High prevalence of undiagnosed diabetes among tuberculosis patients in peripheral health facilities in Kerala

Tackling syndemics by integrating infectious and noncommunicable diseases in health systems of low- and middle-income countries: A narrative systematic review

The co-occurrence of infectious diseases (ID) and non-communicable diseases (NCD) is widespread, presenting health service delivery challenges especially in low-and middle-income countries (LMICs). Integrated health care is a possible solution but may require a paradigm shift to be successfully implemented. This literature review identifies integrated care examples among selected ID and NCD dyads. We searched PubMed, PsycINFO, Cochrane Library, CINAHL, Web of Science, EMBASE, Global Health Database, and selected clinical trials registries. Eligible studies were published between 2010 and December 2022, available in English, and report health service delivery programs or policies for the selected disease dyads in LMICs. We identified 111 studies that met the inclusion criteria, including 56 on tuberculosis and diabetes integration, 46 on health system adaptations to treat COVID-19 and cardiometabolic diseases, and 9 on COVID-19, diabetes, and tuberculosis screening. Prior to the COVID-19 pandemic, most studies on diabetes-tuberculosis integration focused on clinical service delivery screening. By far the most reported health system outcomes across all studies related to health service delivery (n = 72), and 19 addressed health workforce. Outcomes related to health information systems (n = 5), leadership and governance (n = 3), health financing (n = 2), and essential medicines (n = 4)) were sparse. Telemedicine service delivery was the most common adaptation described in studies on COVID-19 and either cardiometabolic diseases or diabetes and tuberculosis. ID-NCD integration is being explored by health systems to deal with increasingly complex health needs, including comorbidities. High excess mortality from COVID-19 associated with NCD-related comorbidity prompted calls for more integrated ID-NCD surveillance and solutions. Evidence of clinical integration of health service delivery and workforce has grown-especially for HIV and NCDs-but other health system building blocks, particularly access to essential medicines, health financing, and leadership and governance, remain in disease silos.

Prevalence and factors associated with diabetes mellitus among tuberculosis patients in South India-a cross-sectional analytical study

OBJECTIVE

To determine the prevalence and determinants of diabetes mellitus (DM) among tuberculosis (TB) patients and to assess the additional yield and number needed to screen (NNS) to obtain a newly diagnosed DM among TB patients.

DESIGN

We undertook a cross-sectional analysis of the cohort data under Regional Prospective Observational Research for Tuberculosis-India consortium. Newly diagnosed TB patients recruited into the cohort between 2014 and 2018 were included. Pretested standardised questionnaires and tools were used for data collection. Prevalence of DM among TB patients was summarised as proportion with 95% CI. Type II DM was diagnosed if random blood sugar level was >200 mg/dL or if the participant had a documented history of DM. NNS by blood glucose testing to diagnose one new DM case among TB patients was also calculated.

SETTING

Three districts of South India: Puducherry, Cuddalore and Villupuram SUBJECTS: Newly diagnosed sputum smear positive pulmonary TB patients aged ≥16 years RESULTS: In total, 1188 TB patients were included. Prevalence of DM among TB patients was 39% (95% CI: 36.2% to 41.8%). In unadjusted analysis, elderly TB, marital status, caste, gender, higher education level, household income and obesity had a significant association with DM. However, in adjusted analysis, only marital status (currently married aPR; 3.77 (95 CI: 2.20 to 6.49), widowed/separated/divorced aPR; 3.66 (95 CI: 1.96 to 6.83)) and body mass index category (normal weight aPR; 3.26 (95 CI: 2.55 to 4.16), overweight aPR; 3.86 (95 CI: 2.69 to 5.52), obesity aPR; 4.08 (95 CI: 2.81 to 5.94)) were found to be significant determinants. The number of TB patients needed to be screened to find a new DM case was 12.

CONCLUSION

We found that one in three TB patients had coexisting DM. The number of TB patients needed to be screened to obtain a newly diagnosed DM patients was also determined. The study supports and highlights the need of RNTCP's effort in bidirectional screening of TB and DM.

Diabetes among tuberculosis patients and its impact on tuberculosis treatment in South Asia: a systematic review and meta-analysis

The escalating burden of diabetes is increasing the risk of contracting tuberculosis (TB) and has a pervasive impact on TB treatment outcomes. Therefore, we conducted this systematic review and meta-analysis to examine the burden of diabetes among TB patients and assess its impact on TB treatment in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). PubMed, Excerpta Medica Database (EMBASE), and CINAHL databases were systematically searched for observational (cross-sectional, case-control and cohort) studies that reported prevalence of diabetes in TB patients and published between 1 January 1980 and 30 July 2020. A random-effect model for computing the pooled prevalence of diabetes and a fixed-effect model for assessing its impact on TB treatment were used. The review was registered with PROSPERO number CRD42020167896. Of the 3463 identified studies, a total of 74 studies (47 studies from India, 10 from Pakistan, four from Nepal and two from both Bangladesh and Sri-Lanka) were included in this systematic review: 65 studies for the prevalence of diabetes among TB patients and nine studies for the impact of diabetes on TB treatment outcomes. The pooled prevalence of diabetes in TB patients was 21% (95% CI 18.0, 23.0; I2 98.3%), varying from 11% in Bangladesh to 24% in Sri-Lanka. The prevalence was higher in studies having a sample size less than 300 (23%, 95% CI 18.0, 27.0), studies conducted in adults (21%, 95% CI 18.0, 23.0) and countries with high TB burden (21%, 95% CI 19.0, 24.0). Publication bias was detected based on the graphic asymmetry of the funnel plot and Egger's test (p < 0.001). Compared with non-diabetic TB patients, patients with TB and diabetes were associated with higher odds of mortality (Odds Ratio (OR) 1.7; 95% CI 1.2, 2.51; I2 19.4%) and treatment failure (OR 1.7; 95% CI 1.1, 2.4; I2 49.6%), but not associated with Multi-drug resistant TB (OR 1.0; 95% CI 0.6, 1.7; I2 40.7%). This study found a high burden of diabetes among TB patients in South Asia. Patients with TB-diabetes were at higher risk of treatment failure and mortality compared to TB alone. Screening for diabetes among TB patients along with planning and implementation of preventive and curative strategies for both TB and diabetes are urgently needed.

Diabetes mellitus and prediabetes among patients with tuberculosis in a single north Indian tertiary care centre

BACKGROUND

Prevalence of diabetes mellitus (DM), though believed to be high among patients with tuberculosis (TB), remains unclear for the want of systematic studies and unequivocal methods of diagnosing DM. This study was done to determine the prevalence of prediabetes and DM in adult patients with TB.

METHODS

This prospective study of one year's duration, carried out at a tertiary care centre included 313 consecutive adult patients diagnosed (either microbiologically, histologically or based on clinical presentation) with pulmonary or extrapulmonary TB. Those without a history of pre-existing DM were subjected to oral glucose tolerance test (OGTT) with 75 g glucose.

RESULTS

In this cohort 85 (27%) patients had pre-existing DM. The remaining 228 patients not diagnosed earlier with DM underwent a 75 g OGTT, of which 63 (28%) were found to have newly detected prediabetes (impaired fasting glucose [IFG] and impaired glucose tolerance [IGT] alone in 36 and 10 patients respectively and both IFG and IGT in a further 17) and DM was diagnosed in 9 (4%) patients (fasting blood glucose [FBG] ˜ 126 mg/dl in 1 and both FBG ˜ 126 mg/dl and 2-h plasma blood glucose [PLBG] ˜ 200 mg/dl in 8 patients). The total prevalence of (newly diagnosed) DM and prediabetes, therefore, was 32% (72 patients); the overall prevalence of DM was 30% (94 patients).

CONCLUSION

This study found high prevalence of prediabetes and diabetes among patients with TB. This underscores the need for a bidirectional screening strategy to improve diagnosis and outcome of both TB and DM.

Diabetes in tuberculosis patients: An emerging public health concern and the determinants and impact on treatment outcome

BACKGROUND

Tuberculosis (TB) and diabetes mellitus are still of much public health concern. Screening of TB patients for diabetes will ensure early case detection, better management of diabetes, and better TB treatment outcome. The objective of this study was to determine the prevalence and associated factors of diabetes in TB patients and their impact on treatment outcome of TB.

MATERIALS AND METHODS

This was a longitudinal follow-up study of registered TB patients under the Revised National Tuberculosis Control Program in all five TB units of Bhopal district. Participants were contacted and the interview was conducted. The blood sugar of all TB patients was checked, and they were followed up to assess the treatment outcome from October 2014 to September 2017. Data were analyzed using SPSS (version 16.0. Chicago, SPSS Inc.). Logistic regression was done to find the factors for diabetes in TB patients. The Chi-square tests were used to find the difference in treatment outcomes and assess the relative risk for poor outcome in diabetic TB patients.

RESULTS

Of total 662 TB patients, 82 (12.39%) were diagnosed as diabetic. Age >50 years, males, higher body mass index, pulmonary TB, patients on Category II treatment, and history of smoking were found to be predictors of diabetes in TB patients. The treatment outcome of TB was more unfavorable (defaulter, failure, and death) in diabetic TB patients (16.17%) than in nondiabetic TB patients (5.8%) (risk ratio = 2.78, 1.469-5.284 confidence interval).

CONCLUSION

The high prevalence of diabetes and the unfavorable treatment outcome in diabetic TB patients make screening and management of diabetes at an early-stage crucial for a better outcome in TB patients.

The Aquilegia pubiflora (Himalayan columbine) mediated synthesis of nanoceria for diverse biomedical applications

Herein, we report an eco-friendly, facile, one-pot, green synthesis of nanoceria for multiple biomedical applications. In the study, cerium oxide nanoparticles (CeO₂-NPs) were synthesized using a simple aqueous extract of Aquilegia pubiflora as an effective reducing and capping agent. The biosynthesized nanoparticles were characterized via UV-vis spectroscopy, X-ray powder diffraction (XRD), high-performance liquid chromatography (HPLC), Fourier transform infrared spectroscopy (FTIR), scanning electron microscopy (SEM), transmission electron microscopy (TEM), and Raman spectroscopy. The NPs were highly stable, exhibited high purity, and had a spherical morphology and mean size of 28 nm. FTIR and HPLC studies confirmed the successful capping of bioactive compounds on the nanoparticles. The well-characterized NPs were evaluated for a number of biomedical applications, and their antimicrobial (antifungal, antibacterial, and antileishmanial), protein kinase inhibition, anticancer, antioxidant, anti-diabetic and biocompatibility properties were studied. Our results showed that the Aquilegia pubiflora mediated CeO₂-NPs were highly active against fungal strains, compared to the tested bacterial strains, with Aspergillus niger resulting in the largest zone of inhibition (15.1 ± 0.27 mm). The particles also exhibited dose dependent leishmanicidal activity with significant LC₅₀ values toward both the amastigote (114 μg mL⁻¹) and promastigote (97 μg mL⁻¹) forms of the parasite Leishmania tropica (KWH23). The NPs were found to be moderately active against the HepG2 cell line, showing 26.78% ± 1.16% inhibition at 200 μg mL⁻¹. Last but not least, their highly biocompatible nature was observed with respect to freshly isolated human red blood cells (hRBCs), making the greenly synthesized CeO₂-NPs a novel candidates for multidimensional medical applications.

Graphical illustration of eco-friendly, facile, one-pot, green synthesis of nanoceria for multiple biomedical applications.

Prevalence of diabetes mellitus among tuberculosis patients in Sub-Saharan Africa: a systematic review and meta-analysis of observational studies

BACKGROUND

Tuberculosis and diabetes mellitus are significant global public health challenges. In Sub-Saharan Africa, study findings regarding prevalence of diabetes mellitus amongst tuberculosis patients have been inconsistent and highly variable. Therefore, this systematic review and meta-analysis estimates the overall prevalence of diabetes mellitus among tuberculosis patients in Sub-Saharan Africa.

METHODS

Four international databases (PubMed, Google Scholar, Science Direct and Cochrane Library) were systematically searched. We included all observational studies reporting the prevalence of DM among TB patients in Sub-Saharan Africa. All necessary data for this review were extracted using a standardized data extraction format by two authors (CT and AA1). STATA Version 14 statistical software was employed to conduct meta-analysis. The Cochrane Q test statistics and I2 test were used to assess the heterogeneity of the studies. Finally, a random effects meta-analysis model was computed to estimate the pooled prevalence of diabetes mellitus in TB patients. Besides, subgroup analysis was done based on different factors.

RESULTS

In the meta-analysis, sixteen studies fulfilled the inclusion criteria and were included. The findings of these 16 studies revealed that the pooled prevalence of diabetes mellitus among tuberculosis patients in Sub-Saharan Africa was 9.0% (95% CI: 6.0, 12.0%). The highest prevalence of diabetes mellitus among tuberculosis patients was found in Nigeria (15%), followed by Tanzania (11%), and then Ethiopia (10%). Besides, the prevalence of diabetes mellitus among HIV infected TB patients was (8.9%) which is slightly higher than HIV uninfected (7.7%) TB patients.

CONCLUSION

Diabetes mellitus among tuberculosis patients in Sub-Saharan Africa was significantly high. Moreover, this study found that there was a high prevalence of DM among HIV infected than uninfected TB patients. It is strongly recommended to screen for DM among TB patients and special emphasis should be given for early screening of DM among TB/HIV co-infected patients.

Prevalence of dysglycemia and clinical presentation of pulmonary tuberculosis in Western India

SETTING

Pune, India.

OBJECTIVES

To estimate the prevalence and risk factors of pre-diabetes mellitus (DM) and DM, and its associations with the clinical presentation of tuberculosis (TB).

DESIGN

Screening for DM was conducted among adults (age  18 years) with confirmed TB between December 2013 and January 2017. We used multinomial regression to evaluate the risk factors for pre-DM (glycated hemoglobin [HbA1c]  5.7-6.5% or fasting glucose 100-125 mg/dl) and DM (HbA1c  6.5% or fasting glucose  126 mg/dl or random blood glucose > 200 mg/dl or self-reported DM history/treatment) and the association of dysglycemia with the severity of TB disease.

RESULTS

Among 1793 participants screened, 890 (50%) had microbiologically confirmed TB. Of these, 33% had pre-DM and 18% had DM; 41% were newly diagnosed. The median HbA1c level among newly diagnosed DM was 7.0% vs. 10.3% among known DM (P < 0.001). DM (adjusted OR [aOR] 4.94, 95%CI 2.33-10.48) and each per cent increase in HbA1c (aOR 1.42, 95%CI 1.01-2.01) was associated with >1+ smear grade or 9 days to TB detection.

CONCLUSION

Over half of newly diagnosed TB patients had DM or pre-DM. DM and increasing dysglycemia was associated with higher bacterial burden at TB diagnosis, potentially indicating a higher risk of TB transmission to close contacts.

A study on prevalence of diabetes and associated risk factors among diagnosed tuberculosis patients registered under Revised National Tuberculosis Control Programme in Bhopal District

CONTEXT

Tuberculosis (TB) and diabetes mellitus (DM) remains a worldwide global public health problem. About 95% of patients with TB live in the low and middle-income countries and more than 70% of patients with DM also live in the same countries, especially in South East Asia. Screening for diabetes in patients with TB will not only ensure early case detection but also better management of diabetes and will lead to better TB treatment outcome.

AIMS

This study aims to determine the prevalence and its associated factors of diabetes and prediabetes among diagnosed cases of TB patients registered under Revised National Tuberculosis Control Programme (RNTCP) in Bhopal city.

SETTINGS AND DESIGN

The current study was a longitudinal follow-up study conducted among registered TB patients under RNTCP in all 5 TB units of Bhopal District.

SUBJECTS AND METHODS

Participants were contacted and interview was conducted after obtaining consent using predesigned and pretested Performa during October 2013-September 2014.

STATISTICAL ANALYSIS USED

Continuous variable were summarized as frequency, mean, and standard deviation. All variables were analyzed using Chi-square test of significance; P < 0.05 was taken as statically significant.

RESULTS

Out of the total 662 TB patients, 352 were male and 310 were female. Out of the total, 82 (12.39%) patients were diagnosed as diabetic and 108 (16.3%) were prediabetic. significant association found with six variables which are age, sex, body mass index, type of TB, Category of TB, and smoking.

CONCLUSION

This study shows feasibility and importance of screening of TB patients.

Screening for diabetes among tuberculosis patients registered under revised national tuberculosis control program, Bhopal, India

Context:

Tuberculosis (TB) and diabetes mellitus (DM) remain a global public health problem. India has the largest number of TB cases; in 2015, out of total global annual incidence of 9.6 million TB cases, 2.2 million were estimated from India. There are 62.4 million people with type 2 diabetes and 77 million people with prediabetes in India, and these numbers are projected to increase to 101 million by the year 2030. Diabetes and TB affect each other at many levels. Screening for diabetes in patients with TB will not only help in early case detection but also better management of both comorbidities.

Aims:

(i) To determine the prevalence of diabetes and prediabetes among diagnosed cases of TB registered under RNTCP in Bhopal district. (ii) To determine additional yield of previously unknown DM and the number needed to screen (NNS) to find out a new case of DM. (iii) To find out the factors associated with diabetes among patients diagnosed with TB registered under RNTCP in Bhopal district.

Settings and Design:

This study was a cross-sectional study conducted on registered patients with TB under RNTCP in two TB units of Bhopal district.

Materials and Methods:

Participants were contacted and interview was conducted after obtaining consent using predesigned and pretested performa during the period of 1^st October 2014 to 30^th March 2015 for a period of 6 months.

Statistical Analysis Used:

Continuous variable were summarized as frequency, mean, and standard deviation. All variables were analyzed using Chi-square test of significance; P < 0.05 was taken as statically significant.

Result:

Of the total 528 patients with TB, 296 was male and 232 were female. Of the total, 63 (11.9%) patients were diagnosed as diabetic. NNS to diagnose a new case of DM was 22.1. Significant association was found with six variables which are age, sex, body mass index, type of TB, category of TB, and smoking.

Conclusion:

This study shows feasibility and importance of screening of patients with TB in existing program settings.

Diabetes and pre-diabetes in tuberculosis patients in western Kenya using point-of-care glycated haemoglobin

Setting: The tuberculosis (TB) clinics of five health facilities in western Kenya. Objective: To assess the prevalence and associated determinants of diabetes mellitus (DM) and pre-diabetes hyperglycaemia among adult TB patients using point-of-care DCA Vantage glycated haemoglobin (HbA1c) devices. Design: This was a cross-sectional study. Results: Of 454 patients, 272 (60%) were males, the median age was 34 years, 175 (39%) were co-infected with the human immunodeficiency virus (HIV), and the median duration of anti-tuberculosis treatment was 8 weeks; 180 (40%) patients reported at least one classical symptom suggestive of DM. The prevalence of DM (HbA1c ⩾6.5%) was 5.1% (95%CI 3.2-7.5), while that of pre-diabetes (HbA1c 5.7-6.4%) was 37.5% (95%CI 33.1-42.2). The number needed to screen (NNS) was 19.6 for DM and 2.7 for pre-diabetes. Combined, 42.6% (95%CI 38.0-47.3) of the patients had either pre-diabetes or DM (NNS 2.3). Seven of the 23 patients with DM knew their prior DM status. Higher rates of DM were associated with age ⩾40 years and a family history of DM, but not obesity, type of TB, HIV status or suggestive symptoms. Conclusions: High rates of pre-diabetes and DM were found in adult TB patients. This study supports the need for routine screening of all patients with TB for DM in Kenya.

Tuberculosis screening among persons with diabetes mellitus in Pune, India

BACKGROUND

Diabetes mellitus (DM) increases tuberculosis (TB) risk, and there is increasing concern over the public health implications of the convergence of these two epidemics. Screening for TB among people with DM is now recommended in India.

METHODS

People with DM seeking care at a large public sector tertiary care hospital clinic in Pune, India, were screened for TB from June 2015 to May 2016. All consenting people with DM were screened for TB at each clinic visit using a five-item, WHO-recommended questionnaire and those with TB symptoms and/or risk factors were tested for active TB using sputum smear microscopty, Xpert® MTB/RIF and TB culture. Categorical data and continuous variables were summarized using descriptive statistics. The x ² test or Wilcoxon rank-sum test was used to ascertain significant associations between categorical and continuous variables, respectively.

RESULTS

Among 630 adults approached for screening, median age was 60 (interquartile range (IQR), 57-64) years and 350 (56%) were females. Median hemoglobin A1c (HbA1c) was 8.7% (IQR, 6.7-9.9) and 444 (70.5%) were poorly controlled DM (HbA1c > 7). Forty-four (7%) had prior history of TB but the proportion with TB risk factors at screening was low (<5%). While 18% of participants reported any TB symptoms, none of these patients were diagnosed with culture confirmed TB.

CONCLUSIONS

Our study failed to yield any active TB cases using a WHO-recommended questionnaire among people with DM. High TB risk populations among people with DM must be identified if TB screening is to be feasible in settings such as India where the DM epidemic continues to rise.

Prevalence and associated factors of tuberculosis and diabetes mellitus comorbidity: A systematic review

Introduction

The dual burden of tuberculosis (TB) and diabetes mellitus (DM) has become a major global public health concern. There is mounting evidence from different countries on the burden of TB and DM comorbidity. The objective of this systematic review was to summarize the existing evidence on prevalence and associated/risk factors of TBDM comorbidity at global and regional levels.

Methods

Ovid Medline, Embase, Global health, Cochrane library, Web of science and Scopus Elsevier databases were searched to identify eligible articles for the systematic review. Data were extracted using standardized excel form and pilot tested. Median with interquartile range (IQR) was used to estimate prevalence of TBDM comorbidity. Associated/risk factors that were identified from individual studies were thematically analyzed and described.

Results

The prevalence of DM among TB patients ranged from 1.9% to 45%. The overall median global prevalence was 16% (IQR 9.0%-25.3%) Similarly, the prevalence of TB among DM patients ranged from 0.38% to 14% and the overall median global prevalence was 4.1% (IQR 1.8%-6.2%). The highest prevalence of DM among TB patients is observed in the studied countries of Asia, North America and Oceania. On the contrary, the prevalence of TB among DM patients is low globally, but relatively higher in the studied countries of Asia and the African continents. Sex, older age, urban residence, tobacco smoking, sedentary lifestyle, poor glycemic control, having family history of DM and TB illness were among the variables identified as associated/risk factors for TBDM comorbidity.

Conclusion

This systematic review revealed that there is a high burden of DM among TB patients at global level. On the contrary, the global prevalence of TB among DM patients is low. Assessing the magnitude and risk/associated factors of TBDM comorbidity at country/local level is crucial before making decisions to undertake TBDM integrated services.

Diabetes and pulmonary tuberculosis: a global overview with special focus on the situation in Asian countries with high TB-DM burden

BACKGROUND

The double burden of tuberculosis (TB) and diabetes mellitus (DM) is hitting certain Asian countries harder than other areas. In a global estimate, 15% of all TB cases could be attributable to DM, with 40% of those cases coming from India and China. Many other countries of South, East, and South-East Asia are of particular concern given their TB burdens, large projected increases in DM prevalence, and population size.

OBJECTIVE

In this narrative review, we aimed to: (i) give an overall insight into the evidence on TB-DM epidemiology from high double burden Asian countries, (ii) present the evidence on bi-directional screening implementation in this region, (iii) discuss possible factors related to higher TB susceptibility of Asian diabetic patients, and (iv) identify TB-DM comorbidity treatment challenges.

METHODS

The PubMed and Google Scholar databases were searched for all studies addressing DM/TB epidemiology, bi-directional screening and management in South, East and South-East Asia.

RESULTS

We identified the DM prevalences among TB patients as ranging from approximately 5% to more than 50%, whereas TB prevalences among diabetic patients were 1.8-9.5 times higher than in the general population in developing Asian countries. Evidence from studies designed to address diagnosis and treatment of the dual disease in these critical regions is scarce as well as the evidence related to possible DM patients' genetic and acquired predisposition for TB.

CONCLUSION

More prospective studies specifically designed to address adequate screening techniques, identify patients at risk, and define an adequate treatment of dual disease in this region are needed without delay.

Diabetes mellitus and tuberculosis: programmatic management issues

In August 2011, the World Health Organization and the International Union Against Tuberculosis and Lung Disease launched the Collaborative Framework for Care and Control of Tuberculosis (TB) and diabetes mellitus (DM) to guide policy makers and implementers in combatting the epidemics of both diseases. Progress has been made, and includes identifying how best to undertake bidirectional screening for both diseases, how to provide optimal treatment and care for patients with dual disease and the most suitable framework for monitoring and evaluation. Key programmatic challenges include the following: whether screening should be directed at all patients or targeted at those with high-risk characteristics; the most suitable technologies for diagnosing TB and diabetes in routine settings; the best time to screen TB patients for DM; how to provide an integrated, coordinated approach to case management; and finally, how to persuade non-communicable disease programmes to adopt a cohort analysis approach, preferably using electronic medical records, for monitoring and evaluation. The link between DM and TB and the implementation of the collaborative framework for care and control have the potential to stimulate and strengthen the scale-up of non-communicable disease care and prevention programmes, which may help in reducing not only the global burden of DM but also the global burden of TB.

Prevalence and Associated Factors of Diabetes Mellitus among Tuberculosis Patients in South-Eastern Amhara Region, Ethiopia: A Cross Sectional Study

Background

The association between diabetes mellitus (DM) and tuberculosis (TB) is re-emerging worldwide. Recently, the prevalence of DM is increasing in resource poor countries where TB is of high burden. The objective of the current study was to determine the prevalence and analyze associated factors of TB and DM comorbidity in South-Eastern Amhara Region, Ethiopia.

Methods

This was a facility based cross-sectional study. All newly diagnosed TB patients attending selected health facilities in the study area were consecutively screened for DM. DM was diagnosed based on the World Health Organization diagnostic criteria. A pre-tested semi-structured questionnaire was used to collect socio-demographic, lifestyles and clinical data. Logistic regression analysis was performed to identify factors associated with TB and DM comorbidity.

Result

Among a total of 1314 patients who participated in the study, the prevalence of DM was estimated at 109 (8.3%). Being female [odds ratio (OR) 1.70; 95% confidence interval (CI) (1.10–2.62)], patients age [41–64 years (OR 3.35; 95% CI (2.01–5.57), 65–89 years (OR 3.18; 95% CI (1.52–6.64)], being a pulmonary TB case [(OR 1.69; 95% CI 1.09–2.63)] and having a family history of DM [(OR 4.54; 95% CI (2.36–8.73)] were associated factors identified with TB and DM comorbidity.

Conclusion

The prevalence of DM among TB patients in South-Eastern Amahra Region is high. Routine screening of TB patients for DM is recommended in the study area.

Sputum smear conversion and treatment outcomes for tuberculosis patients with and without diabetes in Fiji

SETTINGS

Three tuberculosis (TB) treatment centres under the Fiji National Tuberculosis Programme.

OBJECTIVES

To determine the prevalence of diabetes mellitus (DM) among TB patients for the period 2010-2012, and to evaluate sputum smear conversion and anti-tuberculosis treatment outcomes, comparing patients with and without DM.

DESIGN

A retrospective descriptive study using routinely collected data from the TB register and in-patient folders.

RESULTS

Of 577 TB patients identified, information on DM was available for 567 (98%), of whom 68 (12%) had DM. Smear status at 2 months was available for 254 (82%) patients with sputum smear-positive pulmonary TB. The sputum smear conversion rate (from positive to negative) was equivalent in TB patients with and without DM (78% vs. 80%, P = 0.66). Anti-tuberculosis treatment outcome information was available for 462 patients; the difference in outcome comparing successfully treated patients with those unsuccessfully treated was not statistically significant (91% in TB patients with DM vs. 84% in TB patients without DM, P = 0.06).

CONCLUSION

DM is common among TB patients in Fiji. Sputum smear conversion rates were not different in TB patients with and without DM; no difference in treatment success between the two groups was observed.

Promoting operational research through fellowships: a case study from the South-East Asia Union Office

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) jointly developed a new paradigm for operational research (OR) capacity building and started a new process of appointing and supporting OR fellows in the field. This case study describes 1) the appointment of two OR fellows in The Union South-East Asia Office (USEA), New Delhi, India; 2) how this led to the development of an OR unit in that organisation; 3) achievements over the 5-year period from June 2009 to June 2014; and 4) challenges and lessons learnt. In June 2009, the first OR fellow in India was appointed on a full-time basis and the second was appointed in February 2012-both had limited previous experience in OR. From 2009 to 2014, annual research output and capacity building initiatives rose exponentially, and included 1) facilitation at 61 OR training courses/modules; 2) publication of 96 papers, several of which had a lasting impact on national policy and practice; 3) providing technical assistance in promoting OR; 4) building the capacity of medical college professionals in data management; 5) support to programme staff for disseminating their research findings; 6) reviewing 28 scientific papers for national or international peer-reviewed journals; and 7) developing 45 scientific abstracts for presentation at national and international conferences. The reasons for this success are highlighted along with ongoing challenges. This experience from India provides good evidence for promoting similar models elsewhere.

Results of the implementation of a pilot model for the bidirectional screening and joint management of patients with pulmonary tuberculosis and diabetes mellitus in Mexico

BACKGROUND

Recently, the World Health Organisation and the International Union Against Tuberculosis and Lung Disease published a Collaborative Framework for the Care and Control of Tuberculosis (TB) and Diabetes (DM) (CFTB/DM) proposing bidirectional screening and joint management.

OBJECTIVE

To evaluate the feasibility and effectiveness of the CFTB/DM in Mexico.

DESIGN

Prospective observational cohort.

SETTING

15 primary care units in 5 states in Mexico.

PARTICIPANTS

Patients aged ≥20 years diagnosed with DM or pulmonary TB who sought care at participating clinics.

INTERVENTION

The WHO/Union CFTB/DM was adapted and implemented according to official Mexican guidelines. We recruited participants from July 2012 to April 2013 and followed up until March 2014. Bidirectional screening was performed. Patients diagnosed with TB and DM were invited to receive TB treatment under joint management.

MAIN OUTCOME MEASURES

Diagnoses of TB among DM, of DM among TB, and treatment outcomes among patients with DM and TB.

RESULTS

Of 783 DM patients, 11 (1.4%) were unaware of their TB. Of 361 TB patients, 16 (4.4%) were unaware of their DM. 95 TB/DM patients accepted to be treated under joint management, of whom 85 (89.5%) successfully completed treatment. Multiple linear regression analysis with change in HbA1c and random capillary glucose as dependent variables revealed significant decrease with time (regression coefficients (β)  = -0.660, (95% confidence interval (CI), -0.96 to -0.35); and β = -1.889 (95% CI, -2.77 to -1.01, respectively)) adjusting by sex, age and having been treated for a previous TB episode. Patients treated under joint management were more likely to experience treatment success than patients treated under routine DM and TB programs as compared to historical (adjusted OR (aOR), 2.8, 95%CI 1.28-6.13) and same period (aOR 2.37, 95% CI 1.13-4.96) comparison groups.

CONCLUSIONS

Joint management of TB and DM is feasible and appears to improve clinical outcomes.

Improving tuberculosis prevention and care through addressing the global diabetes epidemic: from evidence to policy and practice

Diabetes triples the risk of tuberculosis and is also a risk factor for adverse tuberculosis treatment outcomes, including death. Prevalence of diabetes is increasing globally, but most rapidly in low-income and middle-income countries where tuberculosis is a grave public health problem. Growth in this double disease burden creates additional obstacles for tuberculosis care and prevention. We review how the evolution of evidence on the link between tuberculosis and diabetes has informed global policy on collaborative activities, and how practice is starting to change as a consequence. We conclude that coordinated planning and service delivery across communicable and non-communicable disease programmes is necessary, feasible, and creates synergies that will help to reduce the burden of both tuberculosis and diabetes.