Abstract: diagnosed cases of tuberculosis registered under RNTCP in

Abstract: Context:- Tuberculosis(TB) and of diabetesmellitus (DM) remains a global publichealth problem. India has the largest number of TB cases, in 2015, out of totalglobal annual incidence of 9.6 million TB cases 2.2 million were estimated fromIndia.

62.4 million people with type 2 diabetes and 77 million people with prediabetes in India, these numbers are projected to increase to 101 million bythe year 2030. Diabetes and tuberculosis may affect each other at many levels. Screeningfor diabetes in patients with tuberculosis will not only ensure early casedetection but also better management of diabetes and will lead to bettertuberculosis treatment outcome. Aims: – (i) Todetermine the prevalence of diabetes and pre-diabetes among diagnosed cases oftuberculosis registered under RNTCP in Bhopal District.

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(ii) To determined additional yieldof previously unknown DM and the Number needed to screen (NNS) to find a newcase of DM and (iii) To find out the factors associated with DM among TBpatients. Settings and Design:- .Thecurrent study was a Cross sectional  study conducted on registered tuberculosispatients Under RNTCP in 2 tuberculosis units (TUs) of Bhopal District.

Methods and Material:. Participants were contactedand interview was conducted after obtaining consent by using pre designed andpre tested Performa during the period of 1st October 2014 to 30thMarch 2015 for a period of 6 months. Statisticalanalysis used- Continuous variable were summarized as frequency, meanand standard deviation.

All variable were analyzed using Chi square test ofsignificance; P<0.05 was taken as statically significant. Result- Out of thetotal 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) todiagnose a new case of DM was 22.

1. Significant association found with sixvariables which are age, sex, BMI, type of TB, Category of TB and smoking.Conclusion- This study shows feasibility and importance of screening of TBpatients in existing program settings.Key word: Tuberculosis, Diabetes,associated factors, NNS Key Messages: screening of tuberculosis patients for DM in aroutine setting, demonstrate the feasibility and by earlier identification ofDM give an opportunities for better management of co-morbidity. Introduction:Tuberculosis isone of the major public health problems worldwide and it is major cause ofmorbidity and mortality. India has the highest number of TB cases, In 2015, out oftotal global annual incidence of 9.6 million TB cases  2.

2 million were estimated from India inwhich prevalence of tuberculosis is 195 per lakh and incidence rate is 167 perlakh Population  1. The incidence of DM is also increasingworldwide. In 2015, the International Diabetes Federation (IDF) estimated thatabout 415 million people worldwide suffering from  diabetes mellitus (DM) and this number isexpected to rise to 642 million by 2040.2 InIndia almost 62.4 million people with type 2 diabetes and 77 million peoplewith pre diabetes and  these numbers areprojected to increase to 101 million by the year 2030 3.  Nationwide surveillancestudy of DM had found that the prevalence of known T2DM(Type 2 Diabetesmellitus) in urban areas was 7.

3% 4.Availablereports suggest that 95% of patients with TB and 70% of patients with DM livein the low- and middle-income countries, especially in South East Asia 5.Diabetesaccounts for 14.8% (7.1% to 23.8%) of pulmonary tuberculosis and 20.2% (8.3% to41.

9%) of smear-positive tuberculosis as per a study conducted in India in 20006. Systematic review of studies conducted at multiple settingsshowed that Screening of patients withTuberculosis for Diabetes mellitus yielded high prevalence of Diabetes rangingfrom 1.9% to 35% 7.Diabetesand tuberculosis affect each other at many levels, among TB patients; diabetesmay adversely affect TB treatment outcomes. Screening for diabetes in patientswith tuberculosis can help in early diagnosis  and management of diabetes and will lead tobetter tuberculosis treatment outcome7,8.Theworld health organization(WHO) and International union against tuberculosis andlungs disease(IUATLD) in collaboration with, national TB control programemphasizes the  routine implementation ofbi directional screening of two diseases and recommends the surveillance ofdiabetes among tuberculosis in all countries in primary healthcare settings 9. However, screening methods, reporting and monitoring for the twodiseases in routine health care settings have not been well determined, andoperational research is needed for better information in this field.

The current study was conducted to determinethe overall prevalence of DM among TB patients and to assess whether routinescreening of TB patients for DM within a programme setting might yieldpreviously undiagnosed DM cases offering an opportunity for earlier detectionand management of DMAims: (i) To determine the prevalence of diabetesand pre-diabetes among diagnosed cases of tuberculosis registered under RNTCPin Bhopal District.(ii) To determined additional yieldof previously unknown DM and the Number needed to screen (NNS) to find a newcase of DM and (iii) To find out the factors associated with DM among TBpatients. Subjects and Methods:Study Settings and Design:Thebasic infrastructures of RNTCP Bhopal district consist of 5 TB treatment andsupervision units (TU), 1 per 5 lakh population. Furthermore 5 TU have 24operational designated microscopic centres for identification and management ofTB patients. The study was conducted on registeredtuberculosis patients Under RNTCP in 2 tuberculosis units (TUs) of BhopalDistrict. The current study was a Facility based cross sectional up study conductedon registered cases of tuberculosis in Bhopal equal or above the age of 18years who gave their consent during the period of 1st October 2014to 30th March 2015.Study Duration: Thestudy was undertaken from the 1st October 2014 to 30thMarch 2015 for a period of 6 months.Study Subjects andsampling:- We include all tuberculosis patients of last quarter of 2014 aged 18years and above with established diagnosis of tuberculosis registered intuberculosis units during study period were considered as the targetedpopulation.

Further the consent was obtained and Patients of Type1 Diabetes andSeriously ill patients such as TB meningitis, septicaemia etc and pregnantpatients were excluded from the study Data collection method- The current study wasa cross sectional study conducted on registered cases of tuberculosis in Bhopalequal or above the age of 18 years who gave their consent. Tuberculosis unitswere selected on basis of convenience sampling. After line listing of allregistered tuberculosis patients with the help of Tuberculosis register the dayof DOTS therapy ascertain for all selected patients. Further participants werecontacted and interview was conducted after obtaining consent using predesigned and pre tested Performa which consisted of socio demographic profileincluding age, sex, weight, height, education, occupation economic status &history of any addiction and assessment of tuberculosis status of patientsincluding type of tuberculosis, category, and duration of treatment. Bloodglucose level including both fasting and random blood glucose level of patientswith the help of existing staff of health facility. History of diabetes, familyhistory of diabetes and treatment history of diabetes were recorded. Theparticipants with already diagnosed diabetes mellitus on treatment were confirmedby their records.

Operationaldefinition- Diabetesand pre diabetes  Accordingto American diabetes association (ADA)            Diabetes –fastingblood sugar level ? 126 mg/dl                  Random blood glucose level ?200 mg/dl in patients with classical symptom of hyperglycaemia            Prediabetes-  Fasting blood sugar levelbetween 100-125mg/dl.Statistical analysis used:Datawas entered in Microsoft excel 2007 and analyzed using Epi-info TMen-US version 7.2.1.

0. Continuous variablewere summarized as frequency, mean and standard deviation. Variable wereanalyzed using Chi square test of significance; P<0.05 was taken asstatically significant.Ethicsapproval – Ethicalapproval received from Institutional Ethical Committee of Gandhi MedicalCollege, Bhopal. Informed consent was obtained from patients before conductingthe interview. Results: Atotal of 528 tuberculosis patients were interviewed by using pre testedquestionnaire and assess for their blood glucose level. Out of the total 528tuberculosis 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 diagnosedas diabetic and 91(15.3%) were pre diabetic.The overall prevalence of DM among TB patientsdisaggregated by age, sex, education status, Socioeconomic status, BMI, Smokingstatus, Type of tuberculosis, treatment category  is shown in Table 1.Male Tuberculosis patients (14.8%) were found to be significantly moreassociated with diabetes as compare to female patients (8.1%).  Diabetes among  tuberculosis patients was reported higheramong patients with age more than 50 years (24.

2%) as compare to patients withage less than 50 years(7.4%) and the difference was statically significant(p<0.0001). In current study prevalence ofdiabetes among tuberculosis was more among upper socioeconomic status patients(11.6%) as compare to middle (10%) and lower (6.3%) socio economic statuspatients though the difference was not significant (p=0.44). Prevalenceof Diabetes among illiterate TB patients was more (7.

1%) than literate TBpatients (12.6%) though the difference was not statistically significant(p=0.78).

Tuberculosis patients having BMI more than25 were found to be having significantly more prevalence of diabetes (19%) ascompare 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 thedifference 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 notsignificant(p=0.94). Out of 63 DM patients, 44 (8.3%) had history ofprevious diagnosis of DM and 19 (3.59%) were newly diagnosed.Outof total tuberculosis patients pulmonary TB patients (14.4%) had moreprevalence of diabetes as compare to extra pulmonary TB (3.

9%) and thedifference was statistically significant (p=0.002). In current study 18.

3% TypeII treatment category TB patients had diabetes as compare to 10.04% of Type Itreatment 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 fordifferent 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 orless, the NNS was 45.8 and among those aged (>50) years the NNS was 8.5(Table 2).  The NNS to diagnose one maleDM patient was 19 compared to 27.

6 for females. The additional yield ofscreening among pulmonary TB patients for DM was 36.2% and 20% for extrapulmonary TB patients. However, the NNS to diagnose one DM case among pulmonaryTB patients was 17.3 compared to 123 among extra pulmonary TB patients. NNSamong BMI >25 was 11.

2 and among patients having BMI<25 was 35.2. Amongsmoker tuberculosis patients NNS was 15.3 and in non-smoker tuberculosispatients it was 27.8. Among the Category I TB patients, the NNS was 29.

2compared to 11.8 among previously treated TB cases..Discussion:59% while the NNS to detect a new case of DM was 18. Theprevalence of DM among patients who were older than 40 years was far higherthan among younger persons; sex on the other hand was not associated with the occurrenceof DM. The additional yield of DM was greater among older patients, persons whosought care at a public facility, rural residents and HIV-negative persons. Inall, factors favouring occurrence of DM among TB patients in the study groupwere older age (over 40 years), private facility care and rural residence.

Conversely, patients engaged in occupations with vigorous activity were lesslikely have DM.   In this study we found a high prevalence of DM among the TBpatients (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 toage <50, female gander, non smokers, BMI range <25, type I treatmentcategory and extra pulmonary tuberculosis.Inpresent study the prevalence of diabetes among tuberculosis patients was 11.9%and that of pre diabetes was 15.3 %. Similar results were reported in earlierstudies by Singla et al.

,10 Raghuraman etal.,11 Khanna et al.,12 A.Kumaret al 2013 13 andBalakrishnan et al.

14Zhang Q et al. 2009,15 with 25%, 29%,14.5%,13% and 44% 9.5%, prevalence of diabetesamong TB patients. Thisstudy found a significantly higher prevalence of DM in older TB patients(age>50). Similar finding have been reported by studies from other parts ofIndia and others contries16171819. Thisstudy also reported the higher association of DM and PTB, which is alsoreported in many studies including those by Zhang et al.

15 and Guptan andShah18. This studyhas reported significantly higher prevalence of DM among male gender, which issupported by that reported in the study conducted in south India 20.Result of the current studyshows that diabetes among alcoholic tuberculosis patients to be more as compareto non alcoholic patients, and the difference was not significant. Similarresult seen earlier study 21 11shows that Alcohol consumption was found to be a risk factor for diabetes in TBpatients.The present study shows that diabeteswas more common among TB patients with BMI more 25 (19.0%) as compare to thosewith 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 tuberculosiswas significantly more among type II category tuberculosis patients as compareto Type I treatment category tuberculosis. Finding of this study was supported by earlier study 22,23.In current study we foundthat smoker tuberculosis patients have significantly more diabetes (16.

3%) ascompared to non smoker tuberculosis patients (9.8%) (p=0.0001).

Similar resultwas found in earlier study 24,25.The NNS to detect a new case of DM among TB patients was22.  This number varies in from lower toamong study from south India may we due to higher prevalence of diabetesmellitus. we found that NNS needed to detect one case of DM amongTB patients decreases as the age increases14,26.Thisshows the importance of early screening of patients with TB and will enable usto manage these patients in the early phase. Pre-diabetes diagnose at earlyphase so that primary prevention methods may be initiated timely. As we higherburden of both TB and DM in our country, We need better information, recordingand monitoring system to guide us in managing this co-morbidity, and we need tostrengthen the care of these patients in our existing health services.

Ourstudy had several strengths. The strength ofthis study is that we implement this screening programme in routine programmesettings. We also emphasis on the NNNS todiagnose a new case of DM with respect to different variables so we can focuson the lower value of NNS for screening on large scale. There were a fewlimitations like previous documentation of blood sugar not cross check. Meantime for sugar testing and disease duration was not same for each tuberculosispatients.Thestudy has several programmatic implications as results of current study emphasizesthat National TB control program in collaboration with NCD program should havespecial provision for screening, diagnosis, and management of DM amongtuberculosis patients.

Acknowledgement:Theauthors thank Revised National Tuberculosis Control Program, Madhya Pradesh,India for providing financial assistance for the survey. We are also thankfulto the Department of Education for the support during data collection. We arealso very grateful to Dr. Manoj Verma, DTO Bhopal, for their support duringstudy. References:1.

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