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Preventing Tuberculosis in the Torres Strait

7 Apr 2023

Papua New Guinea experiences some of the world’s highest rates of multi-drug resistant tuberculosis. The Torres Strait Protected Zone permits traditional inhabitants to travel without passport between certain islands and PNG and is now restored following the lifting of COVID-19 restrictions in October 2022. Four local cases were reported last year. In this Q&A, Nursing Director of the Torres and Cape Hospital and Health Service (TCHHS) TB Control Unit (TBCU), J’Belle Foster, walks us through how she and her team are limiting the spread.

TB nurs­es Adana Maza and J’Belle Fos­ter wait­ing out a storm front on an unin­hab­it­ed island while on route to work.

Thanks for join­ing us, J’Belle. For many of our main­land read­ers, the man­age­ment of tuber­cu­lo­sis is not a dai­ly con­cern. For the TCHHS TBCU, it’s your every day. Tell us, where must an effort to con­tain TB begin?

We imple­ment quite a high index of sus­pi­cion when it comes to patients pre­sent­ing with signs and symp­toms of TB.

On the Aus­tralian main­land, it might be unusu­al for clin­i­cians to think TB’ if some­one presents with a cough that has last­ed more than two weeks but for us, that means that min­i­mum cri­te­ria has been met for TB work-up.

This method enables us to keep on top of TB reac­ti­va­tion in pre­vi­ous­ly exposed indi­vid­u­als in our com­mu­ni­ties, and also to iden­ti­fy new cases.

Although the active TB case num­bers of TB are low, we have a large port­fo­lio of cas­es with latent TB that we man­age in the region.

These are the peo­ple who have been exposed to TB in the past, and these are the seedbeds for future cas­es, so we need to make sure we have effec­tive care path­ways in place to pre­vent reactivation.

Local con­trol of TB man­age­ment was first imple­ment­ed around six or sev­en years ago. Since then, has the Unit gained a deep­er under­stand­ing of effec­tive TB management?

When I first estab­lished the TCHHS TBCU in 2016… I asked myself, how am I going to write poli­cies and pro­ce­dures that sup­port evi­dence-based prac­tice in this new TB Unit with­out the evi­dence? Best I go find that evi­dence, and hence, the research project for my PhD the­sis was born.

Every sin­gle study in my PhD the­sis – which is titled Epi­demi­o­log­i­cal pro­file of tuber­cu­lo­sis patients from the Tor­res Strait Islands, includ­ing vis­i­tors from Papua New Guinea to the Tor­res Strait Pro­tect­ed Zone – was care­ful­ly and pur­pose­ful­ly select­ed to make the biggest impact from an oper­a­tional and pro­gram­mat­ic perspective. 

The whole pur­pose was to gath­er evi­dence from our spe­cif­ic region which would give us the best chance of improv­ing the lives of our patients. And improve lives we did!

I tru­ly believe that many areas of remote nurs­ing could ben­e­fit from trans­la­tion­al research, and I am very inter­est­ed in help­ing oth­er nurs­es to under­take research that ben­e­fits their pro­grams and improves patient outcomes.

A sign for PNG nation­als arriv­ing on Boigu Island.

Pow­ered by this research, what ini­tia­tives have you been able to put into place to treat and pre­vent TB?

My team and I imple­ment­ed over 50 ini­tia­tives – I’ll talk about a few of them. 

We work close­ly with the Daru TB Pro­gramme in Papua New Guinea. We have estab­lished ear­ly com­mu­ni­ca­tion; joint­ly devel­oped cross-bor­der poli­cies and pro­ce­dures; estab­lished an agree­ment that we will not dis­charge any patients back to the PNG health sys­tem until we have been giv­en assur­ances that they have suf­fi­cient anti-TB med­ica­tions avail­able for patients; and work togeth­er to avoid over-report­ing of TB cases.

Our con­tact trac­ing of lab­o­ra­to­ry-con­firmed TB cas­es is shared with Daru TB Pro­gramme – as well as the acid-fast bacil­li, cul­ture, Xpert, and/​or chest X‑ray results of any PNG national.

We have trans­lat­ed TB screen­ing mate­ri­als into Tok Pisin (a pho­net­ic lan­guage used by bor­der­lands com­mu­ni­ties in PNG). We part­ner with the Islanders Board of Indus­try Ser­vice (IBIS) each year for World TB Day activ­i­ties and food incen­tive vouch­ers for patients to pro­mote cure and nutri­tion, and have part­nered with Tagai School on Saibai Island to pro­vide fun, inter­ac­tive TB edu­ca­tion to year five stu­dents. I have also pre­vi­ous­ly part­nered with the local rep from the Depart­ment of For­eign Affairs and Trade and the Tor­res Strait Island Region­al Coun­cil to deliv­er mass com­mu­ni­ty TB edu­ca­tion in remote communities.

Edu­ca­tion for clin­i­cians work­ing in the Tor­res Strait is now pro­vid­ed based on the risk pro­file of spe­cif­ic islands or island groups.

We offer TB-relat­ed onboard­ing pack­ages to all staff and train PHC clin­i­cians in the prin­ci­ples of Direct­ly Observed Ther­a­py (DOT) for TB patients and have imple­ment­ed video-DOT. We have arranged extra train­ing in han­dling and ship­ping of bio­log­i­cal spec­i­mens and/​or dan­ger­ous goods to clin­i­cians work­ing on remote islands.

One of my stud­ies showed that we achieve a high yield of TB diag­noses using two instead of three spu­tum spec­i­mens, so now we are approved to dis­charge patients after there are two neg­a­tive spu­tum smears.

We iden­ti­fy Cham­pi­on RNs’ at TI Hos­pi­tal who we trained as train­ers in dif­fer­ent spu­tum col­lec­tion tech­niques (such as nasopha­ryn­geal aspi­rates, naso­gas­tric aspi­rates and spu­tum induc­tion), and have devel­oped a new spu­tum induc­tion procedure.

We have also designed two sep­a­rate TB screen­ing forms for use in the region – one for PNG nation­als and one for res­i­dents of the Tor­res and Cape. This is because the risk pro­files are dif­fer­ent. For exam­ple, the PNG nation­al TB screen­ing forms include ques­tions about expo­sure to wood­fire smoke (used for cook­ing) and expo­sure to betel nut users (which ampli­fies the risk of trans­mis­sion of TB to others).

The BCG vac­cine is now avail­able to PNG nation­als born in Thurs­day Island Hos­pi­tal. We also man­age Australia’s largest BCG vac­ci­na­tion pro­gram, in which the vast major­i­ty of our pop­u­la­tion under five years of age are eli­gi­ble for the vaccine.

Aus­tralia (Saibai) PNG border.

What a well-round­ed strat­e­gy – thank you so much for shar­ing. Can you give us an exam­ple of how it has made an impact? 

I found a sig­nif­i­cant reduc­tion in the time to treat­ment since the TCHHS TBCU com­menced oper­a­tions in the region. The medi­an time to treat over the past 20 years was 124 days, and the TBCU had reduced this to 39 days in just four years! 

This was such an excit­ing find­ing… [Because] the cor­ner­stone of an effec­tive TB pro­gram is to find and treat patients as quick­ly as possible.

Saibai Island mar­kets – where PNG nation­als come to sell their handicrafts.

Speak­ing more glob­al­ly now, has COVID-19 helped or hin­dered TB management?

Dur­ing COVID, the TB cri­sis was large­ly for­got­ten in so many places around the world. There was the dis­rup­tion to health ser­vices, diver­sion of resources towards the COVID-19 response, the decline in TB case detec­tions, and the inter­rupt­ed treat­ment of TB patients.

COVID sur­passed TB as the world’s dead­liest dis­ease in Octo­ber 2020 but TB sur­passed COVID in Octo­ber 2022 in terms of the num­bers of deaths.

Now the glob­al TB prob­lem is far greater than it was pre-COVID… COVID-19 gave TB the foothold it need­ed to grow and thrive.

Unless we find and treat our Latent cas­es, we should expect to see reac­ti­va­tion of TB dis­ease long into the future as a result of ham­pered TB con­trol efforts dur­ing the pandemic.

What we need now is a robust and well-coor­di­nat­ed response to the threat.

TB Out­reach.

We are sure you will be a key play­er in that response, J’Belle, and that it will involve mea­sures iden­ti­fied in your trans­la­tion­al research – such as the imple­men­ta­tion of rapid diag­nos­tic tech­nol­o­gy (Xpert) to reduce treat­ment times and the train­ing of clin­i­cians in fine nee­dle aspi­ra­tion of enlarged lymph nodes to assist with detec­tion of extra­pul­monary TB. Chang­ing tack before we fin­ish up, can you paint a pic­ture for our main­land read­ers of what it is like to work in the Tor­res Strait?

Most of the islands have run­ways but some don’t so the only way in and out is via helicopter. 

Thurs­day Island, where the hos­pi­tal is locat­ed does not have a run­way so it’s a short fer­ry ride over to Horn Island where the air­port is. Trav­el­ling out to the islands is a real treat – every sin­gle time.

You can see tur­tles and dugongs and a croc laz­ing in the sun if you’re lucky. And the colour of the water and the reef – it’s like a dreamscape.

Some of the islands are low lying mud­flats and oth­ers have great tow­er­ing hills with frangi­pa­nis, and coconut, banana and man­go trees. And after work­ing in the Tor­res Strait for the past nine years, walk­ing into some of the Pri­ma­ry Health Cen­tres on these islands now feels like com­ing home.

At the CRANAplus 40th Con­fer­ence this Octo­ber, J’Belle Fos­ter will be dis­cussing the ini­tia­tives she and her team have imple­ment­ed to lim­it the spread of tuber­cu­lo­sis. Head to crana​con​fer​ence​.com to find out more and register.