Global burden of melioidosis was predicted, What’s next?

Direk Limmathurotsakul, MD MSc PhD

Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Thailand

Presented at WMC 9th, Cebu, 8 August 2016

Problems

“How many die of melioidosis each year ?”

- It is the main question that policy makers such as “World Health Organization (WHO)” and “Ministry of Health” in each country want to know the answer

Predicted global distribution of B. pseudomalleiand burden of melioidosis (Nature Microbiology, 2016)

Main Result: We estimate there to be 165,000 (95%CI 68,000-412,000) human melioidosis cases per year worldwide, of which 89,000 (95%CI 36,000-227,000) die.

Cartogram of the incidence as a proportion of national geographical area in 2015; 44% is in South Asia

Predicted mortality of melioidosis worldwide

Disease Predicted incidence

Predicted mortality

Predicted case fatality rate

Source of data

Tuberculosis 8,600,000 1,300,000 15% WHO website

Malaria 219,000,000 660,000 0.3% WHO website

2009 Pandemic Influenza A H1N1

N/A 284,000 N/A LID 2012,12(9)687-695

Melioidosis 165,000 89,000 54% Nature Microbiology

2016

Leptospirosis 1,000,000 59,000 6% PLoS NTD 2015

Severe Dengue 500,000 12,500 2.5% WHO website

Predicted mortality of melioidosis worldwide

Countries(selected)

Predicted Incidence

Predicted Mortality

Predicted Mortality Rate

India 52,506 31,245 60%

Indonesia 20,038 10,224 51%

Bangladesh 16,931 7,056 56%

Nigeria 13,481 8,324 62%

Vietnam 10,430 4,703 45%

Philiipines 9,116 4,510 50%

Thailand 7,572 2,838 38%

Myanmar 6,247 3,687 59%

Cambodia 2,038 1,149 56%

Lao PDR 420 260 62%

IS THIS ENOUGH ?WHAT’S MORE THAN CITATION

LESSON & LEARN: MEDIA

LESSON & LEARN: MEDIA

• BE PREPARED: It takes a lot of time and energy

• You are not alone (Thanks to David, Bart, Eric, etc.)

• You need a strong support team (Faculty, Institution, Public

Relationship team, etc.)

• Press-release, Embargo, … Rules to check

• Media skill training (Please ask around)

• Now, it’s in your THUMBDRIVE

• Please use it only for personal uses

• Don’t put it on YOUTUBE, ANY WEBSITE or ANY MEDIA

IS THIS ENOUGH ?

IS MELIOIDOSIS AN IMPORTANT DISEASE ?

[ ] YES [ ] NO

AT PRE- CONGRESS WORKSHOP:

IS MELIOIDOSIS AN IMPORTANT DISEASE ?

YES

NO

http://www.melioidosis.info

http://www.melioidosis.info

http://www.melioidosis.info

WHAT DO WE NEED TO CONVINCE POLICY MAKERS ?

What I said 3 years ago

• We need to do more for melioidosis prevention

• Policy change is important

• Keep pushing is important

• Networking is important

• Strategy that fits local need is important

“If you would like it to be changed, change it”

“You are wrong, I am right”

can never be right

Researchers, “> 700 died of melioidosis in NE Thailand in 2007”

“Melioidosis has caused six deaths this year”, Public Health Minister

IDENTIFY THE UNDERLYING PROBLEM ?

Examples of ThailandMain problem is the notifiable disease system

(Report 506)

http://www.boe.moph.go.th/boedb/surdata/506wk/y56/en/d72_5256_en.pdf

TRY TO SOLVE IT, TOGETHER AS A NETWORK

• Since 2012, Thailand Melioidosis Network kept pushing the

‘accurate’ data from research into MoPH system

• Since 2012, Thailand Melioidosis Network kept pushing the

‘accurate’ data from research into MoPH system

• Up to 2014, we still failed [Totally, 11 deaths reported]

Examples of ThailandMain problem is the notifiable disease system

(Report 506)

http://www.boe.moph.go.th/boedb/surdata/506wk/y57/en/d72_5257_en.pdf

KEEP PUSHING

• In 2015, we succeeded in pushing data of Ubon Ratchathani

into the system, and we are having a formal attachment to

annual report of MoPH 2015 (expect to release in Nov 2016;

Thanks to everyone in the Network, including CDC Thailand)

Examples of Thailand

In Thailand, 120 died of Dengue per year

40 died of Leptospirosis per year6 died of Melioidosis per year

Examples of Thailand [PAST – under reported]

http://www.khaosod.co.th/view_newsonline.php?newsid=1453033649

http://health.kapook.com/view133876.html

In Thailand, 120 died of Dengue per year

40 died of Leptospirosis per year107 died of Melioidosis per year

Examples of Thailand [PRESENT – 1st step]

In Thailand, 120 died of Dengue per year

40 died of Leptospirosis per year2,000 died of Melioidosis per year

Examples of Thailand [FUTURE – MUST BE RIGHT]

IDENTIFY THE UNDERLYING PROBLEM (AGAIN AND AGAIN) ?

Examples of ThailandMain problem is the notifiable disease system

(Report 506)

Hospitals don’t report melioidosis cases because

1) Melioidosis is never in the top priority list

2) Patients die before culture result came back

3) Final diagnosis is not written; “A24.1”

4) Staffs are too busy to report

5) Staffs don’t know that they have to report

6) Epidemiologists – Clinicians – Microbiologists in the hospitals do not talk to each other

MAKE USE OF AN OPPORTUNITY, &CONNECT THE DOTS

Examples of ThailandNew Communicable Disease Act 2015

http://www.ddc.moph.go.th/file/law/008.pdf

Examples of ThailandNew Communicable Disease Act 2015

We put melioidosis as an example in the campaign of MOPH to educate healthcare officers about ‘new communicable disease Act 2015’

1) Propose a model to put Epidemiologists –Clinicians – Microbiologists to attend the workshop and talk to each other

2) Inform them that it’s compulsory to report melioidosis, it’s A24.1, and it can improve hospital income with the right final diagnosis

LOCAL ADVOCATES ARE NEEDED

“Doctors should do ….”

“MoPH should do….”

“That’s not my duty ….”

“I don’t have the authority to ….”

THOSE ARE WRONG, EVERYONE IS NEEDED

ALSO, STRATEGY IS NEEDED

Conclusion

• We need to do more for melioidosis awareness (Dx, Tx, and

Prevention)

• Policy change is important

• Keep pushing is important

• Everyone is important !!!

• Networking is important !!!

• Strategy that fits local need is important

“Have you done enough ?”

Update of PRE-MEL study

A Single-blind Stepped Wedge Cluster Randomized Controlled BCT to Determine Effectiveness of Prevention

Programme of Melioidosis in Diabetics in Ubon Ratchathani,

NE Thailand, NCT02089152

Jan 15 Jan 16 Jan 17 Jan 18 Jan 19

Preliminary Result data of enrolled patient

9,068 diabetic patients were enrolled into the study

Up to 31st March 2016 (1 y 4 mo : without intervention)

- 856 patients admitted to hospitals at least once

- 67 died

5 died of melioidosis

5 culture-confirmed melioidosis

0 clinical-suspected melioidosis

- 26 had melioidosis (including 5 who died of melioidosis)

18 culture-confirmed melioidosis

8 clinical-suspected melioidosis

(comparable to the sample size calculation)

- 2 withdraw from the study

YOU MIGHT NOT WANT TO MISS PORNPAN’S ORAL PRESENTATION

Acknowledgement

David DanceLOWMRU

Vanaporn WuthiekanunMORU, Thailand

Dr Eric BertheratWHO, Geneva

Prof Sharon Peacock,Cambridge

Every network and YOU !!!

Pseudomallei CP999

• Super Strong• Can kill human • Kills >80,000

humans worldwide yearly

• Needs better awareness diagnosis, treatment and prevention worldwide