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OBP
A COMPLETE GUIDE TO
MAGGOT THERAPY
EDITED BY FRANK STADLER
A COMPLETE GUIDE TO MAGGOT THERAPY
Since the revival of maggot therapy in Western wound care approximately thirty years ago,
vacuum and, importantly, makes the current state of knowledge freely accessible. It is the
. Design by Katy Saunders
EDITED BY FRANK STADLER
Clinical Practice, Therapeutic Principles, Production,
Distribution, and Ethics
FRANK STADLER (ED.)
Clinical Practice, Therapeutic Principles,
Production, Distribution, and Ethics
A COMPLETE GUIDE TO
MAGGOT THERAPY
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Cover image: Line drawing of a green bottle blowy (Lucilia sericata) maggot by Frank
Stadler (2022), CC BY-NC. Cover design by Katy Saunders.
15. Establishment of a Medical Maggot
Rearing Facility and Maggot Therapy
Programme for Human and Veterinary
Medicine in Kenya1
Peter Takáč, Milan Kozánek, Grace A. Murilla,
Phoebe Mukiria, Bernard Wanyonyi Kinyosi, Judith
K. Chemuliti, J. Kimani Wanjerie, Christopher K.
Kibiwott, and Frank Stadler
This case study describes the process and experience of
establishing a maggot therapy programme in Kenya. Initially,
the programme included a technology- and knowledge-transfer
initiative which successfully developed production capacity
and clinical skills among the surgical and nursing workforce at
Kenyatta National Hospital. This work was followed by a pilot
study that demonstrated the positive impact mainstreaming of
maggot therapy can have on the treatment of patients with chronic
and infected wounds. The project highlights the importance of
regulatory and supply-chain barriers that need to be addressed
from the outset when introducing maggot therapy to new markets.
1 This work was funded by the Operational Program of Research and Development
and co-nanced by the European Fund for Regional Development (EFRD). Grant:
ITMS 26240220030: Research and development of new biotherapeutic methods
and its application in the treatment of some illnesses; and by Slovak Aid, Grant:
SAMRS/2010/03/06; The introduction of sterile larval therapy into clinical practice
for human and veterinary medicine in the Republic of Kenya.
© 2022 Chapter Authors, CC BY-NC 4.0 https://doi.org/10.11647/OBP.0300.15
332 A Complete Guide to Maggot Therapy
Introduction
Maggot therapy is the treatment of non-healing or infected wounds with
disinfected y larvae also called maggots. When placed on a wound,
medicinal maggots remove dead tissue, ght infection, and promote
wound healing [1–3]. Maggot therapy has been used to treat all kinds
of chronic wounds including diabetic ulcers, pressure ulcers, burns,
gangrene, and osteomyelitis, to name a few [4]. There are two ways
medicinal maggots may be applied to a wound—free-range or contained
within a mesh bag [5]. During free-range maggot therapy, maggots
are placed directly onto the wound and held in place with a cage-like
dressing made of a fabric material that allows maggots to breathe and
wound exudate to drain o. Alternatively, maggots can be applied
within a mesh bag similar to a tea bag. This is possible because maggots
do not consume solids but liquefy their food in the wound environment.
Digestive secretions and liqueed food easily pass through the mesh
material.
Most maggot therapy around the world employs the greenbottle
blowy Lucilia sericata or the closely related L. cuprina, but other blowy
species such as Cochliomyia macellaria [6], Chrysomya putoria [7], and
Sarconesiopsis magellanica [8] are also used or explored for potential
use. As every medicinal y should, L. sericata feeds only on dead and
devitalised tissue and not on living cells, which does not impede
healing. The competitive feeding of L. sericata larvae quickly removes
dead tissue and slough and thus the source of nutrition for bacteria.
Besides, bacteria are consumed and digested in the process. The removal
of dead tissue also allows better diusion of oxygen into the healthy
tissues, which prevents the proliferation of anaerobic bacteria. However,
the digestive excretions and secretions of maggots convey therapeutic
benets far beyond debridement. Not only do they contain compounds
ecacious against fungal and bacterial pathogens, they also actively
promote wound healing through a range of physiological mechanisms
and pathways. These multiple therapeutic benets of maggot therapy
are discussed in great detail in Chapters 8 to 10 of this book [1–3].
The biological and life-history characteristics of green bottle
maggots make them particularly suitable for biosurgery. They are easily
cultured under insectary conditions, have a fast life-cycle and complete
333
15. Maggot Therapy Programme in Kenya
metamorphosis. The larvae feed preferentially on decomposing esh
and their performance in the wound is generally unaected by illicit
or therapeutic drugs [9], but topical wound care products must be
removed prior to maggot therapy [10]. It is also helpful that medicinal
maggots can be stored for a couple of days at cool temperatures as low
as 6℃, which arrests their activity and slows down growth. This helps
with production scheduling and allows for delivery times of up to 48
hours [11]. All in all, maggot therapy is a highly ecacious wound care
modality and well-suited to high-resource and compromised healthcare
settings alike.
Maggot Therapy in Kenya
The introduction of a maggot therapy treatment programme in a new
jurisdiction requires the establishment of medicinal maggot production
facilities and capabilities among the local workforce. This chapter
presents the activities and outcomes of a programme that sought to
introduce maggot therapy in the Kenyan healthcare system. Transfer
of the necessary technology and know-how to the Kenyan setting
was achieved via a partnership between Scientica Ltd, the Institute of
Zoology at the Slovak Academy of Sciences, and the Kenyan Agriculture
& Research Institute (KARI) with nancial support from SlovakAid,
and diplomatic support from the Ministry of Foreign and European
Aairs of the Slovak Republic. Activities included building a laboratory
for the production of medicinal maggots and the training of medical
and veterinary sta in the clinical aspects and use of maggot therapy.
Because maggot therapy had been a new therapy to the Kenyan health
system, it was also necessary to demonstrate its benet via a clinical
study. This is why the initial establishment of medicinal maggot
production capacity and the training of wound care practitioners was
followed by a pilot study at Kenyatta National Hospital which is also
described below. The chapter concludes with an update on the current
status of maggot therapy in Kenya and some reections on the Kenyan
experience.
334 A Complete Guide to Maggot Therapy
Maggot Therapy Technology Transfer and Training
Pre-project assessment of healthcare provider acceptance. In the rst
instance, it had to be established whether the local healthcare workforce
involved in wound care would be accepting of maggot therapy because
the buy-in of healthcare providers is critical to the successful introduction
of maggot therapy. The Kenyan partners conducted a cross-sectional
survey of sta from Kenyatta National Hospital that are involved in
wound care. The survey did not nd any deep-seated rejection of
maggot therapy among the workforce and any concerns raised could be
easily addressed with an education and sensitisation programme.
Activities carried out by the Slovak partners during the rst half-year
of the project, from December 2010 to the end of May 2011, were intended
to create conditions for the eective launch of the project. A tender was
issued for the supply of instrumentation and other supplies. A draft
plan was developed for reconstruction work, which was subsequently
discussed in detail with KARI and implementation work begun for
breeding and laboratory facilities. Detailed technical specications of
breeding technology were developed, the manufacturer was selected
and the rst insect-rearing cage built, which was tested at the Institute
of Zoology in Bratislava. After some adjustments, the remaining cages
were built. In May 2011, the Slovak team completed the rst mission
to KARI. The trip focussed on the monitoring and assessment of the
construction and refurbishment of the laboratory and insectary facilities,
evaluation of activities, and the planning of activities for the next period
including the required laboratory furniture, appliances, and equipment.
An important aspect of the project was joint awareness raising and
stakeholder engagement with KARI Director Dr Ephraim A. Mukusira
via publicity, workshops, and project presentations:
• Meeting with the Kenyan State Secretary of the Ministry of
Livestock Development, Kennet M. Lusaka EBS.
• Preparation of a training programme for technical sta of
KARI.
• Visits to healthcare facilities that were identied as likely early
adopters of maggot therapy.
335
15. Maggot Therapy Programme in Kenya
• Project presentation at a business lunch with the Ambassador
of the Slovak Republic, Milan Zachar, in Nairobi.
• Interviews with local media representatives concerning the
objectives of the project and its potential contribution to
society in Kenya.
Project activities during the second six-month period, from June 2011 to
December 2011, focussed on nalising the refurbishment works at KARI
to create facilities for medicinal maggot production and related research
activities. In this period, the Slovak team also nalised the standard
operating procedures for the production of L. sericata medicinal maggots
and other species that may be utilised for maggot therapy purposes.
Finally, t he Slovak team coordinated the shipment of purchased insectary
and laboratory equipment, furniture, and supplies. Unfortunately, late
delivery of the shipping container to Bratislava postponed shipment of
equipment by 3 months.
Activities implemented during the six-month period from December
2011 until the end of May 2012 focussed on ne-tuning of the laboratory
and insectary refurbishment at KARI (Figure 15.1). This included the
shipment of laboratory equipment, furniture, and supplies to Mombasa
and then on to KARI. The release of the laboratory equipment was
delayed a further six months due to bureaucratic processes regarding
tax exemption for imported donated goods. We continuously informed
the project manager of Slovak Aid about this unforeseen delay. The
installation of equipment and furniture was nally carried out in May
2012.
In addition to the technology transfer, it was necessary to ensure that
Kenyan laboratory technicians and wound care providers were trained in
the rearing of medicinal ies and the treatment of wounds with maggot
therapy. To that end, two technicians (Phoebe Mukiria and Bernard
Wanyoyi) were trained in the mass rearing of the greenbottle blowy L.
sericata and medicinal maggot production at Scientica Ltd in Bratislava.
The Kenyan clinician Dr Saratian Nyabera Lugia, MD (Chairman of
the Diagnostics Division and Head of Accident and Emergency at Moi
Teaching and Referral Hospital) also travelled to Slovakia for maggot
therapy training at the First Department of Surgery of the Faculty of
Medicine in Bratislava, and at the hospital of Čadca and a hospital in the
town of Liptovský Mikuláš.
336 A Complete Guide to Maggot Therapy
Figure 15.1 Medicinal maggot production and research laboratory facilities
established at KARI (now KALRO). A) Plan drawing of the facility layout. An
under-utilised building was refurbished to house B) a multipurpose room for
washing up, diet preparation, and cool storage of dietary ingredients, C) an
insectary, D) a microscopy research laboratory, and E) a dedicated room furnished
with a laminar flow cabinet for the disinfection of fly eggs, and the preparation
and packaging of medicinal maggots. Photos by P. Takáč, Scientica Ltd and Slovak
Academy of Sciences, CC BY-NC.
Activities implemented during the six-month period from June to
November 2012 focussed on the successful introduction of maggot therapy
to human and veterinary clinical practice in Kenya. Marek Čambal MD,
PhD from the First Surgical Clinic of the University Hospital, Comenius
337
15. Maggot Therapy Programme in Kenya
University of Bratislava, visited Kenya in July 2012 and trained medical
doctors and nursing sta. In addition to these activities, we organised
a public lecture at the hospital on the topic of “Maggot debridement
therapy—A modality for chronic wound treatment”. There was great
interest in the lecture, which was attended by more than 70 doctors and
medical sta.
The most important result of this project was the Kenyatta National
Hospital (KNH) research and ethics approval for a clinical study
entitled “Maggot therapy as a method of treatment of chronic non-
healing wounds”. The Slovak and KARI project teams partnered with
Dr A Wanjeri and Christopher Kibiwott to pilot maggot therapy at
KNH. The ethics and research approval also authorised the KNH group
to administer maggot therapy anywhere in Kenya.
Slovak technology transfer activities concluded with the
dissemination of project outcomes:
• Presentation and exhibition of project outcomes at the
University Library in Bratislava (17 October 2012), attended
by 100 participants. The event was organised by the Platform
of Development NGOs.
• Presentation of project outcomes at the rst Slovak
Development Forum in Nairobi (19–21 November 2012). This
inaugural forum was organised by the Slovak Embassy in
Nairobi with the aim of assessing the almost 17-year history
of support provided by Slovak non-governmental and not-for-
prot organisations, and the aid contributions to Kenya made
by the Slovak government over almost 10 years.
First Clinical Study of Maggot Therapy in Kenya
Study Type and Ethical Clearance
On 26 October 2012, the Kenyatta National Hospital, University of
Nairobi (UoN) Ethics and Research Committee (KNH-UoN ERC)
approved a pilot study entitled “Maggot Debridement Therapy: The
Biotherapeutic Method of Healing Chronic Wounds in Kenya”. The
pilot study was conducted between August and December 2013 at
KNH. 24 patients were treated with a total of 30 maggot applications.
338 A Complete Guide to Maggot Therapy
Repeat applications were necessary for some wounds due to the amount
of necrotic tissue present. Maggot therapy was carried out by two nurses
headed by Dr Wanjeri, a plastic surgeon, and Christopher Kibiwott, a
senior nurse.
The Study Site Selection
Two hospitals, Kenyatta National Referral Hospital in Nairobi and
Tenwek Mission Hospital in Bomet, were initially selected as study
sites due to their high numbers of wound patients. Subsequently, the
study was conducted solely at KNH for ease of access and availability of
patients. Negotiating the study across two sites with logistical diculties
in the transport of medicinal maggots to Bomet proved too dicult.
Patient Selection and Inclusion Criteria
24 patients were recruited for the pilot study after assessing their
wounds and obtaining signed consent. Patients were drawn from the
entire in-patient population at KNH. Criteria for selection included the
presence of one or more infected wounds that had been debrided more
than once without success. Patients and their wounds were excluded
from the study for the following reasons:
• Wounds exhibited granulation tissue without necrosis
• Wounds involved a major blood vessel
• Wounds were covered with eschar that required surgical
debridement
• Ischemic wounds or presence of arterial insuciency
• Wounds with signicant Pseudomonas aeruginosa infection
• Osteomyelitis
• Patients had severe life-threatening infections
• Patients had an allergy to egg yolk (a component of the
maggot-rearing process)
• Patients who had had surgery in the previous 24 to 48 hours
• Patients who refused the therapy
339
15. Maggot Therapy Programme in Kenya
Medicinal Maggot Preparation
Adult L. sericata ies were maintained in the insectary at KARI, Muguga,
at 26±2℃, 40–50% relative humidity, and 12 hours of daylight. Newly
eclosed ies started producing eggs after 7–10 days. Eggs were collected
with an oviposition bait made of minced bovine liver and wheat bran
that was oered to ies for two hours. The bait was covered with a plastic
container tted with holes to make a darkened oviposition chamber
while providing ies with access. Egg masses were placed into 10 mL
Falcon® tubes and disinfected with 1% sodium hypochlorite solution.
The number of eggs disinfected depended on the number of patients to
be treated. The disinfected eggs were then incubated overnight at 27±2℃
for larvae to emerge and grow suciently for medical application.
The larvae were washed and packed aseptically into appropriate-size
biobags or directly into plastic containers for free-range application. The
medicinal maggots were then delivered to KNH.
Maggot Therapy Treatment
A total of 24 patients between 21 and 78 years old with a mean age
of 32 years were recruited to the study from the KNH in-patient
cohort. Of these, 12 were male and eight females. The aetiologies of
the wounds treated included road trac accidents (31%) including
degloving injuries, pressure ulcers, diabetic foot ulcers (42%), fractures,
arteriovenous insuciency, and burns. Biobags were used on only 6
(25%) patients who then needed a repeat treatment with free-range
application of maggots. 23 patients completed maggot therapy treatment
and one participant chose not to continue after the rst application
of medicinal maggots. Aseptic technique was strictly observed and
the usual wound management protocols followed. The wounds were
rinsed with sterile saline and excess moisture was removed with gauze.
Where eschar was present, incisions were made to make it easier for
maggots to access the necrotic tissue. Maggot therapy was performed
using biobags that contained maggots, or free-range (loose) maggots
directly into the wound. The mode chosen depended on the patients’
preference and the size and extent of the wound. After placement of
maggots the wounds were covered lightly with a gauze bandage and left
for 48 hours. Thereafter, the wound was assessed.
340 A Complete Guide to Maggot Therapy
Study Outcome
In 16 patients (67%), complete debridement was achieved with only
one application of maggots. In seven patients, maggot therapy achieved
70% debridement after the rst application and complete debridement
after the second application. The wound of the patient who decided
to discontinue the therapy after 12 hours was 50% debrided after that
short time. The wounds of 18 patients (75%) received regular care
after maggot therapy and healed uneventfully without a need for any
other intervention. The remaining patients had to undergo procedures
such as ap closure and skin grafting. In all patients, maggot therapy
successfully controlled infection without additional antibiotic therapy.
Case examples are presented in Figure 15.2.
Figure 15.2 Examples of successful maggot therapy treatments during the pilot
study. Case 1) Female, age 38, retrovirus disease under treatment, degloving
injury of the head and right arm, road traffic accident. History: One day post-
admission she was taken to theatre for surgical debridement and closure of the
head wound. Due to its size, it was not closed. The degloving injury on the right
hand was not debrided. Wound: 15 cm x 8 cm, 80% necrotic tissue with moderate
infection. Maggot therapy: 1 treatment, 48 hours. Result: 100% debridement,
patient was scheduled for skin grafting the following week, wound fully closed
341
15. Maggot Therapy Programme in Kenya
within ten days. Case 2) Female, age 55, diabetic foot ulcer on sole of the left
foot. History: Surgical debridement was not successful, patient was scheduled for
below knee amputation, antibiotic treatment included Augmentin, Cefuroxime
and Meropenem. Wound: 5 cm x 6cm, 4 cm deep, communicating from the small
toe to the mid-foot area, edematous to the level of the knee, exudating and filled
with slough, odorous, osteomylitis. Maggot therapy: 50% debridement after 1st
and 100% after 2nd treatment, no further antibiotic treatment. Discharged one
week later with much-improved wound. Case 3) Male, age 72, sacral pressure
ulcer. History: Diabetic patient, high blood pressure, prostate cancer. Wound:
Stage 3, septic, exudating purulent discharge, slough, odorous. Maggot therapy:
1 treatment, 95% debridement, followed up with negative pressure therapy and
conventional dressings. Case 4) Female, age 42, ulcerated tumour on left breast.
History: No co-morbidities. Wound: Very large mass, ulcerated, necrotic, filled
with thick sloughy tissue, bled easily, odorous. Maggot therapy: 40% debridement
after 1st treatment, 80% debridement after 2nd treatment. Antibiotic treatment:
Ceftriaxone and metronidazole injection. Photos © Kenyatta National Hospital,
Nairobi.
Current Status of Maggot Therapy
Medicinal maggot production capacity. In 2013, KARI was renamed the
Kenya Agricultural and Livestock Research Organization. The KALRO
insectary houses on average only 3,000 to 4,000 adult ies at any one
time. Due to a lack of demand, there is not daily medicinal maggot
production, and production occurs only when orders are received. It
takes between two to three days to prepare an order depending on the
time and date of order placement. However, the facility has the capacity
(including equipment, materials, and personnel) to maintain more y
colonies and to produce medicinal maggots on a regular basis.
Nevertheless, strict adherence to established standard operating
procedures has led to a shortage of egg yolk powder for medicinal
maggot production. However, this does not seriously jeopardise
production because egg yolk powder can easily be substituted with fresh
poultry egg yolk and albumin. Larger production volumes may lead to
stock-outs of net fabric for the construction of maggot connement and
containment dressings, as it has to be sourced from overseas. It, too, is
not essential for maggot therapy. Free-range treatment using alternative
retention systems could proceed while the netting is sourced. For
example, free guidance on maggot therapy in compromised healthcare
settings can be accessed via www.medmaglabs.com, which explains
the use of ordinary clothing items to construct maggot connement
342 A Complete Guide to Maggot Therapy
dressings, including two step-by-step videos describing free-range
maggot therapy.
Medicinal maggot supply. KALRO supplies medicinal maggots conned
in a biobag or loose maggots in a container for free-range application.
The biobag is packaged in a sterile plastic container with a perforated
lid for ventilation. The packaged medicinal maggots are placed in a
cool box with ice packs and transported immediately to the hospital.
The delivery is done through the informal transport system. Delivery
to Nairobi-based hospitals or homecare patients is relatively fast but
timely and aordable delivery to other parts of Kenya is a challenge.
Demand for medicinal maggots and maggot therapy. Although there
is a growing interest in maggot therapy across Kenya, it is still a much
under-utilised wound care intervention limited to a few patients. Under
current medicinal maggot supply chain arrangements, the reasons
for the slow uptake of maggot therapy include i) the outstanding
regulatory approval by the Pharmacy and Poisons Board, ii) the high
cost of delivery to hospitals outside of Nairobi, and iii) the overall cost of
maggot therapy to poor patients. A consignment of medicinal maggots
to hospitals or homecare settings around Nairobi costs from USD40 to
USD60 for an average treatment. The cost is per application, irrespective
of the size of the wound, and is made up of around USD20 for the
medicinal maggots and USD20 for delivery [12].
Approval of Maggot Therapy in Kenya. The ndings of the pilot study
“Maggot Debridement Therapy: The Biotherapeutic Method of Healing
Chronic Wounds in Kenya” were presented to the KNH-UoN ERC on
6 August 2014 along with a report. After careful assessment, the KNH-
UoN ERC provided a favourable opinion on 20 July 2016, recognising the
benets of maggot therapy for patients with chronic wounds, especially
when antibiotics fail. Despite this favourable nding, maggot therapy
has not yet been approved by the Kenyan Pharmacy and Poisons Board
because there is uncertainty as to whether medicinal maggots are best
governed by human therapeutics regulation or livestock production
regulation. The original ethics and research approval rst granted for
the pilot study in 2013 has been renewed on an annual basis to support
treatment of patients by the KNH team. This means that as of 2021,
343
15. Maggot Therapy Programme in Kenya
seven years after the presentation of their ndings, maggot therapy in
Kenya is still limited to the KNH team, with a national rollout of the
treatment still not possible.
Patients treated and national reach. Between 2013 and 2020, a total
of 140 patients were treated by Christopher Kibiwott and Dr Wanjeri
at KNH and other hospitals such as Aga Khan Hospital, Texas Cancer
Centre, Nyeri Hospital, Oyugis District Hospital in Homa Bay County
(about 400 km from Nairobi), Kiambu District Hospital, and patients in
home care as far aeld as Kisumu, Nyahururu, and Machakos.
Summary
Over ten years later, the introduction of maggot therapy to the Kenyan
healthcare system is still an ongoing process. The initial technology
and knowledge transfer initiative successfully developed production
capacity at KARI/KALRO and clinical skills among the surgical and
nursing workforce at KNH. The subsequent pilot study was also
a success as it convinced the KNH-UoN ERC of the positive impact
that mainstreaming of maggot therapy can have on the treatment of
patients with chronic and infected wounds. However, medicinal maggot
production and the number of patients treated in 2021 is well below
capacity. Without full regulatory approval by the Pharmacy and Poisons
Board, this is unlikely to change, which means that hundreds or even
thousands of patients each year will miss out on ecacious maggot-
assisted wound care. Moreover, what has not yet been addressed is the
development of sustainable and aordable distribution logistics and
supply chain management solutions for medicinal maggot therapy in
Kenya. While good things always take time and the groundwork for
a thriving maggot therapy programme has been laid, there is the danger
that chronic under-utilisation of the production facility and a lack of
funding and sales cashow will erode institutional commitment to the
programme and lead to the closure of the insectary and laboratory.
There are important lessons to be learned. Entrepreneurs and medical
professionals wanting to establish a maggot therapy programme in
their country or region must invest considerable time and eort to
collaborate with and lobby medical regulators to secure approval of
maggot therapy. At the same time, it is not enough to establish medicinal
344 A Complete Guide to Maggot Therapy
maggot production capacity and clinical skills. Medicinal maggots must
also reach patients across the country, including in provincial, rural and
remote locations, and not only near the production facility. It therefore
pays to involve medical supply chain logistics experts and formal as well
as informal transport service providers early on. Please refer to Chapter
17 for guidance on distribution logistics [13], and Chapter 18 for drone-
assisted distribution of medicinal maggots [14].
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15. Maggot Therapy Programme in Kenya
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