BLOCK 22

MAJOR TROPICAL
DISEASES

Department of Parasitology
Faculty of Medicine Gadjah Mada University
 TROPICAL MEDICINE &TROPICAL DISEASES

Scope of studies: diseases which inflict human

health in the tropics whether he or she
contracting the disease is native, or not (a
foreigner as a tourist or a traveler).
The diseased human, should be diagnosed &
treated appropriately by a physician in a clinical
ward to alleviate the illness, whenever possible
to cure totally (clinically & microbiologically /
parasitologically).
In the community, tropical disease should be
controlled based on its epidemiological findings
(host, agent & environment including vector) to
prevent mortality, reduced incidence &
prevalence, minimized its social & economic
impacts.
 Major issues & purpose of studies
Tropical disease issues focused on infectious
diseases that ravage public health in the tropical
world.
The subjects of studies: diseases of global
importance (big 10s tropical diseases under
WHO/TDR program), dealing with its respective
public health importance, epidemiology, control &
prevention.
The purpose studies: is to comprehend, apply
knowledge & technology on the tropical diseases
under studies in cases of diagnosis, treatment &
management, epidemiology and control, &
prevention.
In this respect, global importance & health impacts of
the big 10s will be dealt with.
Tropical Infectious Diseases (TID)

 TID is not necessarily confined to the tropics

only in its geographical distribution, but it can
also infect people in the temperate zones.

 Almost all infectious diseases can be found in

the tropical countries, some of them that are
restrict in the tropics, i.e. sleeping sickness.

 Many TID caused by pathogen (bacteria,

parasites, viruses & fungi).
 Examples of some TIDs
Bacteria tuberculosis, leprosy, cholera, tetanus, plague,
leptospirosis, shigella, campylobacter, typhoid fever,
syphilis, chlamydia, gonococcus, anthrax

Parasites malaria, amebiasis, giardiasis, american, and african

trypanosomiasis, leishmaniasis, ascariasis,
strongyloidiasis, schistosomiasis, taeniasis,
echinococcosis, lymphatic filariasis, loasis,
onchocerciasis, cryptosporidiasis, dracunculiasis,
hookworm, trichinosis.

Viruses HIV, measles, poliomyelitis, viral hepatitis, viral diarrhea,

rabies, Yellow fever, Dengue fever, viral haemorrhagic
fever, arboviruses.

Fungi histoplasmosis. sporotrichosis, cryptococcosis,

coccidiomycosis, blastomycosis, paracoccidiodomycosis
 Tropical Diseases of The
TDR/WHO’s Big 10s
Those include:
1. Malaria
2. Schistosomiasis
3. Lymphatic Filariasis
4. Dengue Haemorrhagic Fever (DHF)
5. Onchocerciasis
6. African trypanosomiasis
7. American trypanosomiasis
8. Leishmaniasis
9. Leprosy
10. Tuberculosis
 1. MALARIA
 Malaria is an infectious disease caused by
Plasmodium, a blood, protozoan parasite, naturally
transmitted biologically by anopheline mosquito.
 The genus Plasmodium causing human malaria :
(1). P. falciparum
(2). P. vivax;
(3). P. malariae,
(4). P. ovale
(5). P. knowlesi
 Direct death could occur in malaria patients due to
cerebral malaria, and other worse complications,
commonly found in in patients suffering from
falciparum malaria
Malaria case in Africa
 Malaria:Distribution and Zones
Indigenous malaria occupies the earth planet
ranging as far north as 640N latitude
(archangel in the USSR) and as far south as
320S (Cordoba in Argentina).
Malaria is found in 12 epidemiological zones:
1. North Americans 7. Afro-Tropical
2. Central Americans 8. Indo-Iranian
3. South Americans 9. Indo-Chinese Hills
4. North Eurasians 10. Malaysian
5. Mediterranean 11. Chinese
6. Afro-Arabian 12. Australasian
World map of Malaria
 Malaria: Global Importance
Among the 10s tropical diseases, malaria is leading in causing
mortality & morbidity. The malaria situation in the world
seems to be not much changing from 50 years ago.

In 1954, WHO estimated that there were 2.5 million death

annually & 250 million new cases world-wide.

In 1997, WHO estimated that out of 52.2 millions death due to

all cases in the world, 2.3 millions were caused by malaria.
Number of new malaria cases ranged from 300-500 millions.
About 90% of them were in tropical Africa, & the disease
was endemic in 100 countries.

In 2006, the world malaria situation is very likely the same.

Even malaria has been increasing in incidence &
prevalence in many countries due to many
constraints, i.e., drug resistance of the malaria
parasites (P. falciparum & P.vivax), and
insecticide resistance of its main vectors in many
malaria endemic countries, i.e., An. gambiae in
Africa.

Malaria vaccine that is cost-effective is still on the

way of development (fatamorgana).
 2. SCHISTOSOMIASIS
 Schistosomiasis in human is a helminthic
infection caused by the blood flukes, human
schistosomes.

 3 species of Schistosoma infect human:

1. S. japonicum,
2. S. mansoni
3. S. haematobium

 Totally, schistosomiasis in the world (WHO,

1997) cause 20 thousands death, with 200
millions cases, and 120 millions disability.
 Schistosomiasis:
cachectic with hepato-splenomegaly
 Schistosomiasis japonicum
The trematode infecting vv. mesenterica superior
heavily & chronically of small intestine may
cause fever, chronic diarhoe, hepatomegaly and
splenomegaly, cachexia, that gradually lead to
risk of death. Ectopic worms may occur in heavy
infections, mostly in the CNS.

Schistosmiasis japonicum spreads in some

countries: China, Japan, The Phillipines &
Sulawesi – Danau Lindu (Indonesia). Its
intermediate snail is Oncomelania sp.
 Schistosomiasis mansoni
 Found in Africa & Madagascar. It spreads through
exported slaves to South America, the Carribean &
Arabia.
 The schistosome inhabit vv.mesenterica inferior of
large intestine, in severe & long-standing infections
may cause a characteristic liver disease called
Symmers pipestem fibrosis.
 It may cause also hepatomegaly & splenomegaly,
and bleeding from esophageal varices. This may
lead to death.
 For completing its life cycle it needs aquatic snail,
commonly Biomphalaria sp.
 Schistosomiasis haematobium
 It is scattered throughout Africa, parts of Arabia,
the Near East, Madagascar and Mauritius.

 The schistosome inhabit vesical plexus causing

urinary schistosomiasis, a primarily obstructive
uropathy, and bladder carcinoma. Secondary
effect are hydroureter, and hydronephrosis.

 For completing its life cycle in water it need

water snail species, commonly Bulinus sp.
Global problem of schistosomiasis
WHO (1997): schistosomiasis in the world
totally caused 30 thousands death, with
about 200 millions cases world-wide, and
120 millions disability.

Schistosomiasis japonicum in Napu valley,

Lindu Lake, Central Sulawesi, tends to be
decreasing in incidence & prevalence due
to ecological changes – economical
activities & development.
 3. LYMPHATIC FILARIASIS
This is a group of helminthiasis caused by
filarial worms, the macrofilaria (adult stage) inhabit
lymph vessels; its offspring, microfilaria (mf) circulate
in the blood either periodically or nonperiodically,
depending on its species or strain & locality.

Species are infecting human in different parts

of the world:
1. Wuchereria bancrofti Filariasis bancrofti
2. Brugia malayi Filariasis malayi
3. Brugia timori Filariasis timori.
 Filariasis bancrofti
Infection is confined to human, widely distributed in
the warmer parts of the world (Africa, Asia, South
America & Oceania).

More than 90% infections found in Asia, in cities the

disease caused by W. bancrofti of urban type,
transmitted by Culex quinquefasciatus is highly
endemic. The infection may prevail in rural areas
like in Papua, it is transmitted by certain species of
Anopheles.

The chronic & heavy infection manifests clinically as

retrograde lymphangitis & frequently hydrocele that
later gradually developing to genital elephantiasis.
Other parts of the body (leg, arms, breast) may be
affected.
 Filariasis malayi
Filariasis malayi is much less widespread
compared to filariasis bancrofti. It distribution in
India, South-east Asia generally & Malay
archipelago

It is not usual in urban areas, less common &

less serious than filariasis bancrofti.

Zoonotic, it may infect monkeys & cats in

forest, instead of human.

Mansonia mosquito is the common vector in

certain rural, swampy, endemic areas. Several
Anopheles may transmit the filarial infection in
towns.
 Filariasis malayi: health impacts

 Health impacts malayan filariasis same as

bancroftian filariasis, the clinical features
similar but less severe.

 Elephantiasis cruris (elephantiasis of the

lower leg, below the knees) is the common
clinical feature, scrotal involvement is not
so gross, chyluria is rare.
 Filariasis timori
 Filariasis timori is confined in its
distribution to Timor Island, Eastern
Indonesia. It is transmitted by Anopheles
barbirostris.
 It causes elephantiasis of the leg,
characterized by lymphangitis & swelling
with sterile abscess.
 Global Importance
 Lymphatic filariasis although it risk disability due
to elephantiasis on many individuals, is not
killing.

 WHO (1998): in 1997, 119.1 millions people

affected lymphatic filariasis of all causes who
showed severe activity limitation.

 Eradication programme with combination of

albendazole & DEC treatment is underway in
many endemic countries.
Lymphatic Filariasis
4. DENGUE HAEMORRHAGIC FEVER
(DHF)
 DHF is one of the variants of Dengue Fever (DF)
which may subsequently develop to Dengue
Shock Syndrome (DSS).
 It is an arboviral disease complex, the agent:
Dengue virus (vir Den) of serotypes 1 (Den-1), 2
(Den-2), 3 (Den-3) & 4 (Den-4), primarily
transmitted by Aedes aegypti & secondarily by
Ae. albopictus.
 Fatal outcome is mainly due to DSS, with case
fatality rate (CFR) ranges up to 10%.
 Dengue Transmission:
horizontal (and vertical ?)
 Global importance
 DF/DHF/DSS spreads widely in South-east Asian
countries where in every countries epidemic
DHF/DSS become a major public health problem.

 WHO (1998) reported in 1997, caused 140

thousands death, with 3.1 millions new cases.

 In Indonesia, DHF/DSS in the last decade has been

developing a continuing cycle of epidemic DHF/DSS
at 3-4 year intervals, or even less, in the early years
of this 21st century

 Its prevention with an effective vaccine is still a big

problem in development.
World population under
mosquito control?
 5. ONCHOCERCIASIS
 Onchocerciasis is a helminthic infection caused by
Onchocerca volvulus.

 About 95% of cases found in Africa, the

remainders in central & south America and Yemen.

 The parasite is only found in human. The adult

worms inhabit subcutaneous tissues or in fibrous
nodules beneath the skin.

 The vector is black fly, Simulium sp. which breeds

on stones in rivers with clean, running water.
 Global Importance
 The disease is a major cause of blindness
(commonly it is called ‘river blindness’due
to its association with river, the blackfly
habitats).
 WHO (1998) reported that in 1997, 45
thousands death, 17.655 millions cases,
and 770 thousands persons with severe
activity limitations.
Lymphatic Filariasis (upper), and
Onchocerciasis (lower)
6. AFRICAN TRYPANOSOMIASIS
In humans is caused by Trypanosoma brucei
gambiense, the cause of gambiense sleeping
sickness, prevailing in west & central Africa, and
Trypanosoma brucei rhodesiense, the cause of
rhodesiense sleeping sickness, prevailing in
east & southern Africa.

It is transmitted by tsetse fly in which the

trypanosome develop cyclically. However, it is
likely that the parasite mechanical transmission
through proboscis occur, and congenital
transmission has also been reported.
 Global Importance
 The late stage of african trypanosomiasis
creates the health problem.
 The main symptoms are realted to disturbed
cerebral functions.
 There is early signs of demenia, followed
with changing in behavior, like a psychiatric
patient.
 Sleep becomes disordered, sleep badly at
night, easily falls asleep during the day, even
while eating and difficult to be awoken.
A hundred thousands death reported in
1997 (WHO,1998), with 150 thousands
new cases, 400 thousands cases, and 200
thousands disabled persons.

 Itis possible that the disease causes

epidemics in a number of African countries
in the 2000s, and warning for
recrudescence of sleeping sickness
particularly in central Africa.
 7. SOUTH AMERICAN
TRYPANOSOMIASIS
It is commonly called ‘Chagas Disease’ in
honour of Dr. Carlos Chagas the first who
described the disease.
It is caused by Trypanosoma cruzi, and
transmitted by reduviid bugs (assasin
bugs, kissing bugs) of the genus Triatoma,
Reduvius, and Panstrongylus.
It is found in humans & animals, and is
widespread in central & south America.
 Global Importance
The disease of longer duration may cause
complications, such as: cardiomegaly,
megacolon, megaesophagus, and other
‘mega’ like small intestine and ureter.
In 1997 (WHO, 1998) it was reported 45
thousands people death, 300 thousands
new cases, and 18 millions cases
worldwide.
 8. LEISHMANIASIS

Leishmaniasis is a parasitic disease caused by a

protozoan complex, Leishmania

Species of Leishmania:
1. L. donovani, causing visceral leishmaniasis
(kala-azar).
2. L. braziliense, causing mucocutaneous
leishmaniasis.
3. L. tropica, and L. mexicana, both causing
cutaneous leishmaniasis
 Clinical Disease & Distribution

Cutaneous lesion due to L. tropica & L. mexicana is

quite similar. It is a small red papule, self limiting,
benign at the site of a bite of its vector, sandfly,
Phlebotomus.

American cutaneous leishmaniasis it may develop to

ulcer on the ears or the face.

L. tropica is found in Middle eastern countries, central

Asia & India.

L. mexicana prevails in central America.

L. braziliensis causes mucocutaneous
leishmaniasis that is characterized by massive
necrotizing inflammation or ulcer. Skin,mucus
membrane & cartilage may be involved. It is
widespread through central & south America.
L. donovani causes visceral leishmaniasis due to it
replicates in spleen, liver & bone marrow. It
causes splenomegaly & hypersplenism. L.
donovani complex comprise: L. infantum, found
in the Mediterranean basin, Central Asia &
China; L. donovani in India and eastern Africa,
and L. chagasi in parts of south and central
America.
 Global Importance
 In 1997, leishmaniasis of all types caused
80 thousands death, 2 millions new cases
with 12 millions of all cases.
 It is possible leishmaniasis is imported to
South-east asian countries through
woman workers coming back from
endemic countries.
 9. LEPROSY
 Leprosy is a disease of human caused by
Mycobacterium leprae, an acid-fast bacillus. It
may affect skin, superfical nerves, lymph nodes,
upper respirtory mucosa, testes and anterior
chamber of the eye.
 The disease is found all over the world where
poverty and overcrowding encourage its spread.
It is not restricted only with warm climate. It has
not decreased in the last three decades.
 Global importance
WHO (1998): in1997 there were 2000 deaths, 570
thousands new cases with prevalence of 1.15
millions, and 3 millions disabled persons with
various types of leprosy.
The most debilitating one is lepromatous leprosy
associating with low immunity; such condition is
common in developing countries due to poverty,
malnutrition & others.
 10. TUBERCULOSIS
 Tuberculosis (TB) is an infection caused by
Mycobacterium tuberculosis, an acid-fast bacillus, that is
commonly called tubercle bacillus.
 The infection is contracted through inhalation of droplet
nuclei which have been coughed by someone with active
pulmonary TB disease.
 TB bacillus after being inhaled it will attack apical lung
and, or regional lymph nodes.
 In low-immunodeficient individual the TB bacillus will
spread to all parts of the lung (milliary), kidney, vertebrae
and CNS. These clinical conditions may lead to death of
the patient.
 Global Importance
WHO reported that TB threatens one-third of the
world’s population. The WHO declared TB a
global health emergency in 1993. Such situation
was encouraged by deteriorating control in some
parts of the world, the spread of HIV, and
population growth.
WHO reported that 1997, 2.91 millions people
death, 7.25 millions new cases, 16.3 millions
prevalence, and 8.42 millions disabled persons
due o TB.
Without a coordinated control effort, TB will infect
an estimated 1 billion more people by 2020, and
will kill 70 million.
 TID CONTROL AND PREVENTION
Actually many tropical diseases are preventable by means
of simple, inexpensive, and currently available methods.
E.g., 25% of malaria deaths can be prevented by the use
of insecticide-impregnated bednets. Comprehensive
childhood vaccination programme would virtually
eliminate infection with the measles and polio virus.

Many of TID that are currently considered tropical were

once endemic in the more temperate climates of
developed countries but were successfully eradicated, or
controlled with combination of public health education,
good sanitation and hygiene, and accessible medication.

Such successful story in the developed countries may not

be encountered in developing countries due to war,
poverty, and perhaps most importantly, by the lack of
political will on both a local, regional, and global level.
THANK YOU !