Population-based mass TB screening intervention among persons with DM

·  Technology for TB Control: While the technology to control TB exists, it is generally underused.

·  DOTS (Directly Observed Treatment, Short-course):

• Originally referred to directly observed treatment with short-course chemotherapy.
• Now a broader public health strategy with five key elements:
1. Political commitment.
2. Case detection through sputum smear microscopy, mostly among self-referring, symptomatic patients.
3. Standard short-course chemotherapy with supportive patient management, including DOT.
4. Reliable drug supply system.
5. Standardized recording and reporting system, including treatment outcome evaluations.

·  MDG Framework for TB Control:

• Comprises two DOTS-focused measures:
• Case detection.
• Treatment success.
• Includes three impact measures applicable to TB control in general:
• Incidence.
• Prevalence.
• Deaths.
• Promotes epidemiological evaluation beyond DOTS and a comprehensive TB control approach.

·  Comprehensive Approach Beyond DOTS:

• Prevention methods and improved patient care.
• Engaging public and private clinicians, especially for patients with HIV or drug-resistant TB.
• Integration of new technologies and optimization of existing tools.

·  Estimating TB Incidence Rates:

• Rarely measured directly; often estimated from:
• Population-based surveys on M. tuberculosis infection or TB disease prevalence.
• Independent, qualitative assessments of surveillance systems.
• Accuracy limitations due to challenges in calculating incidence from prevalence.

·  Regional TB Management Challenges:

• Africa and Eastern Europe face TB control challenges linked to HIV/AIDS and drug resistance.
• Region-specific solutions are needed for these unique problems.

·  DOTS Limitations and Expansion:

• By 2003, DOTS had nearly maxed out the utility of public notification systems.
• Next steps involve:
• Adapting DOTS for non-public healthcare facilities (e.g., in Indonesia).
• Encouraging all medical practitioners to adopt the basic DOTS care package.
• Expanding health services to areas lacking professional healthcare.

·  Factors Influencing TB Incidence and Death Rates:

• Not solely determined by drug treatment; other factors include:
• Nutritional status, tobacco and alcohol use.
• Other infections and genetic susceptibility.
• These determinants warrant further study to fully understand TB dynamics.

·  TB Death Statistics:

• Ideally sourced from reliable vital registration systems.
• Many poorer countries lack systematic or accurate cause-of-death records.

Dye, C., Watt, C.J., Bleed, D.M., Hosseini, S.M. and Raviglione, M.C., 2005. Evolution of tuberculosis control and prospects for reducing tuberculosis incidence, prevalence, and deaths globally. Jama, 293(22), pp.2767-2775. 

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Liu, Q., You, N., Wen, J., Wang, J., Ge, Y., Shen, Y., Ding, X., Lu, P., Chen, C., Zhu, B. and Zhu, L., 2023. Yield and efficiency of a population-based mass tuberculosis screening intervention among persons with diabetes in Jiangsu Province, China. Clinical Infectious Diseases, 77(1), pp.103-111. 

Feasibility and Focus: Mass tuberculosis (TB) screening among persons with diabetes (PWD) is feasible but may not be cost-efficient due to low detection rates.

Cost Efficiency: The high costs were largely driven by diabetes management rather than TB-related expenses.

Targeted Screening: Concentrating screening efforts in populations with at least 100 TB cases per 100,000 persons is effective and should be continued.

Risk-Stratified Approaches: Risk-stratified screening could be more practical in settings with low to medium TB burden.

Symptom Screening Limitations: Relying solely on symptom screening is insufficient for TB detection, highlighting the need for more comprehensive methods.

Program Integration: Successful implementation required collaboration between diabetes and TB control programs, leveraging existing community-based diabetes screening efforts.

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Alisjahbana, B., Sahiratmadja, E., Nelwan, E.J., Purwa, A.M., Ahmad, Y., Ottenhoff, T.H., Nelwan, R.H., Parwati, I., Meer, J.W.V.D. and Crevel, R.V., 2007. The effect of type 2 diabetes mellitus on the presentation and treatment response of pulmonary tuberculosis. Clinical infectious diseases, 45(4), pp.428-435.

Historical Context and Re-Emergence: Diabetes mellitus (DM) was historically known as a risk factor for tuberculosis (TB) but gained less attention in the latter half of the 20th century with advancements in treatment. However, with the recent global increase in type 2 DM, the association between DM and TB has resurfaced, impacting 10%–30% of TB patients.

Epidemiological Data from Indonesia: Indonesia is ranked third worldwide for TB incidence and fourth for DM prevalence. Recent studies have highlighted the significant linkage between DM and TB within this demographic.

Impact of Insulin on TB Outcomes: Before the introduction of insulin in 1922, DM patients frequently succumbed to pulmonary TB. Although TB continues to pose a threat, the prognosis for DM patients has markedly improved with the advent of effective TB treatments.

Clinical Observations in Indonesia: A notable proportion of TB patients in Indonesia are diagnosed with type 2 DM. These patients present with more symptoms but without increased severity on TB diagnostic tests, suggesting a complex interaction rather than direct exacerbation by DM.

Treatment Dynamics and Outcomes: Diabetic patients with TB tend to adhere better to treatment protocols and show lower drug resistance rates. However, DM complicates the treatment outcome, evidenced by higher positive sputum culture rates after six months, even when accounting for other variables.

Recommendations for Dual Screening: Given the intertwined complications and symptoms of both diseases, it is recommended to screen all TB patients for DM, especially those over 35, to optimize management and improve treatment outcomes.