TUBERCULOSIS AND DIABETES PERSPECTIVES

Dr. T. Angel Miraclin Assistant Professor

Department of Medicine – 3 Christian Medical College,Vellore

Tuberculosis and Diabetes:History

• Indian physician Susruta, in 600 A.D.

“phthisis frequently complicated diabetes”

• Autopsy of diabetics in 1883 showed presence of TB granuloma in 50% of diabetics

• Prior to the insulin era: Diagnosis of DM was a death sentence

– Leading cause of death was: Tuberculosis

1.Barach JH. Historical facts in Diabetes. Ann Med Hist; 1928 2.Smurova TF. Lung tuberculosis with associated diabetes mellitus. Excerpta Medico Chest Dis Thorac Surg Tuberc 1980

Diabetes in India - 2015

• Total adult population (1000s)(20-79 years) - 798,988

• Number of deaths in adults due to diabetes - 1,027,911

• Prevalence of diabetes in adults(20-79 years) (%) - 8.7

• Cost per person with diabetes (USD) - 94.9

• Total cases of adults (20-79 years) with diabetes (1000s) - 69,188.6

• Number of cases of diabetes in adults that are undiagnosed (1000s) - 36,061.1

Tuberculosis in India - 2015

• India is the country with the highest burden of TB.

• The World Health Organisation (WHO) statistics for 2015 give an estimated incidence figure of 2.2 million cases of TB for India out of a global incidence of 9.6 million.

• The estimated TB prevalence figure for 2015 is given as 2.5 million.

• It is estimated that about 40% of the Indian population is infected with TB bacteria, the vast majority of whom have latent rather than active TB.

TB is associated with worsening glycemic control in people with diabetes: - The risk is related to how the blood glucose levels varies, i.e.

uncontrolled diabetes and the length of period of uncontrolled diabetes.

- Higher hyperglycaemia, the higher the risk – for example T1DM patients are likely to be more underweight and typically have uncontrolled diabetes.

Medications for TB may interfere with the treatment of diabetes

through drug interactions.

The onset of diabetes may be triggered by TB.

TB infection may progress at a faster rate in people with diabetes than in those without diabetes.

Public health relevance of the association How does TB affect diabetes patients?

• People with diabetes have a 2-3 times higher risk of developing TB disease compared to people without diabetes.

• People with TB and coexisting diabetes have 4 times higher risk of death during TB treatment and higher risk of TB relapse after treatment.

• People with TB and coexisting diabetes are more likely to be sputum positive and take longer to become sputum negative.

• Diabetes may adversely affect TB treatment outcomes by delaying the response time to treatment.

• The emergence of drug-resistant TB may be accelerated by diabetes.

• Diabetes may interfere with the activity of TB medications.

Public health relevance of the association How does diabetes affect TB patients?

Clinical characteristics, treatment outcomes and direct medical costs in hospitalised patients with

tuberculosis and the impact of diabetes on outcomes – A retrospective study.

Our experience from a single medical unit over 3 years

AIM

• To study the clinical profile,cost of care and treatment outcomes among hospitalised patients with tuberculosis.

• To study diabetes as an exposure among patients with tuberculosis and the impact on outcomes.

STUDY DEFINITIONS

• Cure - Negative sputum results at the end of full course of anti-tubercular treatment.

• Default – Loss to follow-up after discharge/stopped treatment at follow-up

• Death – Died during treatment in – hospital.

RESULTS

TOTAL NUMBER OF ADMISSIONS (2013 – 2015)

N = 5488

TOTAL NUMBER OF ADMISSIONS WITH TUBERCULOSIS

N = 138

TOTAL NUMBER INCLUDED IN THE STUDY

N - 120

Non diabetic TB Patients

n = 52

Diabetic TB patients n = 68

PRIMARY OUTCOMES -In hospital mortality

-Cure -Default

-Mean cost per hospitalised person

Parameter Diabetics Non - diabetics p-value

Number of patients 68 52

Demography Mean age(years+SD) 52.2+11.8 37.9+15.6 0.002

Male sex (%) 44(64.7) 36(69.2)

Alcohol abuse (%) 17(25) 10(19.6)

Smoking (%) 30(44.1) 13(25.4) 0.036

State (Tamil- Nadu)(%) 35(51.5) 24(46.1)

Tuberculosis Pulmonary (%) 52(76.4) 36(69.2)

Disseminated (%) 16(23.5) 16(30.7)

Duration of symptoms(months+SD) 3.2+3.1 3.6+4.3

Body weight at admission(kg+SD) 52.7+9.5 42.8+11.2 0.002

Haemoptysis (%) 27(39.7) 16(30.7)

Recurrence (%) 17(25) 6(11.5) 0.063

Sputum smear positivity (%) 52(76.4) 46(88.2)

Daily regimen (%) 45(66.7) 38(73.3)

Diabetes Duration of diabetes(years+SD) 7.36+5.5 - -

Neuropathy (%) 43(63.3) - -

Nephropathy (%) 22(33.3) - -

Retinopathy (%) 21(31.7) - -

Glycosylated Haemoglobin (%+SD) 9.174+2.66 - -

Comorbid illness Hypertension (%) 45(66.1) 2(3.8) 0.000

Ischemic heart disease (%) 12(17.6) 2(3.8) 0.020

HIV (%) 2(3.3) 9(17.3) 0.028

Laboratory investigations Hemoglobin (mg%)+SD 10.7+1.9 10.0+2.2 0.088

Serum Albumin (mg %)+SD 3.0+0.8 2.9+0.8

Serum Creatinine (mg %) 1.0+0.5 0.9+0.6

BASELINE CHARACTERISTICS

0

10

20

30

40

50

60

70

80

90

100

DEATH%(n=19) CURE%(n=40) DEFAULT%(n=61)

PER

CEN

TAG

E %

PRIMARY OUTCOMES

NON DIABETICS

DIABETICS

p- 0.318

p-0.068

p – 0.370

Mean difference in time to sputum smear conversion was

1.3 months.

N=6 N=13

N=22

N=18

N=24 N=37

INTENSIVE CARE

ICU CARE 12%

WARD CARE 88%

PROPORTION REQUIRING INTENSIVE CARE(n=120)

(N=14)

(N=106)

5

9

0

10

20

30

40

50

60

70

80

90

100

DIABETICS NON - DIABETICS

REQUIREMENT OF INTENSIVE CARE BETWEEN GROUPS(n=14)

p – 0.092

0 20000

40000 60000

80000 100000

120000 140000

160000

COST OF CARE - DIABETIC

COST OF CARE NON DIABETIC

COST OF INTENSIVE CARE

COST OF CARE

COST OF CARE - DIABETIC COST OF CARE NON DIABETIC COST OF INTENSIVE CARE

Series1 39799 39793 159479

COST OF CARE Mean duration of

hospitalisation – 10

days.

Lessons learnt from our experience…

• People with TB and coexisting diabetes are more likely to be sputum positive and take longer to become sputum negative.

• Diabetes may adversely affect TB treatment outcomes by delaying the response time to treatment.

• The proportion of recurrent cases are higher in diabetics.

• Hospitalised patients with tuberculosis were found to have poor glycemic control.

• The mean cost of care was higher in hospitalised diabetics with

Epidemiological results from International Projects

• TB patients screened for diabetes – In India, results have shown that prevalence of diabetes among TB patients

ranges between 13-25%, the highest being the particularly in the South → this fits well the 3-fold risk (World Diabetes Foundation(WDF) 08-385 & 10-585).

– In China results have shown that the prevalence of diabetes among TB patients has shown to be 12.4% (WDF10-585)

• Diabetes patients screened for TB: – In India, results have shown that the incidence rate of TB among diabetes

patients was almost 8 timer higher, as compared to TB cases in general population (WDF10-585).

– In China results have shown that the that the incidence rate of TB among diabetes patients was almost 5.5 timer higher, as compared to TB cases in general population(WDF10-585).

DIABETES AND TUBERCULOSIS – A SURVIVAL ANALYSIS

Reed GW, Choi H, Lee SY, Lee M, Kim Y, et al. (2013) Impact of Diabetes and Smoking on Mortality in Tuberculosis. PLoS ONE 8(2): e58044. doi:10.1371/journal.pone.0058044 http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0058044

Recommendations of the task force – the 5 prongs to tackle the epidemic

• Policy

• Programme implementation

• Financing and technical assistance

• Health service delivery

• Advocacy

WHO DMTB REPORT - 2015

Conclusions

• Diabetes is rising rapidly worldwide and is increasingly fueling the spread of TB.

• In people being treated for TB, diabetes is associated with their remaining contagious for longer than usual, and it increases the risk that they will die from TB or become sick again after they have finished treatment.

• The legendary Canadian ice hockey player Wayne Gretzky is famous for his playing strategy, which was

“to [skate] where the puck is going, not where it’s

been.” • This strategy applies just as well to the public health

response to TB and diabetes. • We have witnessed how HIV caused TB to skyrocket in

subSaharan Africa. • The response to that co-epidemic was slower than

necessary, leading to enormous and avoidable loss of life plus economic costs. We must avoid repeating this mistake.

Copyright of this educational material rests with

the author and Christian Medical College, Vellore.

Duplication, revision and redistribution are not

permitted. For any further clarification please

contact the concerned author

© reserved to author and Christian Medical College, Vellore