Transcript presentation - Tropical Health Solutions

David Banks Oration
Biosecurity in North Queensland:
Challenges and opportunities
Rick Speare
Anton Breinl Centre for Public Health and
Tropical Medicine
James Cook University
[email protected]
13 May 2010
Questions
• Are the biosecurity risks in North
Queensland different from other areas in
Australia?
• Do these special risks make Australia
more vulnerable?
• How are they being addressed?
• What are the opportunities to use new
approaches to reduce the risks?
What makes North
Queensland special?
• Receptivity
to dengue
• Porous PNG-Australian border
in Torres Strait
Slide from Scott Ritchie (JCU)
Receptivity is a Qld problem… at present
Slide from Scott Ritchie (JCU)
North Queensland dengue outbreaks
cases per month
400
300
200
North Queensland dengue outbreaks
cases per month
400
300
200
100
0
19
95
19
96
19
97 1
9
1 9 1 95
98 99
6
19 199
99 1 7
9
2 0 98
00 199
9
2
20 00
01 2 0
0
2 0 2 01
02 002
20 200
03 2 3
0
2 0 2 04
04 00
5
2
20 00
05 6
20
2 0 07
06 200
8
2
20 00
07 9
20
08
20
09
0
100
Graph from Dr Scott Ritchie, JCU/QH
Control of Dengue
• Dengue Control Strategy
• Continual enhanced surveillance under
National Notifiable Disease Surveillance
Scheme (NNDSS)
• Dengue Alert and Response Team
• State of Emergency declared to control
2008-2009 Cairns outbreak
Constant vigilence, but dengue is
under control
• Lethal ovitraps
• Biodegradable
• Research on novel
control strategies using a
symbiotic bacterium
(Wolbachia wMelPop)
– Reduces longevity
– Reduces feeding ability
– Inhibits dengue virus
multiplication in mosquito
Pacific Island Countries & Territories
(PICTs)
PNG
22 countries
spread over millions
of km2 of Pacific Ocean
PICTs are doing badly!
Southeast Asia
PICTs
Indonesia
Indo-Papuan
Conduit
Qld’s special link to Asia
and the Pacific
PNG
Australia
Joh Rescues Torres Strait Islands
Torres Strait Treaty 1978
Major outcomes of the Torres Strait
Treaty Act 1984
• “each Party shall apply immigration, customs,
quarantine and health procedures in such a
way as not to prevent or hinder free
movement or the performance of traditional
activities” (article 16)
• Refers to residents
of protected zone
(PZ) and 13 coastal
villages in PNG
(article 10)
What are the current offshore
biosecurity challenges?
• Failed health systems pushing diseased
PNG residents towards Torres Strait
• Emerging infectious diseases (known and
unknown) in Australia’s near neighbours
• Poor control of livestock diseases in PICTs
and Indonesia
• Importation of food products carrying
pathogens
• Climate change, especially in PICTs,
generating environmental refugees
Comparing ICUs: Lake Murray vs
Townsville Mater
POVERTY!
Tuvulu
Climate Change will
have major impacts
in PICTs!
Traditional PNG visitors
• Annually 30,000-53,000
59%
2%
3%
29%
2%
4%
0.6%
0.2%
0.1%
0.5%
0.3%
0.2%
Estimated 4%
come
specifically for
health care
0.1%
House Reps SC Hlth Aging Mar 2010
Contrasts in services
Torres Strait
Western Province
• Well functioning Qld
Health system staffed
by doctors, nurse
practitioners and
remote area nurses
• Specialists visit and
referral - Cairns
• Basic laboratory
services in TS
• Veterinary services
intermittent in PZ
• Minimal or no health
service staffed by
health extension
officers
• Very low vaccination
rates
• Specialist referral –
Port Moresby, but
inadequate
• Minimal lab services
• No veterinary service
Humanitarian emergencies:
Entry into Cairns … and points south
Saibai
Thursday Is
Cairns
What about movement of animals
and animal products?
• AQIS Quarantine offices = 15
Northern Australian
Quarantine Strategy
(NAQS)
Incursions that have occurred and
are under control
• Malaria (surveillance - NNDSS)
• Dengue (enhanced surveillance - NNDSS)
• Japanese encephalitis 1995 (NNDSS,
vaccination of all TS residents)
• TB (NNDSS)
• Leprosy (NNDSS)
Merritt et al 1998
Incursions that are not under control
• Asian tiger mosquito (Aedes albopictus)
found in 10/17 inhabited islands in 2005
Current
Distribution
Predicted
Distribution
Russell et al (2005)
Current Emerging Infectious Disease Threats
• Multidrug resistant TB, particularly in PNG
• Cholera now moved to south coast PNG
• Arboviral diseases (Dengue, Japanese
encephalitis, West Nile, Chickungunya)
• Asian tiger mosquito (A. albopictus) in Torres
Strait
• Rabies moving east in Indonesia
• Highly pathogenic avian influenza and other
avian viruses
• Nipah virus and other bat-borne viruses
• New pathogens emerging from wildlife
MDRTB
Pulmonary TB
(Mycobacterium
tuberculosis)
• Chronic cough
(2 wks)
• Productive
• Haemoptysis
(blood in
sputum)
• Weight loss
• Night sweating
Multidrug Resistant TB (MDRTB)
• TB is a serious disease
• TB prevalence
– Aust 5/100,000
– Western Province 552/100,000 (DoH WestProv 2009)
• MDRTB is resistant to two of the first line drugs
(rifampacin & isoniazid)
• Harder to treat & more expensive
• 30% of Australia’s MDRTB comes through
Torres Strait from Western Province of PNG
• Rate of MDRTB in PNG patients in Torres Strait
– 25-39% (DHA 2009 dha_171209)
Bad enough!
But wait there’s more…
• Inadequate treatment drives MDRTB
• Evolution to extensively drug resistent TB
(XDRTB) is a possibility
Challenges in PNG
• DOTS system to treat TB not implemented
• No reliable routine TB culture
• Inadequate treatment generates multidrug
resistance
• Partial treatment of TB in Australia may
generate MDRTB
• No strategy in Western Province to treat
MDRTB
• HIV is increasing in PNG
Risk of MDRTB to North Queensland?
• Manageable since TB control is
good in Torres Strait and socioeconomic conditions are
protective
• For local residents risk is not
high
• Risk highest to health
professionals in Torres Strait
caring for PNG cases
Management of risk of MDRTB
• In Torres Strait
– Maintain Aust TB control system
– Enhanced surveillance for suspect TB cases
– Protect health care workers
• In Western Province
– Adequately treat PNG patients that present in TS
• Cross-border collaboration (Communications
officers)
• Subsidised boat trips to complete treatment
– Assist PNG to improve TB control in Western
Province
– Assist PNG to establish TB culture facilities at
Daru or Balimo
Facilitated cross-border
movement
• TS Health Issues
Committee (HIC) “Package
of measures”
• Allow travel directly from
Saibai and Boigu to treaty
villages for nominated
health professionals
• Agreed to by both sides
• Implementation date?
Cholera
• PNG cholera epidemic
began in Lae in Oct 2009
• Spread to Madang Oct
2009
• Nov 2009 west along north
coast, and inland to
highlands
• May 2010 first cases in
Port Moresby
• When will it reach the
Western Province?
How will Australia respond?
JE
Other arboviruses?
Dengue
Arboviruses
•
•
•
•
•
Dengue virus (DEV)
Japanese encephalitis virus
Chickunguna virus
West Nile virus
Unknown and undiscovered viruses
Only dengue virus is host specific:
1) humans, 2) Aedes aegypti or A. albopictus
Aedes
albopictus
Receptivity is a Qld problem,
but rain water tank installation
will expand the range
of the vectors south
Unknown arboviruses in PNG?
• Madang encephalitis
• Not JEV?
• Death in children and severe disability
Rabies is moving east
in Indonesia
Not if, but when?
1997
2008
•
Susetya et al. Virus Res 2008;135:144-9.
Indo-Papuan
Conduit
Strategies to defend against rabies
from Indonesia
• Assist PNG to monitor dogs with
neurological signs (no functional vet service)
– Surveillance
– Laboratory capacity
• Assist in control of rabies in Indonesia
• AQIS officers monitoring dogs in Torres
Strait
• AMRRIC improving dog health in Indigenous
communities
• Control in wild dogs & dingoes is a problem
– Vaccinate against rabies by baiting
HPAI?
Other EID?
Other arboviruses?
JE
Bat viruses?
Dengue
MDRTB
Wildlife Diseases:
EID risks
• Two higher risk flying reservoirs
• Bats: Henipaviruses, lyssaviruses, filoviruses,
coronaviruses, rheoviruses, herpesviruses,
other viruses
• Birds: Avian influenza and other avian
diseases
Wildlife EIDs are driven
by habitat destruction,
humans using resources,
climate change
Flying foxes are hosts to a range of RNA viruses
that cause EIDs
Dobsonia magna
• Halpin et al. CID 2007;44:711-717
Highly Pathogenic Avian Influenza
• Pandemic (for birds)
• H5N1 is here to stay
H5N1 in Indonesia
• H5N1 HPAI is widespread
• 165 human cases with 136 fatal (82%)
H5N1
Indo-Papuan
Conduit
Will H5N1 use this route?
Ongoing monitoring of poultry &
wild birds in PNG & Torres Strait
for AI?
Wildlife Disease Surveillance
is essential
"Our findings highlight the critical need for health monitoring
and identification of new, potentially zoonotic pathogens
in wildlife populations, as a forecast measure for EIDs”
(Jones et al. Nature 2008)
We must be looking for
• mortality and morbidity in wildlife, esp bats and birds
• Marine animals – reptiles, mammals, fish?
• Monitoring regularly for particular diseases
– Avian influenza
– Newcastle disease
– West Nile virus (in birds)
– Bat henipaviruses
Australian Wildlife Health Network
• Largely voluntary surveillance
• Should be a parallel system equivalent to
human communicable disease
surveillance system and veterinary
surveillance system
• Not functioning in Torres Strait or Cape
York
• Poorly funded
• Major deficiency in biosecurity surveillance
in North Queensland
Opportunities in PNG
• Assist PNG to establish communicable disease
surveillance in Western Province
• Syndromic surveillance for outbreak diseases
may be best model
• Consider a joint human, livestock, and wildlife
surveillance system (true “One Health”)
• Initially provide expert support from Torres Strait
• Initially provide lab support from Australia
• Utilise the facilitated cross-border movement
approach
Syndromic surveillance in resource
poor environments
• Frontline health workers trained to recognise signs and
symptoms of diseases of outbreak potential (eyes of the
system)
• Supported by a hub of communicable disease control
specialists (brain of the system)
• Backed up by laboratory support to confirm diagnoses
• Used to control human diseases in Mpumulanga
Province (South Africa), Tuvalu, now other PICTs
• Western Province is “virgin soil”
• Why not implement a syndromic surveillance One Health
system that looks for outbreak diseases in humans,
livestock, and wildlife?
Speare et al (2003), Nelesone et al (2006)
Opportunities in Torres Strait
• Establish a functional wildlife disease
surveillance system with good response
capacity
• Improve formal collaboration in outbreak
investigation and response across all three
arms (human, livestock, wildlife)
• Provide cross-border support to
surveillance in PNG, particularly for
diseases with outbreak potential
Way forward
•
•
•
•
Political will at all levels in Australia
Money to demonstrate commitment
Coordinated planning
Strengthening of the Torres Strait surveillance
and response activities to detect and control
disease and pest incursions in a timely manner
• Collaborative partnership with PNG national and
Western Province leaders
• Focus on decreasing the EID risks liable to enter
via the IndoPapuan conduit
• Protect Australia by protecting PNG
Difficult, long-term, but essential
Thank you!
Images
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•
•
•
•
•
•
•
•
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Aedes aegypti http://www.health.gov.bz/www/images/stories/aedes_aegypti_seitlich.jpg
Black-striped wallaby http://www.fauna.com.au/web_pages/animals/marsupials/black_striped_wallaby.html
Leaving on a jet plane - www.thegoodsplace.org/2007/06/boo-hoo-hoo.html
Pasteur & swan neck flasks http://www.daviddarling.info/encyclopedia/P/Pasteur.html
Rabid dog - http://www.jack-russell-terrier.co.uk/advice/vaccinations.html
Port Douglas - http://www.flickr.com/photos/blackdiamondimages/3874757902/
Scott O’Neill - www.uq.edu.au/news/?article=18458
Rain water tank from Scott Ritchie
Scott Ritchie - http://www.jcu.edu.au/phtmrs/staff/academic/JCUDEV_015744.html
Dobsonia magna http://www.henipavirus.org/virus_and_host_info/bats/dobsonia_magna.htm
Literature cited
• Hufnagel L. et.al. PNAS 2004;101:15124-15129
• Jones KE, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL,
Daszak P. Global trends in emerging infectious diseases. Nature
2008;451(7181):990-3.
• Nelesone T, Durrheim DN, Speare R, Kiedrzynski T, Melrose WD.
Strengthening sub-national communicable disease surveillance in a
remote Pacific Island Country by adapting a successful African
outbreak surveillance model. Tropical Medicine and International
Health 2006;11(1):17-21.
• Speare R, Durheim DN, Ogunbanjo GA, Edginton ME, Harris BN.
An effective training strategy for communicable disease control
nurses. African Journal of Nursing and Midwifery. 2003;5(1):50-56.
• Susetya H, Sugiyama M, Inagaki A, Ito N, Mudiarto G, Minamoto N.
Molecular epidemiology of rabies in Indonesia. Virus Research
2008;135:144-9.