Background Immunisation is an effective tool for responding to disease outbreaks, but in low- and middle-income countries (LMICs) accessing vaccine stockpiles can be slowed by logistical challenges. The 7-1-7 outbreak timeliness targets propose that outbreaks be detected within seven days; notification occur within one day; and responses be started within another seven days. For outbreaks of measles, cholera, yellow fever, and meningococcal meningitis, we aim to estimate the impact of initiating outbreak response immunisation (ORI) programs within 15 days of outbreak emergence, relative to the mean ORI response time for each disease since 2000. Methods Using calibrated agent-based models for the four diseases, a status-quo and series of 'Faster response' scenarios were compared for each disease, with a 15-day response time (7-1-7) as the minimum. Findings A 15-day ORI response could avert: 80% of cases from cholera outbreaks relative to a response time of 105 days; 35% of cases from meningococcal meningitis outbreaks relative to a response time of 75 days; 0-35% of cases from yellow fever outbreaks relative to a response time of 105 days (depending on routine vaccine coverage and environmental suitability); and 0-55% of cases from measles outbreaks relative to a response time of 120 days (depending on routine vaccine coverage). Interpretation Improvements made to ORI response time while aiming for 7-1-7 could reduce disease burden and decrease the risk of large outbreaks of vaccine-preventable diseases in LMICs. Efforts to improve response time should be prioritized to higher risk settings. ### Competing Interest Statement The authors declare that they have no competing interests. No author has been paid to write this article by a pharmaceutical company or other agency. ### Funding Statement D.D. has received funding for a PhD scholarship from the National Health and Medical Research Council in Australia (Award Number: 2021/GNT2014056), which partially funded this work. The funding source was not involved in the study. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Model code and outputs are published on Zenodo at and will be publicly available indefinitely. The outbreak data previously used for model calibration are available on Zenodo at .

There have been consistent calls to incorporate gender frameworks into One Health research and policy. Men's and women's roles in relation to animals in many rural and agricultural communities may influence potential pathogen exposure and transmission patterns of zoonotic infectious diseases. However, men's and women's roles related to animals in rural societies are not static but change over time. This article draws on the results of qualitative research about perceptions and practices related to animal species and animal products in five sites located in Eastern Highlands Province and East New Britain, two provinces in Papua New Guinea (PNG). The qualitative research, which aimed to explore animal-human interactions that may pose a risk of zoonotic infections through focus group discussions, formed part of a broader study of zoonotic association and risks for extrapulmonary tuberculosis in PNG. We first introduce participants' descriptions of symptoms of illness that they attributed to zoonotic disease, as well as the animals that they attributed those diseases to. We then draw on an in-depth case study of practices related to rearing pigs - animals with important economic and social value in PNG - to illustrate the impact of social and ecological change on the interplay of gender and relationships with animals. One Health strategies at the community level can focus on gender as a way to understand changes underway in the type and intensity of interactions with animals in rural communities, including their potential impact on zoonotic diseases.

SETTING:Papua New Guinea is a high-burden multidrug-resistant TB (MDR/RR-TB) country that reports low rates of bacteriological confirmation. Sputum drug susceptibility testing for second-line drugs is important. Access to culture is limited. OBJECTIVE:To evaluate the prevalence of mycobacterial sputum sample culture contamination and determine factors associated with contamination. DESIGN:A retrospective analysis of data from a TB diagnostic accuracy study that used culture as the diagnostic reference standard. Data included characteristics of people with presumptive pulmonary TB who provided sputum, sputum quality and culture results. RESULTS:Sputum (1-3 samples) was collected from 174 adults. The median age was 33 years (IQR 24-47). Of 337 samples sent for culture, 28% were contaminated. Contamination was strongly associated with samples self-collected by participants outside clinic hours (aOR 5.69; 95% CI 2.62-12.38). Contamination risk increased with delays in shipping to the reference laboratory (aOR 1.19 per day, 95% CI 1.10-1.29) beyond the minimum 3 days. Contamination was less frequent among people aged 35-44 years compared to 18-24 years (aOR 0.27, 95% CI 0.10-0.73). Sputum quality was not associated with culture contamination. CONCLUSION:Culture contamination could be reduced using spot sputum collection, expedited submission to laboratories and faster shipping when required.

Bacteriological confirmation of TB diagnosis remains a key operational challenge in Papua New Guinea. Sandaun Provincial Hospital (SPH) is the main TB diagnostic and treatment centre of West Sepik Province.To evaluate TB caseload, patient characteristics, and quality of diagnosis at SPH between 2016 and 2021.A retrospective descriptive study using TB treatment, laboratory, and presumptive TB registers to collect data on all TB patients. We used multivariable logistic regression to determine factors associated with bacteriological confirmation.Of 1,305 TB patients registered, 25% were children (<15 years) and 30% had extrapulmonary TB. The quality of sputum was associated with a positive smear microscopy result (P = 0.002). The proportion bacteriologically confirmed was low (37.3%), being higher in young adults 15–44 years (50.6%, 377/745) than in children <15 years (6.3%, 20/319) or older adults ≥45 years (37.6%, 68/181). Bacteriological confirmation was less likely in people travelling ≥3 hours to a health facility (adjusted OR 0.58, 95% CI 0.34–0.97) and extrapulmonary TB (aOR 0.01, 95% CI 0.00–0.03) but more likely for retreatment cases (aOR 1.59, 95% CI 1.00–2.51).Diagnostic services in West Sepik Province need strengthening to achieve a higher proportion of bacteriological confirmation in new pulmonary and extrapulmonary TB cases of all ages and improve access for the rural population.

Multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) is now endemic in the National Capital District (NCD), Papua New Guinea. Loss to follow-up (LTFU) is a challenge.To evaluate and identify risk factors for LTFU, including pre-treatment LTFU, in adults with MDR/RR-TB at Port Moresby General Hospital (PMGH).A retrospective analysis of treatment initiation in adults diagnosed with MDR/RR-TB (2018–2022) and outcomes for a cohort treated for MDR/RR-TB (2014-2019). We assessed the factors associated with LTFU using multivariate logistic regression.Of 95 patients diagnosed with MDR/RR-TB at PMGH from 2018 to 2022, 21 (22%) were lost to follow-up before treatment. Of the 658 adults who initiated treatment for MDR/RR-TB at PMGH from 2014 to 2019, 161 (24%) were lost to follow-up during treatment. A higher proportion of patients on injectable-containing long regimens (110/404, 27%) were lost to follow-up than those on the all-oral regimen containing bedaquiline (13/66, 12%). Treatment loss to follow-up was associated with age (35–54 years age group: aOR 0.49, 95% CI 0.32–0.77; 55–75 years age group: aOR 0.42, 95% CI 0.19–0.90; compared to the 15–34 years age group), residence outside of NCD (aOR 1.79, 95% CI 1.04–3.06), and year of treatment initiation.Pre-treatment LTFU requires programmatic focus. Shorter oral regimens and decentralised services may address the reasons for higher LTFU in younger people and people living outside NCD.

SETTING: Daru Island in Papua New Guinea (PNG) has a high prevalence of TB and multidrug-resistant TB (MDR-TB). OBJECTIVE: To evaluate the early implementation of a community-wide project to detect and treat TB disease and infection, outline the decision-making processes, and change the model of care. DESIGN: A continuous quality improvement (CQI) initiative used a plan-do-study-act (PDSA) framework for prospective implementation. Care cascades were analysed for case detection, treatment, and TB preventive treatment (TPT) initiation. RESULTS: Of 3,263 people screened for TB between June and December 2023, 13.7% (447/3,263) screened positive (CAD4TB or symptoms), 77.9% (348/447) had Xpert Ultra testing, 6.9% (24/348) were diagnosed with TB and all initiated treatment. For 5-34-year-olds without active TB (n = 1,928), 82.0% (1,581/1,928) had tuberculin skin testing (TST), 96.1% (1,519/1,581) had TST read, 23.0% (350/ 1,519) were TST-positive, 95.4% (334/350) were TPT eligible, and 78.7% (263/334) initiated TPT. Three PDSA review cycles informed adjustments to the model of care, including CAD4TB threshold and TPT criteria. Key challenges identified were meeting screening targets, sputum unavailability from asymptomatic individuals with high CAD4TB scores, and consumable stock-outs. CONCLUSION: CQI improved project implementation by increasing the detection of TB disease and infection and accelerating the pace of screening needed to achieve timely community-wide coverage.

Madang Province is located on the northern coast of Papua New Guinea (PNG), a critical mixing point between the populous highlands and more remote regions. Madang Province faces challenges with limited capacity to diagnose and treat TB.To describe the TB caseload and investigate factors associated with known unfavourable treatment outcomes.This is a retrospective cohort study using routinely collected TB programmatic data for treatments commenced 1 January 2019 to 31 December 2021. Using multivariable logistic regression, factors associated with known unfavourable treatment outcomes—death, failure after treatment, and loss to follow-up (LTFU)—were evaluated.Of the 4,668 registered and treated, 3,755 had an evaluated outcome, and 33% had unfavourable outcomes, most commonly LTFU (23%). Unfavourable treatment outcomes were significantly associated with HIV-untested (aOR 2.82 compared to HIV-negative; 95% CI 2.39–3.33), having drug-resistant TB (aOR 3.26 compared to drug-susceptible TB, 95% CI 1.18–9.00), and travel time to the health facility 1–<3 hours by foot (aOR 3.53 compared to <1 hour by foot; 95% CI 1.04–12.06).High LTFU from TB treatment was associated with factors that indicate barriers to access to care and treatment completion. Decentralisation and strengthening of TB services for improved person-centred care and treatment support are urgently required in Madang Province.

BackgroundThere is a lack of empirical data on design effects (DEFF) for mortality rate for highly clustered data such as with Ebola virus disease (EVD), along with a lack of documentation of methodological limitations and operational utility of mortality estimated from cluster-sampled studies when the DEFF is high.ObjectivesThe objectives of this paper are to report EVD mortality rate and DEFF estimates, and discuss the methodological limitations of cluster surveys when data are highly clustered such as during an EVD outbreak.MethodsWe analysed the outputs of two independent population-based surveys conducted at the end of the 2014-2016 EVD outbreak in Bo District, Sierra Leone, in urban and rural areas. In each area, 35 clusters of 14 households were selected with probability proportional to population size. We collected information on morbidity, mortality and changes in household composition during the recall period (May 2014 to April 2015). Rates were calculated for all-cause, all-age, under-5 and EVD-specific mortality, respectively, by areas and overall. Crude and adjusted mortality rates were estimated using Poisson regression, accounting for the surveys sample weights and the clustered design.ResultsOverall 980 households and 6,522 individuals participated in both surveys. A total of 64 deaths were reported, of which 20 were attributed to EVD. The crude and EVD-specific mortality rates were 0.35/10,000 person-days (95%CI: 0.23-0.52) and 0.12/10,000 person-days (95%CI: 0.05-0.32), respectively. The DEFF for EVD mortality was 5.53, and for non-EVD mortality, it was 1.53. DEFF for EVD-specific mortality was 6.18 in the rural area and 0.58 in the urban area. DEFF for non-EVD-specific mortality was 1.87 in the rural area and 0.44 in the urban area.ConclusionOur findings demonstrate a high degree of clustering; this contributed to imprecise mortality estimates, which have limited utility when assessing the impact of disease. We provide DEFF estimates that can inform future cluster surveys and discuss design improvements to mitigate the limitations of surveys for highly clustered data. Main findings: For humanitarian organizations it is imperative to document the methodological limitations of cluster surveys and discuss the utility.Added knowledge: This paper adds new knowledge on cluster surveys for highly clustered data such us in Ebola virus disease.Global health impact of policy and action: We provided empirical estimates and discuss design improvements to inform future study.

Papua New Guinea (PNG) is a high-burden country for TB, with an estimated annual TB incidence rate of 432 per 100,000 population. There are major challenges to the provision of quality care for TB patients with high rates of loss to follow-up, and multidrug-resistant TB is increasingly detected. In 2022-2023, the second Structured Operational Research Training IniTiative (SORT-IT) for TB was undertaken. Eight participants completed the course, and the outputs from these research projects highlight important current operational issues for the PNG TB programme in a range of settings. The first four articles in the series are published in this issue of Public Health Action, with the remainder to follow in subsequent issues.

Background Outbreaks of unknown aetiology in complex settings pose challenges and there is little information about investigation methods. We reviewed investigations into such outbreaks to identify methods favouring or impeding identification of the cause. Methods We used two approaches: reviewing scientific literature and soliciting key informants. Case studies were developed through interviews with people involved and triangulated with documents available from the time of the investigation. Results Ten outbreaks in African or Asian countries within the period 2007-2017 were selected. The cause was identified in seven, of which two had an unclear mode of transmission, and in three, neither origin nor transmission mode was identified. Four events were caused by infectious agents and three by chemical poisoning. Despite differences in the outbreaks, similar obstacles were noted: incomplete or delayed description of patients, comorbidities confounding clinical pictures and case definitions wrongly attributed. Repeated rounds of data collection and laboratory investigations were common and there was limited capacity to ship samples. Discussion It was not possible to define activities that led to prompt identification of the cause in the case studies selected. Based on the observations, we conclude that basing case definitions on precise medical observations, implementing initial comprehensive data collection, including environmental, social and behavioural information; and involving local informants could save precious time and hasten implementation of control measures.

We report the findings of a prospective laboratory diagnostic accuracy study to evaluate the sensitivity, specificity, and predictive values of the Xpert MTB/RIF Ultra assay for Mycobacterium tuberculosis detection in fresh stool specimens from children under 15 years of age with confirmed tuberculosis (TB) disease from Dushanbe, Tajikistan. Six hundred eighty-eight (688) participants were enrolled from April 2019 to October 2021. We identified 16 participants (2.3%) with confirmed TB disease, defined as >= 1 TB sign/symptom plus microbiologic confirmation. With the Xpert MTB/RIF Ultra assay for stool, we found a sensitivity of 68.8% (95% CI, 46.0 to 91.5) and a specificity of 98.7% (95% CI, 97.8 to 99.5) in confirmed TB disease. Our results are comparable to other published studies; however, our cohort was larger and our confirmed TB disease rate lower than most. We also demonstrated that this assay was feasible to implement in a centralized hospital laboratory in a low-middle-income Central Asian country. However, we encountered obstacles such as lack of staffing, material ruptures, outdated government protocols, and decreased case presentation due to COVID-19. We found eight patients whose only positive test was an Xpert Ultra stool assay. None needed treatment during the study; however, three were treated later, suggesting such cases require close observation. Our report is the first from Central Asia and one of a few from a low-middle-income country. We believe our study demonstrates the generalizability of the Xpert MTB/RIF Ultra assay on fresh stool specimens from children and provides further evidence supporting WHO's approval of this diagnostic strategy.IMPORTANCE The importance of this report is that it provides further support for WHO's recent recommendation that fresh stool is an acceptable sample for GeneXpert TB testing in children, especially small children who often cannot produce an adequate sputum sample. Diagnosing TB in this age group is difficult, and many cases are missed, leading to unacceptable rates of TB illness and death. In our large cohort of children from Dushanbe, Tajikistan, the GeneXpert stool test was positive in 69% of proven cases of TB, and there were very few false-positive tests. We also showed that this diagnostic strategy was feasible to implement in a low-middle-income country with an inefficient health care delivery system. We hope that many more programs will adopt this form of diagnosing TB in children. The importance of this report is that it provides further support for WHO's recent recommendation that fresh stool is an acceptable sample for GeneXpert TB testing in children, especially small children who often cannot produce an adequate sputum sample. Diagnosing TB in this age group is difficult, and many cases are missed, leading to unacceptable rates of TB illness and death.

Daru, South Fly District, Papua New Guinea is a high transmission setting for multidrug-resistant tuberculosis (MDR-TB). An emergency response by the Government in 2014 established a high-quality model for treatment and care. Household contact screening and management commenced in 2016 with TB preventive treatment (TPT) for well young child (<5 years) contacts of people with drug-susceptible TB and later expanded to young child contacts of MDR-TB. The model of care is community-based and led by non-specialist health workers, under supervision. An electronic medical record system supports care, reporting and operational research. Community engagement and education has been central, with a concerted focus on peer-led counselling and patient-centred services to improve TPT uptake and completion. Challenges include the application of households as the unit of intervention for detection of active TB and TPT provision. Our implementation experience in Daru has highlighted significant population mixing dynamics with most transmission likely occurring outside the household. We propose a community-wide screening approach with the provision of TPT based on testing to include older children, adolescents, and young adults. As there is the possibility of MDR-TB infection irrespective of the drug susceptibility of the household index case, a novel option is a combination TPT regimen of 6 months of daily isoniazid and levofloxacin (6HLfx). A sensitive aged-related algorithm to detect and exclude active TB is being developed. Ongoing community engagement, quality data systems with operational research to evaluate approaches are critical in high transmission MDR-TB settings.

Mother-to-child-transmission of lead via the placenta is known to result in congenital lead toxicity. Between 2010 and 2021, Médecins Sans Frontières and other stakeholders responded to a severe lead poisoning outbreak related to artisanal gold mining in Northern Nigeria. Extensive environmental remediation occurred following outbreak identification; source control efforts are ongoing within the community. We aimed to describe the prevalence of congenital lead poisoning in this cohort and analyse the association between neonatal blood lead concentration (BLC) and medium-term lead-related outcomes during the study period. Children enrolled in the lead poisoning programme between July 2010 and 25 January 2018 who had a screening BLC at ≤4 weeks of age were included. For time-to-event analysis, medium-term outcomes were classified as lead-related (death from lead encephalopathy, and/or met chelation threshold) and non-lead-related (non-lead-related death, on programme no chelation, exit from programme without chelation). Cox regression analysis and ROC analysis were performed. 1468 children were included. All-cause mortality 2.3%; geometric mean neonatal BLC 13.7 μg/dL; 'lead-related death or treatment' 19.3%. For every doubling in neonatal BLC, there was an almost 8-fold increase in adjusted hazard ratio (HR) for the composite lead-related outcome (p<0.001). A neonatal BLC ≥ 15.0 μg/dL had 95% sensitivity for identifying children who went on to have the composite outcome (with specificity 67%; positive likelihood ratio 2.86). Congenital lead poisoning predicts ongoing exposure in this population, even after environmental remediation. This suggests a complex, early, multidisciplinary approach to source control and exposure management is required when elevated neonatal BLC is observed in lead poisoning clusters in low-and-middle-income contexts.

Healthcare workers (HCWs) are at risk of contracting TB, particularly when in high tuberculosis (TB) burden settings. Routine surveillance data and evidence are limited on the burden of TB amongst HCWs in Indonesia. We aimed to measure the prevalence of TB infection (TBI) and disease among HCWs in four healthcare facilities in Yogyakarta province in Indonesia, and explore risk factors for TBI. A cross-sectional TB screening study targeted all HCWs from four pre-selected facilities (1 hospital, 3 primary care) in Yogyakarta, Indonesia. Voluntary screening included symptom assessment, Chest X-ray (CXR), Xpert MTB/RIF (if indicated) and tuberculin skin test (TST). Analyses were descriptive and included multivariable logistic regression. Of 792 HCWs, 681 consented (86%) to the screening; 59% (n = 401) were female, 62% were medical staff (n = 421), 77% worked in the one participating hospital (n = 524), and the median time working in the health sector was 13 years (IQR: 6–25 years). Nearly half had provided services for people with TB (46%, n = 316) and 9% reported ever having TB (n = 60). Among participants with presumptive TB (15%, n = 99/662), none were diagnosed microbiologically or clinically with active TB disease. TBI was detected in 25% (95% CI: 22–30; n = 112/441) of eligible HCWs with a TST result. A significant association was found between TB infection and being male (adjusted Odds Ratio (aOR) 2.02 (95%CI: 1.29–3.17)), currently working in the participating hospital compared to primary care (aOR 3.15 (95%CI: 1.75–5.66)), and older age (1.05 OR increase per year of life between 19–73 years (95%CI: 1.02–1.06)). This study supports prioritisation of HCWs as a high-risk group for TB infection and disease, and the need for comprehensive prevention and control programs in Indonesia. Further, it identifies characteristics of HCWs in Yogyakarta at higher risk of TBI, who could be prioritised in screening programs if universal coverage of prevention and control measures cannot be achieved.

BACKGROUND: The value, speed of completion and robustness of the evidence generated by TB treatment trials could be improved by implementing standards for best practice.METHODS: A global panel of experts participated in a Delphi process, using a 7-point Likert scale to score and revise draft standards until consensus was reached.RESULTS: Eleven standards were defined: Standard 1, high quality data on TB regimens are essential to inform clinical and programmatic management; Standard 2, the research questions addressed by TB trials should be relevant to affected communities, who should be included in all trial stages; Standard 3, trials should make every effort to be as inclusive as possible; Standard 4, the most efficient trial designs should be considered to improve the evidence base as quickly and cost effectively as possible, without compromising quality; Standard 5, trial governance should be in line with accepted good clinical practice; Standard 6, trials should investigate and report strategies that promote optimal engagement in care; Standard 7, where possible, TB trials should include pharmacokinetic and pharmacodynamic components; Standard 8, outcomes should include frequency of disease recurrence and post-treatment sequelae; Standard 9, TB trials should aim to harmonise key outcomes and data structures across studies; Standard 10, TB trials should include biobanking; Standard 11, treatment trials should invest in capacity strengthening of local trial and TB programme staff.CONCLUSION: These standards should improve the efficiency and effectiveness of evidence generation, as well as the translation of research into policy and practice.

SETTING:Healthcare workers (HCWs) are at an increased risk of TB worldwide. Individual knowledge and attitudes may influence HCW behaviour, and subsequently, TB risk. Indonesia has the second highest case-load globally. OBJECTIVE:To measure TB knowledge and attitudes among a subsection of HCWs in Yogyakarta, Indonesia, and to explore factors associated with knowledge. DESIGN:A cross-sectional study using an online survey targeting all HCW staff was conducted among HCWs from four pre-selected healthcare facilities in Yogyakarta. Descriptive analysis and a multivariable linear regression were undertaken. RESULTS:Of 792 HCWs, 290 (37%) completed the survey; 64% (n = 185) were medical staff, 33% (n = 95) reported previously being tested for active TB and 8% (n = 24) for latent TB. The mean knowledge score was 7.2/11 (SD 1.5): this was higher among medical staff and those with university education (average score increase: 0.53, 95% CI 0.15 to 0.90; and 0.38, 95% CI 0.01 to 0.74, respectively). Participants agreed that free access to TB screening (93%) and treatment (93%) should be available, and 57% of medical and 77% of non-medical staff would take preventive therapy if eligible. CONCLUSION:Participants had practical understanding of TB; however, gaps were identified in knowledge about TB disease progression and prevention. Prevention programmes were viewed positively. We suggest further TB education and engagement programmes for HCWs.

SARS-CoV-2, the virus that causes COVID-19, has resulted in more than 3 million reported deaths worldwide by early May 2021, with case and death incidence at the highest level since the start of the pandemic.1 Australia has been successful at keeping COVID-19 cases to a relatively small number of imported cases, and outbreaks through endemic transmission have largely been detected early,2 thus limiting mortality and morbidity caused by COVID-19.3 The effort and cost to contain outbreaks, particularly those with sustained transmission, have been substantial – more than A$20 billion has been injected into increased hospital funding, purchasing critical equipment, investing in innovative models of care such as telehealth and the vaccine rollout.4 These measures are not only an investment in containing the current COVID-19 epidemic but to ensure that Australia is more prepared to avert emerging pandemics, similar to how countries like Taiwan and Singapore applied lessons from the previous SARS outbreak to contain rapidly early transmission of COVID-19.5 Our nearest neighbour, Papua New Guinea (PNG), has recently not been so fortunate. As of 8 May 2021, there have been 12 226 COVID-19 cases and 121 COVID-19 deaths reported in PNG, with cases increasing substantially since January 2021.6 These numbers are likely to be an underestimate, as there are reports from many provinces about limited testing and delays in reporting.6 Like many countries, PNG had weaknesses in surveillance systems, public health emergency preparedness, and infrastructure, that have hampered a quick and effective response to reduce the spread and harms of COVID-19.7 With attention focussed on the acute threat of COVID-19, re-prioritisation of health facility staff, equipment and beds reduces capacity in other essential services.8 This risks the resurgence of diseases such as human immunodeficiency virus (HIV), tuberculosis (TB) and malaria, as seen in West Africa post the 2014 Ebola epidemic.9 Important preventive measures such as child vaccination and maternal and child health services might also be disrupted. Despite these challenges, PNG has many elements useful for a successful outbreak response. COVID-19 PCR and rapid antigen testing is being utilised in the provinces. The Rita Flynn Field Hospital, for testing and treatment of mild-moderate cases of COVID-19, was opened to relieve pressure on the Port Moresby General Hospital. Screening is occurring at all ports of entry.6 There is a COVID-19 National Hotline, with referrals made to Rapid Response Teams. There is a National Control Centre for COVID-19 and regular public communications. A nation-wide COVID-19 vaccine rollout was launched on 4 May.6 Australia is already offering COVID-19 health assistance by funding infrastructure, donations of personal protective equipment and technical expertise through AUSMAT teams.10 Specialist colleges and societies, such as Australasian College of Emergency Medicine and Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM), have also been working with PNG clinicians to provide remote technical support and capacity building through an online training programme for Papua New Guinean healthcare workers.11 Burnet Institute is supporting the continuation of essential services and targeting community engagement to combat COVID-19 misinformation through existing partnerships like the multi-drug-resistant TB (MDR-TB) programme in Western Province, and Healthy Mothers Healthy Babies partnership in East New Britain. Australia's commitment to send and support the roll-out of the Astra Zeneca COVID-19 vaccine is also vital to the outbreak response.11 There have been 47 international Emergency Medical Team (EMT) clinicians and support volunteers deployed since April, and ongoing support from the World Health Organization (WHO) and Médecins Sans Frontières on the ground.6 The support from Australia with advice on clinical care and setting up emergency management systems has been valuable. While there are anecdotal signs of a reduction in infections in healthcare staff and urban centres generally, there are many challenges still ahead especially including developing surge capacity, maintaining essential services, improved community engagement and vaccine rollout. One of the criticisms during the Ebola 2014 epidemic was that Australia was too slow to send aid teams to West Africa, and when a treatment centre was eventually built and staffed, it closed after only 4 months as the outbreak peak had passed.12 The COVID-19 pandemic threatens to overwhelm an already underfunded and understaffed health system in PNG even with the current support being offered. With only around 500 doctors, PNG leaders are driving the national response, but challenged by a lack of resources, especially human resources,13, 14 while Australia has highly skilled clinicians with COVID-19 experience who could help meet the increased needs. The lack of human resources is complicated by infection among healthcare workers, with 10% of the workforce testing positive at one PNG hospital.15 Australia has learnt valuable lessons regarding infection control measures required to contain COVID-19. With the recent acknowledgements from the US Centers for Disease Control and the WHO of the important role of aerosol transmission,16, 17 PNG also requires teams of highly specialised infection control experts including occupational health experts and ventilation specialists looking at the design and flow of health facilities to minimise transmission risks. In the community, PNG needs to increase the capacity of contact tracing, as well as testing and real time surveillance – this requires the expertise of epidemiologists, laboratory experts and experienced contact tracers who were pivotal to the Australian response. COVID-19 exacerbates the inequities of social determinants of living in PNG. Overcrowding and poverty make adherence to preventive public health measures such as physical distancing, mask wearing and hand washing difficult. Mandatory quarantine or restrictive lockdowns that were employed in Australia successfully where financial supports were available to much of the population would result in suffering for more than 85% of the population that rely heavily on subsistence agriculture.18 Realistic and culturally acceptable solutions need to be found by and with the community, which relies on understanding of risks to determine how best to mitigate them. This is challenged by evolving evidence, misinformation and vaccine hesitancy. Community engagement by trusted figures is key to build and maintain understanding and trust of response measures including vaccination – this needs local leadership but can benefit from exchange with experiences elsewhere. This leads to dual threats – once community transmission is established, there is little chance of successful containment by using standard public health measures – yet health services are unable to cope with a high incidence of disease. One of our greatest fears – that our health services would be overwhelmed and collapse – could happen across the Torres Strait, leading to a humanitarian crisis. In addition, the resurgence in COVID-19 cases and deaths recently in India coincided with the development of variants of concern.6 Unabated COVID-19 circulation allows the virus opportunities to mutate6 and become more transmissible or deadly or escape immune memory from prior infection or vaccination – if this occurs in the Torres Strait, it could also put Australia's health security and COVID-19 vaccination effectiveness at risk. There are successful examples of regional public health emergency response collaborations in PNG to learn from. What started as an emergency response to MDR-TB in Western Province under the leadership of the PNG National TB Program, with funding support by the Australian government pairing technical expertise and clinical support with multi-stakeholder engagement, has resulted in world class treatment success rates, while reducing the health security risk to PNG, Australia and the region.19 While Australia is looking at travel bubbles with other countries with low COVID-19 prevalence, free movement between Australia and PNG through the Torres Strait Treaty is important due to close familial, cultural and economic ties between treaty villages.20 Travel of health professionals, rather than being a risk to the Australian bubble, might help reduce disease transmission and reduce risk in the future. In Australia, we know the extent of resources required to contain the COVID-19 pandemic. We need to increase the scale and diversity of response to COVID-19 beyond emergency support. While focussing on emergency response is important, we also need to look more broadly than only the COVID-19 numbers today. The 2014 Ebola epidemic highlighted significant gaps in the primary healthcare system in West Africa. A sustainable COVID-19 response needs to have a long-term focus on supporting the ability of health services to continue averting the epidemics of malaria, TB and HIV as well as prevention of non-communicable diseases, food insecurity and malnutrition that may follow. An exit strategy must involve planning for future waves, virus variants and preparation for future pandemics. There is much to be gained also for Australian clinicians, particularly infectious diseases physicians, public health doctors and epidemiologists to apply their learning in real-life acutely challenging scenarios. There is a wealth of knowledge and opportunities for bi-directional learning with Papua New Guinean clinicians. New partnerships between clinicians, researchers and academic institutions can lead to future collaborations which will benefit the health security of both countries. Papua New Guineans extended the hand of friendship during our greatest nation-building moments – from World War II to troops deployed during the recent bushfires in 2020.21 The heroes in the COVID-19 response are currently and will continue to be the PNG medical workforce on the frontline during these challenging times. Australia has an opportunity to stand beside them, to provide practical support with additional resources – better surveillance, public health specialists, health resourcing and staff – that could avert a potential humanitarian crisis.

Background In 2016, World Health Organization guidelines conditionally recommended standardised shorter 9–12-month regimens for multidrug-resistant (MDR) tuberculosis (TB) treatment. We conducted a prospective study of a shorter standardised MDR-TB regimen in Karakalpakstan, Uzbekistan. Methods Consecutive adults and children with confirmed rifampicin-resistant pulmonary TB were enrolled between September 1, 2013 and March 31, 2015; exclusions included prior treatment with second-line anti-TB drugs, and documented resistance to ofloxacin or to two second-line injectable agents. The primary outcome was recurrence-free cure at 1 year following treatment completion. Results Of 146 enrolled patients, 128 were included: 67 female (52.3%), median age 30.1 (interquartile range 23.8–44.4) years. At the end of treatment, 71.9% (92 out of 128) of patients achieved treatment success, with 68% (87 out of 128) achieving recurrence-free cure at 1 year following completion. Unsuccessful outcomes during treatment included 22 (17.2%) treatment failures with fluoroquinolone-resistance amplification in 8 patients (8 out of 22, 36.4%); 12 (9.4%) lost to follow-up; and 2 (1.5%) deaths. Recurrence occurred in one patient. Fourteen patients (10.9%) experienced serious adverse events. Baseline resistance to both pyrazinamide and ethambutol (adjusted OR 6.13, 95% CI 2.01; 18.63) and adherence <95% (adjusted OR 5.33, 95% CI 1.73; 16.36) were associated with unsuccessful outcome in multivariable logistic regression. Conclusions Overall success with a standardised shorter MDR-TB regimen was moderate with considerable treatment failure and amplification of fluoroquinolone resistance. When introducing standardised shorter regimens, baseline drug susceptibility testing and minimising missed doses are critical. High rates globally of pyrazinamide, ethambutol and ethionamide resistance raise questions of continued inclusion of these drugs in shorter regimens in the absence of drug susceptibility testing-confirmed susceptibility.

Background Ebola virus disease case definition is a crucial surveillance tool to detect suspected cases for referral and as a screening tool for clinicians to support admission and laboratory testing decisions at Ebola health facilities. We aimed to assess the performance of the WHO Ebola virus disease case definitions and other screening scores. Methods In this systematic review and meta-analysis, we searched PubMed, Scopus, Embase, and Web of Science for studies published in English between June 13, 1978, and Jan 14, 2020. We included studies that estimated the sensitivity and specificity of WHO Ebola virus disease case definitions, clinical and epidemiological characteristics (symptoms at admission and contact history), and predictive risk scores against the reference standard (laboratory-confirmed Ebola virus disease). Summary estimates of sensitivity and specificity were calculated using bivariate and hierarchical summary receiver operating characteristic (when four or more studies provided data) or random-effects meta-analysis (fewer than four studies provided data). Findings We identified 2493 publications, of which 14 studies from four countries (Sierra Leone, Guinea, Liberia, and Angola) were included in the analysis. 12 021 people with suspected disease were included, of whom 4874 were confirmed as positive for Ebola virus infection. Six studies explored the performance of WHO case definitions in non-paediatric populations, and in all of these studies, suspected and probable cases were combined and could not be disaggregated for analysis. The pooled sensitivity of the WHO Ebola virus disease case definitions from these studies was 81.5% (95% CI 74.1-87.2) and pooled specificity was 35.7% (28.5-43.6). History of contact or epidemiological link was a key predictor for the WHO case definitions (seven studies) and for risk scores (six studies). The most sensitive symptom was intense fatigue (79.0% [95% CI 74.4-83.0]), assessed in seven studies, and the least sensitive symptom was pain behind the eyes (1.0% [0.0-7.0]), assessed in three studies. The performance of fever as a symptom varied depending on the cutoff used to define fever. Interpretation WHO Ebola virus disease case definitions perform suboptimally to identify cases at both community level and during triage at Ebola health facilities. Inclusion of intense fatigue as a key symptom and contact history could improve the performance of case definitions, but implementation of these changes will require effective collaboration with, and trust of, affected communities. Copyright (C) 2020 Elsevier Ltd. All rights reserved.

Introduction High quality diagnostic imaging can provide increased diagnostic accuracy and help guide medical decision-making and management, however challenges for radiology in resource-limited settings are numerous. Diagnostic imaging and teleradiology have financial and logistical implications, so evidence of impact is crucial. We sought to test the hypothesis that the implementation of computed radiography with teleradiology consultation support will significantly change diagnoses and treatment plans in a resource limited setting. Method Paired before-after study to determine the therapeutic impact of an add-on diagnostic test. 'Preliminary Plan' and 'Final Plan' forms allowed direct comparison of diagnosis and treatment plans at initial consultation and following radiography and teleradiology. Consecutive consenting patients were included until the sample size (600) was reached. Changes in both diagnosis and treatment plan were analysed in the whole cohort, with sub-analyses of children aged <5 years, and cases of chest radiography. Results Final analysis included 536 cases. Diagnosis changed following radiography and teleradiology in 62% of cases, and treatment plans changed in 61%. In chest radiography cases, 70% of diagnoses and 62% of treatment plans changed, while in children <5 years 66% of diagnoses and 58% of treatment plans changed. Reduced final treatment plans were most common for exploratory surgery (72% decrease), surgical orthopaedic intervention (62% decrease), and TB treatment (52% decrease), allowing more conservative medical or surgical management in 61 cases. Increased final treatment plans were highest in the orthopaedic and interventional surgery and referral categories. Of 42 cases requiring interventional surgery in the final plan, 26 (62%) were identified only after radiography and teleradiology. 16 additional cases were indicated for orthopaedic surgery, 10 cases required patient transfer, and TB treatment was indicated in 45 cases. A change in the original prescription plan occurred in 41% of 536 cases, with one or more prescriptions stopped in 28% of all cases. Conclusion We found that computed radiography with teleradiology had significant clinical value in this resource-limited setting, with the potential to affect both patient outcomes and treatment costs through providing improved diagnostics and avoiding unnecessary treatments and medications.