Forecasting the impact of diabetes mellitus on tuberculosis disease incidence and mortality in India

Trends of type 2 diabetes with pulmonary tuberculosis patients,2013-2022, and changes after the coronavirus disease 2019 (COVID-19) pandemic

BACKGROUND

To describe the trends of Type 2 Diabetes with Pulmonary Tuberculosis (T2DM-TB) patients from 2013 to 2022 and to investigate the impact of COVID-19 lockdown on glycemic control and associated factors in T2DM-TB.

METHODS

In this population-based study of the First Affiliated Yijishan Hospital of Wannan Medical College in China, we described the 10-year trends of patients diagnosed with T2DM-TB. We included patients diagnosed with TB, T2DM-TB and T2DM-TB patients for comparative analysis, aged 15 years or older. Data were missing, and both multidrug-resistant (MDR) TB patients and non-T2DM patients were excluded from our study.

RESULTS

We pooled Type 2 Diabetes (T2DM) and Tuberculosis (TB) data from The First Affiliated Yijishan Hospital of Wannan Medical College in China, gathered between January 1, 2013, and December 31, 2022. The data included 14,227 T2DM patients, 6130 TB patients, and 982 T2DM-TB patients. During the past 10 years, the number of inpatients with TB decreased, while the number of patients with T2DM and T2DM-TB increased year by year. To rule out any influence factors, we analyzed the ratio of the three groups. The ratio of TB/T2DM decreased year by year (p < 0.05), while the ratio of TB-T2DM/TB increasing year by year (p = 0.008). During the COVID-19 epidemic period, there was no significant change in the ratio of TB-T2DM/T2DM (p = 0.156). There was no significant change in the proportion of male patients with TB and TB-T2DM (p = 0.325; p = 0.190), but the proportion of male patients with T2DM showed an increasing trend (p < 0.001). The average age of TB patients over the past 10 years was 54.5 ± 18.4 years and showed an increasing trend year by year (p < 0.001). However, there was no significant change in the age of T2DM or TB-T2DM patients (p = 0.064; p = 0.241). Patients data for the first (2013-2017) and the last (2018-2022) five years were compared. We found that the number of T2DM and TB-T2DM in the last five years was significantly higher than in the first five years, but the number of TB was significantly lower than in the first five years. There is a significant statistical difference in the proportion of TB/T2DM and TB-T2DM/TB, which is similar to the previous results. The average age (56.0 ± 17.6 years) of TB patients in the last five years is significantly higher than in the first five years (53.1 ± 18.9) (p < 0.001). The number of male patients with T2DM in the last five years is higher than that in the first five years, with significant difference (p < 0.001).

CONCLUSION

The trends of T2DM-TB among hospitalized TB patients have increased significantly over the past 10 years, which may be related to the increase in the number of T2DM cases. The COVID-19 pandemic has been effective in controlling the transmission of TB, but it has been detrimental to the control of T2DM. Male patients with T2DM and elderly TB patients are the key populations for future prevention and control efforts.

Predictors for Concurrent Diabetes in Tuberculosis Patients. Perspectives from Two Mining Districts of Eastern Tribal State Jharkhand, in India

Background

Tuberculosis and diabetes both diseases are present in large numbers in the country and we are major contributors to both globally. With the objective to understand the various traits of patients having both tuberculosis and diabetes and to ascertain various possible predictors for such occurrence based on the public health database we carried out this study. We seek answers to questions like they have any effects? Are they having any additive role to play?

Methods

One-year data from the NIKSHAY portal of both districts were analyzed to look for possible associations and other variable traits. Data were analyzed using standard methods to express data in frequency and percentage. Chi-square test was used to establish association, while step-wise approach was used to calculate univariate and multivariate logistic regression analysis for knowing various predictors. P-value of <0.05 was considered statistically significant.

Results

Concurrent diabetes in tuberculosis patients was close to 294 (6%) in the 4933 individuals. In total, 65.2% of the study population were male. Diagnosis of tuberculosis was made most of the time by chest X-ray (49.4%) followed by Microscopy ZN staining and cartridge-based nucleic acid amplification test (CBNAAT). Death was more among diabetics (4.4%) as compared to nondiabetics (3.5%).

Conclusion

Diabetes is increasing in tuberculosis patients; improvement in data quality is needed. More research is required to reveal various other reasons that make tuberculosis patients more prone to develop diabetes.

ECG Forecasting System Based on Long Short-Term Memory

Worldwide, cardiovascular diseases are some of the primary causes of death; yet the early detection and diagnosis of such diseases have the potential to save many lives. Technological means of detection are becoming increasingly essential and numerous techniques have been created for this purpose, such as forecasting. Of these techniques, the time series forecasting technique seeks to predict future events. The long-term time series forecasting of physiological data could assist medical professionals in predicting and treating patients based on very early diagnosis. This article presents a model that utilizes a deep learning technique to predict long-term ECG signals. The forecasting model can learn signals' nonlinearity, nonstationarity, and complexity based on a long short-term memory architecture. However, this is not a trivial task as the correct forecasting of a signal that closely resembles the original complex signal's structure and behavior while minimizing any differences in amplitude continues to pose challenges. To achieve this goal, we used a dataset available on the Physio net database, called MIT-BIH, with 48 ECG recordings of 30 min each. The developed model starts with pre-processing to reduce interference in the original signals, then applies a deep learning algorithm, based on a long short-term memory (LTSM) neural network with two hidden layers. Next, we applied the root mean square error (RMSE) and mean absolute error (MAE) metrics to evaluate the performance of the model and obtained an average RMSE of 0.0070±0.0028 and an average MAE of 0.0522±0.0098 across all simulations. The results indicate that the proposed LSTM model is a promising technique for ECG forecasting, considering the trends of the changes in the original data series, most notably in R-peak amplitude. Given the model's accuracy and the features of the physiological signals, the system could be used to improve existing predictive healthcare systems for cardiovascular monitoring.

Trends in tuberculosis incidence and mortality coefficients in Brazil, 2011-2019: analysis by inflection points

Objective

To analyze the temporal trend of tuberculosis incidence and mortality rates in Brazil between 2011 and 2019.

Methods

This was an ecological time series study of tuberculosis incidence and mortality rates in Brazil between 2011 and 2019. Data were extracted from the Notifiable Disease Information System and the Mortality Information System, and population estimates were from the Brazilian Institute of Geography and Statistics. Trends were analyzed by Joinpoint regression, which recognizes inflection points for temporal analysis.

Results

The average incidence rate of tuberculosis in Brazil in the period was 35.8 cases per 100 000 population. From 2011 to 2015, this coefficient had an annual percentage change of -1.9% (95% CI [-3.4, -0.5]) followed by an increase of 2.4% (95% CI [0.9, 3.9]) until 2019. The average mortality rate between 2011 and 2019 was 2.2 deaths per 100 000 population, with an average annual percentage change of -0.4% (95% CI [-1.0, 0.2]). Amazonas was the only state with an increase in the annual average percentage variation for the incidence rate (3.2%; 95% CI [1.3, 5.1]) and mortality rate (2.7%; 95% CI [1.0, 4.4]) over the years, while Rio de Janeiro state had an increasing inflection for incidence from 2014 to 2019 (2.4%; 95% CI [1.4, 3.5]) and annual average of decreasing percentage variation (-3.5%; 95% CI [-5.0, -1.9]).

Conclusions

During the period analyzed, a decreasing trend in incidence was observed between 2011 and 2015, and an increasing trend for the period from 2015 to 2019. On the other hand, no change in the trend for mortality was found in Brazil.

Diabetes severity is strongly associated with the risk of active tuberculosis in people with type 2 diabetes: a nationwide cohort study with a 6-year follow-up

BACKGROUND

Many have the rising coincidence of diabetes mellitus (DM) and endemic tuberculosis (TB). We evaluated whether the severity of diabetes is associated with an increased risk of active TB infection.

METHODS

 Using a nationally representative database from the Korean National Health Insurance System, 2, 489, 718 people with type 2 DM who underwent a regular health checkup during 2009-2012 were followed up until the end of 2018. The diabetes severity score parameters included the number of oral hypoglycemic agents (≥ 3), insulin use, diabetes duration (≥ 5 years), and the presence of chronic kidney disease (CKD) or cardiovascular disease. Each of these characteristics was scored as one point, and their sum (0-5) was used as the diabetes severity score.

RESULTS

We identified 21, 231 cases of active TB during a median follow-up of 6.8 years. Each parameter of the diabetes severity score was associated with an increased risk of active TB (all P < 0.001). Insulin use was the most significant factor related to the risk of TB, followed by CKD. The risk of TB increased progressively with increasing diabetes severity score. After adjusting for possible confounding factors, the hazard ratio (95% confidence interval) for TB were 1.23 (1.19-1.27) in participants with one parameter, 1.39 (1.33-1.44) in those with two parameters, 1.65 (1.56-1.73) in those with three parameters, 2.05 (1.88-2.23) in those with four parameters, and 2.62 (2.10-3.27) in those with five parameters compared with participants with no parameters.

CONCLUSION

Diabetes severity was strongly associated in a dose-dependent manner with the occurrence of active TB. People with a higher diabetes severity score may be a targeted group for active TB screening.

Rifapentine and isoniazid for prevention of tuberculosis in people with diabetes (PROTID): protocol for a randomised controlled trial

Background

Diabetes mellitus (DM) increases the risk of tuberculosis (TB) and will hamper global TB control due to the dramatic rise in type 2 DM in TB-endemic settings. In this trial, we will examine the efficacy and safety of TB preventive therapy against the development of TB disease in people with DM who have latent TB infection (LTBI), with a 12-week course of rifapentine and isoniazid (3HP).

Methods

The ‘Prevention of tuberculosis in diabetes mellitus’ (PROTID) consortium will randomise 3000 HIV-negative eligible adults with DM and LTBI, as evidenced by a positive tuberculin skin test or interferon gamma release assay, to 12 weeks of 3HP or placebo. Participants will be recruited through screening adult patients attending DM clinics at referral hospitals in Tanzania and Uganda. Patients with previous TB disease or treatment with a rifamycin medication or isoniazid (INH) in the previous 2 years will be excluded. The primary outcome is the occurrence of definite or probable TB disease; secondary outcome measures include adverse events, all-cause mortality and treatment completion. The primary efficacy analysis will be intention-to-treat; per-protocol analyses will also be carried out. We will estimate the ratio of TB incidence rates in intervention and control groups, adjusting for the study site using Poisson regression. Results will be reported as efficacy estimates (1-rate ratio). Cumulative incidence rates allowing for death as a competing risk will also be reported. Approximately 1000 LTBI-negative, HIV-negative participants will be enrolled consecutively into a parallel cohort study to compare the incidence of TB in people with DM who are LTBI negative vs positive. A number of sub-studies will be conducted among others to examine the prevalence of LTBI and active TB, estimate the population impact and cost-effectiveness of LTBI treatment in people living with DM in these African countries and address gaps in the prevention and therapeutic management of combined TB-DM.

Discussion

PROTID is anticipated to generate key evidence to guide decisions over the use of TB preventive treatment among people with DM as an important target group for better global TB control.

Trial registration

ClinicalTrials.govNCT04600167. Registered on 23 October 2020

Tuberculosis and Diabetes in India: Stakeholder Perspectives on Health System Challenges and Opportunities for Integrated Care

Background

India has a dual burden of tuberculosis (TB) and diabetes mellitus (DM). Integrated care for TB/DM is still in the early phase in the country and can be considerably enhanced by understanding and addressing the challenges identified from stakeholders’ perspectives. This study explored the challenges and opportunities at individual, health system and policy level for integrated care of TB/DM comorbidities in India.

Methods

We used an outlier case study approach and conducted stakeholder interviews and focus group discussions with relevant program personnel including field staff and program managers of TB and DM control programs as well as officials of partners in Indian states, Kerala and Bihar.

Results

The integrated management requires strengthening the laboratory diagnosis and drug management components of the two individual programs for TB and DM. Focused training and sensitization of healthcare workers in public and private sector across all levels is essential. A district level management unit that coordinates the two vertical programs with a horizontal integration at the primary care level is the way forward. Substantial improvement in data infrastructure is essential to improve decision-making process.

Conclusion

Bi-directional screening and management of TB/DM comorbidities in India requires substantial investment in human resources, infrastructure, drug availability, and data infrastructure.

Mean platelet volume (MPV): new diagnostic indices for co-morbidity of tuberculosis and diabetes mellitus

Background

Tuberculosis (TB) and type 2 diabetes mellitus (DM) are global health diseases with high morbidity and mortality. Few studies have focused on platelet indices in TB-DM coinfection patients. The objective of this work was to analyze the platelet indices in TB, DM and TB-DM patients to assess the predictive value of the platelet index for the risk of these diseases.

Methods

In total, 246 patients admitted to our hospital were distributed into three groups (113TB, 59 DM and 74TB+DM). A total of 133 individuals were also recruited as healthy controls (HC). Platelet indices, namely, platelet count (PC), mean platelet volume (MPV), plateletcrit (PCT) and platelet distribution width (PDW), were compared among the four groups, and the relationship with inflammatory markers was explored by using statistical software.

Results

Our study discovered that MPV and PCT were significantly downregulated in TB+DM patients (9.951.25fL, 0.200.05%, P<0.0001, P=0.0121, separately) compared with DM individuals (10.921.17fL, 0.220.04%). Moreover, the changes in MPV were significantly higher in TB+DM patients (9.951.25fL, P=0.0041) than in TB patients (9.421.01fL). No differences were found in PLT and PDW among the four groups (P>0.05). The sensitivity and specificity of MPV in the differential diagnosis of DM patients vs TB+DM patients were 64.9 and 66.1% (P<0.0001), respectively, and the sensitivity and specificity of MPV between TB patients and TB+DM patients was 60.8 and 66.4%, respectively (P=0.003). MPV improved the diagnosis sensitivity when it was combined with clinical parameters, such as fasting blood glucose in DM and Mycobacterium tuberculosis culture result in TB (76.3% vs 64.9, 72.6% vs 60.8%, P<0.0001, P=0.001, respectively). In addition, the sensitivity and specificity of PCT in the differential diagnosis of DM patients vs TB+DM patients were 69.5 and 59.4%, respectively (P=0.008). PCT improved the diagnosis sensitivity when combined with fasting blood glucose in DM (72.9% vs 64.9%, P=0.004). In addition, MPV was linked to CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate) in the TB+DM patients (r=0.3203, P=0.0054, r=0.2504, P=0.0307) but PCT was not (r=0.1905, r=0.008675, P>0.05, respectively).

Conclusions

Our research shows that MPV and PCT might be good clinical laboratory markers to distinguish TB+DM patients from TB or DM individuals, thus providing support for earlier clinical diagnosis, prevention, and therapy.