Emerging Infectious DiseasesAustralia is not an Island

Bart Currie

Global and Tropical Health DivisionMenzies School of Health Research, Darwin

Infectious Diseases Department, Royal Darwin Hospital

Lom

bok

Wallace’s LineWeber’s Line

Jakarta

Darwin

Timika

Borneo

Papua

Sulawesi

Bal

i

Java

Timor

Northern

Territory

Lom

bok

Wallace’s LineWeber’s Line

Jakarta

Darwin

Timika

Borneo

Papua

Sulawesi

Bal

i

Java

Timor

Northern

Territory

Which infections for our region?

• Tuberculosis (incl MDR XDR)

• HIV• Influenza; H1N1 (swine)

& H5N1 (avian)• Malaria• Dengue• Hepatitis B• MRSA• Other bacterial sepsis• Multi-resistant Gm -ves

• Melioidosis• Leptospirosis• Rickettsial diseases – scrub

typhus, other• JE• Chikungunya• Zika & other arboviruses• Nipah; other bat-associated• Ebola?• The next SARS?

Which infections for our region?

• Tuberculosis (incl MDR XDR)

• HIV• Influenza; H1N1 (swine)

& H5N1 (avian)• Malaria• Dengue• Hepatitis B• MRSA• Other bacterial sepsis• Multi-resistant Gm -ves

• Melioidosis• Leptospirosis• Rickettsial diseases – scrub

typhus, other• JE• Chikungunya• Zika & other arboviruses• Nipah; other bat-associated• Ebola?• The next SARS?

Which infections for our region?

• Tuberculosis (incl MDR XDR)

• HIV• Influenza; H1N1 (swine) &

H5N1 (avian)

• Malaria• Dengue• Hepatitis B• MRSA• Other bacterial sepsis• Multi-resistant Gm -ves

• Melioidosis• Leptospirosis• Rickettsial diseases – scrub

typhus, other• JE• Chikungunya• Zika & other arboviruses• Nipah; other bat-associated• Ebola?• The next SARS?

“The Red Plague”

• Refers to emerging resistance in Gram negative organisms (E. coli, Klebsiella spp.)

• Cause common infections e.g. UTI in community

• High rates of resistance in Asia-Pacific region

• Some strains pan-drug resistant

Resistance (%ESBL) in the Asia Pacific region

AustraliaECOL: 12%KPNE: 15% New Zealand

ECOL: 11%KPNE: 10%

Hong KongECOL: 46%KPNE: 23%India

ECOL: 78%KPNE: 64%

IndonesiaECOL: 71%KPNE: 64%

Japan†ECOL: 17%KPNE: 11%

KoreaECOL: 37%KPNE: 40%

MalaysiaECOL: 36%KPNE: 45%

PhilippinesECOL: 47%KPNE: 23%

SingaporeECOL: 21%KPNE: 32%

TaiwanECOL: 91%KPNE: 75%

China*ECOL: 54%KPNE: 41%

Thailand*ECOL: 55%KPNE: 50%

Courtesy John TurnidgeACSQHC

Resistance (%ESBL) in the Asia Pacific region

AustraliaECOL: 12%KPNE: 15% New Zealand

ECOL: 11%KPNE: 10%

Hong KongECOL: 46%KPNE: 23%India

ECOL: 78%KPNE: 64%

IndonesiaECOL: 71%KPNE: 64%

Japan†ECOL: 17%KPNE: 11%

KoreaECOL: 37%KPNE: 40%

MalaysiaECOL: 36%KPNE: 45%

PhilippinesECOL: 47%KPNE: 23%

SingaporeECOL: 21%KPNE: 32%

TaiwanECOL: 91%KPNE: 75%

China*ECOL: 54%KPNE: 41%

Thailand*ECOL: 55%KPNE: 50%

Courtesy John TurnidgeACSQHC

Multi-resistant organisms post 2002 Bali bombings

• 35 patients with severe burns transferred to Royal Perth– 19 Multi-resistant Acinetobacter baumannii (MRAB)

– 15 Extended-spectrum B- lactamase producing Gm-negs (ESBL)

– 9 Vancomycin-resistant enterococci (VRE)

– 6 Multi-resistant Pseudomonas aeruginosa (MRPA - 2 fatal)

– 3 MRSA

• Transmission of MROs to 41 non-Bali pts in RPH– 11 bacteremias

– 4 deaths with MRPA

Heath C et al. Aust Infect Control 2003;8:43-54

In 2010, a multi-drug carbapenem-resistant K. pneumoniaewas introduced into the ICU of a Sydney Metropolitan

Hospital by a patient recently returned from Egypt. Three additional patients acquired the organism over several months before

termination of the outbreak. All four patients who developed an infection with this organism died.

Then introduction and spread of carbapenem-resistant bacteria

There have been previous documented cases of infection with imported blaNDM-1-containing bacteria in Australia.

We hypothesise that this carbapenem-resistant Enterobacteriaceae isolate was acquired after transmission from an unidentified carrier of blaNDM-1, possibly

during previous hospital admissions or receipt of home nursing care.

Now community spread of carbapenem-resistant bacteria

Tal et al. Med J Aust 2015;202:270

Resistance in Australia: public attention & funding

Which infections for our region?

• Tuberculosis (incl MDR XDR)

• HIV• Influenza; H1N1 (swine)

& H5N1 (avian)• Malaria• Dengue• Hepatitis B• MRSA• Other bacterial sepsis• Multi-resistant Gm -ves

• Melioidosis• Leptospirosis• Rickettsial diseases – scrub

typhus, other• JE• Chikungunya• Zika & other arboviruses• Nipah; other bat-

associated• Ebola?• The next SARS?

Bats and emerging human viral diseases

Australian bat rabies(lyssavirus)

Nipah & Hendra virusSARS & MERS

EbolaWhat next??

Bat-filled tree may have been ground zero for the West African Ebola epidemic

"I would not say that the future is necessarily less predictable than the past - I think the past was not

predictable when it started." Donald Rumsfeld

So what else is out there?

So what else is out there?

“Prediction is very difficult, especially about the future."

Niels Bohr

Which infections for our region?

• Tuberculosis (incl MDR XDR)

• HIV• Influenza; H1N1 (swine)

& H5N1 (avian)• Malaria• Dengue• Hepatitis B• MRSA• Other bacterial sepsis• Multi-resistant Gm -ves

• Melioidosis• Leptospirosis• Rickettsial diseases – scrub

typhus, other• JE• Chikungunya• Zika & other arboviruses• Nipah; other bat-associated• Ebola?• The next SARS?

198 million cases globally 584,000 deaths (78% <5yo)24 million Southeast Asia 41,000 deaths (29% <5yo)(44% P. vivax)1 million Western Pacific 3,300 deaths (49% <5yo)

Malaria globally and regionally

But Its Worse Than We Thought: February 2015

• 17 Member Countries (from the initial 11 in 2009)– Bangladesh, Bhutan, Cambodia, China, India, Indonesia, DPR Korea, Republic of Korea, Laos,

Malaysia, Nepal, Philippines, Solomon Islands, Sri Lanka, Thailand, Vanuatu, Vietnam

• 18 Research and Service Partners

Vivax Working Group– Identify key research priorities– Build local capacity– Workshops:

• Genotyping, G6PD, Clinical Trials

– Technical grants

Clinical TrialsGenotypingG6PD deficiency testingParasite Prevalence

Asia Pacific Malaria Elimination Network

Asia Pacific Malaria Elimination Network

Successful elimination of malaria inSolomon Islands and neighbouring

countries would be a historicachievement for the health of the

peoples of our region, and it wouldalso pay a dividend for Australia’sown public health and biosecurity.

Harin Karunajeewa et al. MJA 202 (7) · 20 April 2015

Asia Pacific Leaders Malaria Alliance

Created at 2013 East Asia Summit in BruneiSecretariat formally commenced operations January 2014

Asia Pacific Leaders Malaria Alliance

East Asia leaders commit to eliminate malaria from Asia Pacific by 203013th November 2014

198 million cases globally 584,000 deaths (78% <5yo)24 million Southeast Asia 41,000 deaths (29% <5yo)(44% P. vivax)1 million Western Pacific 3,300 deaths (49% <5yo)

Papua New Guinea: our forgotten friends & colleagues?

198 million cases globally 584,000 deaths (78% <5yo)24 million Southeast Asia 41,000 deaths (29% <5yo)(44% P. vivax)1 million Western Pacific 3,300 deaths (49% <5yo)

Papua New Guinea: our forgotten friends & colleagues?

Which infections for our region?

• Tuberculosis (incl MDR XDR)

• HIV• Influenza; H1N1 (swine) &

H5N1 (avian)• Malaria• Dengue• Hepatitis B• MRSA• Other bacterial sepsis• Multi-resistant Gm -ves

• Melioidosis• Leptospirosis• Rickettsial diseases – scrub

typhus, other• JE• Chikungunya• Zika & other arboviruses• Nipah; other bat-associated• Ebola?• The next SARS?

MDR TB: PNG… TSI…Where next??

The 32-year-old Torres Strait Islander died on 29/09/14

“Close connection" with another TSI woman who died from MDR TB in 2013

Contact with at least 50 people

October 14, 2014Amy Remeikis

Papua New Guinea: our forgotten friends & colleagues?

The 32-year-old Torres Strait Islander died on 29/09/14

“Close connection" with another TSI woman who died from MDR TB in 2013

Contact with at least 50 people

October 14, 2014Amy Remeikis Adult wards at PMGH

Mortality 10% 1989Mortality 32% 2013TB 25% of deaths

HIV/AIDS 24% of deathsVincent Pyakalyia

M Med Thesis UPNG 2013

World TB Day March 24 2007

= LTBI active TB

= LTBI (Mx +ve)