Climate change, overcrowding and non-communicable diseases: The 'triple whammy' of tuberculosis transmission risk in Pacific atoll countries

Abstract: The atoll nations of Kiribati, Marshall Islands and Tuvalu are home to the highest rates of tuberculosis in the Pacific region. These countries also have very high rates of poverty, overcrowding and non-communicable diseases such as smoking and diabetes mellitus, which are all well-established risk factors for tuberculosis transmission. In addition, these three countries are among the most vulnerable in the world to the impacts of climate change, due to, inter alia, their very low elevation and extreme susceptibility to sea-level rise and extreme weather events such as cyclones, droughts and storm surges. Tuberculosis transmission rates have been linked to climate activity, such as changing seasons, yet tuberculosis has not hitherto been seriously discussed in the international literature as an infectious disease considered susceptible to climate change. This paper highlights the unique and unprecedented convergence of social and environmental risk factors for tuberculosis transmission risk in these three Pacific atoll countries, which demonstrate that tuberculosis is indeed a 'climate-sensitive' disease warranting international support for climate policy and public health intervention

Climate change, overcrowding and non-communicable diseases: the 'triple whammy' of tuberculosis transmission risk in Pacific Atoll countries

The atoll nations of Kiribati, Marshall Islands and Tuvalu are home to the highest rates of tuberculosis in the Pacific region. These countries also have very high rates of poverty, overcrowding and non-communicable diseases such as smoking and diabetes mellitus, which are all well-established risk factors for tuberculosis transmission. In addition, these three countries are among the most vulnerable in the world to the impacts of climate change, due to, inter alia, their very low elevation and extreme susceptibility to sea-level rise and extreme weather events such as cyclones, droughts and storm surges. Tuberculosis transmission rates have been linked to climate activity, such as changing seasons, yet tuberculosis has not hitherto been seriously discussed in the international literature as an infectious disease considered susceptible to climate change. This paper highlights the unique and unprecedented convergence of social and environmental risk factors for tuberculosis transmission risk in these three Pacific atoll countries, which demonstrate that tuberculosis is indeed a 'climate-sensitive' disease warranting international support for climate policy and public health intervention

Impact of Laboratory Practice Changes on the Diagnosis of Tuberculosis with the Introduction of Xpert MTB/RIF in Kiribati.

The Republic of Kiribati, Central Pacific, has the largest tuberculosis epidemic in the region. There is a national tuberculosis control program, which has used smear microscopy for acid-fast bacilli as the main diagnostic tool for many years. In 2015, an Xpert MTB/RIF machine was procured and became functional within the tuberculosis hospital. The aim of this cross-sectional study, using routinely collected data, was to determine the effects of introducing Xpert MTB/RIF on laboratory smear microscopy practices and the pattern of registered tuberculosis cases. Between February 2015 and January 2016, there were 220 Xpert MTB/RIF assays performed with 6.4% errors and 15% detection of Mycobacterium tuberculosis: one patient showed rifampicin-resistance. One year before and after introducing Xpert MTB/RIF, the number of presumptive tuberculosis patients increased by 9% from 2,138 to 2,322. There were no changes in demographic characteristics, smear-positive results, or acid-fast bacilli grade between the two periods. The number of specimens cultured for Mycobacterium tuberculosis significantly declined from 638 to zero, with 76 positive MTB cultures before and none after introducing Xpert MTB/RIF. There was a significant change in the profile of registered tuberculosis cases with more children (34% versus 21%) and fewer bacteriologically-confirmed cases (29% versus 43%) - P < .001. Since the deployment of Xpert MTB/RIF in Kiribati, there have been a small number of assays performed and this has been associated with no adverse effects on smear microscopy, a stoppage in mycobacterial cultures, and a change in the types and categories of diagnosed tuberculosis

Ten Years On: Highlights and Challenges of Directly Observed Treatment Short-Course as the Recommended TB Control Strategy in Four Pacific Island Nations

Objectives: The internationally recommended tuberculosis (TB) control strategy, Directly Observed Treatment, Short course (DOTS) was implemented in most Pacific Island countries and territories during the year 2000, with expansion of DOTS into outer islands and rural areas over the past ten years. The objective of this study was to better understand successful strategies and challenges faced in implementing DOTS in outer islands and rural areas of selected high burden Pacific countries from the perspective of National TB Program (NTP) staff. Methods: National TB Program Managers or Coordinators from four Pacific countries, Solomon Islands, Vanuatu, Kiribati and Tuvalu, were surveyed and participated in in-depth interviews exploring what had been particularly effective and what challenges had emerged during DOTS implementation in outer islands and rural areas. Information from the interviews was analysed for shared experiences with data coded inductively using a thematic coding scheme. Results: The positive aspects of DOTS implementation in outer islands and rural areas were in three main themes: support from health workers and the community; enablers and incentives; and better treatment completion. The challenges could be categorised in five main themes: working with volunteers; stigma; traditional healers; distance and communication; and financial challenges. Local health workers, pastors, church leaders, chiefs and traditional healers were all key players in the TB Program in outer islands. Local health workers are integral to effective TB control due to accessibility and being known by the community. Conclusions: Reviewing the highlights and challenges of implementing DOTS in outer islands and rural areas in four Pacific countries has revealed some important issues. Increasing support to local health workers, actively engaging with pastors, church leaders, chiefs and traditional healers and addressing the barriers to communication and transport for people living in the outer islands are particular issues to address. Much has been achieved in TB control in outer islands but if the burden of TB is to be reduced and drug resistant TB is to be prevented, additional and ongoing investment is required

Ten years on: highlights and challenges of directly observed treatment short-course as the recommended TB control strategy in four Pacific Island nations

Objectives: The internationally recommended tuberculosis (TB) control strategy, Directly Observed Treatment, Short course (DOTS) was implemented in most Pacific Island countries and territories during the year 2000, with expansion of DOTS into outer islands and rural areas over the past ten years. The objective of this study was to better understand successful strategies and challenges faced in implementing DOTS in outer islands and rural areas of selected high burden Pacific countries from the perspective of National TB Program (NTP) staff. Methods: National TB Program Managers or Coordinators from four Pacific countries, Solomon Islands, Vanuatu, Kiribati and Tuvalu, were surveyed and participated in in-depth interviews exploring what had been particularly effective and what challenges had emerged during DOTS implementation in outer islands and rural areas. Information from the interviews was analysed for shared experiences with data coded inductively using a thematic coding scheme. Results: The positive aspects of DOTS implementation in outer islands and rural areas were in three main themes: support from health workers and the community; enablers and incentives; and better treatment completion. The challenges could be categorised in five main themes: working with volunteers; stigma; traditional healers; distance and communication; and financial challenges. Local health workers, pastors, church leaders, chiefs and traditional healers were all key players in the TB Program in outer islands. Local health workers are integral to effective TB control due to accessibility and being known by the community. Conclusions: Reviewing the highlights and challenges of implementing DOTS in outer islands and rural areas in four Pacific countries has revealed some important issues. Increasing support to local health workers, actively engaging with pastors, church leaders, chiefs and traditional healers and addressing the barriers to communication and transport for people living in the outer islands are particular issues to address. Much has been achieved in TB control in outer islands but if the burden of TB is to be reduced and drug resistant TB is to be prevented, additional and ongoing investment is required

Battling tuberculosis in an island context with a high burden of communicable and non-communicable diseases: epidemiology, progress, and lessons learned in Kiribati, 2000 to 2012

Objectives: To examine the epidemiology of tuberculosis (TB) in Kiribati from 2000 to 2012, document lessons learned, and recommend ways to mitigate the burden of TB in Kiribati. Methods: A descriptive study was performed using data on TB case notifications, prevalence, incidence, mortality, and treatment outcomes from global reports and data files. Progress towards meeting the Millennium Development Goal TB target (to reduce TB incidence by 2015) and the Regional Strategy to Stop Tuberculosis in the Western Pacific 2011–2015 targets (to reduce TB prevalence and mortality by half by 2015 relative to the level in 2000) was examined. Results: TB case notifications and the estimated incidence and prevalence have increased in Kiribati since 2000. From 2000 to 2012, Kiribati reported a total of 3863 TB notifications; in 2012, the case notification rate was 343/100 000 population. The majority (89%) of TB patients complete treatment and/or are cured, and the estimated TB mortality rate has remained relatively stable at around 16/100 000 population. HIV testing of TB patients has increased over recent years from 8% of notifications tested in 2003 to 43% tested in 2012. Of all 818 tests, only four (0.5%) patients were confirmed HIV-positive. Drug-resistant TB has been detected in a small number of cases. Conclusions: TB rates continue to increase in Kiribati and the 2015 goals for TB control are unlikely to be met. This is probably due to the complex mix of risk factors present in Kiribati, including smoking, diabetes, alcohol use, crowded living, and poverty. A comprehensive approach to address these risk factors is needed to mitigate the burden of TB in Kiribati