Don’t Neglect the NTDs!
Rick Speare
Emeritus Professor
James Cook University, Townsville, Australia
&
Director, Tropical Health Solutions
31 October 2013
rickspeare@gmail.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
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Lymphatic filariasis
Dracunculiasis
Onchocerciasis
Soil-transmitted
helminths
Schistosomiasis
Food-borne trematodiasis
Echinococcosis
Taeniasis/Cysticercosis
African trypansomiasis
American trypansomiasis
(Chaga’s disease)
Leishmaniasis
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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
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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
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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
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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.