Abstract: diagnosed cases of tuberculosis registered under RNTCP in

Abstract: Context:- Tuberculosis
(TB) and of diabetes
mellitus (DM) remains a global public
health problem. India has the largest number of TB cases, in 2015, out of total
global annual incidence of 9.6 million TB cases 2.2 million were estimated from
India. 62.4 million people with type 2 diabetes and 77 million people with pre
diabetes in India, these numbers are projected to increase to 101 million by
the year 2030. Diabetes and tuberculosis may affect each other at many levels. Screening
for diabetes in patients with tuberculosis will not only ensure early case
detection but also better management of diabetes and will lead to better
tuberculosis treatment outcome. Aims: – (i) To
determine the prevalence of diabetes and pre-diabetes among diagnosed cases of
tuberculosis registered under RNTCP in Bhopal District.

(ii) To determined additional yield
of previously unknown DM and the Number needed to screen (NNS) to find a new
case of DM and

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(iii) To find out the factors associated with DM among TB
patients.

Settings and Design:- .The
current study was a Cross sectional  study conducted on registered tuberculosis
patients Under RNTCP in 2 tuberculosis units (TUs) of Bhopal District. Methods and Material:. Participants were contacted
and interview was conducted after obtaining consent by using pre designed and
pre tested Performa during the period of 1st October 2014 to 30th
March 2015 for a period of 6 months. Statistical
analysis used- Continuous variable were summarized as frequency, mean
and standard deviation. All variable were analyzed using Chi square test of
significance; P<0.05 was taken as statically significant. Result- Out of the total 528 tuberculosis 296 was male and 232 were female. Out of the total, 63 (11.9%) patients were diagnosed as diabetic. NNS (number need to screen) to diagnose a new case of DM was 22.1. Significant association found with six variables which are age, sex, BMI, type of TB, Category of TB and smoking. Conclusion- This study shows feasibility and importance of screening of TB patients in existing program settings. Key word: Tuberculosis, Diabetes, associated factors, NNS Key Messages: screening of tuberculosis patients for DM in a routine setting, demonstrate the feasibility and by earlier identification of DM give an opportunities for better management of co-morbidity. Introduction: Tuberculosis is one of the major public health problems worldwide and it is major cause of morbidity and mortality. India has the highest number of TB cases, In 2015, out of total global annual incidence of 9.6 million TB cases  2.2 million were estimated from India in which prevalence of tuberculosis is 195 per lakh and incidence rate is 167 per lakh Population  1.  The incidence of DM is also increasing worldwide. In 2015, the International Diabetes Federation (IDF) estimated that about 415 million people worldwide suffering from  diabetes mellitus (DM) and this number is expected to rise to 642 million by 2040.2 In India almost 62.4 million people with type 2 diabetes and 77 million people with pre diabetes and  these numbers are projected to increase to 101 million by the year 2030 3.  Nationwide surveillance study of DM had found that the prevalence of known T2DM(Type 2 Diabetes mellitus) in urban areas was 7.3% 4. Available reports suggest that 95% of patients with TB and 70% of patients with DM live in the low- and middle-income countries, especially in South East Asia 5. Diabetes accounts for 14.8% (7.1% to 23.8%) of pulmonary tuberculosis and 20.2% (8.3% to 41.9%) of smear-positive tuberculosis as per a study conducted in India in 20006. Systematic review of studies conducted at multiple settings showed that Screening of patients with Tuberculosis for Diabetes mellitus yielded high prevalence of Diabetes ranging from 1.9% to 35% 7. Diabetes and tuberculosis affect each other at many levels, among TB patients; diabetes may adversely affect TB treatment outcomes. Screening for diabetes in patients with tuberculosis can help in early diagnosis  and management of diabetes and will lead to better tuberculosis treatment outcome7,8. The world health organization(WHO) and International union against tuberculosis and lungs disease(IUATLD) in collaboration with, national TB control program emphasizes the  routine implementation of bi directional screening of two diseases and recommends the surveillance of diabetes among tuberculosis in all countries in primary healthcare settings 9. However, screening methods, reporting and monitoring for the two diseases in routine health care settings have not been well determined, and operational research is needed for better information in this field. The current study was conducted to determine the overall prevalence of DM among TB patients and to assess whether routine screening of TB patients for DM within a programme setting might yield previously undiagnosed DM cases offering an opportunity for earlier detection and management of DM Aims:  (i) To determine the prevalence of diabetes and pre-diabetes among diagnosed cases of tuberculosis registered under RNTCP in Bhopal District. (ii) To determined additional yield of previously unknown DM and the Number needed to screen (NNS) to find a new case of DM and (iii) To find out the factors associated with DM among TB patients. Subjects and Methods: Study Settings and Design: The basic infrastructures of RNTCP Bhopal district consist of 5 TB treatment and supervision units (TU), 1 per 5 lakh population. Furthermore 5 TU have 24 operational designated microscopic centres for identification and management of TB patients. The study was conducted on registered tuberculosis patients Under RNTCP in 2 tuberculosis units (TUs) of Bhopal District. The current study was a Facility based cross sectional up study conducted on registered cases of tuberculosis in Bhopal equal or above the age of 18 years who gave their consent during the period of 1st October 2014 to 30th March 2015. Study Duration: The study was undertaken from the 1st October 2014 to 30th March 2015 for a period of 6 months. Study Subjects and sampling:- We include all tuberculosis patients of last quarter of 2014 aged 18 years and above with established diagnosis of tuberculosis registered in tuberculosis units during study period were considered as the targeted population. Further the consent was obtained and Patients of Type1 Diabetes and Seriously ill patients such as TB meningitis, septicaemia etc and pregnant patients were excluded from the study  Data collection method- The current study was a cross sectional study conducted on registered cases of tuberculosis in Bhopal equal or above the age of 18 years who gave their consent. Tuberculosis units were selected on basis of convenience sampling. After line listing of all registered tuberculosis patients with the help of Tuberculosis register the day of DOTS therapy ascertain for all selected patients. Further participants were contacted and interview was conducted after obtaining consent using pre designed and pre tested Performa which consisted of socio demographic profile including age, sex, weight, height, education, occupation economic status & history of any addiction and assessment of tuberculosis status of patients including type of tuberculosis, category, and duration of treatment. Blood glucose level including both fasting and random blood glucose level of patients with the help of existing staff of health facility. History of diabetes, family history of diabetes and treatment history of diabetes were recorded. The participants with already diagnosed diabetes mellitus on treatment were confirmed by their records. Operational definition- Diabetes and pre diabetes  According to American diabetes association (ADA)             Diabetes –fasting blood sugar level ? 126 mg/dl                   Random blood glucose level ? 200 mg/dl in patients with classical symptom of hyperglycaemia             Pre diabetes-  Fasting blood sugar level between 100-125mg/dl. Statistical analysis used: Data was entered in Microsoft excel 2007 and analyzed using Epi-info TM en-US version 7.2.1.0. Continuous variable were summarized as frequency, mean and standard deviation. Variable were analyzed using Chi square test of significance; P<0.05 was taken as statically significant. Ethics approval – Ethical approval received from Institutional Ethical Committee of Gandhi Medical College, Bhopal. Informed consent was obtained from patients before conducting the interview. Results: A total of 528 tuberculosis patients were interviewed by using pre tested questionnaire and assess for their blood glucose level. Out of the total 528 tuberculosis 296 were male (mean age 38.25) and 232 were female (mean age 34.7). Out of the total 528 tuberculosis patients, 63(11.93%) patients were diagnosed as diabetic and 91(15.3%) were pre diabetic. The overall prevalence of DM among TB patients disaggregated by age, sex, education status, Socioeconomic status, BMI, Smoking status, Type of tuberculosis, treatment category  is shown in Table 1. Male Tuberculosis patients (14.8%) were found to be significantly more associated with diabetes as compare to female patients (8.1%).  Diabetes among  tuberculosis patients was reported higher among patients with age more than 50 years (24.2%) as compare to patients with age less than 50 years(7.4%) and the difference was statically significant (p<0.0001). In current study prevalence of diabetes among tuberculosis was more among upper socioeconomic status patients (11.6%) as compare to middle (10%) and lower (6.3%) socio economic status patients though the difference was not significant (p=0.44). Prevalence of Diabetes among illiterate TB patients was more (7.1%) than literate TB patients (12.6%) though the difference was not statistically significant (p=0.78). Tuberculosis patients having BMI more than 25 were found to be having significantly more prevalence of diabetes (19%) as compare to patients with BMI less than 25(9.04%). smoker tuberculosis patients having more diabetes (16.3% )as compare to non smokers (9.8%) and the difference was statistically significant (p<0.001). Alcoholic tuberculosis patients having more diabetes (12.6%) as compare to non alcoholic patients (11.7%) but the difference was not significant(p=0.94). Out of 63 DM patients, 44 (8.3%) had history of previous diagnosis of DM and 19 (3.59%) were newly diagnosed. Out of total tuberculosis patients pulmonary TB patients (14.4%) had more prevalence of diabetes as compare to extra pulmonary TB (3.9%) and the difference was statistically significant (p=0.002). In current study 18.3% Type II treatment category TB patients had diabetes as compare to 10.04% of Type I treatment category TB patients and the difference was found to be  statistically significant (p<0.02). Of the 528 TB patients, 63 (11.3%) were found to have DM, of whom 44(4.1%) were newly-diagnosed cases. The additional yield and NNS for different variable shown in table 2. The additional yield of DM cases on screening was 34.9%. The NNS to detect one new case of DM was 22. Among patients aged 50 years or less, the NNS was 45.8 and among those aged (>50) years the NNS was 8.5
(Table 2).  The NNS to diagnose one male
DM patient was 19 compared to 27.6 for females. The additional yield of
screening among pulmonary TB patients for DM was 36.2% and 20% for extra
pulmonary TB patients. However, the NNS to diagnose one DM case among pulmonary
TB patients was 17.3 compared to 123 among extra pulmonary TB patients. NNS
among BMI >25 was 11.2 and among patients having BMI<25 was 35.2. Among smoker tuberculosis patients NNS was 15.3 and in non-smoker tuberculosis patients it was 27.8. Among the Category I TB patients, the NNS was 29.2 compared to 11.8 among previously treated TB cases. . Discussion: 59% while the NNS to detect a new case of DM was 18. The prevalence of DM among patients who were older than 40 years was far higher than among younger persons; sex on the other hand was not associated with the occurrence of DM. The additional yield of DM was greater among older patients, persons who sought care at a public facility, rural residents and HIV-negative persons. In all, factors favouring occurrence of DM among TB patients in the study group were older age (over 40 years), private facility care and rural residence. Conversely, patients engaged in occupations with vigorous activity were less likely have DM.   In this study we found a high prevalence of DM among the TB patients (11.9%) treated in Bhopal; and it was higher among those with age >50 years, male gender, smokers, patients having high BMI range (>25),
type II treatment category and those with Pulmonary tuberculosis as compared to
age <50, female gander, non smokers, BMI range <25, type I treatment category and extra pulmonary tuberculosis. In present study the prevalence of diabetes among tuberculosis patients was 11.9% and that of pre diabetes was 15.3 %. Similar results were reported in earlier studies by Singla et al.,10 Raghuraman et al.,11 Khanna et al.,12 A.Kumar et al 2013 13 and Balakrishnan et al. 14Zhang Q et al. 2009,15 with 25%, 29%, 14.5%,13% and 44% 9.5%, prevalence of diabetes among TB patients. This study found a significantly higher prevalence of DM in older TB patients (age>50). Similar finding have been reported by studies from other parts of
India and others contries16171819. This
study also reported the higher association of DM and PTB, which is also
reported in many studies including those by Zhang et al.15 and Guptan and
Shah18. This study
has reported significantly higher prevalence of DM among male gender, which is
supported by that reported in the study conducted in south India 20.

Result of the current study
shows that diabetes among alcoholic tuberculosis patients to be more as compare
to non alcoholic patients, and the difference was not significant. Similar
result seen earlier study 21 11
shows that Alcohol consumption was found to be a risk factor for diabetes in TB
patients.

The present study shows that diabetes
was more common among TB patients with BMI more 25 (19.0%) as compare to those
with BMI <25 (9.04%) and the difference was statistically significant (P=0.001). Similar result was seen earlier by Soudarnjan R (2014)11. In current study we found that diabetes among tuberculosis was significantly more among type II category tuberculosis patients as compare to Type I treatment category tuberculosis.  Finding of this study was supported by earlier study 22,23. In current study we found that smoker tuberculosis patients have significantly more diabetes (16.3%) as compared to non smoker tuberculosis patients (9.8%) (p=0.0001). Similar result was found in earlier study 24,25. The NNS to detect a new case of DM among TB patients was 22.  This number varies in from lower to among study from south India may we due to higher prevalence of diabetes mellitus. we found that NNS needed to detect one case of DM among TB patients decreases as the age increases14,26. This shows the importance of early screening of patients with TB and will enable us to manage these patients in the early phase. Pre-diabetes diagnose at early phase so that primary prevention methods may be initiated timely. As we higher burden of both TB and DM in our country, We need better information, recording and monitoring system to guide us in managing this co-morbidity, and we need to strengthen the care of these patients in our existing health services. Our study had several strengths. The strength of this study is that we implement this screening programme in routine programme settings. We also emphasis on the NNNS to diagnose a new case of DM with respect to different variables so we can focus on the lower value of NNS for screening on large scale. There were a few limitations like previous documentation of blood sugar not cross check. Mean time for sugar testing and disease duration was not same for each tuberculosis patients. The study has several programmatic implications as results of current study emphasizes that National TB control program in collaboration with NCD program should have special provision for screening, diagnosis, and management of DM among tuberculosis patients. Acknowledgement:The authors thank Revised National Tuberculosis Control Program, Madhya Pradesh, India for providing financial assistance for the survey. We are also thankful to the Department of Education for the support during data collection. We are also very grateful to Dr. Manoj Verma, DTO Bhopal, for their support during study. References: 1.        MINISTRY OF HEALTH AND FAMILY WELFARE. TB India 2016, Revised National TB Control Programme ,Anual Status Report.; 2016. 2.        International Diabetes federation.IDF Diabetes Atlas Seventh Edition 2015. Belgium; 2015. doi:10.1289/image.ehp.v119.i03. 3.        Whiting DR, Guariguata L, Weil C, Shaw J. {IDF} diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pr. 2011;94(3):311-321. doi:10.1016/j.diabres.2011.10.029. 4.        Mohan V Mathur P Deepa R Deepa M Shukla D et. al. Urban rural differences in prevalence of self-reported diabetes in India—The WHO–ICMR Indian NCD risk factor surveillance. Diabetes Res Clin Pract. 2008;80(1). www.ncbi.nlm.nih.gov/pubmed/18237817. 5.        International Diabetes Federation. IDF Diabetes Atlas 5th Edition. Fifth. Belgium; 2011. doi:10.1007/978-90-481-3271-3. 6.        Stevenson CR, Forouhi NG, Roglic G, et al. Diabetes and tuberculosis: the impact of the diabetes epidemic on tuberculosis incidence. BMC Public Health. 2007;7:234 doi:10.1186/1471-2458-7-234 Received: doi:10.1186/1471-2458-7-234. 7.        Jeon CY, Murray MB. 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