Most Australians hear only periodic news items about outbreaks of tuberculosis, but globally the disease remains a top killer. And the emergence of drug-resistant strains pose a major challenge to tuberculosis control programs.
One recent news story documented the life of a young woman from Daru Island who has become a medical refugee in Cairns after contracting a highly drug-resistant form of tuberculosis, known as XDR-TB (extensively drug resistant TB).
Such personal stories (of which there are many) emphasise the human tragedy interwoven with health challenges at multiple levels. They also capture anxiety about the possibility that multi-drug resistant (MDR) forms of tuberculosis may spread and pose a risk to the Australian population.
A Treaty Protection Zone allows Papua New Guinea inhabitants and Australian nationals to mix freely on the outer Torres Strait islands. And due to the difficulty of health-care access as well as a poorly functional tuberculosis control program, Papua New Guinea nationals in the adjacent South Fly district frequently used Torres Strait Island services to access Australian care.
During 2012, the Queensland government shut down health clinics on Boigu and Saibai islands and returned 92 PNG nationals from Cairns to Daru Island for completion of their tuberculosis treatment. Amid concern that these patients were unlikely to receive adequate treatment support, the Federal Government committed $8.5 million via AusAid to improve services at the regional hospital on Daru Island and to support tuberculosis services throughout the Western Province (including the South Fly district) between 2011 and 2015.
The impact of the initial “Stop TB in the Western Province” program is yet to be scrutinised.
A local focus
Ensuring access to high-quality services within Papua New Guinea is the preferred and most effective intervention to assist local communities. It will also reduce their need to seek health care in Australia.
Ironically, the visible epidemic is likely to get worse before getting better, since better functioning diagnostic systems will identify MDR- and extremely drug-resistant (XDR)-TB cases that previously went undetected. This may seem alarming, but it allows for better assessment of the problem and should facilitate improved patient care and better protective strategies.
In reality, health-care services are poorly functional throughout Papua New Guinea and careful consideration should be given to the most cost-effective and sustainable strategies. The situation requires a strong and coordinated cross-border approach that includes all parts of the Australian government to work with central and provincial administrations in Papua New Guinea.
Unfortunately, this important issue has become a political ball being kicked around between the federal and state governments and between political parties.
Australia and tuberculosis
Thankfully, the intended closure of Queensland’s Tuberculosis Control Centre, which would have been a disaster at this crucial time, has been narrowly averted. This should enable the continuation of vital surveillance and control functions within Queensland and the provision of guidance and support to Papua New Guinea colleagues on Daru Island and in the South Fly district.
In general, excellent socioeconomic conditions and effective infection control measures within Australia reduce the risk of local tuberculosis outbreaks. But poor and marginalised populations are at risk, as are immune-compromised people and the rapidly growing portion of the population that is of an advanced age.
Immune senescence associated with old age is a well-characterised risk factor and several tuberculosis outbreaks have taken place in aged-care facilities. The introduction of highly drug-resistant tuberculosis into any of these vulnerable communities would pose a major challenge, since treatment requires two years of multiple drugs that have numerous side effects.
Finding the way forward
Recent evidence suggests that MDR-TB, contrary to previous belief, is often highly transmissible and protection against infections that spread via the air (such as measles and tuberculosis) is notoriously difficult.
Given the health challenges posed at multiple levels and the complexity of the issues involved, careful and objective assessment should guide the assignment of clear roles and responsibilities to the Papua New Guinea and Australian governments involved, as well as to international health agencies.
AusAID has published an expert report on the tuberculosis control situation in the Western Province, and the World Health Organization (WHO) is conducting an independent review of the same.
Insight from these fact-finding missions is vital for understanding the complexities of the situation and ensuring bipartisan support for workable solutions.