BULA VINAKA and a warm welcome to this important side event on Tuberculosis.
Ladies and Gentlemen, the global burden and scourge of TB continues to prevail. The global data that WHO reports annually affirms that, TB remains among the top 10 causes of death worldwide and is the leading cause of death for all infectious disease categories. The report estimates that 3 people die from TB every minute worldwide which tallies to approximately 1.6 million deaths annually.
Just to reflect on information we already know about TB; it is caused by the Mycobacterium tuberculosis bacteria. TB is spread through air when a well person through suspended infectious droplets when a TB infected person coughs or sneezes it allows infectious droplets to be suspended in the air long enough to then be inhaled by an uninfected individual(s).
TB is diagnosed via an array of WHO-recommended laboratory tests and imaging techniques that are feasible and provide highly valid results. The disease is curable, and effective Directly Observed Treatment Supervision (DOTS) intervention is available which involves taking a number of antibiotics continuously and devotedly for a minimum of 6 months.
TB is not new to Fiji, it has been causing disease, claiming lives and exacerbating poverty amongst Fijians since it was identified earlier on during the colonial era.
Until the 1960’s, Fiji was a TB high-burden country. Following the second world war, in the late 1940’s, TB incidence and mortality in Fiji was at its peak so, in 1951, Fiji’s colonial government established the TB control program, with country-wide screening of individuals largely with the use of chest X-rays and the follow on (Twomey) hospital isolation and treatment of identified cases using effective anti-TB therapy.
The use of sputum positive lab diagnosis to confirm TB cases was minimal (approx. 19% TB cases were confirmed with sputum microscopy) at the start but improved tremendously from 1985 onwards and is now the mainstay for TB diagnosis in Fiji. Between 1951- 2010, approximately 14,500 cases were registered at PJ Twomey Hospital. There was a substantial drop in TB caseloads in Fiji in the 1960’s attributed to intensified campaigns of community-driven screening and treatment interventions of the disease. The DOTS strategy was adopted by the National TB Control Program (NTP) in 1997 and since then there have been sustained efforts to reduce the burden of TB in Fiji.
The TB case notification for Fiji underwent a cyclic trend from the year 2000, until 2009. In 2010, when Fiji became a recipient of the Global Fund for Control of TB, HIV/AIDS & Malaria (GFATM) until 2018, the TB case notification rate stabilized at around 49 per 100 000 population. The prevailing case detection and treatment success rates (TSR) for the country at 95% and 81% are above or close to the internationally recommended targets of 70% and 85%, respectively. With the current case notification rates, Fiji is currently categorized as a low burden country, which is an outstanding milestone achievement considering the country’s initial TB status in the 1950’s.
Key to the Ministry and its NTP’s progress over the years in achieving its annual objectives of identifying and successfully treating TB cases around the country includes the following:
- Increasing awareness on the TB management guidelines for primary health care and community health workers – this has resulted in substantial increases in outpatient numbers of presumptive TB cases
- Establishing microscopy diagnostic centers at 6 subdivisional hospitals located in TB high burden and/or hard to reach communities. This is supported by 3 Divisional laboratories that provide geneXpert molecular testing for TB and 1 Mycobacterium National Reference Laboratory that also provides gene Xpert molecular testing in addition to TB cultures, at national level.
- Improving the capacity of the Ministry’s workforce to do screening of high risk groups, early referrals, diagnose cases, support treatment in hospitalised and community settings and treating contacts of TB cases prophylactically. This was achieved through local in-service training to community health workers, doctors and nurses, and overseas workplace-based attachments and trainings abroad in TB Control for TB staff. This was supported by the Global Fund as well as Zero TB World Korea under a KOICA agreement for country support.
- Intensifying campaign on TB screening for PLHIV (People Living with HIV), Diabetics, Prisoners and Contacts and targeted LTBI (Latent TB Infection) screening for TBT (TB Prophylactic Treatment).
- Sustained supply of antituberculous drugs procured from the WHO-sanctioned Global Drug Facility allows for improved accessibility to recommended anti-TB drugs for Fijians. This supply is accessible at all Divisional Hospitals including the National TB Hospital in Tamavua. The Ministry’s investment in the FDC (fixed dose combination) formulary of antituberculous drugs has to an extent, minimized treatment interruption as a result of reduced pill burden during treatment.
- Operating a grant scheme that engaged CSOs (Civil Society Organizations), FBOs (Faith-Based Organizations), Youth, Women and Men’s Groups To support community DOTS programme for patients at the community level and also TB advocacy.
- Steering a governance structure that guides programme outputs, drive research and innovative strategies, and collaborate on TB drug surveillance and programmatic response to MDR TB (Multidrug Resistant Tuberculosis) has led the NTP to be able to meet the obligations of its commitment to the End TB Strategy, the TB Strategic Plan 2016-2020 and realign strategies to reduce the burden of TB based on disease trends, geographical burden, health seeking behaviour of the population ,and risk factors associated with poor outcomes of death and treatment interruption.
Future plans for the Fiji’s TB control program will focus on formulating and implementing an action plan to bridge the achievement of TB elimination in Fiji, to 10-20 incident cases per 100 000 population, within a 3-5year time frame. The plan will focus on intensive control interventions among high-risk cohorts (such as PLHIV, diabetics and the contacts of known TB cases) in high burden and hard to reach communities. In addition, screening and prophylactic treatment of LTBI will be prioritized. The intermediate and long-term strategic plans of the NTP are underpinned by the principles of UHC (Universal Health Coverage) and the “Healthy Islands” ideals.
As the Ministry drives toward supporting the End TB Strategy it endeavours to ensure all TB cases are well supported by community models of care as compared to hospitalised phases of treatment reflected in the low occupancy rates and bed states in mostly the Northern and Central Divisional DOTS centres in Labasa Hospital and Tamavua Twomey Hospital. This allows them to complete treatment at home at the earliest without facing treatment interruption, provide necessary social welfare benefits and develop the capacity for individuals to be TB control advocacy champions in the homes, schools, workplaces and communities rendering early referrals of presumptive cases, support other persons on treatment in the community and advocate for hygienic and social practices to prevent disease transmission.
With regards to TB surveillance, the establishment of the TB information system for use in all the Ministry’s divisions will enhance the notification and the public health response process. Upscaling of laboratory capacity is also earmarked to enable Whole Genome Sequencing to genotype TB strains and drug susceptibility profiles for Fiji and perhaps for the region as well. The possibility of establishing a training center for TB control for the region via WHO collaboration is also a possibility. In addition, there are also plans to undertake prioritized research initiatives on TB control so as to guide and inform the formulation of targeted policies and appropriately align strategic approaches for the control program.
With political commitment from Fiji’s government driving concerted and cohesive effort amongst all stakeholders to achieve its action plan, the Fiji TB control program intends to work hard in the coming 3 years to achieve its elimination targets. Fiji anticipates that perhaps the caucus can suggest an appropriate high-level governance and accountability framework to support and guide the fulfillment of such an endeavor at the regional level.
I wish to take this time to thank our local stakeholders, bilateral and multilateral partners for supporting the TB control work for Fiji thus far. I also wish to invite you all to journey with us in the next 3 years towards fast-tracking TB elimination in Fiji.
Thank you all for your attention.