Tiny healers: the science and promise of maggot therapy.

Join Professor Hilary Ranson, Pro-Vice Chancellor of Research, Culture, and Integrity at Liverpool School of Tropical Medicine, as she engages in a conversation with Professor Yamni Nigam, a Biomedical Sciences expert at Swansea University and an LSTM alumna. Yamni shares her pioneering work on maggot therapy, a revolutionary yet ancient treatment for chronic wounds, and its role in combating antimicrobial resistance. Discover the science behind maggot therapy, patient and clinical perceptions, and how public engagement can overcome barriers to its adoption. Yamni also reflects on her inspiring journey, from her time at LSTM to leading research today.

Transcript

So welcome everybody to our podcast, LSTM in conversation. So my name is Hilary Ranson. I'm a Professor of Medical Entomology here at the Liverpool School of of Tropical Medicine. LSTM, we're celebrating. We've just celebrated our 120/5 anniversary. We were established in 1898 and as such, we were the oldest. We are the oldest Institute in the world dedicated to the study of of Tropical Medicine. And over the past 125 years, we've really been delivering on our our mission, which is to improve health outcomes for disadvantaged populations across the globe through research, education and partnership. And during that time, we've had the opportunity to train some amazing global health leaders, and I'm absolutely delighted to be joined by one of those today. Before I start asking yammy about her work on on maggots, let me just say a few words of introduction as to her career. Pathway to date, yamni graduated from King's College in in London and and came to Liverpool at that point to do a Masters in Applied parasitology and Medical Entomology that took her to Swansea University for a PhD, a postdoc in Brazil, and then back to Swansea University, where she is now and has established a research group on On the use of maggots for all sorts of interesting purposes, which we'll hear more about today. I yamni is a very distinguished academic, having published over 75 different publications and book chapters, and is a advocate of public engagement in science, and I'm really keen to learn more about about how you engage people and convince people that maggot therapy is really something that has a role in medicine today. So welcome yamni. Thank you very much for joining this podcast series. Thank you very much indeed for inviting me on. Thank you. So I guess I'd like to start really by just asking you, what is maggot therapy and why should people be interested in it?

Okay, yes, brilliant. First question. So the concept of maggot therapy is ancient, very ancient. We know that many civilizations and tribes and cultures had used maggots to help treat wounds. Wounds that we now know in today's day and age weren't healing by themselves. They needed some intervention to kind of help them to heal. So modern day maggot therapy encompasses the very same principles that we have read about in the literature and in the world wars and Battlefield surgeons who reported the presence the infestation of natural maggots, maggot therapy, or, you know, entering a wound. But those wounds are always reported to be non Pyrex. There was no feel for the patient. The wounds were non infected. They were healing. So based on all of that, when we came to modern when we come to modern day times, Maga therapy is now a very clinical, has very takes a very clinical approach to this. So the maggots that we use are for particularly non invasive species, Lucille Cerro Carter, the medicinal maggot, the green bottle flies, maggots and these are reared under sterile, aseptic conditions, so sent out clinically to be used on patients to help them disinfect debride and heal their wounds.

So as a as an entomologist myself, I'm keen to know why, why this particular fly? What is it about the maggots from the green bottle fly that make it particularly suitable for its purpose. Yes, indeed, as you'll know, that maggots worldwide can be quite terrible and notorious for causing severe meiosis. You know, very, very severe infections and chronic problems all over the world, especially on the tropical species that we have, however, the one species that we know is non invasive and and in particular, cannot feed on healthy tissue. It will starve on healthy tissue. It's only able to feed on dead tissue. This is what makes Lucille zarikata, the green bottle maggot, absolutely ideal for the clinical use on wound care and wound management. Yeah. So do you really Swansea, and how do you do that? So we have to ensure that there's sterile conditions

to produce these maggots. Can you tell us a little bit about that process? Yeah.

Yes, of course. So we've reared maggots, Lucille, Sarah Carter, at Sondra university, but we've reared them for research. So we didn't need to worry too much about any clinical output, because we weren't sending them anywhere. However, there are factories all over the world which rear maggots clinically for use therapeutically, and the one that we have in the UK, and there's only one in the UK, and that's actually based in a place called Bridge end in South Wales. So very you know, about an hour away from my university, there's a there's a factory called biomond, who also have branches in Germany, and, I think, in the States as well. And and they are the clinical producers of larval therapy of larvae here. They send them all over the UK and all over Europe. But of course, they're living tiny, sterile, reared maggots that are encased in a tiny little bag that are sent out to clinics and the hospitals and surgeries all over Europe, but they will only survive a day in travel, so this is why the companies can't send them to greater, you know, further away, but other companies that are in China and Australia and all over the world can can provide them for their own countries.

So I think, are they? How widespread are they in clinical use in the UK today? Yeah, not as widespread as we would, as I would hope, as an entomologist. Now, as an entomologist, I came across and did my whole doctorate and postdoc on species that are pretty nasty to humans, you know, vectors of of terrible diseases. And I looked at Shay gas disease, and I looked at sleeping sickness. And then when I came across to Swansea University, and I got a lectureship here in anatomy, my head of school said, Could you please teach create a module on wound healing for nurses? And it was then in 1997

that I discovered something called larval therapies. I was researching wounds, and I thought, well, what is this? You know? And it transpired that only then in the sort of late 80s, early 90s, had maggot therapy become a real thing in the UK, and it was, it was mainly because we were seeing wounds that we couldn't treat. And you probably know this phenomenon of global antibiotic resistance. Antimicrobial Resistance was rearing its head. Had started rearing its head in the 60s, but by the 80s and 90s, we were finding wounds that we couldn't heal, and so we went back to see, well, what was there that we were using to treat wounds that had infections and to treat wounds that weren't healing on their own? And it turned out that magnet therapy came up. So larval therapy was being reintroduced into the UK properly. It already been around in America and Canada in the 1930s in the pre antibiotic era, they were actually using it clinically in the 30s. But then, of course, once antibiotics came on the scene, nobody wanted to use maggots. Why would you, you know, but it could pop a pill for any scratch or itch or cough or whatever. And of course, we're now reaping the rewards of popping those antibiotic pills, I think, devastatingly so. So Maga therapy came into use. Now, it began with very few people using it, but the minute people started using it, and they saw the effects. You can turn a wound on its head, which has been stagnant and non healing for about 18 months in four days with one treatment of 100 maggots in a small net bag. What it was they used to use free range, so they were loose maggots. But I think about 10 or 15 years ago, the company decided that they would put them in a little bag, and the maggots could still do their job through that bag, so patients didn't have them crawling around, and nurses and healthcare professionals didn't need to worry about putting them on wounds. So so the UK is using them, but not as widely as we would like, and we've been investigating all sorts of reasons as to why that is the case. Yes, you have a wonderful video on your website. Love A maggot that

sort of dispels some of the myths, I guess, and some of the concerns that presumably have arisen from your public engagement work about obstacles to rolling out the maggot therapy more more widely. And I think one of the things I particularly liked from that was, was this issue about putting them in a bag so that people, they were people, I guess maybe worried that they can start crawling all over them and spread, etc. And so I think that that confinement, and then also, I think concerns about, were they emergent to flies with something else? Maybe you can talk a little bit about what, what are some of the reservations you've encountered in your when discussing this with patients and other groups? Yeah, sure. So, so our work was carrying on, as a scientist, work in labs, we were looking at funding, and we were getting funding, and then in 2016

I got a rejection for a grant to look at the science of maggot therapy from the MRC. And I thought, Well, why is this? And one of one reviewer had said, well, there, there is nobody that wants to use maggots or but there is no yeah. What's the point of doing this research where no.

Will want to use maggots. And I was really annoyed, not just at the rejection, but at that comment. I thought, is that true? I didn't think it was. And of course, when I and my group started researching it, we realized that it was very true, and there is an inherent level of disgust and the idea of having maggots on you lot better now that they're confined exactly as you say, but when they were free range, and people would pour little bit of saline on a little batch of maggots and pour them onto the wound and put them in a dressing, they would start on occasions, if the dressing wasn't sealed properly on the wound, they could escape. And that would freak out a lot of patients, understandably. But maggots are in our in our radar as being tiny, little, disgusting varmints that frequent dust bins or on carcasses of dead animals, which all of these things make them ideal to eat the dead tissue off the wound. Which is what is how they live? You know, which is that, which is their survival. But the reservations are not just that. It's a disgusting treatment, that people don't realize that it's the maggots that are used are clinically reared. They're under very, very strict, sterile conditions that they're and that the eggs are disinfected, and the little maggots that emerge are treated with such great care before their package. So everything's done, done by the book, clinically. But the I mean, there are papers still coming out on it, and we ourselves have published a few papers on the on our research with the perception and the awareness and the perception of magnet therapy. And yes, it's still even in 2024 we had publications saying 50% of patients and nurses find disgust anxiety, they don't believe in the effectiveness, because they don't know about it. There's disbelief that you're even using an ancient modality to try and treat modern day times. And so these are the issues that I thought we needed to address a little bit more. Hence, I set up the swans University love a maggot campaign to try and see if we could go out and talk to people about their fears, about their worries and kind of make them understand that those are myths. You know, the maggots that we are using, they in four days, they will grow from the tiniest, little emerging maggot onto the largest maggot, and at that point they need somewhere dry to pupate. And then they will take two weeks, pretty much to pupate before they even get to the adult stage. So this, this idea that they will come off in flies, which is very much a real fear for a lot of people, can't happen. We remove the bag clinically after four days. I've been, I've worked with clinicians that have removed it after a week, and there's still maggots in there. There's not they've not even turned into pupa. So that wouldn't happen. But these are the things we need to address. You know, people genuinely feel that. That's a concern. It's really interesting. And I guess we have people do associate. I think my image, when I first heard of this topic was was sort of thinking back to to war zones and people using it as historical treatment. But of course, as you've said, With the increasing challenges faced by anti microbial resistance and resistance to antibiotics that such a problem worldwide. This is, you know, alternative strategies, or something that we, we all, need to be thinking about. And so I'd like to ask a little bit about the research side as well. Because presumably, the reason that these, these maggot festival, let um healing wounds is, is they're releasing some sort of anti microbial properties and into the wound and and I believe that your team have have looked into into the properties of the secretions in some detail, and that's produced some very interesting findings. Yes, actually, we've we, we now know that magnet therapy works in three ways on a wound, that the first way is to debride a wound, which is the most important thing that must be done before a wound will progress to heal. And debridement means getting rid of dead, necrotic, unwanted tissue, because that's a barrier to healing. It'll be in the way, and the wound bed won't be able to send good nutrients and good cells if you've got this barrier there. And not only is this barrier a nuisance to healing, but it's also a site for infection. It's something that bacteria would love to thrive on and grow on. So debridement is key, the first step to wound healing. Maggots feed on dead tissue. These species, Lucille, Cerro Carta, feed on dead tissue, so they're ideal to within four days, get rid of that whole necrotic area that needs to be cleared. Now we know how they do this. They do this by secreting enzymes. The enzymes so they don't have teeth, they don't Chomp, they don't bite. They literally secrete these enzymes. They can do it through the bag. The bag, the enzymes turn the wound, the tissue of the wound into a soup, which they can then drink up through the back the tissue. The tissue is cleared. But if you think about where maggots live in nature, this species feeds on dead, decaying

tissue, food protein as food animals, carcasses, animals that have died in the wild, that's where.

Find Lucille sarikata swarming. I think you can smell death within 20 seconds, some of the reading researchers have shown that, you know, they put little dead piglets out, and within 20 seconds, the first female Lucille zarikata had landed and laid her eggs. Those eggs will hatch and the maggots will start to feed. But if you think of what shares this feast with with the maggots, we've got our primary decomposers. We've got bacteria, we've got fungi. So the lucillia have learned to live alongside the bacteria and fungi by producing their own amazing repertoire of antibacterial factors. And the science of the last two decades has shown from all all of the world that we have identified so many of these molecules. Our own group in Swansea have identified a tiny little molecule that we've called ceratocyn, which is less than 500 Daltons, and it's actually incredibly good at destroying resistant bacteria. MRSA was the main one that we worked with. But we've some of the researchers in the States took our molecule and showed that it inhibits bacterial cell division and causes lysis at greater concentrations. So you know, we know that the maggots have this ability to secrete, in their sweat, in their spit, antibacterial factors, antimicrobial factors. And in fact, the German group and a popples group about nine years ago showed that there are 47 distinct antibacterial factors produced by maggots, and the group actually have synthesized some of those and shown that they kill a range of bacteria. And remember, maggots are living creatures. They're evolving. They were they've been around what dipter have been around for 200 million years. I think, so they've evolved to survive. And you know, whether they've tweaked their their their antibacterial factors, as you know they needed to. You know, we think they're amazing, clever little things. So I'm curious. And have you ever come across any, I guess, any microbial compositions in the wounds that proves toxic to the maggots. They can't disinfect, if you like, yeah. So we've we know that clinically, there are a couple of species offer of bacteria that maggots struggle with. One of them, which is a major wound pathogen, is Pseudomonas. And Pseudomonas produces toxins itself. When it's in, it's in the wound, and it's those toxins that can kill Lucille. However, the Danish group of Anderson showed that if you double your dose of maggots, you can overcome the Pseudomonas infection. So it's just just just a question of using more maggots so that they don't, you know, they don't succumb to the Pseudomonas infection. And again, a TVN recently contacted me and said that my patient had strep G, and strep G kill the maggots. So we are coming across a couple of bacteria, which are, you know, the maggots can't fight, and then they can't but one of the most interesting things that I will quickly say is about the inducible nature of maggot secretions. I don't know if you're going to ask me about that later. Sorry. That later. Sorry. Carry on. Carry on. Please. Sorry, yeah, I just find it's just so, so much research has recently shown that if you have maggots that are surrounded by an infection, the antibacterial activity that they will now secrete goes up six fold. It's, it's the inducible thing, like, if we had a cold or a virus that attacked us, our immune system would go crazy trying to destroy so maggots have that in them. They have this inducibility, which I think is absolutely brilliant, absolutely amazing. Yeah, I was, I was, guess I was just thinking about, sort of parallels to my work. I work on in insecticide resistance and mosquitoes and and, you know, eventually, like antibiotics, same thing with insects. You know, organisms evolved to develop resistance. And I just wondered if you or anyone else was exploiting this in the the maggots and trying to actually select for Lucille that would survive Pseudomonas or some of these other pathogens are currently more problematic to cure with maggot therapy. Yeah, no, that, that again, would be absolutely brilliant. Have a great thing to do. We are not working on it as our group. But I, I believe there are groups that are looking at recombinant, looking at, you know, various ways to deal with these issues, but, but no, not, not in Swansea, we're not looking at that. So you've identified, you and others have identified a suite of antimicrobial compounds that are produced by these maggots. So do you think in the future there, there will be, sort of, yes, competent productions of these, and they might be potential be applied, as you know, as a drug or some other form, without the need for live maggots, or do you think it's the benefit of the maggot therapy, as as you you've articulated, that, you know, they clean the wound, they they eat the dead tissue, and that really you need the live maggots to get the full, full benefits of of these. So as an osmologist, I am a huge fan of the living, real thing. I think it's one.

Of the very few insects that do a positive thing for us, we do have a lot of vectors, a lot of insects that are quite, as we know, you know, quite, quite devastating, but, but maggots are brilliant. They don't just debride, they don't just disinfect. We now know, again, the science has shown us that they produce a positive environment for wound healing, not just a positive environment, positive molecules, molecules that are up regulated in the wound bed because of the presence of maggots, which aid healing. So the living, actual living maggot, is doing so many things. It is a little factory of production of debris, enzymes, of disinfecting and anti fungal molecules and of promoting accelerating wound healing. So that's great. That's the living maggot. However, we know that a lot of patients and a lot of nurses and doctors would prefer an appointment or a cream or something that you're addressing that incorporates secretions that might work now that has been tried. And it's been tried, I think in 2012 unsuccessfully. It's been tried a couple of times, and it doesn't seem to work, certainly as well as a living magnet. But I know, and I don't know how I can say very much about it, but all of that is being looked at at the moment. And, you know, I've got a PhD student that's very much looking at what we can do to harness some of these factors, remove them from the maggot, and put them in some way onto a patient's wound without the need for the living maggot. Yeah, you are right. It's being looked at, and I think that is the ultimate aim for an awful lot of people. I still have reservations about it. I still think if you can tolerate the maggots, you're onto women, yes, because, because you said earlier, I think that maggots are evolving creatures, and therefore you sort of evolve the therapy to adapt to the changing microbial

composition of wounds and resistant bacteria as well. So I yeah, I'm absolutely with you there, that the value of, of having a living organism, if you can get over the cringe factor, is it really is exciting as a as a and also a way of learning about, I guess, I mean, I guess that's a question, really. So how much work are you doing, or others in this space to really understand, sort of, the processes by which the maggot degrades the microbial composition of wounds, and are there things that were interesting insights we're learning from from just that process that might be exploited? Yeah, there are several things going on in a wound. Quite often you don't just have a planktonic bacterial infection. You've got a multi, poly microbial infection, which often leads to what we call a biofilm, formation of a bacterial biofilm wounds. Over 80% of chronic wounds have a bacterial biofilm. And so we looked at early on in our research, and in about 2013 we looked at, do maggots have any effect on biofilm? And we found that they did. We found that not only did they break up a biofilm once it's formed. So they've got a particular adhesion molecules that work to degrade a biofilm, but they also prevent a biofilm from forming. And that was amazing, because the consultant microbiologist we were working with at the time said, Well, he he knows that one of the reasons why implants in patients and prosthetic, prosthetic

tissues and so on, fail is because they become infected, because they get this bacterial biofilm. So he went back to Germany and decided to coat his or decided to work with surgeons who would coat their materials, their titanium or whatever, in Magus secretions before implanting, because we know that they prevent biofilm so, so there are many, many processes involved. There's, there's been key pathways that the that have been discovered for the healing processes by particular the Chinese groups have discovered so much about how, you know, how maggots are affecting various wound healing pathways and how their processes of disinfection occur, and so on. So, yes, so there's a lot. I mean, we know that. We know how many antibiotics work in terms of whether they attack the cell cell wall, or whether they attack cell division, or whether and so we're looking at all of the ways in which maggots do these things as well. And certainly, as I said, with serratus in we've shown that we get, we get the bacteria unable to replicate so they become, instead of dividing, they just become long cells and which are no good at all in terms of replication and infection. So does that have applications beyond actual wounds itself? Does that have applications as an antibiotic? So how? How generic is this effect against preventing cell division in in pathogenic bacteria, I guess. Yeah, so of course, we we have focused all our work and looking at wound pathogens and wound bacteria, because that that's what maggots are licensed for, for wound care. But you're absolutely right. You know, if you think about bacterial biofilm, for example, it develops in our teeth every night, the bacteria talk to each other, and they develop this.

So we feel it when we wake up, the slimy with the only way to get rid of it is to abrade it with it with the toothbrush. You could put maggot anti biofilm secretions in toothpaste. You could put it in you could have a use for all sorts of things. One of, one of the bacteria we tested in our laboratory was mycobacterium, which causes TB and aceratin killed it, wiped it out. And so you think, Well, okay, so yes, if haven't, you got a potential here for making this into a tablet, which you could use for, for for TB, or even, we found that it killed Clostridium Clostridium difficile, which is a gram negative anaerobic organism, which we had to it was hard work to grow it up and work with it under anaerobic conditions, but it was wiped out by by ceratosine, by this maggot secretion. So we know there's great potential for maggot secretions, and not just in the wound environment. And obviously you would then look to isolate those, those secretions, those molecules. You can't pop a maggot in your mouth. And

I mean, that might take some sweating,

Yeah, indeed. Can I take you back to how you first got interested in this. You so you, you started off at as an undergraduate biologist, and then what made you decide to come to Liverpool to study entomology and parasitology. I was, I was interested in sex since I was a small child. And I remember, you know, much to the My parents were quite horrified about it. But I loved, I loved insects. I also loved the human body. It was just something that I was fascinated by. So when I got to Kings, I took every course in entomology that I could, every course in human structure and function that I could, and that reinforced my idea that I love both of those things. So Liverpool School of Tropical Medicine, and my interest was always in tropical medicine at that point, and how diseases, how these diseases affected people, malaria and and and other mosquito borne diseases or unaffected people. So it was great to come to Liverpool and learn more that course that I did, I think, taught me more than any other course that I've ever attended in my life. It was an awesome course, and it was literally what it says, applied entomology, or Medical Entomology and applied parasitology, which was brilliant. So it was an eye opener for me and and just inspired me so much to carry on my work in the fields of insects and disease and and, you know, human human populations and so on that that's fascinating. And while you were doing this course, I'm assuming there was an opportunity at that time to do a dissertation project. Did you do that on, on flies? Or what did you do as your dissertation? I did, I did my masters. It was a research project, and I did it on so we were allowed to work in the lab for three months after, after passing exams in the summer. And my research project was working with a wonderful fellow called Professor Richard Ward, who was just he was a medical entomologist, and he was working on sand flies and leishmaniasis, and he was working very much to try and control the vector. Luxemylongi palpus was the one that we were working with, the species of sand fly that we were working with. So I spent three months in the lab with his group looking at ways in which we could attract sand flies to traps and how we could stop them acting as vectors of this dreadful disease. And I loved working with him, and I loved working in the labs, down in the basement at the drop shop, as it was commonly known then, and and we, we published our very first paper. So after, after my master's, I got a PhD in University, working on other diseases and vectors of disease, but looking at the immunology of those insects. So I was trying to find out how they deal with the what is the effect of of

trypanosomes on on regiment bugs, for example, the effects of trypanosomes on Tetsu flies. So that's how I became more interested in it, but the Liverpool School of Tropical Medicine just showed me so much inspiration. You know, Richard Ward was awesome, and we published our first paper, then when I got into Swansea for my first year at Swansea, so, yeah, my first paper ever, and Richard was just a legend. Yes, indeed. It's interesting to hear about your recollections of that. I mean, I don't think the masters course is still running. It might have changed its name tropical disease biology now, but it really does follow a similar structure. And we still have the insectaries in the basement.

We also have some much, let's say, more pleasant insectary conditions to work in, as well as those, but they're still going strong. So

really interesting to hear about your time and how, how that exposure to the range of different

vectors and vector borne diseases has really sort of influenced your your career since then. So you went to Swansea, as you said, and you you studied trypanosomes, and then I think you to Brazil. Is that correct?

I did. I did. We were very fortunate. We got a four month,

sort of not an exchange so much. It was working with fundacco, Oswaldo Cruz in Rio, and they were looking at Shea gas disease, and cruise i and Rangel I, and my work was there, so we went out there. And while I went out there with my professor, and at the time, and we worked together on looking at the the various immune molecules that the vectors had against the parasites, to try and see if we could understand that a little bit more and try and work its way into trying to prevent the human condition. But of course, then my after my postdoc, I was offered a lectureship at Swansea, slightly different path. They wanted me more to focus on human health and and, and then, of course, when I discovered this little insect, Lucilia, Sarah Carter, it's like, oh, my world was back again. So, yeah.

So these days, how do you split your time? Then it sounds like public engagement is is a large part of what you you do, but you also run a research team. You you teach, tell us a little bit about what a day in the life of

yummy is like at Swansea. It's crazy.

It's crazy. It's about juggling everything, isn't it? Excuse me, I'm sure you're all in the in the same boat. We do have a duty to our students, of course. You know they

they need and the demand, of course, quite a good experience and a good learning experience. And so we try our best to provide that. So I teach on a range of anatomy and physiology and pathophysiology courses across to paramedics to nurses to healthcare scientists and so on and so on. So that's great. And I love, I love doing all of that. But then, of course, I teach the nurses and the nurses,

they need to know about wound care and wound management, and they need to know about magnet therapy, because if I can get and I've got it on the curriculum, if I can get get them to understand it, then as they go out into the wards and into the world as nurses, they already have the background. That was one of our biggest problems. We found that not just nurses. Were not just reluctant. They didn't really have a solid awareness of it's an it's an education and knowledge that needs really to be to be shared, I think, with healthcare professionals. But yeah, so the science side of things has become a little bit quieter. I I collaborate now with other people that want to do the science. So they are working in our labs, and they are, and I, of course, I'm working with them, but I'm not in the lab myself all the time. Now, following, you know, looking at the science, but there are other lecturers that I've encouraged to take on the mantle of maggot therapy and saying, Well, why don't you, and I know some lecturers look at honey and look at the effects of honey and wounds. So they are very willing to look at maggot therapy as well in that light. So the science is ongoing. The public engagement side has really gone mad, because I think I'm very lucky we are looking at maggots. And maggots evoke, straight away, all sorts of, oh, oh, my god. Why is that? What are you doing? And so people want to know which is, which is great, because I want to tell him, so it just works out really, really well. So I've gone all over the place talking about maggots. I a little presentation, so it's not death by PowerPoint, but it always helps to talk a little bit with slides and images and so on. But it's more the interaction with the public, which is, which is really great. So we have models. We built models of the fly, the lava, the pupa. So we can talk about the life cycle stages. We can talk about the action of larvae, and we can, and I always take along loads of maggots with me. So these are from the company, so that's clinical grade, sterile maggots. And we invite people to feel how maggots feel, to have a little hold of them and to have a look at them. We've set up stations where we have games, and the games are very much trying to get the maggot message out there, that if you've got a bunch of bacteria, and we've got Tin Can alley of bacteria in an infected wound, and you've got ping pong ball socks, which are maggots, and you chuck those maggots at those bacteria, you eliminate them from the wound, and that's the message that we try and get, and you re offer prizes. We've got cuddly maggots, maggot mugs. We've got maggot key rings and so on. So people take away a memory of what the maggot message as well. We've got leaflets and information and so on. So, yeah,

so I guess you're taking a sort of dual pronged approach. You're working the clinicians and trying to get increased understanding of the benefits of maggot therapy and and yet get that to be considered as an option with with wounds. But obviously they're also working with the broader public to sort of, if they are do have a wound that might benefit from this, that they've got some understanding that can people request maggot therapy? How would it work if, if, if someone's got a wound in their in their clinical team and are not familiar with this absolutely so maggots went on prescription, NHS, prescription in 2004

so they're available as a treatment. But, but you're, you're absolutely right. The.

The problem is not just a reluctance or a barrier to use because of anxiety, and the problem is also budget and cost. So yes, anybody who knows about micro therapy, and when I go out and do my talks, lots of people are sitting there thinking, Oh, my God, I didn't know this was a therapy. I didn't know that this would help in in diabetic foot ulcers, or this would help my sacral ulcer, or whatever. So they can request it. And fortunately, it's still down to the clinician. The attending clinician to say, Yes, this wound is suitable. So first of all, assessment of the wound has to be done. But then they have to think, right, okay, I would like to order this one tiny, little maggot bag that will go on for four days, costs 250 pounds, so it's an expensive treatment. So we're also up against it with cost. But again, if you think about four day treatment compared to a year and a half of maggot therapy, sorry, often antibiotic therapy or all sorts of other interventions, nursing time and so on. It's a winner and cost effective studies have been published to show that maggot therapy is way more cost effective. But unfortunately, with the NHS in the state that it's in, it's all about the local budget. And I know that district and community nurses have to go to GPS to say, right, I think this wound is suitable for maggot therapy. Can I please order it? And GPS would look at it and say, more? No, because it's 250 pounds, and, you know, we don't want to spend that. And so that's what we're up against as well. There are hassle factors of ordering and dispensing, which I think are also problem. Was that your question? I'm

serious, making me think through the sort of practicality of it. So then, is it a home management treatment that you you, you get your packet sent? Well, it's going to go to a GP, or does it go to home and who, who puts it on and then are you sort of discharged? Because I'm thinking about, when you talked about cost effectiveness studies, I'm thinking about all the time potentially saved in clinical visits and follow ups, if it's something that can be managed in the home environment, absolutely, but it has to be clinically managed. So we know that, obviously hospitals, it's fine because a patient is an in treatment and needs a magnet therapy. And we've got, you know, TV ends and nurses around to monitor that in the home environment, you can take a district and community nurse. She will order the maggots, and maggots will arrive at the surgery. She will pick them up, take them to the patient, leave them that you know, as long as there's an outer dressing on it, sometimes, if there's a because the maggots tend to wash the wound out. So there is a quite a bit of exudate on the outer dressing. And that can be changed very, very easily. But it's four days, four to seven day can even leave it on seven days. I know I work with Podiatry in Morrison hospital, and they the patient can't come back for another week, so you leave the maggots on, they'll come in. They'll have the maggots put on, they'll go home. You know, obviously, if the if the wound is on a heel or then they'd have to offload. So you'd give them a boot so they don't and many reports have been a patient killing, squashing,

absolutely so, yeah, yeah. So that that can very much work as an outpatient. People can have them, and they can have, you know, you can have two or three applications. So the nurse will come along and say, Well, you know, it's almost completely clean and cleared, but I'm going to give you another four days, so you'd put on a fresh bag of of l1 maggots, little baby maggots on that. So, yeah, very much can be handled outside and generally, for patients that have undergone this treatment, what's the perception been? I mean, you must have some success stories where persistent wounds have been cleared. I mean, our patient, our patients have undergone magnet therapy. Good advocates for for others. And do you use those as part of your patient, your engagement activities? Absolutely you're absolutely right. Once a patient has had a course on magnet therapy and has seen the results quite often, maggot therapy is still underused. It's a last resort treatment where those patients have had a chronic wound, a smelly, painful, chronic wound, for months, if you put on four days of maggots, and they see that that wound has changed and cleared. And their their quality of life has suddenly changed as well. It's unbelievable because, because you'd be surprised, I met two patients in a car park as I was coming out, and we were talking about maggots, and they said, Oh yeah, we were offered maggot therapy. We said, No. I thought, Okay, why did you say no? And then there are those fears that, oh no, no, no. I couldn't stand it. I'd rather. And one of our surveys showed that whilst 91% of people would have maggot therapy if they were told they had to have an amputation, 9% still said no. They would rather have an amputation. And that is that stunnedness, because that showed us that the fears are so real, people are petrified of maggots on their bodies for whatever reason that they want, and so these are the fears we're trying to combat and talk about and so on. But you're absolutely right, not just patients who see maggot therapy for the first time. Our nurses, who we know are like, Oh, I don't want to do I don't want to do.

If they see the results, they're like the TV ends are won over. They just they can't believe that you've got a therapy that works so well. And I don't have to tell you there's a paper that's just come out of a kick of three case studies by an American group who had three patients that were life had life threatening, multi drug resistant bacteria in a sacral wound, a pressure ulcer on the back. And they had nothing else they could do. They put maggot therapy in all three of them, and they killed all the infection, and they survived. The patients survived life. And so you know that these maggots can do? You know really can combat life threatening infections. And it's amazing. This was 2024 paper that just came out. So, yeah, it, it feels like

all the things are lined up for this really, to explode as a as in terms of its use in clinical practice. I mean that, as you pointed out, there will always be some that are resistant to to this treatment. But, but what if you What would success look like? What's your vision for this in the future?

Yeah, well, as an entomologist, we'd love it to be a mainstream therapy. It isn't a mainstream therapy. It's out there. It's certainly part of the the armory of control of wound infection and for treatment of wounds, but it isn't. It isn't used enough, whether that's because of cost, whether that's because of hassles getting it. I mean, if a, if a, if a clinician orders a little bag of baby maggots, they've got a day they're starving, they need to go on the wound. If the patient hasn't turned up, or the nurse has gone off shift, you've lost 250 pounds, and that's part of the shelf life. Is part of it. I would love to see a slightly better way of delivery. Perhaps eggs could be sent and so and kept until the already people on the patient. Then they'd hatch out within the first 24 hours, and they would do that. I don't know there's so many other ways. If we look across the world, people are looking at it. I know in Australia, they're looking at sending drones with little bags of eggs to rural parts in Africa, they're trying to use it. It's a cheap therapy for in obviously, obviously in the Western world, it's not a cheap therapy because we have such sophisticated ways of trying to deal with things and sterilize them and so on and so on. But I know that many countries in Nigeria and Kenya, I use all these case studies in my in my talks, have shown very, very successful outcomes. So it's like, it can be a worldwide therapy, but it just, you know, it isn't there yet. That would be my dream. Yeah. And I guess, thinking about the cost, I mean the cost of rearing insects with a complex life cycle, such as a Lucilla fly that takes what multiple weeks for generations to produce, and then doing that under sterile conditions. I guess it's not well. It so much the case that it's expensive because demand is low. It's expensive because it really is expensive to produce flies under these conditions. I think so. I think you're absolutely right. It is expensive to produce them. We we know from our own rearing in the in the labs in Swansea that from egg to adult is about a month. And so it is quite it is quite a long process, but we managed to get our female flies laying on liver about nine times. So, you know, we did find that we had a sometimes you had so many eggs, we didn't know what to deal with. You know how to deal with them. So it, and I know that the Factory in South Wales and Bridgend bymond, they've got a very sophisticated process and a lovely way of of manufacturing enough. There's not a problem for them at all. But you can see other countries maybe struggle a little bit with with the cost of it. Yeah, for sure, yeah.

It makes me think of some of the mosquito control programs now that we sterile, release of sterile males, for example, that require huge mosquito factories to to produce these and that that does add expense,

of course,

but nevertheless, I think in this era where one of the biggest threats to human health is antibiotic resistance, I think that the beauty of using a system that has evolved to feed and cleanse wounds using a living system to treat that. It's just it's just beautiful, and I think it's really something that I imagine we're going to hear a lot more about in the coming years, thanks to the work of your group and and others across the globe, and these sort of success stories that you thought of the case you just mentioned in the recent publication. I mean, that surely is going to be a stimulus for both demand from the clinical side and also from the patients. And let's, let's hope that we see this becoming more of a mainstream therapy in in the UK and and in resource constrained settings where, you know, chronic wounds and.

Um, really, really, a major, major issue. Thank you so much for your time today. It's been fascinating hearing more about maggot therapy and about your own journey and your your clear love of Entomology, and I'm so pleased that that your time at in at the Liverpool School of Tropical Medicine was sort of instrumental in your career journey. We hope that we can continue to inspire the next generation of students, and have they will have more alumni from from LSTM working on maggot therapy in the future. Indeed, that's lovely. Thank you very much. Thanks. Hilary, thank you.