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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:

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Don’t Neglect the NTDs!

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  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. 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. 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

  4. NTDs: 17 plus 5 = 22 • 17 NTDs • 5 neglected conditions World Health Assembly Global health is very political!

  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. Schistosomiasis • Diagnose - microscopy, serology • Treat with praziquantel S. haematobium

  7. Dengue • Cairns epidemic – 2008-2009 Ritchie et al. PLoS One. 2013;8(7):e68137

  8. Dengue fever Dengue haemorrhagic fever and dengue shock syndrome

  9. Human African Trypanosomiasis (HAT) • Initial dermatological presentation • Diagnosed when presented 2 mths later with weight loss, fevers, confusion, seizures MJA 2010;192(7):417 J Travel Med.2008;15(5):375

  10. Cutaneousleishmaniasis Stewardson et al. J Trav Med 2010;17(4):278 J Trav Med 2008;15(5):351

  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. 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. Acute stage – intermittent fevers and adenolymphangitis • Pathology is due to reaction to filarial worms (esp. Wuchereriabancrofti) PLUS bacterial skin infections

  14. Male 40 yrs Tuvalu

  15. Mossy foot: elephantiasis due to lymphatic filariasis (Tuvalu)

  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. Solomon Islands – Sifilo, Malaita Province

  18. 2011 – Atoifi, Solomon Islands • 45 year old male presented at outpatients with lymphoedema of his right lower leg Elephantiasis. Due to lymphatic filariasis (LF)?

  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 post-elimination in Pacific Islands. Parasites and Vectors 2013;6:218.

  20. Australian NTDs

  21. Ascaris collected after a community treatment program in India

  22. Heavy infections! • Ascaris lumbricoides (human round worm) “STH” populations have collapsed in Australia!

  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. Strongyloidiasis = infection with Strongyloides stercoralis Chronic strongyloidiasis • Non specific signs & symptoms • Epigastric pain • Urticaria • Episodic diarrhoea • Larva currens Autoinfective larvae Strongyloidiasis is a life-long infection unless treated

  25. Diagnosis & Therapy • Diagnosis • Serology • Faeces - Agar plate test • Therapy • Ivermectin • Monitor serology for at least 12 months to document cure Agar plate with tracks from larvae Page et al. TRSTMH 2006;100:1056

  26. Very high prevalences in rural and remote Aboriginal communities Don’t miss the diagnosis. Patients can die if immunosuppressed

  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. Far north Qld & Victoria Daintree Ulcer Bairnsdale Ulcer

  29. M. ulcerans– Lessons from practice • Increased awareness of Mycobacterium ulceransinfection 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. ulceransis available from the Victorian Infectious Diseases Reference Laboratory (Melbourne). Jenkins et al. MJA 2002;176:182

  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. Australian NTDs

  32. Typical scabies • Papules • Itchy • Symmetrical • Trunk and limbs • Other lesions • Vesicles • Nodules • Chronic (>2 weeks)

  33. Crusted scabies Anbar et al (2007) Dermatology on Line

  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. 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. Crusted scabies can be localised or widespread Cracks. What significance? • Hyperkeratosis • Not necessarily symmetrical

  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. 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. Impact of uncontrolled Crusted Scabies on health of close contacts X56 X3.5 Date sources: Hospital admission data from GDH; Clinic presentation data from Health Centre; Census data (ABS); Internal OneDisease records

  40. Hospital days for scabies and crusted scabies have declined by 40-60% compared to previous 4 years +17% -40% -58% -49%

  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. 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 • Cutaneousleishmaniasis - 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.

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