Suman S. Majumdar

Background: Multidrug-resistant or rifampicin-resistant tuberculosis (MDR/RR-TB) is common in Papua New Guinea (PNG) with poor treatment outcomes reported. Characteristics and treatment outcomes in children with MDR/RR-TB have not been reported. Methods: A retrospective cohort study included children (<15years) who initiated treatment for MDR/RR-TB from 2014 through 2022 at either Port Moresby General Hospital in the National Capital District or Daru Provincial Hospital located in the remote South Fly District of Western Province. The treatment regimens were consistent with the national guidelines. Characteristics associated with mortality were determined by univariate and multivariate analysis. Findings: A total of 368 children were treated for MDR/RR-TB. Median age was 7.8 years (IQR 3.2– 11.3), 37.5% were <5 years; at least 41.3% were underweight and 5.4% HIV-positive. Common sites included pulmonary (50.3%), peripheral lymph node (38.0%) and meningitis (9.8%). Among 66.8% who were microbiologically confirmed, all were positive for rifampicin resistance except one indeterminate result. Treatment regimen included an injectable in 32.6% or bedaquiline in 31.0%. Overall, 82.9% of children achieved treatment success and 9.8% died. Higher mortality was associated with TB meningitis (OR 5.9, 95% CI: 1.8–19.2), living with HIV (OR 4.4, 95% CI: 1.2–15.6) and being diagnosed clinically (OR 2.7, 95% CI 0.99–7.1). Among young children (<5 years), females had a higher risk of death (OR 4.8, 95% CI: 1.1–20.4) than males. Interpretation: High rates of treatment success can be achieved in children with MDR/RR-TB in PNG. Higher mortality in young females is a finding that requires further exploration.

Combined education and counselling can contribute to person-centred care for tuberculosis (TB), improving uptake, adherence, and outcomes of treatment for TB disease and TB infection. Though strongly recommended by the World Health Organization for all people diagnosed with TB, education and counselling is not widely implemented in TB programs around the world. In 2016, a pilot TB education and counselling program, delivered by trained professionals and peers, was initiated to support people on TB treatment in the South Fly District of Papua New Guinea. This article reports on select findings from a qualitative study that examined the socio-cultural dimensions of TB, including treatment support such as education and counselling, in the South Fly District. An assessment on data collected during 128 semi-structured in-depth interviews of the role of counsellors on TB treatment journeys revealed strong participant support for the counsellors and the services they delivered, with particular emphasis on the emotional support provided to address fears and concerns related to TB diagnosis and treatment, and to support treatment adherence; valuable attributes of counsellors; their role as intermediaries between patients and health workers; their provision of biomedical knowledge of TB transmission and disease; and their assistance in addressing stigma and discrimination from family and community. Participants also noted how tackling the socio-structural issues that drive TB transmission in people’s homes and communities were beyond the remit of counsellors’ work. TB education and counselling should be an essential part of all TB services to provide support and encouragement for people to continue treatment to completion.

Daru, South Fly District, Papua New Guinea is a high transmission setting for multidrug-resistant tuberculosis (MDR-TB). An emergency response by the Government in 2014 established a high-quality model for treatment and care. Household contact screening and management commenced in 2016 with TB preventive treatment (TPT) for well young child (<5 years) contacts of people with drug-susceptible TB and later expanded to young child contacts of MDR-TB. The model of care is community-based and led by non-specialist health workers, under supervision. An electronic medical record system supports care, reporting and operational research. Community engagement and education has been central, with a concerted focus on peer-led counselling and patient-centred services to improve TPT uptake and completion. Challenges include the application of households as the unit of intervention for detection of active TB and TPT provision. Our implementation experience in Daru has highlighted significant population mixing dynamics with most transmission likely occurring outside the household. We propose a community-wide screening approach with the provision of TPT based on testing to include older children, adolescents, and young adults. As there is the possibility of MDR-TB infection irrespective of the drug susceptibility of the household index case, a novel option is a combination TPT regimen of 6 months of daily isoniazid and levofloxacin (6HLfx). A sensitive aged-related algorithm to detect and exclude active TB is being developed. Ongoing community engagement, quality data systems with operational research to evaluate approaches are critical in high transmission MDR-TB settings.

Tuberculosis (TB) is a major public health issue in Papua New Guinea, with incidence rates particularly high in the South Fly District of Western Province. We present three case studies, along with additional vignettes, that were derived from interviews and focus groups carried out between July 2019 and July 2020 of people living in rural areas of the remote South Fly District depicting their challenges accessing timely TB diagnosis and care; most services within the district are only offered offshore on Daru Island. The findings detail that rather than ‘patient delay’ attributed to poor health seeking behaviours and inadequate knowledge of TB symptoms, many people were actively trying to navigate structural barriers hindering access to and utilisation of limited local TB services. The findings highlight a fragile and fragmented health system, a lack of attention given to primary health services, and undue financial burdens placed on people living in rural and remote areas associated with costly transportation to access functioning health services. We conclude that a person-centred and effective decentralised model of TB care as outlined in health policies is imperative for equitable access to essential health care services in Papua New Guinea.