TECHNICAL ASSISTANCE FOR THE
PROGRAMMATIC MANAGEMENT OF
MULTIDRUG-RESISTANT TB (MDR-TB) IN
PAPUA NEW GUINEA: MISSION REPORT
June 28 – July 7, 2010
Ma. Imelda D. Quelapio, MD *
* Tropical Disease Foundation, Philippines
Acknowledgment is hereby made to the National Department of Health, Papua New
Guinea (Disease Control Branch, National TB Programme), the Central Public
Health Laboratory, Port Moresby General Hospital, Provincial Health Offices, World
Health Organization – PNG, World Vision Foundation International, Hope World
Wide, NCD Health and other stakeholders and partners.
I. Background 5
II. Terms of reference and Activities 6
III. Findings 8
IV. Recommendations 14
1A - Key persons met 20
1B - Activities conducted during this mission 21
2A - Workshop agenda for the preparation of MDR-TB
Guidelines in PNG 22
2B - Participants in the Workshop for the preparation of
MDR-TB Guidelines in PNG 23
3 – Participants of the Advocacy symposium on
4 - Response to the challenge of drug-resistant TB, NDOH 25
5 - NDOH staff trained in PMDT 26
6 - Proposed framework for PMDT activities 2011-2015 29
AusAID Australian Agency for International Development
CPHL Central Public Health Laboratory
DGH Daru General Hospital
DOT Directly Observed Treatment
DOTS Directly Observed Treatment, Short-course
DRS Drug resistance surveillance
DR-TB Drug-resistant TB
DST Drug Susceptibility Testing
EQA External Quality Assurance
FDC Fixed Dose Combination
GDF Global Drug Facility
GLC Green Light Committee
IMR Institute of Medical Research
HIV Human Immunodeficiency virus
MDR Multidrug-resistant TB
NCD National Capital District
NDOH National Department of Health
NSP New -smear positive
NTP National TB Program
PMDT Programmatic management of drug-resistant TB
PMGH Port Moresby General Hospital
PNG Papua New Guinea
QMRL Queensland Mycobacterium Reference Laboratory
SLD Second-line drug
The Union International Union against Tuberculosis and Lung Diseases
WVI World Vision International
WHO World Health Organization
XDR-TB Extensively drug-resistant TB
Technical Assistance for the programmatic management of MDR-TB
in Papua New Guinea: Mission Report
Date of mission: June 28 – July 7, 2010
Consultant: Ma. Imelda D. Quelapio, MD
DOTS was introduced in Papa New Guinea (PNG) in 1997 starting in the
National Capital District (NCD) and Lae District. 1 Under the Stop TB Strategy for
PNG, the NTP plans to cover 80% of the population in the 67/87 districts and
20/20 provinces in the country in a phased manner within five years (October
2007 – September 2012).2 At the present time, DOTS has been implemented in
9 out of 20 provinces covering 61% of population through funding from the Global
Fund to Fight AIDS, TB and Malaria (GFATM).
In 2007, the estimated annual incidence of all forms of TB in PNG was 250 per
100 000 population; among new smear-positives (NSPs), this was 108 per
100 000 and the prevalence of all cases was 430 per 100 000. The estimated TB
mortality was 60 per 100 000. With a population of 6.6 million, these rates
correspond to 15,796 incident cases for all types, 6,815 incident NSP cases,
27,197 prevalent cases, and 3,817 deaths.3 Based on NTP data, case detection
in 2009 among NSPs was 31% with a treatment success in 2008 of 73%.
For a long time, PNG was faced with the challenge of uncertain and meagre
funding for TB control.1,2 Loose TB drugs obtained from local procurement have
been used until 2007 when fixed drug combination (FDC) was introduced
procured through the Global Drug Facility. The long use of drugs with uncertain
quality and a high pill burden for patients, the lack of an overall DOTS strategy
until recently, could be factors to consider as contributory to the emergence of
multidrug-resistant TB (MDR-TB) facing PNG for years.
Since 1995, MDR-TB has been informally addressed through clinical treatment
offered in hospitals using locally procured second-line anti-TB agents. During this
Country Status Report of National TB Program, Papua New Guinea (1997-2005) NTP, NDOH
Report of Joint Review Mission for National TB Program in Papua New Guinea (2006-2010) NTP,
Global TB Control 2009: Epidemiology, Strategy and Financing, 2009. WHO/HTM/TB/2009.411
time, there was scarce evidence for the proper treatment of MDR-TB. Neither
was there strong political will to treat these cases and the priority was heavily just
on DOTS. However, more recently, guidelines and recommendations on the
comprehensive management of drug-resistant TB (DR-TB) through a framework
have been made available based on best evidence. 4,5 There has been financial
and political momentum and a global push to treat this dreaded strain in the
context of a programmatic approach integrated in national TB programmes. The
National Department of Health (NDOH) of PNG has decided to collectively
address this problem and put together its own national Guidelines for the
Programmatic Management of Drug-resistant TB (PMDT) guided by the available
WHO guidelines with consideration of its unique setting and own experience in
DR-TB management. It was mainly for this purpose that this technical assistance
II. TERMS OF REFERENCE AND ACTIVITIES
The terms of reference of this mission are as follows:
1. To visit sites of MDR-TB management and relevant TB service delivery areas
2. To review the MDR-TB Guidelines development process in PNG
3. To expand the existing framework of the National MDR-TB Guidelines and
prepare a pre-final draft of the Guidelines
4. To suggest a framework for MDR-TB activities to be incorporated in the next
NTP strategic plan of 2011 - 2015
5. In conjunction with a focal person in the NTP, to prepare an initial draft of GLC
application by PNG, focusing on needs assessment of the NTP
This mission was accomplished through site visits to areas relevant in the
management of DR-TB, meetings and discussions with key persons who have been
involved or who will potentially be involved in the management of DR-TB. (Annex 1A
and Annex IB). A major activity in this mission was participation in a two-day
workshop for the preparation of the MDR-TB Guidelines spearheaded by the NTP
and attended by various stakeholders (Annex 2A and Annex 2B). This workshop
Guidelines for the Programmatic Management of Drug-resistant TB, WHO/HTM/TB/2006.361
Guidelines for the Programmatic Management of Drug-resistant TB, Emergency Update 2008,
aimed to discuss the contents of the national MDR-TB Guidelines for PNG and to
inform the participants of the current WHO Guidelines on PMDT 5. Participants
included representatives from the central and provincial levels of healthcare and
other NTP partners. Another important activity was an advocacy symposium on
MDR-TB and XDR-TB (Extensively drug-resistant TB) convened by WHO-PNG
attended by various stakeholders (Annex 3). During this symposium, the NDOH
response to the challenge of drug-resistant TB was presented by the Deputy Health
Secretary (Annex 4).
Site visits were made to:
Port Moresby General Hospital (PMGH) Out-patient TB Clinic and MDR-
TB Ward: the main areas where MDR-TB cases are currently being
treated in PNG.
Central Public Health Laboratory (CPHL): the national TB reference
Central Drug Warehouse, Badili: the national drug storage of NDOH
Nine Mile District Health Facility: a public DOTS health center in Port
Interviews and discussions were made with:
key persons for the programmatic and clinical management of DR-TB,
laboratory management, drug management of TB, data management of
an MDR-TB patient
a treatment partner/observer of the MDR-TB patient
Participation in Workshop for MDR-TB Guidelines preparation (Lae, Morobe)
Discussion on the GLC application template with the NTP, CPHL, PMGH and
III. FINDINGS IN THE MISSION
A. Magnitude of the DR-TB problem in PNG
The magnitude of the DR-TB problem in PNG has been estimated only through
modelling by WHO.6 The country’s first Drug Resistance Surveillance (DRS) is set
to be started this year through funding from the Global Fund to Fight AIDS, TB and
Malaria (GFATM), albeit for only two provinces (NCD and Morobe) 7 and with
technical support from the Queensland Mycobacterium Laboratory (QMRL).
Multidrug and Extensively drug-resistant TB (M/XDR-TB): 2010 Global Report on Surveillance and Response.
Papua New Guinea Proposal to the GFATM Round 6, July 2006
The 2010 WHO Report 6 estimates the MDR-TB rate in PNG among new cases at
1.9% (95% CI: 0.0-7.5) and 13.8% (95% CI: 0.0-36.2) among previously treated
cases. An estimated 530 (95% CI: 9-1,300) MDR-TB cases occur yearly among new
and incident new and relapse TB cases and 73 (95% CI: 0-210) among incident
acquired MDR-TB cases with a total of 603 (95% CI: 0-1,200) cases every year.
Although DRS has not yet been done, there are data available locally that support
the presence of MDR-TB cases in PNG. The table below shows the three surveys
done by CPHL, PNG-Institute of Medical Research (IMR) and Daru General Hospital
(DGH) with varied drug-resistance rates. Specimens at CPHL and DGH were mostly
from DR-TB suspects collected randomly rather than consecutively; hence, results
should be interpreted with caution. Specimens at PNG-IMR were from TB cases in
the community, but at this point in time, it is not clear whether these were
consecutively enrolled cases from a given microscopy centre.
Table 1. Local data on DR-TB available in PNG
Agency Period No. studied Rate of drug-resistant TB
that covered No. of No. with Any MDR-TB
conducted patients DST resistance (no. and %)
the survey results (no. and %)
CPHL* 2008- 126 63 53 (84%) 26 (41%)
PNG IMR** 2009- 150 49 5 (10%) 3 (6%)
DGH *** 2009 28 24 17 (71%) 11 (46%)
* Funded by WHO ** With Swiss Tropical Inst., PGMH, QMRL *** Funded by AusAID
B. Political commitment
Clearly, there is government commitment to expand DOTS and an increasing
recognition of the MDR-TB problem in PNG.
DOTS continues to expand in a phased manner. The first External Review of the
NTP was conducted in May 2009 highlighting the progress of DOTS
implementation and various recommendations.8 While full DOTS is not yet in
The Global Drug Facility Mission Report (PNG), Mar 22-26, 2010 (John Holley, Peter Heibling)
place in all areas, PNG has shifted to FDCs and are now available nationwide;
and DOTS recording / reporting tools have been introduced.
Although MDR-TB patients are receiving treatment, there is no institutional and
systematic strategy yet within the NTP to confront this problem.
There has been interest to establish capacity for MDR-TB management in the
country. Four staff from the NDOH have been trained in PMDT (Annex 5).
While the government has been allocating funds for the local procurement of
drugs for MDR-TB patients, resources for a comprehensive programmatic DR-TB
management, including human resource development and training, ancillary
drugs and patient enablers, recording and reporting, infection control, etc., have
not yet been identified.
C. Diagnosis and the laboratory aspect
The CPHL has staff dedicated to TB work.
It is managed by a Director assisted by a Laboratory Manager, an Officer-in-
charge of the TB laboratory and WHO supported laboratory staff.
o All staff are trained for microscopy; 2 are trained on solid and liquid culture.
There is GFATM funding for additional laboratory training this year and next
EQA implementation has been continuously progressing since 2007 with a
current coverage of 62% of smear microscopy centers (77 of 124 microscopy
centres were visited in 2009).
CPHL has experience in culture.
o TB culture used to be performed in CPHL in the first quarter of 2010;
however, due to inadequate biosafety measures noted in a recent mission,9
this was temporarily stopped.
o Culture and DST have been done in PNG’s supranational laboratory, QMRL
at a 137 USD/specimen. This continues to be the arrangement at the moment
for DR-TB suspects covered by a contract with WHO.
Current case-finding strategy
TB-Infection Control Consultancy Visit, Papua New Guinea, 10-20 May 2010 (Arch. Thea Zuccotti)
o DR-TB suspect referrals from city clinics are admitted to the TB ward of
PGMH where sputum is collected and sent to CPHL.
o For referrals from other provinces, sputum specimens are transported from
there to CPHL.
o CPHL in turn sends the specimens to QMRL for culture and DST.
For MDR-TB treatment follow-up, smears are done every three months after
treatment start and are used as the basis for “conversion” and likely success.
Culture is never done for patients on category IV treatment except at baseline.
D. Treatment for MDR-TB
Ninety-four MDR-TB cases have been initiated treatment since 1995 using
second-line drugs (SLDs) mainly in PMGH, although a number have likewise
been treated in other provinces.
Existing Treatment strategy: In PMGH, smear-positive DR-TB suspects with
known HIV status referred from city clinics are admitted in the MDR-TB ward
even before DST confirmation.
o Patients who had previously received unsupervised category II are restarted
on Category II regimen.
o Patients who had previously received supervised category II are started on
category IV regimen.
o Patients are confined while smear-positive usually till the 4th month. Once
smear-negative, the injectable is discontinued and patients are discharged
through the TB Clinic of the hospital. Instructions are given regarding the
next follow-up, and drugs are supplied to the patient and/or his treatment
partner, usually a family member.
o Category IV regimen: A standardized regimen is used consisting of an
injectable (amikacin from 1995 till early 2009 and capreomycin since 2009-
2010), a fluoroquinolone (ofloxacin) and two oral bacteriostatic second-line
drugs (SLDS), ethionamide and cycloserine. Seventy patients have been
given the earlier regimen with amikacin while 24 have been started on the
new regimen with capreomycin.
Table 2. Standardized Category IV regimen for MDR-TB used in PNG
Period 1995-2009 2009-present
No. treated (N=94) 70 24
Injectable Amikacin 1 gr Capreomycin 500-750 mg
Fluoroquinolone Ofloxacin Ofloxacin 200 mg BID
Other oral Ethionamide Ethionamide 250 mg BID
bacteriostatic SLDS Cycloserine Cycloserine 250 mg BID
o Although the above regimen is consistent with the general principles for
regimen design recommended by the WHO Guidelines, 5 more information is
needed to validate the rationale for the use of capreomycin as the injectable
of choice and ofloxacin as the fluoroquinolone of choice.
o The drug dosages applied need to be in line with those recommended in the
guidelines. Recommendations are weight-based 5
Capreomycin – 1 gram daily for patients >51 kg, given OD rather
than in split doses
Ofloxacin – at least 800 mg daily for patients >33 kg daily
Ethionamide and Cycloserine – at least 750 mg daily for >51kg
o The injectable is given only for 4 months as soon as the smear turns
negative. The recommendation is at least 6 months of the injectable and at
least 4 months from the time of sputum conversion for better chances of a
sustained negative bacteriologic status.
o PMGH MDR-TB ward: This is a 55-bed ward only for non-acutely ill sputum-
positive retreatment cases and confirmed MDR-TB cases with known HIV
status. The cases are managed by a senior clinician and TB specialist who
has been treating MDR-TB since 1995. He is assisted by a team of registrars
(MDs), nurses and other paramedical workers.
The area of the ward is spacious with jalousies on both sides of the
The ward is divided by a semi-complete wall separating males and
females. Patients are mixed regardless of bacteriologic and HIV status.
(No segregation of immunocompromised in-patients from open TB
cases is being done).
Infection control measures such as administrative controls, engineering
controls and personal protective equipment are not observed.
o PMGH TB clinic: This is an outpatient clinic where TB and MDR-TB patients
follow-up after discharge from the Ward and during the continuation phase.
Three registrars, a resident medical doctor and a paramedical health
extension officer assist the senior TB specialist.
o Other provinces: Treatment areas in other provinces have not been
Supervised therapy or directly observed treatment of MDR-TB patients is done
strictly by the ward nurses twice daily at 9AM and 9PM which is commendable.
However, supervised therapy is not strictly enforced after discharge. The
medicines are provided to patients through their family members, and taken on a
There are many patients who have not followed up since discharge. There is no
mechanism in place for actual default tracing other than through phone calls.
o Of the 94 total patients put on treatment since 1995, 24 patients are on the
current regimen, of whom 7 are confirmed MDR-TB by QMRL. Ten patients
are currently admitted in the ward, while 14 have been discharged.
o Twenty- one other MDR-TB patients are receiving category IV treatment in
other provinces: 13 in Western Province (11 in Daru), 2 in Lae (Morobe), 2 in
Madang, 2 in Milne Bay Province.
o Physicians in other provinces consult the TB specialist in PMGH through
phone. No training on MDR-TB management is in place at the moment.
Drugs are either picked up or transported to the requesting physicians and
replenished as necessary based on phone call requests (No invoice or drug
order form raised and submitted).
Adverse drug effects from locally procured SLDs are surprisingly uncommon, and
in fact, not considered a problem at all among patients receiving treatment.
HIV testing is done in all TB/MDR-TB patients; however, there is no policy to
separate the HIV-infected TB cases from the infectious TB cases.
Western Province: a special area in PNG (source: Presentation during Workshop
by Asst. TB/HIV Officer, Daru General Hospital –Annex 2A)
The Western Province is a low density province with 2 people/km 2 and a
population of around 186,000. It has three districts: North, Middle and South Fly.
Daru Island is in the South Fly District which shares its border with Australia and
Indonesia. There is free movement of people between these treaty villages in
PNG and Australia. As DOTS expansion under the GFATM,7 has set the Western
Province for the last year (2011), the TB services are not in place. Hence, people
have the tendency to access TB treatment across the border with Australia. It
was however, noted that DOTS is not being implemented in these cases and
patients return to PNG as treatment defaulters harboring the risk for drug-
Since 2001-2008, there have been 35 patients from the treaty villages diagnosed
with MDR-TB cases. Most cases come from Mabuduan (33%), Dary (19%) Dimiri
(17%) and others.
Eleven patients have been put on the PNG category IV regimen since Oct 17,
2009 in the Daru General Hospital (DGH), 10 of whom are confirmed and one
suspected. Two cases were started on regimens from Australia.
The challenges encountered in DGH are as follows: a) lack of coordination of
patient referrals between PNG and Australia; b) confusion of different drugs and
treatment regimens, c) lack of supervision and monitoring of TB treatments, d)
delay and ineffective clinical management of TB patients (results received late,
lack of guidelines to follow), e.g., mono- and poly-resistant cases e) lack of
trained work force to manage MDR cases, f) lack of beds, isolation ward, g) lack
of systematic drug procurement, drug supply management and h) lack of culture
capacity for monitoring of treatment.
D. Uninterrupted supply of drugs
SLDS used in PNG are locally procured. However, none are WHO pre-qualified
(http://apps.who.int/prequal/ - tuberculosis) as of the date of the visit.
Table 3. List of SLDs used for MDR-TB and their manufacturers
1. Amikacin 500 mg vial Biochem Pharma, India
2. Capreomycin 1 g vial North China Pharmaceutical
3. Ofloxacin 200 mg tab Intas, India
4. Ethionamide 250 mg tab Lupin, India
5. Cycloserine 250 mg tab Lupin, India
Source of information: NDOH Pharmaceuticals Medical Supplies Branch, NDOH
While cost of the standard regimen is apparently lower using locally procured
drugs compared to drugs procured through the GLC mechanism, the quality of
drugs remains uncertain.
Some SLDs were stored in the Badili warehouse together with all the other drugs
The PMGH TB Clinic also stores SLDs with an inventory maintained by the
nurse. Distribution to provinces for the MDR-TB cases is coursed through the TB
specialist managing this clinic through informal verbal requisitions.
E. Recording and Reporting
A category IV Register is available in PMGH but needs to be conformed to the
necessary register format for MDR-TB patients.5
Other essential forms for PMDT5 such as Category IV Treatment Card, Request
Forms, etc. still need to be drafted, printed and disseminated.
No cohort analysis has been done yet on patients started on Category IV
regimen to determine treatment outcomes.
The programmatic management of DR-TB is complex. The requirements for its
proper implementation are multi-faceted based on a wholistic framework for its
control.5 It should be underscored though that quality DOTS must remain a priority in
PNG hand-in-hand with the implementation of PMDT. This mission strongly supports
that recommendations made in the External Review of the NTP in 2009 2 that have
not yet been acted upon be addressed to ensure a good foundation of DOTS as
PMDT is initiated.
Section A below lists four key recommendations for PMDT in PNG. Section B lists
the specific recommendations based on the different components of the framework.
A. Key recommendations
1. Fast track the quality implementation of DOTS particularly in areas where there
are practices that likely promote drug resistance and where MDR-TB treatment
services are most needed.
2. Ensure proper treatment of currently enrolled and future MDR-TB cases to
prevent XDR-TB by putting in place the minimum recommended framework while
taking into consideration the PNG setting.
3. Support CPHL in strengthening laboratory capacity including addressing biosafety
4. Create a core team based within the NTP that will have an oversight of PMDT
implementation in the country.
5. Ensure continuous and non-interrupted supply of quality assured Category IV anti-
6. Ensure cohort-based monitoring of PMDT cases and reporting of culture-
conversion and outcomes.
B. Specific recommendations based on the MDR-TB Control framework
1. Political commitment:
Secure a more comprehensive funding for a sustainable programmatic approach
to MDR-TB management thereby ensuring the proper infrastructure in the
country, e.g., next round of the Global Fund.
Carefully plan the DRS to produce representative results. Request funding from
WHO-HQ which is available to complement the current GFATM fund for only two
provinces. Seek available technical assistance from WHO-WPRO and HQ and
utilize the revised DRS Guidelines.10
Revisit the Treaty Agreements with Australia and fast track setting up of DOTS in
the Western Province to ensure availability of quality services in the PNG side of
Consider application to the Green Light Committee11 to access quality assured
drugs, technical assistance in various aspects, capacity building, etc.
2. Laboratory aspects
Request technical assistance for laboratory aspects through the Global
Laboratory Initiative http://www.who.int/tb/dots/laboratory/gli/en/ particularly on
new diagnostics with consideration of PNG’s background, capacity and
Fast track CPHL upgrade to a status that ensures acceptable biosafety
measures for the performance of culture and DST.
Strengthen CPHL to lead the laboratory network and expand based on the
Send more CPHL staff for training in QMRL.
CPHL to do culture and DST in-country for the diagnosis and follow-up of
treatment. More culture facilities to be established in two or more provinces in
near future so as to give coverage to cases from all over the country.
Consider uptake of new diagnostic methods such as Line Probe Assay and fully
automated NAAT so that turn-around times for MDR-TB diagnosis are
3. Infection control (IC)
Implement recommendations in the last IC mission particularly for CPHL and the
treatment areas for TB.9 Ensure segregation & containment of open cases of TB
Guidelines for surveillance of drug resistance in TB, 4 ed. WHO/HTM/TB/2009.422
Green Light Committee Application Instructions. WHO/HTM/TB/2010.1
in the medical wards, preferably have a contained area for isolation of smear
Appoint a focal point for TB-IC.
Create a pool of IC trainers in PNG and train other health providers as the
4. Treatment delivery
Complete DOTS expansion (Stop TB Strategy) to entire country as soon as
possible. Ideally, PMDT should be made available only in those settings where
Stop TB Strategy has been implemented and community settings for treatment
observation and patient support during treatment are in place. NTP is
encouraged to identify this important principle of “add-on” nature of PMDT
services and therefore implement basic TB services and DOTS first in all the
provinces on a priority basis. This issue may be taken up by NTP in writing with
donors such as Global Fund so as to expedite Stop TB strategy expansion to the
entire country as soon as possible.
Develop a treatment infrastructure for MDR-TB
o Upgrade PMGH ward and TB clinic to become a model site
o Replicate in other areas such as Daru General Hospital, etc.
Ensure quality delivery of treatment:
o Implement strict DOT all throughout treatment by trained health/community
workers preferably, non-family members. Coordinate hospitals with
peripheral treatment services, and engage partners such as World Vision
International (WVI), Hope Worldwide, Church Medical Council, etc., in close
collaboration with the NTP. Utilize ACSM strategies. Preferably, prepare a
document on Strategy for Community-based PMDT care in Papua New
Guinea, in collaboration with NTP partners such as WVI and Hope
Worldwide, so as to cover the communication and adherence issues.
o Review regimen used and the corresponding drug dosages and align with
recommended guidelines. Consider quality, effectiveness, and cost.
o Monitor response to treatment through culture and microscopy.
o Put in a place a mechanism for tracing treatment interrupters and defaulters.
o Manage adverse drug reactions adequately: monitor through physical and
laboratory examinations and provide ancillary drugs for adverse drug
o Provide psychosocial support such as patient enablers to minimize default.
o Do contact tracing to household members of MDR-TB cases and other close
o Conduct patient empowerment activities such skills training while on
treatment, livelihood initiatives, advocacy activities, etc.
Assess other sites of treatment for completeness of MDR-TB implementation
framework and quality of service delivery.
Formalize TB/HIV collaborative activities and offer HIV testing to all TB and
4. Human resource development (HRD) and training
Create a core team led by the NTP Manager assisted by a Focal Person for
PMDT committed to oversee and provide direction to PMDT implementation in
the country. This team is composed of point persons for the different components
of the framework such as treatment delivery, laboratory, infection control, human
resource development and training, drug management, and recording and
Figure 1. Organizational chart of PMDT Core Team under the NTP
Program Manager, NTP
Focal Point for MDR-TB
Treatment delivery Human Resource
Development and Training
Laboratory and Infection
Recording and reporting
Create a case management committee (or consilium) to ensure the review of
individual cases upon enrolment, during treatment and upon treatment
completion. This also serves as a venue to train more health providers in the
management of DR-TB.
Support capacity building to PMDT core team through national trainings,
exposure and technical assistance. Utilize existing training modules for MDR-
Conduct a Training of Trainers at the central level with support from WHO-
WPRO and technical assistance from international facilitators. Central trainers
will then conduct trainings for provincial, district and community levels.
Draft training materials for key audiences, e.g., central level, provincial, district,
community partners, etc. based on a task analysis.
Request technical for different aspects of PDMT, namely, clinical management,
drug management, recording and reporting, etc.
5. Drug management
Train the point person for PMDT drug management who will in turn train those in
charge at different levels.
Ensure quality assurance of SLDs used in the country to prevent XDR-TB.
Encourage local manufacturers to participate in the WHO pre-qualification
program. http://apps.who.int/prequal/. Medical Supplies Branch, NDOH to issue a
notification/ order that WHO pre-qualified suppliers for TB drugs will be given
preference over non-prequalified suppliers/ manufacturers during short-listing for
procurement contract award.
Set up a drug management system for PNG managed by the core PMDT team.
o Procurement: ensure rationale quantification and timely ordering of quality
drugs to avoid stockout and wastage.
Management of Drug-Resistant Tuberculosis Training for Health Facility Staff. WHO 2010 [Draft]
Management of Drug-resistant TB Training for Health Facility Staff in the Philippines.Tropical Disease
Foundation and Department of Health, Philippines 2008
o Storage: ensure a safe and secure space for SLDs at the central level and
the peripheral areas where MDR-TB is being treated. Maintain an efficient
o Distribution: ensure an efficient issuance of drugs from central to peripheral
o Use: keep drugs restricted only to authorized health providers.
6. Recording and reporting; program monitoring and evaluation
Train the point person for recording and reporting who will, in turn, train those in
charge at different levels.
Set up an information system for PNG managed by the core team.
o Draft essential recording and reporting forms for PMDT and incorporate it in
the existing BMU reporting format.
o Establish the flow of reporting from peripheral to central levels.
o Integrate PMDT reporting into a web-based information system integrated
Do a cohort analysis of past, present and future patients.
M and E:
o Conduct yearly program implementation reviews to discuss lessons learned
o Conduct a national workshop at least yearly for monitoring of PMDT
o Request an external monitoring mission for PMDT, preferably via GLC and
WHO Stop TB before end of 2011.
Annex 6 is a proposed framework of MDR-TB activities to be incorporated in the next
NTP strategic plan for 2011 – 2015 assuming that a comprehensive funding for PMDT
is available. The activities and timelines are to be revisited and tailored as soon as DRS
results are available and targets for diagnosis and treatment are set by the NTP.
KEY PERSONS MET
Key agencies and persons Designation
National Department of Health (NDOH)
Dr. Clement Malau Health Secretary
Dr. P. Dakulala Deputy Health Secretary
Mr. Enoch Posanai Executive Manager, Public Health
National TB Program (NTP), NDOH
Dr. Paul Aia Manager, National TB Programme (NTP)
Dr. Robin Yasi Regional NTP Officer (Momase)
Dr. Margaret Kal Regional NTP Officer (Islands)
Central Public Health Laboratory (CPHL), NDOH
Dr. Evelyn Lavu Laboratory Director
Ms. Oscillah Kaminiel Laboratory Manager
Mr. Apeo Manoni OIC, TB Laboratory
Pharmaceuticals Medical Supplies Branch, NDOH
Mr. Vali Karo Principal Advisor, Pharmaceuticals
Port Moresby General Hospital
Dr. Joseph Bana-koiri TB Consultant
Partners and Stakeholders
Dr. Wuatai NCD Health
Marlon Villanueva Technical Advisor ACSM World Vision
Mr Simon Kosap Hope World Wide
World Health Organization, PNG
Dr. Eigil Sorensen Country Representative
Dr. Yamuna Mundade Medical Officer, TB
ACTIVITIES CONDUCTED DURING THIS MISSION
Date Activity Persons met
Mon Briefing on Mission TORs Dr. Eigil Sorensen, WHO
Jun 28 Dr. Yamuna Mundade, WHO
Briefing on Mission Activities Dr. Paul Aia, NTP Manager
Visit to Port Moresby General Hospital TB Clinic Dr. Joseph Bana-Koiri, TB Consultant,
Registrars, nurse, social worker(s), Dr.
Aia, Dr. Mundade
Tue Visit to PMGH TB Ward and participation in Dr. Joseph Bana-Koiri, Dr Randy Moke
Jun 29 weekly rounds and Team, Dr. Aia
Visit to Central Public Health Laboratory Dr. Evelyn Lavu, Lab Director
Ms. Oscillah Kaminiel, Lab Manager
Mr. Apeo Manoni, TB Lab OIC
With Dr. Aia, Dr. Mundade
Meeting on NTP Drug management Mr Graham Wavimbukie, Nat’l Logistics
Meeting on Drug Procurement Mr. Vali Karo, Principal Advisor
Pharmaceutical Medical Supplies, NDOH
Mr. Elani Kou, Senior Purchasing Officer
Visit to Badili, National Warehouse Mr Graham Wavimbukie, National
Port Moresby to Lae, Morobe Logistics Coordinator, Ms Kilala Owen:
Nat’l Logistics Assistant,
Ms Sepora, Logistics Assistant
Wed Visit to Nine Mile Clinic (public DOTS Facility, Sr. Nimai Deravi, Nursing Officer in
Jun 30 Hope Worldwide) charge of DOT Centre and Team
Meeting on NTP Data Management Andrew Kamarepa, National M & E
Travel from Port Moresby to Lae, Morobe
Jul 1 Workshop on the preparation of the MDR-TB See Annex 2A for Workshop agenda and
Fri Guidelines Annex 2B for participants
Sat Travel from Lae to Port Moresby
Jul 3 Report writing
Sun Report writing
Mon Meeting with NTP to review Draft Guidelines Dr. Robin Yasi, NTP
Jul 5 Review of MDR-TB Records in PMGH Dr. Joseph Bana-koiri
Tue Meeting to discuss GLC Application template Dr. Robin Yasi, NTP
Jul 6 Dr. Joseph Bana-koiri, PMGH
Dr. Evelyn Lavu, CPHL
Dr. Yamuna Mundade, WHO
Meeting with NDOH Dr. Dakulala, Deputy Health Secretary
Dr. E. Sorensen, WHO
Wed Symposium on MDR/XDR-TB See Annex 3 for participants.
Jul 7 Debriefing Mr. Enoch Posanai, Executive Manager,
Public Health chaired the meeting.
NTP and other stake-holders
participated: PMGH, CPHL, NCD Health,
WHO, World Vision, JTAI and Hope
WORKSHOP AGENDA FOR THE PREPARATION OF MDR-TB GUIDELINES IN PNG
Day 1 - July 1, 2010
Welcome and Opening P. Aia, NTP Manager
Objectives of the workshop /Proposed elements of the P.Aia
Background on TB Control and DOTS M. Kal, NTP Regional Officer
Epidemiology and magnitude of MDR-TB P. Aia
Causes of MDR-TB R. Yasi, NTP Regional Officer
MDR-TB/XDR-TB Global Response/GLC Y. Mundade, WHO TB Medical Officer
EXPERIENCES – Case-finding and Laboratory
National EQA Assessment in TB Microscopy J. Kumbu, National Laboratory
CPHL Surveillance update on MDR-TB in PNG E. Lavu, CPHL Director
IMR surveillance on drug-resistant TB P. Harino, PNG-IMR Consultant
EXPERIENCES – Clinical /Programmatic management
Clinical experience in current management, PMGH J. Bana-koiri, PMGH TB Consultant
DR-TB drug experience, lab diagnosis and management in A. Marome, Asst. TB&HIV Officer, Daru
Daru General Hospital General Hospital
Experience in the Philippines in Programmatic management of M. Quelapio, MDR-TB Consultant WHO
WHO Framework for PMDT M. Kal
MDR-TB Definitions R. Yasi
DRS Y. Mundade
Case-finding (detection, diagnosis, classification) M. Quelapio
Group 1 – Case-finding, lab and diagnostic algorithms Group 2 J. Bana-koiri, M. Quelapio
– DRS P. Aia, Y. Mundade
Day 2 - July 2
Organization of Lab network including QA for culture and DST A. Manoni, OIC TB Lab, CPHL
Treatment strategies, second-line drugs J. Bana-koiri
MDR-TB PMDT options in implementation M. Quelapio
M and E Recording and Reporting Dr. P. Aia
Training and Human resource development Dr. P. Aia
Drug management G. Wavimbukie, National Logistics
Group 1 – Treatment strategy J. Bana-koiri
Group 2 – Monitoring and community support M. Quelapio
Group 3 – Recording and reporting M. Kal
Group 4 - Training R. Yasi
Finalization Dr. P. Aia
WORKSHOP PARTICIPANTS FOR THE PREPARATION OF MDR-TB GUIDELINES
AGENCY AND PARTICIPANTS DESGINATION
National TB Program
Dr. Paul Aia NTP Manager
Dr. Robin Yasi Regional Medical Officer (Momase)
Dr. Margaret Kal Regional Medical Officer (Islands)
Mr Graham Wavimbukie National Logistics Coordinator (JTAI)
National HIV/STI Programme
Dr John Milan Advisor, HIV Treatment and care
Central Public Health Laboratory
Dr. Evelyn K Lavu Senior Specialist MO & Director CPHL
Mr. Apeo Manoni Officer-in-charge, TB Lab
Janlyn Kumbu National Laboratory Coordinator
Port Moresby General Hospital
Dr. Joseph Bana-koiri TB Consultant, PMGH
PNG Institute of Medical Research (IMR)
Paul Harino Consultant, PNG-IMR
Dr Bernard Belari Physician, AMGH, Lae
Dr Cathy Timothy Physician, AMGH, Lae
Dr Kilagi Vanuga Physician, Goroka General Hospital
Dr Sidney James Surgeon and Actg CEO, Daru General Hospital
Dr. Kendaura Physician, Goroka
Sr Lucy Moris Provincial Disease Control Officer
Dr. Naomi Pomat WP Communication Officer, Daru
Sr Lillian Motup TB Programme officer, Daru General Hospital
Abel Marome Assistant TB/HIV Officer, Daru Hospital
World Vision International
Akissa Kawe District Coordinator for Lae
World Health Organization
Dr. Yamuna Mundade Medical Officer, TB
Ms. Sabina Waffi TB Technical Coordinator WHO (SSA)
PARTICIPANTS OF THE ADVOCACY SYMPOSIUM ON MDR-/XDR-TB
AGENCY AND PARTICIPANTS DESGINATION
Dr Paison Dakulala, Deputy Secretary, NDoH – Co-Chairman
Dr Eigil Sorensen, WHO Representative, PNG – Convenor & Co-chair
National Department of Health
Mr. Enoch Posanai Executive Manager, Public Health
Dr. Goa Tau Executive Manager, Medical Standards Division
Dr. David Mokela Chief Pediatrician and Assistant CEO, PMGH
Dr. Pyakalia National Capital District (NCD) Health
Dr. Wuatai NCD Health
Dr. Joseph Bana-koiri TB Consultant, PMGH
Dr. Evelyn K Lavu Senior Specialist Medical Officer, Central Public
Ms. Oscillah Kaminiel Laboratory Manager
World Health Organisation
Mr Anthony Gomes Laboratory Specialist
Dr Mamel Quelapio Short-term Consultant
Dr Agatha Lloyd MO HIV Care and treatment
Dr Fabian Ndenzako MO HIV Prevention
Dr Yamuna Mundade MO (TB/Lep)
Mr Saipo Henry Sikipris GFATM Grant Co-ordinator
New Zealand AID __
World Vision International
Mr. Marlon Villanueva ACSM Technical Adviser/National TB Manager
Dr. Ernesto Bontuyan National TB Coordinator
University of PNG, Medical School
Professor John Vince Professor of Paediatrics
Response to the challenge of drug-resistant TB, NDOH
Response to the Challenge of MDR-TB in PNG
Papua New Guinea is a high-burden TB country in the Western Pacific Region, as per
WHO estimates. The current estimated prevalence of all forms of TB as per latest estimates is
430 per 100,000 population (for 2007, Tuberculosis Control in the Western Pacific Region, 2009
Report, World Health Organisation). The estimated incidence of positive TB cases in PNG is
108 per 100,000 population (2007).
The following are the estimates for PNG for Multi-Drug Resistant-TB (MDR-TB) as per
the 2010 Global MDR-XDR Surveillance Report of WHO:
– Percentage MDR amongst new cases: 1.9% (0 to 7.5%, 95% CI)
– Percentage MDR amongst re-treatment cases 13.4% (0-36.2%, 95% CI)
– Number of MDR-TB among incident new and relapse TB cases 530 (9-1300,
– Number of MDR-TB among incident total TB cases 600 (0-1200, 95% CI)
By June 2010, more than 30 cases of MDR-TB have been confirmed in PNG. Port
Moresby and Daru have reported most cases, however there are isolated reports from Lae,
Tabubil, Alotau, Madang etc. Keeping in view existing TB situation and lack of representative
survey based information on actual prevalence of MDR-TB in Papua New Guinea it is proposed
to adopt the following strategy to address MDR-TB in Papua New Guinea:
1. Prevent additional emergence of MDRTB and XDR-TB by strengthening all
DOTS and Stop TB activities and conforming to evidence based best
• Increase coverage of DOTS implementation so as to reach 100%
coverage of provinces (currently 9 of 20 provinces)
• Prompt initiation on treatment (Time to register) of identified TB cases
• Ensuring cure of sputum smear positive TB cases
– Use Quality assured drugs;
– Use of drug combinations with appropriate strength (dosage)
– Appropriate duration of treatment (loose drugs)
– Supervision of treatment doses intake (DOT)
• Evidence based and best-practice based TB treatment:
– Reducing over-diagnosis of extra-pulmonary and smear negative
– Reducing incorrect categorization
– Lab testing at change from Intensive Phase to Continuation Phase
of treatment (use of sputum microscopy based follow-up testing)
and at end of treatment
• Drug regulation
– Stopping indiscriminate prescription of TB drugs
– Availability in the market
• Including all TB drugs in Essential Drug List (EDL) and rebate/exemption
from tax and excise
2. Strengthen laboratory services for quality assured and timely diagnosis of MDRTB and
• Assess and improve quantum of TB suspect referral (> 1%) from the population
• Wide-spread access to good quality of smear microscopy
– Provide widespread access to sputum smear microscopy
– Strengthen External Quality Assessment
– Establish efficient sputum transportation mechanism in all parts of the
• Good access to sputum / specimen culture for patients failing TB treatment
• Establishing BSL-3 TB reference lab or in the first stage a BSL-2 plus lab with BSL-3
practices at Central Public Health Laboratory, Port Moresby
• Provide TB culture services in select provincial labs, based on need and workload
3. Expand the programmatic management of MDR-TB and XDR-TB:
• Identify a focal point at NTP level to co-ordinate this activity. Additional HR would
be required at PMGH/ NTP and at CPHL
• Have phased expansion of services, with initial focus on identified hot-spots in
• Develop standard MDR-TB guidelines to ensure standardized treatment in line
with internationally accepted practices
• Develop training methodology and plan for capacity building to foster
incorporation of best practices into NTP services and acceptance of same by
physicians, clinicians and health care workers in the country
• Procure and supply good quality second-line drugs in an uninterrupted manner
• Implementing a rigorous M&E system with robust recording & reporting of PMDT
activities, ongoing cohort based analysis, feedback to implementing centres and
publishing of reports quarterly
• Provide patient support as would be required, including social security
4. Assessment of Drug Resistance situation in the country:
• Undertake Drug Resistance Surveillance periodically, with community based
• Gradually develop laboratory capacity to have on-going Routine Drug
Susceptibility testing for re-treatment cases
5. Implement infection control measures to avoid MDR-TB and XDR-TB
transmission to protect patients, health workers, others working in congregate
• Foster use of natural ventilation in congregate settings of Health facilities –
adequate window surface areas (> 10% of floor space), use of fans, circulators
• Practice triage for TB suspects and patients in congregate settings and OPDs
• Practice segregation of smear positive cases in in-patient settings. Allow
ambulatory treatment as soon as smear conversion is achieved
• Promote use of N-95 masks in laboratories where high risk procedures are done
or by health workers interacting with potentially sputum smear positive MDR-TB
6. Strengthen ACSM to improve care seeking behaviour and cultivate patient-centred
approach to treatment: Improve patient knowledge, attitudes to TB and build confidence
and promote General Health services utilization
7. Promote research and uptake of new TB diagnostics which help in reducing turn-
around-time and time-to-diagnosis of TB and MDR-TB
The above is a transcription of the plan presented by Dr. Paison Dakulala, Deputy Secretary NHSS,
National Department of Health, Papua New Guinea, at an MDR-TB consensus building workshop of
NDoH, WHO PNG and partners on 05 Jul 2010.
NDOH STAFF TRAINED IN PMDT
Person trained Training Date Training agency
Dr. Joseph Bana-koiri Advanced Clinical Feb 2009 The UNION and
TB Consultant, PMGH, NDOH Management, MDR-TB Tropical Disease
Needs Assessment for PMDT Nov 2009 TDF and Center
Dr. Robin Yasi
Regional TB Officer, NTP Needs Assessment for PMDT Nov 2009 TDF and CDC
Infection Control in TB/MDR-TB Nov 2009 TDF and KNCV
Dr. Wesong Boko
Physician, Mt. Hagen
PROPOSED FRAMEWORK OF PMDT ACTIVITIES 2011-2015
Activity Base 2011 2012 2013 2014 2015
A. Political commitment
1. Secure financial support for comprehensive PMDT X
funding for at least 5 years, e.g from GFATM,
2. Establish the country burden for drug resistance and do target-setting
a. Conduct the DRS at 5-year intervals. X X
b. Set targets for case-finding and treatment based on Base Incremental increase to reach
DRS results. line universal access (80% detection
among smear-positives) by 2015
c. Conduct strategic planning to address DR-TB burden X
3. Set a policy for PMDT and ensure the mandate to support implementation in PNG
a. Draft and finalize national MDR-TB Guidelines X
b. Secure official endorsement of PMDT Guidelines,
e.g., through a Department Order from the NDOH
c. Ensure implementation and monitor compliance X X X X X X
4. Endorse comprehensive financial resource support plan
via NDoH and Department of Planning and Finance
(through NEC submission if considered necessary by
5. Apply to the Green Light Committee for PMDT
implementation to secure quality assured drugs, technical X
assistance, capacity building, etc.
6. Meet and discuss Treaty Agreements with Australia and
issue relevant policies for TB and MDR-TB.
7. Conduct advocacy activities to various levels, partners
X X X X
and stakeholders for sustainability
B. Laboratory (subject to Laboratory TA recommendations)
1. Strengthen laboratory infrastructure in PNG
a. Upgrade CPHL and ensure biosafety measures X
b. Expand laboratory network by setting up other culture X X
2. Establish technical capacity for laboratory in-country
a. Seek technical assistance from experts, e.g., through X X
Global laboratory Initiative (GLI), QMRL, etc.
b. Send CPHL staff for training in QMRL or other labs X X X
c. CPHL to draft and finalize Laboratory Manual of X
Procedures with internal quality assurance
d. CPHL to perform culture and DST X X X X X X
e. CPHL to participate in yearly proficiency testing for X X X X X
DST conducted by supranational laboratory, QMRL
f. CPHL to conduct trainings to expansion laboratories X X X X
g. Monitor laboratory procedures through internal quality X X X X X X
h. Request for external evaluation of laboratory X X X X X
C. Infection control
1. Implement recommendations in last mission particularly As recommended
for CPHL, and the treatment areas for TB
2. Appoint a focal person for infection control (IC) X
3. Create a pool of trainers in IC within PNG X
4. Conduct in-country IC trainings As needed in the expansion
D. Treatment delivery
1. Enhance MDR-TB treatment infrastructure in PNG.
a. Develop PMGH TB ward and TB Clinic as the model X
pilot site for other areas to replicate.
b. Develop expansion MDR-TB centers in other areas, X X
e.g., in Angaon Memorial General Hospital, etc.
c. Core team to mentor and monitor sites regularly X X X X X X
2. Establish technical capacity for DR-TB treatment in-country through human resource development
(see section on HRD below).
3. Ensure quality delivery of treatment
a. Implement strict DOT from treatment start till
completion by trained health or community workers,
preferably non-family members. Ensure coordination
between hospital and peripheral treatment sites.
Engage other partners, e.g., WVI, Hope Worldwide,
Church Medical Council, etc.
b. Put in place a tracing mechanism for treatment
interrupters and defaulters
c. Monitor response to treatment through culture and X X X X X X
d. Manage adverse drug reactions: provide ancillary
drugs and monitor through clinical and laboratory
e. Provide psychosocial support such as enablers to
patients and health workers
f. Do contact tracing to MDR-TB household members
and other close contacts.
g. Conduct other patient-centered and patient
empowerment activities, e.g., skills training while on
X X X X X
treatment, livelihood initiatives, etc.
4. Assess treatment areas for MDR-TB in other provinces X X X
4. Implement TB/HIV collaborative activities. X X X X X X
E. Human resource development (HRD)
1. Create a PMDT core team in the NTP consisting of the
focal point, and point persons for the different framework X
components, to direct the country implementation
2. Create a case management committee or consilium for
individual case management
3. Provide capacity building on overall PMDT implementation
a. Seek technical assistance for PMDT from experts
through the GLC, WHO, etc.
b. Train the point person for HRD and training X
c. Conduct a Training of Trainers at the central level
(NTP) with WHO-WPRO support)
d. Conduct provincial, district and community level
X X X
4. Use available training materials for key audiences and X X
modify accordingly based on a task analysis in line with
the MDR-TB Guidelines
F. Drug management
1. Provide capacity building on drug management
a. Train the point person on drug management X
b. Conduct trainings for persons in charge of DM in
PMDT at the central, provincial and district levels.
2. Ensure quality assurance of second-line drugs used in PNG
a. Ascertain quality of drugs X
b. Encourage manufacturers of locally procured
SLDs to participate in WHO pre-qualification.
c. Medical Supplies Branch, NDOH to issue a
X X X X
preference notice for WHO pre-qualified suppliers
over non-qualified suppliers during short-listing
for procurement contract award.
3. Set up a drug management system for PMDT managed by the core team
a. Establish a safe, secure and appropriate storage
space or warehouse at the central level.
b. Establish storage sites in areas expansion areas. X X
c. Procure quality assured drugs in a timely manner. X X X X X X
d. Distribute drugs in a timely manner. X X X X X X
e. Monitor drug stocks monthly to avoid stockout and
X X X X X X
G. Recording and Reporting, Monitoring and Evaluation
1. Provide capacity building on recording and reporting (R & R)
a. Train the point person on R & R X
b. Conduct trainings for persons in charge of R & R in
PMDT at the central, provincial and district levels.
2. Set up an information system for PMDT managed by the core team
a. Draft forms for PMDT records and reports X
b. Incorporate PMDT reporting formats into BMU cohort X
reporting mechanism of NTP
c. Establish the flow of reports from peripheral to central
d. Set up a web-based information system incorporated
e. Core team to monitor R & R implementation
X X X X X X
3. Do a cohort analysis of patients put on treatment X X X X X X
4. Conduct a yearly program implementation review on
X X X X X X
5. Yearly external monitoring of PMDT implementation
X X X X X