Introduction

Tungiasis is a disease caused by parasites that regularly occurs in the marginalised, poor communities of urban and rural Sub-Saharan Africa, South America, and several islands in the Caribbean. The World Health Organisation classifies it as a neglected tropical disease since the health sector and decision-makers are not adequately funding its treatments or raising awareness for preventative action.^2,12 The disease spreads when people walk barefoot on contaminated soil or surfaces that contain sand fleas called Tunga penetrans. Once mature, the female sand fleas burrow underneath the skin, where they feed on blood, grow, and produce eggs.^8,9 This causes itchiness, pain, and swelling, which can result in sleep disturbance, difficulty walking, and an increased risk of developing an abscess. In severe cases, the sand fleas can cause anaemia (due to long-term blood loss) and significant weight loss (due to secondary bacterial infections and pain and discomfort, potentially leading to immobility, loss of appetite and/or malnutrition).^1,2,9,11 This can create a great emotional strain as those with tungiasis can face social isolation due to immobility and ridicule by others in the community, as the disease is closely associated with poverty.¹

Why do community-based interventions matter?

Several things about tungiasis make community-based interventions more important. Firstly, despite the proportion of people with the disease varying greatly from community to community, it could reach as high as around half of the population in affected communities.^2,7 In addition, the disease commonly affects the already most vulnerable – children under 14 years of age, elderly individuals, and people with disability.⁹ The families affected are typically already marginalised and rarely seek medical care.² Another problem is that even after successful treatment, if the patient is again exposed to contaminated soil, recurrent infections are quite common.⁶ 

The control of tungiasis needs collective action, as the behaviours of a few individuals can continue the disease's spread.² Ways to prevent the disease from spreading involve behavioural changes, such as ensuring proper maintenance of the environment, washing feet with soapy water daily, and avoiding walking barefoot.⁵ Domestic animals such as dogs, cats, goats, pigs, and wild animals such as rats and monkeys can also be infected and act as reservoirs where sand fleas breed.² As tungiasis is greatly associated with poverty, it could contribute to the cycle of poverty by making it hard for affected children to attend schools, contributing to a lack of education and impacting household income by infecting their livestock.² 

Sustainable control of the disease would entail engaging the community to create multipronged interventions that would make treatment more accessible, educating the people on how to prevent sand flea infestation, and making household living conditions better.^5,10 This is done through collaboration and coordination between different sectors such as environmental, human, and animal health.¹²

Key community-based interventions

Health education and awareness

The life cycle of Tunga penetrans lasts for several weeks, highlighting the need for continuous campaigns to educate people about its treatment and prevention to reduce the risk of reinfection.⁵ Education should include safe treatment options such as dimeticone (anti-parasite sprays) and proper surgical extraction of the parasites under sterile conditions.² Preventative measures include sealing floors, good hygiene, wearing closed shoes, and the use of certain plant-based repellents such as neem and coconut oil.¹ It is also important that people be informed that certain domestic and wild animals are reservoirs for the disease.⁴ Educational campaigns should target both affected individuals and the wider community to address shared risk factors such as dirt floors and breeding grounds for the parasite.¹ Raising awareness in the community should foster empathy and address the stigma associated with the disease.¹⁰ Schools and community buildings are key places to promote awareness.¹ 

Environmental modifications and housing improvements 

One of the best ways to control tungiasis is by replacing dirt floors with solid floors, as studies show the incidence of severe forms of the disease in children halves if the floors are sealed in their homes.^2,7 Similarly, a seventh of childhood cases can be prevented if solid floors are installed in schools.⁷ However, hygiene remains a priority over floor changes, as contaminated soil could still accumulate in sealed floors if not cleaned regularly.³ In addition, personal hygiene could be improved through the provision of wells and better access to clean water.⁴

Footwear promotion and hygiene practices

Closed shoes are important in the primary prevention of tungiasis, but people in endemic areas (rural areas, remote villages and shanty towns in large cities) see them as impractical since they are too costly to them, and they often wade through wet environments and walk long distances, which would easily destroy them.^1,4 Initiatives to promote shoe use could be implemented to change local perception. Other proven preventative measures include at least once a day washing of the feet with soap and water and twice a day application of coconut oil, aloe vera, jojoba oil, or neem extract to the feet.^1,2,7

Animal and livestock management

Management of animal reservoirs is important, and animal tungiasis treatment using a combination of insect repellants, e.g., chlorfenvinphos, dichlorphos and gentian violet or a combination of imidacloprid and permethrin has been possible.² Unfortunately, weak veterinary health services in endemic areas put the feasibility of this intervention into question.² Other interventions revolve around reducing exposure to animal reservoirs, such as banning free-roaming pigs and encouraging people not to let livestock inside their homes.⁸ 

Case detection and medical treatment

Treatment with dimeticone oils, surgical extraction or cryotherapy under sterile conditions has been effective.^2,6 Following treatment, wounds should be dressed appropriately, and a tetanus vaccine should be administered if warranted.⁹ Community-wide case detection and treatment are important since there is widespread difficulty in mobilisation, therefore visiting the affected person’s home might be preferable.^6,12 To make the detection and treatment of tungiasis accessible and sustainable, disease management should be integrated into the local health systems and existing control programs for other diseases (such as soil-transmitted helminths, malaria, and onchocerciasis), water, sanitation, hygiene, and school-based interventions.^8,10

Barriers to implementing treatments

One key barrier to the implementation of tungiasis treatments is the social stigma surrounding the disease, with some in the community and even health workers referring to individuals affected as illiterate, ignorant, and lazy.¹⁰ This stigma might lead to isolation, emotional distress, and disengagement with preventive measures such as wearing shoes.⁴ Another issue is finding the funding for treatment gaps in tungiasis programs with overreliance on volunteers, limited availability of effective treatments like dimeticone, and lack of research on alternative treatments or preventative measures.^9,12 There is also a lack of guidelines and strategies for prevention, which leaves health workers and NGOs relying on non-evidence-based methods.¹² Political actors fail to publicly recognise tungiasis due to the stigma associated with poverty and underdevelopment and in addition, politicians, health officials and NGOs working in silos leads to poor coordination between stakeholders.^8,12

Success stories

Kilfi county, kenya – community health volunteers

A community group in a coastal area of Kilifi County in Kenya has developed an effective approach to tungiasis control. They are a group of 30 community health volunteers who employ a combination of treatment and preventative approaches. They used a locally-produced herbal medicine containing neem and coconut oil to treat cases. They regularly visited homes, local public and private nurseries, and primary schools to identify and treat infected individuals. They then counselled the children and parents on prevention, such as sealing floors, wearing closed shoes, corralling animals away from family resting places, and good hygiene and sanitation practices. They also promoted spraying of house floors with a solution using neem leaves. Apart from this, they partnered with a shoe brand to distribute free shoes to children. In two years, they had successfully reduced the proportion of children having the disease in schools from 17.6% to less than 1%.² 

Nigeria – community-led tungiasis program

A rural community in Nigeria had identified several factors associated with tungiasis in their local area. In response, grassroots interventions were implemented. These included the provision of free cement to households and schools to seal sandy floors, the promotion of shoe-wearing and environmental hygiene to prevent disease transmission. Additionally, there was a ban on free-roaming pigs and active discouragement of pig farming to prevent tungiasis from spreading. Within a year, tungiasis cases were reduced by half, and the program has since been adopted by neighbouring regions.⁸ Key to the success of activities was the consistent commitment and active support of the traditional leaders of the community.⁸

Kenya – alternative flooring innovation

Concrete floors are an effective way to prevent the spread of tungiasis, but are unfortunately very expensive, need special materials to make, and skilled masons to install them. A pilot study in Kenya was done to develop an alternative to concrete floors.³ The researchers experimented with materials that are readily available in the community, which include soil from termite mounds, fire ash, coconut fibres, and cow dung. In the end, they were successful in creating a floor that is a third of the price of concrete floors. The results of this study suggested a possible 40-50% reduction in contracting the infection.³ They have noted that not all families who received the new floors regularly clean them, which underscores the need for a multipronged approach, not just floor intervention.³

Summary

Tungiasis is a disease that has a huge effect on those who are affected. To adequately treat and control its spread, community-based interventions that promote good hygiene practices, the dissemination of tungiasis information, environmental modifications, the improvement of housing, the use of protective footwear, and the management of animal rearing are urgently needed. Regular case detection and accessibility of treatment are essential. Current political and health system challenges still remain, including tungiasis-related stigma, cultural beliefs, inadequate funding, limited access to clean water or treatments, and lack of political leadership to tackle the disease. Despite this, community-led success stories demonstrate that the reduction of tungiasis cases can be achieved when tailored to local needs and resources.