Bi-directional screening for tuberculosis and diabetes: a systematic review

Objective To assess the yield of finding additional TB or diabetes mellitus (DM) cases through systematic screening and to determine the effectiveness of preventive TB therapy in people with DM. Methods We systematically reviewed studies that had screened for active TB or implemented preventive therapy for TB among people with DM, and those that screened for DM among patients with TB. We searched published literature through PubMed and EMBASE and included studies that reported the number of TB cases identified among people with DM; the number of DM cases identified among patients with TB, or the relative incidence of TB between people with DM who received a TB prophylaxis and those who did not. We assessed the yield of screening by estimating the prevalence of TB or DM in each study, the prevalence ratio and difference where comparison populations were available, and the number of persons to screen to detect an additional case of TB or DM. Results Twelve studies on screening for TB in people with DM and 18 studies on screening for DM in patients with TB met our inclusion criteria. Screening for TB in persons with DM demonstrated that TB prevalence in this population is high, ranging from 1.7% to 36%, and increasing with rising TB prevalence in the underlying population as well as with DM severity. Screening patients with TB for DM also yielded high prevalences of DM ranging from 1.9% to 35%. Two studies examining the role of TB preventive therapy in people with DM did not provide sufficient details for clear evidence of the effectiveness. Conclusion Active screening leads to the detection of more TB and DM with varying yield. This review highlights the need for further research in screening and preventive therapy.     

Trends of Zambia's tuberculosis burden over the past two decades

Objectives To study trends in Zambia’s TB notification rates between 1990 and 2010 and to ascertain progress made towards TB control. Methods Retrospective review of TB notification returns and TB programme reports for the period from 1990 to 2010. Results Two distinct TB trend periods were identified: a period of rising trends up to a peak between 1990 and 2004 and a period of moderately declining trends between 2004 and 2010. Treatment outcomes improved over the two decades. Data on trends in paediatric TB, TB in prisoners and TB in pregnant women remain scanty and unreliable owing to poor diagnostic capability. There were no data available on trends on drug‐resistant TB because of the lack of laboratory services to perform drug sensitivity testing. Conclusions The period of increasing TB between 1990 and 2000 coincided with an increase in HIV/AIDS. The period of slightly decreasing TB between 2004 and 2010 can be attributed to improved TB care, sustained DOTS implementation and improvement in TB diagnostic services. Newer diagnostics technologies for the rapid diagnosis of active TB cases and for drug‐resistant testing, recently endorsed by the WHO, need to be implemented into the national TB programmes to detect more cases and to provide epidemiological and surveillance data from which to obtain an evidence base for guided investments for TB control. Alignment of TB and HIV services is required to achieve improved management outcomes.     

Role of risk factors and socio-economic status in pulmonary tuberculosis: a search for the root cause in patients in a tertiary care hospital, South India

Objective To determine the frequency of underlying risk factors and the socio‐economic impact based on occupation in the development of tuberculosis. Method Retrospective analysis of 207 clinically and microbiologically diagnosed patients with pulmonary tuberculosis (PTB) admitted to Kasturba Hospital in 2005 and 2006. Demographic details and underlying risk factors were statistically evaluated. Results Diabetes mellitus (DM) (30.9%) was the most prevalent condition and significantly more common than other risk factors like smoking (16.9%), alcoholism (12.6%), HIV (10.6%), malignancy (5.8%), chronic liver diseases (3.9%), history of contact with TB (3.4%), chronic corticosteroid therapy (2.9%), chronic kidney diseases and malnourishment (1.5%). There were 82 patients (39.6%) with no underlying risk factor. Men (M:F = 3.7:1) and patients older than 40 years had a higher incidence of co‐existing conditions. PTB was significantly more common in blue‐collar (44%) and white‐collar (27.1%) workers than household workers (12.1%), students (10.6%) and retired/unemployed people (6.3%). Conclusion Pulmonary tuberculosis had a significant impact and predominated in male patients co‐existing with DM. Patients with DM and suggestive pulmonary symptoms should be screened for tuberculosis. More stringent health education and awareness programme should be implemented at the grass root level.     

Global Fund financing of public-private mix approaches for delivery of tuberculosis care

Objectives To map the extent and scope of public–private mix (PPM) interventions in tuberculosis (TB) control programmes supported by the Global Fund. Methods We reviewed the Global Fund’s official documents and data to analyse the distribution, characteristics and budgets of PPM approaches within Global Fund supported TB grants in recipient countries between 2003 and 2008. We supplemented this analysis with data on contribution of PPM to TB case notifications in 14 countries reported to World Health Organization in 2009, for the preparation of the global TB control report. Results Fifty‐eight of 93 countries and multi‐country recipients of Global Fund‐supported TB grants had PPM activities in 2008. Engagement with ‘for‐profit’ private sector was more prevalent in South Asia while involvement of prison health services has been common in Eastern Europe and central Asia. In the Middle East and North Africa, involving non‐governmental organizations seemed to be the focus. Average and median spending on PPM within grants was 10% and 5% respectively, ranging from 0.03% to 69% of the total grant budget. In China, India, Nigeria and the Philippines, PPM contributed to detecting more than 25% TB cases while maintaining high treatment success rates. Conclusion In spite of evidence of cost‐effectiveness, PPM constitutes only a modest part of overall TB control activities. Scaling up PPM across countries could contribute to expanding access to TB care, increasing case detection, improving treatment outcomes and help achieve the global TB control targets.     

Disease profile of children under 5 years attending primary health care clinics in a high HIV prevalence setting in South Africa

Objective To describe the presenting complaints and disease profile of children attending primary health care (PHC) clinics in two provinces of South Africa. Methods Participants were sick children 2–59 months old presenting for care at PHC clinics in KwaZulu‐Natal (KZN) and Limpopo provinces from 2006–2007. Children were assessed by an expert Integrated Management of Childhood Illnesses (IMCI) practitioner. Children for whom parental/guardian consent was obtained were tested for HIV. Results A total of 1357 children attending one of 74 clinics were assessed. HIV seroprevalence overall was 7.1%, but was significantly higher in KZN than Limpopo (7.5 vs. 2.4%; OR = 3.3, 95%CI 1.9–5.8%). Commonest presenting complaints were cough (72%), skin conditions (22%) and diarrhoea (19%). Of 1349 children, 120 (8.9%) had a weight below the third percentile; 108/1357 (8.0%) children required urgent referral, most commonly for severe pneumonia (53.7%) and severe malnutrition (16.7%). In multivariate analyses, severe pneumonia, growth faltering and urgent referral were independently associated with younger age, residence in KZN and HIV infection (P < 0.05). Conclusions Many children with severe illnesses and undiagnosed HIV infection present to PHC facilities. PHC staff require skills to correctly manage these conditions and undertake HIV testing. Although IMCI provides evidence‐based guidelines, implementation must be improved to achieve adequate coverage of life‐saving interventions.     

Screening of patients with tuberculosis for diabetes mellitus in China

Objective There is a high burden of both diabetes (DM) and tuberculosis (TB) in China, and this study aimed to assess feasibility and results of screening patients with TB for DM within the routine healthcare setting of six health facilities. Method Agreement on how to screen, monitor and record was reached in May 2011 at a stakeholders’ meeting, and training was carried out for staff in the six facilities in July 2011. Implementation started in September 2011, and we report on 7 months of activities up to 31 March 2012. Results There were 8886 registered patients with TB. They were first asked whether they had DM. If the answer was no, they were screened with a random blood glucose (RBG) followed by fasting blood glucose (FBG) in those with RBG ≥ 6.1 mm (one facility) or with an initial FBG (five facilities). Those with FBG ≥ 7.0 mm were referred to DM clinics for diagnostic confirmation with a second FBG. Altogether, 1090 (12.4%) patients with DM were identified, of whom 863 (9.7%) had a known diagnosis of DM. Of 8023 patients who needed screening for DM, 7947 (99%) were screened. This resulted in a new diagnosis of DM in 227 patients (2.9% of screened patients), and of these, 226 were enrolled to DM care. In addition, 575 (7.8%) persons had impaired fasting glucose (FBG 6.1 to <7.0 mm ). Prevalence of DM was significantly higher in patients in health facilities serving urban populations (14.0%) than rural populations (10.6%) and higher in hospital patients (13.5%) than those attending TB clinics (8.5%). Conclusion This pilot project shows that it is feasible to screen patients with TB for DM in the routine setting, resulting in a high yield of patients with known and newly diagnosed disease. Free blood tests for glucose measurement and integration of TB and DM services may improve the diagnosis and management of dually affected patients.     

Door-to-door screening as a strategy for the detection of congenital Chagas disease in rural Bolivia

Objective To demonstrate the feasibility of a house‐to‐house screening system used for congenital Chagas disease in rural areas based on an active search for pregnant women and newborns in their homes in addition to passive case detection in health facilities. Methods Exploratory phase conducted by the research team followed by an operational period coordinated by municipal health service. A blood sample was taken for serological and parasitological tests of Trypanosoma cruzi from pregnant women who were searching antenatal care or visited at home by field investigators. Infants born to T. cruzi‐infected women were examined for infection at birth and again at 1 and 7 months of age. Results 64.5% of the pregnant women were infected. Congenital infection was diagnosed at birth in 4.0% (12/299) of the children born to seroreactive mothers. Twelve additional cases of infection (4%) were diagnosed in children between 1 and 7 months of age. Finally, 37% of the children were lost to follow‐up in the exploratory phase and 53% during the operational phase (P = 0.002), significantly fewer than in most passive case detection studies. Conclusion Despite poorer outcomes after door‐to‐door screening activities have been transferred to the health system, a combined strategy based on active and passive case detection appeared to be efficient for identifying rural cases of congenital Chagas disease.     

Short Communication: Low seroprevalence of cryptococcal antigenaemia in patients with advanced HIV infection enrolling in an antiretroviral programme in Ghana

Objectives To determine the prevalence of cryptococcal antigenaemia in a clinic population with advanced HIV infection, with a view to giving antifungal therapy to those testing positive. Methods Serum samples from adults with CD4 count <100 cells/mm³ presenting to a large HIV clinic in Kumasi, Ghana, were tested retrospectively for cryptococcal antigenaemia using a latex agglutination assay, and clinical and demographic data extracted from case notes. Results Of 92 samples tested, two were positive thus giving a prevalence of 2% (95% CI, 0–5.2%). Conclusions The prevalence of cryptococcal antigenaemia in patients with advanced HIV infection enrolling in an antiretroviral programme appears to be low in Kumasi, suggesting that the value of routine testing of outpatients diagnosed with advanced HIV infection may be limited in this population.     

The role of diabetes on the clinical manifestations of pulmonary tuberculosis

Objective Diabetes is associated with pulmonary tuberculosis (TB), possibly due to impaired immunity, and diabetes may exacerbate the clinical manifestations of TB. Our aim was to assess the role of diabetes in the clinical manifestations of TB. Methods We studied 1250 patients with pulmonary TB in an urban population in a cross‐sectional study in Tanzania. All participants were tested for diabetes and HIV co‐infection, and TB culture intensity was assessed. Levels of white blood cells, haemoglobin, acute phase reactants, CD4 count and HIV viral load were measured, and a qualitative morbidity questionnaire was used to identify the prevalence of disease‐related symptoms. Results Tuberculosis patients with diabetes had a higher neutrophil count (B 0.5 × 10⁹ cells/l, 95% CI 0.2; 0.9, P = 0.001) than non‐diabetic TB patients. Serum C‐reactive protein (B 18.8 mg/l, CI 95% 8.2; 29.4, P = 0.001) and alpha‐1‐acid glycoprotein (B 0.2 g/l, CI 95% 0.03; 0.3, P = 0.02) were similarly higher in patients with diabetes. Diabetes did not affect culture intensity or HIV status, but self‐reported fever was three times higher among participants with diabetes than in those without diabetes (OR 2.9, CI 95% 1.5; 5.7, P = 0.002). Conclusion Diabetes is associated with small changes in the manifestations of TB, but may have little clinical significance.     

Prevalence of macrovascular complications and cardiovascular risk factors in people treated for diabetes and living in France: the ENTRED study 2001

AIM: The aim of this study is to estimate the prevalence of macrovascular complications and cardiovascular risk factors among people with diabetes living in France and to compare these prevalences with other national estimates. METHODS: We randomly sampled 10,000 people who received one or more reimbursements for insulin or oral hypoglycaemic treatment from the major national medical insurance system during the period October-December 2001; 3646 of the 10,000 people completed a questionnaire; for a subgroup of 1718 people, their care providers completed a medical questionnaire. RESULTS: The prevalence of diagnosed macrovascular complications was of 17% according to patients (angina or myocardial infarction, 15%; coronary revascularization, 9%) and of 20% overall, according to physicians (angina or myocardial infarction, 16%; coronary revascularization, 6%; stroke, 5%). Macrovascular complications were more frequent in people with type 2 than type 1 diabetes, reflecting an age effect. The prevalences of cardiovascular risk factors in type 1 and type 2 diabetes were: current smoking, 35 and 14%; overweight, 28 and 42%; obesity, 9 and 36%; blood pressure superior to 130/80 mmHg, 29 and 59%; LDL cholesterol superior or equal to 3.4 mmol/l, 18 and 26%, respectively. CONCLUSIONS: Compared with other European countries, elevated blood pressure is more frequent in people with diabetes living in France; compared with US estimates, the prevalence of macrovascular complications is lower, glucose control better and blood pressure control poorer in France. These data, observed in a country with widespread access to care and at low cost to the patient, nevertheless demonstrate an urgent need for improving the cardiovascular risk profile of people with type 1 and type 2 diabetes, both with and without macrovascular complications.