Parasitol Res (2013) 112:3635–3643
DOI 10.1007/s00436-013-3551-8
ORIGINAL PAPER
Tungiasis: a neglected epidermal parasitic skin disease
of marginalized populations—a call for global science
and policy
Kaliyaperumal Karunamoorthi
Received: 26 May 2013 / Accepted: 22 July 2013 / Published online: 15 August 2013
# Springer-Verlag Berlin Heidelberg 2013
Abstract Tungiasis (sand flea disease) is an ectoparasitic skin
disease caused by the female sand flea/jigger flea (Tunga
penetrans). As poverty is the major driving force of the
disease, it can be called as a poverty-associated plague. It is
one of the emerging neglected diseases in Latin America,
Caribbean, sub-Saharan Africa, and India. The aim of the
present scrutiny was to assess the public health impact of
tungiasis, associated risk factors, and emerging opportunities
to prevent and control tungiasis. Searches of PubMed, Google
Scholar, and online search engines (Google, AOL, and Yahoo)
using keywords “parasitic skin disease,” “tungiasis,” “sand
flea,” “ tungiasis-associated risk factors,” “tungiasis preven-
tion and control,” and their synonyms were used as a source of
references. Searches were made without time limitations. Of
167 potential articles identified by these criteria, 51 appropri-
ate were selected for review. Tungiasis is widespread in the
resource-constrained settings of low-income economies. In
the tropics, it is highly prevalent among the impoverished
populations, but the associated risk factors are often poorly
identified and remain uncontrolled. Though it is a self-limiting
disease with considerable morbidity, the parasite may cause
subsequent secondary morbidity through life-threatening
complications and infections like cellulitis, tetanus, and death.
However, the direct and indirect sociocultural, economic, and
health impact of tungiasis is often undervalued and misunder-
stood. A systematic assessment on disease burden is still
dearth and deficient. Over the decades, tungiasis has been
largely neglected by the scientific community, policy makers,
and healthcare stakeholders. In the endemic regions, even
K. Karunamoorthi (*)
Unit of Medical Entomology and Vector Control, Department of
Environmental Health Sciences and Technology, College of Public
Health & Medical Sciences, Jimma University, Jimma, Ethiopia
e-mail: karunamoorthi@gmail.com
tungiasis is not listed for the disease control priorities in the
regional, national, and international agenda. The majority of
the epidermal parasitic skin diseases particularly tungiasis
needs a sustainable global scientific research and control
policy. This urges intensive efforts to develop a road map that
delivers a clear vision towards zero new infection by design-
ing low-cost prevention and control strategies. Besides, there
is an urgency to develop culturally appropriate communica-
tion techniques and workable collaboration on a global scale
by bringing all the stakeholders of endemic countries.
Introduction
Epidermal parasitic skin diseases (EPSD) have been known
since ancient times and occur worldwide. Despite the consid-
erable burden caused by EPSD, this category of parasitic
diseases has been widely neglected by the scientific community
and healthcare providers. Though number of EPSD are preva-
lent, only six are considered as major public health concern:
scabies, pediculosis (head lice, body lice, and pubic lice infes-
tation), hookworm-related cutaneous larva migrans, and
tungiasis (Feldmeier and Heukelbach 2009). Though these
diseases are nonfatal, they do cause considerable morbidity.
People in the bottom billion are the poorest in the world; they
are often subsistence farmers, refugees, and displaced who
essentially live on no money and are stuck and trapped with
many of the poverty-linked diseases (Collier 2007; Sachs
2008). These people are often very illiterate with serious lack
of awareness about the risks of contracting many parasitic and
infectious diseases. These diseases cause serious negative pub-
lic health impact and impose severe economic burdens too
(Kimani et al. 2012). Indeed, the poor socioeconomic status
disproportionally affect the world’s poorest section of the
3636
society and often makes them most vulnerable to many para-
sitic diseases particularly tungiasis.
Tungiasis (jigger flea infestation): a most neglected disease
Tungiasis is a parasitic skin disease caused by permanent
penetration of the female sand flea [Tunga penetrans (also
known as Sarcopsylla penetrans); (Siphonaptera)] into the
epidermis of its host. The “Sand fleas” are also known as
“beach fleas” since they are commonly found along the beach
area. However, generally, people may refer to fleas that just
happen to be developing in sandy areas as “sand fleas.” It is an
exclusively tropical ectoparasitosis imported from the New
World. It is currently present in South and Central America, in
the West Indies (Haiti, Trinidad), in sub-Saharan Africa, and
in the Indian Ocean (Madagascar and the Seychelles). Very
sporadic cases have also been reported in India and Pakistan
(Fig. 1) (Lowry et al. 1996; Stanford 2001). It is also consid-
ered as one of the major traveler’s diseases in the industrial-
ized countries.
It has been estimated that the prevalence of tungiasis may
reach more than 50 % of the population in some of the
hyperendemic zones, with often recurrent and sometimes mas-
sive parasitic infestations, responsible for superinfections and
handicap. This makes it a serious healthcare issue in some of
the low-income countries (Sachse et al. 2007; Feldmeier and
Heukelbach 2009). The prevalence, intensity of infestation, and
morbidity are positively related (Kehr et al. 2007), and the
Fig. 1 The exclusion and inclusion criteria for choosing the appropriate
research articles, notes, and reviews for this narrative review
Parasitol Res (2013) 112:3635–3643
debilitating and disfiguring sequels are common in the
resource-poor rural and urban settings. Fissures, ulcers, gan-
grene, lymphedema, deformation and loss of nails, and auto-
amputation of digits are known sequels (Feldmeier et al. 2003).
Data mining and extraction
The aim of the present scrutiny was to assess the public health
impact of tungiasis, associated risk factors, and emerging
opportunities to prevent and control tungiasis. Searches of
PubMed, Google Scholar, and online search engines (Google,
AOL, and Yahoo) using keywords “parasitic skin disease,”
“tungiasis,” “sand flea,” “tungiasis and poverty,” “tungiasis
and personal hygiene,” “ tungiasis-associated risk factors,”
“tungiasis prevention and control,” and their synonyms
(interchanging the terms) were used as a source of references.
Searches were made without time limitations. In addition,
several references retrieved by the author during the previous
work on EPSD have been used. Articles in English, French,
Portuguese, and Spanish were reviewed and analyzed. Of 167
articles identified by these criteria, 62 were selected and cited
in the reference list (Fig. 1).
Origin of fleas
Fleas (order Siphonaptera) form a unique group of insects.
They have evolved in the early Cretaceous or Jurassic ages
between 125 and 150 million years ago, probably together
with the evolution of marsupials and insectivors. Historically,
fleas are among the most important ectoparasites of humans,
in that several species are the natural vectors of several im-
portant infectious diseases, like plague. It has been estimated
that nearly 2,500–3,000 flea species are known worldwide
(Lewis 1998). They have adopted with the piercing and suck-
ing type of mouthparts. Currently, 15 families with a total of
about 220 genera have been identified (Durden and Hinkle
2009). Out of these, five families and 25 genera are ectopar-
asites of birds and the rest of all other fleas parasitize mam-
mals (Dobler and Pfeffer 2011). Fleas may play a role as
intermediate hosts of parasites and can be an ectoparasitic
nuisance in animals and humans which may cause severe
allergic reactions (Dobler and Pfeffer 2011).
Distribution of sand flea—the jigger flea or chigoe
As of 2009, tungiasis is endemic or potentially endemic to 89
countries with varying degrees of incidence and prevalence
which vary in relation to area and population studied (Fig. 2)
(Gideon, http://web.gideononline.com/web/epidemiology/
disease_info.php?ID=12490&disease=&country=&view=
Parasitol Res (2013) 112:3635–3643 3637

Fig. 2 Geographic distribution of

tungiasis

Print&symptoms and http://web.gideononline.com/web/ of spines are often used for species determination. Among
epidemiology/disease_map.php?disease_id=12490, 2013). them are the combs or ctenidia, a row of enlarged sclerotized
In fact, recent evidence indicates that at least two variants of T. spines on the head (genal ctenidium), which are always absent
penetrans occur that show a considerable degree of genetic in fleas parasitizing birds or on the prothorax (pronotal
heterogeneity (Gamerschlag et al. 2008; Feldmeier and ctenidium) which may be present or absent.
Heukelbach 2009). Interestingly, recently, a new pathogenic The host spectrum includes about 94 % mammals and 6 %
Tunga species (Tunga trimamillata) has been described from birds. It has been reported that usually 99 % of the flea
Ecuador and Peru that can parasitize humans while other population live (as larvae and pupae) on the ground and were
species exclusively parasitize wild animals (Pampiglione not perceived by humans. Thus, the host attacks are only done
et al. 2003). by 1 % of the living flea population (Linardi and Guimaráes
2000). Some flea species can serve as vectors and transmit
human pathogens; however, the complete spectrum of micro-
organisms is not clearly understood (Nagy et al. 2007). It is
Morphology of sand flea—T. penetrans well-known that the parasite of Yersinia pestis, which is caus-
ing plague/black death, transmitted mainly by the rat flea
The sand flea or chigoe flea/jigger is a parasitic arthropod found (Xenopsylla cheopis) and a few more species too.
in most tropical and sub-tropical climates. Fleas are wingless
insects and measures about 1–8 mm in size. It is usually dark
brown in color. The body is laterally compressed with a blunt
head, a compact thorax, and a fairly large, rounded abdomen
(Fig. 3). The eyes are small and vestigial in condition, and it
may or may not be present. There are three pairs of legs present,
while the third pair of hind legs are adapted for the jumping
purpose (some fleas jump 100–200 times their body length).
T. penetrans is the smallest flea measuring about 1 mm
length. Interestingly, sand fleas are capable of jumping nearly
20–30 cm. The bodies of adult fleas bear with many spines
backwardly directed which provide them firmness while
walking or climbing in between hairs of mammals and
feathers of birds. The shape, numbers, presence, and absence Fig. 3 Morphology of sand flea
3638
Fleas life cycle
Both the fleas’ life cycle and tungiasis transmission cycles are
interrelated. Fleas are holometabolous insects, which consist
of four stages (egg, larva, pupa, and adult) in their life cycle.
Fleas develop from eggs to larvae (usually consisting of three
instar generations) and pupae into the adult stage (Fig. 4).
Females lay up to 25 eggs per day and a total of several
hundred during their life. The speed of development process
is greatly dependent on the environmental conditions (Dobler
and Pfeffer 2011; CDC <http://www.dpd.cdc.gov/dpdx/html/
Tungiasis.htm> 2013).
Epidemiology
The sand flea is one of the few parasites, which has
spread from the Western to the Eastern hemisphere.
Originally, the ectoparasite occurred only on the Amer-
ican continent. The flea came to Angola with ballast
sand carried by the ship Thomas Mitchell that left from
Brazil in 1872. Within a few decades, T. penetrans
spread from Angola along trading routes and with ad-
vancing troops in the entire sub-Saharan Africa, includ-
ing areas with tropical rainforest (Heukelbach et al.
2001). At the end of the nineteenth century, the sand
flea reached East Africa and Madagascar. Since then,
tungiasis continues to be an endemic public health issue
and one of the major common diseases in the rural parts
of in sub-Saharan Africa. In 1899, returning British
troops brought T. penetrans to the Indian subcontinent
(Heukelbach 2004).
Sand flea parasitizes a broad spectrum of mammals. Do-
mestic animals such as dogs, cats, and pigs are frequently
affected. Peridomestic rodents such as Rattus rattus are also
important reservoirs (Heukelbach et al. 2004a). In the recent
years, several epidemics have been reported in several coun-
tries (Text box 1).
Text box no. 1: biological and epidemiological character-
istics of T. penetrans
1. Distribution Caribbean, sub-Saharan Africa, Latin America, and
India
2. Infective T. penetrans (also known as S. penetrans) and T.
Agent trimamillata
3. Vector Siphonaptera (female sand flea)
4. Vulnerable Homeless persons, small children, inhabitants of
section poor neighborhood, travelers (rarely)
5. Life cycle Partially on host
6. Transmission Soil-to-skin (very frequent) & fomite (has not been
proved)
7. Incubation 8–12 days
period
Parasitol Res (2013) 112:3635–3643
8. Clinical Identification of parasite (embedded female flea)
diagnosis
9. Typical Surgical extraction of parasite with sterile needle
therapy and dressing of antibiotics. Ivermectin has been
advocated in some publications.
10. Clinical hints Painful papule or nodule, usually on the feet—may
be multiple; begins 1 to 2 weeks after walking
on dry soil; secondary infections and tetanus are
described.
11. Complications Secondary infection, ulcer, chronic lymphedema,
nail deformation or loss, and tetanus
12. Recent 2004: Haiti—132 cases reported
outbreaks 2010: Uganda—20,000 clinical cases and 20 fatal
was reported (Jalava-Karvinen et al. 2008; Pro-
MED <http://www.promedmail.org> 2010)
2011: Ethiopia (1.2 % of school children) (Hall
et al. 2008)
13. Tungiasis in 2011: Israel—reported among Israeli travelers
travelers returning from Ethiopia (nine cases reported)
(Grupper and Potasman 2012)
14. Seasonal Peak in hot and dry season
variation
15. Animal Dogs, cats, pigs, and rats
reservoir
Mode of transmission and disease-causing mechanism
Though both the male and the female sand fleas are hema-
tophagous, only the gravid female penetrates into the skin of
the host (Heukelbach et al. 2001). Sand flea burrows usually
on the feet particularly predilection on periungual regions but
occasionally on the lips, buttocks, and even the eyelids and
undergoes hypertrophy (Feldmeier et al. 2003); within
10 days, the flea increases its volume by a factor of approx-
imately 2,000 finally reaching the size of a pea (Feldmeier
et al. 2003). The brownish part (the decomposing adult sand
flea) can be easily observed. The flea’s hindquarters remain in
contact with the air, providing an avenue for breathing, defe-
cating, and expelling eggs, while creating a painful lesion on
the host’s skin which often serves as an entry point for path-
ogenic microorganisms. Over the course of about 3 weeks, the
flea will expel as many as 800 eggs into the environment, and
eventually, the flea dies and is sloughed from the epidermis by
tissue repair mechanisms. The whole process may last up to
6 weeks (Eisele et al. 2003).
If embedded sand fleas are not taken out appropriately, they
may cause considerable morbidity (Feldmeier et al. 2003).
Furthermore, if left untreated, patients can die of secondary
infections such as tetanus in non-vaccinated individuals and
gangrene. In a study in São Paulo, Brazil, tungiasis was
identified as the port of entry for 10 % of tetanus cases (Litvoc
et al. 1991). During peak transmission, the prevalence of
tungiasis in children living in resource-poor rural and urban
communities in Brazil and Nigeria reached to more than 60 %
Parasitol Res (2013) 112:3635–3643 3639

Fig. 4 Fleas life cycle and

tungiasis transmission cycle
(CDC <http://www.dpd.cdc.gov/
dpdx/html/Tungiasis.htm> 2013)

(Heukelbach 2005; Ugbomoiko et al. 2007a). In contrast, in
high-income communities in these same countries, tungiasis is
restricted to single cases that typically occur when people visit
local beaches (Heukelbach et al. 2007a, b).
Clinical and morphological description
According to Eisele et al. (2003), clinical and morphological
criteria of tungiasis can be divided into five stages shown in
Table 1.
Typical signs and symptoms of tungiasis
The following are the typical signs and symptoms
of tungiasis (Gideon, http://web.gideononline.com/web/
epidemiology/disease_info.php?ID=12490&disease=&
country=&view=Print&symptoms and http://web.gideon
online.com/web/epidemiology/disease_map.php?disease_id=
12490, 2013):
& Skin and soft tissue—rash, wound, lesion, IV device
& Localized or unifocal rash
& Lesion(s) limited to lower extremity(ies)
& Dermal or subcutaneous nodule(s)
& Pruritus
& Subcutaneous or soft tissue lesion(s) or abscess

Table 1 Clinical and morphological description of tungiasis

Stage Duration (after Morphological Clinical signsa Pathophysiology of tungiasis

penetration) features

I 30 min–several A tiny reddish Itching and pain The pathology can be schematically divided into two patterns,
hours spot 1 mm namely, inflammation-related and itch-related. In tungiasis, the
II 1–2 days Beginning of Peal-like nodule develops. predominant morbidity is the result of heavy inflammation
hypertrophy Fleas at anal–genital opening
appear as a black dot. surrounding the lesions, together with secondary bacterial in-
III 2 days–3 weeks Maximal Expulsion of eggs and feces
fection (Feldmeier et al. 2002). Superinfection reinforces the
hypertrophy inflammatory process. Persistent inflammation and superinfec-
IV 3–5 weeks A black crest Involuted lesion contain dead tion frequently lead to long-lasting sequelae—i.e., secondary
parasite morbidity—such as suppuration, ulceration, gangrene, necrosis
V 6 weeks to A residual scar Nail deformation or loss, of surrounding tissue, deformation, and loss of nails, resulting
several lymphedema
months
in physical disability (Heukelbach 2005; Feldmeier et al. 2003).
All heavily infested individuals residing in a resource-poor
a
All are associated with sleep disturbance due to severe itching and pain neighborhood in northeastern Brazil showed signs of acute
3640
and chronic inflammation: 19 % had fissures, 50 % presented
with ulcers, and deformation and/or loss of nails occurred in
69 % (Feldmeier et al. 2003), resulting in walking difficulty in
all patients and difficulty in gripping in half of the patients
with lesions at the fingers. Superinfection of the lesions is
virtually a constant phenomenon (Feldmeier et al. 2002;
Obengui 1989), and a variety of aerobic and anaerobic bacte-
ria have been isolated from embedded sand fleas (Fischer et al.
2002; Heukelbach et al. 2004a, b).
Clinical diagnosis and treatment
The clinical diagnosis must be made taking into consideration the
dynamic nature of the morphology of the lesion (Heukelbach
2004). A broad host of pathogenic microorganisms has been
isolated from superinfected lesions, such as Staphylococcus au-
reus, Streptococcus pyogenes, Enterobacteriaceae, Bacillus spp.,
Enterococcus faecalis, Pseudomonas spp., as well as various
anaerobic pathogens (Feldmeier et al. 2002; Heukelbach et al.
2007a, b).
Standard treatment consists of surgical extraction of the
flea and application of a topical antibiotic. There are no
antibiotics available with proven effectiveness (Heukelbach
and Feldmeier 2006), and clinical trials performed in the last
few years did not show very promising results too
(Heukelbach and Feldmeier 2006). But a few studies suggest
that ivermectin can be handy for tungiasis management. How-
ever, surgical extraction still remains the treatment of choice in
patients with a low parasite load, such as tourists returning
from tungiasis endemic areas (Heukelbach and Feldmeier
2006).
Key risk factors associated with tungiasis
The factors responsible for the higher burden of EPSD in
resource-poor communities are complex and have not been
well-established (Feldmeier and Heukelbach 2009). Indeed,
tungiasis is a disease of the poor and it is a paradigmatic
example for this complex web of causation.
Poor sanitation and personal hygiene
The risk for sand flea infestation is high if feet are not protected
by shoes and socks either because people cannot afford them or
if wearing shoes is not part of local custom (Ugbomoiko et al.
2007b; Heukelbach et al. 2001). Many people, especially chil-
dren, mostly walk barefoot or only wear slippers. Illiteracy,
ignorance, and neglect presumably are other factors favoring
the high tungiasis prevalence of severe pathology in children
living in these circumstances (Heukelbach et al. 2001).
In resource-poor rural and indigenous populations in the
Parasitol Res (2013) 112:3635–3643
hinterland of Brazil, the transmission of sand flea occurred
almost exclusively indoors (Heukelbach 2005). Dwellings in
these settings typically do not possess a solid floor or the
ground is covered with rough concrete or broken tiles with
many crevices, thus providing an ideal habitat for the off-host
development of T. penetrans. In an urban environment, it
spreads in slums where roads and paths are not paved, waste
litters the area, and yards consist of sand or mud (Feldmeier
and Heukelbach 2009).
Socioeconomic and behavioral factors
It has been suggested that crowding, sharing of beds, frequent
population movements, poor hygiene, lack of access to
healthcare, inadequate treatment, malnutrition, and social at-
titudes contribute to the high burden of EPSD in these settings
(Green 1989). It is difficult to disentangle the relative impor-
tance of economic, environmental, and behavioral factors
since they frequently coexist (Heukelbach and Feldmeier
2006). There is, however, circumstantial evidence that ex-
treme poverty and its economic and social consequences play
a pivotal role (Stanton et al. 1987; Heukelbach and Feldmeier
2006). In resource-poor communities in Brazil, the severity of
tungiasis was directly related to the economic status of the
household in which the affected individuals lived (Muehlen
et al. 2006).
Lack of awareness
Though tungiasis is one of the major public health issues in
the resource-limited settings, the degree of awareness about
the cause, mode of spread, and prevention of jiggers among
people is extremely low. It is important to note that the
infected person cannot walk properly due to severe pain. In
sub-Saharan Africa in the most of resource-poor settings, the
people are expected to walk a minimum of 5–10 km to reach
the nearby health facilities to access proper treatment. How-
ever, several studies’ findings suggest that the people
complained that there is lack of support from the healthcare
providers. In addition, in fact, the myths surrounding the
tungiasis are one of the major obstacles to its elimination as
well as eradication.
Tungiasis prevention and control
Behavioral, socioeconomic, and environmental factors have
been identified as the major risk factors associated with the
prevalence and severe pathology of tungiasis. Therefore, ap-
propriate intervention measures must be instigated to reduce
prevalence and intensity of the infestation substantially
(Muehlen et al. 2006; Ugbomoiko et al. 2007b).
Parasitol Res (2013) 112:3635–3643
Planning and monitoring of mass interventions
Rapid assessment methods are commonly used not only to plan
and monitor mass interventions but also to detect parasitized
individuals (Ariza et al. 2010). In endemic areas 95–98 % of
sand flea lesions are restricted to the feet (Heukelbach et al.
2002). The different topographic areas of the feet must be
examined as a rapid method for the existence of sand fleas.
However, the presence of periungual lesions on the toes has
been identified as the most useful rapid assessment to estimate
the prevalence of tungiasis (Ariza et al. 2010).
It has been considered as one of the most reliable and
practical approaches to estimate the overall prevalence and
severity of disease in the endemic areas. This method is ex-
tremely cheap, reliable, and can be rapidly applied with min-
imal disturbance of affected individuals (Ariza et al. 2010).
Healthcare stakeholders
There is no effective chemotherapy available to kill the em-
bedded sand fleas (Heukelbach et al. 2004b, c). However, the
fleas can be taken out surgically with a sterile instrument.
Nevertheless, this requires a skilled hand and good eyesight.
In endemic areas in Brazil, surgical removal is inconsistently
performed and causes more harm than good if not done
appropriately (Feldmeier et al. 2003). However, many studies
indicate that they receive poor responses from their health
sector and healthcare stakeholders.
Insect repellents
Insect repellents could play the pivotal role in the reduction of
tungiasis disease burden as repellents are extremely useful and
helpful whenever and wherever other personal protection mea-
sures are impossible or impracticable (Karunamoorthi and
Sabesan 2009). Repellents can be electronic or can typically
be applied to the exposed skin (Karunamoorthi et al. 2010) or
to the clothes in such a way to minimize the man–vector
contact, eventually minimizing the diseases transmission and
burden (Karunamoorthi and Sabesan, 2010). However, gener-
ally, synthetic repellents have several limitations, including
reduced efficacy owing to sweating, unpleasant odor, expen-
sive, and can cause allergic reactions (Karunamoorthi, 2011).
Furthermore, in most of the resource-poor settings, many vil-
lages do not have proper well-fixed electricity systems, where
traditional plant-based insect repellents could extremely be
useful in the remote rural areas (Karunamoorthi et al. 2008a).
Feldmeier et al. (2006) have conducted an experiment by
using coconut oil as plant-based repellent to prevent sand flea
infestation in an area with extremely high transmission. The
twice-daily application of the repellent on the skin of the feet
3641
decreased the infestation rate by 86 % and reduced intensity of
infestation by 90 % despite ongoing transmission. At the same
time, tungiasis-associated pathology also declined to an insig-
nificant level. As the prophylactic method is simple, it could
be applied by the affected individuals themselves with mini-
mal input from the health sector (Feldmeier et al. 2006). It
shows that application of plant-based insect repellent could
significant prevent the penetration of sand fleas. It could be
one of the appropriate approaches to minimize the tungiasis-
associated morbidity in the majority of the endemic settings.
Plants have been used since ancient times to repel/kill
blood-sucking insects in the human history and even today in
many parts of the world where people are using plant sub-
stances for the same reason (Karunamoorthi et al. 2008b).
Globally, numerous studies evidently suggest that the tradi-
tionally used plant-based insect repellents are promising. This
appropriate strategy affords for the opportunity to minimize
chemical repellents usage and the risks associated with the
adverse side effects (Karunamoorthi et al. 2010). Furthermore,
plant-based repellent products are inexpensive, easily avail-
able, locally known, and culturally acceptable (Karunamoorthi
et al. 2010).
At the moment, there is a general consensus that plant-based
products are safe and the bioactive phytochemicals are easily
biodegradable which creates a renowned interest both among
the researchers and people. In addition, conducting intensive
research and development toward the identification of novel
low-cost, more effective, and affordable plant-based insect
repellents is quite essential and inevitable (Karunamoorthi
2012) for the sustainable reduction of tungiasis. It is important
to note that the plant-based insect repellents are providing an
opportunity not only minimizing the epidermal parasitic skin
diseases (EPSD) like tungiasis but it could also potentially
contain many insect-borne diseases like malaria, where in many
of the tropical countries it is one of the major public health
issues.
Need better understanding and instigation of health
education awareness campaign
The tungiasis mainly affects impoverished populations living
in urban squatter settlements in villages in the rural hinterland
or in traditional fishing communities along the littoral
(Feldmeier et al. 2006). Deficient behavior in seeking
healthcare is one of the important risk factor closely linked
with tungiasis.
Therefore, understanding about the people’s knowledge
and practices towards the tungiasis transmission, prevention,
control, and health seeking behavior is extremely important to
contain tungiasis effectively. Therefore, appropriate commu-
nity based studies must be conducted in the majority of the
3642
endemic settings of Latin America, Caribean, sub-Saharan
Africa, and India.
The misconception and misunderstanding of the people
about the tungiasis must be identified since it is one of the
major barriers to implement effective as well as sustainable
tungiasis control strategies in the resource-limited and ethni-
cally diverse settings. The identified issues must be addressed
effectively by health education campaigns. It can be achieved
by using the locally suitable and culturally appropriate com-
munication strategies through printed and electronic media as
a tool. The health education campaigns must delineate about
the hygienic practices and everyday personal hygiene in order
to prevent sand flea and tungiasis in the endemic settings. It
could be one of the ideal control strategies for the control or
elimination/eradication of tungiasis. It could also lead to elim-
inate other parasitic, infectious, and enteric diseases too.
Conclusion
In the past two decades, the world has made dramatic progress
in terms of improving health in the poorest countries by pro-
viding or accessing quality healthcare and narrowing the
existing gaps between countries with the best and worst health
status (WHO <http://www.who.int/mediacentre/news/releases/
2013/world_health_statistics_20130515/en/index.html> 2013).
Tungiasis is highly prevalent among the poorest section of the
society living around the coastal area, rural hinterland, and
slums due to urban agglomerations. It disproportionately af-
fects the elderly, homeless, displaced people, and is more
common among the impoverished communities. The present
scrutiny has identified some of the key issues as well as
emerging opportunities to control and eliminate tungiasis
successfully in the future.
The rapid assessment method is one of the best strategies to
estimate the prevalence and to identify the risk population. It
can be extremely useful to plan as well as monitor the
tungiasis prevention and control interventions strategies effec-
tively. The appropriate tungiasis control policy needs to be
tailored according to the local conditions, and this scrutiny
recommends the following as regional, national, and interna-
tional agendas concerning tungiasis control priorities:
& In the tungiasis endemic settings, the major risk factors
must be identified.
& Since deficient sanitation is a significant risk factor, it
must be addressed by providing appropriate urban ser-
vices like paved road, electricity, water supply, and
healthcare facilities.
& Free supply of skin disinfectant and hypodermic needles
with proper health education to remove the sand fleas at
the initial stage.
Parasitol Res (2013) 112:3635–3643
& Since poverty is one of the major driving forces for prev-
alence of tungiasis in the endemic settings, poverty alle-
viation programs must be initiated not only to minimize
the burden of tungiasis but also other poverty-associated
parasitic and infectious diseases. Besides, it could also
pave the way to enhance the socioeconomic and health
status of the marginalized population of the society
considerably.
& Furthermore, locally known and culturally acceptable
low-cost intervention strategies must be identified to min-
imize tungiasis as well as other EPSD burden.
Acknowledgments I would like to thank Mrs. Melita Prakash for her
sincere assistance in editing the manuscript. My last but not the least
heartfelt thanks goes to my colleagues of our Department of Environ-
mental Health Science, College Public Health and Medicine, Jimma
University, Jimma, Ethiopia, for their kind support and cooperation.
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