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.