Tungiasis is caused by the “jigger” flea Tungapenetrans. The sanitation related disease has been described to cause severe morbidity among patients in endemic areas 1. According to Black and Fawcett (2008c), more than 1.2 billion people worldwide gained access to improved sanitation between 1990 and 2004 2. However, even with this progress, some 41 percent of the world’s population- an estimated 2.6 billion people, including 980 million children lack access to proper sanitation. Lack of adequate sanitation, poor hygiene and safe portable water are serious global health problems and contribute to deaths of 1.5 million children under the age of five years annually due to sanitation related diseases. In the past few years, the public health importance of tungiasis in resource-poor populations has been highlighted from different countries, including Brazil, Argentina, Haiti, Nigeria and Tanzania 3. School age childrenin developing countries bear the greatest health burden from neglected tropical infections including tungiasis, accounting for an estimated20% of the disability-adjusted life years lost due to infectiousdiseases in children less than 14 years old 4.

About 2.6 million Kenyans are infested with jiggers out of which 1.5 million are school going children who are physically and mentally disabled and unable to walk 5. The impact of the disease is felt heavily among poverty stricken rural-agricultural communities and is believed to inhibit progress and development. Serious infestations of jiggers may lead to severe inflammation leading to loss of toenails, auto amputation of digits, and death may also occur 67. It lowers the quality of life of its victims. The risk of secondary infection, such as tetanus, is also high 8. The jigger menace deprives the pupils’ concentration in class, affects extra curriculum participation often leaving children lethargic and slow in action. Adults who are attacked by the jiggers are entirely dependent as they cannot actively take part in day to day activities. In Ugenya Sub County it is believed that jigger infestation is a curse and once infected, the individual is discriminated.

Tungiasis has a focalized distribution with the disease occurring predominantly in impoverished populations. According to pilot investigations, tungiasis is highly prevalent in parts of Coast, Nyanza, Rift Valley, Western and Central regions of Kenya. However, sustainable control measures against tungiasis can only be developed if the epidemiological situation is well understood. Children are the hardest hit with a recent study estimating a point prevalence of 57% among children aged 5-12years in Murang’a South district, Kenya 9. Unhygienic conditions have been identified as the major causes of tungiasis in Kenya 10. Though such information is already available, more work on epidemiology especially in vulnerable age groups such as children and the aged in other endemic regions need to be pursued. Control measures for tungiasis can only be developed if epidemiological situation is well understood. To fill this gap and validate anecdotal observations, a cross-sectional study was carried in Ugenya Sub County, which provided evidence-based information and form basis for further studies and effective sustainable control measures among school age children and the community as a whole in Kenya.

Summary of the key findings of the study indicate a positive relationship between; gender of pupils, occupation of household head, participants who had ever heard of jiggers, signs and symptoms, Seriousness of jiggers in the area, disease transmission and causes of jiggers, pupils practices like wearing of shoes significantly predict tungiasis infestation.

Study findings indicate a significant association between gender of pupils and them being infested with tungiasis. These data differences were attributed to exposure and environmental factors, rather than difference in susceptibility, thus, we speculate that gender differences are, similar to age, related to different exposure and disease-related behavior. These findings have been consistent across studies and seem to differ from community to community. Research in Cameroon and Trinidad found statistically significant differences between the sexes with which males carried higher disease burden compared to females 157, this could be due to the fact that males are less sensitive to their health compared to females. Higher prevalence was high noted in male children of between classes 5 – 6. This was attributed to the fact that children are allowed to go to school barefooted and play around in the community without shoes as they interact with contaminated ground hence compromised personal hygiene and environmental sanitation. This is in agreement with a study which was conducted in Western Nigeria where majority of those affected by tungiasis were children aged 5 to 14 years old and the elderly 8. Other socio-economic and behavioural factors found in this study included occupation of household head which significantly affected tungiasis occurrence. For example, families with better access to water and using soap are prone to better hygiene standards. In addition, tungiasis can be regarded as a poverty-associated disease 1617 and improving sanitation have been discussed as factors in reduction of tungiasis incidence18.

Current study findings reported a significance dependency between participants who had ever heard of jiggers and tungiasis infestation. This finding emphasizes the importance of education and raising awareness in the prevention and control of tungiasis 19. This finding implies that the level of knowledge on prevention and control and predisposing factors for tungiasis infestation was relatively low. This could explain inability by the locals to take informed prevention and control measures. However, these study findings contradict with a study conducted by Kimani et al., (2012) where the reported level of knowledge on tungiasis prevention was relatively high but there was no related evidence for sand flea prevention and control in the area 19. Another important finding is that majority of the participants’ associated poor hygiene to tungiasis. This is consistent with previous literature that reported poor hygiene and dusty soil as the breeding place as the most important cause of tungiasis infestation 19. It is therefore important that the hygiene status in homesteads is improved to reduce tungiasis 20. Dirty feet and clothes provide a conducive environment for T. penetrans to survive and hide. Several studies have highlighted personal hygiene as an important factor in control and prevention of tungiasis 102122.

The findings indicated a positive significance with regard to knowledge, specifically on signs and symptoms and tungiasis infestation. The knowledge on early signs and symptoms should act as a trigger mechanism for the household members to take appropriate action to prevent and control infestation. Further findings revealed that Itching is the commonest symptoms. Studies by Muehlen (2005) posted that the first evidence of infestation by the sand flea is a tiny black dot on the skin at the point of penetration and then a small inflammatory papule with a central black dot forms within the next few weeks 23. Though the respondents reported mixed attitude toward tungiasis infestation, the problem is often brushed off as a thing of the past, or as a minor problem that can be relegated for more pressing issues.

Positive level of significance was also noted on the seriousness of jiggers as a disease in the study area. These findings are in tandem with a study by Winter et al., 2009 that revealed that tungiasis is associated with poverty and occurs in resource poor countries in the Caribbean, South America and Africa 24. Public health experts warn that heavy jiggers infestations goes beyond mere discomfort and can leads to loss of toe/finger nails, amputation of the digits and could even cause death 23 which only exacerbate the problem further. Study findings indicates that family members play a major role in knowledge transfer while health agents, nurses, and physicians only marginally contribute to knowledge on this parasitic skin disease. Consequently, addressing comprehensive and sustainable solutions to these neglected health problems cannot be the sole responsibility of the health sector but it also requires community participation and multi-sectoral approaches to the health determinants 25. Some of the reported reasons for tungiasis persistence in this study may contribute to continued tungiasis infestation in the area bearing in mind that highest levels of infestation occurs during the dry seasons.

Findings revealed a positive influence on disease transmission and causes of jiggers with disease occurrence. Soil was noted as the main cause of tungiasis. A study by Heukelbach etal., (2004) posted that knowledge on disease cause, transmission, and treatment practices was very similar in both rural and urban settings. The few exceptions can be explained by behavioural or environmental particularities present in one setting, but absent in the other 26. Current study indicated washing of self as one way of prevention and control. Similarly, a high degree of knowledge on the infectious agent of a disease was noted in Brazil by Winter et al., (2009), where 90% knew the flea as the etiological agent of tungiasis 24. A similarly high degree of knowledge on the infectious agent of a disease has been noted in populations suffering from malaria, schistosomiasis and filariasis, parasitic diseases with prevalences in endemic areas similar to tungiasis 27 ^{28 29}.

Study findings reported level of significance between pupil’s wearing of shoes and tungiasis infestation. Pupils behaviour and practices towards a certain disease normally affects occurrence. These findings are in tandem with a study on tungiasis conducted in Brazil, which revealed that there was remarkable reduction in tungiasis when people started using shoes as opposed to sandals 24. This is also in agreement with the study by Kimani et al., (2012) where they found out that people associated tungiasis with poor hygiene and sanitation (79.3%), poverty (43.5%) 19. Although the use of shoes can provide some measure of protection, it is unrealistic as a solution as neither eradication nor elimination of the parasite will occur. However, social efforts to improve hygiene, welfare and standard of living do provide additional protection against the jigger flea as tungiasis is mostly a disease of the poor. Economical, behavioural and cultural constraints may prohibit the intensive use of closed footwear in endemic communities including Eastern Africa.

Study concludes that tungiasis is still a big problem in rural settings and Knowledge on tungiasis infestation does not translate to prevention and control in the areas. More emphasis should be given to improving practices touching on personal hygiene and health education to increase awareness both at school and in the households.

Since it was a Cross-Sectional study, it was therefore difficult to infer causality.

CLTS:Community Led Total Sanitation

ESACIPAC: Eastern and Southern Africa Centre of International Parasite Control

KEMRI: Kenya Medical Research Institute

MDG: Millennium Development Goals

PHAST Participatory Hygiene and Sanitation Transformation

SERU: Scientific Ethical Review Committee

SHNP: School health and nutrition programmes

SPSS: Statistical Package for Social Sciences

STLS: School total led sanitation

UN: United Nations

WASH: Water Sanitation and Hygiene

Not applicable

That all data used in the manuscript is available for sharing; including all relevant raw data, will be freely available to any scientist wishing to use them for non-commercial purposes, without breaching participant confidentiality.

JM- conceived of the study, participated in its design coordination, and helped to draft the manuscript.