Identification of tungiasis infection hotspots with a low-cost, high-throughput method for extracting Tunga penetrans (Siphonaptera) off-host stages from soil samples-An observational study.

BACKGROUND: The sand flea, Tunga penetrans, is the cause of a severely neglected parasitic skin disease (tungiasis) in the tropics and has received little attention from entomologists to understand its transmission ecology. Like all fleas, T. penetrans has environmental off-host stages presenting a constant source of reinfection. We adapted the Berlese-Tullgren funnel method using heat from light bulbs to extract off-host stages from soil samples to identify the major development sites within rural households in Kenya and Uganda. METHODS AND FINDINGS: Simple, low-cost units of multiple funnels were designed to allow the extraction of >60 soil samples in parallel. We calibrated the method by investigating the impact of different bulb wattage and extraction time on resulting abundance and quality of off-host stages. A cross-sectional field survey was conducted in 49 tungiasis affected households. A total of 238 soil samples from indoor and outdoor living spaces were collected and extracted. Associations between environmental factors, household member infection status and the presence and abundance of off-host stages in the soil samples were explored using generalized models. The impact of heat (bulb wattage) and time (hours) on the efficiency of extraction was demonstrated and, through a stepwise approach, standard operating conditions defined that consistently resulted in the recovery of 75% (95% CI 63-85%) of all present off-host stages from any given soil sample. To extract off-host stages alive, potentially for consecutive laboratory bioassays, a low wattage (15-25 W) and short extraction time (4 h) will be required. The odds of finding off-host stages in indoor samples were 3.7-fold higher than in outdoor samples (95% CI 1.8-7.7). For every one larva outdoors, four (95% CI 1.3-12.7) larvae were found indoors. We collected 67% of all off-host specimen from indoor sleeping locations and the presence of off-host stages in these locations was strongly associated with an infected person sleeping in the room (OR 10.5 95% CI 3.6-28.4). CONCLUSION: The indoor sleeping areas are the transmission hotspots for tungiasis in rural homes in Kenya and Uganda and can be targeted for disease control and prevention measures. The soil extraction methods can be used as a simple tool for monitoring direct impact of such interventions.

Management of very severe tungiasis cases through repeated community-based treatment with a dimeticone oil formula: A longitudinal study in a hyperendemic region in Uganda.

Tungiasis (sand flea disease) is a neglected tropical disease that is endemic in Sub-Saharan Africa and Latin America. Tungiasis causes pain, mobility restrictions, stigmatisation and reduced quality of life. Very severe cases with hundreds of sand fleas have been described, but treatment of such cases has never been studied systematically. During a larger community-based tungiasis control programme in a hyperendemic region in Karamoja, northeastern Uganda, 96 very severe tungiasis cases were identified and treated with the dimeticone formula NYDA®. They were repeatedly followed-up and treated again when necessary. The present study traces tungiasis frequency, intensity and morbidity among these 96 individuals over 2 years. At baseline, very severe tungiasis occurred in all age groups, including young children. Throughout the intervention, tungiasis frequency decreased from 100% to 25.8% among the 96 individuals. The overall number of embedded sand fleas in this group dropped from 15,648 to 158, and the median number of embedded sand fleas among the tungiasis cases decreased from 141 to four. Walking difficulties were reported in 96.9% at the beginning and in 4.5% at the end of the intervention. Repeated treatment with the dimeticone formula over 2 years was a successful strategy to manage very severe cases in a hyperendemic community. Treatment of very severe cases is essential to control the spread and burden of tungiasis in endemic communities.

Myth or truth: investigation of the jumping ability of Tunga penetrans (Siphonaptera: Tungidae).

Female sand fleas (Tunga penetrans Linnaeus, 1758, Siphonaptera: Tungidae) cause a severe parasitic skin disease known as tungiasis. T. penetrans is a small flea, measuring less than 1 mm in length. The females of this species burrow into the skin of human and animal hosts and mostly affect the feet. This has led to the anecdotal assumption that T. penetrans, unlike its relatives in the Siphonaptera family, would have a limited jumping ability potentially not reaching higher body parts. However, there is no data supporting this. This study evaluated the jumping capabilities of T. penetrans for height and distance using sticky tapes. The vertical jump of the female T. penetrans ranged from 4.5 to 100 mm with a mean of 40 mm whereas the vertical jump of the male T. penetrans ranged from 1.2 to 138 mm with a mean of 46 mm. The horizontal jump of the female T. penetrans ranged from 18 to 138 mm with a mean of 64 mm and that of the male ranged from 9 to 251 mm with a mean of 80 mm. Based on the literature, fleas of various species have been described as jumping vertically 50-100 times their size and horizontally 5-100 times their size. In this respect, sand fleas appear to have equal expert jumping abilities to their relatives. Their aggregation on people's feet is not likely a result of their poor jumping ability but might be an adaptation to the host's behavior which would require further investigations.

Efficacy of an oral formulation of afoxolaner and milbemycin oxime against Tunga penetrans in naturally infected dogs.

BACKGROUND: The sand flea Tunga penetrans is one of the agents of tungiasis, an important parasitic skin disease affecting humans and several mammalian species. Tungiasis is mainly observed in disadvantaged rural and peripheral urban communities in Latin America and sub-Saharan Africa. The dog is a major reservoir of Tunga fleas. Hematophagous adult female Tunga spp. embed and grow in their host's epidermis and cause cutaneous inflammatory disorders. NexGard Spectra® is an orally administered endectocide for dogs, a co-formulation of the isoxazoline afoxolaner and the macrocyclic lactone milbemycin oxime. The objective of this study was to assess the efficacy of this product against canine tungiasis. METHODS: A blinded, negative-controlled field trial was conducted in a Brazilian community known to be highly endemic for tungiasis. Sixty-six dogs naturally infected with live T. penetrans were randomly allocated to a treated group (44 dogs) and an untreated control group (22 dogs). In a first phase, dogs from the treated group were treated on days 0, 30, and 60. Efficacy was evaluated on the basis of the macroscopic parasitic skin lesions (Fortaleza classification) on days 7, 14, 21, 30, 45, 60, 75, and 90. In a second phase, to evaluate natural reinfections, all dogs were treated on day 90 and evaluated every 2 weeks thereafter until at least 30% of dogs were infected with live sand fleas. RESULTS: During the first phase, efficacy (reduction in live sand fleas) of 92.4% was demonstrated on day 7. From day 14 until day 90, the efficacy of NexGard Spectra® was 100%. In the second phase, all dogs were free of live T. penetrans from 15 until 45 days after the day 90 treatment; 60 days post-treatment, 11% of dogs were reinfected, and 75 days post-treatment, 40% of dogs were reinfected. CONCLUSIONS: NexGard Spectra® was demonstrated to be highly effective against canine tungiasis. In addition to an obvious beneficial effect on the health and welfare of the treated dog, the use of this product may have a one-health benefit on human cases by controlling the main reservoir of sand fleas.

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).

Neurocognitive and mental health outcomes in children with tungiasis: a cross-sectional study in rural Kenya and Uganda.

BACKGROUND: Tungiasis, a neglected tropical parasitosis, disproportionately affects children. Few empirical studies have reported neurocognitive and mental health outcomes of children with ectoparasitic skin diseases like tungiasis. Pathophysiology of tungiasis suggests it could detrimentally affect cognition and behaviour. This study pioneered the investigation of neurocognitive and mental health outcomes in children with tungiasis. METHODS: This was a multi-site cross-sectional study including 454 quasi-randomly sampled school-children aged 8-14 from 48 randomly selected schools in two counties in Kenya and a district in Uganda. The participants were stratified into infected and uninfected based on the presence of tungiasis. The infected were further classified into mild and severe infection groups based on the intensity of the infection. Adapted, validated, and standardized measures of cognition and mental health such as Raven Matrices and Child Behaviour Checklist were used to collect data. Statistical tests including a multilevel, generalized mixed-effects linear models with family link set to identity were used to compare the scores of uninfected and infected children and to identify other potential risk factors for neurocognitive and behavioural outcomes. RESULTS: When adjusted for covariates, mild infection was associated with lower scores in literacy [adjusted ß(aß) = - 8.9; 95% confidence interval (CI) - 17.2, - 0.6], language (aß = - 1.7; 95% CI - 3.2, - 0.3), cognitive flexibility (aß = - 6.1; 95% CI - 10.4, - 1.7) and working memory (aß = - 0.3; 95% CI - 0.6, - 0.1). Severe infection was associated with lower scores in literacy (aß = - 11.0; 95% CI - 19.3, - 2.8), response inhibition, (aß = - 2.2; 95% CI - 4.2, - 0.2), fine motor control (aß = - 0.7; 95% CI - 1.1, - 0.4) and numeracy (aß = - 3; 95% CI - 5.5, - 0.4). CONCLUSIONS: This study provides first evidence that tungiasis is associated with poor neurocognitive functioning in children. Since tungiasis is a chronic disease with frequent reinfections, such negative effects may potentially impair their development and life achievements.

A qualitative case study of community experiences with Tungiasis in high prevalence villages of Bungoma County, Kenya: "The whole body aches and the jiggers are torturing me!"

INTRODUCTION: Tungiasis is a painful skin infection caused by a flea called Tunga Penetrans/jiggers, which enters the epidermis of humans and animals. If untreated it may result in bacterial infection, sepsis, necrosis, and disability. In Kenya, it is estimated that 4% of the population suffer from jigger infestation. The aim of this study was to contribute with knowledge about the experiences of those affected, perceived causes and local coping strategies, to improve the control and elimination of this neglected condition. METHOD: A qualitative case study research design was applied involving fieldwork in Bungoma County, a high-prevalence rural area in Western Kenya. Multiple data collection methods were combined: participant observation, home visits, semi- structured in-depth interviews, and group discussions. In total, 48 informants participated, including infected children and adults, teachers and pupils, public health officers, community health workers and NGO volunteers. RESULTS: Those infected suffered with multiple penetrating wounds on hands and feet that cause disability, resulting in an incapacity to work and school drop-out. People described feeling stigmatized, and at school pupils preferred not to play with infected classmates. People perceived that the sand flea infestation was caused by poverty and that those affected were not even able to cover their basic needs. They were often living in sandy huts that they shared with their animals, without access to soap and clean water. Moreover, those infected were often viewed as ignorant by the rest of the community. Informants perceived recurrence after treatment as inevitable, resulting in creation of hopelessness. Those infected felt that they were left alone with an irremediable plague. There was confusion about effective approaches regarding prevention and treatment at all levels. CONCLUSION: Tungiasis is a debilitating and neglected ailment, inflicting severe suffering and increasing the circle of poverty. To address fatalist attitudes among those affected, national guidelines need to be implemented, and coordination of public health measures regarding prevention and treatment need to be strengthened. Further research is recommended to enable the control and elimination of this neglected tropical disease.

Characterization of tungiasis infection and morbidity using thermography in Kenya revealed higher disease burden during COVID-19 school closures.

BACKGROUND: Tungiasis is a neglected tropical skin disease caused by the sand flea Tunga penetrans. Female fleas penetrate the skin, particularly at the feet, and cause severe inflammation. This study aimed to characterize disease burden in two highly affected regions in Kenya, to test the use of thermography to detect tungiasis-associated inflammation and to create a new two-level classification of disease severity suitable for mapping, targeting, and monitoring interventions. METHODS: From February 2020 to April 2021, 3532 pupils age 8-14 years were quasi-randomly selected in 35 public primary schools and examined for tungiasis and associated symptoms. Of the infected pupils, 266 were quasi-randomly selected and their households visited, where an additional 1138 family members were examined. Inflammation was assessed using infra-red thermography. A Clinical score was created combining the number of locations on the feet with acute and chronic symptoms and infra-red hotspots. RESULTS: The overall prevalence of tungiasis among all the school pupils who were randomly selected during survey rounds 1 and 3 was 9.3% [95% confidence interval (CI): 8.4-10.3]. Based on mixed effects logistic models, the odds of infection with tungiasis among school pupils was three times higher in Kwale (coastal Kenya) than in Siaya [western Kenya; adjusted odds ratio (aOR) = 0.36, 95% CI: 0.18-0.74]; three times higher in males than in females (aOR = 3.0, 95% CI: 2.32-3.91) and three times lower among pupils sleeping in a house with a concrete floor (aOR = 0.32, 95% CI: 0.24-0.44). The odds of finding an infected person among the household population during surveys before the COVID-19 pandemic was a third (aOR = 0.32, 95% CI: 0.19-0.53) of that when schools were closed due to COVID-19 restrictions and approximately half (aOR = 0.44, 95% CI: 0.29-0.68) in surveys done after school re-opening (round 3). Infection intensity was positively correlated with inflammation as measured by thermography (Spearman's rho = 0.68, P < 0.001) and with the clinical score (rho = 0.86, P < 0.001). Based on the two-level classification, severe cases were associated with a threefold higher level of pain (OR = 2.99, 95% CI: 2.02-4.43) and itching (OR = 3.31, 95% CI: 2.24-4.89) than mild cases. CONCLUSIONS: Thermography was a valuable addition for assessing morbidity and the proposed two-level classification of disease severity clearly separated patients with mild and severe impacts. The burden of tungiasis was considerably higher in households surveyed during COVID-19 restrictions suggesting underlying risks are found in the home environment more than in school.

Investigation of human tungiasis cases, Sheema District, Uganda, November 2021-February 2022.

Introduction: no formal surveillance system exists in Uganda for jiggers (tungiasis); however, outbreaks are frequently reported in the media. On 27th January 2022, a news alert reported a jiggers' outbreak in Sheema District, Southwestern Uganda. We investigated to establish the magnitude of the problem and identify possible exposures associated with infestation to inform control measures. Methods: we defined a confirmed case as visible Tunga penetrans (T. penetrans) in the skin of a resident of any of 6 villages in Bwayegamba Parish, Sheema District, in February 2022. A suspected case was self-reported T. penetrans infestation during the three months preceding the interview. We visited all households in the 3 most affected villages in Bwayegamba Parish to identify cases and conducted interviews to identify possible exposures. We described cases by person, place, and time. We assessed socioeconomic status, household construction, mitigation measures against jiggers, and observed participants and their environments for hygiene. We conducted 2 case-control studies. One compared case-households (with ≥1 case) with control-households (without any cases). The second compared individual cases (suspected and confirmed) to neighbourhood controls. Results: among 278 households, we identified 60 case-patients, among whom 34 (57%) were male. Kiyungu West was the most affected village (attack rate=31/1,000). Cases had higher odds of being male (ORMH=2.3, 95% CI=1.3-4.0), <20 years of age (ORMH=2.0, 95%CI=1.1-3.6), unmarried (ORMH=2.97, 95% CI=1.7-5.2), unemployed (ORMH=3.28, 95% CI=1.8-5.8), and having poor personal hygiene (ORMH=3.73, 95% CI=2.0-7.4) than controls. In the household case-control study, case-households had higher odds of having dirty or littered compounds (ORMH=2.3, 95% CI=1.2-4.6) and lower odds of practicing mitigation measures against jiggers (ORMH=0.33, 95% CI=0.1-0.8) than control-households. Conclusion: males, unemployed persons, and those with poor personal or household hygiene had increased odds of tungiasis in this outbreak. Multi-sectoral, tailored interventions that improve standards of living could reduce risk of tungiasis in this area. Adding tungiasis to national surveillance reporting tools could facilitate early identification of future outbreaks.

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.

Efficacy of oral fluralaner (Bravecto) against Tunga penetrans in dogs: A negative control, randomized field study in an endemic community in Brazil.

The sand flea Tunga penetrans is one of the zoonotic agents of tungiasis, a parasitic skin disease of humans and animals. The dog is one of its main reservoirs. This negatively controlled, randomized, double-masked clinical trial evaluated the therapeutic and residual efficacy of fluralaner for treatment of dogs naturally infested with T. penetrans. Sixty-two dogs from an endemically affected community in Brazil were randomly assigned to either receive oral fluralaner (Bravecto chewable tablets) at a dose of 25 to 56 mg fluralaner/kg body weight, or no treatment (31 dogs per group). Dogs were clinically examined using a severity score for acute canine tungiasis (SCADT), parasitological examinations as defined by the Fortaleza classification, and pictures of lesions on days 0 (inclusion and treatment), 7 ± 2, 14 ± 2, 21 ± 2, 28 ± 2, 60 ± 7, 90 ± 7, 120 ± 7 and 150 ± 7. The percentage of parasite-free dogs after treatment was >90% between days 14 and 90 post-treatment with 100% efficacy on study days 21, 28 and 60. Sand flea counts on fluralaner treated dogs were significantly lower (p<0.025) than control dogs on all counts from day 7 to 120. The number of live sand fleas on treated dogs was reduced by > 90% on day 7, > 95% on days 14 and 90, and 100% from day 21 to 60, and with a significant difference between groups from day 7 to 120. From day 7 to day 120, mean SCADT scores were significantly reduced in treated dogs with a mean of 0.10 compared to 1.54 on day 120 in untreated dogs. Therefore, a single oral fluralaner administration is effective for treating and achieving long lasting (> 12 weeks) prevention for tungiasis in dogs.

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.

Prevalence and associated factors of Tunga penetrans infestation among 5-14-year-olds in rural Ethiopia.

BACKGROUND: Tunga penetrans, also known as sand flea, causes Tungiasis in humans and animals. Despite its notoriety as an entomological problem, however, the ectoparasite receives little consideration from public health professionals. It is against this background that this article aims to assess the prevalence of and factors associated with Tunga penetrans infestation among 5-14-year-olds in rural Western Ethiopia. METHODS: From November to December 2020, 487 children aged 5 to 14 were selected from four primary schools in a cross-sectional study using systematic random sampling. Clinical exams, Interviews with parents/guardians and observations of the housing and classroom environments were used to collect data. Descriptive statistics and multivariable regression were used to characterize the data and identify factors associated with Tunga penetrans infestation. RESULT: Tunga penetrans infestation (Tungiasis) was diagnosed in 138 of the 487 children examined, placing the prevalence at 28.3% (95% CI: 24.2%, 32.2%). Mud plastered walls [AOR: 5.83, % CI (3.44-9.88)], having cats in the house [AOR: 5.91, 95% CI (3.51-10.11)], not having separated sleeping quarters for animals [AOR: 4.60, 95% CI (2.69-7.86)], using self-supplied water [AOR: 6.30, 95% CI (3.33-11.93)], walking>30 minutes to school [AOR: 2.37, 95% CI (1.48-3.80)] were associated with Tungiasis. CONCLUSION: In one way or another, several of the identified factors were linked to poverty. Improved house wall materials, fumigation of mud-plastered houses, dusting or spraying insecticides on domestic animals (such as cats), improved access to water, community education about keeping animals separated from living spaces, and hygiene promotion are all needed, with a focus on locally available, low-cost technologies that the poorest families can afford.

Assessment of the role played by domestic animals in jigger infection in Kandara sub-county, Kenya (case control study).

INTRODUCTION: tungiasis is an ectoparasitosis caused by penetration of female sand flea, Tunga penetrans, into the skin of the susceptible animal and the consequent hypertrophy of the parasite. The objective of this study was to assess the association between domestic animals and jigger infection among the residents of Kandara sub-county in central Kenya. METHODS: this was a case-control study that involved 776 individuals. Half of this number entailed case group who were jigger infected while the other half was the control, composed of jigger free participants. Structured questionnaires were, administered among the heads of the households to which the participants belonged to gather information concerning the animals they kept. Univariate analysis was, applied. RESULTS: in this study, there were significant differences in age (P=0.008) between the two groups. Disparities in source of income (P<0.001) and level of education (P<0.001) came out as very significant factors in jigger infection. The case group was 10 times more likely to keep dogs than the control(9.6; 95% CI, 5.9-15.6). Case group was also 7 times more likely to rear chicken in comparison to the control (6.6; 95%, 4.2-10.4). The case group was 12 times more likely to let dogs loose in the compound in comparison to the control (12.1: 95%, 5.9-24.5). When compared to the control, this group was also 17 times more likely to keep chicken inside their houses (16.7: 95% CI, 6.8-35.9). Conclusion: there is a very high association between domestic animals and occurrence of tungiasis in Kandara sub-county.

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.

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.

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.

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.