Results of the implementation of a pilot model for the bidirectional screening and joint management of patients with pulmonary tuberculosis and diabetes mellitus in Mexico.

Martín Castellanos-Joya,Mirtha Irene Jiménez,José Sifuentes-Osornio,Renata Baez-Saldaña,Gabriela Ortiz-Solís,Pablo Cruz-Hervert,Alfredo Ponce-De-León,Elizabeth Ferreira-Guerrero,Lourdes García-García,Norma Mongua-Rodríguez,Miriam Bobadilla-Del-Valle,Leticia Ferreyra-Reyes,Guadalupe Delgado-Sánchez,Rogelio Montero-Campos,Jesús Felipe González-Roldán,Leslie Lorena Salazar,Jen-Hsiang Chuang

doi:10.1371/journal.pone.0106961

Martín Castellanos-Joya, Mirtha Irene Jiménez + Show 15 more

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https://doi.org/10.1371/journal.pone.0106961

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Abstract

BackgroundRecently, the World Health Organisation and the International Union Against Tuberculosis and Lung Disease published a Collaborative Framework for the Care and Control of Tuberculosis (TB) and Diabetes (DM) (CFTB/DM) proposing bidirectional screening and joint management.ObjectiveTo evaluate the feasibility and effectiveness of the CFTB/DM in Mexico. Design. Prospective observational cohort. Setting. 15 primary care units in 5 states in Mexico. Participants: Patients aged ≥20 years diagnosed with DM or pulmonary TB who sought care at participating clinics. Intervention: The WHO/Union CFTB/DM was adapted and implemented according to official Mexican guidelines. We recruited participants from July 2012 to April 2013 and followed up until March 2014. Bidirectional screening was performed. Patients diagnosed with TB and DM were invited to receive TB treatment under joint management. Main outcome measures. Diagnoses of TB among DM, of DM among TB, and treatment outcomes among patients with DM and TB.ResultsOf 783 DM patients, 11 (1.4%) were unaware of their TB. Of 361 TB patients, 16 (4.4%) were unaware of their DM. 95 TB/DM patients accepted to be treated under joint management, of whom 85 (89.5%) successfully completed treatment. Multiple linear regression analysis with change in HbA1c and random capillary glucose as dependent variables revealed significant decrease with time (regression coefficients (β) = −0.660, (95% confidence interval (CI), −0.96 to −0.35); and β = −1.889 (95% CI, −2.77 to −1.01, respectively)) adjusting by sex, age and having been treated for a previous TB episode. Patients treated under joint management were more likely to experience treatment success than patients treated under routine DM and TB programs as compared to historical (adjusted OR (aOR), 2.8, 95%CI 1.28–6.13) and same period (aOR 2.37, 95% CI 1.13–4.96) comparison groups.ConclusionsJoint management of TB and DM is feasible and appears to improve clinical outcomes.

Highlights

Of 361 TB patients, 16 (4.4%) were unaware of their diabetes mellitus (DM). 95 TB/DM patients accepted to be treated under joint management, of whom 85 (89.5%) successfully completed treatment
Patients treated under joint management were more likely to experience treatment success than patients treated under routine DM and TB programs as compared to historical (adjusted OR, 2.8, 95%confidence intervals (CI) 1.28–6.13) and same period comparison groups
To implement the pilot joint management program we conducted the following: 1) invitation of the federal TB and DM programs to state and local levels to participate; 2) establishment of mechanisms for inter-programmatic collaborations with emphasis placed on the participation of state and local levels in planning of activities; 3) cascade training of health personnel who would be participating in screening and joint management of patients; 4) invitation to TB and DM patients and their families to participate; 5) weekly electronic submission and review of case report forms from the health jurisdiction to the federal level; 6) monthly monitor visits to participating primary care clinics; and 7) final meeting to present the results

Summary

Introduction

Tuberculosis (TB) remains a major cause of morbidity and mortality in low- and middle-income countries, where the numbers of individuals with type 2 diabetes mellitus (DM) are increasing rapidly. [1,2] Many studies have explored the relationship between DM and TB, including a recent systematic review in which the risk of TB in DM patients was shown to be three-fold higher than that of individuals without DM. [3] the available evidence indicates that DM comorbidity worsens the clinical outcomes of TB patients. [4,5]Recently, the World Health Organisation (WHO) and the International Union against Tuberculosis and Lung Disease (Union) recognised the need for international guidelines regarding the joint management of TB and DM and published a provisional Collaborative Framework for the Care and Control (CFTB/DM) of both diseases. [6] This framework emphasized establishment of mechanisms of collaboration between national programs of TB and DM, bidirectional screening of TB and DM, and integration of TB and DM management. The World Health Organisation (WHO) and the International Union against Tuberculosis and Lung Disease (Union) recognised the need for international guidelines regarding the joint management of TB and DM and published a provisional Collaborative Framework for the Care and Control (CFTB/DM) of both diseases. [6] This framework emphasized establishment of mechanisms of collaboration between national programs of TB and DM, bidirectional screening of TB and DM, and integration of TB and DM management. [11] Thereby, we conducted this study in order to evaluate the feasibility and effectiveness of bidirectional screening and joint management of TB and DM as recommended by WHO/Union. The World Health Organisation and the International Union Against Tuberculosis and Lung Disease published a Collaborative Framework for the Care and Control of Tuberculosis (TB) and Diabetes (DM) (CFTB/DM) proposing bidirectional screening and joint management

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