Outbreak of multidrug-resistant tuberculosis on Daru Island

The 6 km² island has a population of about 15 000 individuals; in 2015, almost 200 people were being treated for MDR-TB. These numbers suggest that nearly 1% of the population is diagnosed with MDR-TB every year, and this is probably just the tip of the iceberg, because active case finding has yet to be implemented. Most patients with MDR-TB in Daru have never taken tuberculosis drugs, meaning primary transmission is occurring at an extraordinarily high level, which is especially concerning given that there are very few HIV cases in Papua New Guinea.⁴ Whereas WHO estimates that roughly 1000 MDR-TB cases emerge across Papua New Guinea every year, isolated studies from different settings suggest a much higher burden.^{5, 6} Despite direct evidence of high rates of MDR-TB transmission from as early as 2008,⁷ data remain scarce, mainly because Papua New Guinea has no facilities for tuberculosis culture or drug susceptibility testing. Access to MDR-TB treatment also remains poor, with the Australian government stepping in to procure emergency supplies of second-line medicines in 2013–14.⁸

The national and international response to the Daru outbreak has been inadequate. In January, 2015, the Government of Papua New Guinea and international advisors put together an accelerated response plan to address MDR-TB, but to date only a small amount of funding has been released.⁹ In May, 2015, a Green Light Committee assessment of the MDR-TB situation in Daru noted the extremely high MDR-TB prevalence, but went on to make recommendations that were inconsistent with an epidemic response, including restricting use of Xpert MTB/RIF and limiting access to the new drug bedaquiline.¹⁰ In November, 2015, an international meeting on the Daru situation convened by the Papua New Guinea National Department of Health and WHO in Port Moresby emphasised the urgency of responding to the epidemic in Daru, describing the cost of inaction as catastrophic.¹¹ Nevertheless, the Daru epidemic was allocated only 1 hour of discussion at an ad-hoc meeting at the 46th Union World Conference on Lung Health, a week later. The discussion concluded with plans for an update the following year.

That this situation is happening at a time when the global community claims to have learned lessons from the mismanagement of Ebola is worrisome.¹² Why does there seem to be a double standard in implementation of action on outbreaks of deadly infectious diseases? Evidence shows that MDR-TB, which is spread through the air, is just as deadly as Ebola, and has health, population, and economic consequences that will almost certainly eclipse those of both the Ebola and the recent Zika virus outbreaks, deemed a global public health emergency, combined.¹³ Perhaps the protracted disease dynamics of MDR-TB, for which significant transmission events might not be apparent for years, partly contribute to the repeated feeble responses when hotspots of the disease are eventually uncovered.

The sheer scale of the Daru outbreak is alarming, but other aspects are also notable. With little outside support, the men and women working in Daru have mustered heroic efforts to provide services to those living on the island—indeed, several nurses working at the Daru General Hospital have lost their lives to MDR-TB.¹⁴ However, these efforts, when measured against the yardstick of what is needed to stop the spread of MDR-TB, are woefully inadequate. By contrast, an outbreak of MDR-TB on nearby Chuuk Island, Micronesia, demonstrated what is needed to stop MDR-TB: a comprehensive, collaborative approach with adequate investment of resources from multiple stakeholders implemented in an urgent fashion.¹⁵ The devastation caused by MDR-TB might be slow and insidious, but the responses to the outbreak cannot be if the disease is to be eliminated, both in Daru and globally. Promises to “End TB” by 2030 around the world will ring hollow if the disease cannot be stopped even on this remote island.

We declare no competing interests.

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Source: The Lancet Respiratory Medicine