168 Chapter 8 Summary This thesis has described DM-TB comorbidity in a low-income country, the different opportunities to improve DM-TB care and the impact of COVID-19 on TB services. Chapter 1 provides insight into the diabetes and tuberculosis burden globally and in Sub-Saharan Africa. Over 500 million people have diabetes globally, with an estimated 6.7 million deaths annually. More than three-quarters of people living with diabetes reside in low- and middle-income countries, and the number of people living with diabetes is projected to increase to 783 million by 2045. In 2022, 10.6 million people were ill with tuberculosis, with 1.3 million tuberculosis-related deaths. The COVID-19 pandemic impacted TB control efforts, and significant effort is required to revive TB services globally to the pre-pandemic levels. Globally, an estimated 15% of people receiving treatment for TB have comorbid diabetes. Diabetes increases the risk of developing TB disease and death during TB treatment and relapse after TB treatment. To address diabetestuberculosis comorbidity, the World Health Organisation advocates bidirectional screening and treatment for diabetes and tuberculosis. Chapter 2 reviews studies on blood glucose changes in people without diabetes receiving treatment for tuberculosis. We searched PubMed, Web of Science, CINAHL and Embase for original research articles between 1980 and 2021. Out of 1,227 articles identified, we included 14 in the final analysis. All the studies were observational, and the fasting blood glucose test was the most common. Most tests were conducted at baseline and in the third month. Twelve out of the 14 included studies indicated the prevalence of elevated blood glucose was lower at follow-up and end of treatment compared to baseline. Patients with baseline hyperglycemia were more likely to develop unfavourable tuberculosis treatment outcomes and death. Findings from this review indicate the importance of blood glucose screening and monitoring for patients commencing TB treatment, even if they are not known to have diabetes mellitus. In Chapter 3, we describe a protocol for a mixed methods study – the prospective study of a cohort of patients commencing tuberculosis treatment and interviews of healthcare workers. The prospective study of patients aims to describe the epidemiology of diabetes-tuberculosis comorbidity, predictors of elevated baseline blood glucose and unfavourable tuberculosis treatment outcomes. The healthcare worker’s interviews aimed to describe the availability of diabetes services at TB clinics, essential equipment and commodities, opportunities to improve integrated care for DM-TB and the impact of COVID-19 on tuberculosis service delivery.
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