Major Public Health Journal Dedicates Supplement Issue To TB Operational Research in Papua New Guinea

A major Public Health Journal – The Union, published by the International Union Against Tuberculosis and Lung Disease, dedicated a supplement issue to TB operational research in PNG. The articles published – authored by PNG doctors and scientists working in the TB space, showcases TB operational research around PNG. The articles highlights success stories as well as current challenges.

It was pleasing to read the articles because the issue also show cases the next generation of PNG medical researchers.

I have posted below the summary from The Union website regarding the different articles.

A dedicated supplement drawing attention to the important process of building operational research (OR) capacity in Papua New Guinea (PNG) has been released by the journal Public Health Action (PHA).

PNG is a country where tuberculosis (TB), including drug-resistant TB (DR-TB), is highly prevalent. According to the World Health Organization (WHO), PNG has an estimated annual TB incidence rate of 432 per 100,000 people. In addition, the treatment success rate for new diagnoses registered in 2016 was 62 percent.

In 2017-18, the first OR capacity-building programme for TB was conducted in PNG using the Structured Operational Research Training IniTiative (SORT IT) model. The SORT IT programme offers an intensive course in OR that consists of three six-day modules offered over nine to 12 months, and is a collaboration between The Union, Médicins Sans Frontières and WHO’s Special Programme for Training and Research in Tropical Diseases.

The twelve papers presented in the supplement represent the findings from the research projects undertaken by participants of the SORT-IT course, raising important operational issues for PNG’s TB programme and providing opportunities to inform policy and practice.

The implementation of PNG’s national programmatic response to TB only started in 2008. The supplement’s studies confirm the challenges which is exist in in the country, including: the large number of people with TB who remain undetected, low treatment success rate, high numbers of multidrug-resistant TB (MDR-TB) in concentrated locations, large numbers of children with TB, and high numbers of treatment outcomes reported as ‘lost to follow-up’.

OR is fundamental in providing much-needed baseline data, identifying gaps in provision, and evaluating innovations such as new tools and strategies to increase detection of new cases, improve treatment outcomes and aid prevention.

The 12 studies offer important insight into operational challenges and successes, with the aim of increasing the capacity of the workforce to conduct OR, and ultimately improving health care service provision and patient outcomes for people living in PNG and the wider Pacific region. These include:

  • Drug-resistant tuberculosis diagnosis since Xpert® MTB/RIF introduction in Papua New Guinea, 2012–2017: Xpert® MTB/RIF was introduced in PNG in 2012 for the diagnosis of TB and of rifampicin-resistant TB (RR-TB). The study found that the use of Xpert has increased the detection of RR-TB and MDR-TB in PNG. However, the high frequency of MDR-TB emphasises the need to accelerate the in-country availability of drug susceptibility testing. Ongoing surveillance of DR-TB patterns was also identified as being essential to improve treatment guidelines.
  • Impact of GxAlert on the management of rifampicin-resistant tuberculosis patients, Port Moresby, Papua New Guinea: GxAlert is an automatic electronic notification service that provides immediate Xpert® MTB/RIF testing results. It was implemented for the notification of patients with RR-TB at Port Moresby General Hospital. The study found that considerable improvements have been made in timely RR-TB patient management in Port Moresby, although it was unclear to what extent GxAlert was directly associated with these improved patient outcomes.
  • Implementation of screening and management of household contacts of tuberculosis cases in Daru, Papua New Guinea: Community-based household contact screening and management was successfully implemented, under programme conditions, on Daru Island, which can be described as a low-resource setting with a high burden of TB and DR-TB. Of interest, the study also demonstrated a high level of acceptability of screening among household contacts, and a high level of household crowding on the island, increasing the risk of transmission of TB.
  • Outcomes in children treated for tuberculosis with the new dispersible fixed-dose combinations in Port Moresby: New child-friendly fixed dose combinations were introduced at Port Moresby General Hospital for the first-line treatment of children with TB. Despite the use of child-friendly medicines, a recorded high proportion of loss to follow-up highlighted the need for: promotion of bacteriological confirmation of TB amongst children, better retention in care, increased access to HIV testing, and better links with community TB programmes and nutrition services.
  • Challenges in TB diagnosis and treatment: the Kavieng Provincial Hospital experience, Papua New Guinea: Gaps were identified in diagnosis and treatment in the TB treatment cascade at the Kavieng Basic Management Unit. The study concluded that the TB programme requires strengthening to address: the high proportion of patients with a clinical diagnosis of TB, patients not being tested for HIV, and high levels of loss to follow-up. The challenges are complex and will likely require multiple interventions to improve.”

I have been a strong advocate for PNG nationals to conduct research and publish their findings and it is very encouraging to see the articles published.

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A Betel Nut Law Can Help Control Mouth Cancer in Papua New Guinea.

A lot of people reading this article will say – “betel nut chewing is part of our culture. Why do we need a law to control our own culture?” And I agree with all who say this. But the buying and selling of betel nut in our major urban centers is causing a lot of social problems and we have to explore ways how best we can allow people to continue to enjoy their favorite nut without the social problems associated with commercial side of betel nut. The social problems of betel nut chewing appear to be predominantly in the urban centers in PNG with a few exceptions. We already know that betel nut chewing leads directly to mouth cancer. I don’t think there is only one solution to these problems. We should explore other ways to attack the problem from different angles.

I see 3 main factors that are contributing to the social problems associated with betel nut chewing.

  1. Betel nut chewing is a cultural practice in the coastal areas. It was never a cultural practice in the highlands provinces. Introduction of betel nut chewing into the highland provinces has resulted in the habit to flourish outside the context and significance of which betel nut is traditionally chewed. Also it is common belief among some provinces in PNG that betel nut husk and spit can be used by sorcerers to cast spells on the chewer so betel nut chewers in these areas do not throw betel husk nor spit in public places. The same cannot be said of provinces in which betel nut chewing is an introduced practice – the highlands provinces.
  2. The second contributing factor is the commercial aspect of betel nut chewing. Betel nut generates a lot of money for those involved in the business. With the ever increasing cost of goods and services in PNG, more and more people and families will get into the betel nut business, whether it is small scale (e.g. selling betel nut in front of your house) or selling in bulk.
  3. The selling is flourishing because there is a demand for the nut. In other words, the selling will stop or slow down if the demand for betel nut also stop or slow down. It is simple economics – the selling is being driven by the buying.

So these 3 areas need to be targeted to control the habit of betel nut chewing in urban PNG and indirectly reducing mouth cancer rates. This is only my opinion and I welcome comments for discussion.

The Federated States of Micronesia (Pohnpei State), Palau and Marshall Islands are few of the Pacific Island Countries that have a betel nut laws to control the habit of betel nut chewing. Betel nut chewing is now established as a carcinogen by the World Health Organization so like all other cancer causing agents/habits, there should specific laws in countries that this habit is widespread.

So can laws targeted at controlling the habit of betel nut chewing prevent and control the habit? And indirectly control the social problems and unhygienic scenes observed in PNG? Betel nut is widely chewed in Pohnpei (one of the States of FSM) but the streets are clean and there are very few red betel nut stains. Ponhpei introduced the Betel Nut Prohibition Act 2010 to control this habit. The Act prohibits the chewing of betel nut in shops, offices, public areas, parks and spitting of the quid in public places. Offenders are fined or sometimes required to do community service. The Act also mandates shops, private and public institutions to put up notices on the walls or doors to inform the public of the prohibition and the penalty if caught. Betel nut is sold in shops in neatly packed packages. Street hustling to sell betel nut is prohibited. Palau and Marshall Islands also have similar Betel Nut Prohibition Laws. Similar laws ought to be introduced in PNG! Call it Buai Prohibition Act or something similar specific for controlling the sale and buying of betel nut in the urban areas of PNG.

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Visitor Training Program With American Society of Hematology

I was very fortunate in 2016 to be a recipient of the Visitor Training Program (VTP) Award offered by the American Society for Hematology (ASH). The award worth USD 8000 allowed me to travel to Maryland, USA and train at the University of Maryland Medical Center and under a 6 weeks training under the supervision of Professor Zeba Singh.

The Greatest City in America. I saw on this on a side walk bench, I had to take a shot of it.

The VTP award is offered every year to doctors from low income countries to undergo specialized hematology training in the United States under the supervision of a mentor – a ASH member with good standing and track record of supervising trainees.

UMMC 2016

My training plan focused on interpreting and reporting peripheral blood smears, bone marrow biopsy and aspirate smears, lymph node biopsies and interpreting and reporting multi-color flowcytometry.

Professor Zeba taught me a great deal about diagnosing leukemia and lymphoma, training I do not think I would have received in my home country Papua New Guinea.

Dr Itaki and Professor Zeba, UMMC 2016.

I think I was the first (I stand to be corrected) from the Pacific Islands to be awarded the VTP award by ASH. A key milestone of the Award was that the VTP recipient is required to implement a training program to train others within his or her hospital or institution. So I had to do that. I ran a training program for my fellow trainee doctors for 12 months and gave tips on leukemia diagnosis.

Since 2016 I have been advocating other doctors within the Pacific Region to apply for the ASH VTP award to received specialized hematology training in the states.

Dr Itaki, Professor Zeba and a hematology resident, UMMC 2016.

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Healthcare Workforce Mobility Within Pacific Region Will Allow Transfer of Technical Skills And Knowledge

I have been working in the Federated States of Micronesia for nearly 12 months now. I am employed as a General Physician doing outpatient and emergency room coverage. I also sometimes help the medical laboratory scientist read Pap smear slides and peripheral blood smears (I was training to be a Pathologist before coming to Micronesia). I also sometimes help the Public Health Division with disease surveillance and research. And I see the great need for health professionals to come work out here to help the health sector. There is shortage of workforce within the health sector.

Dr Itaki in Micronesia

And I began thinking about  why movement of workforce within the Island States is limited. Papua New Guinea being the biggest country within the Pacific there is little movement of skilled workforce from PNG moving to work in other smaller Pacific Island countries. There may be many reasons for this – maybe lack of awareness, do not know who to contact or how to get a job within the other Pacific Island countries. I would have thought that within the member countries of the Pacific Island Forum and Melanesia Spear Hear Group, there should be some agreement among the member countries to allow skilled workforce to move freely among member countries to share skill workforce.

Fiji has done a great job of exporting skilled workforce within the Pacific. You will find Fijians working in every Pacific Island Countries with a good community within where they work. I think PNG can see what Fiji is doing and emulate their success in supplying skilled workforce to other small Island States who have shortage in skilled workforce.

The Pacific Island Countries share similar culture, tradition and history and creating an avenue for the movement of skilled workforce to move within Pacific Island Countries will allow sharing of human resources and transfer of technical knowledge and skills to host countries.

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Betel Nut Legislation To Control The Sale, Buying & Chewing Of Betel Nut In The Pacific.

The Federated States of Micronesia (Pohnpei State), Palau and Marshall Islands are few of the Pacific Island Countries that have a betel nut legislation to control the habit of betel nut chewing. Betel nut chewing is now established as a carcinogen by the World Health Organisation so like all other cancer causing agents/habits, there should specific legislation in countries that this habit is widespread.

In PNG, betel nut chewing is uncontrolled resulting in unsightly sights within the urban areas. This week I read on social media about police physically assaulting betel nut sellers in Port Moresby. This practice has been going for a while now but it seems that 2019 has been the worst year of police physically abusing people selling betel nut – especially in Port Moresby, PNG’s capital.

So can legislation targeted at controlling the habit of betel nut chewing prevent and control the habit? And indirectly controlling the unhygienic scenes observed in PNG’s capital Port Moresby? Betel nut is widely chewed in Pohnpei (one of the States of FSM) but the streets are clean and there are very few red betel nut stains. Ponhpei introduced the Betel Nut Prohibition Act 2010 in 2010 to control this habit. The Act prohibits the chewing of betel nut in shops, offices, public areas, parks and spitting of the quid in public places. Offenders are fined or sometimes required to do community service. The Act also mandates shops, private and public institutions to put up notices on the walls or doors to inform the public of the prohibition and the penalty if caught. Similar legislation ought to be introduced in PNG!

I think it is about PNG introduced a Betel Nut (or Buai Prohibition Act) Prohibition Act.

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