Don't Neglect the NTDs!

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 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

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.