Tracking down outbreaks and causes of fever in Papua New Guinea

In a remote clinic in Papua New Guinea (PNG), fever can be a slippery thing. Viruses, parasites, and bacteria are just some of the culprits that can increase a patient’s body temperature. But patches of fever across a population – as well as the pathogens in each person’s blood – can reveal outbreaks of potentially preventable, deadly disease.

Deputy Director of the PNG Institute of Medical Research (IMR) Dr Moses Laman and Burnet’s Co-Program Director of Health Security, Professor Leanne Robinson are co-leading an innovative, DFAT Indo-Pacific Centre for Health Security-funded project.

Partnering with Beyond Essential Systems, a group that provides Tupaia data aggregation and visualisation for Asia-Pacific countries, the STRIVE group has created a real-time ‘heat map’ of febrile illness (a temperature of 38°C or higher for two days or more).

Customisable layers of the map include patient gender or age, cases per week, molecular diagnostics, mosquito abundances, and areas where malaria parasites are showing notable mutations.

A member of the World Health Organization Vector Control Advisory Group, she has spent more than 10 years in PNG, including five years as Head of the IMR Vector Borne Diseases Unit.

“Everybody in PNG’s National Department of Health and the provincial health authorities can log in and look at data at the national or local level – for example, to see what proportion of febrile illnesses were malaria, and what proportion were caused by Plasmodium falciparum or Plasmodium vivax,” she said.

Before COVID-19, research nurses in PNG triaged out cases that were clearly pneumonia or influenza-like illness to focus on fevers with unclear cause. These patients received a Rapid Diagnostic Test (RDT) for malaria, sent with a blood sample to the molecular hub in Port Moresby.

Tests were run for all species of malaria parasite and priority viruses including chikungunya, Murray Valley encephalitis, Ross River virus, and the four strains of dengue, and the molecular data uploaded into the platform.

“A key aim of the platform is to allow the real-time visualisation of data, such that if you start seeing a RDT-negative fever rate of more than double what you saw in the past month, it can allow earlier investigation of possible outbreaks of other pathogens,” Professor Robinson said.

“This addressed a need that was identified and prioritised by PNG partners at both the national and provincial level, for ready access to more timely and in-depth information for diseases spread by mosquitoes in key sentinel sites throughout the country.”

STRIVE monitors parasite markers associated with resistance to antimalarial drugs

The STRIVE researchers have helped identify areas where parasites have a mutation that may increase their resistance to antimalarial drugs.

“Our surveillance has shown a higher prevalence of a particular mutation in the P. falciparum parasite that in other places has been associated with delayed parasite clearance for the patient,” she said.

“This information is considered very useful by the National Malaria Control Program to guide where they will decide to inform where they will conduct their studies to monitor the clinical efficacy of the first-line treatment.”

Impact of COVID-19

Amidst the COVID-19 pandemic, some of the six facilities in the STRIVE network have expanded testing to capture cases of acute respiratory illness, expanded data collection, and are providing weekly and monthly summaries to the PNG Provincial Health Authorities. COVID-19 has reinforced the importance of strengthening health systems of developing countries against threats from increasing international travel.

“IMR has led the diagnostic testing of COVID-19 in PNG, and the STRIVE molecular hub has been able to support the response as one of the testing sites. They’re getting through enormous numbers of tests in a week that would normally exceed capacity, because everybody was already working together.

“It’s of no value to implement a program that’s going to stop after three years without having embedded tools, skills and processes to outlive it.”

For example, the team is working with the provincial health teams and National Agriculture Quarantine and Inspection Authority at STRIVE sites to build local capacity for long-term mosquito monitoring.

“The project has strong leadership and engagement at the national and provincial level in PNG – they know which approaches will have a meaningful and sustainable impact,” she said.

“We’re operating in what is often a dynamic and changeable environment in terms of politics and health systems, so working at both the national and the provincial level is critical for having – we hope – a lasting impact on the country’s disease surveillance and response systems.”

Find out more about STRIVE PNG.