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

Tungiasis among children in Kenya is associated with poor nutrition status, absenteeism, poor school performance and high impact on quality of life

Tungiasis is a highly neglected tropical skin disease caused by the sand flea, Tunga penetrans. The flea burrows into the skin inducing a strong inflammatory response, leading to pain and mobility restrictions with potential impacts on quality of life. Few countries implement control efforts and there are few data on the impact of the disease to support policy decisions. We conducted a survey to determine the impact of tungiasis among primary school children across nine counties of Kenya. A total of 10,600 pupils aged 8 to 14 years were randomly selected from 97 primary schools and examined for tungiasis. For 81 cases and 578 randomly selected controls, anthropometric measurements were made, and school attendance and exam scores were collected from school records. Of those with tungiasis, 73 were interviewed regarding their quality of life using a tungiasis-specific instrument. Mixed effect ordered logistic and linear models were used to assess associations between disease status and impact variables. Compared to uninfected pupils, those with tungiasis had lower weight-for-age z-scores (adjusted β -0.41, 95% CI: -0.75-0.06, p = 0.020), missed more days of school the previous term (adjusted Incidence Rate Ratio: 1.49, 95% CI: 1.01-2.21, p = 0.046) and were less likely to receive a high score in mathematics (aOR 0.18, 95% CI: 0.08-0.40, p<0.001) and other subjects. Pupils with severe disease (clinical score >10) were four times more likely to experience severe pain than those with mild disease (OR 3.96, 95% CI: 1.35-11.64, p = 0.012) and a higher impact on their quality of life than those with mild disease (aOR 3.57, 95% CI: 1.17-10.8, p = 0.025) when adjusted for covariates. This study has demonstrated tungiasis has a considerable impact on children's lives and academic achievement. This indicates the need for integrated disease management for school-aged children to protect their physical and cognitive development and their future prospects.

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.

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 β(aβ) = - 8.9; 95% confidence interval (CI) - 17.2, - 0.6], language (aβ = - 1.7; 95% CI - 3.2, - 0.3), cognitive flexibility (aβ = - 6.1; 95% CI - 10.4, - 1.7) and working memory (aβ = - 0.3; 95% CI - 0.6, - 0.1). Severe infection was associated with lower scores in literacy (aβ = - 11.0; 95% CI - 19.3, - 2.8), response inhibition, (aβ = - 2.2; 95% CI - 4.2, - 0.2), fine motor control (aβ = - 0.7; 95% CI - 1.1, - 0.4) and numeracy (aβ = - 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.

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.

National prevalence and risk factors for tungiasis in Kenya

BACKGROUND

Tungiasis is a highly neglected tropical skin disease caused by the sand flea, Tunga penetrans, the female of which burrows into the skin, causing pain and itching. The disease occurs throughout South America and sub-Saharan Africa but there are few systematic data on national disease burdens. The tungiasis research community is keen to develop survey methods to fill this gap. Here we used a school-based, thorough examination method to determine the prevalence and risk factors for tungiasis in Kenya.

METHODS

We conducted the first nationally representative survey of tungiasis, including nine counties covering the major ecological zones of Kenya. A stratified multistage random sampling was used to select 22 primary schools from each of the nine counties and to select up to 114 pupils aged 8 to 14 years in each school. Pupils were examined thoroughly for tungiasis. Two surveys were conducted, the first between May and July 2021 and the second between October 2021 and April 2023 when pupils were also interviewed for risk factors. Mixed effect logistic regression models were used to test associations of independent variables with tungiasis using the school as a random effect.

RESULTS

The overall prevalence of tungiasis in the first survey was 1.35% [95% confidence interval (CI): 1.15-1.59%], and 0.89% in the second survey. The prevalence ranged from 0.08% (95% CI: 0.01-0.59%) in Taita Taveta county to 3.24% (95% CI: 2.35-4.44%) in Kajiado county. Tungiasis infection was associated with county of residence, male sex [adjusted odds ratio (aOR) = 2.01, 95% CI: 1.52-2.67], and lower age (aOR = 0.81, 95% CI: 0.75-0.88). For the first time we demonstrate an association with attending public schools rather than private schools (aOR = 5.62, 95% CI: 1.20-26.22) and lower socioeconomic status (aOR = 0.10, 95% CI: 0.03-0.33). Using a rapid screening method of the top of feet only, would have missed 62.9% of all cases, 78.9% of mild cases and 20.0% of severe cases.

CONCLUSIONS

Tungiasis is widely but heterogeneously distributed across Kenya. School-based surveys offer an efficient strategy for mapping tungiasis distribution.

Tungiasis Stigma and Control Practices in a Hyperendemic Region in Northeastern Uganda

Neglected tropical diseases are known to be highly stigmatized conditions. This study investigates tungiasis-related stigma and control practices in the impoverished Napak District in rural northeastern Uganda, where tungiasis is hyperendemic and effective treatment is unavailable. We conducted a questionnaire survey with the main household caretakers (n = 1329) in 17 villages and examined them for tungiasis. The prevalence of tungiasis among our respondents was 61.0%. Questionnaire responses showed that tungiasis was perceived as a potentially serious and debilitating condition and that tungiasis-related stigma and embarrassment were common. Among the respondents, 42.0% expressed judging attitudes, associating tungiasis with laziness, carelessness, and dirtiness, and 36.3% showed compassionate attitudes towards people with tungiasis. Questionnaire responses further indicated that people made an effort to keep their feet and house floors clean (important tungiasis prevention measures), but lack of water was a common problem in the area. The most frequent local treatment practices were hazardous manual extraction of sand fleas with sharp instruments and application of various and sometimes toxic substances. Reliable access to safe and effective treatment and water are therefore key to reducing the need for dangerous treatment attempts and breaking the vicious cycle of tungiasis stigma in this setting marked by poverty.

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.

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.

A mixed-methods approach to understanding domestic dog health and disease transmission risk in an indigenous reserve in Guyana, South America

Domestic dogs (Canis lupus familiaris) can transmit a variety of pathogens due to their ubiquitousness in urban, rural and natural environments, and their close interactions with wildlife and humans. In this study, we used a mixed-methods approach to assess the role of domestic dogs as potential intermediaries of disease transmission from wildlife to humans among indigenous Waiwai in the Konashen Community Owned Conservation Area, Guyana. To address these objectives we 1) performed physical examinations and collected biological samples to assess Waiwai domestic dog health, and 2) administered questionnaires to characterize the role of dogs in the community and identify potential transmission pathways between wildlife, dogs, and humans. We observed ectoparasites on all dogs (n = 20), including: fleas (100%), ticks (15%), botflies (30%), and jigger flea lesions (Tunga penetrans) (80%). Ten percent of dogs were seropositive for Ehrlichia canis/ewingii, 10% were positive for Dirofilaria immitis, and one dog was seropositive for Leishmania infantum. All dogs (n = 20) were seronegative for: canine distemper virus, Brucella canis, Leptospira serovars, Trypanosoma cruzi, Anaplasma phagocytophilum/platys and Borrelia burgdorferi. Our questionnaire data revealed that the Waiwai remove ectoparasites from their dogs, clean up dog feces, and administer traditional and/or Western medicine to their dogs. White blood cell, strongyle-type ova, and eosinophil counts were lower in dogs that were not frequently used for hunting, dogs that did receive traditional and/or western medicine, and dogs that were frequently kept in elevated dog houses, although differences were not statistically significant. While our results suggest that the Waiwai have developed cultural practices that may promote dog health and/or prevent zoonotic disease transmission, more research is necessary to determine the efficacy of these practices. Our study provides important data on the health of dogs and the potential for disease transmission to humans in a zoonotic hotspot.

Domestic dogs are found throughout the world and interact closely with both wildlife and humans. Dogs can harbor numerous diseases that can be transmitted to other domestic and wildlife species, and human populations. They can serve as bridges, moving diseases between unconnected populations. Additionally, dogs can help in the early detection of wildlife and human diseases. Therefore, understanding what pathogens domestic dogs harbor can inform both wildlife and human health. In this study, we performed physical examinations, collected biological samples, and administered questionnaires to assess dog health and understand the role of dogs as potential bridges of disease transmission from wildlife to humans among indigenous Waiwai in the Konashen Community Owned Conservation Area, Guyana. On physical exam, we observed ectoparasites on all dogs, however, few pathogens were detected with diagnostic screening. Our questionnaire data revealed that the Waiwai engage in husbandry practices that may promote Waiwai dog health.

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.

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.

Questionnaire Modifications and Alternative Scoring Methods of the Dermatology Life Quality Index: A Systematic Review

OBJECTIVES

Dermatology Life Quality index (DLQI) is the most widely used health-related quality of life questionnaire in dermatology. Little is known about existing questionnaire or scoring modifications of the DLQI. We aimed to systematically review, identify, and categorize all modified questionnaire versions and scoring methods of the DLQI.

METHODS

We performed a systematic literature search in PubMed, Web of Science, CINAHL, and PsychINFO. Methodologic quality and evidence of psychometric properties were assessed using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) and Terwee checklists.

RESULTS

The included 81 articles reported on 77 studies using 59 DLQI modifications. Modifications were used for a combined sample of 25 509 patients with 47 different diagnoses and symptoms from 28 countries. The most frequently studied diseases were psoriasis, hirsutism, acne, alopecia, and bromhidrosis. The modifications were categorized into the following nonmutually exclusive groups: bolt-ons or bolt-offs (48%), disease, symptom, and body part specifications (42%), changes in existing items (34%), scoring modifications (27%), recall period changes (19%), response scale modifications (15%), and illustrations (3%). The evidence concerning the quality of measurement properties was heterogeneous: 4 of 13 studies were rated positive on internal consistency, 1 of 3 on reliability, 3 of 5 on content validity, 9 of 22 on construct validity, 6 of 6 on criterion validity, and 1 of 1 on responsiveness.

CONCLUSION

An exceptionally large number of DLQI modifications have been used that may indicate an unmet need for adequate health-related quality of life instruments in dermatology. The psychometric overview of most questionnaire modifications is currently incomplete, and additional efforts are needed for proper validation.

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.

Tickbite-associated chronic pruritic lesions in an Afro-descendant population in the Cauca Department, Colombia. I. Clinical features and impact on health

BACKGROUND

During a health survey in a remote area in southwest Colombia, it became apparent that a high percentage of the population suffered from chronic pruritus in association with high numbers of ticks and tickbites.

OBJECTIVE

To determine the clinical features and severity of tickbite-associated pruritus.

METHOD

At twotime points - 8 weeks apart to account for seasonal effects - a cross-sectional study was conducted encompassing physical examination of the population, histological analysis of skin biopsies, and determining serum for antibodies against spotted fever (SFG) rickettsiae and typhus group (TG) rickettsiae. Ticks were identified using morphological criteria, and infection by rickettsiae was determined by PCR.

RESULTS

About 94.5% of the population (95% CI 92-97%) showed clinical signs of a pruritic arthropod reaction and of chronic pruritus with lichenoid papules and hyper- and hypopigmented nodules on otherwise noninflamed skin. Pruritus markedly impaired the quality of life in terms of sleeping disturbances. No signs for other diseases were observed. Chronic pruritus appeared to be because of repeated tickbites and scratching, but not because of other dermatological or medical conditions. Antibodies against SFG and TG-rickettsiae were detected at 79.0% (95% CI 73-86) and 3.6% (95% CI 0.7-6), respectively. Ticks were identified as Amblyomma cajennense.

CONCLUSION

Remarkably high exposure to tick bites caused an unusually high rate of acute and chronic pruritus and markedly impaired quality of life of the investigated rural community. This underlines the necessity of public health measures and surveillance of rickettsial disease.

Efficacy of a mixture of neem seed oil (Azadirachta indica) and coconut oil (Cocos nucifera) for topical treatment of tungiasis. A randomized controlled, proof-of-principle study

Background

Tungiasis is a neglected tropical skin disease caused by the female sand flea (Tunga penetrans), which burrows into the skin causing intense pain, itching and debilitation. People in endemic countries do not have access to an effective and safe home treatment. The aim of this study was to determine the efficacy of a traditionally used and readily available mixture of neem and coconut oil for treatment of tungiasis in coastal Kenya.

Methodology

Ninety-six children aged 6–14 years with at least one embedded viable flea were randomized to be treated with either a mixture of 20% neem (Azadirachta indica) seed oil in coconut oil (NC), or with a 0.05% potassium permanganate (KMnO₄) foot bath. Up to two viable fleas were selected for each participant and monitored for 6 days after first treatment using a digital microscope for signs of viability and abnormal development. Acute pathology was assessed on all areas of the feet using a previously established score. Children reported pain levels and itching on a visual scale.

Results

The NC was not more effective in killing embedded sand fleas within 7 days than the current standard with KMnO₄, killing on average 40% of the embedded sand fleas six days after the initial treatment. However, the NC was superior with respect to the secondary outcomes of abnormal development and reduced pathology. There was a higher odds that fleas rapidly aged in response to NC compared to KMnO₄ (OR 3.4, 95% CI: 1.22–9.49, p = 0.019). NC also reduced acute pathology (p<0.005), and there was a higher odds of children being pain free (OR 3.5, p = 0.001) when treated with NC.

Conclusions

Whilst NC did not kill more fleas than KMnO₄ within 7 days, secondary outcomes were better and suggest that a higher impact might have been observed at a longer observation period. Further trials are warranted to assess optimal mixtures and dosages.

Trial registration

The study was approved by the Kenya Medical Research Institute (KEMRI) Scientific and Ethical Review Unit (SERU), Nairobi (Non-SSC Protocol No. 514, 1st April 2016) and approved by and registered with the Pharmacy and Poisons Board’s Expert Committee on Clinical Trials PPB/ECCT/16/05/03/2016(94), the authority mandated, by Cap 244 Laws of Kenya, to regulate clinical trials in the country. The trial was also registered with the Pan African Clinical Trial Registry (PACTR201901905832601).

Tungiasis is a disease caused by the female sand flea which burrows into the skin of the feet and causes intense pain and itching. People in endemic tropical areas do not have access to a simple, effective and safe method for treatment at home. The most common treatment used during clinical outreach activities is a foot bath in a disinfectant. Here we report on a clinical trial testing the effectiveness of a mixture of neem and coconut oils to kill the embedded fleas and reduce inflammation, pain and itching. We found the oil mixture reduced the proportion of fleas alive in the foot after 6 days in a similar way as the footbath in disinfectant, which is unavailable to households. However, unlike the footbath, the neem oil treatment caused most of the fleas to rapidly age in the foot and decreased the inflammation, leaving more children pain-free after one week. We conclude the neem and coconut oil mixture could be a promising approach for the treatment of tungiasis but its activity on the fleas might be slower. We need to follow up with longer observation time and test different dosages and application times.

Tungiasis: a highly neglected disease among neglected diseases. Case series from Nduta refugee camp (Tanzania)

Tungiasis is a highly prevalent yet neglected disease of populations affected by extreme poverty. It causes great discomfort and pain, leads to social stigmatization and, when left untreated, can cause serious complications. Although natural repellents have been shown to be effective, too little is being done in terms of systematic prevention and treatment. In addition, self-treatment (usually extraction of fleas with non-sterile sharp instruments) comports high risks of infection, notably with viral hepatitis and human immunodeficiency virus. In this article, we report seven severe cases of tungiasis in children living in a refugee camp in Tanzania, all of whom were treated with surgical extraction of the fleas because the topical treatment (dimethicone) was not available. Refugee camps—particularly in sub-Saharan Africa where tungiasis is endemic—should be considered high-risk areas for the condition. Aid organizations should engage in active case searching, and health promotion should be systematically carried out.

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.

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.

Integrated Management of Skin NTDs-Lessons Learned from Existing Practice and Field Research

Integration of neglected tropical diseases (NTDs) into the public health agenda has been a priority in global health for the last decade. Because a number of these diseases share not only the geographical distribution, but also a common feature which is skin involvement, bringing together a sub-group of 'skin NTDs' is one way forward to promote further integration among NTDs. With these diseases, which include leprosy, Buruli ulcer, yaws, mycetoma, lymphatic filariasis, and leishmaniasis, patients may be left with life-long deformities and disabilities when diagnosis and treatment are delayed. Stigma is another serious consequence of skin NTDs as it places a large barrier on the economic activities and social life of a patient. As a result, this creates a vicious cycle and obstructs a key goal of society, the elimination of poverty. Enhancement in surveillance systems as well as the further development of diagnostic methods, improvement in treatment and management, and identification of preventative measures for skin NTDs are therefore urgently needed. This article summarizes the existing practices and field research on skin NTDs and identifies potential synergies that could be achieved by adopting this integrated approach.

Tungiasis Presenting as Onychomycosis: Probably the First Report of Flea Infestation of the Nail Observed Using Modified Potassium Hydroxide Mount Technique

Tungiasis is an infection/infestation of the flea Tunga penetrans. These are bloodsucking ectoparasitic insects belonging to the phylum Arthropoda, and they do not possess wings, but they have long legs enabling them to jump up to 30 cm high. The fleas are usually present on the skin and in the hair of domestic and wild animals and are prevalent throughout the world. They may also be present in an environment consisting of dry sandy soils, and they infect people who walk barefoot and reside in flea-infested areas. Human tungiasis is both an accidental and zoonotic infection, where the fleas enter the human skin and cause severe morbidity if not properly managed. There are a few reports of human tungiasis, most of which were diagnosed with skin infections. This is a first-of-its-kind observation of fleas in the nail, from a patient who is suspected to be suffering from onychomycosis. The nail in this case was processed differently, by using a modified potassium hydroxide (KOH) mount technique.

Control of Tungiasis in Absence of a Roadmap: Grassroots and Global Approaches

Tungiasis is a tropical skin disease caused by the sand flea Tunga penetrans. It inflicts misery upon tens of millions of people, mostly children, across Central and South America and sub-Saharan Africa, and yet there is no globally accepted roadmap for its control. Here we review how research in the last 15 years has developed control methods and report on new grassroots and digital mapping approaches. Treatment is now possible with a two-component dimethicone, used for the treatment of headlice in Europe, Asia and Canada, but not yet available in most tungiasis-endemic areas. Prevention is possible through the daily use of repellents based on coconut oil. A Kenyan coastal community has successfully controlled tungiasis using a neem and coconut oil mix produced locally to treat cases, combined with spraying floors with neem solution and distributing closed shoes. Development of affordable hard floor technology is underway, although not yet widely available, but is a priority to control off-host stages in the floors of homes. A new web-based digital mapping application will enable researchers and health officials to collaborate, share data and map the prevalence of tungiasis. We conclude that tungiasis can be controlled through a multi-disciplinary, One Health approach.