Three years ago, tuberculosis (TB) became the joint lead as the world’s deadliest infectious disease - neck and neck with HIV/AIDS.
In Papua New Guinea (PNG), the epidemic is such that the government has declared a state of emergency in several provinces. With an estimated 30,000 new cases in 2016, expanding and improving TB care in PNG is an uphill battle.
Médecins Sans Frontières (MSF) is providing TB diagnosis and treatment in two of these provinces: Gulf Province and National Capital District, in conjunction with the Ministry of Health.
In Gulf Province MSF’s teams are based in Kerema – a town seven hours’ drive from the capital, Port Moresby, and literally at the end of the road. Further west, there are no roads and extremely limited access to healthcare and other services.
Patients travel for hours or even days to reach our clinics, using a combination of dinghies, cars and walking. Transport can be prohibitively expensive – around 100 kina (40 US dollars) for a few hours in a dinghy.
It’s not only the extreme geography that is challenging. In the remote villages around Kerema, access to education is limited. The low health literacy of some patients means they were never explained essential facts about TB, including the fact it is infectious, or that it passes through the air. Many people across the country still believe TB is an effect of witchcraft.
These geographical and cultural barriers contribute to one of MSF’s biggest challenges – ensuring that patients adhere to TB treatment. TB is not a simple chest infection. It’s an insidious infection with very hard-to-kill bacteria. Successfully treating TB takes at least six months, using a combination of various antibiotics.
Some patients develop drug-resistant TB: when the bacteria mutates to resist the drugs because they are not taken in the necessary amounts, intervals or combinations. For these patients treatment takes up to two years, including daily injections in the early stages. Patients often encounter serious side effects such as nausea, nerve damage and deafness.
Sticking to TB treatment is critical not only to cure individual patients, but also to reduce the risk of drug resistance developing in the community. Patients who develop drug resistance can infect others with these strong and deadlier strains. If this happens on a larger scale, the epidemic will claim more lives and become even harder to manage.
While patients defaulting on their treatment is a huge problem for our teams, we’re working hard to increase treatment adherence. All patients are provided with counselling and education to improve their understanding of the disease and to follow up their treatment. By embedding an anthropologist in our medical operations, we also try to increase our understanding of the local context and improve treatment adherence.
We have decentralised our care to bring treatment closer to patients. In Gulf Province teams travel for hours, often by boat and road, to visit health posts in small villages for regular consultations. We also provide transport to help patients reach care, as well as run a network of community health workers and treatment supporters who visit patients at home.
In Port Moresby, the outreach team provides home visits for patients with difficulties accessing their clinic or adhering to treatment, in an effort to reduce the still-high rate of patients ‘lost to follow up’.
Enhancing TB management
In many low-income settings, TB continues to be diagnosed as it was a century ago: sputum samples are examined under a microscope for signs of the tuberculosis bacillus. The most reliable test of this type takes two months. In many countries, this is complicated further by the lack of laboratories equipped for TB diagnosis, meaning samples need to be sent to a capital city, or even overseas. For these reasons the disease often goes undiagnosed, or far later than it should. In much of PNG, this remains the case.
In recent years TB diagnoses were revolutionised by a device called the GeneXpert, which can test for the presence of bacteria in less than two hours. (It can also test for resistance to the TB drug rifampicin - meaning it can help diagnose drug-resistant TB.)
MSF uses GeneXpert in both Gulf Province and Port Moresby. This means patients can be diagnosed and begin treatment far quicker. In 2017, our teams started 2,100 people on TB treatment in both projects.