It is perhaps because of this reason that, unlike the bigger countries, in the Pacific region, often the problem of adherence is less acute. Also as the population is small - most islands have 30,000-40,000 inhabitants - it becomes difficult for TB patients to escape the DOTS providers who do a good job of follow-up. No wonder treatment success rates are as high as 90%-95% in some places, as shared by Dr Brostrom.
"We do not aim to change the diabetes incidence through a TB programme. But we do want to address how diabetes affects TB patients in not only the Pacific but also in other parts of the world," he said.
Is TB-stigma a barrier for TB testing in diabetes clinics?
Ms Kerri Viney, Research Fellow at Australian National University and a TB consultant, shared similar thoughts with CNS: "Diabetes has been slowly increasing in this region, as across the world, to the point that it has become a major health problem. We have been talking about the TB-diabetes co-morbidity problem close to about 10 years, but it was only in 2008-2009 that we realized its seriousness. Bidirectional screening is part of the collaborative framework for TB-diabetes care and many countries like Fiji, Kiribati, Marshall Islands, and Micronesia are screening TB patients for diabetes. But the harder part is getting diabetes patients screened for TB. This could partly be due to the stigma attached with TB and also because screening for diabetes can be done easily in a TB clinic, but to test for TB is more complex".
Common risk factors: obesity and tobacco!
According to Dr Brostrom obesity and tobacco are common risk factors for TB and diabetes. Other risk factors would include an unhealthy diet. "This is sort of a suicidal risk factor at this point of time with food insecurity, poverty, poor food choices that are available. It is expensive to eat well and diabetes has now become a disease of the poor because of food insecurity," he said.
Meanwhile, Kerri feels that it is necessary to scale up TB-diabetes collaborative care and not just bidirectional screening. There is need for more data on TB prevalence in patients with diabetes and also more information about the dynamics of the two diseases. She thinks that as it might be an uphill task to screen all diabetes patients for TB, perhaps one may screen those with uncontrolled blood sugar or those on insulin. Another point to ponder upon is about TB prevention in people with diabetes.
Dr Brostrom strongly feels that having successfully integrated TB-diabetes care and control, the next step forward would be to integrate tobacco control with the DOTS programme. But this would not be easy. He cautions that it would be a much tougher job to get someone quit smoking or change his or her dietary habits as compared to completing TB treatment. Yet, it is high time that tobacco control becomes an important component of the collaborative efforts to tackle TB and diabetes.
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