Tuberculosis in PNG: Of myths and misconceptions

Late in 2012, I was an invited fellow of the National Press Foundation of Washington to the International Union against Tuberculosis and Lung diseases’ (the Union) annual conference in Kuala Lumpur, Malaysia. The Union, is one of the world’s peak bodies in the fight against Tuberculosis (TB) along with the ‘Stop TB Partnership’ (a part of the World Health Organization -WHO).  It is these two organizations that largely inform the Government of PNG’s health initiatives, policies and strategies surrounding TB.  It was the Union that developed the Direct Observation Treatment – short course (DOTS) that is now administered by World Vision in many countries, including Papua New Guinea.

By PNG Echo

It was an exponential learning curve.

Nineteen journalists from TB ravaged countries such as India, China, Malawi, Uganda, Indonesia, Russia and South Africa, were intensively tutored at a specially convened pre-conference by such luminaries as Professor Lee Reichman, Founding Executive Director of the New Jersey Medical School Global Tuberculosis Institute and keynote speaker at the conference and Dr. Lucica Ditiu, Executive Secretary, Stop TB Partnership as well as many other notables. I was one of the 19.

The crux of what I learned should be understood by every PNGean because the incidence of TB in PNG is high (430 per 100,000 of population – 72 times higher than Australia) with an increase of 42% over the preceding 10 years.

Much of what was imparted I had not known previously.

Basic facts

• Breathing in of microscopic airborne spores of mycobacterium tuberculosis contained in respiratory fluid (cough or sneeze) ejected into the air by a person who has active TB is how the disease is transmitted.
• Populations with the greatest risk are those that are also affected by poverty.
• Overcrowding is a major risk factor and prison populations in third world or impoverished countries generally have higher than normal TB.  Overcrowded living conditions with poor ventilation likewise.
• Only those with ‘active’ TB can transmit the disease and only those with active TB are sick.
• One in three people (globally) have been infected with the Tuberculosis bacterium at some stage in their lives.  However, only one in ten of those infected will go on to develop active TB and become sick and infectious.

I have latent (inactive TB).

I always wondered why I wasn’t given the TB immunization injection (BCG) like the remainder of my classmates when I was in primary school.

My ‘skin test’ (the prerequisite to the immunization injection) indicated that it was too late the damage had been done.  I was already infected.

I was elated at the time.  All my friends had to have a large painful injection (you tend to exaggerate at that age) and I didn’t.

I never knew nor realized the import nor the significance and possibly never would have had I not attended the conference.

HIV/AIDS and TB – a fatal attraction

For the remaining 90% of us with latent TB,our immune system effectively suppresses the disease.

It is why the local medical doctor will advocate healthy living and lots of fresh air to guard against triggering the disease – the more strain on the immune system caused by bad nutrition, smoking, drug taking etc, the more likely to provide opportunities for this very opportunistic disease.

And TB is extremely opportunistic.

Providing by far the biggest opportunity, is the co-infection with HIV/Aids.  The HIV virus suppresses the immune system and will allow TB free rein in the body of an HIV positive person.

For a person with HIV/AIDS it is vitally important to start TB treatment as early as possible if a cure is to be effected.

Father Brian Cahill, who runs the Catholic Mission in Tapini, Goilala, that also runs the health centre there, told me this of his parishioners:

They contract HIV but they die of Tuberculosis.

Buai

During a dinner hosted by the Lilly Foundation, the philanthropic arm of the international drug company, I had the privilege of sitting between Dr Ditiu and Professor Reichman and being in company of many other leading experts including WHO delegates.

The dinner was especially memorable for the spirited discussion that ensued as to whether the spitting of buai spreads TB.

The consensus was that, while it was possible, it was not probable.

Buai spittle comes from the mouth and infected sputum is in the lungs and needs to be coughed up from there to contain the infected spores.

However, if sputum was hoicked up before the buai spit was ejected then it would contain the infected spores that, when airborne, someone could breath in and become infected  – but that’s not normally what buai chewers do.

Sunlight kills tubercular spores, so buai spit that has been ejected would first have had to contain the infected spores (unlikely) and the infectious material in the spit would be killed off by the sunlight on landing.

So while there are many good reasons to ban buai, as Governor Parkop has done in the NCD (including mouth cancers, litter, unsightly buai spit stains), the spread of tuberculosis is not one of them.

The cure

The good news is that TB is curable, the bad is that it will take a long regimen of treatment with a toxic chemical of drugs for many months.

In a landscape such as PNG where many still believe in witchcraft and where some put their faith in traditional medicine, it is important to point out that while they cannot and do not cause TB, neither can they cure it.

TB, untreated, has a cure rate of 30% – three in ten people will recover spontaneously after many months (years?) of sickness, (albeit with some lasting and severe scarring) the other seven will die.

Dr Jose Caminero, a chest physician who has written extensively on TB in both medical journals and in published book form and who advises Latin American and Middle Eastern Countries on various TB programs, outlined many of the past treatments that were used for TB before the current, effective drug regimen came into use.

These included letting out of blood, avoidance of meat and alcohol and even, (from 1850 well into the 1900s), the locking away of sick patients in sanatoriums located at high altitude to give the sufferers plenty of exercise and fresh air.

My maternal grandmother had active TB, she was sent away for more than a year to such a place.  The patients in these facilities were feared by healthy people in the communities surrounding the sanatoriums and were treated as lepers.

All of these methods recorded a ‘cure’ rate of 30%, according to Dr Caminero.

The very same 30% that were destined to be cured untreated (luckily my grandmother was one.)  In other words these methods were totally ineffectual.

Similarly, a young man from a remote part of PNG asked me how come one of his wantoks recovered from TB while being nursed in the village and treated with traditional medicines, while her baby, who was admitted to a Port Moresby hospital died?

The explanation can be found in the ‘untreated’ TB lottery – his wantok most likely happened to be one of the three who would have recovered regardless.

But it’s one risky lottery; a lottery where you have more than double the chance of losing than winning and where what you stand to lose is your life.

Moreover, every untreated TB case will infect 12-15 other people per year.

It is not an option for TB to go untreated.  Every patient must be treated, if not only to save her/his life then to save the 12-15 lives of those s/he would potentially infect over the course of the disease.

The import of correct treatment.

The regimen for treating TB is harsh.  It’s long and the drugs have side effects, it is why so many find it difficult to last the distance.

The patient will usually feel better within a couple of weeks of commencing treatment, but if the drugs are not taken until the TB has completely exited the sufferers body (around 6 months), the bacteria will lurk there awaiting the opportunity to re-emerge.

When and if it does, it will have developed a resistance to the principle treatment drugs and become what is called Multi-Drug-Resistant Tuberculosis (MDR-TB).

This strain is harder to cure with an even longer and more stringent and toxic drug regime.  If this patient infects another it will be with MDR-TB not the previous drug sensitive strain.

What’s more, MDR-TB has further morphed through negligent management of the drug regimen into a strain that is even more drug resistant, it is known as Extensively Drug Resistant Tuberculosis (XDR-TB).  This strain is extremely difficult to treat and the prognosis for the sufferer is not good.

They usually die.

The Cairns Post reported that there have been at least 6 confirmed cases of XDR-TB in PNG.  The article was dated November 12, 2012.

Is all that can be done, being done in PNG?  The answer is no – but that’s a story for another time.

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