Engagement of private healthcare providers for case finding of tuberculosis and diabetes mellitus in Pakistan

Shifa Salman Habib,Shaikh Muhammad Ayub,Wafa Zehra Jamal,Syed Mohammad Asad Zaidi,Aamir Khan,Rashida Abbas Ferrand,Sana Rafiq

doi:10.1186/s12913-020-05217-2

Abstract

BackgroundThe rising co-epidemic of tuberculosis (TB) and diabetes mellitus (DM) is a challenge for constrained health systems in low and middle-income countries. Diabetes is a known risk factor for tuberculosis and associated with poor tuberculosis treatment outcomes, while tuberculosis is associated with worsening glycemic control. We investigated the performance of bi-directional TB and DM case finding approaches through a private-sector engagement model in Karachi, Pakistan.MethodsBetween July 2016 and July 2018, private health care providers were engaged to generate referrals for bi-directional TB and DM screening at private diagnostic and treatment centers in Karachi, Pakistan. Individuals diagnosed with TB underwent glycated hemoglobin (HbA1c) testing at the time of anti-tuberculous treatment initiation and at three -month follow up stage. All individuals with a history of diabetes or random blood sugar of greater than 200 mg/dl were screened for TB using a chest X-ray and Xpert MTB/RIF.ResultsA total of 6312 persons with tuberculosis were tested on HbA1c at treatment initiation, of whom 1516 (24%) were newly diagnosed with DM. About one third of those with HbA1c in the diabetic range (≥ 6.5%) at baseline were found to have a normal HbA1c (< 5.7%) result at 3-month follow-up. A total of 3824 individuals with DM, of whom 2396 (63%) were known cases and 1428 (37%) were newly identified with random blood sugar > 200 mg/dl, underwent chest x-ray and Xpert MTB/RIF testing, with 321 (13.4%) known and 54 (3.8%) new diabetics respectively identified with tuberculosis.ConclusionThis study demonstrates a high yield of TB and DM through bidirectional screening and the feasibility of engagement of private sector in finding missing cases of tuberculosis and diabetes. Given the high prevalence of undiagnosed DM in individuals with TB tuberculosis patients, there is a need to scale-up DM screening within TB programmes. Increased awareness of the high risk of TB among individuals with DM is needed among private health providers and screening for TB among diabetics should be strongly considered.

Highlights

The rising co-epidemic of tuberculosis (TB) and diabetes mellitus (DM) is a challenge for constrained health systems in low and middle-income countries
In this study we investigated the outcomes of the scale-up of a TB-DM bi-directional screening program in the private-sector in Karachi, Pakistan, modelled on the World Health Organization’s (WHO) Collaborative Framework for care and control of tuberculosis and diabetes [9]
The Institutional Review Board (IRB) is registered with the U.S Department of Health and Human Services (DHHS), Office for Human Research Protections (IRB#00005148)

Summary

Introduction

The rising co-epidemic of tuberculosis (TB) and diabetes mellitus (DM) is a challenge for constrained health systems in low and middle-income countries. Diabetes is a known risk factor for tuberculosis and associated with poor tuberculosis treatment outcomes, while tuberculosis is associated with worsening glycemic control. The International Diabetes Federation has estimated that the number of people living with DM worldwide will rise from 463 million in 2019 to 700 million by 2045 [2]. An estimated 1 million people globally are present with TB-DM comorbidity, higher than the number of patients with TB-HIV coinfection [4]. DM increases the risk of developing TB three-fold and is associated with delayed sputum conversion, treatment failure, relapse and death [6]. TB in turn is associated with worsening glycemic control

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