Don’t Neglect the NTDs!
Rick Speare
Emeritus Professor James Cook University, Townsville, Australia
&Director, Tropical Health Solutions
31 October 2013
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 under-recognised and under-funded.
Neglected diseases of neglected and under-served populations.
In competition with the big three:malaria, HIV/AIDS and TB
NTDs: 17 plus 5 = 22
• 17 NTDs• 5 neglected conditions
Global health is very political!
World Health Assembly
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• RabiesNeglected conditions• Strongyloidiasis• Scabies• Mycetoma• Podoconiasis• Snakebite
Schistosomiasis
• Diagnose - microscopy, serology• Treat with praziquantel
S. haematobium
Dengue• Cairns epidemic – 2008-2009
Ritchie et al. PLoS One. 2013;8(7):e68137
Dengue feverDengue haemorrhagic
fever and dengue shock syndrome
Human African Trypanosomiasis (HAT)
• Initial dermatological presentation• Diagnosed when presented 2 mths
later with weight loss, fevers, confusion, seizures
J Travel Med.2008;15(5):375
MJA 2010;192(7):417
Cutaneous leishmaniasis
J Trav Med 2008;15(5):351
Stewardson et al. J Trav Med 2010;17(4):278
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
• 45 year old male presented at outpatients with lymphoedema of his right lower leg
Elephantiasis. Due to lymphatic
filariasis (LF)?
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 post-elimination 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– Ivermectin
• Monitor serology for at least 12 months to document cure
Page et al. TRSTMH 2006;100:1056
Agar plate with tracks from larvae
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
• Many mites per gram of skin
The crusts are thick layers of keratinised
cells mixed with mites, eggs, shed skins, mite
faeces and bacteria
Highly infectious!
Crusted scabies can be localised or widespread
• Hyperkeratosis• Not necessarily symmetrical
Cracks. What significance?
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
Other CS Close contacts0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.012
0.653000000000001
Scabies-related hospital days per child per year:Community A & Community B (0-14 years)
2009-12
Other CS Close contacts0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
4.0
14.3
Clinic presentations for scabies and/or skin sores for children in first year of life: Community A
2008-2010
X3.5 X56
Date sources: Hospital admission data from GDH; Clinic presentation data from Health Centre; Census data (ABS); Internal OneDisease records
All scabies admissions at Gove District Hospital
1D CS patients Scabies admissions from Community A and
Community B
All scabies admissions at Royal Darwin Hospital
050
100150200250300350400
147
85106
298
88
36 54
350
Days in hospital due to scabies/crusted scabies: Before and after May 2012
Annual ave: May '08 - Apr '12 May '12 - Apr '13
-40%
-49% -58%
+17%
Hospital days for scabies and crusted scabies have declined by 40-60% compared to previous 4 years
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/dipstick-testing-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/S-Z/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.