Speaking 1000 words

ImpactingTB Outcomes

ForDiabetics

Denise Dodge, RN, TB Nurse Consultant/Assistant DirectorVirginia TB/Newcomer Health Program 2016

Through the YearsCase Managing TB with Diabetes

Early 20th Century

• Diabetics that did not die from a diabetic coma, were likely to die from TB

1950’s

• Combined TB-Diabetes clinics were common

Today

• Diabetics are 3 times more likely to develop TB than non-diabetics

Diabetes is the leading risk factor associated with VA TB cases (14.1-21.2%)

Diabetes is the leading risk factor associated with VA TB cases (14.1-21.2%)

..

Heysell et al. Emerg Infect Dis 2010

Steps towards the flipchart

•2007: Routinely checking Serum Drug Levels (SDL)in “slow-responders”

•Diabetics were 6.3 times more likely to be slowresponders and had significantly lower rifampin levelscompared to non-diabetic slow-responders

Heysell et al. Emerg Infect Dis 2010

Steps towards the flipchart

•2007: Routinely checking Serum Drug Levels (SDL)in “slow-responders”

•Diabetics were 6.3 times more likely to be slowresponders and had significantly lower rifampin levelscompared to non diabetic slow-responders

•2011: Measure isoniazid and rifampin levels in all diabetics at two to four weeks of therapy

Heysell et al. Emerg Infect Dis 2010

Steps towards the flipchart

•2007: Routinely checking Serum Drug Levels (SDL)in “slow-responders”

•Diabetics were 6.3 times more likely to be slowresponders and had significantly lower rifampin levelscompared to non diabetic slow-responders

•2011: Measure isoniazid and rifampin levels in all diabetics at two to four weeks of therapy

•2013: New presumed or confirmed TB cases have a HgbA1C drawn. If > 6.5, SDL are performed at 2 – 4 weeks

Heysell et al. Emerg Infect Dis 2010

Steps towards the flipchart

•2007: Routinely checking Serum Drug Levels (SDL)in “slow responders”

•Diabetics were 6.3 times more likely to be slowresponders and had significantly lower rifampin levelscompared to non diabetic slow-responders

•2011: Measure isoniazid and rifampin levels in all diabetics at two to four weeks of therapy

•2013: New presumed or confirmed TB cases have a HgbA1C drawn. If > 6.5, SDL are performed at 2 – 4 weeks

•2016: All presumed or confirmed TB cases who are HIV co-infected have SDL drawn one week after a stable regimen is established.

Key Messages for TB & Diabetes

Design and Development

Denise Dodge2016

About this ResourceTB outreach workers (ORWs) and nurses have anopportunity to promote education and key messages to people over an extended time, during directly observed therapy (DOT). This resource was developed to support ORWs and nurses as they provide education to individuals and community groups. It addresses TB and diabetes. People diagnosed with TB should be checked for diabetes because having diabetes can affect the treatment and management of TB.

Educating PatientsThis flip chart is designed to: Complement and reinforce TB education given

at the time of TB diagnosis, Promote adherence to and completion of TB

treatment, and Promote control of diabetes for patients with

both TB and diabetes.

Conducting the TB and Diabetes Education Sessions

Since TB and diabetes can cause great concern or worry, frame educational information in positive rather than negative terms whenever possible.

Give specific feedback and be realistic in your advice. For example, if it is unlikely that a patient will totally stop smoking and/or drinking, suggest that the patient reduce use of cigarettes and alcohol.

If you do not know the answer to a question, tell the patient that you do not know but that you will talk to the TB case manager and bring the answer back for the patient.

Do not overload a patient with information; use clear, simple language and avoid medical terminology.

Be aware that there may be a stigma about TB and some people believe that the disease is inherited. Explain that TB is spread through the air and infection can be prevented.

About this ResourceTB outreach workers (ORWs) and nurses have anopportunity to promote education and key messages to people over an extended time, during directly observed therapy (DOT). This resource was developed to support ORWs and nurses as they provide education to individuals and community groups. It addresses TB and diabetes. People diagnosed with TB should be checked for diabetes because having diabetes can affect the treatment and management of TB.

Educating PatientsThis flip chart is designed to: Complement and reinforce TB education given

at the time of TB diagnosis, Promote adherence to and completion of TB

treatment, and Promote control of diabetes for patients with

both TB and diabetes.

Conducting the TB and Diabetes Education Sessions

Since TB and diabetes can cause great concern or worry, frame educational information in positive rather than negative terms whenever possible.

Give specific feedback and be realistic in your advice. For example, if it is unlikely that a patient will totally stop smoking and/or drinking, suggest that the patient reduce use of cigarettes and alcohol.

If you do not know the answer to a question, tell the patient that you do not know but that you will talk to the TB case manager and bring the answer back for the patient.

Do not overload a patient with information; use clear, simple language and avoid medical terminology.

Be aware that there may be a stigma about TB and some people believe that the disease is inherited. Explain that TB is spread through the air and infection can be prevented.

1. Complement and reinforce TB education given at the time of TB diagnosis.

2. Promote adherence to and completion of TB treatment.

3. Promote control of diabetes for patients with both TB and diabetes

Implementing the project

• Health Director Update• 2011 – Update on Diabetes and SDL• 2013 – Introduce HgbA1c for each TB suspect/case• 2014 – Introduce flipchart

• Annual TB nurse training• 2011 – 2014: Updates on Diabetes, SDL & HgbA1c• 2014 – Roll out the flipchart

• Outreach working training• 2015 – Roll out the flipchart

One year later……..Is the flipchart being used?• Six question survey polled TB staff

• 36% (43/110) responded • 56% of those who responded have never used the

flipchart• 26% didn’t know it existed• 14% have no TB cases

• 83% of those who have used it said it was easy –very easy to use

One year later……..Is the flipchart being used?• Six question survey polled TB staff

• 36% (43/110) responded • 56% of those who responded have never used the

flipchart• 26% didn’t know it existed• 14% have no TB cases

• 83% of those who have used it said it was easy –very easy to use

• How can we help increase the use of the flipchart?• Develop in other languages – 68%• Provide additional training to staff – 52%

Consider translation, BUT, to what?

Country % of 2015 TB cases with Diabetes United States 17.8

Philippines 15.6

India 8.9

Korea 8.9

Pakistan 6.7

• Most Field staff and some nurses are bilingual• Virginia TB clients come from 35 different countries

Patient View

Healthcare worker view

Week 1

• Stay at home until your doctor or healthcare provider says you may return to school or work.

• To help stop the spread of TB, ask friends not to visit until your doctor or healthcare provider says you can have visitors.

• If possible, keep windows open in your home until your doctor says that you cannot pass TB germs to others.

• Tell your doctor or nurse if you plan to move to another place. They can help make sure you get TB medicines after you move.

• Have you had an HIV test? If not, you should be tested as people with HIV can get very sick from TB. You may need different TB medicines if you have HIV.

Week 1Help stop the spread of TB continuedWhat else do you need to know about TB?

Help stop the spread of TB continued

What else do you need to know about TB?

Week 1¿Cómo puede prevenir el contagio de

TB?• La tuberculosis se propaga por el aire, cuando personas que tienen el

germen tosen, estornudan, hablan, ríen y cantan. La tuberculosis no se propaga con apretones de manos, abrazos, besos, compartiendo comida o ropa de cama.

• La única manera de contagiarse con tuberculosis es inspirar los gérmenes.

• Si ya tiene tuberculosis en su sistema respiratorio, tiene que prevenir que otros se contagien. Si los gérmenes están en otra parte de su cuerpo, lo más probable es que no haya riesgo de contagio.

• Es importante que se cubra la boca cuando tosa o estornude cerca de otras personas. Es posible que tenga que ponerse una mascarilla para salir de su hogar.

• Si utiliza pañuelitos descartables (papel tisú), póngalos en una bolsa plástica y cierre la bolsa hasta que pueda desecharla.

• Siempre lávese las manos después de toser

No hay mensajes

Improvements

• Create supporting written patient handout• Simplify the message, rewrite educator content points• Record/video teaching points• Diabetic 101 education to staff• Improve linkage to healthcare resources for Diabetic

management • To prevent TB disease• Use the tool for TBI clients• Expand HgbA1c to TBI clients• Identify creative ways to increase

testing for TB infection of diabetics