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Public Health Action Health Solutions for the Poor International Union Against Tuberculosis and Lung Disease Public Health Action Health solutions for the poor VOL 9 SUPPLEMENT 1 PUBLISHED 21 SEPTEMBER 2019 PNG SUPPLEMENT The emergency response to multidrug-resistant tuberculosis in Daru, Western Province, Papua New Guinea, 2014–2017 L. Morris,1 S. Hiasihri,2 G. Chan,2 A. Honjepari,1 O. Tugo,3 M. Taune,3 P. Aia,4 P. Dakulala,4 S. S. Majumdar2 http://dx.doi.org/10.5588/pha.18.0074 burden of TB, MDR-TB and TB-human immunodefi- AFFILIATIONS 1 Western Province Health Setting: A response to an outbreak of multidrug-resistant 1 ciency virus (HIV) co-infection. The first report of Department, Daru, tuberculosis (MDR-TB) on Daru Island, South Fly District MDR-TB in PNG was based on an audit of TB case no- Western Province, Papua (SFD), Western Province, Papua New Guinea (PNG) was New Guinea (PNG) tifications from clinics in the Australian Torres Strait 2 Burnet Institute, implemented by a national emergency response taskforce. Islands, bordering the South Fly District (SFD) of West- Melbourne, Victoria, Objective: To describe programmatic interventions for ern Province, which showed a dramatic increase in Australia TB in SFD and evaluate characteristics of TB case notifica- 3 Daru General Hospital, cases among PNG nationals between 1998 and 2002.3 Daru, Western Province, tions, drug resistance and treatment outcomes. Subsequent reports from the Torres Strait Islands clin- PNG Design: This was a retrospective cohort study based on 4 National Department of ics demonstrated alarming rates of MDR-TB, with evi- Health, Port Morseby, PNG routine programmatic data for all patients enrolled on TB dence of person-to-person spread or primary transmis- treatment at Daru General Hospital from 2014 to 2017. CORRESPONDENCE sion.4 In late 2011, Queensland Health (Brisbane, Lucy Morris Results: The response involved high-level political com- QLD, Australia) commenced the transfer of care of 92 Rural Health Services mitment, joint planning, resource mobilisation, commu- Western Province PNG nationals with MDR-TB to the provincial hospi- Division of Health nity engagement and strengthening TB case detection tal, Daru General Hospital (DGH) in SFD. This was in P O Box 1 and treatment. Of 1548 people enrolled on TB treat- Daru, Papua New Guinea conjunction with specific financial support from the e-mail: lucymorrisdaru@ ment, 1208 (78%) had drug-susceptible TB (DS-TB) and Australian Government to improve the management gmail.com 333 (21.5%) had MDR-TB. There was an increase in of TB in Western Province through the provision of KEY WORDS MDR-TB as a proportion of all TB. Treatment success rates clinical staff, a community engagement partner and MDR-TB; outbreak; Daru; Papua New Guinea increased over the study period from 55% to 86% for the establishment of key infrastructure and service DS-TB, and from 70% to 81% for MDR-TB from 2014 to agreements (communications centre, TB ward, drug 2015. The 2014 case notification rate for TB in SFD was supply, laboratory support and an outreach boat).5 1031/100 000, decreasing to 736/100 000 in 2017. Case notifications of MDR-TB in Daru were increasing Conclusion: The outbreak was stabilised through the re- each year: from 59 cases in 2012, 61 in 2013, to 84 in sponse from the national and provincial governments 2014.6 In 2013, SFD reported TB case notifications and international partners. Additional interventions are were almost twice as high as the national rate. The needed to decrease the TB burden in Daru. treatment success rates for drug-susceptible TB (DS-TB) and MDR-TB in 2013 were respectively 65% and 50%.7 Recognising the alarming rates of MDR-TB indicat- ultidrug-resistant tuberculosis (MDR-TB, defined ing an outbreak, the emergence of XDR-TB and the Mas TB resistant to at least isoniazid and rifampi- need for a concerted programmatic response, the PNG cin) is a continuing global public health crisis and a National Department of Health (NDoH) convened an major threat to achieving the World Health Organiza- Emergency Response Taskforce for MDR-TB in Western tion’s (WHO) target to end the TB epidemic by 2035. Province and other ‘hot spot’ provinces, such as the Globally, 458 000 new cases of MDR-TB were reported Gulf District and the National Capital District, in Au- in 2017, with evidence of increasing incidence each gust 2014.8 The response in SFD involved a year.1 MDR-TB emerges and spreads in populations multi-stakeholder partnership under the leadership of served by weak health systems, and transmission con- the provincial government and the NDoH. tinues due to gaps in detection, treatment and preven- The aim of the present study was to describe pro- tion. The burden of MDR-TB at the regional, country grammatic interventions for TB in SFD during the and sub-national levels is often unknown due to the emergency response, from January 2014 to December lack of adequate diagnostics and surveillance, which 2017, and to evaluate the burden, trends and charac- requires molecular testing or specialised laboratories. teristics of TB case notifications, drug resistance and As approximately 10% of MDR-TB globally is classified treatment outcomes during this period. as extensively drug-resistant TB (XDR-TB, i.e., TB resis- tant to the fluoroquinolones and second-line inject- METHODS able drugs) and 30% as either fluoroquinolone-resis- Received 20 September 2018 tant or injectable-resistant (pre-XDR-TB), further Study design and study population Accepted 5 March 2019 resistance would be a matter of concern.2 This is a retrospective cohort study of routine pro- Papua New Guinea (PNG) is one of only 14 coun- grammatic data from 1 January 2014 to 31 December PHA 2019; 9(S1): S4–S11 tries classified by the WHO as having the triple high 2017. The study participants were all registered for TB © 2019 The Union Public Health Action Daru MDR-TB emergency response S5 treatment at the Daru TB Basic Management Unit, gory, diagnostic test results, outcomes, culture moni- ACKNOWLEDGEMENTS This research was conducted which provides diagnosis and treatment for people toring and DST results. as part of the first from SFD. The current WHO definitions (2017 PNG guide- Operational Research Course lines) were used for DS-TB and MDR-TB enrolment and for Tuberculosis in Papua Setting New Guinea (PNG). The outcomes,15 with one modification: patients who had specific training programme Western Province is the largest but most sparsely pop- a permanent regimen change of at least two anti-tu- that resulted in this ulated province in PNG.9 The remoteness and limited publication was developed berculosis drugs due to adverse drug reactions were not roads make access to and delivery of health and essen- and implemented by the strictly classified as treatment failures if the patient Burnet Institute (Melbourne, tial services challenging. Health indicators, where VIC, Australia) in was responding to treatment with no evidence of clini- available, are some of the worst in PNG.10 The Fly collaboration with the PNG cal or microbiological failure. In a retrospective review, Institute of Medical Research River divides the province into three districts, North, (Goroka) and University of patients who met this criterion had a change of the in- Middle and South Fly. Daru Island (population 15 142) PNG (Port Moresby), and jectable to bedaquiline (which became part of the PNG supported by the PNG is the main residential and service town in SFD (popu- National Department of protocol in 2016) or a drug not considered to be core lation 59 152) and is notably crowded for an island of Health Emergency Response in the regimen (e.g., para-amino salicylic or pyrazin- Taskforce for MDR and approximately 15 km2 (average household size 7.5).11 amide). The denominator for case notification rates XDR-TB, the National TB DGH, the provincial referral hospital, is the only facil- Programme and Western was taken from the last available PNG national census Provincial Health Office, ity to provide TB diagnosis and treatment in SFD and (2011).10 For 2014, case-level data on DS-TB patients Daru, PNG. The model is is managed under the NDoH. It is a 100-bed provincial based on the Structured were not available, and aggregate numbers from rou- Operational Research and referral hospital providing inpatient and outpatient tine programme reports to the NTP were used instead. Training Initiative (SORT IT), services, including specialist care. It has a large TB de- a global partnership led by Numbers and proportions were calculated for cases the Special Programme for partment with a 40-bed inpatient unit and ambulatory registered and treatment outcomes. For geospatial Research and Training in TB services. The Daru TB Basic Management Unit has Tropical Diseases at the analysis of disease burden, residence was linked to lo- management, supervision and monitoring responsibil- World Health Organization cal-level government areas, and 2015 case notification (WHO/TDR). ity for SFD. The provincial government leads the TB The authors acknowledge rates for DS-TB and MDR-TB were used. The data were programme in Western Province with support from the support of the following imported into MapInfo Pro v.16 (Pitney Bowes; Stam- individuals and institutions the Australian Government through international that contributed to this ford, CT, USA) to generate maps. partners and the National TB Programme (NTP). research and/or programme from which the operational Ethics research was conducted: the Diagnostic methods and treatment model Ethics approval was provided by the PNG Medical Re- Fly River Provincial Two sputum samples were collected from presumptive Government (Daru, PNG), search Advisory Council, Port Moresby, PNG, and the TB patients where possible, and microscopy was per- the National Department of Alfred Hospital Ethics Committee, Melbourne, VIC, Health (Port Moresby, PNG), formed at the DGH laboratory using Ziehl–Nielsen the Australian High Australia.
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