Screening of Diabetes and HIV Infection in Newly Diagnosed Pulmonary Tuberculosis Patients

Awais Jamil, Aftab Gohar, Ch. Haider Ali 1,2,3. House Officer Bahawal Victoria Hospital, Bahawalpur Abstract Objective: Aim of the study was to investigate the prevalence of diabetes and HIV infection by screening in newly diagnosed pulmonary tuberculosis patients. Methods: This cross sectional study was conducted in Pulmonology department Bahawal Victoria Hospital Bahawalpur. From 1 June 2018 to 1 June 2019 after taking approval from the institutional ethical committee. Total 159 newly diagnosed pulmonary tuberculosis patients were recruited by non-probability consecutive sampling. Mean and SD was calculated for numerical variables like age , BMI, FBG, Hemoglobin and monthly income. Ferquancy and percentages were calculated for categorical variables like gender, smooking status, educational status, alcohol consumption, prevelance of HIV and diabetes, Ch square test was use to check significant different in PTB and Non PTB patients. P value of < 0.05 was taken as significant. Results: Significant difference was found between age (p=0.000), BMI (p=0.000), FBG (p=0.000), hemoglobin (p=0.000), gender (p=0.002) and alcohol consumption (p=0.034), in groups, except education status (p=0.090) and monthly income (p=0.068). The main outcome variables of this study were HIV infection and diabetes. HIV infection was noted in 3.1% (n=5) and 1.9% (n=3) patients for PTB and non-PTB group respectively. While, 8.2% (n=13) and 4.4% (n=4) patients suffered from diabetes, for both the groups respectively. Conclusion: The results of our study revealed that on screening of newly diagnosed pulmonary tuberculosis patients with HIV infection and diabetes, their prevalence was high as compared to non-pulmonary tuberculosis group. But this difference was statistically non significant (P value 0.474 and 0.166).


Introduction
Diabetes is metabolic disorder. Insulin resistance is the main pathogenesis in development of type 2 diabetes mellitus. Type 2 diabetes is usually affects elderly patients. Type 2 diabetes mellitus is accelerating pandemic throughout the world {1}. 230 million population of the world suffer from diabetes. It has been estimated that this population will reach up to 552 million until 2030 {2}. It is recorded that 471 billion USD were spent to treat diabetes in 2012 {3}. For the developing countries, it is a great socio economic burden. It is alarming that prevalence of diabetes has significantly risen in past two decades. In 2011 diabetes prevalence was ranging from 7.6% (5.2 million people) to 11% in Pakistan and it is expected to reach up to 15% (14 million) until 2030 {4}. Pakistan is on number 7 place in list of countries having diabetes mellitus. It is estimated that if this trend continues than it will become number 4. Overall ratio of diabetes is that its prevalence in urban population is 22.04% and in rural area is 17.15% in Pakistan {5}. Pakistan health care system is overburdened and under resource in dealing with this situation. Considering the present situation, it demands a national effort in not only treating but more on preventing the diabetes mellitus. Many complications are associated with diabetes mellitus. Cardiovascular diseases due to diabetes is main cause of premature illness and deaths {6}. It is main cause of renal failure and blindness. It is associated with amputations due diabetic foot development.
Tuberculosis is one of the main public health problem worldwide {7}. It has been investigated that one third population of world is suffering from mycobacterium infection {8}. Patients of pulmonary tuberculosis clinically present mainly with cough, fever, hemoptysis and weight loss. Diabetes is well known risk factor for tuberculosis {9}. World health organization has classified that eight of ten countries which have highest burden of diabetes also have high burden of tuberculosis {10}. In developing countries such as Pakistan, India, Bangladesh and Brazil where tuberculosis is endemic, the burden of these two diseases and interaction between them will be more dangerous. World health organization has declared global epidemic both diabetes and tuberculosis {11}.
Relationship and association of HIV with tuberculosis is great socio economic threat and public health problem in developing countries. World health organization had estimated in 1992 that about four million population of the world had been infected by both HIV and mycobacterium tuberculosis {12}. Association between HIV and tuberculosis is evident by high incidence of tuberculosis in HIV infected patients. In developing countries where health care systems are already overburdened these two epidemics impose grave social and medical implications.
To best of our knowledge in south Punjab of Pakistan no study had been conducted to investigate the prevalence of diabetes and HIV infection in newly diagnosed pulmonary tuberculosis patients. So this study was conducted to investigate the prevalence of these diseases in newly diagnosed pulmonary tuberculosis patients. It will provide a base for further research on this issue and will create awareness. Study done by Qiuzhen Wang et al. was taken as reference study {13}.

Materials and methods
This cross sectional study was conducted in pulmonology department Bahawal Victoria Hospital Bahawalpur. From 1 June 2018 to 1 June 2019 after taking approval from the institutional ethical committee. Total 159 newly diagnosed pulmonary tuberculosis patients were recruited by non-probability consecutive sampling. To study the prevalence of diabetes and HIV infection in non-tuberculosis group, by cluster random sampling 159 subjects were recruited from same communities as that of tuberculosis patients. Written permission of study was signed by each individual recruited in study. Exclusion criteria of study were: 1) patients with age < 18 years of age, 2) patients who had already taken anti tuberculosis drugs, 3) patients who were known to have diabetes and HIV infection 4) patients who had any history of oncological disorder and 5) patients who had other immunosuppressive conditions. Sample size of study was calculated by using a reference study done by Qiuzhen Wang et al. for which confidence interval was taken as 95%, study strength and odd ratio of diabetes in newly diagnosed pulmonary tuberculosis patients was 3.17% {13}.
All patients were recruited from outpatient department. Detailed medical history of individual was taken and through clinical examination was conducted to record any complication of the disease and to assess any sign of other immunosuppressive disorder. Blood pressure and vitals were recorded at time of pulmonary tuberculosis patients. Blood samples were also taken to check glucose levels and hemoglobin level. Personal information like age, gender, living area, income, body mass index duration of symptoms was taken by filling the Performa.
Pulmonary tuberculosis was diagnosed according the guidelines of National Tuberculosis Program. Patients were investigated with smear examination who were suspected to have pulmonary tuberculosis. Patients who were smear negative but having clinical and radiological suspicion were also labelled as pulmonary tuberculosis after discussing it with radiologist and chest consultants.
Diabetes was diagnosed by using standard method of checking fasting plasma glucose levels as recommended by World Health Organization. Venous blood was used after overnight fasting to check plasma glucose level. Patients having plasma glucose level greater than 126mg/dl were diagnosed as diabetics. Screening of HIV infection was done in each individual recruited in study by using ELISA method.
Data was analyzed by using SPSS volume 23. Quantitative variables like age, body mass index, plasma glucose levels and age were statistically analyzed by their mean and standard deviation and t-test was applied to check the significance. Qualitative variables like gender, living area, HIV infection, diabetes and income were statistically analyzed by frequency and percentage and chi-square test was used to check the significance. P value < 0.05 was considered as statistically significant.
The main outcome variables of this study were HIV infection and diabetes. HIV infection was noted in 3.1% (n=5) and 1.9% (n=3) patients for PTB and non-PTB group respectively. While, 8.2% (n=13) and 4.4% (n=4) patients suffered from diabetes, for both the groups respectively. No significant difference was found between HIV (p=0.474) and diabetes (p=0.166), in groups. (Table. 2).

Discussion
Results of study showed that prevalence of diabetes mellitus on screening in newly diagnosed pulmonary tuberculosis patients was higher (8.2%) than in non-pulmonary tuberculosis (4.4%) group. Similarly study also showed that HIV infection on screening was higher (3.1%) in newly diagnosed pulmonary tuberculosis patients than in non-pulmonary tuberculosis (1.9%) group. But this difference was statiticlly non significant with P value 0.474 and 0.166.
To best of our knowledge there was no data available about prevalence of diabetes and HIV infection among newly diagnosed pulmonary tuberculosis patients as well as comparative data from non-pulmonary tuberculosis controls from the same community collected at same time. The study was designed to discover the hidden prevalence of HIV infection and diabetes mellitus in newly diagnosed pulmonary tuberculosis patients in Pakistan generally and in our local geographical area specially. Strength of this study is that, to define diabetes mellitus accurately, primary data obtained from newly diagnosed pulmonary tuberculosis patients and nonpulmonary tuberculosis group was used. While in other studies, either the prevalence of diabetes mellitus in non-pulmonary tuberculosis patients was not reported or the it was estimated from secondary data with inherent biases {14-15}. Study done by Tahir

Conclusion
The results of our study revealed that on screening of newly diagnosed pulmonary tuberculosis patients with HIV infection and diabetes, their prevalence was high as compared to non-pulmonary tuberculosis group. But this difference was statistically non significant (P value 0.474 and 0.166).