1. Improving TB-DM Care in the Pacific: Partnerships and Progress R. Brostrom, MD-MSPH Hawaii TB Control Branch Chief Regional TB Field Medical Officer, CDC-DTBE CDR USPHS

2. 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

3. 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.” “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

4. US Pacific Region for TB Control

6. Pacific Partnerships for TB

7. Public Private Mix: New Priority? Tuberculosis Campaign Challenges: 1912 “Lack of therapeutic treatment standards” “Poor reporting of cases under supervision” “Excessive charges to patients” Tuberculosis Campaign Challenges: 1912 “Lack of therapeutic treatment standards” “Poor reporting of cases under supervision” “Excessive charges to patients”

8. 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

9. TB cases with DM Percent Adult TB Patients with Diabetes *Stephenson, BMC Public Health. 2007; 7: 234 ** Restrepo, Bull WHO, 2011; 89: 352-9

10. Leung CC, et.al., Diabetic control and risk of tuberculosis: a cohort study. Am J Epidemiol. 167, 2008 A 1 c > 7 No DM A 1 c < 7 DM

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

12. 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

13. Partnerships in the Pacific Partial List of Best Practices

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

15. Best Practices: Saipan Island

16. Best Practices: RMI Community Clinic

17. Best Practices: TB Screening

18.  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)

19. Best Practices: TB-DM Educational Tool Australian Respiratory Council Standardized approach DOT-based education Weekly topics: TB and DM Simplified and focused “Brief Intervention” 5 min or less Repeated messages

21. Best Practices: Operational Research CDC, 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?

22. 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

23. 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 ImprovedTBOutcomes

24. 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

25. Questions?

26. Pacific Partnerships for TB-DM Small programs Multi-tasking is the rule “Culture of collaboration” 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 TB rates very high Diabetes rates very high 40% over 40 “Double-digit diabetes” Resource limited setting Challenge Opportunity

27. Best Practices: Ummm Not so Much …