Setting: A response to an outbreak of multidrug-resistant tuberculosis (MDR-TB) on Daru Island, South Fly District (SFD), Western Province, Papua New Guinea (PNG) was implemented by a national emergency response taskforce. Objective: To describe programmatic interventions for TB in SFD and evaluate characteristics of TB case notifications, drug resistance and treatment outcomes. Design: This was a retrospective cohort study based on routine programmatic data for all patients enrolled on TB treatment at Daru General Hospital from 2014 to 2017. Results: The response involved high-level political commitment, joint planning, resource mobilisation, community engagement and strengthening TB case detection and treatment. Of 1548 people enrolled on TB treatment, 1208 (78%) had drug-susceptible TB (DS-TB) and 333 (21.5%) had MDR-TB. There was an increase in MDR-TB as a proportion of all TB. Treatment success rates increased over the study period from 55% to 86% for DS-TB, and from 70% to 81% for MDR-TB from 2014 to 2015. The 2014 case notification rate for TB in SFD was 1031/100 000, decreasing to 736/100 000 in 2017. Conclusion:The outbreak was stabilised through the response from the national and provincial governments and international partners. Additional interventions are needed to decrease the TB burden in Daru.
Setting: Bedaquiline (BDQ) was introduced in the multidrug-resistant tuberculosis (MDR-TB) programme in Daru in remote Papua New Guinea in 2015, along with a core package of active drug-safety monitoring (aDSM). Objective: To assess interim results and safety of BDQ for the treatment of MDR-TB from 1 July 2015 to 31 December 2017. Design: A retrospective cohort analysis of routine programme data. Results: Of 277 MDR-TB patients, 77 (39%) received BDQ with a total of 8 serious adverse events including 5 (6.5%) deaths, of which 1 (1.3% QTcF prolongation, grade 3) was attributable to BDQ. Of 200 (61%) patients who did not receive BDQ, there were 17 (9%) deaths. Completeness of monitoring for the BDQ group was 90% for 5 electrocardiograms and 79% for 2 cultures. In the interim result indicator analysis at month 6 in the BDQ and non-BDQ groups, there were respectively 0% and 1% lost to follow-up; 6.5% and 8.5% who died; 94% and 91% in care; and 92% and 96% with negative culture among those monitored. Conclusion:Early experience in Daru shows BDQ is safe and feasible to implement with aDSM with good interim effectiveness supporting the rapid adoption and scale-up of the 2019 WHO MDR-TB treatment guidelines in the programme and in similar remote settings. * Among eligible patients who had 2 valid culture tests sent 30 days apart (see Figure 2 for full definitions). MDR-TB = multidrug-resistant tuberculosis; BDQ = bedaquiline.
The emergence and spread of multidrug-resistant tuberculosis (MDR-TB) poses a major threat to the global targets for TB control. In recent years, an evolving science and evidence base for MDR-TB has led to much needed changes in international guidelines promoting the use of newer TB drugs and regimens for MDR-TB, however, there remains a significant implementation gap. Due to the complexity of treating MDR-TB, management of cases is often supported by an expert multidisciplinary team, or clinical expert group. This service is often centralized, and may be delivered through a telemedicine platform. We have implemented a Web-based “store-and-forward” telemedicine service to optimize MDR-TB patient care in Daru, a remote and resource limited setting in Papua New Guinea (PNG). From April 2016 to February 2019, 237 cases were discussed using the service. This encompassed diagnostic (presumptive) and treatment cases, and more recently, support to the scale up of preventative therapy for latent TB infection. There were 75 cases in which the use of Bedaquiline was discussed or mentioned, with a high frequency of discussions occurring in the initial period (26 cases in the first 12 months), which has appeared to decrease as clinicians gained familiarity with use of the drug (15 cases in the last 12 months). This service has supported high quality clinical care and fostered collaboration between clinicians and technical experts in a shared learning environment.
Tools related to PEC used in the pilot can be found on the Burnet Institute website at https://www.burnet.edu. au/projects/283_rid_tb_ patient_education_and_ counselling.
T imely screening, diagnosis and treatment initiation are critical components for effective tuberculosis (TB) services. Studies from different countries have found an association between delayed treatment initiation and unfavourable treatment outcomes for drug-susceptible TB (DS-TB). [1][2][3][4] There is less evidence on the impact of delayed treatment initiation for drug resistant TB (DR-TB), although this may be due to methodological limitations in existing studies and programmatic factors that obscure any such effect. 5,6 Early diagnosis and prompt, effective TB treatment is important for infection control and for preventing transmission. [7][8][9][10][11][12] Infectiousness rapidly decreases once patients initiate effective treatment. 9,10 This is particularly important for preventing the transmission of DR-TB, which is more complex and costly to treat, and has lower treatment success rates globally compared to DS-TB. 13 Early, effective TB treatment is an important strategy for managing the infection risks that can result from the exposure of susceptible individuals to active TB disease in health facilities. 14 The staff of health facilities have been shown to be at increased risk of tuberculous infection and active TB disease relative to the general population. [15][16][17][18] On Daru Island, Western Province, Papua New Guinea (PNG), there is a high burden of TB, with a case notification rate of over 1% in the population. 19 Person-to-person transmission of DR-TB is apparent, with 69% of cases infected by primary transmission in 2017. An emergency response was commenced in Daru in 2015. Key components of the response included early access to rapid diagnostics and effective treatment. The Daru General Hospital also implemented the FAST strategy (Finding TB cases Actively, Separating safely, and Treating effectively), which emphasises rapid diagnosis and effective treatment. 11 Despite this, hospital staff have reported a number of challenges to early diagnosis and delays in treatment initiation.The time taken from patient presentation to treatment initiation has not been quantified following the commencement of the Emergency Response Taskforce for MDR and XDR-TB, and little is known about the factors that might influence the timeliness of diagnosis and treatment.This study aims to assess the timeliness of treatment initiation for TB patients presenting at Daru General Hospital and to identify patient characteristics associated with delayed treatment initiation. METHODS DesignThis was a retrospective cohort study reviewing routine programme data. The study included all TB patients started on treatment for DS-TB and DR-TB at Daru General Hospital from 1 January to 30 September 2017.
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