Health agencies collaborate to boost response to dual crisis of diabetes and TB in Ebeye

May 31, 2017

The island of Ebeye is the most populous of the Kawajalein Atoll in the Republic of the Marshall Islands and is nearly completely covered by roads and man-made structures. Photo: NASA.

With 466 cases identified per 100,000 people, the Republic of the Marshall Islands (RMI) has one of the highest tuberculosis (TB) prevalence in the world. Despite many decades of efforts to eradicate the devastating disease, it has continued to spread in the overcrowded atoll communities fueled by poor nutrition, high rates of diabetes, substandard housing and poor health seeking behaviours.

Ebeye – the most populous island in the Kawajalein Atoll in RMI – also faces a dual epidemic of non-communicable diseases (NCDs) such as diabetes. In fact, diabetes is the number one public health problem and the leading cause of premature mortality in the RMI, affecting over 20% of the adult population. The high rates of diabetes are primarily the result of extremely poor diets with low levels of fresh vegetables and fruit consumption and lack of physical activity. These risk factors are compounded by socio-economic and structural determinants, including an overdependence on imported hyper-processed foods due to lack of arable land.

Both TB and diabetes affect people who are in their productive years, presenting a risk to development progress that has been achieved if prevention efforts are not successful. TB concentrates in certain vulnerable segments of the population, such as the elderly, the poor, migrants as well as those with compromised immune systems such as diabetics or people living with HIV.

To help bring the situation under control in RMI, the Ministry of Health, supported by several agencies including the United Nations Development Programme (UNDP), the World Health Organization, the US Center for Disease Control (CDC) and the Pacific Islands Health Officer Association (PIHOA), embarked on a mass screening and treatment programme in early 2017. The screening, which in addition to TB also checked for Hansen’s disease (also known as leprosy), diabetes and high blood pressure, was preceded by a pre-registration phase of all residents through a fingerprint digitizing system to improve tracking and management of patients. The unique approach also provided opportunities for weight checkups and health counselling. 

Slide
Clients undergo screening for blood sugar before chest X-rays, which is essential as diabetes is an important comorbidity of TB in RMI. Photo: Ferdinand Strobel/UNDP.
Slide
Clients undergo screening for blood sugar before chest X-rays, which is essential as diabetes is an important comorbidity of TB in RMI. Photo: Ferdinand Strobel/UNDP.

Specialist doctors, epidemiologists, nurses and volunteers from RMI and abroad participated in the screening and subsequent case management. New cases identified resulted in the near doubling of the usual annual caseload of around 50.

“One person can have TB and at the same time diabetes and hypertension, but if we just follow the conventional way of running a programme with one programme only focusing on TB, while another on hypertension and yet another on diabetes - it can be fragmented,” said Dr. Eunyoung Ko, WHO Country Liason Officer in Northern Micronesia.

“Through this screening programme, we tried to integrate the many programme components into one. Combining the programmes together results in cost efficiency and it is more convenient for the people. It’s a very good example of a public health programme that can be a model for the Pacific island countries.”  

Mareta Hauma leads the TB programme in Ebeye and is confident the screening will significantly improve TB and comorbidities control and management: “With this screening we will know for sure how many cases we have out there and we will make sure we follow up on them. By doing that, we will be able to control TB in this community.”

Slide
The mass screening campaign was a collaborative effort, including colleagues such as Mareta Hauma, TB Coordinator in Ebeye. Photo: Ferdinand Strobel/UNDP.
Slide
A mobile X-ray machine procured by UNDP for the Ministry of Health through the Western Pacific Integrated HIV and TB Programme is operated by a volunteer radiologist from the United States participating in the screening. Photo: Ferdinand Strobel/UNDP.
Slide
Members of the mass screening campaign team review a suspected TB case. Photo: Ferdinand Strobel/UNDP.

As part of the mass screening campaign, TB clinicians met on a daily basis to review suspected TB cases. Health staff, including volunteer specialists and epidemiologists from abroad, participated in the operation.

“To know how to do active case finding is a bit of a lost art. We had to go back to the literature from the 1950s to know how to set things up, and know what to expect for population characteristics,” said Dr. Richard Brostrom, TB Control Branch Chief, US CDC in Hawaii. “Really what has changed is the technology we have now with the GeneXpert, which is a phenomenal diagnostic tool that we use in conjunction with the X-ray. We will look at the results very critically and if we think that we are going to be successful in improving the programme in terms of the rates of diseases then we would like to export this [approach] to other high-risk places in the Pacific.”

The mass screening campaign was supported by UNDP through the Western Pacific Integrated HIV, TB Programme which supports the RMI national programmes procure much needed diagnostics, medicines and commodities, laboratory support and staffing. For this campaign, UNDP procured a portable X-ray machine.

“UNDP in the Pacific works closely with a range of partners, including civil society, governments, WHO, US CDC, PIHOA, the Pacific Community and others to build resilient and sustainable health systems,” said Maisoon Elbukhari Ibrahim, Programme Manager, UNDP Pacific Office in Fiji. “Only by ensuring that health responses are inclusive and reach all vulnerable groups will we be able to achieve the health-related Sustainable Development Goals.”

It is hoped that the mass screening campaign, if proven successful, can be replicated in other TB and NCD ‘hotspots’ around the region and contribute to longer and healthier lives for the people of Ebeye and other Pacific island communities.