Neglected Tropical Diseases

Tropical diseases are the diseases that are most prevalent in tropical regions of the world. There are around 14 tropical diseases that causes great morbidity but still ranks low in the international health agendas and being "neglected" since it is confined to certain regions and does not spread across the globe. These diseases are eliminated in developed countries but are prevalent in developing countries because of improper sanitation.Here,I hope I have covered almost all the neglected tropical diseases.

1. Neglected Tropical Diseases Presented by Dr.R.SINDHU Postgraduate Dept.Of Public Health Dentistry SRM Dental College

2. CONTENTS Introduction Soil transmitted helminthiasis Schistosomiasis Oncocerciasis Dracunculiasis Lymphatic filiriasis Trachoma Leprosy Buruli ulcer Leishmaniasis Chagas disease Human African trypanomiosis Dengue fever Conclusion R eferences

3. The Society of Tropical Medicine of Philadelphia in 1903 The Royal Society of Tropical Medicine and Hygiene in 1909[Patrick Manson-President and inventor of ”mosquito theory”] These institutions officialized the designation “tropical diseases” in medical terminology. The designation “tropical diseases” was invented in19 th century. It arose at no particular date and was gradually consolidated, as microorganisms came to be acknowledged as the causal factors of diseases and transmission. Since most of the new colonies were located in the tropics, these curious and exotic diseases were said to be “tropical”. Introduction NTDs are a group of infectious diseases that cause substantial illness and impair physical and cognitive development. They generally are rare or absent in developed countries, but are often widespread in the developing world.

4. Unsafe water, lack of access to health services, inadequate housing, malnutrition and poor sanitation,filthy environments,abundant insects and other vectors contribute to efficient transmission of infection Neglected tropical diseases have traditionally ranked low on national and international health agendas. They do not spread to distant countries through travellers unless there is an outbreak.

5. SOIL TRANSMITTED HELMINTHIASIS Hookworm ( Necator & Ancylostoma spp ) Whipworm ( Trichuris sp ) Roundworm ( Ascaris lumbricoides ) They are transmitted by eggs present in human faeces, which contaminate the soil in areas where sanitation is poor. Approximately 1.5 billion[24%] people are infected with soil-transmitted helminths worldwide . Over 267 million preschool-age children and over 568 million school-age children live in areas where these parasites are intensively transmitted, and are in need of treatment and preventive interventions . The worms feed on host tissues, including blood, which leads to a loss of iron and protein. chronic intestinal blood loss that can result in anaemia. The worms increase malabsorption of nutrients . L oss of appetite,a reduction of nutritional intake and physical fitness . In particular,  T. trichiura  can cause diarrhoea and dysentery.

6. CONTROL STRATEGY D eworming :yearly (prevalence-20%), Twice yearly(50%) H ealth and hygiene education P rovision of adequate sanitation   Medicines – albendazole (400 mg) and mebendazole (500 mg) Global target The global target is to eliminate morbidity due to soil-transmitted helminthiases in children by 2020. This will be obtained by regularly treating at least 75% of the children in endemic areas. People at risk are: preschool children school-age children women of childbearing age adults in certain high-risk occupations such as tea-pickers or miners.

7. Schistosomiasis (bilharzia) 3species China and far east Africa,South America and Carribean Africa and Middle east P revalent in tropical and subtropical areas, especially in poor communities without access to safe drinking water and adequate sanitation. Infections are acquired with contact of fresh water where aquatic snails(intermediate host) present. The worms of all species live in the blood vessels of the human host and the major symptoms are caused by the eggs laid by the female worm. “African species” causes blood in the urine in children and severe damage to the urinary tract, as well as bladder cancer in later life ( urogenital schistosomiasis ). In Intestinal schistosomiasis ,eggs get trapped in Liver and cause chronic Liver damage and Liver fibrosis 200 million people are infected globally,90 % of those are in Africa B lood flukes ( trematode worms)

8. CONTROL STRATEGY L arge-scale treatment of at-risk population groups, access to safe water, improved sanitation, hygiene education, and snail control . P eriodic , targeted treatment with praziquantel ( preventive chemotherapy  ) Groups targeted for treatment are : School-aged children in endemic areas. Adults considered to be at risk in endemic areas, and people with occupations involving contact with infested water, such as fishermen, farmers, irrigation workers. Entire communities living in highly endemic areas

9. Onchocerciasis (river blindness) River blindness was the first disease to be tackled on a large scale in Africa in the last 4 decades. In 1970, up to 50% of African populations living on the banks of fast moving rivers suffered impaired vision . It is transmitted to humans through exposure to repeated bites of infected blackflies of the genus  Simulium . Larvae produced by the adult worms in the human body migrate across the eye . Severe itching Skin irritation Irreversible blindness Onchocerca volvulus

10. In 1974 the Onchocerciasis Control Programme (OCP ) controlled river blindness by spraying insecticides using planes and helicopters into West Africa’s major rivers where the Black Flies breed . The OCP relieved 40 million people from infection, prevented blindness in 600 000 people, and ensured that 18 million children were born free from the threat of the disease and blindness . African Programme for Onchocerciasis Control (APOC) was launched in 1995  Ivermectin TREATMENT Ivermectin at least once yearly for between 10 to 15 years

11. Dracunculiasis Also known as “Guinea worm disease” Infection is acquired from swallowing infected water fleas infected with guinea worm larvae Affects subcutaneous tissues[leg and foot] The adult female worm lay eggs, emerges through the skin forming blisters usually around the ankle Dracunculus medinensis Blisters cause burning sensation Allergic reactions Arthritis The worm then emerges from the skin over the course of a few weeks One end is tied and removed slowly.

12. In 1984, the WHO asked the United States  Centers for Disease Control and Prevention  (CDC) to spearhead the effort to eradicate dracunculiasis in endemic areas-Pakistan , Yemen and 17 countries in Africa ; an effort that was further supported by the CARTER CENTER. In 1986, Jimmy Carter and the Carter Center began leading the global campaign, in conjunction with CDC,  UNICEF and   WHO .   Close to Eradication

13. Lymphatic filariasis (LF – elephantiasis) Wuchereria bancrofti (90%) Brugia malayi Brugia timori Infection occurs when filarial parasites are transmitted to humans through mosquitoes . It is usually acquired in childhood causing hidden damage to the lymphatic system . Culex (urban and semi-urban) Anopheles (rural areas) Aedes (endemic islands in the Pacific) ASYMPTOMATIC No external signs of infection but still cause damage to the lymphatic system and the kidneys, and alter the body's immune system . ACUTE local inflammation involving skin, lymph nodes and lymphatic vessels CHRONIC lymphoedema (tissue swelling) or elephantiasis (skin/tissue thickening) of limbs and hydrocele (scrotal swelling)

14. Filaria Endemic Districts Endemic district 250 (in 20 States/UTs) Population: 600 Million

15. WHO’s strategy is based on 2 key components : Large-scale treatment Interruption of transmission of filariasis by Annual MDA for 5 years or more to the population except: children below 2 years pregnant women seriously ill persons Morbidity management and disability prevention  - Home based management of lymphoedema cases and up-scaling of hydrocele operations in the identified CHCs / District hospitals/ medical colleges . Success in 2020 will be achieved if patients have access to the following minimum package of care: Treatment for episodes of adenolymphangitis (ADL ); S urgery for hydrocele; Treatment of infected persons with antifilarial medicines. Albendazole / D iethylcarbamazine citrate 

16. MDA has been stopped in: Goa,Daman & Diu,Pondicherry (2013) Tamilnadu,Assam & Lakshadweep(2015)

17. Trachoma Chlamydia trachomatis Eye discharge Swollen eyelids Trichiasis  (turned-in eyelashes) Swelling of  lymph nodes  in front of the ears Sensitivity to bright lights. International Trachoma Initiative (ITI) promotes an integrated approach named the SAFE strategy S-surgery A-Antibiotics F-face-washing and E-environmental improvements to reduce the infestation of flies. Azithromycin (single oral dose of 20 mg/kg) or topical tetracycline (one percent eye ointment twice a day for six weeks). In 1996,WHO launched “GET 2020 ” and eliminated Trachoma in Morocco It is known to be a public health problem in 41 countries , and is responsible for the blindness or visual impairment of about 1.9 million people . In 2016, 190.2 million people lived in trachoma endemic areas and were at risk of trachoma blindness It spreads by both direct and indirect contact with an affected person's eyes or nose. Children spread the disease more often than adults. Poor sanitation, crowded living conditions, and not enough clean water and toilets also increase spread. L eading infectious cause of blindness worldwide

18. Leprosy Mycobacterium leprae It mainly affects the skin and nerves

19. MULTIDRUG THERAPY MB leprosy Rifampicin,clofazimine,dapsone PB leprosy Rifampicin,dapsone

20. NATIONAL LEPROSY ERADICATION PROGRAMME(2015-16) 1.DPMR Services Total 115 (Govt.- 61 and NGO- 54) Institutions have been recognized for conducting Reconstructive Surgery to correct the disability in Leprosy Affected Persons. During the year 2015-16 a total of 3107 RCS (Govt. – 934 and NGO – 2173) were conducted. A total of 276 Relapse cases were confirmed and treated at District Hospitals. MCR foot-wears were provided to 52227 Leprosy Affected Persons with Grade I disability. 2.ASHA Involvement ASHAs under the NRHM were involved in Leprosy programme for last 8 years. However during 2015-16, their participation has substantially improved. Out of the total 127334 new cases detected cases brought by ASHA were 29379(23.07%) . ASHAs also helped in completion of treatment in 22753 cases. Incentives were paid during the year to 20944 ASHAs . 3.Child cases with Grade II disability To give focus on the policy of No. child cases with disability, information on the cases of Gr. II disability in children was collected and compiled at the central level. Out of the total 11230 new child cases detected during 2015-16, the number of child cases with Gr. II disability was 162 . 4.Training Medical officer –9189, Health supervisor 4665, Health Workers 16436, Lab Technician- 305, NMS 399, Para Medical Workers 366 and ASHA/ AWWs-167649 Central Leprosy Training & Research Institute, Chengalpattu , Tamilnadu conducted 16 courses for 150 participates . Regional Leprosy Training & Research Institute, Gouripur , West Bengal has conducted 1 course for 9 participants. Chhattisgarh has conducted 46 courses for 646 participants. 5.IEC/BCC Activities State level IEC activities were carried out in a campaign mode during the Anti Leprosy Fortnight starting from 30th January 2016 and ending on 13th February 2016(Newspaper ads,posters,press conference,tv / radio,wall painting,..) Central level Newspapers in Hindi, English and Regional languages which were released through DAVP on 30th January 2016. Leprosy awareness drive was conducted by IRCTC where message were displayed on flask, menu card , napkins cups etc.

21. Buruli ulcer Mycobacterium Ulcerans Originated from Buruli,Uganda,Africa where the large number of cases were reported late in 1960s and 1970s. Mode of spread is not known. Few cases of death from sepsis,tetanus and haemorrhage have been reported Increasing number of bone infections which could complicate are also being reported Starts as a painless itchy nodule,which left untreated leads to massive skin ulceration,debilitating complications including contracture deformities and amputation of the limb Reported in 33 countries in Africa, the Americas, Asia and the Western Pacific. Some countries in West and Central Africa – Benin, Cameroon, Côte d’Ivoire, Democratic Republic of the Congo and Ghana – report the majority of cases. Australia and Japan are major endemic countries outside Africa.

22. Ten years ago, treatment relied almost exclusively on surgery that involved extensive excision, skin grafting and, in some patients, amputation of limbs. 30 September 2015 | WHO in collaboration with the Foundation for Innovative New Diagnostics ,innovative diagnostic test developed by researchers at Harvard University that can lead to rapid confirmation of Buruli ulcer in a patient . B oronate -assisted fluorescent thin-layer chromatography to selectively detect mycolactone when visualized with ultraviolet light . Results are ready in an hour Rapid diagnosis of Buruli ulcer now possible at district-level health facilities Clinical diagnosis of Buruli ulcer currently relies on well-trained, experienced health workers. Polymerase chain reaction – the most widely used diagnostic test because of its high sensitivity – can be done only in reference laboratories, remote from affected communities; results will be available after few weeks

23. LEISHMANIASIS Leishmania The parasite is transmitted to humans and animals(dogs) through the bite of an infected sandfly (mosquito Phlebotomus ) second-largest parasitic killer in the world (after  malaria), responsible for an estimated 200,000 to 400,000 infections each year worldwide Visceral leishmaniasis Mucocutaneous leishmaniasis Post- kala azar dermal leishmaniasis (PKDL) Visceral leishmaniasis kala-azar , black fever , and  Dumdum fever  East Africa and the Indian subcontinent - L . donovani    Europe, North Africa, and Latin America- L . infantum Parasite migrates to the internal organs such as the  liver,spleen and  bone marrow

24. HIV infection increases the risk of developing active VL by between 100 and 2320 times , while VL accelerates HIV replication and progression to AIDS. The risk of treatment failure for VL is high . 35 countries throughout the world have reported cases of VL/HIV co-infection In southern Europe , up to 70% of cases of visceral leishmaniasis in adults are associated with HIV infection and particularly in men (94.8%). Co-infection cases have also been reported recently from Ethiopia (569 cases), Brazil ( 91), Sudan (8) and India (7). VL/HIV co-infection http://www.who.int

25. South-East Asia, Middle East, Southern Europe, Eastern Africa and Latin America but majority of the cases are from the Indian subcontinent, Sudan and Brazil

26. National Kala- azar Elimination Programme The Elimination strategy 1.Early diagnosis & complete case management Single Dose 10mg/ kgbw Liposomal Amphotericin B (LAMB) Combination regimens (e.g. Miltefosine & Paromomycin ) Amphotericin B emulsion Miltefosine Amphotericin B deoxycholate in multiple doses 2.Integrated Vector Management and Vector Surveillance I ndoor residual spraying twice a year in all houses ( upto six feet height) and complete coverage of cattle sheds in villages which had a Kala- azar case reported in the last 3 years  3.Supervision , monitoring, surveillance and evaluation 15-20% of KA patients seek treatment in the private sector. Information from private sector is essential to have better picture of burden of disease and sustain the gains achieved towards elimination. 4.Strengthening capacity of human resource in health Engaging ASHA at community level, ANM at sub-health centre level, laboratory technicians at PHCs. 5.Programme management C oordination between centre and state level offices( drug requests, procurement and transportation of drugs, diagnostics and commodities)

27. Chagas disease Trypanosome Chagas disease in South America is a disease of poor quality housing because it is transmitted by Triatomine bugs When a person is infected from a bed bug bite , the organism invades and damages the heart and other organs, although the pathology takes many years to develop. Amphotericin B 109 million people at risk 7 .7 million infected 21000 deaths/year Currently,a vaccine is being tested COMPLICATION S pread through blood transfusion and because of increased migration from endemic areas to USA and Europe and the donation of blood by migrants, the disease is being found in non-South Americans through transfusion. Acute toxicity -nausea , vomiting, rigors, fever, hypertension or hypotension, and hypoxia. Chronic - nephrotoxicity

28. Domestic transmission of the disease has been controlled in 5 countries (the southern cone in South America) by indoor house spraying with insecticide . The remaining countries in South America have similar control plan.

29. Human African Trypanosomiasis (HAT) African Sleeping Sickness Transmitted by the tsetse fly that breeds in savanna and riverine woodland in a belt across Africa. When humans become infected from the bite of the fly, the parasites first invade the blood and later invade the CNS with fatal consequences if untreated. Fever Rashes Headache Severe fatigue Muscle & joint pain Edema around eyes and hands Weightloss

30. DENGUE FEVER Aedes aegypti Ae . albopictus . Severe dengue (Dengue Haemorrhagic Fever) was first recognized in the 1950s during dengue epidemics in the Philippines and Thailand . Today , severe dengue affects most Asian and Latin American countries and has become a leading cause of hospitalization and death among children and adults in these regions. Infected person with Dengue becomes infective to mosquitoes 6 to 12 hours before the onset of the disease and remains upto 3 to 5 days. 4 SEROTYPES of the virus DENV: DENV1 DENV2 DENV3 DENV4

31. Abrupt onset of high fever Severe frontal headache Pain behind the eyes which worsens with eye movement Muscle and joint pains Loss of sense of taste and appetite Measles-like rash over chest and upper limbs Nausea and vomiting Symptoms similar to dengue fever Severe continuous stomach pains Skin becomes pale, cold or clammy Bleeding from nose, mouth & gums and skin rashes Frequent vomiting with or without blood Sleepiness and restlessness Patient feels thirsty and mouth becomes dry Rapid weak pulse Difficulty in breathing Dengue Haemorrhagic fever Dengue fever Dengue should be suspected when a high fever (40°C/104°F) is accompanied by any of these 2 symptoms Symptoms usually last for 2–7 days, after an incubation period of 4–10 days after the bite from an infected mosquito.

32. TREATMENT Prevention is better than cure No drug or vaccine is available for the treatment of Dengue/DHF The control of Aedes Aegypti mosquito is the only method of choice D engue shock syndrome : Replacement of plasma losses Correction of electrolyte and metabolic disturbances Blood transfusion Immunization In late 2015 and early 2016, the first dengue vaccine, Dengvaxia (CYD-TDV) by Sanofi Pasteur, was registered in several countries for use in individuals 9-45 years of age living in endemic areas. VECTOR CONTROL MEASURES PERSONAL PROPHYLACTIC MEASURES Use of mosquito repellent creams, liquids, coils, mats etc. Wearing of full sleeve shirts and full pants with socks Use of bednets for sleeping infants and young children during day time to prevent mosquito bite BIOLOGICAL CONTROL   Use of larvivorous fishes in ornamental tanks, fountains, etc. Use of biocides CHEMICAL CONTROL Use of chemical larvicides like abate in big breeding containers Aerosol space spray during day time ENVIRONMENTAL MANAGEMENT & SOURCE REDUCTION METHODS Detection & elimination of mosquito breeding sources Management of roof tops, porticos and sunshades Proper covering of stored water Reliable water supply HEALTH EDUCATION COMMUNITY PARTICIPATION

33. CONCLUSION WHO goal is to reduce the health and socioeconomic impact due to NTDs, especially among vulnerable groups, and to eliminate specific NTDs where feasible, thus contributing to the achievement of the Millennium Development Goals . This will be accomplished through the achievement of the following five objectives: 1. To strengthen political commitment, advocacy and resource mobilization for NTDs. 2. To enhance NTD programme management and intersectoral collaboration in order to sustain and scale up NTD programmes. 3. To scale up access to quality NTD prevention and case management interventions . 4. To strengthen integrated NTD surveillance, monitoring and evaluation. 5. To strengthen research capacity on NTDs and implement research to fill programmatic knowledge gaps.