Smoking, DM, and TB

• Smoking and TB Risk: Current smokers exhibit a higher TB incidence rate (0.60%) compared to never smokers (0.56%) and former smokers (0.59%). After adjusting for confounders, current smokers have a significantly higher TB risk (aHR 1.158), while former smokers show a reduced risk (aHR 0.947). TB risk increases with smoking intensity and duration. Smoking cessation is recommended to reduce TB risk, with emphasis on maintaining weight after quitting. Weight loss post-cessation increases TB risk. See also: Lin TB Lab
• Smoking and Active TB Risk: Current smoking doubles the risk of active TB compared to never smokers, with risk escalating based on cigarette consumption and years of smoking. Smoking contributes to 17% of TB cases in Taiwan, highlighting its significant role in TB incidence. The impact of smoking-related TB is more pronounced in individuals under 65 years. See also: Australia Scholarships
• Diabetes and TB in Indonesia: Indonesia has a high TB incidence and a growing diabetes prevalence, with studies showing strong connections between the two diseases. Routine diabetes screening for TB patients, especially those over 35, is recommended to improve management and treatment outcomes. Metformin use in TB-DM patients is linked to a higher treatment success rate and reduced all-cause mortality.
• Mtb Sensitization and Type 2 Diabetes: Mtb sensitization increases the risk of type 2 diabetes (T2DM), primarily through insulin resistance. Insulin resistance explained 18.3% of the Mtb-T2DM association, while β-cell dysfunction was not a significant factor.
• TB Screening in Diabetic Patients: Mass TB screening among persons with diabetes is feasible but not cost-efficient in low detection settings. Targeted screening in high TB incidence areas is more effective, with risk-stratified approaches recommended for lower-burden settings. Successful TB screening implementation requires integration with existing community-based diabetes screening efforts.
• Diabetes and TB Risk in Spain: Diabetic patients with TB are younger and have higher triglycerides, and are more frequently from Hindustan. TB incidence is higher among diabetic patients with elevated HbA1c levels, peaking at HbA1c ≥ 9%. No significant difference in TB localization, radiography, or skin test results based on HbA1c levels, but TB incidence increased with higher HbA1c.
• Diabetes and TB Disease Vulnerability: DM increases the risk of TB, with more severe DM increasing susceptibility. Effective TB elimination strategies should address both TB and DM management, especially in regions with high TB burdens and rising DM prevalence.

Recommendations:

• Smoking cessation and weight maintenance are crucial to reduce TB risk.
• Diabetic TB patients should be regularly screened and managed to improve treatment outcomes.
• Risk-based TB screening in diabetic populations, especially in high-burden areas, is recommended.

References:

1. Kim, S.H., Park, Y.M., Han, K., Ko, S.H., Kim, S.Y., Song, S.H., Kim, C.H., Hur, K.Y. and Kim, S.K., 2022. Association of weight change following smoking cessation with the risk of tuberculosis development: A nationwide population-based cohort study. Plos one, 17(4), p.e0266262.
2. Lin, H.H., Ezzati, M., Chang, H.Y. and Murray, M., 2009. Association between tobacco smoking and active tuberculosis in Taiwan: prospective cohort study. American journal of respiratory and critical care medicine, 180(5), pp.475-480.
3. Magodoro, I.M., Aluoch, A., Claggett, B., Nyirenda, M.J., Siedner, M.J., Wilkinson, K.A., Wilkinson, R.J. and Ntusi, N.A., 2024, October. Association Between Mycobacterium tuberculosis Sensitization and Insulin Resistance Among US Adults Screened for Type 2 Diabetes Mellitus. In Open Forum Infectious Diseases (Vol. 11, No. 10, p. ofae568). US: Oxford University Press.
4. 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.
5. 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.
6. Chung, E., Jeong, D., Mok, J., Jeon, D., Kang, H.Y., Kim, H., Kim, H., Choi, H. and Kang, Y.A., 2024. Relationship between metformin use and mortality in tuberculosis patients with diabetes: a nationwide cohort study. The Korean Journal of Internal Medicine, 39(2), p.306.
7. Antonio-Arques, V., Caylà, J.A., Real, J., Moreno-Martinez, A., Orcau, À., Mauricio, D., Mata-Cases, M., Julve, J., Navas Mendez, E., Puig Treserra, R. and Millet, J.P., 2022. Glycemic control and the risk of tuberculosis in patients with diabetes: A cohort study in a Mediterranean city. Frontiers in public health, 10, p.1017024.
8. Baker, M.A., Lin, H.H., Chang, H.Y. and Murray, M.B., 2012. The risk of tuberculosis disease among persons with diabetes mellitus: a prospective cohort study. Clinical Infectious Diseases, 54(6), pp.818-825.

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Transmission Control and Treatment Access Challenges

1. Clinical and Biological Predictors of Treatment Outcomes

• Key Findings: Early culture conversion is the strongest predictor of successful MDR-TB treatment. Younger age, male sex, normal BMI, no prior TB treatment, and absence of HIV, CKD, or cavitary lung lesions improve outcomes. Prediabetes is linked to delayed sputum conversion and poor prognosis if HbA1c levels are high. See also: Lin TB Lab NTU
• Action Plan: Implement Early Monitoring Protocols: Introduce routine and rapid culture conversion testing within the first two months of treatment. Incorporate regular HbA1c testing for TB patients to identify and manage prediabetes early, potentially through lifestyle interventions or medications.

2. Diagnostic and Treatment Access Challenges in Urban Settings

• Key Issues: Low identification and diagnosis rates for DR-TB in urban Indonesia. Significant delays between diagnosis and treatment, particularly for marginalized populations. Limited diagnostic support and reliance on phenotypic drug susceptibility testing (pDST).
• Action Plan: Enhance Diagnostic Capacity and Accessibility: Scale up active case-finding strategies, particularly in high-density and underserved areas. Establish more accessible diagnostic centers with faster molecular testing (e.g., GeneXpert) to reduce delays and improve linkage to care.

3. Geographic Hotspots and Transmission Control

• Critical Insights: MDR-TB hotspots exhibit higher transmission rates and specific genotypic clustering (e.g., LAM sublineage). Direct transmission is a significant contributor to MDR-TB in hotspot regions, even among treatment-naïve individuals. Spatial clustering indicates the need for geographically targeted interventions.
• Action Plan: Targeted Public Health Interventions: Deploy resources to identified hotspots with enhanced screening, treatment adherence support, and community education. Integrate geographic and mathematical modeling to adapt strategies dynamically based on emerging data.

References:

1. Soeroto, A.Y., Pratiwi, C., Santoso, P. and Lestari, B.W., 2021. Factors affecting outcome of longer regimen multidrug-resistant tuberculosis treatment in West Java Indonesia: A retrospective cohort study. PloS one, 16(2), p.e0246284.
2. Lestari, B.W., Nijman, G., Larasmanah, A., Soeroto, A.Y., Santoso, P., Alisjahbana, B., Chaidir, L., Andriyoko, B., Van Crevel, R. and Hill, P.C., 2024. Management of drug-resistant tuberculosis in Indonesia: a four-year cascade of care analysis. The Lancet Regional Health-Southeast Asia, 22:100294.
3. Viswanathan, V., Devarajan, A., Kumpatla, S., Dhanasekaran, M., Babu, S. and Kornfeld, H., 2023. Effect of prediabetes on tuberculosis treatment outcomes: A study from South India. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 17(7), p.102801.
4. Zelner, J.L., Murray, M.B., Becerra, M.C., Galea, J., Lecca, L., Calderon, R., Yataco, R., Contreras, C., Zhang, Z., Manjourides, J. and Grenfell, B.T., 2016. Identifying hotspots of multidrug-resistant tuberculosis transmission using spatial and molecular genetic data. The Journal of infectious diseases, 213(2), pp.287-294.
5. Manjourides, J., Lin, H.H., Shin, S., Jeffery, C., Contreras, C., Santa Cruz, J., Jave, O., Yagui, M., Asencios, L., Pagano, M. and Cohen, T., 2012. Identifying multidrug resistant tuberculosis transmission hotspots using routinely collected data. Tuberculosis, 92(3), pp.273-279.
6. Wulandari, D.A., Hartati, Y.W., Ibrahim, A.U. and Pitaloka, D.A.E., 2024. Multidrug-resistant tuberculosis. Clinica Chimica Acta, 559, p.119701.

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