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Fiji is a low tuberculosis (TB) burden country, with a TB incidence rate of 24 cases per 100 000 population and a high treatment success rate of 90% (2012 data). 1 However, diabetes mellitus (DM) is very common in Fiji, and its prevalence is thought to be increasing. The STEPwise approach to Surveillance (STEPs) study conducted in 2002 reported a population prevalence of 16% for DM. 2 A more recent estimate, using a different methodology, gave a DM prevalence among adults in Fiji of 10.9%, with impaired glucose tolerance in a further 11.0%. 3 This remarkably high prevalence of DM is a matter of concern for TB control in Fiji. Published data from other settings have concluded that people with DM have a significantly increased risk of developing TB and worse treatment outcomes, with a higher risk of mortality and treatment failure during anti-tuberculosis treatment than among patients without DM. [4][5][6] In response to this evidence, the Fiji National Tuberculosis Programme (NTP) introduced random blood glucose (RBG) testing to screen for DM in all registered TB patients in 2011. 7 A recent local study reported DM in 14% of TB patients in Fiji. 8 It has been noted by local clinical and public health staff that sputum smear-positive TB patients with DM take longer to convert to smear-negative than TB patients without DM, and that they thus require longer periods of hospitalisation. However, this observation has not been verified empirically, and there are no published data from Fiji reporting sputum smear conversion or treatment response in TB patients with and without DM.In the present study, we aimed to evaluate treatment outcomes and sputum smear conversion in TB patients with DM and compare these indicators in TB patients without DM. METHODS Study designThis was a retrospective descriptive study using routinely collected data from the TB register and in-patient folders from three TB treatment hospitals in Fiji. SettingFiji is an island nation, located in the Pacific Ocean, classified as an upper middle-income economy. 9 It comprises 332 islands, of which 110 are inhabited. The population of 837 231 comprises 56.8% i-Taukei (indigenous Fijians) and 37.5% Fijians of Indian descent; the remaining 5.7% are from other ethnic backgrounds. 10 The Fiji NTP is largely funded by the government, and TB diagnosis and treatment are provided free of charge. Three government hospitals provide TB services for the entire country; the private sector is not involved in TB control. All patients diagnosed with TB are registered as TB cases and treated at one of the three TB treatment centres. The majority of TB patients are admitted for the 2-month intensive phase of treatment, during which they receive anti-tuberculosis treatment and clinical follow-up. Clinical evaluation on admission routinely includes a full medical history and RBG screening if the patient is not known to have DM. If RBG is 6.1 mmol/l, fasting blood glucose (FBG) is tested. If the FBG is 7 mmol/l, 8 patients are diagnosed as having DM and referred to a ph...

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of which 130 are inhabited, some of which are several hundred kilometers from established TB services. The country has a well-developed, comprehensive public health system with three divisions (Central Eastern, Northern and Western Divisions), each with a central hospital. Additional health services are provided through a network of 17 subdivisional hospitals, 78 health centres and 101 nursing stations. 3 Established in 1951, the Fiji NTP has applied the DOTS strategy since 1997. Current Fiji TB guidelines recommend that any person suffering from cough of >2 weeks should submit three sputum specimens for acid-fast bacilli microscopy to one of four laboratories in the country. 4 Patients diagnosed with smearpositive sputum are registered as smear-positive PTB, while those with smear-negative sputum or with symptoms and signs of extra-pulmonary TB are further investigated, registered and treated for TB if the diagnosis is made. All TB patients in Fiji are registered in a TB patient register, one of which is kept in each of the three DOTS centres in each division of the country. Defi nitions of TB are in line with World Health Organization (WHO) TB guidelines. 5 Data on education, awareness and training activities in 2010 and 2011 (training courses, duration of courses, facilitators, trainees) were collected from the quarterly FRCS activity reports and monthly NTP reports. Data on all TB patients (numbers of cases, stratifi ed by type of TB) registered from 2008 to 2011 were collected from the TB patient registers at the three DOTS centres. Information on population estimates for Fiji was obtained from the Health Information Unit, Ministry of Health, Fiji. These data were collected into a structured pro forma between October 2011 and June 2012, and single-entered into an electronic database (Excel, Microsoft, Redwoods, WA, USA). Analyses were performed in relation to the introduction of the education, awareness and training activities, i.e., before (2008 and 2009) and during the activities (2010 and 2011). The χ 2 test was used to assess differences in TB case notifi cations before and during the training activities, with odds ratios (ORs), their 95% confi dence intervals (CIs) and P values calculated as appropriate. Differences at the 5% level were regarded as signifi cant.

Although a good correlation between Xpert and the two tests were shown in the study, Xpert should not replace the routine first-line TB diagnostic tests used in Fiji for reasons related to logistics and sustainability. A further evaluation of the assay's performance is required over a longer time period to gauge its diagnostic value in detecting smear-negative, Xpert-positive cases in Fiji.

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This study shows that there are deficiencies in the practice of sputum smear examination in Fiji with respect to sputum quality and recommended number of submitted samples, although the results support the continued use of three sputum samples for TB diagnosis. Ways to improve sputum quality and adherence to recommended guidelines are needed.