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This is where we tell your stories, cover topical issues and promote meaningful initiatives.
Preventing Tuberculosis in the Torres Strait
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.
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.
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.
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.
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.
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 cranaconference.com to find out more and register.