ReacciónWhile people living with diabetes are more vulnerable to various respiratory and bacterial infections, including TB, health-care settings that provide diabetes care may have limited procedures for infection control (139). Some of the people who attend clinics that provide diabetes care will have undiagnosed TB, which may present a risk of transmission. Data are lacking on the exact time it takes to become non-infectious after effective TB treatment is commenced. Experts have suggested that reduction of infectiousness occurs much earlier than culture or smear conversion – possibly as early as 2–3 days after initiation of effective TB treatment in people with drug-susceptible TB and 2 weeks after effective TB treatment in people with drug-resistant TB (112). Ideally, diabetes should be managed in people with TB within the TB care facility for at least the first 2 weeks of TB treatment and longer if the clinical presentation indicates.
Given the evidence of an increased risk of TB disease and poor TB treatment outcomes among people living with diabetes, reasonable steps should be taken to reduce the risk of transmission in clinic and hospital environments. Experience of the impact of coronavirus disease 2019 (COVID-19) on people living with diabetes and the resulting heightened awareness of the importance of infection control in health-care settings should be leveraged to improve infection control in clinics in which diabetes is managed.
The WHO consolidated guidelines on tuberculosis. Module 1: infection prevention and control (25) provide recommendations on preventing the transmission of TB in health-care and other congregate settings. Box 6 summarizes those recommendations. The WHO Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level (140) provide additional details on IPC measures to prevent transmission of infectious diseases that apply to all health-care settings.
Implementation of TB IPC measures requires national, subnational and facility managerial oversight, with identification of focal points at all levels who will liaise with the TB IPC focal points in the NTP. Enforcement of TB IPC measures is more likely to be successful if it becomes part of the job description of specific, named clinic staff. Health-care facilities, including diabetes clinics, should have an IPC plan which includes a plan for TB IPC that covers administrative, environmental and respiratory protection measures. The plan should ideally be based on a TB IPC facility risk assessment after review of issues such as patient flow, high-risk areas and personal protection measures. An example of a TB risk assessment tool is provided in the TB infection control operational handbook (112). The plan may be supported by SOPs and flowcharts on reducing transmission in a clinic through screening and triage of people who are symptomatic and respiratory separation. Environmental awareness, increased spacing and opening windows can help to reduce transmission risks, and training of all clinic staff and educational displays can reinforce the messages and help to prevent transmission of all respiratory infections, including TB.
Information, education and counselling should also be provided to people with TB and their family members to reduce the risk of transmission to the family and the community. Patient groups, carers and patients should receive targeted messages about the risks of infection (and TB) for people living with diabetes. They should include the importance of adhering to TB treatment, advice on cough etiquette, sleeping alone, avoiding congregate settings and spending as much time as possible outdoors when feasible, until the individual is no longer infectious (112). Patient groups and community representatives can work with health-care professionals to develop messages targeted at different audiences (e.g. for people affected by TB, carers, community leaders) to make them meaningful and widely available.
In order to minimize the time spent in health-care facilities, community or home treatment support for TB is recommended over health facility-based treatment support or unsupervised treatment (31). Digital and virtual technology could reduce the frequency of in-person attendance in diabetes clinics if the resources are made available (85,141,142).
Periodic evaluation of IPC practices is essential to ensure that the measures are appropriate. Assessment of TB IPC should be part of routine supervision of all health facilities that provide care for diabetes. A standardized checklist for periodic evaluation of IPC practices can be used in such an assessment, which can also be used to measure progress over time. An example of such a checklist that can be adapted by countries to suit their context is provided in Annex 6.
