Diversity of Mycobacterium tuberculosis in the Middle Fly District of Western Province, Papua New Guinea: microbead-based spoligotyping using DNA from Ziehl-Neelsen-stained microscopy preparations

Tuberculosis remains the world’s leading cause of death from an infectious agent, and is a serious health problem in Papua New Guinea (PNG) with an estimated 36,000 new cases each year. This study describes the genetic diversity of Mycobacterium tuberculosis among tuberculosis patients in the Balimo/Bamu region in the Middle Fly District of Western Province in PNG, and investigates rifampicin resistance-associated mutations. Archived Ziehl-Neelsen-stained sputum smears were used to conduct microbead-based spoligotyping and assess genotypic resistance. Among the 162 samples included, 80 (49.4%) generated spoligotyping patterns (n = 23), belonging predominantly to the L2 Lineage (44%) and the L4 Lineage (30%). This is consistent with what has been found in other PNG regions geographically distant from Middle Fly District of Western Province, but is different from neighbouring South-East Asian countries. Rifampicin resistance was identified in 7.8% of the successfully sequenced samples, with all resistant samples belonging to the L2/Beijing Lineage. A high prevalence of mixed L2/L4 profiles was suggestive of polyclonal infection in the region, although this would need to be confirmed. The method described here could be a game-changer in resource-limited countries where large numbers of archived smear slides could be used for retrospective (and prospective) studies of M. tuberculosis genetic epidemiology

Fieldwork in isolated locations and under-resourced settings: practical insights from research in the remote Gogodala Homelands of Papua New Guinea

This case provides an analysis of fieldwork logistics in the tropical nation of Papua New Guinea. The fieldwork was part of an interview-based study focusing on tuberculosis treatment adherence. The town of Balimo, where the study was based, is at the centre of a remote region that is difficult to access and demonstrates many of the challenges facing health systems in countries like Papua New Guinea. Retrospective analysis was used to identify fieldwork considerations for researchers and assist others to do similar research. Practical lessons learned are described in the context of infrastructural, economic and cultural factors. These lessons are important when planning research in unfamiliar settings, as well as to understanding challenges associated with healthcare delivery. The need for local collaboration and involvement was demonstrated. The importance of researchers attempting to get an insider perspective of the data was also highlighted. This was achieved through undertaking interviews in both urban and village settings, as well as gaining insights from local cultural mentors. Health services research should be guided by local conditions and integrated with local programmes. Following proper integration and planning, researchers should not forget the practical considerations that are particularly important in remote and resource-limited settings

The social determinants of tuberculosis treatment adherence in a remote region of Papua New Guinea

Abstract Background Papua New Guinea (PNG) is a diverse and culturally-rich country with severe infrastructural and health problems. Tuberculosis (TB) is widespread, and the number of cases with drug resistance is rising. Treatment adherence is known to be important for both effective treatment and limiting the emergence of drug resistance. The aim of this study was to construct a matrix of the factors that act as facilitators or barriers to TB treatment adherence in a remote region of PNG. Methods The study was based in the Balimo region of the Western Province. People known to have undergone TB treatment, as well as staff involved in managing people with TB, were asked to participate in an in-depth interview about their experiences. Purposive sampling was used to identify a diverse range of participants, from different geographic locations, social backgrounds, and with successful and unsuccessful treatment outcomes. The interview data was analysed based on grounded theory methodology. Results The study identified a range of factors that influence TB treatment adherence, with these being classified as personal, systems, and sociocultural. These factors are presented along with suggested recommendations for adaptations to DOTS-based treatment in this region. Barriers included the challenges associated with travel to treatment sites, and the difficulties of undertaking treatment alongside the daily need to maintain subsistence food production. However, facilitators were also identified, including the positive influence of religious beliefs, and high confidence in the ability of DOTS-based treatment to cure TB. Conclusions Documenting the wide range of factors that influence treatment adherence in a severely affected remote population will assist in improving TB control. These results provide impetus for further community-based efforts aimed at improving access to TB diagnosis and treatment, and maintaining successful treatment outcomes in the face of emerging drug resistance

The epidemiology of tuberculosis in the rural Balimo region of Papua New Guinea

Objective: Papua New Guinea (PNG) has an emerging tuberculosis (TB) epidemic which has become a national public health priority. In Western Province, there are few data about TB outside Daru and the South Fly District. This study describes the epidemiology of TB diagnosed at Balimo District Hospital (BDH) in the Middle Fly District of Western Province, PNG. Methods: All patients (n = 1614) diagnosed with TB at BDH from April 2013 to February 2017 were recorded. Incidence of reported new cases was calculated for the combined Balimo Urban and Gogodala Rural local level government areas. Analyses investigated patient demographic and clinical information, differences between pulmonary and extrapulmonary TB patients, and predictors of treatment failure. Results: The average case notification rate (2014–2016) was 727 TB cases per 100 000 people per year. One-quarter of TB cases were in children, and 77.1% of all cases had an extrapulmonary TB diagnosis. There was a 1:1.1 ratio of female to male TB cases. When comparing pulmonary and extrapulmonary TB patients, extrapulmonary TB was more likely in those aged up to 14 years and over 54 years. Extrapulmonary TB was more likely in new patients, and pulmonary TB more likely in previously treated patients. Residence in rural regions was associated with treatment failure. Conclusion: There is a high burden of TB in the Balimo region, including a very high proportion of extrapulmonary TB. These factors emphasise the importance of BDH as the primary hospital for TB cases in the Balimo region and the Middle Fly District, and the need for resources and staff to manage both drug-susceptible and drug-resistant TB cases

Molecular Evidence of Drug-Resistant Tuberculosis in the Balimo Region of Papua New Guinea

Papua New Guinea (PNG) has a high burden of tuberculosis (TB), including drug-resistant TB (DR-TB). DR-TB has been identified in patients in Western Province, although there has been limited study outside the provincial capital of Daru. This study focuses on the Balimo region of Western Province, aiming to identify the proportion of DR-TB, and characterise Mycobacterium tuberculosis (MTB) drug resistance-associated gene mutations. Sputum samples were investigated for MTB infection using published molecular methods. DNA from MTB-positive samples was amplified and sequenced, targeting the rpoB and katG genes to identify mutations associated with rifampicin and isoniazid resistance respectively. A total of 240 sputum samples were collected at Balimo District Hospital (BDH). Of these, 86 were classified as positive based on the results of the molecular assays. For samples where rpoB sequencing was successful, 10.0% (5/50, 95% CI 4.4⁻21.4%) were considered rifampicin-resistant through detection of drug resistance-associated mutations. We have identified high rates of presumptive DR-TB in the Balimo region of Western Province, PNG. These results emphasise the importance of further surveillance, and strengthening of diagnostic and treatment services at BDH and throughout Western Province, to facilitate detection and treatment of DR-TB, and limit transmission in this setting

Additional file 1: of The social determinants of tuberculosis treatment adherence in a remote region of Papua New Guinea

Interview guide. Semi-structured interview guide developed for the study. (DOCX 17 kb