Volume 199 - Issue 9
The Papua New Guinea cholera outbreak: implications for PNG, Australia and the Torres Strait
Authors: John J Hall, James A Gillespie, Alexander Rosewell and Pilly Mapira
Med J Aust 2013; 199 (9): 576-577. || doi: 10.5694/mja13.10516
Published online: 4 November 2013
Published online: 4 November 2013
The PNG cholera crisis highlights the need for more investment in infrastructure, particularly in the area of water, sanitation and hygiene, and more locally appropriate and responsive health systems in PNG.
Australian assistance is needed to control outbreaks in the short term and to develop infrastructure and health systems in the longer term
The world is currently in the midst of the seventh documented cholera pandemic, which commenced in 1960. Since 2000, there has been a global increase in the incidence of cholera with 7543 deaths globally in 2010. This pandemic is significantly different to the previous six pandemics. The fifth and sixth pandemics had been caused by the “classic” biotype and lasted from 7 to 24 years. This seventh pandemic has been caused by a new biotype of Vibrio cholerae serogroup 01 called El Tor and has persisted for over 50 years. It has become endemic in countries in which cholera had not been reported for many years.1
The longevity and geographical spread of the current pandemic has been linked to more mobile populations, increased maritime trade and increased sea water temperatures associated with global warming, creating ideal conditions for the transmission of V. cholerae. It is within this global context that the cholera outbreak in Papua New Guinea must be viewed.
The outbreak of cholera in PNG was first reported in August 2009 in Morobe Province on the north coast.2,3 By early 2011 cholera had spread further along the north coast and then south to cover about half of PNG’s provinces with a total 15 414 cases reported, including 493 deaths, and a case fatality rate (CFR) of 3.2%.3 Cholera was first reported in Daru in Western Province in November 2010. Daru is only 50 kilometres from the Australian border. The outbreak in Western Province was associated with the highest number of cases, 3945, and with the highest CFR, 8.8%.3 Cholera risk factors in the PNG outbreak included defecating in the open or river, and knowing someone who had travelled to a cholera-affected area, while protective factors included having soap for handwashing in the home.4 The Torres Strait Treaty signed between PNG and Australia at the time of independence ensures that PNG nationals from 13 specified villages in Western Province are permitted to cross into Australian territory for traditional activities such as marriage, trade and fishing, with an estimated 2000 crossings annually. There has been concern about the health impact in northern Australia of these border crossings.5,6 The Australian media has posed the transmission of cholera across the Torres Strait as a real risk.7
Cholera — prevention and control
Reduced CFRs in a cholera outbreak are associated with early treatment with either oral rehydration solution, for mild or moderate dehydration, or intravenous fluids, for severe dehydration, and mobilising health services to deliver these interventions immediately. Other essential tasks in the initial phase are identification of the source of the outbreak and securing safe drinking water sources. Antibiotics have been shown to limit gastrointestinal shedding of the vibrios but resistance is now a major issue in their use.1 Long-term control is still dependent on improved (safe) water supply and (safe) sanitation with the promotion of personal hygiene.1 Two oral cholera vaccines with killed whole cells of V. cholerae been endorsed by the World Health Organization and may provide a future control intervention in acute epidemic outbreaks.1
The Papua New Guinea context
PNG is a case study of the impact of rapid demographic, social and economic change on population health. From 2014, a multibillion-dollar liquefied natural gas project to pipe natural gas from the Highlands and Gulf Province to Port Moresby for export to Asian markets is expected to more than double the gross domestic product of PNG, becoming the main source of government revenue.8 Extractive industries (mining, gas, timber) have led to population displacement and resettlement, which has placed PNG at greater risk of spread of disease, especially in growing peri-urban settlements where cholera transmission has been most intense.4 Internally displaced people were among the most vulnerable to excess mortality.4
At the same time, the more than 7 million people living in PNG remain among the poorest in the Asia–Pacific region. In 2012, PNG ranked 156th (out of 187 countries) on the Human Development Index. It has some of the worst health indicators in the region compared with its Pacific neighbours, making slow progress in achieving the Millennium Development Goals.9 Health services in PNG are weak, with significant challenges in providing services in rugged terrain, compounded by inadequate government investment and strategic planning, corruption, poor law and order, with chronic shortages (or complete absence) of essential medicines, lack of skilled health workers in rural health centres, a continuing high burden of disease from malaria, tuberculosis (TB) and HIV, acute or chronic undernutrition in children and low immunisation rates.9,10 In 2010 only 41% of the PNG population had access to improved water sources, and only 45% had access to improved sanitation.10 The result is a population with a poor general health status, especially among the young, malnourished and immunocompromised, who are the most vulnerable in a cholera outbreak.9
It is within this context that the PNG Department of Health was confronted with the cholera outbreak in August 2009. National, provincial and some district cholera task forces were established to develop cholera preparedness and response plans for the relevant jurisdictions.3 While cholera treatment centres were established within the grounds of provincial hospitals, the difficulties of access to rural communities put massive obstacles in the way of the provision of timely treatment, referral and accurate surveillance for much of the population.
Cholera control measures in Western Province and at the Torres Strait border, based on PNG national cholera control strategies3 and international evidence, aimed to:
train clinical and public health staff in outbreak identification, verification, reporting, assessment and response;
improve access to safe water and sanitation in the settlements of Daru, the treaty villages and more broadly;
strengthen national laboratory capacity;
ensure adequate rehydration supplies and zinc supplements for the clinical management of the disease across the country; and
improve planning for emerging diseases nationally.
Implementing these procedures was faced with almost insuperable challenges. Western Province has almost no road network and is characterised by a large system of rivers and mangroves, with villages usually located along rivers with limited communication and resources for disease surveillance. The vast majority of the population live traditional lifestyles in remote villages, and drink untreated river water. Latrines remain uncommon, in part due to the high water tables. Further factors contributing to the spread of cholera in Western Province included the mass gatherings associated with royalty payments from extractive industries, where thousands of villagers travel to and stay in the cholera-affected settlements of an already challenged provincial capital, Daru, for weeks before returning to their villages. High cholera mortality associated with a disease previously unknown to the locals triggered desertion of villages and relocation through and to non-affected areas, thus further driving transmission. These constraints in the delivery of cholera control measures resulted in the high incidence and CFR in Western Province, as mentioned above.
Implications for the Torres Strait Islands and Australia’s development assistance
Despite media alarmism, the cholera problem has remained non-existent on the Australian side of the Torres Strait, thanks to excellent infrastructure, 100% of the population having access to improved water supply and sanitation, and a well nourished population with low rates of the diseases that cause immunosuppression.10 The health system functions well, with the capacity and resources for a rapid and effective public health response to outbreaks. Higher literacy rates and media coverage mean health promotion messages can be transmitted and taken up at an early stage.
In response to the cholera reports in the Western Province of PNG, Queensland Health issued media alerts outlining education messages as well as strategies to strengthen the cholera control activities in the Torres Strait should they be needed.11 Queensland Chief Health Officer Jeannette Young noted that “The fact that hygiene and food preparation practices in the Torres Strait are good, there is ready access to safe drinking water, and there is safe disposal of human wastes, means the risk of a local outbreak is low”.11 Queensland communicable diseases surveillance reports for the weeks after the Western Province outbreak confirmed that cholera had not spread across the Torres Strait.12
An Australian response needs to focus on PNG. Australia has been the largest bilateral donor to PNG since independence in 1975, with health as a priority sector. The current PNG–Australia Partnership for Development program is targeting several key areas, mainly in HIV and AIDS, TB and malaria through the PNG health sector-wide approach.13 The cholera crisis highlights the need for more intelligent use of internal and external investment in health services to build local capabilities. A shift in aid towards developing better infrastructure, particularly in the area of water, sanitation and hygiene, along with building locally appropriate and responsive health systems, will establish a framework to encourage future PNG governments to invest the likely bounty of the energy and minerals boom in sustainable national public health programs.
Competing interests
No relevant disclosures.
References
- Harris JB, LaRocque RC, Qadri F, et al. Cholera. Lancet 2012; 379: 2466-2476. 0_i1115688
- Rosewell A, Dagina R, Murhekar M, et al. Vibrio cholerae O1 in 2 coastal villages, Papua New Guinea [letter]. Emerg Infect Dis 2011; 17: 154-156. 0_i1115690
- Papua New Guinea Department of Health. National situational report on cholera in Papua New Guinea as of 28th April 2011. Port Moresby: PNG Department of Health, 2011. 0_i1115692
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- Batten A. Aid and oil in Papua New Guinea: implications for the financing of service delivery. Canberra: Development Policy Centre, Australian National University, 2011. http://devpolicy.anu.edu.au/pdf/papers/DP_4_-_Aid_and_oil_in_Papua_New_Guinea_implications_for_the_financing_of_service_delivery.pdf (accessed May 2013).
- Bolger J, Mandie-Filer A, Hauck V. Papua New Guinea’s health sector: a review of capacity, change and performance issues. ECDPM discussion paper 57F. Maastricht: European Centre for Development Policy Management, 2005. http://www.ausaid.gov.au/Publications/Pages/5887_4407_5885_6927_4021.aspx (accessed May 2013).
- World Health Organization. World health statistics 2010. Geneva: WHO, 2011. http://www.who.int/whosis/whostat/2010/en (accessed Sep 2013).
- Queensland Health. Cholera risk still low to Torres Strait residents [media release]. 19 Nov 2010. http://www.health.qld.gov.au/news/media_releases/torres_cholera2_1119.pdf (accessed May 2013).
- Queensland Health. Statewide weekly communicable diseases surveillance report. 6 Dec 2010. Brisbane: Queensland Government, 2010. http://www. health.qld.gov.au/ph/documents/cdb/weeklyrprt_101206.pdf (accessed May 2013).
- Foster M, Condon R, Henderson S, et al. Papua New Guinea country report. Evaluation of Australian aid to health service delivery in Papua New Guinea, Solomon Islands and Vanuatu. Working paper 1. Canberra: AusAID, 2009. http://www.ode.ausaid.gov.au/publications/documents/working-paper-health-service-delivery-png.pdf (accessed May 2013).
Provenance: Not commissioned; externally peer reviewed.