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

19 journalists and health reporters in Kuala Lumpur to learn about Tuberculosis
19 journalists and health reporters in Kuala Lumpur to learn about Tuberculosis


It was an exponential learning curve.

Professor Lee Reichman
Professor Lee Reichman

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.

Lucia
Dr Lucica Ditiu

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).

This healthy little girl has latent TB - just like one in three others.
This healthy little girl has latent TB – just like one in three others.

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.

Father Brian Cahill on the hill overlooking Tapini in Goilala, Central Highlands, where TB is rampant
Father Brian Cahill on the hill overlooking Tapini in Goilala, Central Highlands, where TB is rampant

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.

buai-chewingSunlight 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.

2012-09-18 09.07.39In 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 spent many months in a sanatorium with TB -she was one of the 30% that survived.
My maternal grandmother spent many months in a sanatorium fighting TB -she was one of the three in ten that survive.

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.

Catherina Abrahams of Daru died of XDRTB in a Cairns Hospital in March  2013. She had been treated there for a year in an isolation ward since she arrived in Australia on a tourist visa.
Catherina Abrahams of Daru died of XDRTB in a Cairns Hospital in March 2013. She had been treated there for a year in an isolation ward since she’d arrived in Australia on a tourist visa – estimated cost, over half a million dollars

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.

Please click here for links to more articles by the author on Tuberculosis in PNG

Share Button

8 thoughts on “Tuberculosis in PNG: Of myths and misconceptions

  1. A very nice article, informative and educational. Thank you Dr Susan Merrell. Am quite interested in the theory behind Buai as an agent of spreading TB. Am a nerd, a freaking lab rat (well on a serious note, am studying in Japan, working on understanding the insecticide resistance of insects at molecular level) and theories we usually propose based on observation or the theoretical knowledge we have, practical work at molecular level (talking at DNA and protein level) usually proves wrong. While I agree on the theory that organs/tissues spitting out the buai is physiologically far from the organ containing the TB bacteria, it is the same system (body) that is hosting every tissues and organs. And these tissues and organs are all interconnected with veins and arteries where any form of matter be it viruses or bacteria are conveyed between tissues and organs. Am sure, it might have been mentioned during the conference, that the TB bacteria can develop resistance to high temperatures very rapidly and blue light on the other hand has proven to have a powerful bacteria-killing ability “in the laboratory.” However, its still an ongoing process to determine the efficacy of blue in the field as we dont always have blue light out in the public places. While I agree on buai not acting as an agent in spreading TB, my concerns still persist, more practical work is needed to understand the mechanisms behind buai and TB. Em tasol and thanx again for the great article.

    • Hi Dave, Thanks for your comments. As a scientist, I’m sure you have more questions than I can supply the answer to. The conversation ensued because those assembled knew I worked in PNG and Buai spitting needs more scientific investigation as far as TB transmission is concerned.
      However, as a dinnertime discussion, the consensus of opinion after a vigorous debate taking in many factors was that it’s possible but not probable.
      And while a dinnertime discussion will not substitute for scientifically collected data – the discussion was amongst the leading figures in TB eradication – a wealth of experience and knowledge.

      • Thanx Dr. Merrell. If its from the leading figures in TB eradication then probably I’ll just follow where the wind blows. AM an insect guy, not a bacteriologist hence at times my points might be vague, loosing significance. And yes, its a very tricky scenario, there are alot of variables to consider. Nevertheless, thanx for putting in all that effort to help my people back at home, we need such information to guide us in our daily living. It might not completely eradicate TB but hey, they say, a journey of a thousand miles begin with a step. Have a good day Dr. Merrell.

  2. Pingback: Homepage

  3. Many people who have TB fear they have Hiv and refuse to visit hospitals and die without treatment. Also many people blame sorcery for TB and many vulnerable persons have been targeted through assault, other violence and even death

  4. Pingback: http://vimeo.com/82670077

  5. Pingback: MEN