Integrating TB and non-communicable diseases services: Pilot experience of screening for diabetes and hypertension in patients with Tuberculosis in Luanda, Angola

Comorbidity profiles among sputum-positive tuberculosis patients in Cameroon

Introduction

Comorbid non-communicable diseases (NCDs) like diabetes, cardiovascular diseases (CVD), kidney diseases, and hypertension, could have implications for tuberculosis (TB) treatment management and increase the disease burden amongst active TB patients.

Methods

This cross-sectional study aimed at profiling comorbidities amongst sputum-positive TB patients in the South West and Littoral regions of Cameroon and was relevant for improving disease management and public health interventions. Diabetes was defined by elevated blood glucose, body mass index (underweight: <18.5 kg/m2, normal: 18.5-<25.0 kg/m2, overweight: 25-<30 kg/m2 and obese: ≥30.0 kg/m2) and hypertension by elevated blood pressure levels (i.e., systolic ≥130 mmHg or diastolic ≥80 mmHg). Socio-demographic and clinical data were collected using case report forms. Descriptive analysis was performed, bivariate logistic regression analysis was computed with at least one comorbidity as the dependent variable (global model) and a multivariable logistic regression analysis was done to provide adjusted odds ratios (final model). The covariate with the highest p-value was removed until p < 0.25 cut-off, using R software version 4.3.1. p-value <0.05 at 95% confidence interval was considered statistically significant.

Results

Five hundred and forty-nine sputum-positive microscopically confirmed active TB patients were enrolled into this study. Two-thirds (65.8%) of the total patients were male. Overall, 56 sputum-positive TB patients had at least one non-communicable disease, thus a prevalence of 10.2% (95% CI = 7.9-13.0). The most frequently recorded NCD was diabetes 4.4% (95% CI = 3.1-6.7) followed by kidney disease 2% (95% CI = 1.1-3.6), hypertension 0.9% (95% CI = 0.4-2.2), and CVD 0.91% (95% CI = 0.4-2.2). Three TB patients (0.6%) had all four comorbidities examined. Age group (p < 0.001), and level of education (p = 0.049) were factors significantly associated with having at least one comorbidity.

Discussion

Our findings showed that diabetes was significantly the most prevalent comorbid NCD amongst sputum-positive TB patients (p < 0.001). HIV status, occupation, body mass index (BMI), and alcohol intake were not significantly associated with having at least one comorbidity. Implementing public health intervention programmes such as systematic screening of TB patients for NCDs especially diabetes is highly recommended for better control of these diseases.

Non-communicable comorbidities in pulmonary tuberculosis and healthcare utilization: a cross-sectional study of 2021 Indonesian national health insurance data

BACKGROUND

Limited research exists on the comorbidity of pulmonary tuberculosis with non-communicable diseases (NCDs) and its implications for healthcare utilization in Indonesia. The lack of investigation into NCD comorbidity among pulmonary tuberculosis patients could adversely affect both the healthcare system and the national health insurance scheme. Understanding the NCD comorbidity among pulmonary tuberculosis patients, associated factors, and healthcare utilization is crucial for ensuring the effective and efficient delivery of health services.

METHOD

This study utilized an observational cross-sectional design based on anonymized sample data from tuberculosis cases covered by Indonesia's National Health Insurance in 2021. Chi-square tests were employed to analyze dependent and independent variables, while unadjusted and adjusted logistic regressions were used to explore further associations.

RESULTS

The prevalence of NCD comorbidity in tuberculosis patients was 11.81%. Aged over 60 (aOR 5.16; [CI] 4.23-6.3), married (aOR 1.19; [CI] 1.05-1.34), and unemployed (aOR 1.27; [CI] 1.08-1.49) were associated with the NCD comorbidity in pulmonary tuberculosis patients. Factors associated with increased inpatient service utilization among pulmonary tuberculosis patients included aged over 60 (aOR 5.69; [CI] 4.81-6.74), male (aOR 1.32; [CI] 1.23-1.40), self-employment (aOR 1.42; [CI] 1.29-1.56), having insurance subsidized by central government (aOR 1.89; [CI] 1.73-2.08) or local government funds (aOR 1.75; [CI] 1.58-1.93), and having comorbidity non-communicable diseases (aOR 1.80; [CI] 1.66-1.96).

CONCLUSION

Pulmonary tuberculosis patients exhibit a significant prevalence of NCD comorbidity, which substantially impacts healthcare utilization. Early detection and management of these conditions are critical to mitigate burdens on both the healthcare system and the financial sustainability of the national health insurance scheme. Integrating health services for tuberculosis and NCDs through bidirectional screening is essential for comprehensive patient care.

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.

The collaborative framework for the management of tuberculosis and type 2 diabetes syndemic in low- and middle-income countries: a rapid review

INTRODUCTION

Given the absence of international guidelines on the joint management and control of tuberculosis (TB) and type 2 diabetes mellitus (T2D), the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (The Union) launched in 2011 a policy framework to address the growing syndemic burden of TB-T2D. This review aimed at mapping the available evidence on the implementation of the Union-WHO Framework, explicitly, or bi-directional TB-T2D health programs as an initiative for co-management in patients in low- and middle-income countries (LMIC).

METHODS

A rapid review was performed based on a systematic search in PubMed and Web of Science electronic databases for peer-reviewed articles on The Union-WHO Framework and bi-directional interventions of TB and T2D in LMIC. The search was restricted to English language articles and from 01/08/2011 to 20/05/2022.

RESULTS

A total of 24 articles from 16 LMIC met the inclusion criteria. Four described the implementation of The Union-WHO Framework and 20 on the bi-directional interventions of TB and T2D. Bi-directional activities were found valuable, feasible and effective following the Union-WHO recommendations. Limited knowledge and awareness on TB-T2D comorbidity was identified as one of the barriers to ensure a functional and effective integration of services.

CONCLUSIONS

This review revealed that it is valuable, feasible and effective to implement bi-directional TB and T2D activities (screening and management) according to the Union-WHO Framework recommendations, especially in countries that face TB-T2D syndemic. Additionally, it was apparent that gaps still exist in research aimed at providing evidence of costs to implement collaborative activities. There is need for TB and T2D services integration that should be done through the well-stablished TB programme. This integration of two vertical programmes, could ensure patient-centeredness, continuum of care and ultimately contribute for health systems strengthening.

Multimorbidity in African ancestry populations: a scoping review

OBJECTIVES

Multimorbidity (MM) is a growing concern linked to poor outcomes and higher healthcare costs. While most MM research targets European ancestry populations, the prevalence and patterns in African ancestry groups remain underexplored. This study aimed to identify and summarise the available literature on MM in populations with African ancestry, on the continent, and in the diaspora.

DESIGN

A scoping review was conducted in five databases (PubMed, Web of Science, Scopus, Science Direct and JSTOR) in July 2022. Studies were selected based on predefined criteria, with data extraction focusing on methodology and findings. Descriptive statistics summarised the data, and a narrative synthesis highlighted key themes.

RESULTS

Of the 232 publications on MM in African-ancestry groups from 2010 to June 2022-113 examined continental African populations, 100 the diaspora and 19 both. Findings revealed diverse MM patterns within and beyond continental Africa. Cardiovascular and metabolic diseases are predominant in both groups (80% continental and 70% diaspora). Infectious diseases featured more in continental studies (58% continental and 16% diaspora). Although many papers did not specifically address these features, as in previous studies, older age, being women and having a lower socioeconomic status were associated with a higher prevalence of MM, with important exceptions. Research gaps identified included limited data on African-ancestry individuals, inadequate representation, under-represented disease groups, non-standardised methodologies, the need for innovative data strategies, and insufficient translational research.

CONCLUSION

The growing global MM prevalence is mirrored in African-ancestry populations. Recognising the unique contexts of African-ancestry populations is essential when addressing the burden of MM. This review emphasises the need for additional research to guide and enhance healthcare approaches for African-ancestry populations, regardless of their geographic location.

Integration Challenges and Opportunity of Implementing Non-Communicable Disease Screening Intervention with Tuberculosis Patient Care: A Mixed Implementation Study

Background

Despite the comorbidity, early detection and treatment of the two diseases are highly recommended; however, a few pilot studies were conducted, which are mainly focused on diabetes mellitus screening and the integration opportunity and challenges were not known. The study aimed to identify integrated implementation challenges and opportunities of non-communicable disease and risk factors screening intervention with tuberculosis patient care.

Methods

A mixed implementation study design was used. Data were collected from a sample of 443 tuberculosis patients, 21 key informants and facility observations. For quantitative data, descriptive statistics for proportion were summarized in tables and figures. Four distinct implementation frame was adapted for thematic analysis of audio recordings, daily verbatim transcription, and descriptive field notes.

Results

The prevalence of hypertension and diabetes mellitus among tuberculosis patients were 6.55% and 5.64%, respectively. Totally 9 subthemes and 21 new codes were developed, of which 13 and 8 new codes were developed for integrated implementation challenges and opportunities, respectively. The absence of medical equipment, skill and knowledge training, record and report system, cooperative integration, feedback, referral system, shortage of supporting agencies, and services not free were external challenges, whereas lack of trained health workers, focal persons, and increased workload and absence of awareness creation were internal challenges. Despite the challenges, the presence of health extension programs, non-governmental organizations, community health care insurance and associations for diabetes mellitus were external opportunities. Availability of assigned focal persons, trained stakeholders, guidelines, information systems and compatible tuberculosis program structure were internal opportunities.

Conclusion

The majority of TB patients were not comorbid with NCDs. We build a favourable system for integrated implementation developing an integration platform and structural authority at a different organization by addressing identified challenges and applying facilitators is crucial.

Predictors of Tuberculosis and Non-Communicable Disease Comorbidities Among Newly Enrolled Tuberculosis Patients, Southern Ethiopia

Introduction

Non-communicable diseases are comorbid with tuberculosis, however only a few record review based studies have been conducted, which are more concentrated on elevated glucose levels. This study aimed to assess non-communicable disease comorbidity and its predictors among tuberculosis patients.

Methods

A prospective cross-sectional study design was used and the data were collected by a previously validated tool from a sample of 443 tuberculosis patients using cluster random sampling methods. Multinomial logistic regression was interpreted by relative risk to predict the association of comorbidity status with independent variables.

Results

The majority (87.81%) of TB patients were not comorbid with NCDs. The prevalence of hypertension and diabetes mellitus among tuberculosis patients were 6.55%, and 5.64%, respectively. The people who had a risk score >8 were 6.47 times more likely to have tuberculosis comorbid with one non-communicable disease compared to those with a risk score ≤8. The relative risk of tuberculosis patients with BMI >25 is 3.33 times compared to those with a BMI <23 of being comorbid with one non-communicable disease vs tuberculosis patients without non-communicable diseases. Those tuberculosis patients with an awareness of non-communicable disease comorbidities are 9.33 times more likely to have tuberculosis with multi-comorbidities compared to those who are unaware.

Conclusion

The majority of TB patients were not comorbid with NCDs. The person's weight, family size of more than five, monthly income >3000 birr, risk score >8 and BMI >25 significantly predict comorbidity with one non-communicable disease compared to those without a comorbidity. The presence of non-communicable disease comorbidity, treatment awareness, and being aged 50+ years significantly predict the presence of multi-comorbidities compared to those without comorbidity. For early detection and management of both diseases, establishing bidirectional screening platforms in tuberculosis care programs is urgently required.

Post-TB health and wellbeing

TB affects around 10.6 million people each year and there are now around 155 million TB survivors. TB and its treatments can lead to permanently impaired health and wellbeing. In 2019, representatives of TB affected communities attending the '1st International Post-Tuberculosis Symposium´ called for the development of clinical guidance on these issues. This clinical statement on post-TB health and wellbeing responds to this call and builds on the work of the symposium, which brought together TB survivors, healthcare professionals and researchers. Our document offers expert opinion and, where possible, evidence-based guidance to aid clinicians in the diagnosis and management of post-TB conditions and research in this field. It covers all aspects of post-TB, including economic, social and psychological wellbeing, post TB lung disease (PTLD), cardiovascular and pericardial disease, neurological disability, effects in adolescents and children, and future research needs.

Diabetes-Tuberculosis Care in Eswatini: A Qualitative Study of Opportunities and Recommendations for Effective Services Integration

Objective: This study describes the availability of basic services, equipment, and commodities for integrated DM-TB services, best practices by healthcare workers, and opportunities for better integration of DM-TB care in Eswatini. Methods: A qualitative design was used. Twenty-three healthcare workers participated in a survey and key informant interview. Results: Most respondents indicated DM and TB care are integrated and clients access blood pressure and fasting/random blood glucose assessment. Few respondents indicated they provide visual assessment, hearing assessment, and HbA1c testing. Respondents experienced stockouts of urinalysis strips, antihypertensive drugs, insulin, glucometer strips, and DM drugs in the previous 6 months before the interview. Four main themes emerged from the qualitative interviews-quality and current standards of care, best practices, opportunities, and recommendations to improve integrated services delivery. Conclusion: While DM care is provided for TB patients, the implementation of integrated DM-TB services is suboptimal as the quality and current standards of care vary across health facilities due to different patient-level and health system challenges. Some identified opportunities must be utilized for a successful DM-TB integration.

Effect of Tuberculosis (TB) and Diabetes mellitus (DM) integrated healthcare on bidirectional screening and treatment outcomes among TB patients and people living with DM in developing countries: a systematic review

A systematic review (Prospero CRD42017075562) including articles published between 1 January 1990 and 31 October 2021 was performed to synthesize evidence on the effect of integrating tuberculosis (TB) and diabetes mellitus (DM) healthcare on screening coverage and treatment loss to follow-up as compared to non-integrated care services for TB and DM in low- to middle-income countries (LMICs). Searches were performed in PubMed, Web of Science, WHO Global Index Medicus, and Cochrane Central Library. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and we adopted Cochrane data collection form for Randomized Controlled Trials (RCTs) and non-RCTs. Due to heterogeneity and limited data of studies included, meta-analysis was not performed. Of 6902 abstracts, 10 studies from South America, Asia, and Africa were included. One study from Zimbabwe showed 57% increase in DM screening among TB patients in integrated care as compared to non-integrated care; 95% CI: 54.1, 59.8. Seven studies with before-after comparison groups reported increased screening coverage during implementation of integrated healthcare that ranged from 10.1% in Mexico to 99.1% in China. Three studies reported reduction in loss to follow-up among TB patients in integrated care; two in China showed 9.2%, 95% CI: -16.7, -1.7, and -9.5%, 95% CI: -18.4, -0.7 differences, while a study from Mexico showed -5.3% reduction, 95% CI: -9.8, -0.9.With few and heterogenous included studies, the synthesized evidence is weak to establish effect of TB/DM integrated care. Therefore, further robust studies such as randomized clinical trials and well-designed observational studies are needed.

Potential and challenges for an integrated management of tuberculosis, diabetes mellitus, and hypertension: A scoping review protocol

In many low- and middle-income countries (LMICs), the epidemiological transition is characterized by an increased burden of non-communicable diseases (NCDs) and the persistent challenge of infectious diseases. The transmission of tuberculosis, one of the leading infectious diseases, can be halted through active screening of risk groups and early case findings. Studies have reported comorbidities between tuberculosis (TB) and NCDs, which necessitates the development of an integrated disease management model. This scoping review discusses the possibilities and problems of integration in managing TB and NCDs, with a particular emphasis on diabetic mellitus (DM) and hypertension screening and control. We will conduct this review following Arksey and O'Malley's framework for scoping review. We will use key terms related to integrated management, i.e., screening, diagnosis, treatment, and care, of TB, DM, and hypertension in PubMed, Scopus Database, and ScienceDirect for research published from January 2005 to July 2021. This review will also consider grey literature, including unpublished literature and international disease management guidelines on TB, DM, and hypertension from WHO or other health professional organization. We will export the search results to citation manager software (EndNote). We will remove duplicates and apply the inclusion and exclusion criteria to identify the set of papers for the review. After screening the titles and abstract, two authors will independently review the full text of selected studies and extract the data. We will synthesize all selected studies qualitatively and the results will be discussed with the experts. The results will be used as the basis of the development of a guideline for integrated TB, DM, and hypertension management.

Integrated Management of Type 2 Diabetes and Gestational Diabetes in the Context of Multi-Morbidity in Africa: A Systematic Review

Introduction

Many adults diagnosed with gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) also have other known or unknown comorbid conditions. The rising prevalence of GDM and T2DM within a broader context of multimorbidity can best be addressed through an integrated management response, instead of stand-alone programs targeting specific infectious and/or chronic diseases.

Aim

To describe GDM and T2DM screening, care and cost-effectiveness outcomes in the context of multimorbidity through integrated interventions in Africa.

Methods

A systematic review of all published studies was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk Of Bias in Non-randomised Studies of Interventions (ROBINS-I) was used to assess risk of bias. Data synthesis was conducted using narrative synthesis of included studies.

Results

A total of 9 out of 13 included studies reported integrated diabetes mellitus (DM) screening, 7 included integrated care and 9 studies addressed cases of newly detected DM who were asymptomatic in pre-diabetes stage. Only 1 study clearly analysed cost-effectiveness in home-based care; another 5 did not evaluate cost-effectiveness but discussed potential cost benefits of an integrated approach to DM screening and care. Compared to partial integration, only 2 fully integrated interventions yielded tangible results regarding DM screening, care and early detection of cases despite many that reported barriers to its sustainability.

Conclusion

Though few, integrated interventions for screening and/or care of DM in the context of multimorbidity within available resources in health systems throughout Africa exist and suggest that this approach is possible and could improve health outcomes.

Association between Mycobacterium tuberculosis genotype and diabetes mellitus/hypertension: a molecular study

Background

A paucity of studies focused on the genetic association that tuberculosis (TB) patients with non-communicable diseases (NCDs) are more likely to be infected with Mycobacterium tuberculosis (MTB) with more potent virulence on anti-TB drug resistance than those without NCDs. The study aimed to document the predominant genotype, determine the association between MTB genotypes and NCD status and drug resistance.

Methods

We conducted a molecular study in 105 TB patients based on a cross-sectional study focused on the comorbid relationship between chronic conditions and TB among 1773 subjects from September 1, 2019 to August 30, 2020 in Guizhou, China. The participants were investigated through face-to-face interviews, followed by NCDs screening. The DNA of MTB isolates was extracted prior to genotyping using 24 loci MIRU-VNTR. The subsequent evaluations were performed by phylogenetic trees, combined with tests of statistical power, Chi-square or Fisher and multivariate logistic regression analysis.

Results

The Beijing family of Lineage 2 (East Asia) was the predominant genotype accounting for 43.8% (46/105), followed by Lineage 4 (Euro-America) strains, including Uganda I (34.3%, 36/105), and the NEW-1 (9.5%, 10/105). The proportion of Beijing strain in patients with and without NCDS was 28.6% (8/28) and 49.4% (38/77), respectively, with a statistical power test value of 24.3%. No significant association was detected between MTB genotype and NCD status. A low clustering rate (2.9%) was identified, consisting of two clusters. The rates of global, mono-, poly- and multi-drug resistance were 16.2% (17/105), 14.3% (15/105), 1.0% (1/105) and 4.8% (5/105), respectively. The drug-resistant rates of rifampicin, isoniazid, and streptomycin, were 6.7% (7/105), 11.4% (12/105) and 5.7% (6/105), respectively. Isoniazid resistance was significantly associated with the Beijing genotype of Lineage 2 (19.6% versus 5.1%).

Conclusions

The Lineage 2 East Asia/Beijing genotype is the dominant genotype of the local MTB with endogenous infection preponderating. Not enough evidence is detected to support the association between the MTB genotype and diabetes/hypertension. Isoniazid resistance is associated with the Lineage 2 East Asia/Beijing strain.

Supplementary information

The online version contains supplementary material available at 10.1186/s12879-022-07344-z.

Improving TB Surveillance and Patients' Quality of Care Through Improved Data Collection in Angola: Development of an Electronic Medical Record System in Two Health Facilities of Luanda

TB Programs should promote the use of digital health platforms, like Electronic Medical Records (EMR) to collect patients' information, thus reducing data incompleteness and low accuracy and eventually improving patients' care. Nevertheless, the potential of digital health systems remains largely unexploited in low-resource settings. Angola is one of the 14 countries with a triple burden of TB, TB/HIV and MDR-TB (multidrug-resistant TB) and it is among the three countries, together with Congo and Liberia that have never completed a drug-resistance survey so far. The Sanatorium Hospital of Luanda and the Tuberculosis Dispensary of Luanda are the two reference health facilities in Luanda dealing with most of the TB cases, and they both rely entirely on paper-based data collection. The aim of this paper is to describe a three-stage process for the development of a TB EMR system in these two health facilities of Luanda and to share the lessons learned. The description is focused on the activities that took place from March 2019 to January 2020. Main lessons learned were identified in the importance of engaging all the stakeholders in the development process, in the mainstream of the “think digital” transition, in the promotion of a monitoring and evaluation (M&E) culture and in the planning of the system's sustainability. This approach may be replicated in similar contexts where the development of a TB EMR system is sought, and the lessons learned could assist and facilitate the programming of the interventions.

Non-communicable disease co-morbidity and associated factors in tuberculosis patients: A cross-sectional study in Gabon

BACKGROUND

There are only limited data from resource-limited settings available on the prevalence of non-communicable diseases and associated risk factors of tuberculosis patients. This study investigated non-communicable disease co-morbidity in tuberculosis patients from Moyen Ogooué Province, Gabon.

METHODS

All patients aged 18 years or older consulting for tuberculosis (TB) symptoms in Gabon's Moyen Ogooué province and neighbouring provinces from November 2018 to November 2020 were screened for diabetes mellitus, hypertension, and risk factors thereof (obesity, dyslipidaemia, smoking and alcohol consumption). Logistic regression was performed to identify factors associated with TB-diabetes and TB-hypertension co-morbidities.

FINDINGS

Of 583 patients included, 227 (39%) were diagnosed with tuberculosis. In tuberculosis-confirmed patients, the prevalences of hypertension and diabetes were 16·3% and 12·8%, respectively. The prevalence of diabetes was twice as high in tuberculosis patients compared to non-tuberculosis patients. Factors independently associated with hypertension-tuberculosis co-morbidity were age >55 years (aOR=8·5, 95% CI 2·43, 32·6), age 45-54 years (aOR=4.9, 95%CI 1.3-19.8), and moderate alcohol consumption (aOR=2·4; 95% CI 1·02- 5·9), respectively. For diabetes-tuberculosis co-morbidity, age >55 years was positively (aOR=9·13; 95% CI 2·4-39·15), and moderate alcohol consumption inversely associated (aOR=0·26, 95% CI 0·08- 0·73). One-hundred-and-four (46%) of the tuberculosis patients had at least either dyslipidaemia, hypertension, diabetes, or obesity with a majority of newly-diagnosed hypertension and diabetes.

INTERPRETATION

Integration of screening of non-communicable diseases and their risk factors during TB assessment for early diagnosis, treatment initiation and chronic care management for better health outcomes should be implemented in all tuberculosis healthcare facilities.

FUNDING

This study was supported by WHO AFRO/TDR/EDCTP (2019/893,805) and Deutsches Zentrum für Infektiologie (DZIF/ TTU 02.812).

Gradient association between pulmonary tuberculosis and diabetes mellitus among households with a tuberculosis case: a contact tracing-based study

Pulmonary tuberculosis (PTB) and diabetes mellitus (DM) remain high morbidity and mortality, especially when they are comorbid with each other. Screening for diabetes mellitus in tuberculosis is essential as the incidence and mortality of DM in the population with PTB are higher than in the general people. We aimed to examine the gradient association of tuberculosis on developing DM, the additional yield and the number needed to screen (NNS) to find a new diabetes case. A cross-sectional study was conducted on 801 tuberculosis cases and 972 household contacts in Guizhou, China, from April 2019 to October 2020. After screening for PTB among contacts, all participants were screened for DM and interviewed. Kendall's tau-b test and proportional odds logistic regression analysis were applied to identify the gradient associations. Among the 1773 subjects, the additional yield of screening was 21.8%. The NNSs of the non-PTB group, the sputum-culture negative and positive groups were 50, 60 and 113, respectively. The gradient incremental establishment of DM and PTB were positively correlated. The general trend on the gradient of DM significantly increased with the gradient increase of PTB. Age 35 years and over, excessive edible oil intake and DM family history were identified as significant predictors of diabetes. Integrated screening for DM targeted to different gradients of PTB combined with associated factors is necessitated to achieve a higher additional yield.

Yield, NNS and prevalence of screening for DM and hypertension among pulmonary tuberculosis index cases and contacts through single time screening: A contact tracing-based study

INTRODUCTION

Diabetes mellitus (DM), hypertension and pulmonary tuberculosis (PTB) are catastrophic illnesses that collectively lead to increased mortality and premature death. However, the size of the problem and the appropriate approach to deal with the burden is still unclear. We aimed to evaluate the yield, number needed to screen (NNS) to prevent one death or adverse event for screening DM and hypertension and assess the prevalence and contributors to DM and/or hypertension.

METHODS

Based on PTB contact tracing, a cross-sectional study was conducted among 801 PTB index cases and 972 household contacts from April 2019 to October 2020 in Guizhou, China. All the participants were screened for DM and hypertension. The yield was calculated as the proportion of newly detected cases among the study subjects, excluding known cases. The NNS was computed by dividing the number needed to treat for risk factors by the prevalence of the unrecognized diseases. The univariate and multivariate logistic regression analyses were applied to determine the independent predictors of DM and/or hypertension.

RESULTS

Of the 1,773 participants, the prevalence of DM and hypertension was 8.7% (70/801) and 15.2% (122/801) in the PTB patients, 3.2% (31/972) and 14.0% (136/972) in the contacts, respectively. The prevalence of DM and/or hypertension was 21.2% (170/801) among the PTB patients and 15.4% (150/972) among their contacts. The screening yields to detect new cases of DM and hypertension among PTB patients were 1.9% and 5.2%, and that in the contacts were 0.8% and 4.8%, respectively. The NNS for DM was 359 for the PTB cases and 977 for the contacts, 299 for PTB cases and 325 for hypertension, respectively. Older age, under or overweight and obesity, family history hypertension and earlier diagnosis of other chronic conditions were the independent predictors for DM and/or hypertension among both PTB cases and their contacts.

CONCLUSION

Screening for DM and hypertension should be mandated in PTB patients and their household contacts to disclose undetected cases of these two conditions during TB contact tracing, which might reduce the potential cardiovascular disease deaths.

Association between diabetes and food insecurity in an urban setting in Angola: a case–control study

Diabetes is common in urban settings in Sub-Saharan Africa. Household food insecurity has been suggested to increase the chance of developing diabetes among adults. The relationship between diabetes and food insecurity has not been explored in Angolan urban settings so far. This case–control (1:2) study investigated the association between diabetes and food insecurity among adults attending six healthcare facilities in Luanda (Angola) between April 2019 and September 2019. All subjects with fasting blood glucose (FBG) levels ≥ 126 mg/dl were included as cases. For each case, the next two subjects with FBG levels < 110 mg/dl were included as controls, to warrant the achievement of the set 1:2 ratio. Food insecurity was assessed using the Food Insecurity Experience Scale (FIES). A total of 663 participants (221 cases and 442 controls) were enrolled in the study. Median FIES raw score was 7 (IQR 1–8) in cases and 5 (IQR 2–8) in controls (p = 0.09). The distribution of FIES levels (0–3; 4–6; 7–8) was different between cases and controls (p < 0.0001), with highest FIES scores (7–8) recorded in 53.0% of cases and 38.2% of controls. Our findings revealed an association between diabetes and severe food insecurity among adults attending healthcare facilities in the capital city of Angola.

Challenges and Innovations Brought about by the COVID-19 Pandemic Regarding Medical and Pharmacy Education Especially in Africa and Implications for the Future

BACKGROUND

Multiple measures introduced early to restrict COVID-19 have dramatically impacted the teaching of medical and pharmacy students, exacerbated by the lack of infrastructure and experience with e-learning at the start of the pandemic. In addition, the costs and reliability of the Internet across Africa pose challenges alongside undertaking clinical teaching and practical programmes. Consequently, there is a need to understand the many challenges and how these were addressed, given increasingly complex patients, to provide future direction.

METHOD

An exploratory study was conducted among senior-level medical and pharmacy educators across Africa, addressing four key questions, including the challenges resulting from the pandemic and how these were dealt with.

RESULTS

Staff and student members faced multiple challenges initially, including adapting to online learning. In addition, concerns with the lack of equipment (especially among disadvantaged students), the costs of Internet bundles, and how to conduct practicals and clinical teaching. Multiple activities were undertaken to address these challenges. These included training sessions, developing innovative approaches to teaching, and seeking ways to reduce Internet costs. Robust approaches to practicals, clinical teaching, and assessments have been developed.

CONCLUSIONS

Appreciable difficulties to teaching arising from the pandemic are being addressed across Africa. Research is ongoing to improve education and assessments.

Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future

Background

There has been an appreciable increase in the number of people in Africa with metabolic syndrome and Type 2 diabetes (T2DM) in recent years as a result of a number of factors. Factors include lifestyle changes, urbanisation, and the growing consumption of processed foods coupled with increasing levels of obesity. Currently there are 19 million adults in Africa with diabetes, mainly T2DM (95%), estimated to grow to 47 million people by 2045 unless controlled. This has a considerable impact on morbidity, mortality and costs in the region. There are a number of issues to address to reduce the impact of T2DM including improving detection rates and current access to services alongside addressing issues of adherence to prescribed medicines. There are also high rates of co-morbidities with infectious diseases such as HIV and tuberculosis in patients in Africa with T2DM that require attention.

Objective

Document ongoing activities across Africa to improve the care of patients with T2DM especially around issues of identification, access, and adherence to changing lifestyles and prescribed medicines. In addition, discussing potential ways forward to improve the care of patients with T2DM based on ongoing activities and experiences including addressing key issues associated with co-morbidities with infectious diseases.

Our Approach

Contextualise the findings from a wide range of publications including internet based publications of national approaches coupled with input from senior level government, academic and other professionals from across Africa to provide future guidance.

Ongoing Activities

A number of African countries are actively instigating programmes to improve the care of patients with T2DM starting with improved diagnosis. This recognises the growing burden of non-communicable diseases across Africa, which has been neglected in the past. Planned activities include programmes to improve detection rates and address key issues with diet and lifestyle changes, alongside improving monitoring of care and activities to enhance adherence to prescribed medicines. In addition, addressing potential complexities involving diabetes patients with infectious disease co-morbidities. It is too early to fully assess the impact of such activities.

Conclusion

There are a number of ongoing activities across Africa to improve the management of patients with diabetes including co-morbidities. However, more needs to be done considering the high and growing burden of T2DM in Africa. Ongoing research will help further benefit resource allocation and subsequent care.

[Prevalence of comorbidity tuberculosis and diabetes mellitus in Paraguay, 2016 and 2017Prevalência de comorbidade tuberculose-diabetes mellitus no Paraguai, 2016 e 2017]

Objetivo.

Estimar la prevalencia nacional y regional de la comorbilidad tuberculosis (TB) y diabetes mellitus (DM) e identificar los factores asociados con esta comorbilidad en Paraguay.

Métodos.

Estudio transversal en pacientes con TB notificada en 2016 y 2017 y registrados en la base de datos del Programa Nacional de Control de la TB. La prevalencia de DM, definida por autonotificación, se estimó en pacientes con TB. Para conocer los factores asociados con la comorbilidad TB-DM se empleó un modelo multivariante de regresión binomial para ajustar las razones de prevalencia (RP) según los errores estándar por el clúster de región sanitaria.

Resultados.

Entre 2016 y 2017 se notificaron 5 315 casos de TB. La prevalencia de la comorbilidad TB-DM fue 6,3% en 2016, 6,0% en 2017 y 6,2% en ambos años. Fue más alta en Itapúa (9,2%), Alto Paraguay (8,0%), Alto Paraná (7,5%), Central (7,4%) y Asunción (7,2%). La mediana de edad de personas con DM fue más alta que la de las que no tenían DM (55 y 33 años; P < 0,001). Tener una edad mayor de 45 años (RP = 18,3), el sexo femenino, antecedente de hipertensión arterial (HTA) (RP = 2,17), baciloscopía de diagnóstico de tres cruces (RP 1,98), y antecedente de enfermedad pulmonar obstructiva crónica (EPOC) (RP 1,68) estuvieron asociados con mayor comorbilidad. En cambio, se asociaron con menor comorbilidad pertenecer a la población indígena (RP = 0,26), la infección por el virus de la inmunodeficiencia humana (RP = 0,44), historia de adicción a drogas (RP = 0,49), el sexo masculino (RP = 0,64), y la TB extrapulmonar (RP = 0,75).

Conclusiones.

La prevalencia de la comorbilidad de TB y DM en Paraguay, por autonotificación, fue 6,2% en el periodo 2016-2017 y varió entre las regiones sanitarias. La edad, una alta carga bacilar al diagnóstico y la comorbilidad con HTA y EPOC se asociaron a una mayor comorbilidad. Estos hallazgos permitirán priorizar grupos de población para aumentar rendimiento del cribado, diagnóstico, tratamiento y prevención de la comorbilidad TB-DM en Paraguay.