Fixing the problem by facing it?
By: Double Burden Of Tb
Tags: Double Burden Of Disease, Tuberculosis, Diabetes, Policy

In the last three blog posts, we gave you some information about the problem and burden of Tuberculosis, Diabetes and the interaction between them. This is important because the double burden of disease of TB and Diabetes is a significant problem, especially in Brazil. Maybe if you read the other blog posts, you are asking yourself, shouldn’t Brazil do something to face this double burden of disease? Shouldn’t they change something to make things better? Well, that is exactly what they tried to do.

Missed our last blog or do you want to refresh your memory? You will find it here!

Interventions tackling Tuberculosis

Over the years, a number of interventions have been launched in Brazil to reduce the incidence/deaths of TB. In the 90s, Brazil implemented the Family Health Strategy (FHS), to make care for people with TB part of primary care. This way care became free and this contributed to addressing the disease (1). Research also shows that people enrolled in the Programa Bolsa Família (PBF, also known as Family Income Transfer Program) have better treatment outcomes. This program provides cash transfers for low-income families to increase utilization of public services. In this way, the economic burden is reduced (1, 2).

In addition, the Directly Observed Therapy (DOT) was part of the FHS, which reduced the treatment abandonment rates, deaths and multidrug-resistant tuberculosis (1). Also, the “fixed dose treatment” was introduced in 2009 which also reduced the treatment abandonment rates. These interventions have been fundamental to reducing infections and deaths, and will be of great importance in the future as well (1). All these interventions made it possible for Brazil to meet the Millennium Development Goals (MDG) of the WHO before the 2015 deadline (1).

As you read in our previous post, the diagnosis of TB still often comes too late or not at all in people with diabetes and TB. Among other things, this has ensured that ending TB is one of the Sustainable Development Goals (SDGs) of the WHO (3). With this “End TB Strategy” that they designed in 2014, they want to lower the incidence of TB with 80% and the deaths with 90% by 2030. Besides that, the WHO also wants to reduce costs for TB-affected households (one of the big issues in Brazil) (3). With this strategy, they target people at risk of infection and who have poor access to healthcare (3). It consists of three pillars:

Integrated, patient- centered TB care and prevention; Bold policies and supportive systems; Intensified research and innovation (4).

However, the success of this approach depends on how countries adapt this to their own settings (3). Improving current initiatives could help Brazil achieve these goals for elimination by 2035 (1).

Did you know that March 24 is World TB Day? This takes place every year to raise awareness of all the terrible consequences of tuberculosis. This year’s slogan was “The Clock is Ticking”!

Intervention — Double Burden

One of the main interventions in Brazil on the double burden of TB and Diabetes is a project implemented by a partnership between the Pan American Health Organisation (PAHO) and the Ministries of Health (MoH) from Brazil and Mexico (5). The overall goal of the project is to improve the timely identification of Diabetes and TB in people of the Americas, which includes Brazil, to improve specific treatment opportunities (6). To reach this overall goal, the project focuses on five different aspects:

To apply the diabetes-TB guidelines to develop an instrument to facilitate TB-screening among diabetes patients; To include TB risk assessment as established in the new guidelines in the standard of care for people with diabetes, especially during the diagnosis; Incorporate TB screening to existing diabetes guidelines; To increase awareness of the double burden of TB and diabetes, especially amongst health professionals; To improve monitoring of screened, diagnosed and treated cases via the development of better ways of data collection and analysis (6).

There is also a World Diabetes Day. This year it was on November 14th. On this day, attention was focused on improving access to diagnosis and treatment of diabetes.

To be able to make the project work, it is really important to improve the healthcare systems by improvement in capacity and coordination (5). That is why, before the real project started, doctors, nurses and other health professionals received training on screening, diagnosis, treatment, use of databases and awareness raising (5). During the trial phase of the project, 20 health care centres in three different cities were selected, two cities in Brazil and one in Mexico. At least 1000 diabetes patients per city were tested on TB by a health professional who received the training beforehand (5). Due to the screening, multiple patients could be diagnosed with TB and receive specific treatment which increases their quality of life.

Due to the success of this project, there came more awareness about the double burden of TB and Diabetes. That is why, The WHO/The Union guideline “Collaborative Framework for Care and Control of Tuberculosis and Diabetes” (2011) was translated and adapted into the Latin American context. In addition, a range of training, screening and patient education materials were produced in Spanish and Portuguese as well, which makes it easier to educate both the health professionals and patients on the double burden of disease (5).