BLOCK 22

MAJOR TROPICAL
DISEASES
SUGENG JUWONO MARDIHUSODO
Dr, MSc, Prof.
Department of Parasitology GMU
January 2, 2007
 TROPICAL MEDICINE AND TROPICAL DISEASES:
Scope of Studies

Scope of studies on tropical medicine (tropmed) is actually

on that of diseases which inflict human health in the
tropics whether he or she contracting the disease is
native, or not (i.e. a foreigner as a tourist or a traveller).
The diseased human therefore should be diagnosed and
treated appropriately by a physician in a clinical ward to
alleviate his or her illness, and whenever possible to cure
the suffering totally (clinically and
microbiologically/parasitologically).
In the community, such a communicable, tropical disease
should be controlled based on its epidemiological
findings (host, agent and environment including vector)
to prevent mortality, reduced incidence and prevalence,
and minimized its social and economic impacts.
 Major issues, and purpose of
studies
Tropical disease issues are mainly focused on infectious
diseases that ravage public health in the tropical world.
The subjects of studies include diseases of global
importance (the common, big 10s of the tropical
diseases under WHO/TDR programme), dealing with
its respective public health importance, epidemiology,
control and prevention.
Therefore, the purpose of studies is to comprehend and
apply knowledge and technology on the tropical
diseases under studies in cases of diagnosis,
treatment and management, epidemiology and control,
and prevention.
In this respect, global importance and health impacts of the
big 10s will be dealt with.
Tropical Infectious Diseases (TID)
A 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, and some of them that are
restrictly in the tropics, i.e. sleeping sickness.
There are so many TID that inflict human health
which are caused by pathogen, belonging to
groups of bacteria, parasites, viruses and 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/WHOs 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 the infection
of Plasmodium, a blood, protozoan parasite, which is
naturally transmitted biologically by anopheline mosquito.
The genus Plasmodium causing human malaria include
for species:
(1). P. falciparum; (2). P. vivax;
(3). P. malariae, and (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 and 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 and 250 million new cases world-wide.
In 1997, WHO estimated that out of 52.2 milions 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,
and 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 and
prevalence in many countries due to many
constraints, i.e., drug resistance of the malaria
parasites (P. falciparum and 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.
 2. SCHISTOSOMIASIS
Schistosomiasis in human is a helminthiasis or
helminthic infection caused by the blood flukes, human
schistosomes.
There are three species of Schistosoma commonly infect
human:
1. S. japonicum,
2. S. mansoni,and
3. S. haematobium
Totally, schistosomiasis in the world (as recorded by the
WHO in 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 and 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 and
Sulawesi (Indonesia). Its intermediate snail is
Oncomelania sp.
 Schistosomiasis mansoni
The trematode infection is found in Africa and
Madagascar. Then it spreads through exported slaves to
South America, the Carribean and Arabia.
The schistosome inhabit vv.mesenterica inferior of large
intestine, and in severe and long-standing infections may
cause a characteristic liver disease called Symmers
pipestem fibrosis.
It may cause also hepatomegaly and 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
A record of WHO in 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 and prevalence
due to ecological changes economical
activities and development.
 3. LYMPHATIC FILARIASIS
This is a group of helminthiasis caused by filarial worms,
the macrofilaria (the adult stage) of which inhabit
lymph vessels; its offspring, microfilaria (mf) circulate
in the blood either periodically or nonperiodically,
depending on its species or strain and locality.
Three species are infecting human in different parts of the
world:
1. Wuchereria bancrofti causing Filariasis bancrofti
2. Brugia malayi, causing Filariasis malayi
3. Brugia timori, causing Filariasis timori.
 Filariasis bancrofti
The infection is confined to human. It is widely distributed in
the warmer parts of the world, including Africa, Asia,
South America, and Oceania.
More than 90% of all infections are found in Asia, where in
some cities the disease (caused by W. bancrofti of urban
type, transmitted by Culex quinquefasciatus) is highly
endemic. The infection may prevail in some rural areas
like in Papua, it is transmitted by certain species of
Anopheles.
The chronic and heavy infection manifests clinically as
retrograde lymphangitis, and frequently hydrocele that
later gradually developing to genital elephantiasis. Other
parts of the body (e.i., leg, arms, breast) may be
affected.
Lymphatic Filariasis (upper), and
Onchocerciasis (lower)
 Filariasis malayi
Filariasis malayi is much less widespread
compared to filariasis bancrofti. It has patchy
distribution in India, South-east Asia generally,
and many in the Malay archipelago.
It is not usual in urban areas, less common and
less serious than filariasis bancrofti.
The disease is zoonotic, it may infect monkeys and
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
The health impacts of malayan filariasis is
the same as that of bancroftian filariasis,
and the clinical features are 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 and
swelling with sterile abscess.
 Global Importance
Lymphatic filariasis although it risk disability due
to elephantiasis on many individuals, is not
killing.
WHO in 1998 reported that in 1997, 119.1
millions people affected lymphatic filariasis of all
causes who showed severe activity limitation.
Eradication programme with combination of
albendazole and DEC treatment is underway in
many endemic countries.
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 of
which is Dengue virus (vir Den) of serotypes 1
(Den-1, 2 (Den-2), 3 (Den-3), and 4 (Den-4),
primarily transmitted by Aedes aegypti, and
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 that 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 the nematode Onchocerca volvulus.
About 95% of all cases are found in Africa, the
remainders are in central and 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 blindnessdue
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.
6. AFRICAN TRYPANOSOMIASIS
The disease in humans is caused by Trypanosoma
brucei gambiense, the cause of gambiense
sleeping sickness, prevailing in west and central
Africa, and
Trypanosoma brucei rhodesiense, the cause of
rhodesiense sleeping sickness, prevailing in
east and 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, then followed with changing in
behaviour, like a psychiatric patient. Sleep
becomes disordered, sleep badly at night
and 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.
It is 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
The disease is commonly called Chagas
Disease in honour of Dr. Carlos Chagas
the first who described the disease.
The disease 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 and animals, and is
widespread in central and 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.
There are four 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 and Distribution
Cutaneous lesion due to L. tropica and L. mexicana is quit
similar. It is a small red papule, self limiting, benign at the
site of a bite of its vector, sandfly, Phlebotomus. In the
american cutaneous leishmaniasis it may develop to
ulcer on the ears or the face. L. tropica is found in Middle
eastern countries, central Asia, and India. L. mexicana
prevails in central America.

L. braziliensis causes mucocutaneous leishmaniasis that is

characterized by massive necrotizing inflammation or
ulcer. Skin,mucous membrane and cartilage may be
involved.
L. braziliensis causes mucocutaneous
leishmaniasis that is characterized by massive
necrotizing inflammation or ulcer. Skin,mucus
membrane and cartilage may be involved. It is
widespread through central and south America.
L. donovani causes visceral leishmaniasis due to it
replicates in spleen, liver and bone marrow. It
causes splenomegaly and hypersplenism. L.
donovani complex comprise: L.infantum,found in
the Mediterranean basin, Central Asia and
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
It was reported by WHO (1998), in1997 there were
2000 deaths, 570 thousands new cases with
prevalence of 1.15millions, 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
and malnutrition, and 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 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,
vertebraeand CNS. These clinical conditions may lead to
death of the patient.
 Global Importance
WHO reported that TB threatens one-third of the
worlds 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 programmes 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 !