Don’t Neglect the NTDs! Rick Speare Emeritus Professor James Cook University, Townsville, Australia & Director, Tropical Health Solutions 31 October 2013 email@example.com Presented at: • Rural Medicine Australia 2013 • Cairns 30 Oct – 2 Nov 2013 • Hosts: – Australian College of Rural and Remote Medicine – Rural Doctors Association of Austalia Neglected Tropical Diseases Tropical diseases of international or regional public health importance that are underrecognised and under-funded. Neglected diseases of neglected and underserved populations. In competition with the big three: malaria, HIV/AIDS and TB NTDs: 17 plus 5 = 22 • 17 NTDs • 5 neglected conditions World Health Assembly Global health is very political! Check the list: cross-out the non-Australian NTDs • • • • • • • • • • • Lymphatic filariasis Dracunculiasis Onchocerciasis Soil-transmitted helminths Schistosomiasis Food-borne trematodiasis Echinococcosis Taeniasis/Cysticercosis African trypansomiasis American trypansomiasis (Chaga’s disease) Leishmaniasis • • • • • • Leprosy Buruli ulcer Trachoma Yaws Dengue Rabies Neglected conditions • Strongyloidiasis • Scabies • Mycetoma • Podoconiasis • Snakebite Schistosomiasis S. haematobium • Diagnose - microscopy, serology • Treat with praziquantel Dengue • Cairns epidemic – 2008-2009 Ritchie et al. PLoS One. 2013;8(7):e68137 Dengue fever Dengue haemorrhagic fever and dengue shock syndrome Human African Trypanosomiasis (HAT) MJA 2010;192(7):417 • Initial dermatological presentation • Diagnosed when presented 2 mths later with weight loss, fevers, confusion, seizures J Travel Med.2008;15(5):375 Cutaneous leishmaniasis Stewardson et al. J Trav Med 2010;17(4):278 J Trav Med 2008;15(5):351 GIDEON to help with the diagnosis • Global Infectious Disease Epidemiology Network - http://www.gideononline.com/ • An assistant for the diagnosis of infectious diseases • Provides probabilities Lymphatic Filariasis • Very common NTD • End-stage is elephantiasis • Common cause of fever in PNG in highly endemic areas • JCU 1993 - WHO Collaborating Centre for Control of Lymphatic Filariasis and Soil Transmitted Helminths Acute stage – intermittent fevers and adenolymphangitis • Pathology is due to reaction to filarial worms (esp. Wuchereria bancrofti) PLUS bacterial skin infections • Male 40 yrs Tuvalu • Mossy foot: elephantiasis due to lymphatic filariasis (Tuvalu) JCU’s contribution to Global Programme for Elimination of Lymphatic Filariasis • Developed an antigen detection test for Bancroftian filariasis - 1990s • Showed that mass drug administration could break the transmission cycle - 1990s • WHO CC Provides advice on LF to the 22 Pacific Countries and Territories (PICTs) in the PacELF • Assisted PICTs to eliminate LF (success in some) • Tools to quantifying disability Has LF really gone? Solomon Islands – Sifilo, Malaita Province 2011 – Atoifi, Solomon Islands Elephantiasis. Due to lymphatic filariasis (LF)? • 45 year old male presented at outpatients with lymphoedema of his right lower leg Response to elephantiasis case • Local research team conducted survey • No transmission occurring • Good model for response to a case of elephantiasis in countries where LF had been “eliminated” Harrington et al. A practical strategy for responding to a case of lymphatic filariasis postelimination in Pacific Islands. Parasites and Vectors 2013;6:218. Australian NTDs Ascaris collected after a community treatment program in India Heavy infections! • Ascaris lumbricoides (human round worm) “STH” populations have collapsed in Australia! Strongyloidiasis • Strongyloidiasis = infection with Strongyloides stercoralis excluded from the Soil Transmitted Helminths (STH) • It is a helminth (parasitic nematode) • People get infected by infective larvae that penetrate skin Why was strongyloidiasis not a NTD STH? Strongyloidiasis = infection with Strongyloides stercoralis Chronic strongyloidiasis • Non specific signs & symptoms – Epigastric pain – Urticaria – Episodic diarrhoea • Larva currens Strongyloidiasis is a life-long infection unless treated Autoinfective larvae Diagnosis & Therapy • Diagnosis – Serology – Faeces - Agar plate test • Therapy Agar plate with tracks from larvae – Ivermectin • Monitor serology for at least 12 months to document cure Page et al. TRSTMH 2006;100:1056 Very high prevalences in rural and remote Aboriginal communities Don’t miss the diagnosis. Patients can die if immunosuppressed Buruli ulcer • • • • • Nectrotising skin disease Chronic ulcer Mycobacterium ulcerans Grows in subcutaneous tissue Greater destruction subcutaneously • Always more extensive than it appears • Can become oedematous Far north Qld & Victoria Bairnsdale Ulcer Daintree Ulcer M. ulcerans – Lessons from practice • Increased awareness of Mycobacterium ulcerans infection in the endemic areas (south-east Victoria and far north Queensland) is important in early diagnosis. • The disease may present with an acute onset and oedema, without ulceration. • Early diagnosis can reduce the extent of surgical excision and minimise the risk of relapse. • A diagnostic polymerase chain reaction (PCR) test with 96% sensitivity and 100% specificity for M. ulcerans is available from the Victorian Infectious Diseases Reference Laboratory (Melbourne). Jenkins et al. MJA 2002;176:182 Trachoma (Chlamydia trachomatis) • “Sandy blight” • Australia is the only developed country with trachoma! • Remote Aboriginal communities in NT, WA, SA • Inflammation of tarsal conjunctiva • Scaring & trichiasis SAFE = surgery; antibiotics; facial cleanliness; environment without flies Australian NTDs Typical scabies • • • • • Papules Itchy Symmetrical Trunk and limbs Other lesions – Vesicles – Nodules • Chronic (>2 weeks) Anbar et al (2007) Dermatology on Line Crusted scabies CRUSTED SCABIES: Thick hard crusts of keratin • Crusting (hyperkeratosis) • Build up of stratum corneum • Called crusted scabies or Norwegian scabies • Occurs in leprosy, HIV, Down’s syndrome, HTLV-I, some people • Aborigines in remote areas • This is not an allergic response The crusts are thick layers of keratinised cells mixed with mites, eggs, shed skins, mite faeces and bacteria • Many mites per gram of skin Highly infectious! Crusted scabies can be localised or widespread Cracks. What significance? • Hyperkeratosis • Not necessarily symmetrical Scabies in Australia • Rare in mainstream Australia • Usually typical scabies • Far too common in remote Aboriginal communities • Some people in these communities have a propensity to develop crusted scabies • Superspreaders! Scabies can’t be controlled when crusted cases are present One Disease at a Time: Special role • Focus on eliminating crusted scabies in East Arnhem Land • Detect cases of crusted scabies • Ensure these people are cured • Keep them free of scabies • Support scabies control generally Impact of uncontrolled Crusted Scabies on health of close contacts Clinic presentations for scabies and/or skin sores for children in first year of life: Community A 2008-2010 16.0 14.0 0.6 X3.5 12.0 X56 0.5 10.0 0.4 8.0 14.3 6.0 0.653 0.3 0.2 4.0 2.0 0.7 Scabies-related hospital days per child per year: Community A & Community B (0-14 years) 2009-12 0.1 4.0 0.0 0 Other CS Close contacts 0.012 Other CS Close contacts Date sources: Hospital admission data from GDH; Clinic presentation data from Health Centre; Census data (ABS); Internal OneDisease records Hospital days for scabies and crusted scabies have declined by 40-60% compared to previous 4 years Days in hospital due to scabies/crusted scabies: Before and after May 2012 400 350 300 250 200 150 100 50 0 +17% 350 298 -40% 147 -58% -49% 88 106 85 54 36 All scabies admissions at Gove District Hospital 1D CS patients Scabies admissions from Community A and Community B Annual ave: May '08 - Apr '12 All scabies admissions at Royal Darwin Hospital May '12 - Apr '13 Don’t Neglect the NTDs • GPs have an important role in improving health in marginalised and under-served populations • NTDs are more common in these groups • Look out for the rare imported NTD • Diagnose, treat and manage our local NTDs • Advocate for specific NTD control programs where indicated Source of images where not attributed or original • • • • • • • • • • • • World Health Assembly - http://health.howstuffworks.com/medicine/healthcare/who2.htm Schistosomiasis – haematuria - http://s160131.gridserver.com/wp-content/uploads/dipsticktesting-to-detect-haematuria.jpg S. haematobium egg http://en.m.wikipedia.org/wiki/File:Schistosoma_haematobium_egg_4843_lores.jpg Cutaneous leishmaniasis - http://www.who.int/leishmaniasis/cutaneous_leishmaniasis/en/ Strongyloides parasitic female http://ruby.fgcu.edu/courses/davidb/50249/web/strongy%20145.htm Strongyloides infective larave - http://www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/SZ/Strongyloidiasis/body_Strongyloidiasis_il2.htm Larva currens – Dr Wendy Page Buruli ulcer - http://en.wikipedia.org/wiki/File:Buruli_ulcer_hand_Peru.gif Typical Scabies - http://www.dermis.net/dermisroot/en/16647/image.htm Crusted scabies – toe – Dermatological Atlas (http://dermatlas.med.jhmi.edu/derm/) ScabiesCrusted_5_050904 Figure of scabies distribution - http://www.indianpediatrics.net/sept2001/sept-995-1008.htm Trachoma - CDNA. Guidelines for the public health management of trachoma in Australia.. Comm Aust. 2006.