improving tb-dm care in the pacific: partnerships and progress r. brostrom, md-msph hawaii tb...

Improving TB-DM Care in the Pacific:

Partnerships and Progress

R. Brostrom, MD-MSPHHawaii TB Control Branch ChiefRegional TB Field Medical Officer, CDC-DTBECDR USPHS

TB-DM: Partnerships and Progress in the Pacific

  • Stop TB Strategy and PPM• TB-DM in the Pacific• Pacific Partnerships

• Clinical Partners• Policy Partners• Research Partners

• Summary - Questions

Components of the Stop TB Strategy

 1. Pursue high-quality DOTS expansion and enhancement

2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations

3. Contribute to health system strengthening based on primary health care

4. Engage all care providers

Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches

5. Empower people with TB, and communities through partnership

Foster community participation in TB care, prevention and health promotion

6. Enable and promote program-based operational research

“Evidence suggests that failure to involve all care providers used by TB suspects and patients:

• hampers case detection, • delays diagnosis, • leads to inappropriate and incomplete treatment, • contributes to increasing drug resistance,• places an unnecessary financial burden on

patients.”

WHO Stop TB <http://www.who.int/tb/careproviders/ppm/en/>

US Pacific Region for TB Control

Pacific Partnerships for TB 

Public Private Mix: New Priority?

Tuberculosis Campaign Challenges: 1912

“Lack of therapeutic treatment standards”

“Poor reporting of cases under

supervision”

“Excessive charges to patients”

Advancing TB-DM Care: Why Partnerships?

 • Expertise Sharing

• Out of our TB comfort zone• Chronic Disease model• Training Needs for screening

• Resource Sharing• Attempting minor program expansion in a

time of major program contraction• Maximize external funding support• Glucometers, A1C test kits, TSTs

TB cases with DM 

*India **Mexico Pacific Islander0%

10%

20%

30%

40%

50%

60%

70%

Perc

ent A

dult

TB P

atie

nts

with

Dia

bete

s

*Stephenson, BMC Public Health. 2007; 7: 234 ** Restrepo, Bull WHO, 2011; 89: 352-9

Leung CC, et.al. , Diabetic control and risk of tuberculosis: a cohort study. Am J Epidemiol. 167, 2008

A1c > 7

No DM

A1c < 7

DM

Baker et al. BMC Medicine 2011, 9:81 The impact of diabetes on TB treatment outcomes: A systematic review

TB-DM Outcomes: Relapse

Baker et al. BMC Medicine 2011, 9:81 The impact of diabetes on TB treatment outcomes: A systematic review

TB-DM Outcomes: Death during TB Tx

Partnerships in the PacificPartial List of Best Practices

Year Activity Partnership

2005 After CDC site-visit, CNMI TB program makes programmatic adjustments for DM cases

Federal-state collaboration

2007 CNMI TB Program shares cases with CNMI Diabetes Program for DM education

State Programs (public-public mix)

2008 CNMI presents draft TB-DM Standards at the USAPI Regional TB Meeting (PITCA)

Multinational collaboration

2009 Regional DM Programs attend annual Pacific Islands TB Meeting to find shared activities

National Programs (public-public mix)

2009 Guam TB Program partners with Guam DM Program for data collection

State Programs (public-public mix)

2010 CNMI Partners with Australian Respiratory Council to create TB-DM Teaching Tool

International collaboration

2011 FSM and RMI partner with National DM Program for screening in DM clinic

National Programs (public-public mix)

2011 Hawaii TB Program partners with Community Clinics for patient education in TB clinic

State Program (public-private mix)

Best Practices: Regional Standards(Curry Center, CDC Diabetes Program)

Best Practices: Saipan Island

Best Practices: RMI Community Clinic

Best Practices: TB Screening

Best Practices: TB Screening  Ebeye: 3/10 to 8/11 (18 mo.)

Asymptomatic Diabetics Screened: 264 # TSTs Completed 146 # TSTs Positive 40 (27%) # abnormal CXR 9 # culture positive cases 5

Asymptomatic people with diabetes in Ebeye:TB Case Rate: 3,425 / 100,000

(11 x NTP Rate: 298 / 100,000)

Best Practices: TB-DM Educational ToolAustralian Respiratory Council

• Standardized approach• DOT-based education• Weekly topics: TB and DM

• Simplified and focused

• “Brief Intervention”• 5 min or less• Repeated messages

Best Practices: Operational ResearchCDC, SPC

Kiribati• Evaluating extent of TB-DM• Outcomes for TB-DM

Hawaii - Guam - Saipan• Measuring A1C in TB-DM cases• Can TB programs improve glucose control

during treatment?

Best Practices: Hawaii Clinics  TB-DM Integration Plan - October 2011

Establish Referral Centers for DM care

Diabetes Education Training RN’s DOT Staff

Integrate for Public-Public Mix Latent Screening Centers LTBI Treatment Centers DOT Centers

TB-DM: Partnerships for Progress - Summary

Improve Patient

Care During TB

Tx

External Public Partners

(WHO, CDC)

NGO’s

(Australian Respiratory

Council)

Regional Partners

(FJ Curry, SPC)

Local and External Diabetes Programs

Local Private and Public Partners

(Clinics)

ImprovedLife-LongDiabetesControl

ImprovedTB

Outcomes

Acknowledgments• US Centers for Disease Control and Prevention• WPRO, World Health Organization • International Union Against TB and Lung Diseases• Curry International TB Center• Secretariat for the Pacific Community• Australian Respiratory Council• CNMI Public Health Department• Pacific Islands Health Officers Association• Pacific Islands TB Controllers Association

Questions?

Pacific Partnerships for TB-DM

• Small programs• Multi-tasking is the rule

• “Culture of collaboration”

• TB rates very high• Diabetes rates very high

• 40% over 40 • “Double-digit diabetes”

• Resource limited setting

Cha

lleng

eO

ppor

tuni

ty

Best Practices: Ummm Not so Much…