Hrev_master [page 16] [Healthcare in Low-resource Settings 2023; 11:11161] Maggot therapy could provide affordable and efficacious wound care in Lebanon and other low- and middle-income countries Salman Shayya,1,2 Frank Stadler3,4 1Institute of Legal Medicine, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany; 2Lebanese University, Faculty of Science Hadath Beirut, Faculty of Public Health Fanar and Ain W Zain, Lebanon; 3Applied BioSciences, Macquarie University, Sydney, New South Wales, Australia; 4School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia Abstract The poor economic situation, ongoing political instability, and the 2020 Beirut explosion have seriously eroded the capaci- ty of the Lebanese healthcare system. Insecure fuel supplies and the rationing of electricity to a few hours per day make mat- ters worse. New strategies are required to deliver healthcare that is more resilient in the face of ongoing disruption. Maggot therapy for the treatment of chronic and infected wounds could make a meaningful difference in Lebanon. When placed in a wound, medicinal maggots remove dead tis- sue, control infection and stimulate wound healing. It is an inexpensive, easy to use, and highly efficacious therapy, even under austere conditions. This review provides an introduction to maggot therapy and briefly explains its therapeutic benefits before dis- cussing the role it can play in the Lebanese healthcare system. Finally, the prerequisites and enablers for successful integration of maggot therapy into the Lebanese health- care system are outlined. Introduction Maggot therapy (MT) is the use of live fly larvae (maggots) for the treatment of wounds that fail to heal. MT is used for the treatment of a wide range of chronic wounds including infected wounds and wounds with dead tissue and/or slough such as leg ulcers, pressure ulcers, diabetic foot ulcers, gangrenous wounds, osteomyelitis, surgical wounds, and burns.1 When applied to the wound, medicinal maggots remove dead tissue, control infection, and stimulate wound healing.2 Maggot therapy compares favorably with conventional wound treat- ment while it can also be cost effective compared to conventional treatment approaches.3,4 For wounds to heal, it is necessary that dead tissue and other debris are removed. This process is known as debridement. When placed into a wound, medicinal mag- gots crawl about with the aid of their paired mouth hooks while excreting digestive enzymes into the wound environment.5 This leads to the liquefaction of dead tissue which is then either ingested by the mag- gots or it drains from the wound.6 Infection often plays an important part in preventing chronic wounds from healing. Medicinal maggots control infection in a number of ways. First, their feeding activity in the wound removes dead tissue which is a source of nutrition for bacteria, and it dis- rupts bacterial biofilm via mechanical means. The very act of ingestion and diges- tion of bacteria-rich necrotic tissue by the maggots contributes to the reduction of the bacterial burden in the wound. Moreover, the maggots’ secretions and excretions have potent antibacterial properties and contain sodium bicarbonate which increases the pH of the wound and inhibits bacterial growth.6,7 Wounds are said to be chronic when they fail to pass in an orderly manner through the three phases of healing: inflam- mation, proliferation, and remodeling. In such wounds, maggot therapy interrupts chronic inflammation and promotes the growth of new tissue, including blood ves- sels.8 A successfully healing wound exhibits the growth of granulation tissue, but for this to occur, fibroblasts must migrate into the clean wound bed to bring about granulation. The secretions of medicinal maggots have been shown to promote fibroblast growth and their migration across the wound bed.9,10 Full healing and tissue regeneration can only succeed if the growing tissue is supplied with blood and oxygen which in turn depends on the growth of new blood vessels. Maggot therapy promotes the for- mation of new blood vessels and increases the blood supply to the wound.11 In addi- tion; maggot excretions stimulate the pro- duction of the patients’ own tissue growth factors that promote healing of the wound12, while also contributing maggot-derived growth factors and other hormones that closely resemble those of the human body. This way maggots further stimulate tissue growth in the wound.13 In summary, medicinal maggots bring about wound healing through multiple com- plex interactions with the wound environ- ment, resident microbes, and the patients’ physiological response to the injury. This is Healthcare in Low-resource Settings 2023; volume 11:11161 Correspondence: Frank Stadler, Applied BioSciences, Macquarie University, Sydney, New South Wales, Australia. Tel: +61.422731540. E-mail: frank.stadler@mq.edu.au Key words: maggot therapy; larval debride- ment therapy; wound care; low- and middle- income country; Lebanon. Contributions: the article is a collaborative effort between the authors in response to the Beirut port explosion and subsequent medical emergency. Preparation of the article was led by SS, particularly concerning the Lebanese healthcare system and the potential for maggot therapy integration. FS provided overall guid- ance and contributed the maggot-therapy- related technical content. Conflict of interest: FS is currently Adjunct Fellow at Macquarie University, Centre Manager for the ARC Training Centre for Facilitated Advancement of Australia’s Bioactives (FAAB), also at Macquarie University, and founder/director of MedMagLabs, a Similitude Pty Ltd business, seeking to bring affordable maggot therapy services to Australia and underserved health- care settings around the world. This article was conceived and written prior to spin-out of MedMagLabs from research conducted at Griffith University. SS has no conflicts of interest to report. Ethics approval and consent to participate: not applicable. Informed consent: not applicable. Patient consent for publication: not applicable. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received for publication: 17 January 2023. Accepted for publication: 2 May 2023 This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11161 doi:10.4081/hls.2023.11161 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guar- anteed or endorsed by the publisher. No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2023; 11:11161] [page 17] difficult to replicate with any other single wound care intervention - may it be drug or device. Where is maggot therapy used? Maggot therapy has been used for thou- sands of years and records date back to antiquity. However, it was the orthopedic surgeon William S. Baer at Johns Hopkins Hospital, Baltimore, who in the 1920’s established maggot therapy in modern clin- ical wound care.14 Unfortunately, the initial popularity of maggot therapy was relatively short-lived and declined in the 1940s with the emergence and widespread availability of antibiotics like penicillin, and the improvement of surgical techniques.15 Then, beginning in the 1980s and 90s, mag- got therapy experienced a renaissance due to the growing prevalence of wound infec- tions caused by antibiotic-resistant bacte- ria15 and a growing burden of wounds relat- ed to chronic health conditions such as dia- betes and cardiovascular disease. In 2004, maggot therapy was approved by the United States Food and Drug Administration as a device for the debridement of wounds. Now, maggot therapy has once again become an accepted and widely used wound treatment in the United States, Europe, and elsewhere. As for the Middle East, maggot therapy is regularly used in Egypt16 and Iran,17 as well as in Turkey and Israel.18 However, it appears that Lebanese wound care providers have no access to medicinal maggots. Maggot therapy in Lebanon As the economic situation in Lebanon worsens due to ongoing political instability, the 2020 Beirut blast, and COVID 19 it becomes necessary to consider new strate- gies to strengthen the healthcare system. It follows a brief discussion as to how the implementation of maggot therapy could assist Lebanon in the treatment of infected and necrotic wounds sustained in sudden- onset disasters such as the Beirut blast, as well as the affordable management of chronic wounds resulting from diabetes or cancer. In the Beirut port blast on 4 August 2020, flying and falling glass shards from building facades and interiors were the main cause of injury and death.19 The injuries were accompanied by severe lacer- ations and abrasions as witnessed in the emergency wards of treating hospitals. Blindness and loss of limbs have been the main causes for lasting disability suffered by casualties.20 According to reports from the American University of Beirut Hospital AUH, some patients required extensive reconstructive surgery.20 As has been evi- dent in the aftermath of the Beirut blast, such sudden-onset disasters can easily over- whelm local healthcare systems not only because of mass casualties but because healthcare facilities and other infrastructure may also be damaged. For example, Saint George Hospital University Medical Center was severely damaged after the explosion.21 More than 100 of its healthcare profession- als, doctors, residents, nurses and adminis- trative staff, sustained injuries ranging from mild to critical.21 In the Achrafieh area, the Hotel Dieu de France hospital took in over 700 wounded victims.22 Teams from Médecins Sans Frontières (MSF) who have been providing assistance reported 737 peo- ple who received treatment for wounds.23 Moreover, on August 15, 2021, a fuel tank blast in Akkar North Lebanon killed 28 peo- ple and injured nearly 80 people. As a rule, disasters of this nature result not only in acute injury from the impact itself but also in many infections that pre- vent wounds from healing. Maggot therapy is an ideal treatment for such wounds for reasons explained earlier. In addition, the availability of medicinal maggots in disas- ters would give first responders greater freedom and a larger window of opportunity to treat casualties without having to fear the consequences of either infection or injury- related tissue necrosis. This is because both infection and tissue necrosis can be success- fully treated with maggot therapy.24 In Lebanon, as in other low- and mid- dle-income countries, the transition to a modern life style and the rapid economic, cultural and social changes are associated with a rapid rise in obesity, vascular disease, and diabetes.25 Over a 12-year study period, the change in obesity prevalence annual rates ranged between +4.1% in children and adolescents and +5.2% in adults.26 Up to 25% of diabetes patients will suffer one or more lower limb ulcers.26 These diabetes- related health complications are common in the Arab world with a higher prevalence in eastern Arab countries. Given the high cost of chronic wound care and the impact of ulcers on the patient’s quality of life, it is easy to see how access to maggot therapy could deliver affordable and highly effica- cious wound care. At best of times, the Lebanese popula- tion has insufficient access to healthcare. According to 2017 statistics, the distribu- tion of healthcare professionals per 10,000 citizens was 31.3 physicians, 36.4 nurses and midwives, 15.2 dentists, and 18.9 phar- macists.27 Likewise, the WHO28 records Lebanon as having 49.42 skilled health per- sonnel per 10,000 population (in 2014) compared to 162.4 for Australia (in 2015). It is against this backdrop of an ailing healthcare system and the ever-present threat of natural and man-made disasters (including conflict), that the introduction of maggot therapy to the Lebanese healthcare system should be considered. This will require i) local production or just-in-time international supply of medicinal maggots, ii) regulatory approval, iii) health insurance cover, iv) clinical workforce training, and v) patient education. Local production in Lebanon could be performed using the calliphorid fly Lucilia sericata which is identified at the taxonom- ic and molecular level.29 Moreover, it has been shown to produce a variety of bioac- tive compounds that promote wound heal- ing, angiogenesis and tissue regeneration. Also it attenuates inflammation and elimi- nates bacteria.30 The objectives for maggot therapy in chronic wound care in Lebanon would be to prevent the deterioration of existing wounds and symptoms management to ensure patient comfort and an improved quality of life.31 In patient-centric care, wellbeing is defined as attaining physical, psychologi- cal, social, and spiritual resources to over- come physical, psychological and/or social challenges.32 The definition of wellbeing in relation to wound management is detailed in A Complete Guide to Maggot Therapy.33 Medicinal maggots are highly perish- able and must be delivered within 24-48 hours from dispatch.34 This means they can- not be stored in distribution centers like ordinary medicines but must be delivered just-in-time to the point of care.34 Production and supply of Lebanese clinics may or may not be possible from regional businesses in neighboring countries. The requirements for medicinal maggot produc- tion can range from fairly low-tech to sophisticated, which means that during the introduction of maggot therapy in Lebanon, a local university or other research institu- tion could produce the maggots at modest expense. However, professionalization of production and marketing of medicinal maggots to wound care providers is neces- sary for maggot therapy to become a main- stream treatment in Lebanon or any other jurisdiction for that matter. The commercial supply of medicinal maggots and their routine use generally requires the approval by national health authorities. In the case of Lebanon, this would be the Ministry of Public Health (MOPH). The testing and introduction of new drugs or treatments should also be reviewed by the country’s physicians and Review No n- co mm er cia l u se on ly [page 18] [Healthcare in Low-resource Settings 2023; 11:11161] public health experts to ensure adequate treatment, palliative care, and optimized pain control in Lebanon. If medicinal mag- gots are to be approved as pharmaceutical drugs, then a dossier needs to be prepared that demonstrates the quality, safety and efficacy of the drug and follows the specifi- cations of the Common Technical Document (CTD).27 The complete dossier should be registered at the pharmacy department of the MOPH. Importantly, wide uptake of maggot therapy depends on national or private health insurance reimbursement. In Lebanon, the health care system is charac- terized by an array of financing intermedi- aries including the National Social Security Fund (NSSF) that covers formal sector employees, the Civil Servant Cooperative (CSC) that covers civil servants, four mili- tary schemes that cover the uniformed armed forces, and the private healthcare insurers and the MOPH.35 However, insur- ance covers only 75% of hospitalisation and is limited to life threatening and obstetric conditions. Therefore, it is a large financial burden for Lebanese patients to access advanced diagnostics and other care for conditions which do not fall under the cur- rent coverage including illnesses such as cancer and chronic health conditions like diabetes and its complications.36 In addi- tion, many refugees from neighboring coun- tries find it difficult to access healthcare in Lebanon because most have no health insur- ance coverage and rely solely on the United Nations Relief and Works Agency UNRWA services.36 Furthermore, Lebanese elderly and retired workers still lack a social insur- ance system that provides them with ade- quate health cover.35 Currently, initiatives are under way with international support to strengthen the health system and enhance institutional resilience.32 Introduction of maggot therapy may well align with these reform objectives but close cooperation and negotiation with insurance providers would still be required for making maggot therapy eligible for reimbursement. Maggot therapy is a relatively simple treatment and does not require surgical expertise which means that nurses and, with guidance, even laypersons such as family members can conduct maggot therapy.17 Nevertheless, practitioners will need at least basic training to learn how to apply medici- nal maggots and how to make sure only patients and wounds benefiting from the treatment will receive the therapy. For the past two decades, there have been numerous practitioner-focused publications explain- ing in detail the indications and contraindi- cations for maggot therapy as well as the various application techniques. For exam- ple, Chadwick and colleagues37 articulate the consensus for the treatment of the dia- betic foot with maggot therapy, and com- mercial medicinal maggot producers sup- port their clients with clinical advice. Multi- lingual and highly visual treatment guid- ance for healthcare providers and patients, especially in compromised healthcare set- tings, has been developed at MedMagLabs and can be accessed free-of-charge via www.medmaglabs.com in English, French, and Arabic language. Maggot therapy can only be used when the patient agrees to it. Therefore, it is important that wound care patients and the general public are aware of the treatment and understand how it works. The idea of maggot therapy may provoke in some patients and healthcare providers strong feelings of disgust, or what has also been coined the ‘yuk’ factor. However, feelings of disgust or fear are actually not a major barrier to maggot therapy acceptance, espe- cially for patients who are confronted with an ostracizing chronic wound. Patient con- cerns about the treatment are best addressed with accurate information provided by trusted wound care providers. Conclusions In the context of Lebanon’s ailing healthcare system and precarious social and economic situation, it would be prudent to introduce maggot therapy to treat chronic wounds and to strengthen the country’s resilience in the face of ever-looming natu- ral and man-made disasters in a volatile region. What is true for Lebanon applies also to many other countries struggling in a climate of COVID 19, economic depres- sion, and/or conflict. Maggot therapy has not yet reached its full potential and remains underutilised, especially in low- and middle-income countries. However, efforts are under way to build capacity in conflict-affected communities and other compromised healthcare settings to produce medicinal maggots and treat chronic wounds with maggot therapy.24,38,39 References 1. Mexican Association for Wound Care and Healing. “Clinical Practice Guidelines for the Treatment of Acute and Chronic Wounds with Maggot Debridement Therapy; 2010. Accessed 15 August 2021. Available from: h t t p s : / / s 3 . a m a z o n a w s . c o m / a a w c - new/memberclicks/GPC_larvathera- py.pdf 2. Sherman RA. Mechanisms of maggot- induced wound healing: what do we know, and where do we go from here? Evid Based Complement Alternat Med 2014;2014:592419.  3. Eamkong S, Pongpanich S, Rojanaworarit C. Comparison of curing costs between maggot and conventional therapies for chronic wound care. J Health Res 2010;24:21-5. 4. Bennett SB, Abnderson SP, Rai MK, et al. Cost-effectiveness of interventions for chronic wound debridement: an evaluation in search of data. Wounds UK 2013;9:9. 5. Wood L, Hughes M. Reviewing the effectiveness of larval therapy. J Comm Nursing 2013;27:11-14. 6. Choudhary V, Choudhary M, Pandey S, et al. Maggot debridement therapy as pri- mary tool to treat chronic wound of ani- mals. Veterinary World 2016;9:403-9. 7. Cazander G, Pritchard DI, Nigam Y, et al. 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