High tuberculosis incidence among people living with diabetes in Indonesia

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.gov NCT04600167 . Registered on 23 October 2020.

Number needed to screen for TB in clinical, structural or occupational risk groups

BACKGROUND: Screening for active TB using active case-finding (ACF) may reduce TB incidence, prevalence, and mortality; however, yield of ACF interventions varies substantially across populations. We systematically reviewed studies reporting on ACF to calculate the number needed to screen (NNS) for groups at high risk for TB.METHODS: We conducted a literature search for studies reporting ACF for adults published between November 2010 and February 2020. We determined active TB prevalence detected through various screening strategies and calculated crude NNS for - TB confirmed using culture or Xpert® MTB/RIF, and weighted mean NNS stratified by screening strategy, risk group, and country-level TB incidence.RESULTS: We screened 27,223 abstracts; 90 studies were included (41 in low/moderate and 49 in medium/high TB incidence settings). High-risk groups included inpatients, outpatients, people living with diabetes (PLWD), migrants, prison inmates, persons experiencing homelessness (PEH), healthcare workers, and miners. Screening strategies included symptom-based screening, chest X-ray and Xpert testing. NNS varied widely across and within incidence settings based on risk groups and screening methods. Screening tools with higher sensitivity (e.g., Xpert, CXR) were associated with lower NNS estimates.CONCLUSIONS: NNS for ACF strategies varies substantially between adult risk groups. Specific interventions should be tailored based on local epidemiology and costs.

Prevalence, Incidence, and Characteristics of Tuberculosis Among Known Diabetes Patients — A Prospective Cohort Study in 10 Sites, 2013–2015

What is already known about this topic?

The association of diabetes mellitus (DM) with both increased risk of tuberculosis (TB) and unfavorable treatment outcomes has been identified by many studies (1). However, epidemic data for TB cases in DM patients is absent in China.

What is added by this report?

This current population-based prospective cohort study, conducted in ten counties located in eastern, central, and western China during 2013–2015, revealed a high prevalence and incidence of TB in known DM patients. Most TB cases were captured by active case-finding and a much higher presence of being asymptomatic among TB/DM patients was obtained.

What are the implications for public health practice?

Active case-finding should be carried out in DM patients and populations at high risk for developing TB. A TB symptom screening-based case-finding strategy is not enough; chest radiography check should be done once a year for these patients.

Educational counselling of patients with combined TB and diabetes mellitus: a randomised trial

SETTING

Newly diagnosed pulmonary TB with diabetes mellitus (DM) comorbidity attending clinics in Bandung City, Indonesia.

OBJECTIVE

To describe the effect of educational counselling on patients' knowledge about TB (transmission, treatment, risk factors) and DM (symptoms, treatment, complications, healthy lifestyle), adherence to medication, and to assess characteristics associated with knowledge.

DESIGN

All patients received counselling and were then randomised to either structured education on TB-DM, combined with clinical monitoring and medication adjustment (intervention arm), or routine care (control arm). Knowledge and adherence were assessed using a questionnaire.

RESULTS

Baseline and 6-month questionnaires were available for 108 of 150 patients randomised (60/76 in the intervention arm and 48/74 in the control arm). Patients knew less about DM than about TB. There was no significant difference in the proportion with knowledge improvement at 6 months, both for TB (difference of differences 14%; P = 0.20) or for DM (10%; P = 0.39) between arms. Intervention arm patients were more likely to adhere to taking DM medication, with fewer patients reporting ever missing oral DM drugs than those in the control arm (23% vs. 48%; P = 0.03). Higher education level was associated with good knowledge of both TB and DM.

CONCLUSIONS

Structured education did not clearly improve patients' knowledge. It was associated with better adherence to DM medication, but this could not be attributed to education alone. More efforts are needed to improve patients' knowledge, especially regarding DM.

The effect of a structured clinical algorithm on glycemic control in patients with combined tuberculosis and diabetes in Indonesia: A randomized trial

AIMS

Diabetes mellitus (DM) is associated with worse tuberculosis (TB) treatment outcomes, especially among those with poor glycemic control. We examined whether a structured clinical algorithm could improve glycemic control in TB patients with DM.

METHODS

In an open label randomized trial, TB-DM patients were randomized to scheduled counselling, glucose monitoring, and adjustment of medication using a structured clinical algorithm (intervention arm) or routine DM management (control arm), with glycated hemoglobin (HbA1c) at month 6 as the primary end point.

RESULTS

We randomized 150 pulmonary TB-DM patients (92% culture positive, 51.3% male, mean age 53 years). Baseline mean HbA1c was 11.0% in the intervention arm (n = 76) and 11.6% in the control arm (n = 74). At 6 months, HbA1c had decreased more in the intervention arm compared with the control arm (a difference of 1.82% HbA1c, 95% CI 0.82-2.83, p < 0.001). Five patients were hospitalized in the intervention arm and seven in the control arm. There was more hypoglycemia (35.0% vs 11.8%; p = 0.002) in the intervention arm. Two deaths occurred in the intervention arm, one due to cardiorespiratory failure and one because of suspected septic shock and multiorgan failure.

CONCLUSION

Regular monitoring and algorithmic adjustment of DM treatment led to improved glycemic control.

The Growing Importance of Tuberculosis Preventive Therapy and How Research and Innovation Can Enhance Its Implementation on the Ground

Ending the tuberculosis (TB) epidemic by 2030 requires two key actions: rapid diagnosis and effective treatment of active TB and identification and treatment of latent TB infection to prevent progression to active disease. We introduce this perspective by documenting the growing importance of TB preventive therapy on the international agenda coupled with global data showing poor implementation of preventive activities in programmatic settings. We follow this with two principal objectives. The first is to examine implementation challenges around diagnosis and treatment of active TB. Within this, we include recent evidence about the continued morbidity and heightened mortality that persists after TB treatment is successfully completed, thus elevating the importance of TB preventive therapy. The second objective is to outline how current TB preventive therapy activities have been shaped and are managed and propose how these can be improved through research and innovation. This includes expanding and giving higher priority to certain high-risk groups including those with fibrotic lung lesions on chest X-ray, showcasing the need to develop and deploy new biomarkers to more accurately predict risk of disease and making shorter treatment regimens, especially with rifapentine-isoniazid, more user-friendly and widely available. Ending the TB epidemic requires not only cure of the disease but preventing it before it even begins.