A clinician's perspective on providing TB services in the Torres Strait

For many decades, Australia has been fortunate to have a low prevalence of tuberculosis (TB). 1 This has resulted from a rm commitment to screening for and managing TB since early last century. Because of the low rates of disease, the current population, unfortunately, perceives TB to be a “disease of the past”. Such a perception leads to complacency, even among subgroups of policymakers, who place importance on short-sighted spending cuts over long-term TB control in an era in which drug-resistant TB is an emerging biosecurity threat to Australia. One component of effective TB control is prompt identi cation and treatment and monitoring of index cases and screening of contacts. In 2001, the Cairns Regional TB Control Unit initiated this response when the rst case of multidrug-resistant TB (MDR-TB) was detected in the Torres Strait region.2 The initial and subsequent cases were in people from Western Province in Papua New Guinea (PNG) who resided within the Torres Strait Protected Zone and, by treaty law, are free to travel back and forth from Western Province to the outer islands of Torres Strait for traditional purposes. As new cases emerged from Western Province, the regional control unit established TB outreach services on Saibai and Boigu Islands to treat these patients, both for humanitarian reasons and to reduce the health risk to Australian citizens. The clinics employed medical, nursing and radiographic staff and had access to the Brisbane TB reference laboratory. They carried out ongoing surveillance during a patient’s treatment cycle, to detect any treatment failure or default, and post-treatment follow-up, to ensure the patient was cured. Over the past decade, the number of TB and MDR-TB cases originating from Western Province has increased substantially and the demand on the clinics has been large.2 However, the actions of the clinics have been credited with there being no MDR-TB cases detected in the Australian population in this region. The Australian clinics were set up out of necessity, as Western Province has no established, comprehensive TB service. Further, Western Province has been plagued by long-term political unrest, poverty and lack of transportation, resulting in minimal access for local residents to their regional hospital on Daru Island. The intention of the Saibai and Boigu clinics has always been to hand over care of PNG residents once a clinic and a TB outreach program were established on the PNG side of the border. Over the past few years, there have been regular meetings between Queensland TB control units, the Australian Government, the Western Province local government, the PNG national TB program team and Daru hospital staff. The aim of the meetings has been to facilitate, step by step, the transfer of responsibility for TB management to PNG, including clinical input from both Queensland and PNG health services. As yet, there is no such service within Western Province or through a clinical base at Daru Hospital with an outreach service to Western Province. Unexpectedly, during the rst half of 2011, the Queensland Government directed that the TB outreach clinics on Saibai and Boigu Islands be closed in June 2011.3-5 No remedial plan for treatment continuation was included, leaving the 50 patients from PNG who were being treated for TB in a dire situation. Importantly, there was no plan for the ongoing management of patients from Western Province. Through strong pressure from TB clinicians in Australia, operation of the Australian services has been extended, and they will remain open until early 2012 to ensure completion of the treatment cycle for current patients. AusAID is supplying funding to establish TB health services within Western Province,5,6 but the program is in its infancy. There is considerable concern that extensively drug-resistant TB will emerge in the region and eventually Stephen D Vincent MB BS(Hons), FRACP, Physician