TB or Not TB: Development of an Integrated Occupational and Community Health TB Surveillance Program
Authors: Nowosiwsky Andry , Burke Nicholas , Moore John D. , Krieger Gary R. 
Published: March 2016

Abstract

OBJECTIVE
Tuberculosis (TB) is one of the oldest diseases known to mankind. However, in many locations around the world, tuberculosis has now become a "re-emerging infectious disease" that can significantly impact workforce operations. As part of the PNG LNG Project, a comprehensive TB management strategy was developed that included both the workforce and key proximal communities. Pre-placement evaluations, ongoing surveillance and community incidence and prevalence studies were conducted in an integrated fashion. Innovative technology, including use of the GeneXpert platform, was systematically utilized at both key worksite locations and target communities to support pro-active TB mitigation efforts.

METHODS
Based on the findings of pre-project health risk and impact assessments (i.e. inside and outside the fence evaluations) and building on the corporate approach for TB control in Company workplaces, the Project determined that a comprehensive TB management program was essential. PNG has a significant underlying burden of TB with an increasing burden of multi-drug resistant TB (MDRTB), while local health capacity to accurately diagnose and treat TB is variable. Importantly, there are no current indications that the PNG TB burden is related to HIV co-infection. Given the large workforce used during the Project's construction phase and focus on maximizing local hires, a comprehensive program to rapidly assess potential workforce TB status was needed. Existing assessment methods including questionnaires, TB skin tests, and chest x-rays. As all of these methods had significant limitations a more rapid, sensitive and specific diagnostic system - the GeneXpert platform – was required. Comprehensive pre-employment evaluation was performed utilizing a combination of questionnaires, physical examinations and state of the art interferon-gamma release assays (IGRA) with the GeneXpert platform applied to suspect cases to enable rapid assessment and referral. In the proximal worksite communities, the PNG Institute of Medical Research performed systematic TB incidence and prevalence studies. In addition, TB knowledge, attitudes, practices and belief surveys were conducted along with an assessment of local public health capacity for TB diagnosis and treatment. Enhanced laboratory diagnostics, including GeneXpert and improved microscopy training, were added.

RESULTS
In line with the Project team's expectation, the underlying burden of TB was extremely high in local proximal worksite communities. TB incidence and prevalence levels were 2–4 times higher than reported government data. In one area, the TB burden recorded is one of the highest ever documented in the world. HIV co-infection was not significant as HIV rates were &lt;2%. Not surprisingly, workforce pre-employment burden of both latent and active TB were significant and reflected the local population burden of disease. Detailed data will be presented regarding workforce IGRA experience, active surveillance results and the benefits of the GeneXpert platform.

NOVEL / ADDITIONAL INFORMATION
The development of an integrated, (workforce and community) comprehensive TB management and monitoring program represents a new benchmark both for PNG and the oil and gas industry. As noted through multiple engagements with the PNG government and donor community such an approach can be replicated by others in the extractives as well as non-extractives industries using field proven methods pioneered on the PNG LNG Project. In so doing the improvement in coverage and data quality can assist in improving public health policy development and implementation.