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).

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.

Factors associated with tungiasis among school-age children in Kwale County, rural Kenya.

BACKGROUND: The parasitic disease tungiasis, caused by the flea Tunga penetrans, remains an important public health problem among children and the elderly. The study assessed the factors influencing prevention and control of tungiasis infection among school-age children in Kwale County, Kenya. METHODS: A cross-sectional survey was conducted in five villages in Lunga Lunga subcounty among 538 children ages 5-14 y. The study employed a mobile application tool in collecting sociodemographic, knowledge, perception and practice data on prevention and control of tungiasis with frequencies and bivariate and multivariate regression analysis used. RESULTS: The prevalence of tungiasis was found to be 62.1% (328/528), with fathers' education level, place of residence and wearing shoes being factors associated with infection. Those who wore shoes were less likely to be infected compared with those who did not (odds ratio 0.059 [95% confidence interval 0.29 to 0.12]). Children living in Dzombo B and Kinyungu were less likely to be infected with tungiasis compared with those living in Bandu, holding other factors constant. CONCLUSION: Creating awareness of the cause of tungiasis remains of key public importance. Hygiene promotion, including wearing of shoes and the general cleanliness of the environment at the community level, needs to be implemented.

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.

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.

Travelers' tropical skin diseases: Challenges and interventions.

Tropical regions receive a significant part of the traveling population. It is very important that health professionals are familiar with the main tropical skin diseases and able to advice patients appropriately. This article reviews the main tropical diseases of travelers, with an emphasis on diagnosis, management, and prevention. Among others, cutaneous larva migrans, myiasis, tungiasis, Chagas disease, Dengue fever, African trypanosomiasis, filariasis, and leishmaniasis are discussed. Increasing awareness among travelers and health care professionals can help reduce morbidity and mortality. Continued research on new drugs and vaccines is needed to reduce the risks of tropical diseases.

Serie parasitosis en dermatología: tungiasis / Dermatology iconography: tungiasis

La tungiasis es una ectoparasitosis causada por la penetración en la piel de la pulga hembra Tunga penetrans. Esta enfermedad no es específica del hombre y se distribuye en regiones cálidas y secas alrededor del mundo. Se adquiere por contacto directo con el suelo en donde habitan los parásitos adultos. En zonas endémicas, su alta prevalencia se asocia a pobreza y falta de acceso al sistema de salud. Además es frecuente entre viajeros que visitan regiones endémicas y que regresan a sus lugares de origen. Presentamos un caso típico de tungiasis en un paciente 39 años que había realizado un viaje reciente a zona endémica. (AU)

Tungiasis is an ectoparasitosis caused by penetration into the skin of the female flea Tunga penetrans. This disease is not human-specific and is distributed worldwide in warm, dry regions. It is acquired by direct contact with the soil where the adult parasites live. In endemic areas, its high prevalence is associated with poverty and lack of access to the health system. It is also frequent among travelers visiting endemic regions and returning to their places of origin. We present a typical case of tungiasis in a 39 year old patient who had made a recent trip to an endemic area. (AU)

Prevalence and clinical aspects of tungiasis in south-west Nigerian schoolchildren.

Tungiasis is highly prevalent in resource-poor communities in sub-Saharan Africa, but studies among schoolchildren are scanty. We assessed prevalence, parasite load and clinical aspects of tungiasis in schoolchildren in south-western Nigeria. A total of 545 schoolchildren was examined. Of these, 133 (24.4%; 95% CI, 20.9-28.2%) were infested with Tunga penetrans Boys showed a higher prevalence than girls (31% versus 18%, P < 0.0001); in those infested, the median number of lesions was two, with no gender difference (2 boys, interquartile range, 1-4; 2 girls; interquartile range, 1-4; P = 0.34). The maximum number of 44 lesions was found in a 14-year-old boy. Desquamation was present in 90.2%, followed by erythema (54.9%) and oedema (43.6%); 54.9% showed any chronic pathology and more one-third nail deformations. Our study indicates that tungiasis is an important health problem in rural Nigerian schoolchildren. Sustainable interventions are required to control the disease in this and similar communities.

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.

Regression of severe tungiasis-associated morbidity after prevention of re-infestation: a case series from rural Madagascar.

Tungiasis (sand flea disease) is a neglected tropical disease. Heavy infestation results in mutilation of the feet and difficulty in walking. We identified eight individuals with extremely severe tungiasis in rural Madagascar. To prevent reinfestation, four individuals received solid shoes and four received a daily application of an herbal repellent effective against Tunga penetrans. Over a period of 10 weeks the feet were examined and the severity of tungiasis-associated morbidity was measured. Within this period, the severity score for acute tungiasis decreased 41% in the shoe group and 89% in the repellent group. The four major inflammation-related symptoms disappeared in the four patients of the repellent group, but only in two patients of the shoe group. Those observations indicate that cases with extremely severe tungiasis, associated morbidity almost totally disappears within 10 weeks if the feet are protected by a repellent. Wearing shoes reduced acute morbidity only marginally.

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.

Placa hiperpigmentada en el pie de un paciente keniata / Hyperpigmented Plaque on the Foot of a Kenyan Patient

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Knowledge, attitude and practices on jigger infestation among household members aged 18 to 60 years: case study of a rural location in Kenya.

INTRODUCTION: Jigger infestation is an important but neglected public health problem. The study assessed the knowledge, attitude and practices of household members on jigger infestation, practices and control within Murang'a district, a rural location in Kenya. METHODS: A cross-sectional descriptive study design was used. Structured interview schedules and observation checklist were used to collect quantitative data. A sample size of 271 household members was interviewed. Descriptive and inferential statistics were analyzed and odds ratios computed at 95% confidence interval to determine variables association. RESULTS: On knowledge, 70.1% acknowledged poor hygiene and sanitation contributes to jigger infestation while 16.6% identified jigger flea as the cause of jigger infestation. Over half (53.9%) reported jiggers are transmissible from person to person. Majority (94.8%) identified signs and symptoms of jigger infestation. Over a quarter (23.6%) reported an infested household member and 18.8% infested persons were confirmed during the study. Many (59.8%) held the opinion that, jigger infested persons are lazy, 26.2% reported they are poor and 12% reported they either have specific blood or are from certain families. Below half (48.7%) believed in myths and misconceptions on jiggers. Majority (90.8%) reported needles/pins were the mostly used jigger removal items followed by thorns 38.7%. About two thirds (62.0%) were not aware of communal jigger prevention and control activities. The Chi-square results showed that, the village, type of house floor and compound maintenance were significantly associated with jigger infestation (p<0.05). CONCLUSION: Knowledge on jigger infestation is high but this has not translated to jigger prevention and control in the area.

Tungiasis: a poorly documented tropical dermatosis.

Tungiasis is the parasitic skin disease caused by the sand flea Tunga penetrans, also called the jigger flea, found in most intertropical countries. The contamination occurs when walking barefoot in the sand: adult females actively burrow the foot epidermis leading to self-limited lesions responsible for itching or pain. The diagnosis is made on clinical observation and history of travelling to an endemic country. The simple treatment is surgical extraction of the flea.

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.

[Tungiasis in native Amerindians in Vaupés province: epidemiology, clinical aspects, treatment, and prevention]. / Tungiasis en población indígena del departamento de Vaupés: epidemiología, clínica, tratamiento y prevención.

INTRODUCTION: Tungiasis, the skin infestation with the flea Tunga penetrans, occurs in poor communities. Objective. To present a study of this condition among native Amerindians from Vaupés (Colombia). METHODS: After reviewing this topic, we present a description of the geographic area and the housing of the affected subjects; animal carriers infected with this zoonosis were also detected. We illustrate the clinical aspects and complications. Patients were treated with creolin (liquid cresol). We modified the floor of malocas in two communities using wet clay, and we educated the community on this parasite. RESULTS: About 95% of the 33,000 inhabitants of Vaupés are native Amerindians. Some households have dry sandy floors, where food leftovers attract dogs infested with tungiasis. From 1996 to 2007 we confirmed 942 human cases of this parasitic disease. Among the native communities, 3 to 8 per 1,000 persons and 62% of the dogs have tungiasis. Feet were affected in 98% of the patients. Severe cases, with more than 20 lesions, occurred among children and the elderly. Complications included secondary infections, pain, anonychia (loss of toenails), toe deformities, amputation of toes and walking problems. Three patients died as a result of sepsis originating from toe infections. Topic use of liquid creolin and extraction of the parasite cured the problem in humans and dogs. Floor modifications eradicated the problem in one community. CONCLUSIONS: Tungiasis is an intradomiciliary disease. Favorable conditions for infestations include dry sandy floors and infected dogs. Treatment of the floors with creolin and wet clay resulted in control of one focus of the disease; this method could be applied more widely. This is the first known research study on tungiasis in Colombia, a disease that affected the soldiers of the Spanish Conquistador Gonzalo Jiménez de Quesada in the 1500s.