[7] This disease is of special public health concern in highly endemic areas such as Nigeria, Trinidad and Tobago, and Brazil, where its prevalence, especially in poor communities, has been known to approach 50%.

[4] The patient with a single flea may present as early as stage 2 when, though the erythema is barely perceptible, a boring pain and the curious sensation of pleasant itching occur.

The radical metamorphosis during the 3rd to 6th day after penetration, or neosomy, precedes the formation of a small caldera-like rim rampart as a result of the increased thickness of the flea's chitin exoskeleton.

Around the 25th day after penetration, the lesion looks like a black crust and the flea's carcass is removed by host repair mechanisms and the skin begins to heal.

[citation needed] Tungiasis is strictly caused by chigoe fleas (the term transmission does not apply because Tunga penetrans is itself responsible for the disease.)

The occurrence of tungiasis lesions on the toes, between them, and on the soles can be easily explained because most of the victims are poor, walk barefoot, and live in places where the sand (home to chigoe fleas) constitutes the floor.

[15] T. penetrans has been documented to use various warm-blooded animals as reservoir hosts, including humans, pigs, dogs, cats, rats, sheep, cattle, donkeys, monkeys, birds, and elephants.

[11] In dividing the natural history of the disease, the Fortaleza Classification formally describes the last part of the female flea's life cycle where it burrows into its host's skin, expels eggs, and dies.

The hypertrophic zone between tergites 2 and 3 in the abdominal region begins to expand a day or two after penetration and takes the appearance of a life belt.

Chitinous clasps that are built for the abdominal enlargement surround these regions and hold onto the hypertrophic zone, giving them the appearance of a three-leafed clover.

[3] Although these results reflect a laboratory setting, the general lack of success for T. penetrans’s reproductive (opportunistic) R-strategy is surprising given the number of fleas that a single person can attract.

[citation needed] Though vaccines would be useful, due to the ectoparasitic nature of chigoe flea, they are neither a feasible nor an effective tool against tungiasis.

The non-toxic nature of Zanzarin, combined with its "remarkable regression of the clinical pathology" make this a tenable public health tool against tungiasis.

As part of that effort, Mexico launched the Campaña Nacional para la Erradicación de Paludismo, or the National Campaign for the Eradication of Malaria.

As a consequence of this national campaign, other arthropods were either eliminated or significantly reduced in number, including the reduviid bug responsible for Chagas disease (American Trypanosomiasis) and T.

[19] While other species gradually gained resistance to DDT and other insecticides that were used, T. penetrans did not; as a result, the incidence of tungiasis in Mexico is very low when compared to the rest of Latin America, especially Brazil, where rates in poor areas have been known to be as high or higher than 50%.

Due to the secondary infection that can cause serious medical issues, the recommended course of action upon diagnosis is a surgical extraction of the fleas followed by the application of a topical antibiotic.

[4] Oral ivermectin is considered by some in endemic areas to be a panacea against the fleas but studies using high doses have failed to validate this hypothesis.

[2,5][full citation needed] For superinfections, trimethoprim, sulfamethoxazole, metronidazole, amoxicillin, (with/without clavulanate) have been used successfully, though these treat only secondary infections.

[4] The gum of the mammee apple (Mammea americana), a fruit that also goes by the name Saint Domingo apricot, has also been used to kill the chigoe flea, though this has not been reported in the main T. penetrans literature.

[23] Topical treatment with low-viscosity dimethicone silicone oils, commonly used for head lice, is an emerging and effective method for suffocating parasites without the use of toxins.

The World Health Organization has recognized this treatment as both highly effective and safe, based on extensive research and its application in severe cases of parasitic infestations.

[24][25] These low-cost oils have demonstrated a strong track record in the global treatment of even treatment-resistant head lice, making them a promising option for addressing this neglected tropical disease.

[citation needed] For the most part, the chigoe flea lives 2–5 cm below the sand, an observation which helps explains its overall distribution.

This preferred ecological niche offers a way to decrease transmission among humans by investing in concrete grounds as opposed to the sand that is usually used in shacks and some favelas.

Indeed, Nany et al. (2007) report that "In shacks with concreted ground being cleaned every day with water, Tunga [penetrans] larvae were hardly found.

"[3] In a longitudinal study conducted from March 2001 to January 2002, incidence of tungiasis was found to vary significantly with the local seasons of an endemic community in Brazil.

[15] Acting as both biological vectors and definitive hosts, humans have spread Tunga penetrans from its isolated existence in the West Indies to all of Latin America and most of Africa via sea travel.

[26] The first case of tungiasis was described in 1526 by Gonzalo Fernández de Oviedo y Valdés, where he discussed the skin infection and its symptoms on crew members from Columbus's Santa Maria after they were shipwrecked on Haiti.

The spread to greater Africa occurred throughout the 17th and 19th centuries, specifically in 1872 when the infected crewmen of the ship Thomas Mitchell introduced it into Angola by illegal dumping of sand ballast, having sailed from Brazil.