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. 2019 Mar 6;19(1):147.
doi: 10.1186/s12913-019-3975-7.

Operationalization of bi-directional screening for tuberculosis and diabetes in private sector healthcare clinics in Karachi, Pakistan

Mashal S Basir  1 , Shifa S Habib  2 , Syed M A Zaidi  2 , Saira Khowaja  3 , Hamidah Hussain  3 , Rashida A Ferrand  4 , Aamir J Khan  3
Affiliations

Operationalization of bi-directional screening for tuberculosis and diabetes in private sector healthcare clinics in Karachi, Pakistan

Mashal S Basir et al. BMC Health Serv Res. .

Abstract

Background: Many countries are facing overlapping epidemics of tuberculosis (TB) and diabetes mellitus (DM). Diabetes increases the overall risk of developing Tuberculosis (TB) and contributes to adverse treatment outcomes. Active screening for both diseases can reduce TB transmission and prevent the development of complications of DM. We investigated bi-directional TB-DM screening in Karachi, Pakistan, a country that ranks fifth among high TB burden countries, and has the seventh highest country burden for DM.

Methods: Between February to November 2014, community-based screeners identified presumptive TB and DM through verbal screening at private health clinics. Individuals with presumptive TB were referred for a chest X-ray and Xpert MTB/RIF. Presumptive DM cases had random blood glucose (RBS) tested. All individuals with bacteriologically positive TB were referred for diabetes testing (RBS). All pre-diabetics and diabetics were referred for a chest X-ray and Xpert MTB/RIF test. The primary outcomes of this study were uptake of TB and DM testing.

Results: A total of 450,385 individuals were screened, of whom 18,109 had presumptive DM and 90,137 had presumptive TB. 14,550 of these individuals were presumptive for both DM and TB. The uptake of DM testing among those with presumptive diabetes was 26.1% while the uptake of TB testing among presumptive TB cases was 5.9%. Despite efforts to promote bi-directional screening of TB and DM, the uptake of TB testing among pre-diabetes and diabetes cases was only 4.7%, while the uptake of DM testing among MTB positive cases was 21.8%.

Conclusion: While a high yield for TB was identified among pre-diabetics and diabetics along with a high yield of DM among individuals diagnosed with TB, there was a low uptake of TB testing amongst presumptive TB patients who were recorded as pre-diabetic or diabetic. Bi-directional screening for TB and DM which includes the integration of TB diagnostics, DM screening and TB-DM treatment within existing health care programs will need to address the operational challenges identified before implementing this as a strategy in public health programs.

Keywords: Active-case-finding; Bi-directional screening; Diabetes; Operational constraints; Tuberculosis.

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Conflict of interest statement

Author’s information

MSB was responsible for initiating the diabetes pilot for community-based screening, diagnosis and treatment at IRD. She is currently pursuing her Master of Public Health degree at Columbia University. SSH is a public health researcher who is involved with impact evaluations of new diagnostic technologies such as Xpert MTB/RIF testing and computer-aided detection for TB in the Pakistani population. Her on-going research focuses on impact of anti-tuberculosis treatment on HbA1C levels among Diabetics with TB. SMAZ is a medical epidemiologist and Program Manager on the TB-DM bidirectional-screening program. SK is a program development expert and was the Director of Strategy and Operations at IRD when the TB-DM bidirectional-screening program was rolled out. HH is a public health professional who serves as Country Director of IRD Bangladesh and was instrumental in scaling drug resistant TB (DR-TB) treatment sites to 10 cities across Pakistan through Global Fund support. RF is a Professor at London School of Hygiene and Tropical Medicine, and is Chief Scientist for a multi-country RCT for treatment of HIV-associated chronic lung disease. AJK is an epidemiologist and social entrepreneur, currently testing social business models for the delivery of affordable lung health and diabetes care in Bangladesh, Indonesia, and Pakistan. Aamir was the driving force behind launching the bi-directional TB-DM screening program in Karachi.

Ethics approval and consent to participate

The study was approved by the Institutional Review Board (IRB) at Interactive Research and Development (IRD), Karachi, Pakistan. The IRB is registered with the U.S. Department of Health and Human Services (DHHS), Office for Human Research Protections (IRB#00005148). The ethics committee formally approved using verbal consent. Verbal consent was obtained from participants prior to conducting blood glucose and Xpert MTB/RIF tests and documented on the screening forms. De-identified data from the project was used for data analysis.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Diagnostic algorithm and results of TB-DM bidirectional screening Feb-Nov, 2014, Karachi, Pakistan
See this image and copyright information in PMC

References

    1. World Health Organization. World Health Organization Global Tuberculosis report 2015.
    1. Baker MA, Harries AD, Jeon CY, Hart JE, Kapur A, Lönnroth K, Ottmani SE, Goonesekera SD, Murray MB. The impact of diabetes on tuberculosis treatment outcomes: a systematic review. BMC Med. 2011;9(1):1. doi: 10.1186/1741-7015-9-81. - DOI - PMC - PubMed
    1. Sicree R, Shaw J, Zimmet P, Heart BI. The global burden. Diabetes and impaired glucose tolerance Baker IDI Heart and Diabetes Institute. 2010.
    1. Lönnroth K, Roglic G, Harries AD. Improving tuberculosis prevention and care through addressing the global diabetes epidemic: from evidence to policy and practice. The Lancet Diabetes & Endocrinology. 2014;2(9):730–739. doi: 10.1016/S2213-8587(14)70109-3. - DOI - PubMed
    1. Harries AD, Satyanarayana S, Kumar AM, Nagaraja SB, Isaakidis P, Malhotra S, Achanta S, Naik B, Wilson N, Zachariah R, Lönnroth K. Epidemiology and interaction of diabetes mellitus and tuberculosis and challenges for care: a review [review article]. Public Health Action 2013;3(Supplement 1):3–9. - PMC - PubMed