Strongyloides stercoralis, a worm that can enter the body as a larvae and lives in the small intestine, was first documented in French soldiers returning from excursions into Indochina in the 19th century. However, it wasn’t until World War Two veterans started turning up with repeat cases of strongyloidiasis, the disease caused by the worm, 40 years later, that medical scientists recognised the full extent of the danger posed by the disease.
It had previously been assumed that the worm had died off after being treated, but in fact Strongyloides thrives inside the human body and can live undetected for decades due to its unique autoinfective lifecycle. When the host’s immunity drops, or when given corticosteroids, the autoinfective larvae can increase exponentially, penetrating the intestine wall and migrating to other organs. The underlying cause of septicaemia, meningitis or multiple-end organ failure can go unrecognised.
Often described as one of the world’s most neglected tropical diseases, strongyloidiasis has recently been estimated to infect 8.1 per cent of the world’s population – an astonishing 614 million people, most of whom live in the poorer countries of the world.
While previously considered rare in Australia, the 2021 NT Australian of the Year Dr Wendy Page and colleagues at Miwatj Aboriginal Health Corporation have found the disease affected up to 60% in some Aboriginal communities in East Arnhem Land and have spent decades developing programs to fight it.
Wendy has taught Flinders University students on rotation at Nhulunbuy, raising awareness of the disease and its relatively simple treatment with each student she meets. For her work in diagnosing, treating and raising awareness tirelessly about the disease, Wendy has received a slew of honours and recognition for her work and is recognised as a world expert on strongyloidiasis.
Each time the spotlight beckons, Wendy shows not a glimmer of interest in any personal accolades, but deftly diverts the spotlight firmly back onto the worm, in her indefatigable quest to have strongyloidiasis declared a notifiable disease in Australia. If the disease is declared notifiable like COVID, hepatitis A and a range of other well-known health threats, then resources will be devoted to tracking, tracing and treating the disease when it is found.
“I think awards like the Australian of the Year give people the chance to take a cause further,” Wendy says.
“I am just one of so many GPs who are passionate about their work and love what they do. We don’t have time to go on social media and we are relatively private people who just want to get on with the work we are doing.
“There is a tremendous network of dedicated, highly skilled medical staff across the NT and we have made sure that tropical diseases are well documented – with staff volunteering to pool their knowledge and expertise voluntarily for the Tropical Health Orientation Manual, which is now used to provide information for doctors coming into northern Australia about diseases they are likely to find here.
“The Manual has been developed over 20 years, and started with the realisation that we needed to describe the conditions most common in the NT, because they were very different to the conditions that doctors coming in from city areas would have seen before.
“It has made sure that people know about how to identify, investigate, diagnose and treat diseases like strongyloidiasis, which are found not only in a range of northern Australian communities, but also in migrants from many other countries.”
Summing up years of concern about lack of awareness about strongyloidiasis, Wendy co-wrote a landmark article for GP’s entitled ‘Chronic strongyloidiasis - don’t look, and you won’t find’, outlining their important role in early diagnosis, treatment and prevention of life-threatening complications.
The worm can remain undetected in the small intestine for decades, but when a patient has cancer treatment or other interventions that affect the body, its response is to multiply and spread rapidly through the body.
Wendy moved to Nhulunbuy with her husband in 1993, undertaking to stay five years – and has stayed for decades. One of the reasons was the satisfaction of working with Miwatj.
“When you look at most hospital environments, you see hierarchies as a triangle, with doctors at the apex, determining how things are managed and making the decision, but Aboriginal Community Controlled Health Organisations reverse that triangle, so the doctor is required to listen to patients and respect the community’s priorities,” Wendy says.
“We have lots of interaction with individuals and find out their relationship to their family, so often you might see three or four generations of a family in one day, which is really important if you want to treat something like Strongyloides, as you have to trace contacts – just as we do now with COVID.”
After seeing the impact of the worm on many communities in East Arnhem Land, Wendy was galvanised to become an outspoken advocate for Strongyloides recognition and treatment when a much loved colleague died.
“In 1999 our colleague, an Aboriginal Health Worker from Miwatj, a beautiful person and queen of her people needed to go to Adelaide for treatment and she passed away while she was there, from disseminated strongyloidiasis,” Wendy says.
“It had a huge impact on so many people in the community and she was so missed, we decided that many others could die in similar circumstances, but we had the drugs to treat the disease, once it was diagnosed – this was an issue we could do something about.
“In 2000 we introduced Ivermectin, a relatively new drug which has a wonderful effect in controlling the Strongyloides stercoralis, and we found we were able to reduce the rate of infection from 60% to under 10% in some communities.
“Strongyloidiasis is one of the most neglected tropical diseases – affecting so many, and treatable, but traced and eliminated far too infrequently.
“It is high time it is recognised as a notifiable disease because it can affect not just people in the far north of Australia, but anyone who has been on holiday to a sub-tropical location, as well as many people who migrate to Australia.”
Wendy and colleagues have now formed a group Strongyloides Australia to campaign for the disease to be recognised as notifiable.
In the meantime, she will continue to treat patients and welcome new Flinders students to Miwatj.
“It’s great to see the students come through and I am sure to tell them about Strongyloides stercoralis,” Wendy says.
“We need to be passing the baton on, with more people having the word (and not the worm) on the tip of their tongue. It’s remarkably persistent, so we need to be as well!”
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