TB Diagnostic Technologies

· TB Diagnostic Technologies and Hospital Impact

• Medical Center A in Taipei transitioned to auramine-rhodamine staining from Ziehl-Neelsen staining by 2014, aiming to improve TB detection and patient isolation.
• Enhanced diagnostic sensitivity resulted in doubling the positive sputum smear rate from 22.8% to 48.1%, especially for non-cavitary lung lesions.
• The median duration of non-isolated infectiousness reduced significantly from 12.5 days to 3 days, and the total number of non-isolated infectious patient-days decreased by 69% from 2001 to 2014.
• Suggestion: Implement continuous training for healthcare staff on the latest TB diagnostic technologies to maintain high detection rates and reduce the time to isolation.

· Risk Factors and Control Measures in Healthcare Settings

• Inadequate ventilation and insufficient environmental cleaning in healthcare settings heighten TB transmission risks.
• Frequent healthcare visits are closely linked to increased TB incidence, necessitating robust infection control measures in high-traffic areas like internal medicine and family medicine.
• Suggestion: Prioritize the installation of germicidal ultraviolet systems and upgraded ventilation in outpatient areas to minimize airborne transmission.

· Epidemiological Insights and Trends

• TB incidence and related mortality have declined in younger populations (<20 and 20–50 years) in mainland China, reflecting effective control measures.
• However, SS- TB cases and mortality in the >50 age group remained high, indicating ongoing vulnerabilities.
• Suggestion: Develop targeted health campaigns and screening programs focused on the elderly to address the persistently high TB rates in this demographic.

· Regional and Systemic Challenges in Taiwan

• Increased Health System Delay (HSD) in diagnosing TB was noted between 2003 and 2008, influenced by factors such as patient’s age, gender, and the type of health facility visited.
• Eastern Taiwan showed shorter HSDs due to a higher concentration of TB-specialized providers, while medical centers experienced longer delays.
• Suggestion: Enhance the distribution and accessibility of specialized TB healthcare services across different regions to ensure timely diagnosis and treatment.

· Link Between TB and Chronic Conditions

• Tuberculosis is a significant risk factor for developing chronic obstructive pulmonary disease (COPD), with risks increasing due to delays in TB treatment initiation.
• Early diagnosis and timely treatment of TB are crucial to mitigate COPD risk.
• Suggestion: Strengthen the integration of TB and COPD management protocols to improve patient outcomes and reduce the incidence of COPD among former TB patients.

See also: https://lintblab.weebly.com

References:

1. Sun H-Y, Wang J-Y, Chen Y-C, Hsueh PR, Chen Y-H, Chuang Y-C, et al. (2020) Impact of introducing fluorescent microscopy on hospital tuberculosis control: A before-after study at a high caseload medical center in Taiwan. PLoS ONE 15(4): e0230067.
2. Pan, S.C., Chen, C.C., Chiang, Y.T., Chang, H.Y., Fang, C.T. and Lin, H.H., 2016. Health care visits as a risk factor for tuberculosis in Taiwan: a population-based case–control study. American journal of public health, 106(7), pp.1323-1328.
3. Liu, K.H., Xiao, Y.X. and Jou, R., 2024. Multidrug-resistant tuberculosis clusters and transmission in Taiwan: a population-based cohort study. Frontiers in Microbiology, 15, p.1439532.
4. Huang, F. and Bello, S.T., 2024. Spatiotemporal analysis of regional and age differences in tuberculosis prevalence in mainland China. Tropical Medicine & International Health, 29(9), pp.833-841.
5. Fu, H., Lin, HH., Hallett, T.B. et al. Explaining age disparities in tuberculosis burden in Taiwan: a modelling study. BMC Infect Dis 20, 191 (2020).
6. Chen, C.C., Chiang, C.Y., Pan, S.C., Wang, J.Y. and Lin, H.H., 2015. Health system delay among patients with tuberculosis in Taiwan: 2003–2010. BMC infectious diseases, 15, pp.1-9.
7. Lee C-H, Lee M-C, Lin H-H, Shu C-C, Wang J-Y, et al. (2012) Pulmonary Tuberculosis and Delay in Anti-Tuberculous Treatment Are Important Risk Factors for Chronic Obstructive Pulmonary Disease. PLoS ONE 7(5): e37978.

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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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