Emerging Infectious Diseases Australia is not an Island

Emerging Infectious Diseases Australia is not an Island Bart Currie Global and Tropical Health Division Menzies School of Health Research, Darwin Infectious Diseases Department, Royal Darwin Hospital

Borneo Sulawesi Papua Timika Jakarta Java Bali Wallace s Line Lombok Weber s Line Timor Darwin 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?

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 India ECOL: 78% KPNE: 64% China* ECOL: 54% KPNE: 41% Thailand* ECOL: 55% KPNE: 50% Malaysia ECOL: 36% KPNE: 45% Hong Kong ECOL: 46% KPNE: 23% Korea ECOL: 37% KPNE: 40% Singapore ECOL: 21% KPNE: 32% Philippines ECOL: 47% KPNE: 23% Japan ECOL: 17% KPNE: 11% Taiwan ECOL: 91% KPNE: 75% Indonesia ECOL: 71% KPNE: 64% Courtesy John Turnidge ACSQHC Australia ECOL: 12% KPNE: 15% New Zealand ECOL: 11% KPNE: 10%

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

Then introduction and spread of carbapenem-resistant bacteria In 2010, a multi-drug carbapenem-resistant K. pneumoniae was 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.

Now community spread of carbapenem-resistant bacteria Tal et al. Med J Aust 2015;202:270 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.

Resistance in Australia: public attention & funding

Bats and emerging human viral diseases Australian bat rabies (lyssavirus) Nipah & Hendra virus SARS & MERS Ebola What next?? Bat-filled tree may have been ground zero for the West African Ebola epidemic

So what else is out there? "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? Prediction is very difficult, especially about the future." Niels Bohr

Malaria globally and regionally 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)

But Its Worse Than We Thought: February 2015

Asia Pacific Malaria Elimination Network 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 Genotyping G6PD deficiency testing Parasite Prevalence Clinical Trials

Asia Pacific Malaria Elimination Network

Successful elimination of malaria in Solomon Islands and neighbouring countries would be a historic achievement for the health of the peoples of our region, and it would also pay a dividend for Australia s own 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 Brunei Secretariat formally commenced operations January 2014

Asia Pacific Leaders Malaria Alliance

East Asia leaders commit to eliminate malaria from Asia Pacific by 2030 13 th November 2014

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)

MDR TB: PNG TSI Where next?? October 14, 2014 Amy Remeikis 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

Papua New Guinea: our forgotten friends & colleagues? October 14, 2014 Amy Remeikis 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 Adult wards at PMGH Mortality 10% 1989 Mortality 32% 2013 TB 25% of deaths HIV/AIDS 24% of deaths Vincent Pyakalyia M Med Thesis UPNG 2013

World TB Day March 24 2007 = LTBI active TB = LTBI (Mx +ve)