This document summarizes a presentation on neglected tropical diseases (NTDs). It discusses 17 NTDs and 5 neglected conditions that primarily impact neglected and underserved populations. It provides examples of several NTDs that impact Australia such as strongyloidiasis, buruli ulcer, trachoma, scabies, and provides clinical pictures and descriptions. It emphasizes the role of general practitioners in improving health in marginalized groups through diagnosing, treating, and advocating for control programs for local NTDs.

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
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Lymphatic filariasis
Dracunculiasis
Onchocerciasis
Soil-transmitted
helminths
Schistosomiasis
Food-borne trematodiasis
Echinococcosis
Taeniasis/Cysticercosis
African trypansomiasis
American trypansomiasis
(Chaga’s disease)
Leishmaniasis
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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

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

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
Elephantiasis.
Due to lymphatic
filariasis (LF)?
• 45 year old male presented at outpatients
with lymphoedema of his right lower leg

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 postelimination 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
Agar plate with tracks from
larvae
– Ivermectin
• Monitor serology for at least 12
months to document cure
Page et al. TRSTMH
2006;100:1056

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

28. Buruli ulcer
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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
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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. 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!

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

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
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

42. 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

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
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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.