Post on 25-Dec-2015
Tuberculosis and Diabetes
Christine S. Ho MD, MPHMargaret Wheeler MD
Overview
• Review the epidemiology of TB• Review the epidemiology of DM• Review the relationship between TB and DM• Implications of epidemiology and risk
– Screening, presentation, diagnosis, treatment• Issues in co-management of TB and DM• Cases
Tuberculosis in the United States - 2008
CDC/DTBE National Tuberculosis Surveillance System Highlights
Reported TB Cases* United States, 1982–2008
10,000
12,000
14,000
16,000
18,000
20,000
22,000
24,000
26,000
28,000
1984 1987 1990 1993 1996 1999 2002 2005 2008
• *Updated as of May 20, 2009.
*Updated as of May 20, 2009.
TB Case Rates,* United States, 2008
< 3.5 (year 2000 target)3.6–4.2
> 4.2 (national average)
D.C.
*Cases per 100,000.
Reported TB Cases by Race/Ethnicity* United States, 2008
Hispanic or Latino(29%) Black or
African-American(25%)
Asian(26%)
White(17%)
American Indian or Alaska Native (1%)
Native Hawaiian orOther Pacific Islander (<1%)
*All races are non-Hispanic. Persons reporting two or more races accounted for less than 1% of all cases.
Number of TB Cases inU.S.-born vs. Foreign-born Persons
United States, 1993–2008*
0
5000
10000
15000
20000
1993 1996 1999 2002 2005 2008
U.S.-born Foreign-born
No.
of
Cas
es
*Updated as of May 20, 2009.
0
10
20
30
40
50
1993 1996 1999 2002 2005 2008
TB Case Rates by Race/Ethnicity* United States, 1993–2008**
Cas
es p
er 1
00,0
00
WhiteBlack or African-AmericanHispanic
American Indian/Alaska NativeAsian/Pacific Islander
*All races are non-Hispanic. In 2003, Asian/Pacific Islander category includes persons who reported race as Asian only and/or Native Hawaiian or Other Pacific Islander only.**Updated as of May 20, 2009.
Percentage of TB Cases Among Foreign-born Persons, United States*
>50%25%–49%
<25%
1998 2008
DC DC
*Updated as of May 20, 2009.
Percent of Foreign-born with TB by Time of Residence in U.S. Prior to Diagnosis,
2008
0%
20%
40%
60%
80%
100%
All Mexico Philippines India
Missing* <1 yr 1–4 yrs >5 yrs
* Foreign-born TB patients for whom information on length of residence in the U.S. prior to diagnosis is unknown or missing.
TB in the US
Translated clinically• Risk factors for TB
– Exposure• Household contacts• Foreign-born from TB endemic regions• Congregate settings- shelters, prisons, hospitals• Poverty
– Impaired immunity (host factors)• Substance abuse: IVDA, Smoking,Heavy ETOH• Nutritional status: underweight, Vit D• Systemic disease: CA, silicosis, HIV, DM, renal dz; gastric
bypass, celiac sprue• Immune compromise: HIV, steroids, TNF inhibitors,
transplant• Age
Risk factors for Latent TB Infection
• Foreign born• Prisoners• Homeless/marginally housed• Injection Drug Users• Racial/ethnic minorities• Recent contact to TB
Risk Factors for Progression to Active TB
• Recent exposure/contact with TB case• Diabetes• HIV• Other medical conditions:
• Renal failure• Smoking• Immunosuppressants: s/p transplant, steroids. Anti-TNF• s/p gastrectomy/ jejuno-ileal bypass• Silicosis• Malnutrition
Epidemiology of DMin the United States
0
1
2
3
4
5
6
7
1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06
Year
Per
cen
t w
ith
Dia
bet
es
0
2
4
6
8
10
12
14
16
18
20
Nu
mb
er w
ith
Dia
bet
es (
Mil
lio
ns)Percent with Diabetes
Number with Diabetes
Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2008
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
1994
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
1995
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
1996
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
1997
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
1998
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
1999
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
2000
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
2001
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
2002
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
2003
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
2004
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
2005
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
2006
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
2007
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Obesity (BMI≥30 kg/m2) Diabetes
<4.5%Missing data4.5 - 5.9% 6.0 - 7.4%7.5 - 8.9% ≥9.0%
18.0 -21.9%<14.0%Missing Data
14.0 - 17.9%22.0 - 25.9% ≥26.0%
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
2008
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
Obesity (BMI ≥30 kg/m2)
Diabetes
1994
1994
2000
2000
No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%
No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
2008
2008
Prevalence DM by Age/Sex/Ethnicity US 2007
Increase in Prevalence DM by Ethnicity and Sex 1980-2007
Obesity & DM Prevalence in FB
• Increase with length of residenceOza-Frank, 2009
• Odds Ratio of DM among Foreign-born– Highest among East Indians (OR 3-4)– Latinos (OR 2)– Chinese
Oza-Frank, 2010Venkaya 2008
Percent Chronic Illness/Risk by Nativity and Ethnicity
Risk Native N. Hisp. N. Asia FB FB Hisp FB Asia
Obesity 23 30 11 16 21 5
cigs 24 20 15 14 14 12
DM 6 11 6 6 7 6
HTN 24 25 24 24 19 19
CV 8 8 7 6 5 5
Dey,CDC 2006
Tuberculosis and Diabetes
Audience response: TB increases the risk of DM
• True ?
• False ?
Not that we know of….
• No evidence to suggest that having tuberculosis or taking medications for tuberculosis increases the risk for diabetes
• Increased hyperglycemia with active disease and with rifampin-induced medicine interactions, but not development of DM
Audience response: Diabetes increases the risk of tuberculosis
• True ?
• False ?
Why increased risk?
Diabetes and Active TB – Evidence?• First described by the Romans..• 2008 Systematic review
– 13 observational studies show increased risk of TB in DM patients
– 3 prospective cohort studies showed RR 3.1 (CI 2.3-4.6)
– 8 case-control studies with OR 1.2-7.8 – Assoc’d with higher background TB incidence,
younger ageJeon, PLoS 2008
• Studies since 1995— OR 1.5-7.8 of TB in pts w/DM
Jeon et al. 2008
RR 1
Relative Risk Varying by TB Incidence
Variable RR 95% CI
Background TB Incidence ≥100 3.3 2.1-5.2
≥10 and<100 2.2 1.4-3.5
<10 1.9 1.1-3.2
Region C. America 6.0 5.0-7.2
Europe 4.4 2.5-7.8
Asia 3.1 2.3-4.3
N. Am Hispanics 2.7 2.3-3.2
N. Am Nat. Am. 1.9 0.3-10
N. Am Non-Hisp. 1.23 1.1-1.3
Diabetes and Active TB
• Contacts– Hong Kong prospective study of 4661 close contacts– RR 3.4 for both early ( 3month) and late ( within 5yrs)
diseaseLee MS, Int J
Tuberc Lung 2008
• Attributable Risk (India,2000) – 21 million DM; 900K pulm.TB– 15% excess pulmonary TB cases in DM pts– 20% excess smear positive cases in DM pts
Stevenson, BMC Pub Health 2007
Relative Risk - Progression to Active TB
Condition Relative Risk of TB
HIV 7-16
Healed TB 3-8
DM 2.3-4.8
Smoking 1.5-2.0
Renal Disease 2.1-52.5
Gastric bypass 1.7-2.0
Attributable Risk Depends on Relative Risk and Underlying
Prevalence
RR Prevalence Population Attributable Risk
HIV 8.3 1% 7%
DM 3.0 3.4% 6%
3.0 10% 17%
3.0 20% 29%
Raviglione, WHO
Implications : Screening
? Screen TB for DM– Tanzania study of OGT on all with TB
Mugusi, 1990
• Saipan experience– TB and DM epidemics – clinics cross-screening
Case #1
• 62 year old Salvadorean woman with DM who came to the US 4 years ago presents for primary care.
• Should she be screened with a TST?
• Yes• No
TB Case Rates in U.S.-born vs. Foreign-born Persons United
States, 1993–2008*
0
10
20
30
40
1993 1996 1999 2002 2005 2008
U.S. Overall U.S.-born Foreign-born
Case
s pe
r 100
,000
*Updated as of May 20, 2009.
Global TB Incidence 2005
From WHO data (http://www.who.int/tb/publications/global_report/2007/)
80% of TB Cases
www.tbalert.org/worldwide/world
Countries Accounting for 80% TB Cases
1. Afghanistan2. Bangladesh3. Brazil4. Cambodia 5. China*6. Republic of Congo7. Ethiopia8. India*9. Indonesia*10.Kenya11.Mozambique
12. Myanmar13. Nigeria14. Pakistan15. Philippines16. Russia17. South Africa18. Tanzania19. Thailand20. Uganda21. Viet Nam22. Zimbabwe
An Approach to Immigrant Health: Risk Assessment
• Health risks of native country
• Health risks of travel– both initial and recurrent
• Health risks of adopted country
High Risk Travel Medicine• 50% of US residents traveling abroad are FB visiting home
• Higher risk of getting sick while traveling for FB
• Riskier behavior – Visits while pregnant, sick or with children– Longer stays, eat like hosts. – More often sex, rural areas, contact to sick relatives– Travel for health care or use health care– dentistry etc
• But less often vaccinated/prophylaxed/tested when back
Bacaber. JAMA. 2004;291:2856-2864.Deren S et al.. Am J Public Health.
2003;93:812-816.
New Immigrants and Risk of TB
Origin Time in U.S. Case Rate
U.S. Born 2.7
Foreign-Born Total 21.5
≦1 year 121.0
>1 and 5 years≦ 30.0
> 5 years 11.9
Cain et al. 2007 AJRCCM
Where do we go from here?TBESC foreign-born study: co-morbidities
N=264 respondents n %
Smoked more than 100 cigarettes in lifetime 89 33.7
Diabetes 53 20.1
Taking medicines that contain steroids 16 6.1
HIV/AIDS 11 4.2
Cancer 7 2.7
Kidney dialysis 4 1.5
Organ transplant 1 0.4
Silicosis or coal miner lung disease 1 0.4
Slide courtesy of Jenny Flood, M.D and CA DPH TB staff
Intersection of risks: TB infection; medical; and population risks
TB
AIDS, diabetes, renal dialysis…Foreign-born
Slide courtesy of Jenny Flood, M.D and CA DPH TB staff
1,835,000
185,00095,858
45,047 34,087
3,297
1
10
100
1,000
10,000
100,000
1,000,000
10,000,000
Nu
mb
er
of p
eo
ple
(lo
g s
cale
)
Diabetes RheumatoidArthritis
HIV/AIDS Renaldialysis
Crohn'sDisease
Organtransplantrecipients
Selected populations in CA with medical risk factors for TB, and LTBI estimates
636,000 (35%)
Foreign-born Foreign-born (FB):(FB):
31,450(17%)
13,551(14%)%)
11,27811,278(25%)(25%)
1,5071,507(4%)(4%)
730(22%)
FB with LTBI: 119,000 6,000 2,500 2,100 300 150
Slide courtesy of Jenny Flood, M.D and CA DPH TB staff
Case #1 Answer
• YES!• Born in TB-endemic region• New immigrant• DM• 3 overlapping risk factors
• Remote history of BCG-vaccination
Case #2
Dr. B is a retired physician from Russia who came to the US 10 years ago. She is screened and has 15mm of induration.
Do you believe her TST result?Would you get a chest x-ray?Would you get sputum specimens?Would you treat?
Dr. B
• Issues to consider– Immigrated from TB-endemic country– Healthcare worker– Exposure to drug-resistant TB– BCG vaccination effects on TST/Beliefs regarding
this
Active TB and Diabetes
Does DM affect presentation and treatment of active disease?
• Yes
• No
Case #3-Mr. W
• Mr. W is a 61 y.o. Chinese man referred from a local health dept clinic for an abnormal CXR
• PMH:– exercise-controlled DM with FS 120’s– chronic low back pain – h/o colon cancer s/p hemicolectomy
Mr. W (2)
• Pt well until fell off bike 2/20/09• In ED:
– L-S spine showing narrowed disk space L4-S1– Instructed to f/u with PCP regarding incidental
finding of low grade fever,
• Pt is meticulous & records temps at home: 99-100F consistently for over 1 month
Mr. W (3)
• No other remarkable symptoms at that time • PCP orders GI appointment for repeat
colonoscopy• Meanwhile patient develops scant cough, and
some fatigue, wonders about needing a CXR• Luckily, MD orders CXR 4/1/09
TB is more advanced at presentation in diabetics
• More often smear positive• More frequently present with hemoptysis• More often with cavitary lesions• More often with fever
Restrepo , Epi and Inf 2009
• More delayed diagnosis versus rapid disease progression?
DM and Presentation of TB
• Cavitary lesions – 51% of pts with DM – 39% of pts without DM (Shaikh, 2003)
• Lower lung lesions – 24% of pts with DM – 2.4% of pts without DM (Alisjahbana 2007)
• 20% of 280 CA TB pulmonary cases reported DM– 66% of smear-positive cases have DM– 31% of DM cases had cavitary disease vs. 14% non-
diabetics
• Not great studies…case-series, retrospective case-control – most do not look at DM
• EPTB mostly due to immunosuppression– HIV, ESRD known risk factors
DM?• Retrospective case-control study in Taipei with 75 pts
with EPTB– 20% with DM– TB peritonitis: 27% with DM vs. 7% without DM
(OR 5, CI 1.1-23.4) Weng 2009
DM Risk Factor for Extrapulmonary Disease- Not clear???
Audience response: Diabetics do just as well once treated
• True
• False
Treatment and Communication
• May have multiple providers—PCP/TB• Low-income, diverse pts with DM
– More than 50% low literacy/numeracy– Limited English proficiency– Sensory deficits: vision and hearing– Subtle cognitive impairments common in
longstanding DM– Use teach-back method
Mr.W (4)
• Empiric RIPE rx started for miliary TB • PCP contacted to start DM medicines to
optimize glucose control• 4/22 patient develops new R leg numbness• What might the pain/numbness from?• Would you have done anything differently?
Mr.W(5)
• DDx includes: ???– Mononeuritis multiplex– Paradoxical reaction– Other thoughts?
• B6 increased to 100mg, ibuprofen given• Pain/sciatica has worsened. Now unable to
negotiate stairs – has moved to downstairs bedroom.
• What is going on?
Mr.W (5)
• Post ED MRI on 3/5/09 shows reactive infiltrative process of L2, compression fx of L3, deg dz L3 through S1.
• Diagnosis – Pott’s disease
Case #4
• Mr. R is a 30 year old man with DM and has lived in the US for 10 yrs. He traveled to Chiapas 4 months ago and ran out of his DM meds. He presents with fatigue, 20 pound weight loss and cough with hemoptysis. He went to visit his ill sister, who had a respiratory illness.
• He lives in an apartment with 14 other day laborers.
Mr. R’s CXR
Mr. R
• Mr. R is started on INH, Rifampin, Pyrazinamide, Ethambutol and Vitamin B6
• His diabetic control worsens• He continues to lose weight• His AST and ALT are elevated into the 80s• His creatinine is normal
Treatment Issues - Rifampin
• Rifampin levels may be lower in diabetics– 17 age and sex-matched TB cases w/w/o DM– AUC 12.3 with DM; 25.9 no DM– Peak levels 50% as high in those with DM– Assoc’d with higher body weight and poor glucose
control– Consider rifampin levels for slow sputum
convertors Nijland, CID
2006
Treatment Issues – Rifampin cont’d
• Rifampin raises blood glucose even in non-diabetics
• Induces CYP450 enzyme system• Affects metabolism of sulfonylureas and
thiazolidinediones• Blood glucose control may worsen while
diabetics taking Rifampin
Treatment Issues Cont’d
• Diabetics at increased risk of hepatotoxicity• Screen with LFTs for INH,Rif or PZA-induced
hepatitis• At increased risk for INH-related neuropathy• EMB and PZA need dose adjustment in renal-
impaired patients• Chronic renal insufficiency or renal failure a
morbidity of DM – so check Cr!
Mr. R (2)
A. Increase DM managementB. Drug susceptibility testingC. Check rifampin levelsD. Assess adherenceE. Change TB drug regimenF. All except D
Mr. R (3)
• Insulin started. His cultures are pan-sensitive. He begins to gain weight. At 8 weeks his smears are still culture positive.
• Do you change his regimen in any way?
Risk of Relapse is associated with
• Culture status at 2 month
• Presence of Cavitations
Does DM Impact TB Treatment and Cure?
• Previously thought not to affect treatment• Four new studies from Baltimore, Texas,
Taiwan and Indonesia reveal:– Delayed culture conversion– Higher mortality
– Dooly, 2009; Restrepo 2008; Wang 2008; Alisahlanda,2007
• Culture conversion< 90 days in CA TB pts:– 86% in pts with DM– 92% in pts without DM
Response to Treatment
• Unclear if increased drug resistance in DM
• Relapse may be more frequent– Recent Shanghai study
• 20% relapse rate in pts with DM• 5% relapse rate in pts without DM
Zhang et al. Jpn J Infect Dis, 2009
Global Stance
IUATLD – Assumption to Evidence; 4 Recommendations
1. Collaboration between TB and DM care and control initiatives
2. Screening for active TB among DM people3. Screening for DM among TB patients4. Management of TB and DM co-morbidity
Domestic Stance – What makes sense now?
• Follow IUATLD recommendations in pertinent populations
• In Diabetics who have another risk for TB, (i.e. foreign-born) screen for TB with symptom review and TB test
• Screen for DM in all TB patients• Open communication between DM and TB
providers
Beyond Screening?
• Co-management of DM and TB through DOT?– Uncontrolled DM hampers the inflammatory
response in any infection– At SFDPH, uncontrolled diabetics are actively
managed with primary care providers to control hyperglycemia promptly
– Rifampin effects monitored closely; patients bring in glucose records to TB visits
Summary
• DM growing in prevalence world-wide• Uncontrolled DM may increase risk of TB• TB presents in more advanced stage in DM• Treatment time may be longer in DM pts to
“assure the cure”• Important implications in populations with high
prevalence for both diseases• Screening across clinics for DM and TB may be a
wave of the future
Thank you!
• Curry National TB Center• Gisela Schecter – CA DPH• Dean Schillinger – UCSF • Jenny Flood – CA DPH• Masae Kawamura – SFDPH• CDC Division of TB Elimination