Risk Factors and Effective Strategies for TB with Comorbidities

• General Understanding and Mortality in Low-Burden Settings:

  • TB burden does not always correlate with TB mortality, as observed in a study from Brunei with an 8.9% TB mortality rate, where risk factors included age, renal disease, cancer, and, contrary to expectations, female gender. Many deaths were due to non-TB comorbidities, emphasizing the importance of holistic patient assessments in TB treatment.

• Risk Factors and Disease Progression:

  • Major risk factors for TB include undernutrition, HIV infection, alcohol abuse, smoking, and diabetes mellitus (DM). TB risk significantly increases in people living with HIV (PLWH), correlating with immunodeficiency levels. Despite antiretroviral therapy (ART), HIV-related TB risk remains elevated.

  • Clinical presentations in PLWH vary by immune status, with low CD4 T-cell counts linked to classic pulmonary TB, while very low counts are often associated with extrapulmonary TB, including cases with pleuritis, meningitis, or lymphadenitis.

• Diabetes Mellitus and TB Interplay:

  • DM increases the risk of TB and is associated with a higher prevalence of drug-resistant TB, older age, and severe pulmonary manifestations in TB patients. Blood glucose control during TB treatment is critical, as glucose intolerance may appear in TB patients and impact treatment outcomes. Routine blood glucose testing, including HbA1c, helps manage comorbid TB-DM.

• Diagnostic and Treatment Strategies:

  • GeneXpert and other molecular tests are recommended for TB diagnosis in PLWH and challenging TB cases, aiding in prompt treatment initiation. Full GeneXpert scale-up could reduce diagnosis times, patient visits, and mortality.

  • TB treatment protocols are generally similar for both TB-HIV and TB-DM, though PLWH face higher treatment failure and drug toxicity risks. ART should begin within two weeks of TB treatment for PLWH, but with certain TB complications, ART initiation is delayed.

• TB Challenges in Papua New Guinea (PNG):

  • PNG faces a high TB and multidrug-resistant TB (MDR-TB) burden, exacerbated by young population demographics and high loss to follow-up due to socioeconomic and geographic barriers. Young patients often remain untreated, raising community transmission risks.

  • Decentralized TB services, enhanced diagnostics at primary care levels, and treatment support could improve TB outcomes, addressing high treatment dropout rates and accessibility issues in remote areas.

References:

1. Chaw L, Jeludin NH, Thu K. Prevalence and risk factors associated with tuberculosis mortality in Brunei Darussalam. Asian Pac J Trop Med 2023; 16(1): 9-15.

2. Goletti, D., Pisapia, R., Fusco, F.M., Aiello, A. and Van Crevel, R., 2023. Epidemiology, pathogenesis, clinical presentation and management of TB in patients with HIV and diabetes. The International Journal of Tuberculosis and Lung Disease, 27(4), pp.284-290.

3. Williams, V., Onwuchekwa, C., Vos, A.G., Grobbee, D.E., Otwombe, K. and Klipstein-Grobusch, K., 2022. Tuberculosis treatment and resulting abnormal blood glucose: a scoping review of studies from 1981-2021. Global Health Action, 15(1), p.2114146.

4. Langley, I., Lin, H.H., Egwaga, S., Doulla, B., Ku, C.C., Murray, M., Cohen, T. and Squire, S.B., 2014. Assessment of the patient, health system, and population effects of Xpert MTB/RIF and alternative diagnostics for tuberculosis in Tanzania: an integrated modelling approach. The Lancet Global Health, 2(10), pp.e581-e591.

5. Charles, F., Lin, Y.D., Greig, J., Gurra, S., Morikawa, R., Graham, S.M. and Maha, A., 2024. Loss to follow-up among adults with drug-resistant TB in Papua New Guinea. Public Health Action, 14(3), pp.85-90.

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