Don't Neglect the NTDs!

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Don’t Neglect the NTDs! Rick Speare Emeritus Professor James Cook University, Townsville, Australia & Director, Tropical Health Solutions 31 October 2013 [email protected]

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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.

Transcript of Don't Neglect the NTDs!

Page 1: 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

[email protected]

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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

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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

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NTDs: 17 plus 5 = 22

• 17 NTDs• 5 neglected conditions

Global health is very political!

World Health Assembly

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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

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Schistosomiasis

• Diagnose - microscopy, serology• Treat with praziquantel

S. haematobium

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Dengue• Cairns epidemic – 2008-2009

Ritchie et al. PLoS One. 2013;8(7):e68137

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Dengue feverDengue haemorrhagic

fever and dengue shock syndrome

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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

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Cutaneous leishmaniasis

J Trav Med 2008;15(5):351

Stewardson et al. J Trav Med 2010;17(4):278

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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

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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

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Acute stage – intermittent fevers and adenolymphangitis

• Pathology is due to reaction to filarial worms (esp. Wuchereria bancrofti) PLUS bacterial skin infections

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• Male 40 yrs Tuvalu

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• Mossy foot

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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?

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Solomon Islands – Sifilo, Malaita Province

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2011 – Atoifi, Solomon Islands

• 45 year old male presented at outpatients with lymphoedema of his right lower leg

Elephantiasis. Due to lymphatic

filariasis (LF)?

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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.

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Australian NTDs

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Ascaris collected after a community treatment program in India

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Heavy infections!• Ascaris lumbricoides (human round worm)

“STH” populations have collapsed in Australia!

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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?

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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

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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

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Very high prevalences in rural and remote Aboriginal communities

Don’t miss the diagnosis. Patients can die if immunosuppressed

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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

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Far north Qld & Victoria

Bairnsdale Ulcer Daintree Ulcer

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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

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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

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Australian NTDs

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Typical scabies

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

• Chronic (>2 weeks)

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Anbar et al (2007) Dermatology on Line Crusted scabies

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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

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• 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!

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Crusted scabies can be localised or widespread

• Hyperkeratosis• Not necessarily symmetrical

Cracks. What significance?

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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

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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

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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

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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

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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

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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.