Tuberculosis in Australia's Top End First Nations highlights health and life expectancy gaps: a call to arms

The incidence of TB is decreasing, but still, almost 25% of the world's population are infected [[1]Global tuberculosis reportWorld Health Organization; 2020. Licence. CC BY-NC-SA 3.0 IGO, Geneva2020Google Scholar]. TB has largely been eradicated in many wealthy nations and has a disproportionate prevalence in developing nations [[1]Global tuberculosis reportWorld Health Organization; 2020. Licence. CC BY-NC-SA 3.0 IGO, Geneva2020Google Scholar]. The World Health Organisation describes TB as 'a disease of poverty and economic distress, vulnerability, marginalisation, stigma and discrimination'. Hence, it is not surprising that globally, First Nations people are inordinately affected by TB. Australian First Nations are no exception. Rates of TB infection for First Nations Australians are 5-6 times higher than for the Australian-born, non-Indigenous population. In this journal edition, Meumann and colleagues describe a retrospective observational study conducted over a 31-year period (1989-2020) in Australia's Top End [[2]Meumann EM HK Ralph AP Farmer B Globan M Stephenson E Popple T Boyd R Kaestli M Seemann T Vandelannoote T Lowbridge C Baird RW Stinear TS Williamson DA Currie BJ Krause VL Tuberculosis in Australia's tropical north: a population-based genomic epidemiological study.Lancet Regional Health Western Pacific. 2021; https://doi.org/10.1016/j.lanwpc.2021.100229Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. The Top End is located in the northern region of the Northern Territory (NT), which includes Darwin, the capital city, Arnhem Land and other parts, where the highest rates of TB in the country occur. The authors combined public health surveillance data with genomic sequencing of TB to investigate trends in both incidence and transmission. Their findings confirm that vulnerable populations continue to be worst affected and shed light on how TB is being transmitted. Forty-eight percent of cases were born overseas, with two-thirds of these from developing countries in Southeast Asia known to have high TB incidence (Indonesia, Timor-Leste, the Philippines and Vietnam). Cases included asylum seekers and illegal fishers and crew. These overseas-born cases largely represent a vulnerable group of culturally and linguistically diverse people, whose proficiency in English and disease-specific health knowledge may be limited [[3]Yu Y Xiao L Chamberlain DJ. Perceptions of care in patients from culturally and linguistically diverse background during acute and critical illness: A integrative literature review.Aust Crit Care. 2020; Google Scholar]. Whilst only 7% of cases were Australian born and non-Indigenous, 44% of cases were Australian First Nations. Mortality was significantly higher in Australian First Nations than overseas-born cases (12.5% vs 3.1%, respectively), the median age of death for First Nations people with TB was significantly younger than in both Australian-born non-Indigenous cases and overseas-born cases (49, 63 and 77 years, respectively), and almost 80% of all paediatric cases were First Nations children. Australia reached its target of pre-elimination of TB in non-Indigenous Australians (<1 per 100,000) more than 10-years ago, but Meumann and colleagues modelled that TB pre-elimination in the Top End would not be reached until ∼2066 for First Nations (based on the 5% per year incidence reduction over the past 30 years). Genome sequencing confirmed that TB control measures should be focused on specific geographical regions to reach the goal earlier. Twenty-eight putative transmission clusters were identified. Of these clusters, 86% were for First Nations cases, and most of these were from specific remote areas. Further analyses suggested that both reactivation from latency and recent transmission with progression contributed to TB incidence. They rightly suggest that 'TB control resources should continue to be directed to TB hotspot regions, focusing on timely and complete case detection, contact tracing, and latent TB treatment'. The example of TB in Australia's Top End highlights the need for immediate action. The large gaps in health and life expectancy between First Nations and other Australians have been well publicised within Australia and have attracted international attention [[4]EditorialClosing the gap for Aboriginal health.Lancet. 2019; 393: 718Summary Full Text Full Text PDF Scopus (4) Google Scholar]. The health gap remains a key Federal priority, and the government aims to close the gap by 2032. However, Australia is not on track to reach most targets related to closing the gap [[5]Commonwealth of Australia, Department of the Prime Minsiter and Cabinet. 2020 Closing the Gap Report 2020. https://ctgreport.niaa.gov.au/sites/default/files/pdf/closing-the-gap-report-2020.pdf Date last accessed 30.03.20Google Scholar]. The Top End TB example highlights the need to address multiple factors prevalent amongst First Nations people that contribute to poor outcomes of TB and other diseases. These factors include overcrowding, homelessness, smoking, malnutrition, and diabetes. Efforts to curb smoking is particularly pertinent as smoking' increases the risk of contracting TB, increases the risk of recurrent TB and impairs the response to treatment of the disease' [[6]World Health OrganisaionSmoking and tuberculosis: a dangerous combination.Last updated 23.02. 2018Google Scholar]. Smoking rates amongst Australian First Nations remain unacceptably high at almost 40% [[5]Commonwealth of Australia, Department of the Prime Minsiter and Cabinet. 2020 Closing the Gap Report 2020. https://ctgreport.niaa.gov.au/sites/default/files/pdf/closing-the-gap-report-2020.pdf Date last accessed 30.03.20Google Scholar]. Importantly, Meumann and colleagues state that normalisation of cough (i.e., chronic cough is considered normal) and under-recognition of TB by clinicians contribute to delayed diagnosis. Chronic cough is an important symptom of TB. Both cough normalisation in Aboriginal children and under-detection of chronic cough was highlighted in recent studies in remote Western Australia: both clinicians [[7]Laird P Walker R Lane M Chang AB Schultz A. We won't find what we don't look for: Identifying barriers and enablers of chronic wet cough in Aboriginal children.Respirology. 2019; (resp.13642)PubMed Google Scholar] and Aboriginal families [[8]D'Sylva P Walker R Lane M Chang AB Schultz A. Chronic wet cough in Aboriginal children: It's not just a cough.J Paediatr Child Health. 2018; 55 (833-43)PubMed Google Scholar] normalised chronic wet cough, resulting in under-detection of disease by clinicians [[7]Laird P Walker R Lane M Chang AB Schultz A. We won't find what we don't look for: Identifying barriers and enablers of chronic wet cough in Aboriginal children.Respirology. 2019; (resp.13642)PubMed Google Scholar]. Therefore, efforts to improve timely TB detection and management, and reduce transmission, should include the facilitation of timely health-seeking for chronic cough by First Nations people and optimal management of chronic cough by clinicians. Such efforts would require the provision of culturally secure health information for communities and further training of clinicians in the management of chronic cough. Strategies and initiatives to combat disease should be developed in partnership with First Nations people and local service providers to ensure an increased likelihood of sustained and successful knowledge translation [[9]Kirk MA KC Yankey N Birken SA Abadie B Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research.Implement Sci. 2016; 11Google Scholar] Such an approach has resulted in significant improvements in timely health care seeking by families and respiratory health outcomes elsewhere in remote parts of Australia [[10]Laird P Walker R Lane M Totterdell J Chang AB Schultz A. Recognition and Management of Protracted Bacterial Bronchitis in Australian Aboriginal Children: A Knowledge Translation Approach.Chest. 2021; 159: 249-258Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. In summary, TB contributes to the large disparity in health outcomes between First Nations and other Australians. Resolving the disparity is possible but would take a comprehensive and culturally secure approach. Literature search and manuscript writing were conducted by PL and AS. Dr Laird receives salary support from the Perth Children's Hospital Foundation New Investigator grant. A/Prof Schultz receives support from a NHMRC TRIP fellowship [Grant APP1168022] and a NHMRC/MRFF Investigator Grant [APP1193796]. No payment was received by was received by a pharmaceutical company or other agency for any authors to write this paper. Tuberculosis in Australia's tropical north: a population-based genomic epidemiological studyOur findings support prioritisation of timely case detection, contact tracing augmented by genomic sequencing, and latent TB treatment to break transmission chains in Top End remote hotspot regions. Full-Text PDF Open Access