Targeted case-finding approach generates promising results
 

Kiribati, a small island nation in the Western Pacific Ocean, has the unenviable recognition of having the highest incidence of Tuberculosis (TB) among its neighbouring Pacific island countries, with a rate of 349 per 100,000 in 2018.

“Finding more cases of TB needs to be the priority right now. We must fast track activities that can detect the disease at its very early stages, put people on treatment and increase awareness in the community,” said Dr. Alfred Tonganibeia, a Public Health Specialist with the Ministry of Health and Medical Services on Tarawa Atoll in Kiribati.

Dr. Alfred Tonganibeia works at the main government hospital on South Tarawa, one of the 32 atolls and reef islands that make up the country. 

“As you can imagine, if you see it on a map, Kiribati is very spread out. I’m on the main island where the capital is. This island is highly populated. More than 50 percent of the country’s population are located here.”

Overcrowding and poverty as well as other risk factors such as diabetes, alcohol use and smoking, have created ideal conditions for the spread of TB.

“People are squeezed, especially in the main towns and the main areas of the island. People come here for work, and at the same time they bring diseases and they spread diseases,” he said.

“There are a lot of factors for the situation. The overcrowding situation in Kiribati is one. People live very close to each other. Some of the houses aren’t well built. There is poor ventilation. There is an average of 8-9 persons per house.”

And the situation will only worsen with the impact of climate change and rising sea-levels, further limiting the livable space in the islands.

Addressing TB through the National TB Programme is one of Kiribati’s national health priorities, and is closely linked with the goals of the Kiribati Development Plan and the National Health Strategic Plan, which aims to improve population health and health equity through continuous improvement in the quality and responsiveness of health services.

Due to effective coordination efforts and the introduction of new diagnostic tools, such as GeneXpert and portable x-ray machines, new cases of TB are being identified and diagnosed in the country.

Across the Western Pacific, TB is a persistent public health challenge. The region accounts for 18 percent of TB cases around the world. Globally, it continues to be the top infectious killer, claiming the lives of 1.5 million people in 2018.

In addition, the world is seeing increasing numbers of cases of drug resistant strains of TB. In 2018, there were four cases in Kiribati, where people with drug resistant TB were identified and put on treatment.

“People have slowly got to know what TB is. We’ve tend to see a lot of people with TB over the years who came to the hospital diagnosed very late. A lot of them came in with smear positive results (confirmed cases), which indicates a very late diagnosis. The proportion is substantially high, over 50 percent.”

The National TB Programme is now turning to an approach recommended by the World Health Organization that involves active case-finding activities in select hotspot areas with high concentrations of TB, with support from the United Nations Development Programme (UNDP)  through the Multi-Country Western Pacific Integrated HIV/TB Programme financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Active case-finding – or screening – aims to identify cases of TB at an early stage, which dramatically reduces the risks of poor disease outcomes and further transmission, and also limits the social and economic impacts of TB on society.

While screening an entire population would yield the best results, it is also extremely costly. Selective active case-finding in hotspot areas, on the other hand, is one of the most economical and effective approaches to detect TB cases.

“We looked at the whole Tarawa area, we looked at the number of cases reported from each district over the past five years, and we looked at the patterns. From there we could tell which areas had the highest incidence of TB – that’s how we came up with the hotspots, and settled on Bairiki for the pilot project.”

From January to June 2019, 13 percent of all new TB cases in Kiribati were in Bairiki, one of the largest towns in South Tarawa with an estimated population of 3,208 within a land area of less than half a square kilometer.

“The objective was simple. We wanted to go out there, find more cases, find those who will likely transmit TB, put them on treatment, bring them the cure - stop TB transmission,” explained Dr. Alfred.

“One of the advantages of taking a targeted approach like this is that whatever you invest in that activity, you will definitely find people living with TB. And that is what we experienced.”

The targeted approach of the pilot was assisted by new diagnostic equipment procured by the Multi-Country Western Pacific Integrated HIV/TB Programme, including a mobile x-ray and GeneXpert machine.

“We’ve been doing active case-finding for a number of years, using very basic tools. With better resources, like those used in Bairiki, it’s really a game changer. We’re already seeing the benefits.”

The hotspot case-finding activity was a collaborative effort, conducted in September 2019 with about 30 health workers, including from the hospital, clinics and health promotion departments. In total, 3,891 people were screened for TB over 11 days, with 7 new cases being identified. 

Each newly diagnosed patient was immediately put on treatment, contact tracing was conducted and arrangements made for directly observed treatment (DOTS), all part of the TB control strategy being implemented by the National TB Programme. 

In addition to the TB screening of the local population, there was also health promotion activities conducted for the surrounding community.

“Long ago, people used to say that it was a problem and were afraid of it. But now they all understand that TB is a curable disease and they are not afraid of it. If they have symptoms they come and get tested,” said Salaamo Tabaru, a nurse who has been working at the local TB clinic for 10 years.

Slowly but surely, the hard work to raise awareness among the public on TB prevention and transmission, and the need for testing, is paying off.

“When I heard of the planned hotspot screening, I was pleased, because there are some people that may have wanted to come to our office for treatment or getting tested, but they couldn’t because they didn’t have money for bus fare. When we go to their village, it’s good because it’s near their house. They can come with their friends and household members,” she noted.

“It’s very important to continue to go into the community to raise awareness of how to prevent transmission – people must be aware to cover their mouths if they cough. And for those on DOT, they must adhere to their medication.”

“People used to change their addresses so that the DOT workers couldn’t find them. Long ago they would run away or hide themselves from us. But now they understand. They are not shy about having TB. They are waiting to take the medication. When their DOT workers sometimes don’t come on time, they will even come to our office to ask to take their medication. They feel they are getting well because of the treatment, so they don’t want to miss any doses. People are very happy,” she said.

“We came with a lot of information, IEC materials, pamphlets. Everyone who comes in, goes out with a pamphlet. And we also have the health promotion team on the ground who advise people who come in during the screening. People who are waiting to be seen are exposed to prevention information. Then at the end of the screening line, they are also given materials for them to read at home,” added Dr. Alfred.

From Dr. Alfred’s perspective, the hotspot case-finding activity was a success and should be expanded in the future to put an end to TB in Kiribati.

“If we put more effort into this, repeat the same process at other hotspots, maybe bigger hotspots, it would assist in finding cases at very early stages. That’s what is most important, finding those high-risk people at very early stages will have a significant impact. If we can identify the cases early, and get them on treatment as soon as possible, we will stop the transmission. No more transmission in the community. This will help Kiribati as a whole in the long run,” he said.