Tropical Diseases: Emerging Concerns

Tropical Diseases: Emerging Concerns


Hello. I’m Norman Swan. Welcome to this program
on tropical diseases. Australians are much more
vulnerable to tropical diseases than you might imagine. And they can occur
anywhere in the nation, because of migration, travel
and Indigenous acquisition. You’ll find a number
of useful resources available on the Rural Health
Education Foundation’s website, rhef.com.au. Let me introduce our panel to you. Bart Currie
is an infectious disease physician at the Royal Darwin Hospital and Professor of Medicine at
the Northern Territory Clinical School at Flinders University. He’s also Head of the Tropical and
Emerging Infectious Diseases Division of the Menzies School of Health Research
at Charles Darwin University. – Welcome, Bart.
– Thank you. Bart’s areas of interest include clinical and epidemiological aspects
of tropical and emerging infections, and development
of treatment guidelines as well as clinical toxicology. Anne Gardner has recently taken up
a position as a Professor of Nursing on the Canberra campus
of the Australian Catholic University. Previously, she was the inaugural
Professor of Tropical Health at James Cook University, which was a joint position between the School of Nursing,
Midwifery and Nutrition and the
Townsville Health Service District. – Welcome, Anne.
– Thank you. Anne’s clinical research interests are focused primarily
on infection control and wound care. John McBride is an infectious disease
physician and clinical microbiologist, Professor of Medicine
at James Cook University at Cairns Base Hospital clinical school. Welcome, John. John has a particular interest in the tropical infectious diseases of North Queensland
and the western Pacific. He has studied dengue fever,
HIV in Papua New Guinea, leptospirosis
and rickettsial infections. Peter Shannon is a GP and is currently Medical Director
of the Canberra Travel Doctor TMVC. He’s also worked overseas in a TB
Screening program in Bangkok, as well as in a refugee camp
in Northern Thailand and as an embassy doctor in Laos. – Welcome, Peter.
– Thank you, Norman. Welcome to you all. What do we mean, Bart,
when we talk about tropical diseases? Just things that happen
when it’s warm and wet? I guess, you divide it into what’s
happening overseas in the tropics and then what’s happening
in the tropical areas of Australia. We’ll be focusing
mostly on infectious diseases, but, of course, really,
the majority of problems these days are the chronic diseases that occur,
particularly diabetes, but also trauma, such as motor vehicle
accidents and things like that. So things that people
come back with, Peter? It’s much the same as Bart was saying. Of course, the most important
medical problems that Australians have travelling overseas are, in fact,
the diseases they take with them, their pre-existing medical conditions or the first manifestations of the sort
of diseases we would see in Australia. But, of course, once they’re there, they also suffer from car accidents,
motorbike accidents, alcohol and drug-related incidents. So they take their
blocked arteries with them. They do indeed, but that
doesn’t stop them from suffering from what we might think of
more as tropical diseases – of course, the diarrhoeas
and gastroenteritis-type diseases from what you eat, and what you get bitten by – so malaria, dengue fever,
Japanese encephalitis, rabies – those sorts of things. Charming. John, when we look at Australia now, what’s the pattern of infectious disease
that we think about, in terms of tropical infections? I suppose we’ve broadened our concept of
tropical disease and tropical medicine to include that fairly nebulous topic
of tropical health, and that really deals with
an ageing population or people with diabetes
and other chronic diseases in a tropical environment. They’re interacting with infections and other heat-related conditions
and humidity and so on that they don’t have
problems with down south. So it’s a whole new spectrum of diseases
that we’re looking at apart from the infectious diseases. NORMAN: Talk to me a bit
about the infectious diseases. JOHN: Well, the diseases that we… ..in terms of the infections, it varies from
some of the viral infections. You notice up there we’re probably gonna talk
a little bit about dengue, but some of the bat-borne viruses, and Japanese encephalitis, which is a mosquito-borne virus
called an arbovirus, which is transmitted
in the Torres Strait. And then moving through
to some of the bacterial infections… NORMAN: That’s an Indigenous infection,
Japanese encephalitis? You can catch it
in Australian territory? JOHN: The area that has been exposed
and is suffering with… ..has… is being exposed
to this infection, is the people in the Torres Strait. So the northern Torres Strait Islands have annual activity
of Japanese encephalitis. This is a virus
which is amplified in pigs, picked up by the local mosquitoes there
and transmitted to the local population. But, of course,
there’s a vaccination program there. Although we had cases many years ago, there haven’t been any cases
since the vaccination program started. Do we have any
Indigenous spread of malaria? Certainly there are areas of Australia
which are receptive for malaria, and there have been small outbreaks
over the last decades. In the Daintree
there was one in the early 1990s, and just last year
there were some cases of malaria which were transmitted
in the Torres Strait Islands as well. And that actually occurs a little bit more frequently
than most people realise. And falciparum or vivax – which? Mostly it’s vivax, although this year there were some falciparum cases
occurring in the Torres Strait. And going into
the local mosquito population? Yeah. Into
the local mosquito population. – We’ve got very talented…
– You’re scaring me here. So it’s in…? Is it still there
in the mosquito population? I haven’t checked
with the entomologists, but I’m pretty sure it’s been
knocked out, it’s getting a bit cold. – Right. So it’s closer than we think?
– Yeah. Not too far off. And in terms of nursing in the tropics, which you’ve got
a lot of experience of, Anne, what are the issues there? Well, a lot of the issues are to do with the fact that the protocols
that nurses follow are protocols that are written
for the south-eastern corner. So, things like the climate – the great humidity, high temperatures,
those sorts of things – mean that dressings don’t stay on, some of the really practical things
are difficult. The other thing, of course,
is just the vast expanse. Nurses are often sole practitioners
in remote communities. NORMAN: You’re often the front line
in recognising these infections. That’s exactly right. Is the burden increasing, decreasing,
staying the same? What’s the story? Certainly the burden of some things
is increasing, because of the nature of our region. Dengue is definitely on the increase
in the South-East Asian region, and that’s impacting on Australia. We’re also seeing emerging things that have possibly
been in our environment for millennia, but are now becoming evident, such as the bat-associated diseases, the rabies virus, or the bat lyssavirus,
which is very much a rabies virus, and also Hendra. So these have been around
almost certainly. But because of the interaction between
humans and our natural environment, which is increasing, these are becoming evident
in Northern Australia. What about seasons? Is there a huge difference
between the wet and dry? Yes. For us in Darwin, for instance,
at the hospital, it’s a massive difference. This time of year
in the middle of the year we’re like
a southern Australian hospital with people who have come up
as tourists, the grey nomads coming in
with strokes, heart attacks. And then the wet season comes
and things change completely and we get
a large amount of infectious diseases, which we’ll be talking about. Peter, people get scared
about things like cholera and so on. I think you’ve got a slide here
which just describes… This is a bit of a reality check on what’s common and what’s not
when it comes to infectious disease. Absolutely. For the most part, the capital-letter
diseases are not common in travellers. That said, they do occur, and people are right
to be mindful of that and to take the precautions
that need to be taken. But, yes, things like cholera
certainly fall very low down the list. And what about drug resistance? That we’re seeing people
actually getting in Australia or emerging
or coming across the Torres Strait? John? Resistance is a problem
everywhere in the world. But I suppose one of the
starkest examples we have in Australia is the emergence of
the multi-drug-resistant tuberculosis, which we know is occurring in the
western province of Papua New Guinea and coming across
into the Torres Strait from travellers. As far as we know, it’s not being
transmitted in the Torres Strait. But that’s one example. Other examples are people coming from… The introduction
of a very resistant bacteria like E. coli and staphylococcus
from overseas. So now… And I think staphylococcus
is probably something that a lot of people
are very familiar with, and the proportion of
resistant Staph aureus in our population in Far North Queensland’s
approaching 40% of isolates are now resistant
to the common antibiotics that we’re using against staphylococcus. NORMAN: It’s truly scary. Give me an idea
of the risk management approach that you take, Peter, towards this. For people leaving Australia, we of course, first,
as I’ve already mentioned, have a look at their
pre-existing health conditions. We then need to look
at where they’re going, what they’re likely to be doing
when they get there, identifying whether
the sorts of people they are doing the sorts of travel
that they’re planning to do are going to come into contact
with particular things, identifying which they should be, and then we advise them on ways
that they could minimise their risk. That might be a behaviour change.
It might be a vaccination. In the case of malaria,
it might be prophylaxis. There’s a whole range of things. And in terms of the risk
of getting the common problems, is that just the same
as the risk you’d identify here? If you look as if you’ve got
unstable angina, then don’t go – that sort of thing. Well, we don’t try and say to people,
‘Don’t go.’ But certainly we
often need to be advising them on what might be practical
for them to achieve in terms of their travel plans, in terms of what illnesses
they may have or conditions they may have
to start with, and maximising their medication
before they go. And I’m a pregnant diplomat
about to go to rural Cambodia? (Laughs) Yes, that, of course,
is one of the big, hard questions. Again, we never say to people,
‘Don’t go.’ But it’s very rare
that travel is essential, and sometimes it’s very easy to suggest that perhaps you could wait
until a certain event has passed before you decide
to embark on your travel. I have said to some people, ‘Don’t go,’
if they’re pregnant, to a highly malarious area. But that’s just what I have said. But, as you said, you can’t always
be accepted for what you say. That’s right.
There are things that we can do. Personal protection is a very
important part of preventing malaria. Anybody can sleep under a bed net
at night. Anybody can wear long sleeves,
long pants, closed shoes and a big hat to minimise the skin
that can be exposed to mosquitoes. Of course, bed nets don’t work
for all forms of mosquitoes. No. But a bed net
is better than no bed net. NORMAN: True. In fact, bed nets have brought the rates
of malaria down very dramatically in some endemic countries. So, I think the bed nets
have been a real revolution in the control of malaria… I understand
if you go to… around the Pacific, the Solomon Islands mosquitoes feed at different times from
the Papua New Guinea mosquitoes. But I think even in Papua New Guinea
and the Solomons, there are bed nets. Bed nets have been great. Depends what time you go to bed,
I suppose. (Laughter)
NORMAN: That’s right. What are the biggest burdens of disease? We were talking there about, with Peter, for travellers, common diarrhoea
is the one over all the rest. What about in Australia, in terms
of the common tropical diseases, apart from diabetes and heart disease? What are the biggest burden issues? I suppose when you look at it,
both from numerical terms – and when we talk about numerical terms
in North Queensland, then dengue becomes quite a problem. Last year we had… two years ago we
had an epidemic with over 1,000 cases in Cairns and surrounds. But when we talk about
morbidity and mortality, then we’re looking at
diseases like melioidosis, which affects mostly Indigenous people, but also with people
who have immunosuppression or alcohol use, diabetes, and it can be a fatal disease for them. So there’s much more
morbidity and mortality associated with
a disease like melioidosis, even though there’s far fewer cases. And then when we talk about
things like tropical health, diabetic ulcers and so on,
which are very common… And you’d see a lot of scabies as well. Yes, that’s right.
That’s a huge problem. And, of course, it then opens up the possibility
of other bacterial infections like staphylococcal
and streptococcal infections. Peter, we’ve had a question
come in about vaccines. Do you have to be
a highly specialised travel… Well, you’d say yes, of course. ..doctor to know about the vaccines? Or are there some rules of thumb here? I think it’s most importantly
about going back to first principles. Again, you look –
who is the person who is travelling? Where are they going?
What are the risks? What are their
risks of exposure to that? And then you say, ‘Well, we have
a vaccine for this particular problem.’ It might be typhoid. And are there reasons why we shouldn’t
give this vaccination? Not often. And then we would offer it. But it is simple stuff like making sure
you’re tetanus is up to date and… Well, the routine vaccinations
are very important, and tetanus is a significant one. Measles is another one –
one of my favourites. I know it’s neither tropical
nor emerging, but it’s vaccine-preventable. And then you move into things
like hepatitis A, typhoid, hepatitis B, for longer-term travellers. And then the more esoteric ones
like the Japanese encephalitis. So you don’t use cholera vaccine
in all your travellers? (Laughs) Cholera’s a very popular word. It’s, in reality, a very unusual illness
for travellers to get unless they’re working in a refugee
or a medical situation. One of the great benefits
of the cholera vaccine we have is that it does provide some protection
against some E. coli infections. E. coli is one of the most common causes
of bacterial diarrhoea in travellers. So it has a use for people, particularly people
who might have another predisposition that would make it more likely
that they would get a severe illness, a gastrointestinal illness. And there are still
some countries in the world which require
yellow fever immunisation? There are still many countries
that require yellow fever vaccination. None in our immediate region. They’re all in either South America
or in Central Africa. And is there any cross immunity
with dengue for yellow fever immunisation? Not that I’m aware of, but there’s a lot
of speculation about that, and I think
there’s a lot of work being done on trying to combine
the two vaccinations or use one
sort of to piggyback the other. A bigger issue is things like
doing tests for these diseases and whether there’s confusion
once you’ve been infected with one. And we’ll come back to that later when we’re starting to talk about
these particular illnesses. Let’s go to our first case study. This is Mark, who’s a 45-year-old Indigenous man from a Top End remote community. Comes to local health centre with some fever and abdominal pain. He’s had some symptoms for about a week. He’s got type 2 diabetes. And here’s the clue – it’s during the wet season. Mark… Bart? I think, the first thing is that
clearly this is an infectious disease, because of the fever. And so it’s unlikely… It could just be the flu
or food poisoning. But that’s still an infectious disease. So the question is
what sort of infectious disease here. It could be a virus, such as an unusual presentation
of influenza, but the clue here is the wet season
and the abdominal pain. And in a diabetic, what we have to do
in the Top End of Australia is think of melioidosis. But, of course, this could be
some other infectious disease or even appendicitis, with the fever. So it requires a good history
and examination, of course. What is melioidosis? Well, melioidosis
is a bacterial infection, and the bacteria survive in the soil
in the endemic areas, soil and surface water. And, particularly during the wet season,
these organisms, these bacteria, penetrate through the skin,
through open cuts usually, or through trauma, and occasionally with severe
weather events they can be inhaled. And so melioidosis in a healthy person
may not cause much sickness at all, but if someone has
one of the risk factors for melioidosis, then it can be
a very serious disease indeed. And because of the last two
very heavy wet seasons in the tropical north of Australia, which is the La Niña cycles, we’ve had massive amounts of rain and we’ve had 155 cases
of melioidosis confirmed with 20 deaths, in the Top End
of the Northern Territory. NORMAN: What do people die of?
– Of septicaemia, basically. 55% present with pneumonia, and they may often be
blood-culture positive. And then
there’s this other presentation, such as with the patient
we’re describing here, which is a genitourinary presentation
with prostatic abscess. That’s about 14%. What are the risk factors? The risk factors – 40% are diabetic,
40% have hazardous alcohol intake, 20% have chronic lung disease, but, importantly, 20% of people have
no risk factor at all that we ascertain. Of those people with no risk factors,
the 20%, it’s very unusual
for them to be critically ill. So you shouldn’t die if you’re
a healthy person from melioidosis if you get diagnosed and treated early. So, healthy people get melioidosis,
but they may often present, for instance, just with a skin wound
or a small sore. You can get rash,
you can get skin manifestations. The skin manifestations of melioidosis are just like any streptococcal
or staphylococcal infections. So they’re not specific, clinically. The important thing here is that if someone presents
with a non-healing wound or sore which hasn’t responded to
dicloxacillin, flucloxacilin, cephalexin then it’s important for the swab to be
processed by the microbiology laboratory on selective media, which will enable the organism – Burkholderia pseudomallei,
the bacterium that causes this – to be cultured out
and make the diagnosis. So these skin legions
are very non-specific. So you have to think about it
and then tell a lab, and they will then give you your answer. And the other diag…
Blood cultures? Is that the other way? Blood cultures are very important because over half of the patients
overall will be blood-culture positive. Some people will be
blood-culture positive without any obvious
system manifestations. So no pneumonia,
no genitourinary infection, but just blood-culture positive
presenting with fevers alone. Any antibody tests? The antibody test,
the serology test is available, but the diagnosis is really made
by culturing the bacteria. And would you treat
with a negative culture? What we do is we have
in our guidelines – for people suspected of melioidosis,
we use particular antibiotics. For instance,
we would use high-dose ceftriaxone, which will cover
the other bacterial causes of that type of presentation,
such as pneumonia. And we would only go
to the specific melioidosis therapy – which is ceftazidime or, for critically ill people,
meropenem intravenously – we would only do that once
we’ve confirmed that it is melioidosis. The one exception being
that if someone is critically ill and we think
they may die within 24 hours, our evacuation teams
now carry meropenem with them on the planes to give to people who they believe on assessment are potentially… have
a life-threatening septicaemic shock. We’ve got some pictures
of acute disease. One is the pneumonia… ..which looks pretty devastating. JOHN MCBRIDE: I was gonna ask, Bart, do you have trouble controlling the use of those broad-spectrum
antibiotics in those situations? Is there a tendency for your registrars
or doctors at the hospital to think that
their patient’s got melioidosis and they want to use
the meropenem or the ceftazidime? No. Uh… Our doctors are pretty good at following
the guidelines, actually, John. So if they are ending up in ICU, then in the wet season we use meropenem on our critically ill people
with sepsis in ICU. So that’s the gold-standard drug
for confirmed melioidosis. But if they’re not going to ICU, and they’re well enough
to give time for the diagnosis, then they will either
be on ceftriaxone quite often or possibly timentin –
ticarcillin, clavulanic acid – both of which
will cover and hold melioidosis except in the critically ill people until we have time
to make the diagnosis. And, Anne,
presumably this is an important one for nurses to pick up
in remote locations. Yes, it is. That’s right. So nursing…
History is really important. You know, people have been exposed when they’ve got
a past history of diabetes, and certainly if they’ve been cleaning
up in the wet season, for example. – So, look at the manuals.
– That’s right, yes. Keep the old bibles. Take us through some of these other
investigations we’ve got pictures of. We’ve got some more
chest X-rays of fatal melioidosis, just to give you a sense
of what it can look like. BART CURRIE: So these are
all people who died from melioidosis, just showing that there quite often is this upper-low presentation
on chest X-ray. 10% of the cases
mimic tuberculosis, in fact, so they’re not critically ill,
but they present just like tuberculosis, with night sweats, fever
and a chronic cough. And they may be sick
for a couple of months until they present and have a sputum
which cultures the bacteria. And so the differential
very much for those is tuberculosis. This is a liver abscess, or a large
liver abscess, here in that person. And this is just showing… This is 14% of our cases present
like this with genitourinary infection. Obviously,
the prostatic abscess is in males. And that’s just showing
CT scan and ultrasound showing fairly large
prostatic abscesses, which do require drainage. And that’s the pus that you can
see there, which has aspirated. And, indeed,
20% of the males with melioidosis will have prostatic abscesses even if they present with,
say, pneumonia or skin disease. So we do CT scans of abdomen and pelvis
on all our adult melioidosis patients. Because if they have a prostatic
abscess, it needs to be drained. ‘Cause, presumably,
it keeps on coming back. Exactly. Before we started routinely
scanning abdomens of people with melioidosis, we’d have some people who would have recurrent fevers
over a period of one to two months, presenting initially with pneumonia. And we were surprised
their pneumonia was getting better but they were getting fevers again. And then when we realised
these people often had a hidden abscess
somewhere in the abdomen, usually prostate, but could be kidney, psoas abscess, liver abscess,
for instance. Nasty stuff.
Do you see much in Queensland? Probably not as much
as in the Northern Territory, but we certainly see enough to
keep us knowledgeable about melioidosis, and we’re always appreciative
of Bart’s helpful advice. Tell me a bit more
about parasitic infections that we should be concerned about. Well, parasitic infections
include the… Well, they certainly
include the scabies, which we’ve talked about
to a certain extent. But one of the helminthic infections which can cause infection, particularly
in an Indigenous population, is strongyloidiasis, which is a helminthic infection,
soil-borne. This is a relatively common infection. NORMAN SWAN: We’ll come back
to this slide in a moment. We’ll talk about strongyloidiasis
for a moment. But its importance is mainly in relation
to when people’s immune systems have been compromised
with high doses of steroids or they’re put on cancer chemotherapy. If they’re harbouring strongyloides,
then the strongyloides can actually reach very high concentrations
and cause disease in itself. And its presentation? In that sort of state, it can cause pneumonia or a CNS disease
like meningitis, and usually the diagnosis
is a bit of a surprise. But if we screen for strongyloides in people who are
going to be immunosuppressed and treat the strongyloides
before it becomes a problem, then that can be prevented. So it’s mostly
in Indigenous populations? Mostly in Indigenous,
but in rural populations as well. The take-home message for us has been that it’s incredibly important
to get the message across that for any Indigenous person
in Central or Northern Australia who’s going on to
more than 14 days of prednisilone at a dose of 20mg for an adult or more, so 20mg a day or more
for 14 days or longer, strongyloides needs to be considered, because it’s in that group that virtually all our cases
of disseminated disease have occurred. With the protocol
which our rural staff follow, we haven’t had a death
for over ten years from disseminated strongyloidiasis by following that prevention
of opportunistic infection protocol. NORMAN: And the test is? The test is a combination of serology
and stool examination, and also we, now in our guidelines,
in those high-risk areas, we’re actually
empirically giving ivermectin to people going on
this immunosuppressive regimen. So if they fulfil the criteria for
two weeks or more of immunosuppression, we then give them ivermectin
as a preventative. Talk to me about scabies. OK, well, scabies is a mite, it’s an ectoparasite
which burrows into the skin. It causes a lot of itching, and most people who have got scabies
are well aware of the diagnosis. It’s an intensely itchy condition. But there are two forms of scabies. This first slide
shows the classical scabies, which is usually between the fingers,
often on the buttocks, and you can see
down the bottom left-hand corner there where someone’s scabies has become
infected probably with staphylococcus. ‘Cause you can see
the pus coming out there. So skin infections after scabies
are a big problem. Another form of scabies
is this crusted scabies. Now, the classical form of scabies, you might only have a dozen or so mites causing a lot of itching,
a lot of problems. These people have got hundreds
of thousands of mites on their person, and it causes
gross thickening of the skin. Treatment involves
use of oral ivermectin, topical antiparasitic drugs,
plus keratolytics. It’s usually a very long treatment. These people are isolated in hospital,
because they’re highly infectious. And, in fact, normal scabies
can be quite infectious too. You can get outbreaks in nursing homes
and so on. It’s quite easily
spread around the hospital. So this is one disease where we do actually
practise a lot of infection control. ANNE: Good. – And it’s a major nursing issue.
– Yes, it is. And nurses and Aboriginal health workers
in communities can make a big contribution
in terms of community programs, with programs like Healthy Skin. So encouraging the whole community
to clean houses, improving washing,
both bedding and the person. The trouble is that a lot of
the problems are outside of health. So it’s good hygiene, good housing, reducing the number of people in houses
and those sorts of things. Access to good water supply,
including hot water in colder seasons, when people might otherwise
not want to wash. And, Bart, the crusted form of scabies can affect your general health
quite significantly. Yes. Until there were protocols
to diagnose and treat this early, and also recognise that through those
awful damaged fissured skin areas there can be bacterial incursion
into the body – until it was recognised,
the mortality was 50% within five years. And often these were
people in their 20s to 30s. Dying of what? Dying of sepsis from the bacteria that were getting in
through those skin lesions. So now with the protocols
that are available both rurally and in the hospitals
when they get admitted, we’re looking for secondary
severe sepsis through the skin, but we’re also doing, as John said, the various specific treatment protocols
with multi-doses of ivermectin. So these people are… The mortality is much lower now. But, of course, they will get
crusted scabies again once they get reinfected
back in their communities. So we have to then implement, as Anne said,
the community-based programs to try and prevent the transmission. And identifying these people
with crusted scabies is important, because what we’ve found is that in the outbreaks
in a lot of the remote communities there may be one or two people
with crusted scabies who are core transmitters. So they’re transmitting the infection
to many other people in the community because of the large number of mites
that they have. Question from Western Australia – should a doctor in the Kimberley region be alert to the same diseases
as a doctor in Northern Queensland? Bart, you’re right in the middle
of that. (Laughter) Some people say once you go north… There’s certainly a lot of diseases
which are common right across the north, but when we talk about dengue,
for instance, that only occurs in North Queensland. Scrub typhus – we’ve got
a lot in North Queensland, a little bit in Darwin, I think there’s been
one recorded case in the Kimberleys. So different diseases
have different patterns. But melioidosis, I’m pretty sure…
and Japanese encephalitis, there’s cases of that
occurring in the Kimberleys. So we’ve got a lot of diseases
in common, but there are some
important differences as well. Yeah, the fact that the dengue mosquito is not present in the Northern Territory
or in the Kimberley means that we can’t at the moment
have local transmission of dengue, unlike in Queensland. But otherwise things are very similar. There are different species of jellyfish
across the area, but I don’t think
we’re talking about that. No, we’re not.
A question for you from Mr Pulow, Peter. Should we be thinking
of different diseases if the patient’s a migrant versus
being a traveller from overseas? Different groups of people
who return to Australia, whether they’ve arrived for
the first time… or not returning… if they arrive for the first time
or returning from travel, there are different risk factors
depending again on who they are, where they’ve come from,
how they’ve got here obviously. So it’s always very important… you
know, treat everybody as an individual. You look at where they’ve come from,
what they were doing there, how they’ve got here, and from that you can make an assessment
of what’s more likely. If you’re a refugee from Iraq, you may have actually acquired diseases if you’ve been sitting in
an Indonesian village for two years, rather than your problem
coming from Iraq. Your dengue and malaria
you don’t pick up in Iraq, but you can get it on your way through. JOHN: You’re saying
there are important differences between people who visit friends and relatives, versus the occasional backpacker,
for instance, that they… Yes, absolutely. Australia being
a country of migrants, of course, a category of people we call VFRs –
visiting friends and relatives – returning to the home country, often for the first time,
but not always, they’re a high-risk group of travellers. They take less precautions, probably because they believe
that they’re of the area, and therefore at lower risk,
which, of course, is not true. A general practitioner asks
what factors should influence which malaria-prevention medication
is prescribed? Um… Really, I’m gonna sound like
a cracked record. It’s the same thing. It’s where they’re going,
what the risk factors are, the likelihood of exposure. For example, you might think all
of South-east Asia is a malaria area. Therefore, everybody going
to South-east Asia should get a malaria prophylaxis
of some sort. If you’re travelling
mainly in tourist areas, then your likelihood of coming across
malaria is much lower. We might often decide… NORMAN: Because of spraying
and it’s an urban area. All of those things, and countries that
rely on tourism have figured out that if their tourists
don’t get malaria, they’re more likely to say nice things
about the country. No doubt, up to a point,
there’s some geographical differences. There still are a couple of places
in the world where chloroquine can be used
as a prophylaxis. But we wouldn’t do that,
partly because you can rarely get it, and why would you when you have
very efficient other medications to use? What guidelines do you recommend
for anti-malarials? Which one? Do you use the yellow book,
or from the CDC, or the Australian guidelines or what? We… The CDC and also
the WHO travel website are very useful. Some might say that the CDC’s a little
bit, being American, risk-averse, and perhaps not as realistic
as some others. I like a resource called Fit For Travel, from the Scottish National
Health Service, which has very good malaria maps, and I think is a much more realistic
reflection of… of risks of malaria. Another question has come in from a general practitioner in
New South Wales saying more patients come back with bedbugs,
sometimes from quite fancy hotels. Is there any health risks from bedbugs? Well, they’re a nuisance for a start, and you’re highly contagious,
potentially, if you have them. But the important message,
as you say, is we think of this as a disease
of backpackers, but it’s not. In New York they’ll tell you – it starts
in five-star hotels and works down. NORMAN: You can never get rid of them.
– You can never get rid of them. PETER: In the hotel or in the patient.
– Throw out the bags… I think the thing is the main issue
will be the secondary infections, which will be your own staphylococcal
and streptococcal bacteria getting in, and potentially
if you’re, say, diabetic, you could have some pretty serious
infection following a bedbug bite because of the bacteria
that are on your own skin. So be careful.
Let’s go to our next case study. Peter – 16 years old. He’s an Indigenous young man from
a remote Northern Territory community. He comes to a general practitioner,
an urban clinic, while he’s in town for a footy carnival. He complains of a swollen left knee
and says he’s also had a bit of fever. He has no known past history of illness, except for some chronic suppurative
otitis media as a young child. He can’t remember injuring his knee
during football games, and on examination
has a mildly hot swollen knee. While slightly tender, the range of knee
movement is decreased only slightly. His temperature is 38.
He has no other joints involved. We listen to his heart – it’s normal.
No murmurs. John, what are you going to do for him? I think the things to consider
in a young man of this age is may have become
recently sexually active, and one of the things
you need to consider is… NORMAN: Gonococcal arthritis.
– Gonococcal arthritis. Even chlamydia will cause an arthritis. So both of those infections
will cause arthritis. And they certainly need to be
looked at… looked for. But in this particular case, I think the No.1 diagnosis needs
to be… that needs to be considered is rheumatic fever. Joint pain
in any Aboriginal or Indigenous child, up to this sort of age, needs to have rheumatic fever
actively considered. NORMAN: Bart?
– Yes, absolutely. We’d always be recommending
that a person presenting like this, even though they may not be
very unwell… ..it is mandatory
that they be admitted to hospital – that’s what we say
in the Northern Territory anyway – for investigation of possibly
rheumatic fever, a work up. Then, if rheumatic fever is confirmed, the education process
starts right there, with our public health unit coming over
and seeing the person, and talking with him about their future as a person with rheumatic fever,
rheumatic heart disease. These days, how do you make
the diagnosis? The diagnosis is made as it has been
for a long time… NORMAN: Major and minor symptoms.
– Yes, through the Jones criteria. But there are revised Jones criteria,
modified Jones criteria, and, for the last five or six years, there’s been the Australian version
of the Jones criteria. And we’ve actually lowered the bar
for Indigenous people, so that, for instance, a monoarthritis
would not be considered traditionally as a major criteria and
you would need to have polyarthritis, but for the Australian
Indigenous context, our work over some years have shown that certainly they can present
with a single joint swollen and inflamed or indeed they may occasionally present
with a polyarthralgia without actually an active arthritis. So those are some of the modifications
that are made so they can fulfil the criteria – if they have a single joint swollen
and hot and tender provided you’ve excluded other things,
such as gonococcal arthritis. And also a polyarthralgia
can fulfil the criteria, plus the other aspects
of the Jones criteria. So as well as that, the next thing
is the echocardiogram, which will establish whether
they have already got valve damage. And that’s critical, because it’s the valve damage which
eventually leads to fatal outcomes in unfortunately quite a few people
still each year in Northern Australia. And, in fact,
Peter is admitted to hospital and his arthritis
resolves spontaneously, but his echo does show thickened mitral
valve and mild mitral regurgitation, so he’s had it for a while. Yeah, well, what this means is that
although this was his first presentation he almost certainly had had at least one
and probably a number of episodes of acute rheumatic fever previously
which had not been diagnosed, possibly because
they might have been quite subtle but also because
they may have been missed when he presented
to a health facility previously. And so what this means
is he already has damaged valves and the whole basis of management
for here on in for this young man is to have suppressive
or prophylactic benzathine penicillin, which is intramuscular injections
once every four weeks. And that’s to prevent further episodes
of acute rheumatic fever, which, unfortunately, if they occur
will lead to progressive valve damage and eventually a valve
which either needs to be replaced or the potential for him
dying of heart failure. I think we’ve got a picture here
of an Indigenous child in heart failure,
and it’s a child who died. BART: Yes, that was a child
who died at the age of 16 after a number of episodes
of acute rheumatic fever, and died in the Intensive Care
at Royal Darwin Hospital – with this presentation,
was so unwell with this florid carditis that there was not unfortunately time
to stabilise the patient and transfer somewhere where they could
potentially have life-saving surgery. And so, that still happens –
every year there are children dying in Central and Northern Australia and young adults with the complications
of acute rheumatic fever. NORMAN: Anne? I was just going to say
it’s a really important disease for people who work in the Top End
to remember about, because people coming in
as locums from Southern Australia, it’s a disease that you see so rarely. So people that work
in Northern Australia really need to kind of keep it
in the front of their minds, and remind locums, for example. So, John, if you were working
in New South Wales, you wouldn’t necessarily
think of this, would you? But you might see it occasionally? Well, certainly, you should
still consider it in New South Wales, particularly in Indigenous communities
and people from the South-West Pacific. Pacific Islanders have a high risk
of this as well, and they’ve got a big problem
in New Zealand with rheumatic fever. But why is it particularly a problem
in the north? It’s a disease of
socio-economic disadvantage. It’s entirely an issue related… NORMAN: But why… It is more common
in the north than it is… It wasn’t more common in the north
100 years ago. It was incredibly important
in Melbourne and Sydney up until the middle of last century, when there were people
living in overcrowded conditions. So, rheumatic fever has been recognised. It’s not a tropical disease
specifically – it’s a disease of socio-economic
disadvantage. And the key treatment is penicillin G? Well, the treatment… The penicillin is there to just
eradicate the streptococcus from the throat
or if it is potentially on the skin. But it doesn’t actually alter the course
of acute rheumatic fever. What you need to do
is give the benzathine penicillin to prevent further episodes. So the treatment of the acute episode
is really just treating the fever, and then if there is heart failure,
treating that. And then the inflammation
will eventually die down, and then you hopefully prevent
further episodes. The role of steroids
is a little uncertain, but in florid cases some people
would consider using steroids. And how often do you see choreia? Choreia is relatively common as one of the major manifestations
of acute rheumatic fever, still. And so we get cases of choreia
every year. And if people have choreia with
their first episode of rheumatic fever, then if they were to get it again, then often they manifest as choreia…
the next time around. In addition, even though
they may have just choreia clinically and their heart may sound normal, an echocardiogram will often show they
have subtle damages to their valves. And, indeed, we always repeat
the echocardiogram three to six months
after an episode of choreia, and then we find that up to half of them
have evidence of valve damage as well. – And there’s guidelines?
– Yes. Look, I think that there are
Australian guidelines which are consensus guidelines
that are available on the web. And they’re very thorough,
and they basically talk about diagnosis and prevention
and also secondary prophylaxis. Is the consensus guidelines developed under the auspices
of the Heart Foundation? Yeah. Let’s move now to another case study. Susan, she’s 25 years old. She presents to her doctor’s clinic with a mild fever,
headache and aching joints. She wonders if she has seasonal flu. They’ve been developing
over the last four days. She came back from India, she tells you,
two weeks ago after a six-week holiday, and she’s been experiencing diarrhoea
sporadically since her return. What are you going to do for her, Peter? Well, common things occur commonly, and we should not rule out the
possibility that she has the flu, but… It’d be far more boring if she had,
but you know… It would, yes. You can’t make
any conversation about that. A quick travel history – that she had
a six-week holiday in India – will immediately raise,
should immediately raise, the question of malaria
and, for that matter, dengue fever, as two common causes. It’s very important to remember also that although fever
is a cardinal symptom of malaria, many other symptoms occur
with malaria infection as well, and diarrhoea is not uncommon. Coughs as well and joint aches and pain
occasionally also. So the presence of other symptoms
does not exclude malaria. Interestingly in this case, the other key factor is the time
since she left India. Dengue fever and malaria
are both spread by mosquitoes. Dengue fever tends to develop
quite quickly – within three or four days
of being bitten by a mosquito. If she’s been back in Australia
for two weeks, it’s probably more likely that
if this fever is of a tropical origin, that it’s malaria, which takes
a couple of weeks to develop, or can take up to a couple of… Can you tell clinically whether
this is vivax or falciparum? I’m not aware of any clinical test
that will differentiate. You need a blood test,
you need a thick and thin film to make the diagnosis of malaria, and a competent microscopist
should be able to tell you which strain
of the malaria parasite it is. Nurses are often taught
about temperature charts. – Different patterns of temperature.
– Yes. But if you’ve got more than one
infection, then that doesn’t work. Well, there’s all sorts of confounding.
Temperature charts exist in textbooks. For good reason. If you’ve been in India and
you’ve been bitten by one mosquito and had one infective episode
of malaria, then it’s possible
that your fever may follow whatever the course is
for the particular strain you have. MAN: You’d have to wait
for an awful long time. And that’s assuming all the parasites
are of the same age. If you’ve had multiple infectious bites, it’s all mixed up
and it’s not really a good guide. Having said that,
if this woman developed a fever three or four months after coming back, it’s much more likely to be vivax
than… That clinical pattern
absolutely suggests vivax, yes. From the dormant hypnozoites… Bart, what do you think
of these new rapid diagnostics? Yeah, well, there are some good ones
and some not so good ones. The rapid diagnostic test
or the antigen test for malaria is very useful and is being
increasingly used worldwide. It is more sensitive
for falciparum malaria than for vivax. So there is a test for vivax, a rapid
test, which may miss some of the cases, but for falciparum it’s particularly
good – that’s an antigen test. And particularly if there is
no expertise in microscopy to identify the species
of malaria parasite, then at least it gives you
a positive and gives you an idea which malaria it might be. The issue for dengue
is a little more complicated in that there are some tests out
on the market including in Australia which have false positives. Their specificity is not as good as the
manufacturers would make you believe. And that can be quite dangerous,
because we’ve certainly in Darwin had patients who have been told
that they’ve got dengue on the basis of a rapid diagnostic test, when in fact when we think, ‘Well,
this doesn’t quite look like dengue,’ and test them for malaria,
they indeed had malaria and not dengue. So the rapid test gave a false result. But there’s a really good new rapid test
available for an antigen test for dengue which is called the anti-NS1 test, which is being increasingly used
around Australia, and it has both good sensitivity
and specificity. So it’s a complicated area, but I think people need to be mindful that some of the rapid tests
that are being pushed commercially can be quite problematic. What advice do you give, Peter, for
people going overseas for a long time? An overseas posting to a rural area
of Cambodia or something like that? I mean, is this doxycycline
for your life or what? In principle, of course
that’s what you should say, and doxycycline is a medication
that can be used for long periods, though very few people will ever remain
on any medication for a long period of time, particularly as it’s not giving them an
obvious benefit on a day by day basis. All medications have side effects. And, you know,
other precautions against them to protect yourself from malaria
are equally important. Personal protection is very important – insect repellents, bed nets
to sleep under we’ve spoken about, dressing appropriately,
long sleeves, long pants, clothes, shoes and a big hat
reduce the amount of skin that’s exposed for mosquito bites. How safe is anti-malarial prophylaxis
for pregnant women? Very difficult. Doxycycline of course,
as everybody would know, is contraindicated in pregnancy – although probably not –
I think I can say this – in the very early weeks of pregnancy. And if you are on doxycycline
and discover that you’re pregnant and immediately stop taking it, you probably don’t need to be
worrying too much. Other medications later in pregnancy
perhaps are safer. – Lariam might be safe.
NORMAN: What about young children? Difficult for the same reason. Of course, again,
doxycycline is contraindicated. Relatively young children
can take the alternatives – Malarone for example
and Lariam if you like – but newborns certainly can’t. The first couple of months of life,
it’s a very difficult… There’s a certain formulation
of Malarone as well which is Malarone Junior. Yes, there’s a number
of different formulations. So, John, you’ve lived
in dengue central, don’t you? Tell me about dengue fever. So, dengue is a… We have quite a few
epidemics in Far North Queensland, and we’ve had epidemics
in Townsville, Cairns, the Torres and, just more recently,
smaller cities like Innisfail and Tully have had epidemics. It’s usually brought in by a traveller,
a febrile traveller. Often not picked up or not diagnosed
for whatever reason. We’d like to sort of be able to pick up
more of those initial cases, but they infect our local mosquito
population and then epidemics ensue. So, some of the epidemics
are quite large. Two years ago we had an epidemic
of over a thousand people. But some of the epidemics
are very small, some of the outbreaks
only are a handful of cases. But we’ve had 40 outbreaks since 1990. NORMAN: So it’s not truly endemic yet?
JOHN: Not endemic. NORMAN: Unlike this map
which is, well, suggesting… JOHN: Well, this is epidemic activity. The red area is areas that have got
Aedes aegypti and have dengue epidemic activities. The other areas
which are in the mustard colour are areas that have
the Aedes aegypti mosquito, which is the vector for dengue,
and they’re receptive for dengue. So we noticed Africa before
has a lot of these countries where Aedes aegypti exist. Now, it’s likely that dengue does occur
in most of those countries. It’s just that it’s not diagnosed because the laboratory facilities
are unable to pick it up. And this is 2000 –
things have progressed since then. So this is the Aedes aegypti mosquito
on the right-hand side, and this is the virus
on the left-hand side. The Aedes aegypti mosquito,
as we’ve discussed previously, is just concentrated
in North Queensland, but there are other vectors,
like Aedes albopictus, which has moved into the Torres Strait, which has a tolerance
for colder temperatures. And if that moved into Australia, you could potentially
have dengue outbreaks further south than we currently have. The Aedes aegypti love human habitation. They breed in these containers which
are usually found around the house. So they’re called
anthropophilic mosquitoes. They love living with humans. Not quite as much with albopictus. So it’s arguable whether
they’re as efficient vector of dengue as the Aedes aegypti. NORMAN: And the clinical aspects?
– What’s that? NORMAN: The clinical aspects. Usually, the classical dengue fever is a high fever, headaches, and the headaches are usually with pain behind the eyes
and pain with movement of the eyes and the rash,
which doesn’t occur with every case. It’s usually a macular rash. In this picture here, you’ll sort of see
little islands of sparing, and that’s fairly characteristic
of the dengue rash. So this is a macular rash –
it can be varied from a light sunburn right through to the severe rash
that you see there, and I think there’s a more subtle one
in the next picture. So a macular rash – not everyone has it, but it’s a good clue
when they do have it. Rash plus fever plus headache
equals dengue, but it can be some other things. You would be thinking of dengue
hopefully before the rash appeared, ’cause it’s not often the first… Well, there’s an initial rash
that they can get, and usually about day four or five,
the rash can become more severe. And so they can get
this terminal rash as well. So there’s two different types
of rashes. We shouldn’t forget muscle aches
and pains as well. Very severe muscle aches and pains. And it’s important to remember that recently there’s been an increase
in measles coming in, and measles can be just like dengue except they’ve got a really nasty cough
and their eyes are often a lot redder. And they have the red throat as well. But measles needs to be thought about
as well, because it’s on the increase. We might be finding out that
more doctors are more familiar with dengue fever than they are
with measles diagnosis. NORMAN: Don’t forget white spots
on the buccal mucosa. And treatment
is probably just supportive? Well, just for the classical dengue
fever, yes, supportive treatment, but the reason we get excited
about dengue is this occurrence of
dengue haemorrhagic fever, so areas that have… NORMAN: So what is dengue
haemorrhagic… ‘Cause they don’t call that
so much anymore under… I mean, it’s supposed to be called
complicated dengue, isn’t it? The WHO have brought out
new guidelines, and they’re calling it
complicated dengue, but a lot of people know it
as dengue haemorrhagic fever. NORMAN: Haemorrhages aren’t
necessarily a strong feature… Haemorrhage is a bit of a misnomer because many people
don’t have a haemorrhage. As in this picture, haemorrhage can be
a feature of dengue haemorrhagic fever, but the main pathophysiology
is haemoconcentration. So at about the time of lysis,
about the fourth day of the fever, when the fever comes down, the capillaries become quite leaky
and you lose intravascular volume, you drop your blood pressure,
the pulse goes up and that person becomes shocked. And if they’re not treated with
intravenous fluid, it can be fatal – up to 20% fatality rates
in some countries before intravenous fluids
were introduced. But in places like Vietnam and Thailand, where they’re right onto this diagnosis
very quickly and institute intravenous fluids, their mortality rate has been
brought down to less than 1%. As with second or subsequent infections
with new serotypes. That’s correct. There’s four serotypes,
and it’s usually the second or third. And we’ve yet to see a dengue vaccine? Well, actually, it’s really exciting, because a dengue vaccine
is being trialled right at the moment in Thailand,
including in very young children. And this is a vaccine, of course,
made against all four serotypes. And there’s a real possibility… You know, people say, ‘It’s gonna be
ten years till the malaria vaccine.’ They’ve been saying that for 30 years.
But for dengue it’s real. This vaccine is looking very promising,
so that will have a massive impact. That would be fantastic. And there are other things that are
happening in the dengue field as well with modification of the mosquitoes. So they’re introducing a bacteria
into mosquitoes called Wolbachia
which makes them immune to dengue. So if these mosquitoes can outbreed
the local population, that may also stop dengue. So there’s some very exciting things
happening in dengue world. We’ve had a question come in from
a general practitioner in Queensland saying he heard you talking
about albopictus and who’s heard of a chikungunya.
Tell us about chikungunya. Chikungunya is an alphavirus, very
closely related to the Ross River virus. Some of the symptoms are very similar
with aches and pains but usually quite high fever
and rash as well. So it’s usually clinically confused
with dengue, but there’s a lot more joint pains of a type that you would sort of see
in Ross River virus infection. NORMAN: Can you die of it?
– Sorry? NORMAN: Can you die of it? There were fatalities, there was a huge
outbreak in the Indian island… NORMAN: Mauritius
or something like that. Mauritius and Reunion,
the island of Reunion, and then it moved up to India – and I think there were
millions of cases in India. And quite a lot of deaths. There were deaths from what they thought
was an encephalopathy, which is of course very rare
with Ross River. It’s seen in animals with Ross River,
but not humans. And there’s also mother to child
transmission of chikungunya, and it can be transmitted
in the blood supply. So it’s like a really revved up
Ross River-type virus infection, with a number of complications
potentially, in the very old in particular. And you’ve got these revved up
mosquitoes in the Torres Strait ready to invade Australia. – Absolutely, yeah.
– Very comforting, this conversation. Let’s go to our next case study – What are the next steps? Well, first of all, John,
what’s he liable to be complaining of? What are the symptoms here? Well, the classical presentation
for tuberculosis is with respiratory illness,
so it’s a lung disease. Usually associated with night sweats,
weight loss and a chronic cough. Often with a little bit of blood
in the cough. So we know that PNG is a highly
endemic country for tuberculosis, driven by the HIV epidemic. And so, Steve, if he’s working with
the population of Papua New Guinea, would be pretty highly exposed
to tuberculosis. So he’s probably become infected and may have manifested those symptoms
up in New Guinea. Now, up in New Guinea, the diagnosis
would probably involve a chest X-ray, and, if he was lucky,
maybe a sputum smear, and he would have been started
on full drug regimen. But they don’t have the facilities
up there at this stage to see whether the TB bug is resistant. And this is looking a little bit
like it might be resistant because he’s not responding
to treatment. NORMAN: How long do you wait
before you see a response? Usually within a few weeks,
they’ll start to put on weight and the night sweats will go. NORMAN: A few weeks – four, six, eight?
What? Two to four? Yeah, well, sometimes
it may be as long as four, and it may even be as long as
eight weeks in sensitive tuberculosis to actually become smear-negative. Sometimes even longer than that in some
of the people coming in from overseas. Are there tests to know whether or not
you’ve got multi drug-resistant TB? Well, the only way to know
whether it’s multi drug-resistant is to do resistance testing. Now, there is a new test that’s being
introduced in Australian laboratories. I mean, we’ve always had the capacity
to test, but this is a very rapid test – it’s a PCR test
which looks for rifampicin resistance as well as looking for
the TB organism itself. So it’s a dual PCR which looks for TB
and rifampicin resistance. And why is it associated with HIV?
What’s the link? HIV causes immunosuppression… Why is multi drug-resistant TB
linked to HIV? You can see why TB is,
but why drug-resistant? The multi drug-resistant story is coincident with the outbreak
or the increase in TB cases. Multi drug-resistant TB was going to
be here anyway, even if it wasn’t… It’s just because you’ve got a lot of TB
being treated with a lot of drugs – it’s inevitable
you’re going to get resistance? That’s right, and probably the HIV
epidemic drove that increase in a number of TB cases, but it’s very hard
to get treatment of TB right, and we need 100% compliance
with treatment to prevent resistance from developing. So that’s where nurses come in
looking, you know… That’s right. I mean,
in the long term it’s about DOTs, Directly Observed Treatment, so nurses are very important
in terms of actually making sure that patients take their medication. I thought randomised trials had shown
that DOTs wasn’t effective. ANNE: Well… I think that’s interpretation
of those trials. I think that the vast majority of people involved in public health
around tuberculosis would say Directly Observed Therapy is the best
thing we have at the moment while we’re waiting for new drugs
and for vaccines. And so, how much extensively resistant
tuberculosis do we have on our doorstep, such as they have in South Africa,
where there’s almost nothing available? Well, we’re really fearing that
from happening. There’s been no cases of XDR-TB as
it’s called that I know of in Australia. From PNG there’ve been…
There’ve been two cases of XDR-TB in Australia diagnosed,
but not from Papua New Guinea. So from PNG there’ve been – as published just recently
by Graham Simpson from the Cairns Tuberculosis
Control Unit – there have been 40 cases
of multi drug-resistant tuberculosis present in the Torres Strait, Papua
New Guineans from Western Province. So, those 40 cases,
a number of them had in addition to the resistance
to rifampicin and isoniazid, which means that
they’re multi drug-resistant, had resistance
to one of the injectables, but they were still sensitive
to the quinolone. So they weren’t officially
extremely drug-resistant TB – they’re pre-XDR-TB. But the next step of course
is resistance to quinolones, which would make them XDR-TB. Fortunately, quinolones aren’t used much
in Papua New Guinea – they’re not available – but in general, globally, the XDR-TB
is on the increase where there is all these drugs
potentially being used. And there have been these two cases
come in from overseas to Australia. The message there will be,
‘If you don’t treat the TB right, you’ll get multi drug-resistant TB. If you don’t treat
the multi drug-resistant TB right, you’re going to get…
NORMAN: Extensively drug-resistant. And this chap would get quinolones?
What would be the treatment for him? Yeah, the quinolones and… He’d get a number of drugs – at least four drugs
to which it’s fully sensitive – and that would include an injectable
and probably moxifloxacin. And, Peter, just before we wind up, just remind us about
sexually transmissible diseases and overseas travel, because presumably
now we’re seeing imported HIV. – We are seeing.
NORMAN: We have been since the ’80s. Yes, it’s an issue of huge importance, and it is essential that anybody
preparing someone for travel always include a discussion
about sexually transmitted diseases. It can sometimes be very difficult. Perhaps it’s easier with some groups
of travellers than with others, but it’s essential in all groups. But travellers take a lot of risks,
and I mean… Our sexual health services up in Cairns see a dizzying array
of sexually transmitted diseases and risk-taking of local travellers. Nobody would suggest that it’s
an easy thing to do or to constrain. But it’s something
you need to think about… PETER: Absolutely. ..with an initial infection. Thank you all very much indeed. What are
your take-home messages? Peter? When you see someone who’s going away, look at them,
look at where they’re going and look at
what they’re going to be doing to assess their risks,
and then make some decisions about what they need in terms of advice
and medication and vaccinations. And if something unusual turns up
in your surgery, ask where they’ve been. Always. Travel history is essential. NORMAN: John? I think probably two from me, sorry. One would be think about dengue,
even in areas receptive for dengue, because if you diagnose
a case of dengue, you could potentially stop an epidemic
from occurring. And always think about rheumatic fever
in a kid with arthritis. And you stop an epidemic because
you keep that person away from… From the local mosquitoes. When a person’s known to have dengue, we’re not aware of any case
of known dengue starting an epidemic of dengue fever
in the community. It’s the ones we don’t know about
which start the epidemics. NORMAN: Anne?
– I’ve got two messages too. Nurses are just as important as doctors
in terms of the history that they take, so have a broad idea
about what all the possibilities are. And the other role for nurses
is in prevention – prevention of things, managing of things
like scabies and strongyloides. NORMAN: Bart? Yeah, I guess for those working
in Central and Northern Australia, there’s a lot of resources out there
that are available from people who over the years
have worked on things – particularly the CARPA manual
for instance, first point. Second point is keep in close contact
with the local public health unit who know what’s going on across borders and about the notifiable diseases, and they can provide resources as well. And the third thing is that in most of
the remote and rural health centres, there’s a really good
working relationship between the health workers,
nurses and doctors, who all work together
to really improve health. Thank you all very much –
it’s been an edifying if not a bit unpleasant
in terms of the photographs. But a great program,
and I hope you’ve enjoyed it too, this program on tropical diseases. We are grateful
to the Australian Government Department of Health and Ageing
for making this program possible. Thanks to you for taking the time
to watch and ask questions. If you’re interested
in obtaining more information about the issues raised tonight,
there are resources available on the rural Health
Education Foundation’s website. That’s rhef.com.au. Don’t forget to complete and send in
your evaluation forms to register for CPD points. I’m Norman Swan,
and I’ll see you next time�

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