When two public health emergencies collide

How vaccine advocacy, strong partnerships and capacity building can mitigate the impact of covid on tuberculosis care in Papua New Guinea.

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Papua New Guinea (PNG) is a geographically, ethnically and linguistically diverse country, with more than 800 languages spoken, and with 87% of the population living rurally and many facing poverty.¹

It is also in the top 10 countries with the highest burden of tuberculosis (TB) globally, with the additional challenge of multi-drug-/rifampicin-resistant TB (MDR/RR-TB).²

Covid has overtaken TB as the deadliest single infectious disease worldwide, with 1.8 million recorded deaths globally by the end of 2020,³ compared with 1.4 million estimated TB deaths in 2019.¹ With the arrival of covid in PNG, health services, already facing complex challenges from one deadly respiratory infection, were forced to adapt to another. Recently, an outbreak of the highly infectious Delta variant has been confirmed,^{4, 5} and authorities are battling to prevent suffering and death caused not only by covid, but from the resulting impact to essential health services, including TB care.

TB treatment, especially MDR-TB, is prolonged and burdensome, with 80% of MDR-TB patients and their households globally experiencing catastrophic costs because of their diagnosis². Despite the availability of new drugs and emerging evidence for shorter treatment regimens, global success rates for treating MDR-TB remain low at 57%². Deaths from TB are estimated at 4,000 a year in PNG, with an estimated TB incidence of 432 per 100,000 people, more than 60 times that of Australia’s.²

PNG declared a public health emergency in 2014 after identifying three hotspot regions responsible for nearly half of all MDR-TB notifications nationally: South Fly district of Western Province, Gulf Province and National Capital District.⁶

Daru Island of South Fly district is the outbreak epicentre and the capital of Western Province. In 2015, there were 594 MDR notifications per 100,000 people, and MDR-TB consistently accounts for approximately 20% of all TB cases.⁶ Molecular epidemiology supports primary transmission of a common outbreak strain over secondary acquisition of resistance through failed treatment.⁷

In recent years, PNG has made important gains in TB care, including introducing Xpert® MTB/RIF (a rapid molecular test) in 2012 for TB and RR-TB⁸ diagnosis, reducing reliance on smear microscopy. The introduction of community-based, patient-centred models of care in Daru and Port Moresby have improved treatment outcomes,⁶ there has been a scale-up of preventive therapy for latent TB infection,⁸ and gaps in case detection have improved.²

However, the covid pandemic threatens this progress.

The WHO estimates that there were 500,000 additional TB deaths globally and 1.4 million fewer people receiving TB care in 2020 than in 2019.⁹ This represents a 21% global drop in patients on treatment, disproportionately affecting high-TB burden countries, including PNG’s neighbours Indonesia (42%) and the Philippines (37%).⁹

The true extent of this impact is unknown in PNG, but there have been reports of increased rates of patients lost to follow up, decreased TB enrolments and interruptions in TB laboratory diagnostic services because of staff becoming unwell or redeployed to support the COVID-19 response. Ongoing research into the impact of covid on PNG essential services is being led by the PNG Institute for Medical Research.¹⁰

Initially, the impact of covid in PNG appeared relatively limited, with less than 1000 reported cases by the end of 2020,¹¹ but testing is underutilised, and the true numbers probably well exceed those reported.

In 2021, cases surged and peaked in April. Some health services were scaled back, and a covid field hospital was established in Port Moresby. PNG is currently experiencing another surge with a four-fold increase in reported cases nationally and increased weekly test positivity,¹² and with several cases of the Delta variant genetically linked to Indonesian strains.⁴

Responding to concurrent public health emergencies in a resource-limited setting requires resilience and creative solutions.

Adjustments have been made to TB care in PNG, including limiting clinic numbers, longer-term medication supply for patients on directly observed therapy (DOTS) and discharging non-critical TB patients from hospital.

Staff became advocates for “Niupela Pasin” (new normal) guidelines, which include the implementation of strict mask use, hand washing and physical distancing. Healthcare workers were upskilled through the rollout of the DFAT-supported covid Healthcare E-learning program (CoHELP initiative) across PNG.¹³ Existing expertise in TB community engagement were redirected to develop and implement educational resources modelled on TB education tools, initially for covid community awareness and then later for vaccination.

Measures central to the covid response in Australia, such as lockdowns, contact tracing and quarantine, have proved challenging to implement in PNG, highlighting the importance of vaccination.

Unfortunately, vaccine hesitancy has been widespread¹⁴. Misinformation and concerns about vaccine development and fear of side effects are common,¹⁴ but complacency and vaccine apathy are also significant contributors.¹⁵ Some people don’t believe covid is a significant threat to PNG, viewing it as a mild infection, or a “white man’s disease”,¹⁶ and question the value of a vaccine that doesn’t offer complete protection. A key challenge has been communicating the value of vaccination to prevent severe covid disease and hospitalisation, and therefore protect essential health services.

Western Province and National Capital District currently led the country in covid vaccinations; 25% and 50% respectively of 2021 first-dose targets were reached by the 20 September, whereas the national average was 6.7%.¹² Successes were built on strong partnerships between local health authorities, the World Health Organisation and partner organisations. Q&A sessions with healthcare workers and community advocates prioritised empathic, respectful discussion to prevent feelings of coercion. Community and church leaders were vaccinated early as “covid vaccine champions”, improving uptake, and volunteers were trained to lead education sessions.

Unfortunately, early successes have been followed by a plateau in vaccinations, and misinformation¹⁷ and negativity bias are an ongoing battle. There have been reports of refused second doses following further dissemination of vaccine misinformation through social media. Vaccination teams describe threats to their safety¹⁸ and there are reports of reduced presentations to essential health services because of vaccination fears.

Considering these challenges, every covid vaccine administered is a success.

Both the benefits and limits of the vaccine roll-out are becoming increasingly evident as the Delta variant spreads. Sadly, deaths are increasing, including those of essential workers,¹⁹ and the full impact of the current surge, and the Delta variant on essential health services and TB care, remains to be seen.

Dr Anne Hoey is an Infectious Diseases Physician working with Burnet Institute in Daru, Papua New Guinea as a TB Specialist in Public Health. In addition to supporting the TB program she has provided technical support to the Western Provincial Health Authority in COVID-19 vaccine awareness.

Dr Stefanie Vaccher is an epidemiologist working with Burnet Institute in Papua New Guinea. She has been actively involved in the COVID-19 response in PNG over the past year.

Stacia Finch is a researcher at Burnet Institute in Daru, Papua New Guinea. As the Project Analyst-Health Information and Quality Improvement, she supports the Western Province TB program with monitoring and evaluation, particularly around health information and data systems.

Dr Khai Lin Huang is an infectious diseases physician at Burnet Institute and Northern Health. He is acting co-head of the Tuberculosis Elimination and Implementation Science Working Group at Burnet.

References

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