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Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
Don't Neglect the NTDs!
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 …

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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  • 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 underrecognised and under-funded. Neglected diseases of neglected and underserved 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 S. haematobium • Diagnose - microscopy, serology • Treat with praziquantel
  • 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) 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. Cutaneous leishmaniasis 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. Wuchereria bancrofti) PLUS bacterial skin infections
  • 14. • Male 40 yrs Tuvalu
  • 15. • Mossy foot
  • 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 Elephantiasis. Due to lymphatic filariasis (LF)? • 45 year old male presented at outpatients with lymphoedema of his right lower leg
  • 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. 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 Strongyloidiasis is a life-long infection unless treated Autoinfective larvae
  • 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. 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 Bairnsdale Ulcer Daintree Ulcer
  • 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. 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. Anbar et al (2007) Dermatology on Line Crusted scabies
  • 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 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. 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. 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/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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