Public Health Action VOL
3 SUPPLEMENT 1
PUBLISHED
InternaƟonal Union Against Tuberculosis and Lung Disease Health soluƟons for the poor
4 NOVEMBER 2013
Screening tuberculosis patients for diabetes in a tribal area in South India S. Achanta,1 R. R. Tekumalla,2 J. Jaju,1 C. Purad,1 R. Chepuri,1 R. Samyukta,3 S. Malhotra,4 S. B. Nagaraja,1,5 A. M. V. Kumar,6 A. D. Harries7,8 http://dx.doi.org/10.5588/pha.13.0033
Setting: Ten peripheral health institutions of a tribal tuberculosis unit, Saluru, Vizianagaram District, South India. Objective: To assess among tuberculosis (TB) patients: 1) the feasibility of screening for diabetes mellitus (DM), 2) the prevalence of DM, 3) the demographic and clinical features associated with DM, and 4) the number needed to screen (NNS) to find one new case of DM. Design: Cross-sectional study: all TB patients registered from January to September 2012 were screened for DM using a screening questionnaire and random blood glucose, followed by fasting blood glucose (FBG) measurements using a glucometer. DM was diagnosed if FBG was ⩾126 mg/dl. Results: Of 381 patients, 374 (98%) were assessed for DM, suggesting feasibility of screening, and 19 (5%) were found to have DM (12 were newly diagnosed and 7 had a previous diagnosis of DM). The only characteristic associated with DM was age ⩾40 years. The NNS to detect a new case of DM among all TB patients was 31; among those aged ⩾40 years, the NNS was 20, and among current smokers it was 21. Conclusion: Screening of TB patients for DM was feasible and effective, and this should inform national scaleup. Other key considerations include the continued provision of free TB-DM screening, with co-location and integration of services.
I
ndia has the highest burden of tuberculosis (TB) in the world,1 and an estimated 63 million people living with diabetes mellitus (DM).2 Evidence suggests that the DM population has a significantly increased risk of developing active TB (two or three times higher than in those without DM).3–6 Three recently published epidemiologic studies in South India in about 1500 patients with TB found a high prevalence of DM: about 25% in Tamil Nadu,7 32% in Karnataka8 and 44% in Kerala.9 A landmark project conducted by the International Union Against Tuberculosis and Lung Disease (The Union), the World Health Organization (WHO) and the national authorities in India on bidirectional screening of TB and DM, modelled on the Collaborative Framework for care and control of tuberculosis and diabetes, was implemented in eight tertiary centres and more than 60 peripheral health facilities in eight tuberculosis units (TUs), including Vizianagaram.10 The India Tuberculosis–Diabetes Study Group (ITDG) assessed the feasibility and results of screening TB patients for DM with pooled data from the project sites.11 The study
showed that of 8109 TB patients who were assessed for DM, 1084 (13%) were found to have DM, based on fasting blood glucose (FBG) measurements. Based on these data, a policy decision was made by India’s Revised National TB Control Programme (RNTCP) to implement countrywide screening of TB patients for DM.11 One limitation of this study, however, was that it published only aggregate data from all sites, and may have missed site-specific variations, and other socio-demographic and clinical factors affecting the effectiveness and feasibility of the screening programme. We therefore analysed individual patient data and described the effectiveness of screening all TB patients for DM in one tribal TU. The tribal area is remote and difficult to access due to poor connectivity and lack of other basic infrastructure. Indicators relating to literacy, economic status, social status and access to health care services are poor among tribes compared to the general population.12 The tribes are in transition from a forest-centred way of life to a rural, settled farming lifestyle. Given the different lifestyle, more access to unprocessed, fibrerich foods, including fruit and vegetables in their diet and greater daily physical activity, we hypothesized that the prevalence of DM would be considerably lower in tribal areas when compared with the rest of the country. The specific objectives of the study were to assess, among a cohort of TB patients: 1) the feasibility of screening for DM, 2) the prevalence of DM, 3) the demographic and clinical features associated with DM, and 4) the number needed to screen (NNS) to find one new case of DM among TB patients.13,14
AFFILIATIONS 1 World Health Organization Country Office in India, New Delhi, India 2 District TB Centre, Ministry of Health and Family Welfare, Government of Andhra Pradesh, Visakhapatnam, India 3 State TB Cell, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Andhra Pradesh, Hyderabad, India 4 All India Institute of Medical Sciences, New Delhi, India 5 Department of Community Medicine, Employees State Insurance Corporation (ESIC) Medical College, Bangalore, India 6 International Union Against Tuberculosis and Lung Disease ( The Union), South-East Asia Office, New Delhi, India 7 The Union, Paris, France 8 London School of Hygiene & Tropical Medicine, London, UK CORRESPONDENCE S Achanta District TB Centre Government Hospital for Chest and Communicable Diseases Pedda Waltair Visakhapatnam Andhra Pradesh, India 530017 e-mail: [email protected]; [email protected] KEY WORDS TB; bidirectional screening; DM; India; NNS
METHODS Study design This was a descriptive study of all TB patients attending the study TU.
Setting The study was conducted in Saluru TU (a geographical area defined under the RNTCP as a sub-district-level programme management unit, covering a population of 250 000), with TB diagnostic and treatment services being delivered through a network of primary, secondary and tertiary health care facilities. Saluru TU is a sub-division of one of the initial 30 districts identified in India for piloting the roll-out of non-communicable disease prevention and control activities through the National Programme for Prevention of Cancer, Diabetes, Cardiovascular Disease and Stroke, with communitybased screening of all individuals aged >30 years for
Received 22 May 2013 Accepted 2 July 2013
PHA 2013; 3(S1): S43–S47 © 2013 The Union
Public Health Action DM.15 The TU is termed tribal because >70% of the population belong to one of the Scheduled Tribes. Screening and diagnosis of DM followed national guidelines, which stipulate that FBG should be used with cut-off thresholds in line with those recommended by the WHO.16 Briefly, FBG ⩾ 126 mg/dl (⩾7 mM) indicates DM; FBG 110–125 mg/dl (6.1–6.9 mM) indicates impaired fasting glucose (IFG); and FBG < 110 mg/dl (
3 SUPPLEMENT 1
PUBLISHED
InternaƟonal Union Against Tuberculosis and Lung Disease Health soluƟons for the poor
4 NOVEMBER 2013
Screening tuberculosis patients for diabetes in a tribal area in South India S. Achanta,1 R. R. Tekumalla,2 J. Jaju,1 C. Purad,1 R. Chepuri,1 R. Samyukta,3 S. Malhotra,4 S. B. Nagaraja,1,5 A. M. V. Kumar,6 A. D. Harries7,8 http://dx.doi.org/10.5588/pha.13.0033
Setting: Ten peripheral health institutions of a tribal tuberculosis unit, Saluru, Vizianagaram District, South India. Objective: To assess among tuberculosis (TB) patients: 1) the feasibility of screening for diabetes mellitus (DM), 2) the prevalence of DM, 3) the demographic and clinical features associated with DM, and 4) the number needed to screen (NNS) to find one new case of DM. Design: Cross-sectional study: all TB patients registered from January to September 2012 were screened for DM using a screening questionnaire and random blood glucose, followed by fasting blood glucose (FBG) measurements using a glucometer. DM was diagnosed if FBG was ⩾126 mg/dl. Results: Of 381 patients, 374 (98%) were assessed for DM, suggesting feasibility of screening, and 19 (5%) were found to have DM (12 were newly diagnosed and 7 had a previous diagnosis of DM). The only characteristic associated with DM was age ⩾40 years. The NNS to detect a new case of DM among all TB patients was 31; among those aged ⩾40 years, the NNS was 20, and among current smokers it was 21. Conclusion: Screening of TB patients for DM was feasible and effective, and this should inform national scaleup. Other key considerations include the continued provision of free TB-DM screening, with co-location and integration of services.
I
ndia has the highest burden of tuberculosis (TB) in the world,1 and an estimated 63 million people living with diabetes mellitus (DM).2 Evidence suggests that the DM population has a significantly increased risk of developing active TB (two or three times higher than in those without DM).3–6 Three recently published epidemiologic studies in South India in about 1500 patients with TB found a high prevalence of DM: about 25% in Tamil Nadu,7 32% in Karnataka8 and 44% in Kerala.9 A landmark project conducted by the International Union Against Tuberculosis and Lung Disease (The Union), the World Health Organization (WHO) and the national authorities in India on bidirectional screening of TB and DM, modelled on the Collaborative Framework for care and control of tuberculosis and diabetes, was implemented in eight tertiary centres and more than 60 peripheral health facilities in eight tuberculosis units (TUs), including Vizianagaram.10 The India Tuberculosis–Diabetes Study Group (ITDG) assessed the feasibility and results of screening TB patients for DM with pooled data from the project sites.11 The study
showed that of 8109 TB patients who were assessed for DM, 1084 (13%) were found to have DM, based on fasting blood glucose (FBG) measurements. Based on these data, a policy decision was made by India’s Revised National TB Control Programme (RNTCP) to implement countrywide screening of TB patients for DM.11 One limitation of this study, however, was that it published only aggregate data from all sites, and may have missed site-specific variations, and other socio-demographic and clinical factors affecting the effectiveness and feasibility of the screening programme. We therefore analysed individual patient data and described the effectiveness of screening all TB patients for DM in one tribal TU. The tribal area is remote and difficult to access due to poor connectivity and lack of other basic infrastructure. Indicators relating to literacy, economic status, social status and access to health care services are poor among tribes compared to the general population.12 The tribes are in transition from a forest-centred way of life to a rural, settled farming lifestyle. Given the different lifestyle, more access to unprocessed, fibrerich foods, including fruit and vegetables in their diet and greater daily physical activity, we hypothesized that the prevalence of DM would be considerably lower in tribal areas when compared with the rest of the country. The specific objectives of the study were to assess, among a cohort of TB patients: 1) the feasibility of screening for DM, 2) the prevalence of DM, 3) the demographic and clinical features associated with DM, and 4) the number needed to screen (NNS) to find one new case of DM among TB patients.13,14
AFFILIATIONS 1 World Health Organization Country Office in India, New Delhi, India 2 District TB Centre, Ministry of Health and Family Welfare, Government of Andhra Pradesh, Visakhapatnam, India 3 State TB Cell, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Andhra Pradesh, Hyderabad, India 4 All India Institute of Medical Sciences, New Delhi, India 5 Department of Community Medicine, Employees State Insurance Corporation (ESIC) Medical College, Bangalore, India 6 International Union Against Tuberculosis and Lung Disease ( The Union), South-East Asia Office, New Delhi, India 7 The Union, Paris, France 8 London School of Hygiene & Tropical Medicine, London, UK CORRESPONDENCE S Achanta District TB Centre Government Hospital for Chest and Communicable Diseases Pedda Waltair Visakhapatnam Andhra Pradesh, India 530017 e-mail: [email protected]; [email protected] KEY WORDS TB; bidirectional screening; DM; India; NNS
METHODS Study design This was a descriptive study of all TB patients attending the study TU.
Setting The study was conducted in Saluru TU (a geographical area defined under the RNTCP as a sub-district-level programme management unit, covering a population of 250 000), with TB diagnostic and treatment services being delivered through a network of primary, secondary and tertiary health care facilities. Saluru TU is a sub-division of one of the initial 30 districts identified in India for piloting the roll-out of non-communicable disease prevention and control activities through the National Programme for Prevention of Cancer, Diabetes, Cardiovascular Disease and Stroke, with communitybased screening of all individuals aged >30 years for
Received 22 May 2013 Accepted 2 July 2013
PHA 2013; 3(S1): S43–S47 © 2013 The Union
Public Health Action DM.15 The TU is termed tribal because >70% of the population belong to one of the Scheduled Tribes. Screening and diagnosis of DM followed national guidelines, which stipulate that FBG should be used with cut-off thresholds in line with those recommended by the WHO.16 Briefly, FBG ⩾ 126 mg/dl (⩾7 mM) indicates DM; FBG 110–125 mg/dl (6.1–6.9 mM) indicates impaired fasting glucose (IFG); and FBG < 110 mg/dl (
