improving tb-dm care in the pacific: partnerships and progress r. brostrom, md-msph hawaii tb...
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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
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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
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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/>
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US Pacific Region for TB Control
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Pacific Partnerships for TB
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Public Private Mix: New Priority?
Tuberculosis Campaign Challenges: 1912
“Lack of therapeutic treatment standards”
“Poor reporting of cases under
supervision”
“Excessive charges to patients”
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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
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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
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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
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Baker et al. BMC Medicine 2011, 9:81 The impact of diabetes on TB treatment outcomes: A systematic review
TB-DM Outcomes: Relapse
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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
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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)
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Best Practices: Regional Standards(Curry Center, CDC Diabetes Program)
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Best Practices: Saipan Island
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Best Practices: RMI Community Clinic
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Best Practices: TB Screening
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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)
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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
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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?
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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
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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
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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
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Questions?
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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
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Best Practices: Ummm Not so Much…