NCD Screening in TB Contact Tracing

Diabetes and TB Incidence

• Korea's National Health Insurance Data Analysis: Diabetic individuals exhibit a 48% increased risk of tuberculosis (TB).Risk escalates with diabetes duration; over 5 years of diabetes corresponds to a 57% heightened TB risk. Stronger diabetes-TB links observed in men and younger adults. Newly diagnosed diabetics with high fasting plasma glucose (FPG) levels face a 79% greater TB risk. See also: Lin TB Lab

TB Treatment Outcomes

• Study from Taiwan NHIRD (2002-2013): Post-TB treatment phases see elevated risks of diabetes, acute myocardial infarction (AMI), and stroke, especially with treatment durations of 7-12 months. Risks are influenced by age, gender, and pre-existing non-communicable diseases (NCDs).Emphasizes the need for vigilant monitoring for NCDs following TB treatment.

Latent TB in Type 1 Diabetes Patients

• Cross-Sectional Study in Dar es Salaam: 14.9% prevalence of latent TB among type 1 diabetes mellitus (T1DM) patients, with variations across developmental stages. Significant correlation found between uncontrolled HbA1c levels and higher latent TB prevalence.

Observational Challenges and Mendelian Randomization Insights

• Challenges in Diabetes and PTB Relationship Studies: Issues include reverse causality, confounding factors, and type differentiation (T1DM vs. T2DM).Poor glycemic control linked to increased TB risk; metabolic disturbances in T1DM enhance susceptibility to PTB.
• Mendelian Randomization Findings: Genetic studies suggest a link between T1DM and PTB, with correlations to higher HDL-C levels but no direct causal relationships with other T1DM-related traits.

TB and Non-Communicable Diseases in Myanmar

• Yangon, Myanmar Cross-Sectional Study: TB patients often exhibit behavioral risk factors like smoking and drinking more frequently than general population. Nutritional disparities show TB patients more likely to be underweight; significantly lower incidence of overweight/obesity. Higher diabetes prevalence among TB patients, with implications for integrated screening of NCDs during TB contact tracing.

Integration of NCD Screening in TB Contact Tracing

• Efficiency and Cost-Effectiveness: Incorporating NCD screening during TB contact investigations can identify undiagnosed conditions, improving early intervention and management. Highlights the necessity for community-wide screening initiatives, particularly for diabetes, to address the dual burden of TB and NCDs.

References:

1. Yoo JE, Kim D, Han K, Rhee SY, Shin DW, Lee H. Diabetes status and association with risk of tuberculosis among Korean adults. JAMA network open. 2021 Sep 1;4(9):e2126099.
2. Salindri, A.D., Wang, J.Y., Lin, H.H. and Magee, M.J., 2019. Post-tuberculosis incidence of diabetes, myocardial infarction, and stroke: retrospective cohort analysis of patients formerly treated for tuberculosis in Taiwan, 2002–2013. International Journal of Infectious Diseases, 84, pp.127-130.
3. Majaliwa, E.S., Muze, K., Godfrey, E., Byashalira, K., Mmbaga, B.T., Ramaiya, K. and Mfinanga, S.G., 2023. Latent tuberculosis in children and youth with type 1 diabetes mellitus in Dar es Salaam, Tanzania: a cross section survey. BMC Infectious Diseases, 23(1), p.740.
4. Jiang, Y., Zhang, W., Wei, M., Yin, D., Tang, Y., Jia, W., Wang, C., Guo, J., Li, A. and Gong, Y., 2024. Associations between type 1 diabetes and pulmonary tuberculosis: a bidirectional mendelian randomization study. Diabetology & Metabolic Syndrome, 16(1), pp.1-9.
5. Zayar, N.N., Chotipanvithayakul, R., Bjertness, E., Htet, A.S., Geater, A.F. and Chongsuvivatwong, V., 2023. Vulnerability of NCDs and Mediating Effect of Risk Behaviors Among Tuberculosis Patients and Their Household Contacts Compared to the General Population in the Yangon Region, Myanmar. International Journal of General Medicine, pp.5909-5920.
6. Hamada, Y., Lugendo, A., Ntshiqa, T., Kubeka, G., Lalashowi, J.M., Mwastaula, S., Ntshamane, K., Sabi, I., Wilson, S., Copas, A. and Velen, K., 2024. A pilot cross-sectional study of non-communicable diseases in TB household contacts. IJTLD OPEN, 1(4), pp.154-159.

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Integrated health policies

· Diabetes and Tuberculosis (TB) Risk:

• Individuals with diabetes are 2-3 times more likely to contract TB than those without diabetes.
• TB in diabetics tends to present more severely, with higher TB scores, extensive lung cavitation, and prolonged periods to achieve negative smear or culture results.
• Poorly controlled diabetes can double the mortality risk during TB treatment and increase the bacterial load of Mycobacterium tuberculosis, potentially prolonging infectiousness.
• Screening for TB in diabetic patients may not be very effective outside of high-incidence areas.

· Management Challenges in Diabetes and TB:

• Drug interactions, particularly with rifampicin, complicate the management of diabetes in TB patients, necessitating dosage adjustments or alternative medications.
• Metformin is preferred for its safety profile and minimal interaction with rifampicin but carries risks like gastrointestinal side effects and lactic acidosis in those with impaired kidney function.
• Diabetic patients with active TB should avoid specialized diabetes services in early TB treatment to prevent the spread of TB, emphasizing the need for integrated care approaches.

· Global Health Policies and Diabetes Impact on TB:

• Stabilizing diabetes prevalence at 2015 levels in 13 high TB burden countries could significantly reduce TB incidence by 20.3% and mortality by 42.7% by 2035, potentially preventing 1.1 million TB deaths over 20 years.
• Integrated health policies are crucial, involving bidirectional screening for diabetes and TB at primary healthcare centers and adapting the DOTS framework for managing non-communicable diseases in resource-limited settings.

· Chronic Kidney Disease (CKD) and TB:

• Global increases in CKD prevalence have strengthened the link between CKD and TB infection.
• A study from 2008 to 2013 showed a higher incidence of TB in males with comorbidities such as heart failure, stroke, and diabetes, particularly from CKD stage 3 onwards.
• The risk of TB escalates with the progression of CKD, suggesting intensified TB prevention strategies for CKD patients from stage 3.

· RePORT-Brazil Study on TB and Diabetes:

• The "RePORT-Brazil" study involved individuals with culture-confirmed pulmonary tuberculosis and their close contacts.
• 62% of TB patients exhibited dysglycemia (prediabetes or diabetes), with diabetes significantly linked to a higher risk of transmitting M. tuberculosis to close contacts, underlining the complex relationship between metabolic disorders and TB management and transmission

References:

1. Amelia, G. and Suryanto, J., 2024. Sensitivity Analysis of Diabetes Mellitus and Tuberculosis for Confounders: A Comprehensive Systematic Review. The Indonesian Journal of General Medicine, 1(1), pp.28-45.
2. van Crevel, R.; Critchley, J.A. The Interaction of Diabetes and Tuberculosis: Translating Research to Policy and Practice. Trop. Med. Infect. Dis. 2021, 6, 8.
3. Shu, CC., Wei, YF., Yeh, YC. et al. The impact on incident tuberculosis by kidney function impairment status: analysis of severity relationship. Respir Res 21, 51 (2020).
4. Mangamba, L.M.E., Halle, M.P., Onana, C.L.M., Tochie, J.N., Ngamby, V., Noubibou, J.C.E., Balkissou, A.D., Tewaffeu, D.G., & Ngahane, B.H.M. (2023). Impact of Chronic Kidney Disease on the Mortality of Tuberculosis Patients: A Cross-Sectional Study in Douala. Health Sciences and Disease, 24(2).
5. Xiao, J., Ge, J., Zhang, D., Lin, X., Wang, X., Peng, L. and Chen, L., 2022. Clinical characteristics and outcomes in chronic kidney disease patients with tuberculosis in China: A retrospective cohort study. International Journal of General Medicine, 15, p.6661.
6. Carr, B.Z., Briganti, E.M., Musemburi, J., Jenkin, G.A. and Denholm, J.T., 2022. Effect of chronic kidney disease on all-cause mortality in tuberculosis disease: an Australian cohort study. BMC Infectious Diseases, 22(1), p.116.
7. Pan, S.C., Ku, C.C., Kao, D., Ezzati, M., Fang, C.T. and Lin, H.H., 2015. Effect of diabetes on tuberculosis control in 13 countries with high tuberculosis: a modelling study. The lancet Diabetes & endocrinology, 3(5), pp.323-330. See also: Lin TB Lab
8. Arriaga, M.B., Rocha, M.S., Nogueira, B.M., Nascimento, V., Araújo-Pereira, M., Souza, A.B., Andrade, A.M., Costa, A.G., Gomes-Silva, A., Silva, E.C. and Figueiredo, M.C., 2021. The effect of diabetes and prediabetes on Mycobacterium tuberculosis transmission to close contacts. The Journal of Infectious Diseases, 224(12), pp.2064-2072.

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Interaction between DM and TB exacerbates disease progression

Public Health Challenges and Epidemiology: Tuberculosis (TB) presents varying challenges across economic contexts. Rapid diagnosis and treatment are essential in regions with high TB prevalence to manage and prevent the disease, primarily through addressing the reactivation of latent TB infections (LTBI). In areas with lower incidence, TB tends to concentrate within high-risk groups, necessitating strategies tailored to local epidemiological patterns and social determinants. Additionally, understanding the demographic shifts towards older populations and the impact of diabetes mellitus (DM) on TB, including increased risk and poorer outcomes, is crucial.

Impact of Diabetes on Tuberculosis: Diabetes significantly increases the risk of developing active TB and affects treatment outcomes. The interaction between DM and TB exacerbates disease progression, with DM patients experiencing higher mycobacterial loads and unique lung lesions. This underscores the importance of integrated health strategies that simultaneously address both TB and DM, including enhanced screening and research into the transmission dynamics among these patients.

Study Insights and Special Populations:

• A study in metro Atlanta, Georgia (2016-2019) on HIV-negative adults with type 2 diabetes (T2DM) highlighted that LTBI was less prevalent in diabetic patients compared to controls. This suggests unique interplays between T2DM and LTBI, impacting screening and management approaches.
• The WHO emphasizes LTBI screening in populations with compromised immune systems, such as those undergoing dialysis or with chronic kidney disease (CKD), due to elevated TB risk.

Health Outcomes and Quality of Life in TB Survivors: TB survivors face considerable health challenges, including increased risks of TB recurrence and mortality. Chronic conditions such as respiratory diseases and cardiovascular issues are more prevalent among these individuals, leading to diminished quality of life and increased healthcare needs. Social and economic repercussions include stigma and financial hardship, emphasizing the need for comprehensive healthcare strategies that integrate TB care with broader health services to manage ongoing issues and improve life quality.

Epidemiological and Clinical Integration: The convergence of TB and DM epidemics, especially in regions like South-East Asia, the Western Pacific, and the Middle East, driven by rising rates of diabetes due to obesity and aging populations, calls for integrated public health responses. These should consider the compounded effects of both diseases on mortality, treatment failure, and relapse rates.

Advancements in Screening and Treatment: Advancements in technology and healthcare strategies, such as single-cell analysis and predictive modeling, hold promise for enhancing the understanding and management of TB-DM comorbidity. These tools can help in identifying new therapeutic targets and biomarkers, improving the precision of diagnostics and treatments.

Comprehensive Care for TB Survivors: Addressing the long-term health effects faced by TB survivors requires a multifaceted approach that includes lung function evaluations, pulmonary rehabilitation, and cardiovascular care. Economic support and social integration programs are also vital to mitigate the socio-economic impacts of TB on survivors and their families.

References:

1. Lee, P.H., Fu, H., Lee, M.R., Magee, M. and Lin, H.H., 2018. Tuberculosis and diabetes in low and moderate tuberculosis incidence countries. The International Journal of Tuberculosis and Lung Disease, 22(1), pp.7-16.
2. Salindri, A.D., Haw, J.S., Amere, G.A., Alese, J.T., Umpierrez, G.E. and Magee, M.J., 2021. Latent tuberculosis infection among patients with and without type-2 diabetes mellitus: results from a hospital case-control study in Atlanta. BMC Research Notes, 14(1), p.252.
3. Zhang, X., Chen, P. and Xu, G., 2022. Update of the mechanism and characteristics of tuberculosis in chronic kidney disease. Wiener klinische Wochenschrift, 134(13), pp.501-510.
4. Kaur, R., Egli, T., Paynter, J., Murphy, R., Perumal, L., Lee, A., Harrison, A., Christmas, T., Lewis, C. and Nisbet, M., 2023. Tuberculosis and diabetes: increased hospitalisations and mortality associated with renal impairment. Internal Medicine Journal, 53(9), pp.1588-1594.
5. Choi, H., Han, K., Jung, J.H., Park, S.H., Kim, S.H., Kang, H.K., Sohn, J.W., Shin, D.W. and Lee, H., 2023. Long-term mortality of tuberculosis survivors in Korea: a population-based longitudinal study. Clinical Infectious Diseases, 76(3), pp.e973-e981. See also: https://tbreadingnotes.blogspot.com/2024/07/non-communicable-diseases-in-tb.html
6. Dodd, P.J., Yuen, C.M., Jayasooriya, S.M., van der Zalm, M.M. and Seddon, J.A., 2021. Quantifying the global number of tuberculosis survivors: a modelling study. The Lancet Infectious Diseases, 21(7), pp.984-992.

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Nutritional problems in tuberculosis management

A study investigates the role of nutritional rehabilitation in reducing tuberculosis (TB) incidence and mortality in South-East Asia, emphasizing undernutrition as a significant risk factor. It employs a deterministic compartmental model to simulate TB transmission across 10 countries, categorizing individuals by nutritional status to assess intervention outcomes. This model is effective, enabling an in-depth analysis of how nutritional status impacts TB dynamics and intervention efficacy.[1] See also: TB control in China

Independent variables include nutritional status variations, the extent of intervention coverage, and TB service enhancements, while dependent variables measure TB incidence and mortality. Confounders such as COVID-19 disruptions and differences in healthcare infrastructure are considered, with control scenarios involving no nutritional interventions and standard TB services. This setup allows for precise evaluations of how nutritional improvements can influence TB outcomes under different conditions.[1] See also: https://tbreadingnotes.blogspot.com/2024/10/impact-of-diabetes-itself-and-glycemic.html

The results show that nutritional interventions significantly lower TB incidence and mortality, particularly in high-risk populations. For instance, in India, interventions among household contacts are projected to reduce TB incidence and mortality by 5.7% and 6.2%, respectively, by 2030. Broadening these interventions to cover 30% of the general population could lead to a 23.6% reduction in incidence and a 35.5% decrease in mortality. These findings illustrate the critical need to integrate nutritional support into comprehensive TB prevention strategies, especially in regions where undernutrition is a prevalent TB driver.[1] See also: Lin TB Lab

Malnutrition significantly elevates tuberculosis (TB) risk by impairing cell-mediated immunity (CMI), making malnourished individuals more susceptible to progressing from latent to active TB. This risk is compounded in impoverished populations where poor nutrition and higher TB incidence are interconnected. Case studies from historical contexts illustrate the impact of nutrition on TB rates.[2] See also: Spatial information for TB

During World War I, Denmark experienced increased TB rates as it exported most of its protein-rich foods. However, following a German blockade in 1918 that inadvertently improved local food availability, TB rates declined, contrasting with continued increases in neighboring countries still engaged in the war. A similar pattern was observed at the Trondheim Naval Training School in Norway, where TB rates initially remained high despite improved housing and hygiene. It was only after the diet was nutritionally fortified that TB morbidity significantly decreased.[2]

Further evidence comes from World War II, where British and Russian prisoners of war (POWs) consumed the same prison diet, but the British had access to additional food supplements from the Red Cross. This resulted in substantially lower TB rates among British POWs (1.2%) compared to their Russian counterparts (15-19%). The correlation between better nutrition, higher plasma protein levels, and reduced TB severity was evident. These cases underscore the critical need to understand the timing of malnutrition and TB onset to discern cause-effect relationships, especially since TB can cause symptoms resembling malnutrition, further complicating analyses. Additionally, vitamin supplementation among family contacts of TB patients has shown potential in reducing TB risk, suggesting broader implications for nutritional interventions in TB prevention strategies.[2]

Among dialysis patients, factors such as current smoking, shorter dialysis duration, active radiographic lesions, and fever significantly contribute to the prevalence of TB. This increased risk in individuals with renal failure can be attributed to enhanced immune cell apoptosis, lymphocyte depletion, and dysfunction of polymorphonuclear leukocytes, all of which are worsened by oxidative stress and uremic toxins. Moreover, the dialysis population inherently carries a high TB risk; while a positive QFT-GIT test indicates significant risk, there is a notable 49.6% rate of negative conversion. However, persistent positivity in QFT-GIT testing correlates with a higher hazard ratio and specificity for future TB development, underscoring the complex interplay between TB risk factors and management in vulnerable populations such as those undergoing dialysis.[3]

Cardiovascular disease was most prevalent in the diabetes mellitus (DM) group, while anemia was notably higher in the tuberculosis-diabetes mellitus (TB-DM) group. Smoking and alcohol consumption were more common among the tuberculosis (TB) group, followed by the TB-DM group. Additionally, the TB-DM group exhibited poor glycemic control, with HbA1c levels averaging 10.47%, significantly higher than the 8.17% observed in the DM group. Despite similar nutritional parameters like albumin, globulin, and total proteins across groups, vitamin B12 levels were distinctly elevated in the TB-DM group, with a vast majority (95.83%) showing HbA1c levels above 6.5.[4]

The TB group showed a significant incidence of low serum albumin (71.91%), and vitamin D deficiency was most prevalent in the TB-DM group (73.68%), suggesting more severe nutritional deficits compared to the DM (50%) and TB (42.86%) groups. The TB-DM group also faced elevated vitamin B12 levels, with 66.67% exceeding 2000 pg/ml. These patients also demonstrated significantly higher glycemic parameters and a greater prevalence of low mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH), which are indicative of anemia risk. Collectively, these findings illustrate that the coexistence of TB and DM compounds health risks, exacerbating metabolic disturbances and nutritional deficiencies, thus leading to a higher incidence of cardiovascular diseases and more challenging diabetes management.[4]

References:

1. Mandal, S., Bhatia, V., Bhargava, A., Rijal, S. and Arinaminpathy, N., 2024. The potential impact on tuberculosis of interventions to reduce undernutrition in the WHO South-East Asian Region: a modelling analysis. The Lancet Regional Health-Southeast Asia, p.100423.

2. Cegielski, J.P. and McMurray, D.N., 2004. The relationship between malnutrition and tuberculosis: evidence from studies in humans and experimental animals. The international journal of tuberculosis and lung disease, 8(3), pp.286-298.

3. Shu, C.C., Hsu, C.L., Wei, Y.F., Lee, C.Y., Liou, H.H., Wu, V.C., Yang, F.J., Lin, H.H., Wang, J.Y., Chen, J.S. and Yu, C.J., 2016. Risk of tuberculosis among patients on dialysis: the predictive value of serial interferon-gamma release assay. Medicine, 95(22), p.e3813.

4. Patel, D.G., Baral, T., Kurian, S.J., Malakapogu, P., Saravu, K. and Miraj, S.S., 2024. Nutritional status in patients with tuberculosis and diabetes mellitus: A comparative observational study. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 35, p.100428.

Air pollutants and the risk of TB

A study investigated whether exposure to household air pollutants (HAP), particularly fine particulate matter (PM2.5) and carbon monoxide (CO), from cooking and lighting behaviors is linked to an increased risk of active tuberculosis (TB). The researchers hypothesized that kerosene and biomass fuel use elevate HAP levels, which mediate TB risk. A hospital and community-based case–control study was conducted in five peri-urban, high-density suburbs of Lilongwe, Malawi. Cases included female TB patients on treatment, while controls were age-matched female cooks without TB from neighboring households. Data collection incorporated structured interviews, health measurements (e.g., BMI and HIV status), and personal exposure monitoring for PM2.5 and CO.[1] See also: https://tbreadingnotes.blogspot.com/2024/08/immunologic-metabolic-and-genetic.html

The study reported that PM2.5 exposure levels among participants (average 170 µg/m³) far exceeded the WHO guideline of 25 µg/m³, with even higher concentrations observed in cooking areas of case households. Kerosene lighting was significantly associated with TB risk (odds ratio [OR] 3.73), and this relationship was partially mediated by increased PM2.5 (16.8%). Conversely, while biomass cooking was linked to elevated PM2.5 and CO levels, no statistically significant association with TB was identified. Other factors, including lower BMI, HIV positivity, and advanced age, were independently associated with increased TB risk, and area PM2.5 emerged as a strong contributor to TB odds (OR 6.74).[1] See also: https://tbreadingnotes.blogspot.com/2024/10/type-2-diabetes-mellitus-and-recurrent.html

The findings suggest that reducing kerosene use and improving home ventilation could help mitigate TB risk by lowering HAP exposure, particularly PM2.5. Although no significant connection between biomass cooking and TB was observed, the study underscores the need for additional research with larger sample sizes to better understand these relationships. The results partially support the hypothesized mediating role of HAP in TB risk and emphasize the importance of addressing environmental exposures in TB prevention strategies.[1] See also: https://tbreadingnotes.blogspot.com/2024/10/quantifying-global-number-of.html

A study found that increased concentrations of PM2.5, PM10, and NO2 are associated with higher TB risk, with no significant modifying effects of sex or age. PM2.5 and PM10 facilitate Mycobacterium tuberculosis colonization in deep lung tissues, disrupt iron balance in respiratory cells, and promote alveolar cell senescence, reducing the effectiveness of antimicrobial peptides (HBD-2 and HBD-3) while enhancing intracellular M. tb growth. PM exposure also impairs antibacterial T-cell immune function. NO2 exposure damages airway mucosa and ciliary clearance, enabling pathogen entry, and prolonged exposure suppresses pro-inflammatory cytokine expression, weakening host resistance to M. tb. While satellite-based air pollutant data may not accurately represent individual exposure levels, the findings suggest that reducing air pollution could play a crucial role in TB prevention and control.[2] See also: https://tbreadingnotes.blogspot.com/2024/08/yield-and-efficiency-of-population.html

Progress toward ending tuberculosis (TB) has been highly uneven across countries, with some achieving substantial mortality reductions while others struggle due to frail health systems, underinvestment, and inflexible approaches. High-burden countries face persistent challenges in case finding and diagnosis, as only 38% of TB cases were tested using WHO-recommended rapid molecular diagnostics in 2021. Most TB deaths occur in just eight countries, with over half concentrated in India, Indonesia, and Nigeria. Despite these challenges, some sub-Saharan African countries have demonstrated that rapid declines in TB mortality are possible with existing tools, underscoring the importance of focused interventions and system strengthening.[3]

Innovations in TB diagnostics and treatments hold promise but face slow adoption due to barriers like cost, infrastructure limitations, and regulatory hurdles. Advances such as oral swabs, urine antigen tests, and AI-assisted chest x-rays could improve case detection, particularly in asymptomatic or high-risk populations. Shorter treatment regimens for drug-susceptible and multidrug-resistant TB have improved outcomes and reduced healthcare demands, yet high costs and limited access to essential drugs like bedaquiline hinder widespread adoption. Additionally, preventive treatment strategies such as shorter TPT regimens show potential to reduce TB incidence but are constrained by logistical and regulatory gaps.[3] See also: Lin TB Lab

Addressing social and environmental determinants of TB is critical, particularly in light of the role of air pollution, undernutrition, and food insecurity in increasing TB risk. Undernutrition has been identified as the leading risk factor since 2009, emphasizing the need for nutritional support for patients and households. Investments in TB programs, including the development of new vaccines and better diagnostic tools, could not only reduce TB-related mortality but also yield significant societal benefits. However, achieving the Sustainable Development Goals (SDGs) for TB will require sustained international funding, equitable resource allocation, and the integration of TB care into broader health and social development frameworks.[3]

Tuberculosis (TB) remains the leading infectious cause of adult deaths globally, with over 10 million new cases annually, largely driven by poverty, overcrowding, and poor living conditions. Advances such as rapid molecular testing and whole-genome sequencing have improved TB diagnosis and drug resistance detection, while new drugs like bedaquiline and delamanid have transformed drug-resistant TB care with shorter, all-oral regimens. However, treatment for drug-susceptible TB remains reliant on the standard 6-month regimen, and the BCG vaccine provides limited protection for adults, spurring the development of new vaccines and shorter latent TB treatments. WHO emphasizes patient-centered care, including socioeconomic support like cash transfers, to reduce barriers and improve outcomes. Despite technological advances, reducing TB morbidity, mortality, and stigma requires stronger political commitment, equitable access to high-quality healthcare, and targeted efforts to address the social determinants of the disease.[4]

References:

1. Jagger, P., McCord, R., Gallerani, A., Hoffman, I., Jumbe, C., Pedit, J., Phiri, S., Krysiak, R. and Maleta, K., 2024. Household air pollution exposure and risk of tuberculosis: a case–control study of women in Lilongwe, Malawi. BMJ Public Health, 2(1).

2. Lu, J.W., Mao, J.J., Zhang, R.R., Li, C.H., Sun, Y., Xu, W.Q., Zhuang, X., Zhang, B. and Qin, G., 2023. Association between long-term exposure to ambient air pollutants and the risk of tuberculosis: A time-series study in Nantong, China. Heliyon, 9(6).

3. Reid, M., Agbassi, Y.J.P., Arinaminpathy, N., Bercasio, A., Bhargava, A., Bhargava, M., Bloom, A., Cattamanchi, A., Chaisson, R., Chin, D. and Churchyard, G., 2023. Scientific advances and the end of tuberculosis: a report from the Lancet Commission on Tuberculosis. The Lancet, 402(10411), pp.1473-1498.

4. Furin, J., Cox, H., & Pai, M. (2019). Tuberculosis. Lancet (London, England), 393(10181), 1642–1656.