WHAT CAUSES JIGGERS (TUNGIASIS)

WHAT CAUSES JIGGERS (TUNGIASIS)  

By Stephen Kimotho 

There are numerous rumours, misleading stories and beliefs about jiggers. So, what causes jiggers? and  how serious is this disease in Kenya? For us to clearly understand the stigma associated with jiggers it will be important to shed some light on the nature of this disease and its effects on the victim.

Neglected Tropical Diseases

Tungiasis is one of the neglected tropical diseases (NTDs) that  is common in many parts of the world. Tungiasis is prevalent in settings of extreme poverty, especially among the rural poor and some disadvantaged urban populations. Like many neglected tropical diseases, it has a serious impact on the health of the affected individuals

Tungiasis is a skin disease

Tungiasis is a skin disease caused by the impregnated female sand flea Tunga penetrans (T. penetrans). Tungiasis is characterized by the development of single or multiple, white, grey, or yellowish  nodular lesions with a brown-black coloured opening at the centre and surrounding spots  reddening. The inflammation of the  and formation of pus around the infested part, enfeebling sequelae - such as loss of nails and difficulty in walking and sitting among other symptoms - are not only indicative of the infliction caused by tungiasis, but also mark persons with tungiasis as different, rendering them susceptible to stigmatization by the unaffected members of the community.

How serious is the jigger disease in Kenya? 

It is estimated that over 2.6 million Kenyans are infested with jiggers and 70% of those are children below 12 years. In an official statement to the Kenya National Assembly in 2010 on the severity of jigger infestations in Kenya, former Minister of Public Health and Sanitation, Beth Mugo 

 alluded that nearly 10 million were at risk of infestation. Between  2008 -2010, it was estimated that over 265 tungiasis-related deaths occurred and at least 13 families in Murang’a County were reported to have contracted the HIV virus through the sharing unsterilized safety pins to extract Jiggers. In addition, it is estimated that over 800,000 individuals suffering from tungiasis were unable to take part in the voter registration exercise in  2010 because of jigger-related ailments. Statistics for the participation by tungiasis sufferers in 2013 general elections were not available by the time I was carrying out this research.

If not not controlled in time jiggers can immobilize the victim or even cause death. (See some serious cases captured in this video below)

What parts of the body does Jigger flea attack.

In most cases jigger fleas preferentially infests in the upper surface of  the toes, in between the nails (subungual folds of the toes), soles, heels, hands and knees. However, contrary to the believes of many, infestation at other parts of the body, including the genitals, groin, face, elbows, wrists, breasts, back, thighs, and gluteus region has also been reported in many parts of the country. See the pictures below 

 

Life cycle of a Jigger Flea

Jigger fleas' life cycle lasts about one month and begins after the eggs expelled by the pregnant female fall onto the ground. Larvae hatch from the eggs in suitable environments with loose and dry soil. The larvae develop into a pupa after burrowing into the soil. Adults hatch from the pupae, and both males and females feed on their warm-blooded host. The female penetrates the epidermis and thrusts its head into the superficial dermis, and punctures blood vessels for nourishment (Macías & Sashida, 2000). Within 1–2 weeks, after embedding on the skin, the flea increases its volume by a factor of roughly 2,000–3,000, frequently reaching a diameter of up to 1 cm (Eisele et al., 2003). The females expel about 100 eggs over a 2–week period and die, and are sloughed from the host’s skin. 

Manifestation of this disease 

After the flea penetrates into the skin, the lesion itches and patients normally start to scratch, and consequently, promotes the entry of bacteria through the sore epidermis. The inflammatory process is often reinforced by super infection. According to Feldmeier et al. (2002), long–lasting sequelae may result from persistent inflammation and super infection and lead to secondary morbidity such as deformation and loss of nails, suppuration, ulceration or gangrene, that may eventually lead to physical disability.

Symptoms of Tungiasis

The major symptoms of jiggers include: itching, inflammation, severe pain, a black dot at the centre of a swollen red lesion and often surrounded by what looks like a white halo. Gangrene is another common complication of severe infestation and super infection. In non-vaccinated individuals, lesions may be a port of entry for tetanus infection. Medical researchers have reported death from illnesses associated with tungiasis (Pilger et al., 2008).

Treatment and Control

Buckendahl, et al. (2010) argues that since it is almost impossible to eradicate jigger flea while the perilous living conditions commonly witnessed in impoverished communities persist, morbidity control may be the only option. Lack of effective chemotherapy to kill fleas after infestation has also been identified as a great impediment to the treatment of tungiasis by researchers. Extraction of the flea surgically with a sterile instrument is the commonly recommended treatment of tungiasis. However, extraction of jigger flea requires a skilled hand and good eyesight. 

Scholars argue that, in many resource-poor communities surgical removal of jigger flea is often inconsistently done and ends up causing more harm than good if incorrectly done.

Jigger stigma – Part 1

The forgotten Ones’

They face kind of a death – a social death.

Jigger stigma  – Part 1

As we entered in Ndiritu’s, compound (not his real name) my attention was immediately drawn to a rather disturbing sight. A boy lay prostrate on the dusty ground next to their house. This is one of the areas known for the high infestation rate of Tunga Penetrans (locally known as jiggers or Ndutu among the Agikuyu people). The jigger flea is the smallest known flea that causes the deforming disease, tungiasis.

Another look at the boy, made me feel awful at the level of poverty in this home. He looked sickly. A cloud of flies hovered over his face and gapping mouth. His brothers played in the compound next to him. They were all limping from the sores and wounds caused infestation with jigger fleas. Their little feet were  swollen and a distressing site to behold. 

That day, the were not in school. The teacher had sent them home to extract jiggers and get some medical attention for ringworm infections on their skulls (locally known as magata). As they played, they seemed sometimes bothered by their sleeping sickly brother. Once in a while, one of them would rush and flag away the swarm of flies from his face. Then he would quickly run back to play with his mates.

The compound was littered with all kinds of trash. Maize cobs, chicken droppings and and dry leaves were all over the compound. The chicken kept on scratching the ground for food raising dust around the sleeping boy and throwing some loose soil on him. But he was obviously oblivious of all this.

Chicken  scratching the ground for food next to the sleeping boy

This was one of the families I had planned to visit for an in-depth interview on stigma associated with jiggers. Mr and Mrs Ndiritu have six children. Simon (not his real name) who lay a few yards  from us was one of them. As we came to learn later, Simon was physically and mentally challenged. He could hardly walk. According to the father, Simon used to crawl out of their house, but the intense infestation by jigger fleas on his feet, elbow and knees had totally crippled him. 

Their house was made of mounds of red soil. Chunks of the red soil had fallen off wall leaving the house in a dilapidated state. An empty  plastic tank stood near the house and the chicken structure next to it, completed the scene.

On hearing some commotion from outside, Ndiritu emerged from his house and greeted us. He recognized my guide and approached us with a broad smile. As he approached us, he shot a quick glance at his son on the dusty ground and then proceeded to where we were standing.

  

In his hands, Ndiritu held an old polythene paper. It was full of coins. As he welcomed us, he got pretty preoccupied with the coins. He counted and re-counted the coins and it was obvious that something was not adding up. As he was about to do it once more, he looked up at us and he looked disturbed.

He finally marshalled enough courage and informed us that he hoped that the coins would be enough to buy a Kilogram of maize flour. “Now I am afraid, my family is not assured of a meal this evening,” he said sadly. We had carried our gift basket, so we decide to inform him that he needed not to worry about that anymore. Upon receiving this good news, he brightened up praised the God incessantly for the providence.

Ndiritu was apparently a friendly person. I had no problem striking a rapport with him. The interview lasted for one hour. I learnt a lot from this man who was now in his mid fifties. Two of his sons were not going to school because of jigger infestation. I also came to learn that this family suffered from intense stigmatization because of jiggers. Few people from this community visited this family. People believed this family was cursed. Sadly, Ndiritu's family also believed that there was a curse upon them. 

They also believed that the jigger infestations among the family members was an evil spell cast upon them by their enemies. According to Ndiritu, the family did not have to go to hospital for treatment because curses and witch craft cannot be treated by modern  hospitals. They believed in prayers. They believe that God will came to their rescue one day. However, their faith was dwindling and they were quickly losing hope of recovering from the tungiasis. 
But something more dispiriting worried Ndiritu. Ndiritu and his family believed that severe jigger attacks could also be a premonition for a death of a family member. "This kind of infestation often signaled that someone in the family will die soon." he whispered apprehensively. 

“God I don’t want to lose any of my children, not now” he murmured mournfully as he held his chin. The expression on his face gave it away. He was really afraid of this.

The story from Ndiritu's family was simply overwhelming. Before leaving family, the social worker who had accompanied us prepared a solution of potassium permanganate and washed the feet of all the members of the family. As we bid Ndiritu's family goodbye and set off for the next respondent, the picture of the poor boy lying on the ground kept on haunting me.

WHAT IS STIGMA?

WHAT IS STIGMA? 

Stephen Kimotho 

One philosophical assumption that I will make here is that stigmas are social constructions. Social constructionists hold as their cardinal assumption that in a society, people jointly construct their understanding of phenomena in their world and meanings are developed during social interaction.

 Social constructionist approaches to stigma spring from Goffman’s (1963) seminal work, Stigma: Notes on the Management of Spoiled Identity, originally published in 1963. Goffman’s theory of stigma derived from his analysis of people’s lives, for instance, those who are physically challenged, mentally ill, blind, deaf, prostitutes, and homosexuals. Goffman averred that individuals are categorized by the society on the basis of the anticipated normative values – separating the “normal” from the “deviants.” Stigma, according to Goffman, refers to an attribute that is profoundly degrading, reducing the individual that possesses a particular trait from a whole to an aspersed and discredited one (Goffman, 1963), and consequently the person is socially disregarded. The gist of this approach is the understanding that stigma arises during a social interaction.

 By defining stigma as a spoiled identity, which means that a person is somehow not normal or accepted by society because of a physical disability, signs of “immoral” or non-conforming behaviour, or membership to a particular group, Goffman cast stigma as a social construction in which society determines which statuses deserve to be stigmatized (Smith, 2009). 

As such, the creation and maintenance of stigmatizing beliefs and stereotypes about any condition or disease would be represented in the common  language of the people in that society.

Therefore, stigma is the process whereby society negatively defines a particular mark as “… an attribute that is deeply discrediting….” (Goffman, 1963, p.3). In other words, at its most basic level, stigma, from social constructionists’ point of view, is a powerful discrediting and sullying social label that radically alters the way individuals view themselves and are viewed by others as persons. In general, stigmas result from stereotypic labels, which may or may not be true but nonetheless affect a person’s social standing and self-image. 

Reference

Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice Hall.