Biosecurity in North Queensland:

Challenges and opportunitiesRick Speare

Anton Breinl Centre for Public Health and Tropical Medicine

James Cook UniversityRichard.speare@jcu.edu.au

13 May 2010

David Banks Oration

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 outbreakscases per month

0

100

200

300

400

North Queensland dengue outbreakscases per month

0

100

200

300

400

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

PICTs are doing badly!

22 countries spread over millions

of km2 of Pacific Ocean

Southeast Asia

Indonesia

PICTs

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 willhave major impacts

in PICTs!

Traditional PNG visitors

• Annually 30,000-53,000 59%

3%

2%4%

29%

2%

0.6%

0.5%0.3%

0.2%

0.2%

0.1%

0.1%

House Reps SC Hlth Aging Mar 2010

Estimated 4% come

specifically for health care

Contrasts in services

Torres Strait• 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

Western Province• 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

Russell et al (2005)

Predicted Distribution

Current Distribution

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 socio-economic 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

Dengue

Other arboviruses?

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

Receptivity is a Qld problem, but rain water tank installation

will expand the range of the vectors south

Aedesalbopictus

Unknown arboviruses in PNG?

• Madang encephalitis

• Not JEV?

• Death in children and severe disability

Rabies is moving east in Indonesia

• Susetya et al. Virus Res 2008;135:144-9.

1997

2008

Not if, but when?

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

MDRTB

Bat viruses?

Other arboviruses?Other EID?HPAI?JE

Dengue

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

• Halpin et al. CID 2007;44:711-717

Flying foxes are hosts to a range of RNA virusesthat cause EIDs

Dobsonia magna

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%)

Indo-Papuan Conduit

Will H5N1 use this route?

H5N1

Ongoing monitoring of poultry & wild birds in PNG & Torres Strait

for AI?

Wildlife Disease Surveillance is essential

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

"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)

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

Thank you!

Difficult, long-term, but essential

Images• 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.