The role of diabetes co-morbidity for tuberculosis treatment outcomes: a prospective cohort study from Mwanza, Tanzania

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.

Implementation of the WHO's collaborative framework for the management of tuberculosis and diabetes: a scoping review

OBJECTIVE

To map evidence on the implementation of the WHO's collaborative framework for the management of tuberculosis (TB) and diabetes mellitus (DM) comorbidity, globally.

DESIGN

Scoping review.

METHODS

Guided by Arksey and O'Malley's scoping review framework, this review mapped literature on the global implementation of the framework for the management of TB and DM comorbidity, globally. An extensive literature search for peer-reviewed studies, theses, studies in the press and a list of references from the selected studies was conducted to source-eligible studies. PubMed, Google Scholar, Web of Science, Science Direct, the EBSCOhost platform (academic search complete, health source: nursing/academic edition, CINAHL with full text), Scopus and the WHO library were used to source the literature. We performed title screening of articles using keywords in the databases, after which two independent reviewers (RS and PV) screened abstracts and full articles. Studies from August 2011 to May 2021 were included in this review and the screening was guided by the inclusion and exclusion criteria. Findings were analysed using the thematic content analysis approach and results presented in the form of a narrative report. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension was used as a checklist and for explaining the scoping review process.

RESULTS

This review found evidence of the WHO TB-DM collaborative framework's implementation in 35 countries across the globe. TB-DM comorbidity was identified in patients through bidirectional screening of both patients with TB and patients with DM in rural and urban settings.

CONCLUSION

Due to the paucity of evidence on mechanisms of collaboration, we recommend further research in other implementing countries to identify techniques used for diagnosis and integration of TB and DM services, in order to ensure that effective and joint management of TB-DM comorbidity in populations is achieved.

Global, regional, and national prevalence of diabetes mellitus in patients with pulmonary tuberculosis: a systematic review and meta-analysis

BACKGROUND

Both pulmonary tuberculosis (PTB) and diabetes mellitus (DM) are major global public health problems. We estimated the global, regional, and national prevalence of diabetes mellitus in a population with PTB.

METHODS

We searched for observational studies of DM in people with PTB using the PubMed and Embase electronic bibliographic databases, focusing on articles published in the English language from database inception until March 31, 2021. We included original research that reported the prevalence of DM in PTB or those that had sufficient data to compute these estimates. Studies were excluded if they did not provide primary data or were case studies or reviews. Two authors independently extracted the articles and collected detailed information using a predefined questionnaire. A country-specific random-effects meta-analysis was used for countries with two or more available studies, and a fractional response regression model was employed to predict the prevalence of DM in PTB for countries with one or no study. The study was registered with the International Prospective Register of Systematic Reviews, using the registration number CRD42018101989.

RESULTS

We identified 22,658 studies, and 153, across 51 countries, were retained for data extraction. The global prevalence of DM among patients with PTB was estimated to be 13.73% (95% confidence interval [CI] 12.51-14.95). The prevalence rates were 19.32% (95% CI 13.18-25.46) in the region of the Americas, 17.31% (95% CI 12.48-22.14) in the European region, 14.62% (95% CI 12.05-17.18) in Southeast Asia, 13.59% (95% CI 7.24-19.95) in the western Pacific region, 9.61% (95% CI 4.55-14.68) in the eastern Mediterranean region, and 9.30% (95% CI 2.83-15.76) in the African region. The country with the highest estimated prevalence was the Marshall Islands (50.12%; 95% CI 4.28-95.76).

CONCLUSION

Comorbid PTB and DM remain prevalent worldwide.

Diabetes Status and Association With Risk of Tuberculosis Among Korean Adults

IMPORTANCE

The risk of tuberculosis (TB) associated with diabetes status, considering impaired fasting glucose or duration of diabetes, has not been well established.

OBJECTIVE

To evaluate the association of diabetes status with the development of TB in the general population.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used data from the Korean National Health Insurance System database. Adult participants without a history of TB who underwent a health screening in 2009 were included. Eligible participants were followed up for incident TB cases from 1 year after the day of health screening until December 31, 2018. Data analysis was performed from September 2019 to September 2020.

EXPOSURES

Five levels of diabetes status were evaluated: normal glucose, impaired fasting glucose (considered as without diabetes), new-onset diabetes, diabetes duration less than 5 years, and diabetes duration 5 years or longer (considered as having diabetes).

MAIN OUTCOMES AND MEASURES

Newly diagnosed TB.

RESULTS

Among 4 423 177 participants, the mean (SD) age was 46.5 (13.9) years, and there were 2 597 142 men (58.7%). A total of 26 458 participants (0.6%) received a diagnosis of TB within a median (interquartile range) of 8.3 (8.1-8.6) years of follow-up. An increased risk of TB was observed in participants with diabetes compared with those without diabetes (adjusted hazard ratio [aHR], 1.48; 95% CI, 1.42-1.53). Although participants with impaired fasting glucose did not show an increased risk of TB incidence (aHR, 0.97; 95% CI, 0.93-1.01), the risk of TB incidence increased with diabetes duration (new-onset diabetes, aHR, 1.32; 95% CI, 1.23-1.42; diabetes duration <5 years, aHR, 1.45; 95% CI, 1.36-1.54; diabetes duration ≥5 years, aHR, 1.57; 95% CI, 1.48-1.66). Among participants with new-onset diabetes, compared with those in the lowest decile (fasting plasma glucose [FPG] level ≥126 but <128 mg/dL), the risk of TB was significantly increased for those in the highest decile (FPG level ≥202 mg/dL, aHR, 1.79; 95% CI, 1.42-2.26).

CONCLUSIONS AND RELEVANCE

These findings suggest that longer diabetes duration is associated with development of TB, showing a dose-response association. Among participants with new-onset diabetes, incident TB was more common among those with FPG levels greater than or equal to 202 mg/dL.

Readiness of healthcare facilities with tuberculosis services to manage diabetes mellitus in Tanzania: A nationwide analysis for evidence-informed policy-making in high burden settings

Introduction

Double disease burden such as Tuberculosis and Diabetes mellitus comorbidity is evident and on rising especially in high burden settings such as Tanzania. There is limited information about the availability of tuberculosis/diabetes integrated healthcare services in Tanzania. Therefore, this study explored the availability and examined the readiness of healthcare facilities with tuberculosis services to manage diabetes mellitus in Tanzania.

Methods

We abstracted data from the 2014–2015 Tanzania Service Provision Assessment Survey datasets. The service availability was assessed by calculating the proportion of tuberculosis facilities reported to manage diabetes mellitus. There were four domains; each domain with some indicators for calculating the readiness index. High readiness was considered if the tuberculosis facilities scored at least half (≥50%) of the indicators listed in each of the four domains (staff training and guideline, diagnostics, equipment, and medicines) as is recommended by the World Health Organization-Service Availability and Readiness Assessment manual while low readiness for otherwise.

Results

Out of 341 healthcare facilities with tuberculosis services included in the current study, 238 (70.0%) reported providing management for diabetes mellitus. The majority of the facilities were dispensaries and clinics 48.1%; publicly owned 72.6%; and located in rural 62.6%. Overall, the readiness of tuberculosis facilities to manage diabetes was low (10.8%). Similarly, the readiness was low based on the domain-specific readiness of trained staff and guidelines.

Conclusion

Although the majority of the healthcare facilities with tuberculosis services had diabetes mellitus services the overall readiness was low. This finding provides a piece of evidence to inform the policymakers in high burden and low resource countries to strengthen the co-management of tuberculosis and diabetes.

Forecasting tuberculosis using diabetes-related google trends data

Online activity-based data can be used to aid infectious disease forecasting. Our aim was to exploit the converging nature of the tuberculosis (TB) and diabetes epidemics to forecast TB case numbers. Thus, we extended TB prediction models based on traditional data with diabetes-related Google searches. We obtained data on the weekly case numbers of TB in Germany from June 8^th, 2014, to May 5^th, 2019. Internet search data were obtained from a Google Trends (GTD) search for 'diabetes' to the corresponding interval. A seasonal autoregressive moving average (SARIMA) model (0,1,1) (1,0,0) [52] was selected to describe the weekly TB case numbers with and without GTD as an external regressor. We cross-validated the SARIMA models to obtain the root mean squared errors (RMSE). We repeated this procedure with autoregressive feed-forward neural network (NNAR) models using 5-fold cross-validation. To simulate a data-poor surveillance setting, we also tested traditional and GTD-extended models against a hold-out dataset using a decreased 52-week-long period with missing values for training. Cross-validation resulted in an RMSE of 20.83 for the traditional model and 18.56 for the GTD-extended model. Cross-validation of the NNAR models showed a mean RMSE of 19.49 for the traditional model and 18.99 for the GTD-extended model. When we tested the models trained on a decreased dataset with missing values, the GTD-extended models achieved significantly better prediction than the traditional models (p < 0.001). The GTD-extended models outperformed the traditional models in all assessed model evaluation parameters. Using online activity-based data regarding diabetes can improve TB forecasting, but further validation is warranted.

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

Background

In context of the rapidly expanding diabetes mellitus (DM) epidemic in India and slowly declining tuberculosis (TB) incidence, we aimed to estimate the past, current, and future impact of DM on TB epidemiology.

Methods

An age-structured TB-DM dynamical mathematical model was developed and analyzed to assess the DM-on-TB impact. The model was calibrated using a literature review and meta-analyses. The DM-on-TB impact was analyzed using population attributable fraction metrics. Sensitivity analyses were conducted by accommodating less conservative effect sizes for the TB-DM interactions, by factoring the age-dependence of the TB-DM association, and by assuming different TB disease incidence rate trajectories.

Results

In 1990, 11.4% (95% uncertainty interval (UI) = 6.3%-14.4%) of new TB disease incident cases were attributed to DM. This proportion increased to 21.9% (95% UI = 12.1%-26.4%) in 2017, and 33.3% (95% UI = 19.0%-44.1%) in 2050. Similarly, in 1990, 14.5% (95% UI = 9.5%-18.2%) of TB-related deaths were attributed to DM. This proportion increased to 28.9% (95% UI = 18.9%-34.1%) in 2017, and 42.8% (95% UI = 28.7%-53.1%) in 2050. The largest impacts originated from the effects of DM on TB disease progression and infectiousness. Sensitivity analyses suggested that the impact could be even greater.

Conclusions

The burgeoning DM epidemic is predicted to become a leading driver of TB disease incidence and mortality over the coming decades. By 2050, at least one-third of TB incidence and almost half of TB mortality in India will be attributed to DM. This is likely generalizable to other Asian Pacific countries with similar TB-DM burdens. Targeting the impact of the increasing DM burden on TB control is critical to achieving the goal of TB elimination by 2050.

Is there a connection between gestational diabetes mellitus, human immunodeficiency virus infection, and tuberculosis?

Pregnancy is associated with insulin resistance similar to that found in type 2 diabetes mellitus (DM). The prevalence of gestational diabetes mellitus (GDM) in key tuberculosis (TB) endemic countries, such as India and China, has been increasing rapidly in the last decade and may be higher in human immunodeficiency virus (HIV) infected women. Pregnancy is also an independent risk factor for developing active TB; however, little is known about the interaction of GDM, HIV and TB. We review the epidemiology and immunology of GDM, and significant research gaps in understanding the interactions between GDM, pregnancy, and TB in women living with and those without HIV.

Availability and readiness of diabetes health facilities to manage tuberculosis in Tanzania: a path towards integrating tuberculosis-diabetes services in a high burden setting?

BACKGROUND

The burden of tuberculosis (TB) and diabetes mellitus (DM) is rising and substantially affecting the low-income countries, including Tanzania. Integrated management of TB and DM is becoming of importance in TB high burden countries. In this study, we sought to assess the availability and readiness of diabetes facilities to manage TB in Tanzania.

METHODS

The present study was based on a secondary analysis of the 2014-2015 Tanzania Service Provision Assessment Survey data. We calculated the service availability as a percentage of diabetes facilities offering TB services: diagnosis and treatment. Regarding the readiness of diabetes facilities to provide TB management, we calculated based on the three domains: staff training and guideline, diagnostics, and medicines as identified by World Health Organization-Service Availability and Readiness Assessment (SARA) manual. A score of at least half (≥50%) of the indicators listed in each of the three domains was considered as high readiness. We used a descriptive statistics to present our findings.

RESULTS

There were 619 DM facilities all over the country of which only 238 (38.4%) had TB services.72.6 and 62.6% of these DM facilities with TB services were publicly owned and located in rural settings respectively. Generally, DM facilities had low readiness to manage TB; 12·6%. More specifically, all DM facilities had low readiness in terms of trained staff and guidelines. However, in the domain of diagnostics and medications, higher levels of care (hospitals) had a comparatively higher level of readiness to manage TB.

CONCLUSION

Most of the DM facilities had low availability and readiness to manage TB. The findings of our study display an urgent need to mobilize important resources to enhance the integration of TB services in DM facilities. This includes medications, management guidelines, diagnostics, and health professionals who have received refresher training on TB/DM co-management. However, presently, few DM facilities may be allowed to start managing TB as per the Strategic and Action Plan for the Prevention and Control of Non-Communicable Diseases in Tanzania 2016-2020.

Analytical Exploration of Potential Pathways by which Diabetes Mellitus Impacts Tuberculosis Epidemiology

We aimed to develop a conceptual framework of diabetes mellitus (DM) effects on tuberculosis (TB) natural history and treatment outcomes, and to assess the impact of these effects on TB-transmission dynamics. The model was calibrated using TB data for India. A conceptual framework was developed based on a literature review, and then translated into a mathematical model to assess the impact of the DM-on-TB effects. The impact was analyzed using TB-disease incidence hazard ratio (HR) and population attributable fraction (PAF) measures. Evidence was identified for 10 plausible DM-on-TB effects. Assuming a flat change of 300% (meaning an effect size of 3.0) for each DM-on-TB effect, the HR ranged between 1.0 (Effect 9-Recovery) and 2.7 (Effect 2-Fast progression); most effects did not have an impact on the HR. Meanwhile, TB-disease incidence attributed directly and indirectly to each effect ranged between -4.6% (Effect 7-TB mortality) and 34.5% (Effect 2-Fast progression). The second largest impact was for Effect 6-Disease infectiousness at 29.9%. In conclusion, DM can affect TB-transmission dynamics in multiple ways, most of which are poorly characterized and difficult to assess in epidemiologic studies. The indirect (e.g. onward transmission) impacts of some DM-on-TB effects are comparable in scale to the direct impacts. While the impact of several effects on the HR was limited, the impact on the PAF was substantial suggesting that DM could be impacting TB epidemiology to a larger extent than previously thought.

Coinfections and comorbidities in African health systems: At the interface of infectious and noninfectious diseases

There is a disease epidemiological transition occurring in Africa, with increasing incidence of noninfectious diseases, superimposed on a health system historically geared more toward the management of communicable diseases. The persistence and sometimes emergence of new pathogens allows for the occurrence of coinfections and comorbidities due to both infectious and noninfectious diseases. There is therefore a need to rethink and restructure African health systems to successfully address this transition. The historical focus of more health resources on infectious diseases requires revision. We hypothesise that the growing burden of noninfectious diseases may be linked directly and indirectly to or further exacerbated by the existence of neglected tropical diseases (NTDs) and other infectious diseases within the population. Herein, we discuss the health burden of coinfections and comorbidities and the challenges to implementing effective and sustainable healthcare in Africa. We also discuss how existing NTD and infectious disease intervention programs in Africa can be leveraged for noninfectious disease intervention. Furthermore, we explore the potential for new technologies-including artificial intelligence and multiplex approaches-for diagnosis and management of chronic diseases for improved health provision in Africa.

Association between diabetes mellitus and active tuberculosis: A systematic review and meta-analysis

The burgeoning epidemic of diabetes mellitus (DM) is one of the major global health challenges. We systematically reviewed the published literature to provide a summary estimate of the association between DM and active tuberculosis (TB). We searched Medline and EMBASE databases for studies reporting adjusted estimates on the TB–DM association published before December 22, 2015, with no restrictions on region and language. In the meta-analysis, adjusted estimates were pooled using a DerSimonian-Laird random-effects model, according to study design. Risk of bias assessment and sensitivity analyses were conducted. 44 eligible studies were included, which consisted of 58,468,404 subjects from 16 countries. Compared with non-DM patients, DM patients had 3.59–fold (95% confidence interval (CI) 2.25–5.73), 1.55–fold (95% CI 1.39–1.72), and 2.09–fold (95% CI 1.71–2.55) increased risk of active TB in four prospective, 16 retrospective, and 17 case-control studies, respectively. Country income level (3.16–fold in low/middle–vs. 1.73–fold in high–income countries), background TB incidence (2.05–fold in countries with >50 vs. 1.89–fold in countries with ≤50 TB cases per 100,000 person-year), and geographical region (2.44–fold in Asia vs. 1.71–fold in Europe and 1.73–fold in USA/Canada) affected appreciably the estimated association, but potential risk of bias, type of population (general versus clinical), and potential for duplicate data, did not. Microbiological ascertainment for TB (3.03–fold) and/or blood testing for DM (3.10–fold), as well as uncontrolled DM (3.30–fold), resulted in stronger estimated association. DM is associated with a two- to four-fold increased risk of active TB. The association was stronger when ascertainment was based on biological testing rather than medical records or self-report. The burgeoning DM epidemic could impact upon the achievements of the WHO “End TB Strategy” for reducing TB incidence.

Prevalence of diabetes mellitus in newly diagnosed pulmonary tuberculosis in Beira, Mozambique

Introduction

Data regarding the association between diabetes mellitus (DM) and tuberculosis (TB) in Africa are scarce. DM screening among TB patients in Mozambique was carried out.

Methods

The study was implemented from January to August 2016 in three Urban Health Centers in Beira, Mozambique and recruited adult (>18 years) patients newly diagnosed with pulmonary TB.

Results

Three hundred and one patients were enrolled (67.4%, males mean age 31.7(SD 11 years). Diabetes was diagnosed in only 3 patients (1%) and impaired glucose tolerance (IGT) in an additional 6 subjects (2%).

Conclusion

A lower than expected prevalence of DM was observed, which could be explained by the lack of traditional risk factors for DM (overweight, age over 45 years, hypertension and smoking) in Mozambique.

Tuberculosis associated mortality in a prospective cohort in Sub Saharan Africa: Association with HIV and antiretroviral therapy

OBJECTIVE

Nine out of ten tuberculosis deaths occur in tuberculosis-burdened countries, particularly Sub Saharan Africa. In these setting mortality has not been fully described. We describe the magnitude and pattern of TB mortality in Tanzania.

METHODS

A multicenter prospective cohort study was conducted among HIV infected and uninfected pulmonary tuberculosis patients from time of anti-TB treatment initiation to completion. Patients were censored at the time of treatment completion, or at their last visit for those who did not complete TB treatment. Kaplan-Meier curves were used to estimate time to death; cox proportional hazards model was used to examine risk factors for mortality.

RESULTS

A total of 58 deaths out of 1696 patients (3.4%) occurred, two thirds (n=39) during the first two months of treatment. Compared to HIV un-infected TB patients, mortality risk for TB/HIV co-infected patients was least when antiretroviral therapy (ART) was initiated after 14 days of anti-TB (RR=3.55; 95% CI: 1.44, 8.73 p<0.0001) and highest when ART was initiated 90 days or less prior to anti-TB and within the first 14 days of anti-TB therapy (RR=10; 95% CI: 3.28, 30.54; p<0.0001).

CONCLUSION

Meticulously planned and supervised antiretroviral therapy reduces mortality among TB/HIV patients. Among patients with TB/HIV naïve of ART, withholding ART until the third week of anti-tuberculosis therapy will likely reduce TB mortality in Tanzania. Patients on ART and later develop tuberculosis should be closely monitored.

Tuberculosis and diabetes: current state and future perspectives

This review outlines the association between tuberculosis and diabetes, focusing on epidemiology, physiopathology, clinical aspects, diagnosis and treatment, and evaluates future perspectives, with particular attention to developing countries.

High diabetes mellitus prevalence with increasing trend among newly-diagnosed tuberculosis patients in an Asian population: A nationwide population-based study

AIMS

Our aims were to investigate the prevalence of diabetes mellitus (DM) among patients with newly-diagnosed tuberculosis (TB) and to determine its associated factors in an Asian population.

METHODS

The data were obtained from the National Health Insurance Research Database and included 9831 newly-diagnosed TB individuals in the period of 2000-2010. The data were divided into a DM group and a non-DM group. We measured the prevalence and the associated comorbidities of DM.

RESULTS

During 2000-2010, the prevalence of DM progressively increased, with an average prevalence rate of 27.9%. The patients with ages of 55-64 years had the highest association of DM (OR=3.53) compared with those under 45 years. TB patients with heart failure, ischemic heart disease, cerebral vascular disease, hypertension, dyslipidemia, chronic kidney disease, and liver disease were more likely to associate with DM (ORs=1.27, 1.23, 1.30, 2.32, 3.26, 1.6, and 1.68, respectively) compared to those without the variables.

CONCLUSIONS

The prevalence of DM among TB patients in Taiwan was high and tended to increase in the past decade. Clinically, inquiring about DM history and screening routinely for those without DM history among TB patients should be carried out in Taiwan.

Transient Hyperglycemia in Patients With Tuberculosis in Tanzania: Implications for Diabetes Screening Algorithms

BACKGROUND

Diabetes mellitus (DM) increases tuberculosis risk while tuberculosis, as an infectious disease, leads to hyperglycemia. We compared hyperglycemia screening strategies in controls and patients with tuberculosis in Dar es Salaam, Tanzania.

METHODS

Consecutive adults with tuberculosis and sex- and age-matched volunteers were included in a case-control study between July 2012 and June 2014. All underwent DM screening tests (fasting capillary glucose [FCG] level, 2-hour CG [2-hCG] level, and glycated hemoglobin A1c [HbA1c] level) at enrollment, and cases were tested again after receipt of tuberculosis treatment. Association of tuberculosis and its outcome with hyperglycemia was assessed using logistic regression analysis adjusted for sex, age, body mass index, human immunodeficiency virus infection status, and socioeconomic status. Patients with tuberculosis and newly diagnosed DM were not treated for hyperglycemia.

RESULTS

At enrollment, DM prevalence was significantly higher among patients with tuberculosis (n = 539; FCG level > 7 mmol/L, 4.5% of patients, 2-hCG level > 11 mmol/L, 6.8%; and HbA1c level > 6.5%, 9.3%), compared with controls (n = 496; 1.2%, 3.1%, and 2.2%, respectively). The association between hyperglycemia and tuberculosis disappeared after tuberculosis treatment (adjusted odds ratio [aOR] for the FCG level: 9.6 [95% confidence interval {CI}, 3.7-24.7] at enrollment vs 2.4 [95% CI, .7-8.7] at follow-up; aOR for the 2-hCG level: 6.6 [95% CI, 4.0-11.1] vs 1.6 [95% CI, .8-2.9]; and aOR for the HbA1c level, 4.2 [95% CI, 2.9-6.0] vs 1.4 [95% CI, .9-2.0]). Hyperglycemia, based on the FCG level, at enrollment was associated with tuberculosis treatment failure or death (aOR, 3.3; 95% CI, 1.2-9.3).

CONCLUSIONS

Transient hyperglycemia is frequent during tuberculosis, and DM needs confirmation after tuberculosis treatment. Performance of DM screening at tuberculosis diagnosis gives the opportunity to detect patients at risk of adverse outcome.

Is there an effect of glucose lowering treatment on incidence and prognosis of tuberculosis? A systematic review

The association between diabetes and incidence of tuberculosis is well established, and observational studies have shown poor treatment outcome in tuberculosis related to hyperglycemia. The WHO recommends screening for diabetes among all patients with tuberculosis and optimized glycemic control aiming at improving tuberculosis outcome. However, no intervention studies support this notion. Patients with tuberculosis are often vulnerable with high degree of comorbidity, and, therefore, at high risk of adverse effects of intensive glucose control. Controlled intervention studies of the effect of glucose lowering treatment on tuberculosis outcomes are clearly warranted to justify screening for- and tight control of diabetes.

Characteristics of tuberculosis in the state of Minas Gerais, Brazil: 2002-2009

OBJECTIVE

To analyze the profile of tuberculosis cases reported between 2002 and 2009 in the state of Minas Gerais, Brazil, according to sociodemographic, clinical, and laboratory characteristics, as well as to comorbidities and mortality.

METHODS

This was a descriptive, epidemiological study based on data obtained from the Brazilian Case Registry Database and the Brazilian Mortality Database for the 2002-2009 period.

RESULTS

There were 47,285 reported cases of tuberculosis, corresponding to a mean incidence of 22.3/100,000 population. The individuals diagnosed with tuberculosis were predominantly in the 20- to 49-year age bracket and male (62.4% and 67.0%, respectively). Individuals with a low level of education accounted for 18.5% of the cases. New cases, cases of recurrence, and cases of retreatment accounted for 83.7%, 5.7%, 5.7%, respectively. The rates of cure and treatment noncompliance were 66.2% and 11.2%, respectively; multidrug-resistant tuberculosis was identified in 0.2% of the cases; and the mortality rate was 12.9%. The directly observed treatment, short-course (DOTS) strategy was applied in 21.8% of the cases. Sputum smear microscopy and culture were performed in only 73.9% and 12.9% of the cases, respectively. Chest X-rays were performed in 90.5% of the cases. Pulmonary tuberculosis was the predominant form (in 83.9%). Comorbidity with alcoholism, HIV infection, and diabetes mellitus were identified in 17.2%, 8.3%, and 3.8%, respectively.

CONCLUSIONS

During the study period, the numbers of new cases, cases of treatment noncompliance, and deaths were high, comorbidities were common, and there was a failure to perform adequately basic tests for the diagnosis of tuberculosis. Multidisciplinary approaches, expanded use of the DOTS strategy, better knowledge of the distribution of tuberculosis, and improvements in the databases are needed in order to achieve better control of the disease in the state of Minas Gerais.

Endocrine dysfunction among adult patients with tuberculosis: An African experience

A broad spectrum of endocrine conditions has been reported among adult patients with tuberculosis in Africa. This review aims to describe the magnitude and pathogenesis of the following endocrinopathies among patients with tuberculosis in Africa: adrenal insufficiency, diabetes mellitus, disorders of calcium and vitamin D metabolism, thyroid dysfunction and hypogonadism. PubMed database and Google scholar were used to search for the relevant published English language studies and case reports relating to endocrine abnormalities and tuberculosis in Africa up to July 2013. The search terms used were endocrine dysfunction, endocrine abnormalities, adrenal insufficiency, diabetes mellitus, thyroid dysfunction, hypogonadism, disorders of calcium and vitamin D metabolism, tuberculosis, Africa. Reference lists of the identified articles were further used to identify other studies. Adrenal insufficiency, diabetes mellitus and calcium-vitamin D abnormalities were the most prevalent and frequently reported endocrine disorders among adult patients with tuberculosis in Africa. A meticulous endocrine evaluation among tuberculosis patients with suspected endocrine abnormalities should be encouraged in Africa and other high TB endemic regions. Treatment of these endocrine disorders has generally been shown to improve quality of life and reduce mortality.

Tuberculosis comorbidity with communicable and non-communicable diseases: integrating health services and control efforts

Recent data for the global burden of disease reflect major demographic and lifestyle changes, leading to a rise in non-communicable diseases. Most countries with high levels of tuberculosis face a large comorbidity burden from both non-communicable and communicable diseases. Traditional disease-specific approaches typically fail to recognise common features and potential synergies in integration of care, management, and control of non-communicable and communicable diseases. In resource-limited countries, the need to tackle a broader range of overlapping comorbid diseases is growing. Tuberculosis and HIV/AIDS persist as global emergencies. The lethal interaction between tuberculosis and HIV coinfection in adults, children, and pregnant women in sub-Saharan Africa exemplifies the need for well integrated approaches to disease management and control. Furthermore, links between diabetes mellitus, smoking, alcoholism, chronic lung diseases, cancer, immunosuppressive treatment, malnutrition, and tuberculosis are well recognised. Here, we focus on interactions, synergies, and challenges of integration of tuberculosis care with management strategies for non-communicable and communicable diseases without eroding the functionality of existing national programmes for tuberculosis. The need for sustained and increased funding for these initiatives is greater than ever and requires increased political and funder commitment.