Cutaneous larva migrans and tungiasis in international travelers exiting Brazil: an airport survey

Sudden emergence and spread of cutaneous larva migrans in Sudan: A case series calls for urgent actions

Cutaneous larva migrans (CLM) is a self-limiting dermatosis parasitic disease that is caused by zoonotic hookworm mainly infects cats, dogs, and accidentally humans. The disease affects hosts through the invasion and the migration of the hookworm larva into top layers of the skin. The disease occurs in tropical and subtropical regions; where people commonly are infected when sitting or barefoot walking on places contaminated with feces of infected cats or dogs. Due to self-limiting nature of the disease, the exact burden and prevalence are commonly underestimated. In this communication, we investigated all cases presented to the skin-diseases outpatient clinic' at the reference hospital of Tropical Diseases Medicine in Khartoum state between January 2019 and January 2021. This is the first-ever a case series report of cutaneous larva migrans in Sudan. We identified 15 cases of CLM presented with rash (100 %), redness of skin (67 %), and only adults were presented with larva crawling under their skins (27 %). Infection sites were (53 %) leg, (40 %) foot, only 7 % showed abdominal infection. The majority of patients were children or young adults, 47 % of them are ≤5 year-old, male to female ratio is 2.75:1. Duration of infection was one to three weeks and all patients fully recovered after treatment with albendazole. This urges for One Health interventions including deworming cats and dogs, improving water, sanitation, and hygiene, community-engagement and raising awareness in area with risk of infection.

Current status of the knowledge on the epidemiology of tungiasis in the Americas

Objectives.

To present the state-of-the-knowledge on the epidemiology of tungiasis in the Region of the Americas.

Methods.

A search of publications on the epidemiology of tungiasis in the Americas was performed in PubMed and LILACS databases from January 2007 to June 2021. In addition, a manual literature search on articles on the epidemiology of tungiasis was performed.

Results.

A total of 83 articles were analyzed which contained relevant information on tungiasis cases and their geographical distribution, prevalence and risk factors, life cycle, sites where transmission takes place, and zoonotic aspects. The on-host and off-host life cycles have been researched in detail. In certain contexts, the whole life cycle is completed indoors enabling transmission around the whole year. Cases were reported from 10 countries; 71% of them were from Brazil. In the general population, the prevalence varied between 1.0% and 82.6% according to the settings. Age-specific prevalence indicated that children and the elderly bear the highest disease burden. Risk factor studies indicate that tungiasis is associated with severe poverty.

Conclusions.

In the Americas, there are important gaps in information and knowledge of tungiasis. Understanding the burden, epidemiology, distribution, magnitude, related risk factors, and reservoirs, among others, is needed to develop and implement integrated control measures tailored to the context and patterns of transmission in the affected communities.

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.

Tungiasis in domestic, wild, and synanthropic animals in Brazil

Tungiasis is an ectoparasitic skin disease of humans and warm-blooded animals caused by fleas of the genus Tunga (Jarocki, 1938). Dogs, cats, pigs, and synanthropic rodents are the main animal reservoirs. Of the 14 known species, 12 are found in Latin America and, among these, eight are found in Brazil, including the two zoonotic species Tunga penetrans and Tunga trimamillata. Tunga penetrans predominates among humans and Brazilian pets, where the dog is the most affected species, and its presence is a risk factor associated with the disease in humans. Tunga spp. are widely distributed throughout the national territory, with T. penetrans being the most dispersed and the most frequent in animals from endemic areas, especially in underprivileged communities. Infections in animals, associated with inadequate management, favor the spread and perpetuation of the disease. Intense injuries can result in sequelae and serious clinical conditions, compromising the health, welfare, and productivity of animals, as well as leading to death. Health precariousness, lack of control and neglect in the management of populations of domestic and synanthropic animals, poor hygiene habits of individuals, lack of information from both the population and related professionals, lack of effective treatment, and of perception of tungiasis as a disease are among the main challenges for the control of this parasitosis. As recommended for other zoonotic Neglected Tropical Diseases, strategies based on the concept of One Health can guarantee more effective results in the fight against human and animal tungiasis.

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.

Seasonal variation and persistence of tungiasis infestation in dogs in an endemic community, Bahia State (Brazil): longitudinal study

Tungiasis is a zoonosis neglected by authorities, health professionals, and affected populations. Domestic, synanthropic, and sylvatic animals serve as reservoirs for human infestation, and dogs are usually considered a main reservoir in endemic communities. To describe the seasonal variation and the persistence of tungiasis in dogs, we performed quarterly surveys during a period of 2 years in a tourist village in the municipality of Ilhéus, Bahia State, known to be endemic for tungiasis. Prevalence in dogs ranged from 62.1% (43/66) in August 2013 to 82.2% (37/45) in November 2014, with no significant difference (p = 0.06). The prevalence of infestation remained high, regardless of rainfall patterns. Of the 31 dogs inspected at all surveys, period prevalence was 94% (29/31; 95% CI 79.3-98.2%) and persistence of infestation indicator [PII] was high (median PII = 6 surveys, q1 = 5, q3 = 7). Dogs < 1 year of age had a higher mean prevalence of 84.5%, as compared with 69.3% in the older dogs. No significant difference was found between the risk of infestation and age or sex (p = 0.61). Our data indicate that canine tungiasis persisted in the area during all periods of the year. The seasonal variation described in human studies from other endemic areas was not observed, most probably due to different rainfall patterns throughout the year. The study has important implications for the planning of integrated control measures in both humans and animal reservoirs, considering a One Health approach.

Global output of research on epidermal parasitic skin diseases from 1967 to 2017

Background

Epidermal parasitic skin diseases (EPSD) occur in most countries and cause a considerable health and economic burden, particularly in the tropics and subtropics. The aim of this study was to assess and analyse peer-reviewed literature on EPSD in humans. The results of this study serve as an indicator of the extent the scientific community, health authorities, and international health agencies interact with EPSD as a health problem that is commonly associated with poverty and poor hygiene.

Methods

A bibliometric analysis methodology was used. The Scopus database was used to retrieve documents about EPSD for the study period (1967–2017). The study focused on scabies, tungiasis, pediculosis, hookworm-related cutaneous larva migrans (HrCLM), myiasis, and cutaneous strongyloidiasis. Documents that specifically and explicitly discuss EPSD in animals, aquatic organisms, and birds were excluded.

Results

In total, 4186 documents were retrieved. A fluctuated growth of publications on EPSD in the past five decades was found. The retrieved documents received 43 301 citations, an average of 10.3 citations per article and an h-index of 74. The keywords “scabies” and was the most commonly encountered keyword followed by the keywords “head lice” and “pediculosis”. The most active journal involved in publishing articles on EPSD was the International Journal of Dermatology (164; 3.9%). Researchers from 93 different countries published the retrieved articles. The USA led with 735 (17.6%) documents, followed by the UK (274; 6.5%), and Germany (259; 6.2%). In terms of institutions, the Charité – Universitätsmedizin Berlin in Germany was the most active in this field with 78 (1.9%) publications, followed by the Universidade Federal do Ceará in Brazil with 52 (1.2%) publications.

Conclusions

Research on scabies and pediculosis dominated the field of EPSD research to the expense of tungiasis, HrCLM, myiasis, and cutaneous strongyloidiasis. There was an underrepresentation of literature from the tropics and subtropics despite EPSD being common in these areas. This could possibly be explained by the presence of limited number of non-English journals in the Scopus database. International research collaborations and research networking should be strengthened to help advance and prioritize research on EPSD.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0456-x) contains supplementary material, which is available to authorized users.

Canine tungiasis: High prevalence in a tourist region in Bahia state, Brazil

Tungiasis is a parasitic skin disease neglected by authorities, health professionals, and the general population. Its occurrence is significantly associated with poverty. A cross-sectional study was conducted to describe the prevalence of tungiasis, associated clinical signs and risk factors of the canine population at a tourist site in the city of Ilhéus, Bahia (northeast Brazil). All village households were visited and dogs inspected after authorization by owners. A semi-structured questionnaire was administered. Of the 114 dogs included in the study, 71 (62.3%) were infested; all of them had lesions on their pads. An ectopic lesion on the nose was observed in one dog (1.4%). The number of manipulated lesions outnumbered the number of vital and avital lesions with an average of 88.3%. Edema (95.8%) and hyperkeratosis (85.9%) were the most prevalent clinical signs. Behavioral disorders such as excessive licking (6/71; 8.5%), disobedience (1/71; 1.4%) and prostration (2/71; 2.8%) were reported. In the multi-variate analysis, semi-restricted condition of the dogs (adjusted OR=8.58; 95% CI=2.47-29.76) and the presence of sand on the compound (adjusted OR=14.23, 95% CI=2.88-70.28) were significantly associated with infestation. We concluded that, infestation with Tunga spp. is highly endemic in the canine population of the village. The low level of restrictions on dogs and the presence of sand in areas most frequented by the animals are perpetuating factors of infestation in the community, subject to integrated and multidisciplinary intervention measures.

Airport surveys at travel destinations--underutilized opportunities in travel medicine research?

BACKGROUND

Research in destination airports, especially in resource-poor areas, allows unique immediate access to travelers at the conclusion of their trip. Response rates are high and the recall gap small. Trip-related health matters can be elicited relatively easily. An insight into travelers' decision-making processes on location would fill large gaps in our knowledge regarding travel health advice provision; yet, this approach is still much underutilized.

METHODS

Using PubMed, ScienceDirect, Google Scholar, and ProQuest, a review of the literature on airport surveys was conducted to determine where they were used, their response rates and purpose, and location-relevant methodological information.

RESULTS

The lack of methodological guidelines in the reviewed literature resulted in recommendations for planning and conducting an airport survey at a destination airport.

CONCLUSIONS

Millions of travelers in airports around the world represent an underutilized sample of potential study participants for topics that cannot be studied adequately in other settings. Benefiting from close cooperation between travel health professionals and airport authorities, researchers can expect not only large-scale convenience samples for surveys, but also opportunities to explore exciting and creative research topics to broaden our understanding of travel medicine and health.

Health and safety issues for travelers attending the World Cup and Summer Olympic and Paralympic Games in Brazil, 2014 to 2016

IMPORTANCE

Travelers from around the globe will attend the 2014 Fédération Internationale de Football Association (FIFA) World Cup and the 2016 Olympic and Paralympic Games in Brazil. Travelers to these mass gathering events may be exposed to a range of health risks, including a variety of infectious diseases. Most travelers who become ill will present to their primary care physicians, and thus it is important that clinicians are aware of the risks their patients encountered.

OBJECTIVE

To highlight health and safety concerns for people traveling to these events in Brazil so that health care practitioners can better prepare travelers before they travel and more effectively diagnose and treat travelers after they return.

EVIDENCE REVIEW

We reviewed both peer-reviewed and gray literature to identify health outcomes associated with travel to Brazil and mass gatherings. Thirteen specific infectious diseases are described in terms of signs, symptoms, and treatment. Relevant safety and security concerns are also discussed.

FINDINGS

Travelers to Brazil for mass gathering events face unique health risks associated with their travel.

CONCLUSIONS AND RELEVANCE

Travelers should consult a health care practitioner 4 to 6 weeks before travel to Brazil and seek up-to-date information regarding their specific itineraries. For the most up-to-date information, health care practitioners can visit the Centers for Disease Control and Prevention (CDC) Travelers' Health website (http://wwwnc.cdc.gov/travel) or review CDC's Yellow Book online (http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014).

Tungiasis - A Janus-faced parasitic skin disease

Tungiasis is a parasitic skin disease caused by the penetration of female sand fleas (Tunga penetrans). It is acquired when people walk barefoot or rest on soil, where sand fleas have completed the off-host cycle. Tungiasis is a classic poverty-associated disease which belongs to the family of neglected tropical diseases (NTD). It has a Janus-face: while in travellers tungiasis usually is a benign self-limiting skin disease, inhabitants of endemic areas suffer from heavy infestations and severe, frequently debilitating and incapacitating morbidity. We describe the epidemiological and clinical characteristics of travel-associated tungiasis and compare these features to the situation in resource-poor communities in South America and sub-Saharan Africa.

Tungiasis: a neglected epidermal parasitic skin disease of marginalized populations--a call for global science and policy

Tungiasis (sand flea disease) is an ectoparasitic skin disease caused by the female sand flea/jigger flea (Tunga penetrans). As poverty is the major driving force of the disease, it can be called as a poverty-associated plague. It is one of the emerging neglected diseases in Latin America, Caribbean, sub-Saharan Africa, and India. The aim of the present scrutiny was to assess the public health impact of tungiasis, associated risk factors, and emerging opportunities to prevent and control tungiasis. Searches of PubMed, Google Scholar, and online search engines (Google, AOL, and Yahoo) using keywords "parasitic skin disease," "tungiasis," "sand flea," " tungiasis-associated risk factors," "tungiasis prevention and control," and their synonyms were used as a source of references. Searches were made without time limitations. Of 167 potential articles identified by these criteria, 51 appropriate were selected for review. Tungiasis is widespread in the resource-constrained settings of low-income economies. In the tropics, it is highly prevalent among the impoverished populations, but the associated risk factors are often poorly identified and remain uncontrolled. Though it is a self-limiting disease with considerable morbidity, the parasite may cause subsequent secondary morbidity through life-threatening complications and infections like cellulitis, tetanus, and death. However, the direct and indirect sociocultural, economic, and health impact of tungiasis is often undervalued and misunderstood. A systematic assessment on disease burden is still dearth and deficient. Over the decades, tungiasis has been largely neglected by the scientific community, policy makers, and healthcare stakeholders. In the endemic regions, even tungiasis is not listed for the disease control priorities in the regional, national, and international agenda. The majority of the epidermal parasitic skin diseases particularly tungiasis needs a sustainable global scientific research and control policy. This urges intensive efforts to develop a road map that delivers a clear vision towards zero new infection by designing low-cost prevention and control strategies. Besides, there is an urgency to develop culturally appropriate communication techniques and workable collaboration on a global scale by bringing all the stakeholders of endemic countries.

Prevalence and zoonotic potential of canine hookworms in Malaysia

BACKGROUND

Canine hookworm infection is endemic in Southeast Asian countries with a prevalence ranging from 70% to 100%, with zoonotic transmission representing a potentially significant public health concern. However, there are limited data available on the prevalence of canine hookworms in Malaysia. This study was conducted to determine the prevalence of hookworm and Ancylostoma species among dogs in Malaysia.

METHODS

Faecal samples were collected from 221 dogs living in urban areas, rural areas and animal shelters in Selangor. Faecal samples were processed using the formal-ether concentration technique followed by wet mount preparation and iodine staining for the detection of hookworm eggs. Samples positive for hookworm eggs were examined using PCR, targeting ITS2 and 28 s rRNA region, and subsequently sequenced in both directions. The sequences were phylogenetically analysed using MrBayes for Bayesian Inference.

RESULTS

The overall prevalence of hookworm among dogs was 48% (95%CI; 41.41-54.95). Rural stray dogs had the highest prevalence 71.4% (95%CI; 61.13-81.49) followed by urban stray dogs, recording 48% (95%CI; 34.15-61.85) and lastly dogs in shelters with 28.7% (95%CI; 19.56-37.84). Logistic regression identified rural stray dogs as a high risk group (OR = 4.55, 95%; 2.50-8.31) and keeping dogs in shelters as a protective factor (OR = 0.24, 95%; 0.14-0.43). Molecular methods identified both Ancylostoma ceylanicum and Ancylostoma caninum with A. ceylanicum being predominant among urban stray dogs. Rural dogs had a higher prevalence of A. caninum than A. ceylanicum, while both species showed equal distribution among dogs in shelters. Phylogenetic analysis placed A. ceylanicum isolated from dogs in one group with A. ceylanicum human isolates.

CONCLUSION

This study indicates that dogs have the potential to act as reservoir hosts of human hookworm infection in Malaysia. This finding necessitates the inclusion of dogs in any interventions to combat hookworm in the country.

Mini review: Hookworm-related cutaneous larva migrans

Hookworm-related cutaneous larva migrans (HrCLM) is a parasitic skin disease caused by the migration of animal hookworm larvae in the epidermis. Since these larvae cannot penetrate the basal membrane of human skin, they remain confined to the epidermis and are unable to develop and complete their lifecycle. By consequence, HrCLM is a self-limiting disease. However, if not treated promptly, the skin pathology may persist for months. HrCLM is endemic in many resource-poor communities in the developing world. In high-income countries, HrCLM occurs sporadically or in the form of small epidemics. Travelers account for the great majority of cases seen by health-care professionals in high-income countries. Transmission occurs when naked skin comes into contact with contaminated soil. Exposure may also occur indoors. Exceptionally, larvae may be transmitted through fomites. The first clinical sign is a small reddish papule. Thereafter, the characteristic serpiginous, slightly elevated, erythematous track becomes visible. Itching becomes more and more intense. Excoriations induced by scratching facilitate bacterial superinfection of the lesion. The diagnosis is essentially clinical. It is supported by a recent travel history and the possibility of exposure. The drug of choice is ivermectin in a single dose (200 μg per kg bodyweight). Repeated treatments with albendazole (400 mg daily) are a good alternative in countries where ivermectin is not available.

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.

Epidermal parasitic skin diseases: a neglected category of poverty-associated plagues

Epidermal parasitic skin diseases (EPSD) are a heterogeneous category of infectious diseases in which parasite-host interactions are confined to the upper layer of the skin. The six major EPSD are scabies, pediculosis (capitis, corporis and pubis), tungiasis and hookworm-related cutaneous larva migrans. We summarize the current knowledge on EPSD and show that these diseases are widespread, polyparasitism is common, and significant primary and secondary morbidity occurs. We show that poverty favours the presence of animal reservoirs, ensures ongoing transmission, facilitates atypical methods of spreading infectious agents and increases the chances of exposure. This results in an extraordinarily high prevalence and intensity of infestation of EPSD in resource-poor populations. Stigma, lack of access to health care and deficient behaviour in seeking health care are the reasons why EPSD frequently progress untreated and why in resource-poor populations severe morbidity is common. The ongoing uncontrolled urbanization in many developing countries makes it likely that EPSD will remain the overriding parasitic diseases for people living in extreme poverty. We advocate integrating control of EPSD into intervention measures directed against other neglected diseases such as filariasis and intestinal helminthiases.

Epidemiological and clinical characteristics of hookworm-related cutaneous larva migrans

Hookworm-related cutaneous larva migrans is caused by the migration of animal hookworm larvae in the human skin. The disease mainly occurs in resource-poor communities in the developing world, but it is also reported sporadically in high-income countries and in tourists who have visited the tropics. Diagnosis is made clinically in the presence of a linear serpiginous track moving forward in the skin, associated with itching and a history of exposure. Itching is typically very intense and can prevent patients from sleeping. Bacterial superinfection occurs as a result of scratching. Treatment is based on oral drugs (albendazole or ivermectin) or the topical application of tiabendazole. To control hookworm-related cutaneous larva migrans at the community level, regular treatment of dogs and cats with anthelmintic drugs is necessary, but this is seldom feasible in resource-poor settings. Animals should be banned from beaches and playgrounds. For protection at the individual level, unprotected skin should not come into contact with possibly contaminated soil.