Argument for Inclusion of Strongyloidiasis in the Australian National Notifiable Disease List
Abstract
:1. Introduction
2. The Australian National Notifiable Disease Surveillance System (NNDSS)
3. Criteria for Inclusion on the National Notifiable Disease List
- The disease is important to Indigenous health, and closing the health inequity gap between Indigenous and non-Indigenous Australians is a priority.
- A public health response is required to detect cases of strongyloidiasis and to establish the true incidence and prevalence of the disease.
- There is no alternative national surveillance system to gather data on the disease.
- There are preventive measures with high efficacy and low side effects.
- Data collection is feasible as cases are definable by microscopy, PCR, or serological diagnostics.
- Achievement of the Sustainable Development Goal (SDG) # 6 on clean water and sanitation.
4. Prevalence of Strongyloidiasis in Australia
5. Socioeconomic Impact Caused by Strongyloidiasis
6. Recommendation to Make Strongyloidiasis a Notifiable Disease
Author Contributions
Acknowledgments
Conflicts of Interest
Dedication
References and Note
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# | Criterion | Score | Notes on Strongyloidiasis |
---|---|---|---|
Priority setting | |||
1 | Necessity for public health response | 2/4 = case reporting important for detecting outbreaks that require investigating or contacts require routine intervention | A public health response and immediate intervention is required based on the following: 1. Inadequate hygiene and sanitary conditions are the main factors for human strongyloidiasis. A person can get infected when coming into contact with or near infected human or dog faeces. In low socioeconomic status communities, such as some Indigenous communities, sanitation conditions present a high risk for strongyloidiasis transmission, contamination, re-infection, and recurrence [30]. Therefore, it is crucial to get a public health response to create and maintain adequate sanitary and hygiene conditions in the communities to prevent the disease. Culturally comprehensive health education for understanding the nature of infectious diseases and how they are transmitted is fundamental for maintaining hygienic conditions [48]. 2. There is the opportunity to highlight environmental health role in the public health response. There is an opportunity to make a difference in endemic communities and specific families/communities with high need targeting the SDG # 6 on clean water and sanitation. 3. Interventions programs such as targeted mass drug administration (MDA) have shown to be very effective in reducing the reservoir of human infection, and need to be implemented regularly on a local and national level in endemic communities [7]. 4. Another intervention program in an endemic Indigenous community incorporated S. stercoralis screening into the adult health check, and positive cases were treated and followed up. This selective chemotherapy intervention resulted in a decreased risk of potentially fatal hyperinfection and decreased prevalence in the community [13,49]. 5. Strongyloidiasis has been shown to prevent weight gain in children, and therefore it is critical to identify and treat S. stercoralis infection to avoid intervention by social services. This intervention can result in child removal from parents into care if the child shows signs of malnutrition [49]. An environmental health response to geographic hot spots would also bring in the SDG # 6 on clean water and sanitation. |
2 | Utility and significance of notification for prevention programs | 1/4 = Need to establish burden of illness for monitoring or research purposes/priority setting | The geographic prevalence of S. stercoralis within Australia is essential to understand and map the hotspots. Notification and establishing the true burden of infection will improve monitoring, prevention and research, for assessing the effectiveness of prevention and control programs at the local and regional levels. Currently, there are no true disability-adjusted life years (DALYs) identified for strongyloidiasis, mainly because of poor estimates of disease prevalence. |
3 | Vaccine preventability | 0/4 = No vaccine available | No vaccine available |
4 | Importance for Indigenous health | 4/4 = Very high | Strongyloidiasis is endemic in the Indigenous population, affecting up to 60% of the population in some remote communities. Strongyloidiasis has been and continues to be an issue in the Australian Indigenous population, causing unnecessary morbidity and mortality in all age groups [39]. Many in the Australian Indigenous population, as a result of socioeconomic conditions and compromised/suppressed immunity due to chronic disease, are unusually susceptible to both acute strongyloidiasis, and life-threatening disseminated and/or hyperinfective strongyloidiasis. |
5 | Emerging or re-emerging disease | 2/4 = slowly re-emerging or increasing incidence/prevalence disease over the past 5 years | Strongyloidiasis has been called ‘the most neglected of Neglected Tropical Diseases’ [14]. Cases have been reported since the early 1900s. The literature shows that the prevalence of the disease trend declined following mass drug administration (MDA) of ivermectin (2010) and albendazole (1995) in these communities [7,13]. However, the disease has never been eliminated and tends to reappear [5,41]. The disease has been neglected, and the real prevalence of the disease is underestimated due to lack of disease surveillance. Due to the unique autoinfective cycle of S. stercoralis, chronic strongyloidiasis lasts for a lifetime if not effectively diagnosed and treated. Cases of hyperinfection and iatrogenic fatal dissemination are predicted to increase as the infected populations age and are at a higher risk of being immunosuppressed. Corticosteroids have been considered a factor in 65% of fatalities from hyperinfection [50]. Another factor contributing to this emerging disease status with increasing cases of severe, complicated strongyloidiasis, has been the lack of awareness of strongyloidiasis in medical personnel who have been trained in Australia. |
6 | Communicability and potential for outbreaks | 2/4 = Medium | There is a potential for outbreaks in poor-infrastructure settings with low sanitary and hygiene conditions, which together produce a high risk for strongyloidiasis transmission from person to person via faecal-skin and faecal-oral routes [51]. |
7 | Severity and socioeconomic impacts | 1/4 = low severity and socioeconomic impacts in chronic strongyloidiasis (strongyloidiasis in healthy person) or 2/4 = medium severity and socioeconomic impacts in disseminated or hyperinfective strongyloidiasis | In healthy people, chronic strongyloidiasis may have only mild, intermittent, and non-specific symptoms. However, the autoinfection feature of this helminth and parthenogenesis, allows single larvae reproducing within the host leading to a chronic, long-lasting disease. If not diagnosed and treated, the disease can take a more serious form as the person becomes immunocompromised/immunosuppressed, with an often-fatal outcome. A case fatality rate of almost 90% has been reported [6]. Strongyloidiasis presents unnecessary cost to the health systems, as strongyloidiasis is both preventable and treatable if diagnosed early, and in the chronic stage. The diagnostic and treatment costs, including selective chemotherapy, targeted MDA and water, sanitation and hygiene (WASH) have been estimated in previous research and shown to be affordable [52,53]. It was estimated in US citizens that presumptive preventive intervention would decrease DALYs caused by intestinal parasites, including Strongyloides, by up to 1976- saving USD 16.4 million [54]. |
8 | Preventability | 4/4 = preventive measure with high efficacy/low side effects/high acceptability and uptake | Adequate sanitary and hygiene conditions including safe water supply, proper toileting and hygiene facilities would provide long term sustainable prevention and elimination of strongyloidiasis [51]. This should be combined with health education and research to determine the gold standard for strongyloidiasis diagnosis. Treatment of chronic strongyloidiasis prevents hyperinfection. Currently, ivermectin is the drug of first choice to treat human strongyloidiasis, followed by albendazole [55]. Ivermectin and albendazole, given according to therapeutic guidelines for strongyloidiasis [41], have been shown to eliminate the disease in 70% to 85% of those with chronic strongyloidiasis. Both drugs have negligible side effects. Ivermectin requires only one to two administrations. Albendazole requires two courses of daily doses for three days. A single dose is ineffective [7,13]. |
9 | Level of public concern and/or political interest | 2/4 = low to medium public concern or political interest or 3/4 = medium to high public concern or political interest | Strongyloidiasis is an overlooked, neglected disease [14]. However, when people are made aware of the disease, there is high public concern. This is illustrated by a recently published article on strongyloidiasis in ‘The Conversation’ which received a large number of responses by the general public showing their interest and concern about the disease [56]. Closing the Gap (the health inequity gap between Indigenous and non-Indigenous Australians) is a high priority in mainstream Australia [57]. The fact that locally-acquired infection in Australia is almost exclusively seen in Indigenous communities should be of great public and political concern. |
Feasibility of collection | |||
10 | A case is definable | 4/4 = Case has an acceptable laboratory definition with or without a clinical definition | A strongyloidiasis case is definable and we propose to notify strongyloidiasis by the laboratories based on positive serology or parasitological diagnosis [58]. In disseminated and hyperinfective strongyloidiasis, faecal examination has higher sensitivity due to large numbers of viable larvae and the patient is usually in a hospital setting at the time of diagnosis. In immunocompetent persons, chronic strongyloidiasis might not always be detected by microscopy due to low and irregular larval load, and serology has the highest sensitivity and is recommended [29]. |
11 | Data completeness is likely to be acceptable | 2/4 = Data represent a proportion of community cases with a known undercount | Data on the prevalence of strongyloidiasis is limited. Studies suggest that up to 60% of the population in Indigenous rural or remote communities is infected with strongyloidiasis. A study in North Queensland found that 10% of the non-Indigenous population has strongyloidiasis [40]. It is believed that the disease is likely to be more widespread in Australia that the current data suggest. |
12 | Alternative surveillance mechanisms | 4/4 = No alternative surveillance mechanisms in place. | There is no surveillance mechanism available to monitor and report on strongyloidiasis. |
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Beknazarova, M.; Whiley, H.; Judd, J.A.; Shield, J.; Page, W.; Miller, A.; Whittaker, M.; Ross, K. Argument for Inclusion of Strongyloidiasis in the Australian National Notifiable Disease List. Trop. Med. Infect. Dis. 2018, 3, 61. https://doi.org/10.3390/tropicalmed3020061
Beknazarova M, Whiley H, Judd JA, Shield J, Page W, Miller A, Whittaker M, Ross K. Argument for Inclusion of Strongyloidiasis in the Australian National Notifiable Disease List. Tropical Medicine and Infectious Disease. 2018; 3(2):61. https://doi.org/10.3390/tropicalmed3020061
Chicago/Turabian StyleBeknazarova, Meruyert, Harriet Whiley, Jenni A. Judd, Jennifer Shield, Wendy Page, Adrian Miller, Maxine Whittaker, and Kirstin Ross. 2018. "Argument for Inclusion of Strongyloidiasis in the Australian National Notifiable Disease List" Tropical Medicine and Infectious Disease 3, no. 2: 61. https://doi.org/10.3390/tropicalmed3020061