#4 Prevention- and treatment approaches on diabetes mellitus type 2 and tuberculosis in Southern African countries
Last week, Fleur introduced us to regional- and national measures for both prevention- and treatment for tuberculosis (TB) disease and type 2 diabetes mellitus (T2DM) that are taken by the South African government. However, it is important to note that South Africa is not alone in this double burden of disease. Therefore, this blog post is dedicated to international prevention- and treatment measures and answering the question: What can other countries learn from- or teach South Africa?
This question will be answered with special attention to countries in the Southern African region, because the context of these countries is similar to each other and learned lessons can be adopted to the other countries. Southern Africa includes the following countries: Angola, Botswana, Lesotho, Madagascar, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe as seen in figure 1.
Prevalence of TB & T2DM in Southern Africa
The WHO Global Tuberculosis Report (2020) estimated that South Africa’s incidence of TB is 615 cases per 100,000 inhabitants. Other countries that have a relative high prevalence of TB incidence are Lesotho (654/100,000) and Namibia (486/100,000), as seen in figure 2. Besides those three mentioned countries are also Angola, Mozambique, Zambia and Zimbabwe included in ‘The 30 high TB burden countries for the period 2016–2020’ of the WHO. Nevertheless, since South Africa has the largest population of all countries in the Southern African regions, their total prevalence of approximately 360,000 TB cases is the highest of all countries in the Southern African region.
According to the ‘Diabetes Atlas’ (2019) of the International Diabetes Federation (IDF) South Africa has the highest diabetes prevalence in adults aged 20 to 79 in the region of Southern Africa, namely 12.8% of South Africans. Also, Botswana (5.5%), Angola (3.9%) and Namibia (3.8%) ranked high. Zimbabwe (1.2%) has the lowest prevalence of Diabetes in Southern Africa. An overview of these rates can be found down below in figure 2. Furthermore, the IDF estimates that in the African Region the number of people with Diabetes will increase from 19.4 million in 2019 to 47.1 million in 2045, thus almost doubling in 26 years. It is estimated that in Africa around 70 to 90% of diabetes is T2DM. T2DM is the diabetes type that influences TB, as you might have read in our first blog post.
Approaches for treatment for (MDR-)TB in Southern Africa
As previously said, is TB relatively the largest issue in Lesotho, Namibia and South Africa. In this part of the blog post we will focus on the availability of treatment for multidrug-resistant TB (MDR-TB), because attention towards this increasing topic is important since action can prevent further escalation of the prevalence of MDR-TB. It is estimated by the WHO that worldwide MDR-TB cases increased in 2019 with 10% in comparison to a year earlier, resulting in a total of 206,030 patients with MDR-TB. MDR-TB is a type of TB that is drug resistance towards two types of drugs: isoniazid and rifampicin. It is part of rifampicin-resistant TB (RR-TB) and makes up for approximately 78% of RR-TB cases. We first introduced you to MDR-TB with Tsolefelo in blog post 2 and 3, who suffered from it. Feel free to read her story first, before continuing reading this blog post.
Treatment for MDR-TB is harder than TB. Firstly, because it is more expensive than treatment for drug-receptive (DR-)TB. Secondly, treatment is more intensive for patients, since the duration is longer and there are more side-effects to it, in comparison to DR-TB. Thirdly, treatment for MDR-TB is not always effective (worldwide around 57%). On average 86% of all worldwide patients with diagnosed MDR-TB are being treated. However, only 57% of them were treated with a favourable outcome. The gap between diagnosed MRR/MDR-TB patients and MRR/MDR-TB patients on treatment is the largest in countries in the African- and Western Pacific region. The reason for this is that capacity for (MDR-)TB diagnosis is well established, but capacity for MDR-TB treatment stays too far behind. The WHO therefore recommends decentralising health services in those countries. South Africa is one of the countries, of the thirty highest MDR-TB burden list, that has the smallest gaps. What can other countries in the Southern African region learn from South Africa’s approach?
One of the contributing factors is the community-based care approach in South Africa. This has been thought to be effective, since the MDR-TB prevalence differs greatly per region in South African resulting in not enough capacity within those high prevalent regions, e.g. KwaZulu-Natal. Within this approach, stable patients are being treated at home with medication or, if they live close enough to the nearest health clinic, they have to pick up their medication themselves. During this pilot, 51% of community-based patients were treated successfully, whereas 34% of hospital-based patients were cured. After this success, the community-based approach was further expanded. If you want to learn more about this approach, we invite you to watch the following video of Doctors without Borders:
Prevention measures in Southern Africa for T2DM
South Africa has the highest prevalence of diabetes, with Botswana, Angola and Namibia following behind. These high rates of diabetes are closely associated with overweight and obesity. As mentioned in the second blog: Life style related risk factors of diabetes mellitus type 2 and tuberculosis in South Africa, is 54% of South Africans overweight and another 28.3% is obese. These rates are lower than in Botswana, Angola and Namibia. In Botswana is 18.80% of all adults overweight and 11.80% of adults is obese. In Angola and Namibia respectively 15.80% and 13.30 of all adults are overweight and 6.80% and 8.40% are obese. These graphs support the described ‘health risk’ of overweight/obesity on T2DM in literature and also our blog post two. Thus, prevention of T2DM should involve prevention of overweight/obesity. Prevention programs for diabetes should be aimed at keeping a healthy weight and diet, but also daily activity. However, there are already many programs in place for prevention of overweight and obesity, this raises the question how can we increase the effectiveness of them?
A study conducted in South Africa, found that: “Many overweight and obese South African women do not want to lose weight although they may be aware of the health consequences of being overweight”. Besides, some women associated being skinny with disease and/or HIV/AIDS. Another study, connected those causes of stigma around weight, among other things, to all countries in the African region. Therefore, it is recommended to all countries struggling with high prevalence of overweight and/or obesity to put prevention programs in place to prevent- and reverse obesity. But nevertheless focus on changing the internal willingness of those aimed at. This can be provided with educational programs on why a healthy diet and weight are important.
Final note
First of all, it is important to note that one approach or measure can work in one country or region, but might not have the same sought after effect in another place. Therefore, it is recommended to launch pilots, to see if the approach works in the aimed region. As recommended by the WHO and as it works in South Africa, a community-based approach for (MDR-)TB is a good example of this. Furthermore, all countries in Southern Africa should not solely invest in prevention programs for overweight and obesity to prevent T2DM, but also put effort in providing educational programs to reduce the stigma concerning thinness. Lastly, countries should invest in communication with each other, so effective approaches can easily be implemented across borders.
Next week we will have a last post on the influence of COVID-19 and our double burden of disease.
Written by Bo Veldhuizen
