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 Australian College of Rural and Remote Medicine – Rural Doctors Association of Austalia 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 Global health is very political! World Health Assembly

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 J Travel Med.2008;15(5):375 MJA 2010;192(7):417

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

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

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

15. Male 40 yrs Tuvalu

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

17. 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?

18. Solomon Islands – Sifilo, Malaita Province

19. 2011 – Atoifi, Solomon Islands 45 year old male presented at outpatients with lymphoedema of his right lower leg Elephantiasis. Due to lymphatic filariasis (LF)?

20. 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.

21. Australian NTDs

22. Ascaris collected after a community treatment program in India

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

24. 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?

25. 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

26. 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

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

28. 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

30. Far north Qld & Victoria Bairnsdale Ulcer Daintree Ulcer

31. 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

32. 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

33. Australian NTDs

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

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

36. 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

37. 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!

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

39. 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

40. 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

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

42. -40% -49% -58% +17% Hospital days for scabies and crusted scabies have declined by 40-60% compared to previous 4 years

43. 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

44. Source of images where not attributed or original World Health Assembly - http://health.howstuffworks.com/medicine/healthcare/who2.htmhttp://health.howstuffworks.com/medicine/healthcare/who2.htm Schistosomiasis – haematuria - http://s160131.gridserver.com/wp-content/uploads/dipstick- testing-to-detect-haematuria.jpghttp://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/http://www.who.int/leishmaniasis/cutaneous_leishmaniasis/en/ Strongyloides parasitic female - http://ruby.fgcu.edu/courses/davidb/50249/web/strongy%20145.htm 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.htmhttp://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.gifhttp://en.wikipedia.org/wiki/File:Buruli_ulcer_hand_Peru.gif Typical Scabies - http://www.dermis.net/dermisroot/en/16647/image.htmhttp://www.dermis.net/dermisroot/en/16647/image.htm Crusted scabies – toe – Dermatological Atlas (http://dermatlas.med.jhmi.edu/derm/) ScabiesCrusted_5_050904http://dermatlas.med.jhmi.edu/derm/ Figure of scabies distribution - http://www.indianpediatrics.net/sept2001/sept-995-1008.htmhttp://www.indianpediatrics.net/sept2001/sept-995-1008.htm Trachoma - CDNA. Guidelines for the public health management of trachoma in Australia.. Comm Aust. 2006.