings can help to establish the diagnosis when other parts of the parasite are lacking. The Fortaleza staging may represent a tool for pathology reporting purposes.

Outbreak of tungiasis following a trip to Ethiopia

Tungiasis is a skin disease caused by the ectoparasite sand flea Tunga penetrans. Although tungiasis is an important health problem in endemic areas, mainly South America and sub-Saharan Africa, it is reported uncommonly in travelers. We describe an outbreak of tungiasis in a group of travelers to Ethiopia. Following the diagnosis of tungiasis in a member of a group of 17 Israeli travelers to Ethiopia, other affected members were identified by photograph assisted self diagnosis. The characteristics, including relevant demographic and epidemiologic data were recorded using a telephone interview and computerized questionnaire, and analyzed subsequently. The attack rate of tungiasis in the travel group was 53% (9 patients). Most of the patients (89%) wore open sandals during prolonged periods of their journey, but the pattern of shoeware use was similar in unaffected group members. An insect bite was not felt by any patient. The median number of skin lesions was one, and most lesions were located on the foot (7 of 9 travelers), but the hands were also affected in 2 travelers. All skin lesions healed without a need for a major intervention and without major sequela within 5 weeks of their appearance. Tungiasis may be underdiagnosed in travelers. Medical personnel should include tungiasis in pre-travel recommendations, and post-travel assessment.

Jigger flea infestation (tungiasis) in rural western Tanzania: high prevalence and severe morbidity

Epidemiologic and clinical data on the parasitic skin disease tungiasis are limited from sub-Saharan Africa, and virtually nonexistent from the East African region. We performed a community-based cross-sectional study in two villages in Kasulu district, western Tanzania. Study participants were examined for the presence of tungiasis and disease-associated morbidity. In total, 586 individuals >5 years of age were enrolled, and 249 (42.5%; 95% CI: 38.5-46.5) diagnosed with tungiasis. The ≥45 year-olds showed highest prevalence of tungiasis (71.1%) and most severe parasite load (median number of embedded fleas: 17.5; interquartile range: 15-22.5). Prevalence was slightly, but not significantly, higher in males than in females (45.3 vs 39.7%; p=0.17). Itching (68.3%), pain (38.6%) and ulcers (30.1%) were common; 22.1% of individuals found it difficult to walk due to tungiasis, and in 21.3% loss of toenails was observed. Considering the high prevalence and considerable morbidity in the population, we conclude that tungiasis is a public health threat in the study villages and that the disease needs to be recognized by health authorities. Future studies on risk factors, animal reservoirs and evidence-based control measures are needed.

Tungiasis in a beach volleyball player: a case report

Tungiasis is an infestation caused by penetration of the skin by the gravid female of the flea Tunga penetrans Linnaeus 1758 (Insecta, Siphonaptera: Tungidae). Tunga penetrans is currently found in Central and South America, sub-Saharan Africa, and Central Asia. Prevalence is very high in Brazil. We present a case of tungiasis in an Italian beach volleyball player who acquired the infestation in Brazil.

Control of tungiasis through intermittent application of a plant-based repellent: an intervention study in a resource-poor community in Brazil

BACKGROUND

Tungiasis, an ectoparasitosis caused by the female sand flea Tunga penetrans, is an important health problem in many impoverished communities in the tropics. Sand flea disease is associated with a broad spectrum of clinical pathology and severe sequels are frequent. Treatment options are limited.

METHODOLOGY/PRINCIPAL FINDINGS

We assessed the effectiveness of the intermittent application of the plant-based repellent Zanzarin to reduce infestation intensity and tungiasis-associated morbidity in a resource-poor community in Brazil, characterized by a very high attack rate. The study population was randomized into three cohorts. Initially, during a period of four weeks, the repellent was applied twice daily to the feet of all cohort members. This reduced the number of embedded sandfleas to 0 in 98% of the participants. Thereafter members of cohort A applied the repellent every second week twice daily for one week, members of cohort B every fourth week for one week, and members of cohort C served as controls. Infestation intensity and tungiasis-associated morbidity were monitored during five months. The intermittent application of Zanzarin for one week every second week significantly reduced infestation intensity from a median 4 lesions (IQR 1-9) during the whole transmission season. In contrast, in cohort B (application of the repellent every fourth week) the infestation intensity remained twice as high (median 8 lesions, IQR 9-16; p = 0.0035), and in the control cohort C 3.5 times as high (median 14 lesions; IQR 7-26; p = 0.004 during the transmission season). Tungiasis-related acute pathology remained very low in cohort A (median severity score 2; IQR 1-4) as compared to cohort B (median severity score 5; IQR 3-7; p<0.001), and control cohort C (median severity score 6.5; IQR 4-8; p<0.001).

CONCLUSIONS/SIGNIFICANCE

Our study shows that in a setting with intense transmission, tungiasis-associated morbidity can be minimized through the intermittent application of a plant-based repellent.

Imported tungiasis in a Japanese student returning from East Africa

Ectoparastiosis by Tunga penetrans is becoming more common in non-tropical countries as people travel more to endemic areas. We present here a classic case of imported tungiasis including a history of visit to an endemic region and its typical presentation. Diagnosis with dermoscopy, treatment and prevention are discussed.

An ectopic case of Tunga spp. infection in Peru

Tungiasis is a neglected ectoparasitism of impoverished areas in South America and sub-Saharan Africa. The sand flea Tunga spp. preferably infests the soles and the periungueal and interdigital regions of the feet. Ectopic tungiasis is rare, even in highly endemic areas. We describe a case of an indigenous patient in Peru who presented with a nodular lesion in the extensor aspect of the knee and whose biopsy was compatible with Tunga spp. This is the first documented case of knee tungiasis in an endemic country. The historical, clinical, histological, and current epidemiological aspects of tungiasis in Peru are discussed here.

Controlling tungiasis in an impoverished community: an intervention study

Background

In Brazil, tungiasis is endemic in some resource-poor communities where various domestic and sylvatic animals act as reservoirs for this zoonosis. To determine the effect of control measures on the prevalence and intensity of infestation of human and animal tungiasis, a repeated cross-sectional survey with intervention was carried out.

Methodology/Principal Findings

In a traditional fishing community in Northeast Brazil, humans and reservoir animals were treated, and premise-spraying using an insecticide was done, while a second fishing community served as a control. Both communities were followed up 10 times during a 12-month period. At baseline, prevalence of tungiasis was 43% (95% confidence interval [CI]: 35%–51%) and 37% (95% CI: 31%–43%) in control and intervention villages, respectively. During the study, prevalence of tungiasis dropped to 10% (95% CI: 8%–13%; p<0.001) in the intervention village, while the prevalence remained at a high level in the control village. However, after one year, at the end of the study, in both communities the prevalence of the infestation had reached pre-intervention levels. Whereas the intensity of infestation was significantly reduced in the intervention community (p<0.001), and remained low at the end of the study (p<0.001), it did not change in the control village.

Conclusion/Significance

Our study shows that a reduction of prevalence and intensity of infestation is possible, but in impoverished communities a long-lasting reduction of disease occurrence can only be achieved by the regular treatment of infested humans, the elimination of animal reservoirs, and, likely, through environmental changes.

Trial Registration

Controlled-Trials.com ISRCTN27670575

Tungiasis is a disease caused by the sand flea Tunga penetrans, a parasite prevalent in many impoverished communities in developing countries. The female sand flea penetrates into the skin of animals and humans where it grows rapidly in size, feeds on the host's blood, produces eggs which are expelled into the environment, and eventually dies in situ. The lesions become frequently superinfected and the infestation is associated with considerable morbidity. Clearly, tungiasis is a neglected disease of neglected populations. We investigated the impact of a package of intervention measures targeted against on-host and off-host stages of T. penetrans in a fishing community in Northeast Brazil. These measures decreased disease occurrence only temporarily, but had a sustained effect on the intensity of the infestation. Since infestation intensity and morbidity are correlated, presumably the intervention also lowered tungiasis-associated morbidity. Control measures similar to the ones used in this study may help to effectively control tungiasis in impoverished communities.

Tungíase disseminada tratada com ivermectina

A tungíase é ectoparasitose causada pela penetração da Tunga penetrans na pele do hospedeiro. A infestação por essa pulga está associada à pobreza e ocorre em comunidades carentes na América do Sul e Central, no Caribe e na África sul-sahariana. No Brasil, é mais prevalente em assentamentos urbanos precários, áreas rurais e comunidades de pescadores em todo o país. O tratamento consiste na retirada dos parasitas e, nos casos com infecção secundária, antibioticoterapia. Até o momento, não há droga no mercado com eficácia clínica satisfatória. Relata-se caso de tungíase disseminada tratada com ivermectina oral.

Imported tungiasis: a report of 19 cases and review of the literature

Tungiasis is an infestation caused by penetration in the skin of the gravid female of the flea Tunga penetrans. In the period 1991-2006, 19 patients with imported tungiasis were observed at our Institute. All patients were subjected to general and dermatological examination, laboratory tests (including bacteriological examinations) and surgical excision of the lesions with histopathological examination. In all patients tetanus prophylaxis was made. All patients were followed up for at least six weeks. Thirteen patients were males (68.4%) and 6 females (31.6%). The age ranged from 3 to 71 years (average age: 37.8 years). Eleven patients (57.9%) contracted the infestation in Central and South America and 8 (42.1%) in Africa. In 17 patients (89.5%) tungiasis was localized to the feet, in one to the hands and in one to a thigh. In 13 patients (68.4%) the infestation was characterized by a single lesion; in the other 6 patients (31.6%) the lesions were two. In 15 patients (78.9%) tungiasis was characterized by a papular or nodular lesion. Crusted (2 patients), pustular (2 patients) and bullous (1 patient) lesions were also observed; furthermore, one patient presented with a plantar wart-like lesion. In only one patient bacteriological examinations showed the growth of Staphylococcus aureus and Escherichia coli. All patients healed without complications.