1. Biosecurity in North Queensland: Challenges and opportunities Rick Speare Anton Breinl Centre for Public Health and Tropical Medicine James Cook University Richard.speare@jcu.edu.au 13 May 2010 David Banks Oration

2. 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?

3. What makes North Queensland special? Receptivity to dengue Porous PNG-Australian border in Torres Strait

4. Slide from Scott Ritchie (JCU)

5. Receptivity is a Qld problem… at present Slide from Scott Ritchie (JCU)

6. Graph from Dr Scott Ritchie, JCU/QH

7. 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

8. 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

9. Pacific Island Countries & Territories (PICTs) PNG PICTs are doing badly! 22 countries spread over millions of km 2 of Pacific Ocean

10. Southeast Asia Indonesia PICTs

11. Indo-Papuan Conduit Qld’s special link to Asia and the Pacific

12. PNG Australia

13. Joh Rescues Torres Strait Islands

14. Torres Strait Treaty 1978

15. 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)

16. 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

17. Comparing ICUs: Lake Murray vs Townsville Mater POVERTY!

18. Tuvulu Climate Change will have major impacts in PICTs!

19. Traditional PNG visitors Annually 30,000-53,000 59% 3% 2% 4% 29% 2% 0.6% 0.5% 0.3% 0.2% 0.1% House Reps SC Hlth Aging Mar 2010 Estimated 4% come specifically for health care

20. 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

21. Humanitarian emergencies: Entry into Cairns … and points south Saibai Thursday Is Cairns

22. What about movement of animals and animal products? AQIS Quarantine offices = 15 Northern Australian Quarantine Strategy (NAQS)

23. 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

24. 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

25. 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

26. MDRTB

27. Pulmonary TB (Mycobacterium tuberculosis) Chronic cough (2 wks) Productive Haemoptysis (blood in sputum) Weight loss Night sweating

28. 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)

29. Bad enough! But wait there’s more… Inadequate treatment drives MDRTB Evolution to extensively drug resistent TB (XDRTB) is a possibility

30. 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

31. 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

32. 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

33. 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?

34. 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?

35. JE Dengue Other arboviruses?

36. 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

37. Receptivity is a Qld problem, but rain water tank installation will expand the range of the vectors south Aedes albopictus

38. Unknown arboviruses in PNG? Madang encephalitis Not JEV? Death in children and severe disability

39. Rabies is moving east in Indonesia Susetya et al. Virus Res 2008;135:144-9. 1997 2008 Not if, but when?

40. Indo-Papuan Conduit

41. 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

42. MDRTB Bat viruses? Other arboviruses? Other EID? HPAI? JE Dengue

43. 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

44. Halpin et al. CID 2007;44:711-717 Flying foxes are hosts to a range of RNA viruses that cause EIDs Dobsonia magna

45. Highly Pathogenic Avian Influenza Pandemic (for birds) H5N1 is here to stay

46. H5N1 in Indonesia H5N1 HPAI is widespread 165 human cases with 136 fatal (82%)

47. Indo-Papuan Conduit Will H5N1 use this route? H5N1 Ongoing monitoring of poultry & wild birds in PNG & Torres Strait for AI?

48. 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)

49. 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

50. 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

51. 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)

52. 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

53. 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

54. Thank you! Difficult, long-term, but essential

55. Images Aedes aegypti - http://www.health.gov.bz/www/images/stories/aedes_aegypti_seitlich.jpgAedes 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 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.htmlwww.thegoodsplace.org/2007/06/boo-hoo-hoo.html Pasteur & swan neck flasks - http://www.daviddarling.info/encyclopedia/P/Pasteur.html http://www.daviddarling.info/encyclopedia/P/Pasteur.html Rabid dog - http://www.jack-russell-terrier.co.uk/advice/vaccinations.htmlhttp://www.jack-russell-terrier.co.uk/advice/vaccinations.html Port Douglas - http://www.flickr.com/photos/blackdiamondimages/3874757902/http://www.flickr.com/photos/blackdiamondimages/3874757902/ Scott O’Neill - www.uq.edu.au/news/?article=18458www.uq.edu.au/news/?article=18458 Rain water tank from Scott Ritchie Scott Ritchie - http://www.jcu.edu.au/phtmrs/staff/academic/JCUDEV_015744.htmlhttp://www.jcu.edu.au/phtmrs/staff/academic/JCUDEV_015744.html Dobsonia magna - http://www.henipavirus.org/virus_and_host_info/bats/dobsonia_magna.htm http://www.henipavirus.org/virus_and_host_info/bats/dobsonia_magna.htm

56. 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.