Screening for prevalence of current TB disease and latent TB infection in type 2 diabetes mellitus patients attending a diabetic clinic in an Indian tertiary care hospital

Prevalence and factors associated with tuberculosis infection in India

BACKGROUND

The risk of tuberculosis (TB) disease is higher in individuals with TB infection. In a TB endemic country like India, it is essential to understand the current burden of TB infection at the population level. The objective of the present analysis is to estimate the prevalence of TB infection in India and to explore the factors associated with TB infection.

METHODS

Individuals aged > 15 years in the recently completed National TB prevalence survey in India who were tested for TB infection by QuantiFERON-TB Gold Plus (QFT-Plus) assay were considered for this sub-analysis. TB infection was defined as positive by QFT-Plus (value >0.35 IU/ml). The estimates for prevalence, prevalence ratio (PR) and adjusted risk ratio (aRR) estimates with 95% confidence intervals (CIs) were calculated.

RESULTS

Of the 16864 individuals analysed, the prevalence of TB infection was 22.6% (95% CI:19.4 -25.8). Factors more likely to be associated with TB infection include age > 30 years (aRR:1.49;95% CI:1.29-1.73), being male (aRR:1.26; 95%CI: 1.18-1.34), residing in urban location (aRR:1.58; 95%CI: 1.03-2.43) and past history of TB (aRR:1.49; 95%CI: 1.26-1.76).

CONCLUSION

About one fourth (22.6%) of the individuals were infected with TB in India. Individuals aged > 30 years, males, residing in urban location, and those with past history of TB were more likely to have TB infection. Targeted interventions for prevention of TB and close monitoring are essential to reduce the burden of TB in India.

Impact of diabetes itself and glycemic control status on tuberculosis

Objectives

To explore the impact of diabetes itself and glycemic control status on tuberculosis (TB).

Methods

A total of 3393 patients with TB and diabetes mellitus (DM) who were hospitalized in the Public Health Clinical Center of Chengdu from January 1, 2019, to December 31, 2021, were retrospectively included and divided into three groups according to baseline glycemic control status: two groups according to glycemic status at discharge, two groups according to cavity occurrence, three groups according to sputum results, and three groups according to lesion location. The influencing factors and the differences in cavity occurrence, sputum positivity and lesion location among different glycemic control groups or between different glycemic status groups were analyzed.

Results

In this TB with DM cohort, most of the subjects were male, with a male to female ratio of 4.54:1, most of them were 45-59 years old, with an average age of 57.44 ± 13.22 years old. Among them, 16.8% (569/3393) had cavities, 52.2% (1770/3393) were sputum positive, 30.4% (1030/3393) had simple intrapulmonary lesions, 68.1% (2311/3393) had both intra and extrapulmonary lesions, only 15.8% (537/3393) had good glycemic control,16.0% (542/3393) and 68.2% (2314/3393) had fair and poor glycemic control, respectively. Compared with the non-cavity group, the sputum-negative group and the extrapulmonary lesion group, the cavity group, sputum-positive group, intrapulmonary lesion group and the intra and extrapulmonary lesion group all had higher fasting plasma glucose (FPG) and glycosylated hemoglobin A 1c (HbA1c) and lower good glycemic control rates at admission (all P<0.001). Another aspect, compared with the good glycemic control group, the poor glycemic control group had a higher cavity occurrence rate, sputum positive rate, and greater proportion of intrapulmonary lesions. Moreover, FPG and HbA1c levels and poor glycemic control were significantly positively correlated with cavity occurrence, sputum positivity, and intrapulmonary lesions and were the main risk factors for TB disease progression. On the other hand, cavity occurrence, sputum positivity, and intrapulmonary lesions were also main risk factors for hyperglycemia and poor glycemic control.

Conclusion

Diabetes itself and glycemic control status could impact TB disease. Good glycemic control throughout the whole process is necessary for patients with TB and DM to reduce cavity occurrence and promote sputum negative conversion and lesion absorption.

Acceptability and feasibility of tuberculosis-diabetes mellitus screening implementation in private primary care clinics in Yogyakarta, Indonesia: a qualitative study

BACKGROUND

The relationship between Tuberculosis (TB) and Diabetes Mellitus (DM) is intricate and intertwined, posing significant global health challenges. In addition, the increasing prevalence of DM worldwide raises concerns regarding the potential resurgence of tuberculosis. The implementation of tuberculosis prevention strategies is of the utmost importance, especially in countries like Indonesia that encounter a dual burden of TB and DM. The significance of TB screening in private primary care settings for patients with diabetes cannot be overstated. Implementing TB screening protocols in private primary care settings can assist in identifying diabetic patients with tuberculosis. Therefore, this study aims to explore the acceptability and feasibility of tuberculosis-diabetes mellitus screening implementation in private primary care clinics.

METHODS

We conducted implementation research with an exploratory qualitative design. Fifteen healthcare professionals from five private primary health care clinics in Yogyakarta, Indonesia, participated in five focus groups. The discussions were audio recorded, transcribed verbatim, and thematically analyzed. As part of the feasibility assessment, surveys were conducted in each clinic. We conducted a thematic analysis in accordance with the theoretical framework of acceptability and the feasibility assessment.

RESULTS

We identified that most private primary care clinics deemed the implementation of TB screening in DM patients acceptable and practicable. We revealed that the majority of diabetes patients enthusiastically accepted TB-DM screening services. In addition, we found that the healthcare professionals at the clinic are aware of the nature of the intervention and demonstrates a positive attitude despite a subtle burden. The stigma associated with COVID-19 has emerged as a new implementation barrier, joining TB stigma, lack of resources, and regulatory issues. We identify concealed and tiered screening as a potential method for enhancing the implementation of TB-DM screening.

CONCLUSIONS

The implementation of TB screening in DM patients in private primary care clinics had the potential to be acceptable and feasible. To achieve a successful implementation, consideration should be given to supporting factors, hindering factors, and strategies to improve TB screening in DM patients.

The prevalence of tuberculosis infection in India: A systematic review and meta-analysis

Background & objectives

The National Prevalence Survey of India (2019-2021) estimated 31 per cent tuberculosis infection (TBI) burden among individuals above 15 years of age. However, so far little is known about the TBI burden among the different risk groups in India. Thus, this systematic review and meta-analysis, aimed to estimate the prevalence of TBI in India based on geographies, sociodemographic profile, and risk groups.

Methods

To identify the prevalence of TBI in India, data sources such as MEDLINE, EMBASE, CINAHL, and Scopus were searched for articles reporting data between 2013-2022, irrespective of the language and study setting. TBI data were extracted from 77 publications and pooled prevalence was estimated from the 15 community-based cohort studies. Articles were reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and were sourced using a predefined search strategy from different databases.

Results

Out of 10,521 records, 77 studies (46 cross-sectional and 31 cohort studies) were included. The pooled TBI prevalence for India based on the community-based cohort studies was estimated as 41 per cent [95% confidence interval (CI) 29.5-52.6%] irrespective of the risk of acquiring it, while the estimation was 36 per cent (95% CI 28-45%) prevalence observed among the general population excluding high-risk groups. Regions with high active TB burden were found to have a high TBI prevalence such as Delhi and Tamil Nadu. An increasing trend of TBI was observed with increasing age in India.

Interpretation & conclusions

This review demonstrated a high prevalence of TBI in India. The burden of TBI was commensurate with active TB prevalence suggesting possible conversion of TBI to active TB. A high burden was recorded among people residing in the northern and southern regions of the country. Such local epidemiologic variation need to be considered to reprioritize and implement-tailored strategies for managing TBI in India.

A systematic review and meta-analysis of active case finding for tuberculosis in India

Background

Active case finding (ACF) for tuberculosis (TB) is the cornerstone case-finding strategy in India's national TB policy. However, ACF strategies are highly diverse and pose implementation challenges in routine programming. We reviewed the literature to characterise ACF in India; assess the yield of ACF for different risk groups, screening locations, and screening criteria; and estimate losses to follow-up (LTFU) in screening and diagnosis.

Methods

We searched PubMed, EMBASE, Scopus, and the Cochrane library to identify studies with ACF for TB in India from November 2010 to December 2020. We calculated 1) weighted mean number needed to screen (NNS) stratified by risk group, screening location, and screening strategy; and 2) the proportion of screening and pre-diagnostic LTFU. We assessed risk of bias using the AXIS tool for cross-sectional studies.

Findings

Of 27,416 abstracts screened, we included 45 studies conducted in India. Most studies were from southern and western India and aimed to diagnose pulmonary TB at the primary health level in the public sector after screening. There was considerable heterogeneity in risk groups screened and ACF methodology across studies. Of the 17 risk groups identified, the lowest weighted mean NNS was seen in people with HIV (21, range 3-89, n=5), tribal populations (50, range 40-286, n=3), household contacts of people with TB (50, range 3-undefined, n=12), people with diabetes (65, range 21-undefined, n=3), and rural populations (131, range 23-737, n=5). ACF at facility-based screening (60, range 3-undefined, n=19) had lower weighted mean NNS than at other screening locations. Using the WHO symptom screen (135, 3-undefined, n=20) had lower weighted mean NNS than using criteria of abnormal chest x-ray or any symptom. Median screening and pre-diagnosis loss-to-follow-up was 6% (IQR 4.1%, 11.3%, range 0-32.5%, n=12) and 9.5% (IQR 2.4%, 34.4%, range 0-86.9%, n=27), respectively.

Interpretation

For ACF to be impactful in India, its design must be based on contextual understanding. The narrow evidence base available currently is insufficient for effectively targeting ACF programming in a large and diverse country. Achieving case-finding targets in India requires evidence-based ACF implementation.

Funding

WHO Global TB Programme.

Incidence and prevalence of pulmonary tuberculosis among patients with type 2 diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

The epidemic of type 2 diabetes mellitus (T2DM) poses a great challenge to pulmonary tuberculosis (PTB) control. However, the incidence and prevalence of PTB among T2DM patients has not been fully determined. This meta-analysis aimed to provide the estimation on the global incidence and prevalence of PTB among T2DM patients (T2DM-PTB).

METHODS

Online databases including Web of Science, PubMed, China National Knowledge Infrastructure and Cochrane Library were searched for all relevant studies that reported the incidence or prevalence of T2DM-PTB through 31 January 2022. Pooled incidence and prevalence of T2DM-PTB with 95% confidence interval (CI) was estimated by the random-effect model. All statistical analyses were performed using R software.

RESULTS

A total of 24 studies (14 cohort studies, 10 cross-sectional studies) were included. The pooled incidence and prevalence of T2DM-PTB were 129.89 per 100,000 person-years (95% confidence interval (CI): 97.55-172.95) and 511.19 per 100,000 (95% CI: 375.94-695.09), respectively. Subgroup analyses identified that the incidence of T2DM-PTB was significantly higher in Asia (187.20 per 100,000 person-years, 95% CI: 147.76-237.17), in countries with a high TB burden (172.04 per 100,000 person-years, 95% CI: 122.98-240.68) and in studies whose data collection ended before 2011 (219.81 per 100,000 person-years, 95% CI: 176.15-274.28), but lower in studies using International Classification of Diseases-10 codes (73.75 per 100,000 person-years, 95% CI: 40.92-132.91). The prevalence of T2DM-PTB was significantly higher in countries with a high TB burden (692.15 per 100,000, 95% CI: 468.75-1022.04), but lower in Europe (105.01 per 100,000, 95% CI: 72.55-151.98).

CONCLUSIONS

This systematic review and meta-analysis suggests high global incidence and prevalence of PTB among T2DM patients, underlining the necessity of more preventive interventions among T2DM patients especially in countries with a high TB-burden. Key messagesA total of 24 studies (14 cohort studies, 10 cross-sectional studies) containing 2,569,451 T2DM patients were included in this meta-analysis.The pooled incidence and prevalence of T2DM-PTB are 129.89 per 100,000 person-years (95% CI: 97.55-172.95) and 511.19 per 100,000 (95% CI: 375.94-695.09) respectively.The incidence of T2DM-PTB was significantly higher in Asia, in countries with a high TB burden and in studies whose data collection ended before 2011, but lower in studies using International Classification of Diseases-10 codes.The prevalence of T2DM-PTB was significantly higher in countries with a high TB-burden, but lower in Europe.

The yield of chest X-ray based versus symptom-based screening among patients with diabetes mellitus in public health facilities in Addis Ababa, Ethiopia

Background

Patients with diabetes mellitus (DM) are at increased risk of developing TB, but the best screening algorithm for early detection and treatment of TB remains unknown. Our objective was to determine if combining routine chest X-ray screening could have a better yield compared with symptom-based screening alone.

Methods

We conducted this cross-sectional study between September 2020 and September 2021 in 26 public health facilities in Addis Ababa, Ethiopia. All DM patients attending the clinics during the study period were offered chest X-ray and symptom screening simultaneously followed by confirmatory Xpert testing. We analyzed the number and proportion of patients with TB by the diagnostic algorithm category and performed binary logistic regression analysis to identify predictors of TB diagnosis.

Results

Of 7394 patients screened, 54.6 % were female, and their median age was 53 years. Type-2 diabetes accounted for 89.6 % of all participants of the patients. Of 172 symptomatic patients, chest X-ray suggested TB in 19, and 11 of these were confirmed to have TB (8 bacterilogicially confirmed and 3 clinically diagnosed). Only 2 of the 152 asymptomatic patients without X-ray findings had TB (both bacteriologically confirmed). X-ray was not done for one patient. On the other hand, 28 of 7222 symptom-negative patients had X-ray findings suggestive of TB, and 7 of these were subsequently confirmed with TB (6 clinically diagnosed). When combined with 8 patients who were on treatment for TB at the time of the screening, the overall point prevalence of TB was 380 per 100,000. The direct cost associated with the X-ray-based screening was 42-times higher.

Conclusion

Chest X-ray led to detection of about a third of TB patients which otherwise would have been missed but the algorithm is more expensive. Its full cost implication needs further economic evaluation.

Tuberculosis and comorbidities: treatment challenges in patients with comorbid diabetes mellitus and depression

Tuberculosis is one of the leading causes of death worldwide, primarily affecting low- and middle income countries and individuals with limited-resources within fractured health care systems. Unfortunately, the COVID-19 pandemic has only served to aggravate the already existing diagnostic gap, decreasing the number of people who get diagnosed and thereby complete successful treatment. In addition to this, comorbidities act as an external component that when added to the TB management equation, renders it even more complex. Among the various comorbidities that interact with TB disease, diabetes mellitus and depression are two of the most prevalent among non-communicable diseases within the TB population and merits a thoughtful consideration when the healthcare system provides care for them. TB patients with diabetes mellitus (TB-DM) or depression both have an increased risk of mortality, relapse and recurrence. Both of these diseases when in presence of TB present a ‘vicious-circle-like’ mechanism, meaning that the effect of each disease can negatively add up, in a synergistic manner, complicating the patient’s health state. Among TB-DM patients, high glucose blood levels can decrease the effectiveness of anti-tuberculosis drugs; however, higher doses of anti-tuberculous drugs could potentially decrease the effects of DM drugs. Among the TB-depression patients, not only do we have the adherence to treatment problems, but depression itself can biologically shift the immunological profile responsible for TB containment, and the other way around, TB itself can alter the hormonal balance of several neurotransmitters responsible for depression. In this paper, we review these and other important aspects such as the pharmacological interactions found in the treatment of TB-DM and TB-depression patients and the implication on TB care and pharmacological considerations.

The Footprint of Diabetes Mellitus on the Characteristics and Response to Anti-Tuberculous Therapy in Patients with Pulmonary Tuberculosis from Saudi Arabia

Background

Right now, a tuberculosis (TB) and diabetes mellitus (DM) syndemic is re-emerging worldwide. Given the contradictory results of the impact of DM on the natural history of pulmonary TB (PTB), this study was undertaken to shed light on the precision of this hypothesis from a community with a substantial caseload of both diseases.

Methods

The present 5-year, retrospective, cohort study involved 487 (60.8% males, and 39.2% females) adult PTB patients (mean age 53.71 ± 15.78 years) selected from Dr. Soliman Fakeeh Hospital (DSFH), Jeddah, Kingdom of Saudi Arabia (KSA). The relevant patients' clinical, radiological and microbiological data were extracted from the hospital medical and laboratory database.

Results

In our study, the cumulative prevalence of DM among PTB subjects was 27.1%. Both diabetic and non-diabetic groups were matched with regard to gender (p = 0.46); however, diabetic patients were significantly older (p = 0.0001). Patients with concomitant DM displayed higher frequency of the classic clinical presentations of PTB and were 1.8 times more likely to have cavitary lesions on imaging studies (p = 0.012). Furthermore, diabetic patients showed higher initial sputum acid-fast bacillus (AFB) smear grade (p = 0.0001) and were more prone to have delayed culture conversion as compared to their non-diabetic counterparts (77.55 ± 37.74 versus 54.95 ± 27.67 days, respectively; p = 0.0001) which points out to less favorable treatment outcome.

Conclusion

DM showed an impact on different aspects of PTB. Accordingly, integrated bi-directional screening programs for both diseases in the KSA need to be implemented to upgrade health-care services of patients with dual diagnosis.

Prevalence and risk factors associated with latent tuberculosis infection among household contacts of smear positive pulmonary tuberculosis patients in South India

OBJECTIVE

We aimed to determine the prevalence and find the risk factors associated with latent tuberculosis infection (LTBI) among the household contacts (HHC) of pulmonary TB patients.

METHODS

This cohort study was conducted from 2014 to 2019. Pretested standardised questionnaires and tools were used for data collection. The prevalence of LTBI among HHCs of TB patients was summarised as proportion with 95% confidence interval (CI). Mixed-effects generalised linear modelling function (meglm) in STATA with family Poisson and log link was performed to find the factors associated with LTBI.

RESULTS

In total, 1523 HHC of pulmonary TB patients were included in the study. Almost all HHC shared their residence with the index case (IC) for more than a year; 25% shared the same bed with the IC. The prevalence of LTBI among the HHC of TB patients was 52.6% (95% CI: 50.1-55.1%). In an adjusted model, we found that among HHC belonging to the age group of 19-64 years (aIRR = 1.2; 95% CI: 1.1-1.3; p-value: 0.02), to the age group >65 years (aIRR = 1.4, 95% CI: 1.1-1.9, p-value: 0.02) and sharing the same bed with the IC (aIRR = 1.2, 95% CI: 1.1-1.3, p value: 0.04) were independent determinants of LTBI among the HHC.

CONCLUSION

One in two household contacts of TB patients have latent tuberculosis infection. This underscores the need of targeted contact screening strategies, effective contact tracing and testing using standardised methods in high TB burden settings.