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Don’t Neglect the NTDs!
Rick Speare
Emeritus Professor
James Cook University, Townsville, Australia
&
Director, Tropical H...
Presented at:
• Rural Medicine Australia 2013
• Cairns 30 Oct – 2 Nov 2013
• Hosts:
– Australian College of Rural and Remo...
Neglected Tropical Diseases
Tropical diseases of international or regional
public health importance that are underrecognis...
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
Onchocercias...
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...
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 ass...
Lymphatic
Filariasis
• Very common NTD
• End-stage is
elephantiasis
• Common cause of fever
in PNG in highly endemic
areas...
Acute stage – intermittent fevers and
adenolymphangitis

• Pathology is due to reaction to filarial worms (esp.
Wuchereria...
• Male 40 yrs Tuvalu
• Mossy foot
JCU’s contribution to Global Programme
for Elimination of Lymphatic Filariasis
• Developed an antigen detection test for
B...
Solomon Islands – Sifilo, Malaita Province
2011 – Atoifi, Solomon Islands

Elephantiasis.
Due to lymphatic
filariasis (LF)?

• 45 year old male presented at outpatie...
Response to elephantiasis case
• Local research team conducted survey
• No transmission occurring
• Good model for respons...
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
Helminth...
Strongyloidiasis = infection with
Strongyloides stercoralis
Chronic strongyloidiasis
• Non specific signs & symptoms
– Epi...
Diagnosis & Therapy
• Diagnosis
– Serology
– Faeces - Agar plate test

• Therapy

Agar plate with tracks from
larvae

– Iv...
Very high prevalences in rural and
remote Aboriginal communities

Don’t miss the diagnosis.
Patients can die if immunosupp...
Buruli ulcer
•
•
•
•
•

Nectrotising skin disease
Chronic ulcer
Mycobacterium ulcerans
Grows in subcutaneous tissue
Greate...
Far north Qld & Victoria

Bairnsdale Ulcer

Daintree Ulcer
M. ulcerans – Lessons from practice
• Increased awareness of Mycobacterium ulcerans
infection in the endemic areas (south-...
Trachoma (Chlamydia trachomatis)
• “Sandy blight”
• Australia is the only
developed country with
trachoma!
• Remote Aborig...
Australian NTDs
Typical scabies
•
•
•
•
•

Papules
Itchy
Symmetrical
Trunk and limbs
Other lesions
– Vesicles
– Nodules

• Chronic (>2 wee...
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
s...
The crusts are thick
layers of keratinised
cells mixed with mites,
eggs, shed skins, mite
faeces and bacteria

• Many mite...
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
commun...
One Disease at a Time:
Special role
• Focus on eliminating crusted scabies in East
Arnhem Land
• Detect cases of crusted s...
Impact of uncontrolled Crusted Scabies on health of
close contacts
Clinic presentations for scabies and/or skin sores
for ...
Hospital days for scabies and crusted scabies have
declined by 40-60% compared to previous 4 years
Days in hospital due to...
Don’t Neglect the NTDs
• GPs have an important role in improving
health in marginalised and under-served
populations
• NTD...
Source of images where not attributed or
original
•
•

•
•
•
•
•
•
•
•
•
•

World Health Assembly - http://health.howstuff...
Don't Neglect the NTDs!
Don't Neglect the NTDs!
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Don't Neglect the NTDs!

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Neglected Tropical Diseases (NTDs) are a group of 17 diseases and 5 neglected conditions. Australia is fortunate in having only 2/17 NTDs and 3/5 neglected conditions. This presentation was delivered to rural doctors at a conference in Australia to raise awareness about NTDs and to stress the need for early disgnosis.

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Don't Neglect the NTDs!

  1. 1. Don’t Neglect the NTDs! Rick Speare Emeritus Professor James Cook University, Townsville, Australia & Director, Tropical Health Solutions 31 October 2013 rickspeare@gmail.com
  2. 2. 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
  3. 3. 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
  4. 4. NTDs: 17 plus 5 = 22 • 17 NTDs • 5 neglected conditions World Health Assembly Global health is very political!
  5. 5. 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
  6. 6. Schistosomiasis S. haematobium • Diagnose - microscopy, serology • Treat with praziquantel
  7. 7. Dengue • Cairns epidemic – 2008-2009 Ritchie et al. PLoS One. 2013;8(7):e68137
  8. 8. Dengue fever Dengue haemorrhagic fever and dengue shock syndrome
  9. 9. 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
  10. 10. Cutaneous leishmaniasis Stewardson et al. J Trav Med 2010;17(4):278 J Trav Med 2008;15(5):351
  11. 11. 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
  12. 12. 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
  13. 13. Acute stage – intermittent fevers and adenolymphangitis • Pathology is due to reaction to filarial worms (esp. Wuchereria bancrofti) PLUS bacterial skin infections
  14. 14. • Male 40 yrs Tuvalu
  15. 15. • Mossy foot
  16. 16. 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?
  17. 17. Solomon Islands – Sifilo, Malaita Province
  18. 18. 2011 – Atoifi, Solomon Islands Elephantiasis. Due to lymphatic filariasis (LF)? • 45 year old male presented at outpatients with lymphoedema of his right lower leg
  19. 19. 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.
  20. 20. Australian NTDs
  21. 21. Ascaris collected after a community treatment program in India
  22. 22. Heavy infections! • Ascaris lumbricoides (human round worm) “STH” populations have collapsed in Australia!
  23. 23. 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?
  24. 24. 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
  25. 25. 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
  26. 26. Very high prevalences in rural and remote Aboriginal communities Don’t miss the diagnosis. Patients can die if immunosuppressed
  27. 27. 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
  28. 28. Far north Qld & Victoria Bairnsdale Ulcer Daintree Ulcer
  29. 29. 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
  30. 30. 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
  31. 31. Australian NTDs
  32. 32. Typical scabies • • • • • Papules Itchy Symmetrical Trunk and limbs Other lesions – Vesicles – Nodules • Chronic (>2 weeks)
  33. 33. Anbar et al (2007) Dermatology on Line Crusted scabies
  34. 34. 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
  35. 35. 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!
  36. 36. Crusted scabies can be localised or widespread Cracks. What significance? • Hyperkeratosis • Not necessarily symmetrical
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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.

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