Introduction

Tungiasis, a tropical disease recently classified by the World Health Organisation (WHO) as a neglected tropical disease (NTD), is caused by the parasitic flea, Tunga penetrans (also known as the T. penetrans flea, sand flea, jigger, chica, nigua, pique, pico, or suth). This condition primarily affects impoverished communities in tropical and subtropical regions, particularly in Sub-Saharan Africa, South America and the Caribbean. The WHO estimates a 7% to 63% prevalence of tungiasis in endemic regions. Sand fleas prefer sandy environments such as beaches and farms. Characterised by painful lesions, tungiasis can lead to significant discomfort, secondary infections and in severe cases, disfigurement or disability. The disease thrives where hygiene and sanitation measures are poor, making their improvement pivotal for effective prevention.

What is tungiasis?

Tungiasis is caused by the female T. penetrans flea, which burrows into the skin (most often on the feet) to lay its eggs, and 95 to 98% of tungiasis affects the feet, primarily the skin around toenails, toes, soles, and heels.¹ Once embedded, the flea swells by approximately 2000 times its size (to about 1 cm) within a week as it matures, maintaining contact with the environment through a hole and eventually expelling 100-200 eggs into the environment in the space of two weeks.¹ The flea eventually dies and is shed by the host's skin. Embedded fleas cause extreme inflammation, itching, pain, deep fissures, ulcers, and abscesses. If left untreated, superinfection of the lesions can lead to complications such as tetanus, cellulitis, sepsis, or necrosis, and even gangrene, limb amputation, or death in individuals with impaired blood flow and/or immunity.^1,2,3 

There is still no drug treatment for tungiasis, with the best treatment being surgical removal of the embedded flea under sterile conditions, wound care, prevention of infections, and management of the affected site.⁴ These treatment options are not available to many affected by tungiasis, and in desperation, many resort to removing fleas with thorns or other non-sterile sharp objects, exposing themselves to infections and transmission of diseases such as HIV,  hepatitis B virus, and hepatitis C virus.³  

Developing tungiasis is closely linked to environmental conditions and human behaviours. The parasite thrives in sandy or dusty soil, particularly in areas with high temperatures and low humidity.⁵ Barefoot walking, the presence of domestic animals, and inadequate sanitation amplify the risk of infestation.⁴ These factors highlight the importance of targeted interventions focused on sanitation as well as personal and environmental hygiene.⁴

Hygiene and tungiasis prevention

Hygiene practices are essential to tungiasis prevention. By reducing the direct exposure of individuals to contaminated soil, hygiene interventions limit the opportunities for flea penetration. Some key hygiene measures include:

Use of footwear

The single most effective personal hygiene measure against tungiasis is consistent footwear usage. Shoes and socks act as a barrier, preventing sand fleas from accessing the skin. Studies have shown that wearing closed-toe shoes significantly reduces the incidence of tungiasis.^5,6 However, barriers to adopting this practice, such as poverty, cultural norms, and limited access to affordable footwear, exist in affected communities.

Skin care and hygiene

Regular washing of feet with soap and water helps remove fleas before they embed into the skin. Moreover, applying moisturising agents reduces skin cracks that could serve as entry points for fleas. Topical insecticides have also proven effective in controlling the spread.¹⁰ Communities where oils such as dimethicone oil, tea tree oil, neem oil, and coconut oil are applied regularly to feet experience fewer cases.^3,5,6 For individuals in endemic regions, performing daily foot inspections can help identify and address infestations early.

Clean clothes and regular washing also make it difficult for T. penetrans to thrive.⁵ Some studies show boys are at greater risk of developing tungiasis. This is thought to be linked to lifestyle and hygiene practices, which differ from girls.² For similar reasons, those with disabilities, young children, and the elderly (4–15 years and ≥60 years) are also at an increased risk of developing the disease.^5,7

Household hygiene

Hygiene measures within the household are equally important. Regular sweeping and cleaning of floors, especially in sandy or dusty environments, can reduce the risk of infestation. Encouraging households to invest in mats or rugs for bare floors provides an additional barrier against fleas. Unsealed earthen floors have been linked to an increased risk of developing tungiasis; therefore, sealed, washable floors are recommended.^7,8 The most infested areas are under beds and hammocks.⁵ Communities which have adopted the practice of treating floors with neem solution or other plant-based repellents saw a significant reduction in the disease.^5,9 Frequent laundering of clothes and bedding further minimises exposure.

Wound care

After flea extraction, wound care is important when preventing secondary infections. The wound should be cleaned and kept dry with regularly changed dressings covering it.⁴ 

Sanitation and tungiasis prevention

While personal hygiene is essential, it must be complemented by environmental sanitation efforts to break the cycle of tungiasis transmission. Poor sanitation creates an ideal breeding ground for T. penetrans. The interventions include:

Soil management

Since T. penetrans thrives in sandy or dusty soil, managing these environments can significantly reduce flea populations. Effective solutions include:

• Soil treatment: application of insecticides has shown promise in controlling flea populations, with insecticides such as hypercypermethrin and methylcarbamates being recommended to chemically treat the soil and floors in Kenya for example, however, these insecticides are toxic to the environment, humans, and animals and raise ethical concerns⁵
• Vegetation management: clearing vegetation near residential areas can potentially minimise flea habitats

Animal hygiene

Domestic animals, including dogs, cats, and livestock, often harbour T. penetrans, acting as reservoirs.¹¹ Regular grooming, treatment with anti-parasitic agents, and restricting animals’ access to human living spaces can reduce transmission risk. The cost of flea treatments and the lack of veterinary health services in endemic areas are limitations, however.⁵ Additionally, there are no widely accepted, safe, affordable insecticides for the treatment of tungiasis in animals.¹² 

Clean public spaces

Community cleaning drives targeting shared spaces, such as playgrounds and markets, can help limit the spread of fleas. Additionally, installing infrastructure such as cement or pavement in place of dirt paths, for example, would reduce conditions that support flea proliferation.

Community approach to the prevention of tungiasis

Education and behavioural change

Educating at-risk populations about the life cycle of T. penetrans and its transmission is crucial. Awareness campaigns should emphasise:

• The importance of wearing shoes
• Regular cleaning and inspection of feet
• Avoiding prolonged contact with infested soil

Community drives, interactive workshops, and visual aids have proven effective in supporting behaviour change in resource-limited settings. In Kenya, for example, community health volunteers conduct home visits in their community to promote healthy hygiene practices and the use of health services.⁵

School-based interventions

Schools are effective platforms for promoting hygiene and sanitation. Programs that provide students with shoes, teach foot hygiene, and involve them in environmental cleaning activities can have a ripple effect, influencing families and communities. 

Additionally, schools can introduce health and sanitation drives where students actively participate in monitoring hygiene and sanitation practices at home and in their communities. These groups may also serve as a platform for peer education, amplifying awareness.

Collaboration with local governments

Local governments play a pivotal role in sustaining interventions. Policies which prioritise access to affordable footwear, enforce waste management regulations, and fund environmental improvements create long-term impacts. Governments can also coordinate vaccination programs, such as tetanus immunisations, to mitigate secondary risks associated with tungiasis.

Research and monitoring

Ongoing research is essential for understanding tungiasis’ epidemiology and evaluating intervention effectiveness. Data-driven strategies enable resources to be allocated efficiently, ensuring interventions target high-risk areas.⁵ Collaborations between academic institutions and local health agencies can lead to innovative solutions tailored to specific community needs.

Partnerships with non-governmental organisations and international organisations

Non-governmental organisations (NGOs) and international bodies such as the WHO bring valuable resources and expertise to endemic regions. Partnerships can provide funding for infrastructure improvements, such as the construction of concrete floors, and support large-scale awareness campaigns. They can also supply essential materials like shoes and soap, ensuring that vulnerable populations have access to preventive tools.

Challenges in tungiasis prevention

Despite the clear benefits of hygiene and sanitation in preventing tungiasis, challenges remain. These include:

• Poverty and resource constraints: in many endemic regions, poverty limits access to basic necessities, including shoes, soap, and clean water. Addressing these barriers requires coordinated efforts from governments, NGOs, and international organisations
•  Cultural practices: Some communities have cultural or traditional practices that discourage footwear use in addition to superstitions and stigmas surrounding tungiasis, which hinder prevention and treatment.⁶ Tailored educational campaigns which respect local customs while promoting change are essential. Engaging community leaders can facilitate acceptance of new practices
• Climate change and urbanisation: Climate change and rapid urbanisation may expand the habitats of T. penetrans, potentially increasing the disease’s reach. Urban planning that prioritises sanitation and pest control can help mitigate these risks, particularly in informal settlements

Conclusion

Hygiene and sanitation play a vital role in tungiasis prevention, offering simple yet effective measures to end the parasite’s life cycle. By combining personal hygiene practices with environmental interventions and community engagement, significant progress can be made in reducing the burden of this neglected disease. However, achieving lasting success requires addressing systemic challenges such as poverty, resource limitations, and cultural barriers.

As the global health community continues to prioritise neglected tropical diseases, the fight against tungiasis serves as a reminder of the profound impact of basic hygiene and sanitation. With sustained commitment and collaboration, affected communities can receive adequate support and move closer to living free from the effects of tungiasis.