The looming epidemic of diabetes-associated tuberculosis: learning lessons from HIV-associated tuberculosis

Comparison of CD4+/CD8+ Lymphocytic Subpopulations Pre- and Post-Antituberculosis Treatment in Patients with Diabetes and Tuberculosis

Is there a CD4+ and CD8+ immunity alteration in patients with pulmonary tuberculosis (TB) and diabetes (DM) that does not recover after antituberculosis treatment? This prospective comparative study evaluated CD4+ and CD8+ lymphocytic subpopulations and antituberculosis antibodies in patients with diabetes and tuberculosis (TB-DM), before and after antituberculosis treatment. CD4+ T cell counts were lower in patients with TB-DM compared to those with only TB or only DM, and these levels remained low even after two months of anti-TB treatment. Regarding the CD8+ T cell analysis, we identified higher blood values in the DM-only group, which may be explained by the high prevalence of latent tuberculosis (LTBI) in patients with DM. IgM antituberculosis antibodies levels were elevated in patients with only TB at baseline, and 2 months post-anti-TB treatment, IgG did not express any relevant alterations. Our results suggest an alteration in CD4+ immunity in patients with TB-DM that did not normalize after antituberculosis treatment.

Glycerol contributes to tuberculosis susceptibility in male mice with type 2 diabetes

Diabetes mellitus increases risk for tuberculosis disease and adverse outcomes. Most people with both conditions have type 2 diabetes, but it is unknown if type 1 and type 2 diabetes have identical effects on tuberculosis susceptibility. Here we show that male mice receiving a high-fat diet and streptozotocin to model type 2 diabetes, have higher mortality, more lung pathology, and higher bacterial burden following Mycobacterium tuberculosis infection compared to mice treated with streptozotocin or high-fat diet alone. Type 2 diabetes model mice have elevated plasma glycerol, which is a preferred carbon source for M. tuberculosis. Infection studies with glycerol kinase mutant M. tuberculosis reveal that glycerol utilization contributes to the susceptibility of the type 2 diabetes mice. Hyperglycemia impairs protective immunity against M. tuberculosis in both forms of diabetes, but our data show that elevated glycerol contributes to an additional adverse effect uniquely relevant to type 2 diabetes.

Prevalence and associated factors of diabetes mellitus among patients with tuberculosis in South Korea from 2011 to 2018: a nationwide cohort study

OBJECTIVES

This study aimed to identify the prevalence of diabetes mellitus (DM) among patients with tuberculosis (TB) using a nationwide cohort in South Korea.

DESIGN

A retrospective cohort study.

SETTING

This study used the Korean Tuberculosis and Post-Tuberculosis cohort, which was constructed by linking the Korean National Tuberculosis Surveillance, National Health Information Database (NHID) and Statistics Korea data for the causes of death.

PARTICIPANTS

During the study period, all notified patients with TB with at least one claim in the NHID were included. Exclusion criteria were age less than 20 years, drug resistance, initiation of TB treatment before the study period and missing values in covariates.

OUTCOME MEASURES

DM was defined as having at least two claims of the International Classification of Diseases (ICD) code for DM or at least one claim of the ICD code for DM and prescription of any antidiabetic drugs. Newly diagnosed DM (nDM) and previously diagnosed DM (pDM) were defined as DM diagnosed after and before TB diagnosis, respectively.

RESULTS

A total of 26.8% (70 119) of patients were diagnosed with DM. The age-standardised prevalence increased as age increased or income decreased. Patients with DM were more likely to be men, older, had the lowest income group, had more acid-fast bacilli smear and culture positivity, had a higher Charlson Comorbidity Index score and had more comorbidities compared with patients without DM. Approximately 12.5% (8823) patients had nDM and 87.4% (61 296) had pDM among those with TB-DM.

CONCLUSIONS

The prevalence of DM among patients with TB was considerably high in Korea. To achieve the goal of TB control and improve the health outcomes of both TB and DM, integrated screening of TB and DM and care delivery in clinical practice are necessary.

The Case for Integrating Health Systems to Manage Noncommunicable and Infectious Diseases in Low- and Middle-Income Countries: Lessons Learned From Zambia

Noncommunicable diseases (NCDs) are the leading cause of death in the world, and 80% of all NCD deaths occur in low- and middle-income countries (LMICs). The COVID-19 pandemic has demonstrated that patients with NCDs are at increased risk of becoming severely ill from the virus. Disproportionate investment in vertical health programs can result in health systems vulnerable to collapse when resources are strained, such as during pandemics. Although NCDs are largely preventable, globally there is underinvestment in efforts to address them. Integrating health systems to collectively address NCDs and infectious diseases through a wide range of services in a comprehensive manner reduces the economic burden of healthcare and strengthens the healthcare system. Health system resiliency is essential for health security. In this article, we provide an economically sound approach to incorporating NCDs into routine healthcare services in LMICs through improved alignment of institutions that support prevention and control of both NCDs and infectious diseases. Examples from Zambia's multisector interventions to develop and support a national NCD action plan can inform and encourage LMIC countries to invest in systems integration to reduce the social and economic burden of NCDs and infectious diseases.

Perspectives d’élimination de la tuberculose : la stratégie OMS à l’épreuve de la pandémie de COVID-19

La tuberculose (TB) reste un problème majeur de santé publique au niveau mondial. En 2020, elle était la deuxième cause de décès due à un seul agent infectieux, après le COVID-19. La stratégie « Mettre fin à la TB » de l'Organisation Mondiale de la Santé vise à obtenir, d'ici à 2035, une réduction de 95 % de la mortalité et de 90 % de l'incidence de la tuberculose par rapport à 2015. Après 20 années de baisse régulière de l'incidence estimée dans le monde (2 %/an en moyenne), la situation mondiale de la tuberculose s'est heurtée aux effets de la pandémie de COVID-19. Pour la première fois depuis plus de dix ans, une augmentation nette des décès et une réaugmentation du nombre de nouveaux cas estimés a été constatée. La pandémie pourrait présenter une opportunité pour de nouvelles solutions technologiques et collaborations et le partage des ressources visant à renforcer l'ensemble des systèmes de santé.

Potential to Use Fingerprints for Monitoring Therapeutic Levels of Isoniazid and Treatment Adherence

A fingerprint offers a convenient, noninvasive sampling matrix for monitoring therapeutic drug use. However, a barrier to widespread adoption of fingerprint sampling is the fact that the sample volume is uncontrolled. Fingerprint samples (n = 140) were collected from patients receiving the antibiotic isoniazid as part of their treatment, as well as from a drug-naive control group (n = 50). The fingerprint samples were analyzed for isoniazid (INH) and acetylisoniazid (AcINH), using liquid chromatography high-resolution mass spectrometry. The data set was analyzed retrospectively for metabolites known to be present in eccrine sweat. INH or AcINH was detected in 89% of the fingerprints collected from patients and in 0% of the fingerprints collected from the control group. Metabolites lysine, ornithine, pyroglutamic acid, and taurine were concurrently detected alongside INH/AcINH and were used to determine whether the fingerprint sample was sufficient for testing. Given a sufficient sample volume, the fingerprint test for INH use has sensitivity, specificity, and accuracy of 100%. Normalization to taurine was found to reduce intradonor variability. Fingerprints are a novel and noninvasive approach to monitor INH therapy. Metabolites can be used as internal markers to demonstrate a sufficient sample volume for testing and reduce intradonor variability.

Increased Risk of Incident Diabetes Among Individuals With Latent Tuberculosis Infection

OBJECTIVE

In cross-sectional U.S. studies, patients with diabetes had twice the prevalence of latent tuberculosis infection (LTBI) compared with those without diabetes. However, whether LTBI contributes to diabetes risk is unknown. We used longitudinal data to determine if LTBI is associated with increased diabetes incidence.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study among U.S. Veterans receiving care in the Veterans Health Administration from 2000 to 2015. Eligibility included all patients without preexisting diabetes who received a tuberculin skin test (TST) or interferon-γ release assay (IGRA). We excluded patients with a history of active TB and those diagnosed with diabetes before or within 2 years after LTBI testing. Patients were followed until diabetes diagnosis, death, or 2015. LTBI was defined as TST or IGRA positive. Incident diabetes was defined by use of ICD-9 codes in combination with a diabetes drug prescription.

RESULTS

Among 574,113 eligible patients, 5.3% received both TST/IGRA, 79.1% received TST only, and 15.6% received IGRA only. Overall, 6.6% had LTBI, and there were 2,535,149 person-years (PY) of follow-up after LTBI testing (median 3.2 years). The diabetes incidence rate (per 100,000 PY) was greater in patients with LTBI compared with those without (1,012 vs. 744; hazard ratio [HR] 1.4 [95% CI 1.3-1.4]). Increased diabetes incidence persisted after adjustment for covariates (adjusted HR [aHR] 1.2 [95% CI 1.2-1.3]) compared with those without LTBI. Among patients with LTBI, diabetes incidence was similar in those treated for LTBI compared with those who were not treated (aHR 1.0 [95% CI 0.9-1.1]).

CONCLUSIONS

Comprehensive longitudinal data indicate that LTBI is associated with increased diabetes incidence. These results have implications for people with LTBI, ∼25% of the global population.

Host Metabolic Changes during Mycobacterium Tuberculosis Infection Cause Insulin Resistance in Adult Mice

Tuberculosis (TB) is a highly infectious bacterial disease that primarily attacks the lungs. TB is manifested either as latent TB infection (LTBI) or active TB disease, the latter posing a greater threat to life. The risk of developing active TB disease from LTBI is three times higher in individuals with type 2 diabetes mellitus (T2DM). The association between TB and T2DM is becoming more prominent as T2DM is rapidly increasing in settings where TB is endemic. T2DM is a chronic metabolic disorder characterized by elevated blood glucose, insulin resistance, and relative insulin deficiency. Insulin resistance and stress-induced hyperglycemia have been shown to be increased by TB and to return to normal upon treatment. Previously, we demonstrated that adipocytes (or fat tissue) regulate pulmonary pathology, inflammation, and Mycobacterium tuberculosis (Mtb) load in a murine model of TB. Metabolic disturbances of adipose tissue and/or adipocyte dysfunction contribute to the pathogenesis of T2DM. Thus, pathological adipocytes not only regulate pulmonary pathology, but also increase the risk for T2DM during TB infection. However, the cellular and molecular mechanisms driving the interaction between hyperglycemia, T2DM and TB remain poorly understood. Here, we report the impact of Mtb infection on the development of insulin resistance in mice fed on a regular diet (RD) versus high-fat diet (HFD) and, conversely, the effect of hyperglycemia on pulmonary pathogenesis in juvenile and adult mouse models. Overall, our study demonstrated that Mtb persists in adipose tissue and that Mtb infection induces irregular adipocyte lipolysis and loss of fat cells via different pathways in RD- and HFD-fed mice. In RD-fed mice, the levels of TNFα and HSL (hormone sensitive lipase) play an important role whereas in HFD-fed mice, ATGL (adipose triglyceride lipase) plays a major role in regulating adipocyte lipolysis and apoptosis during Mtb infection in adult mice. We also showed that Mtb infected adult mice that were fed an RD developed insulin resistance similar to infected adult mice that were overweight due to a HFD diet. Importantly, we found that a consequence of Mtb infection was increased lipid accumulation in the lungs, which altered cellular energy metabolism by inhibiting major energy signaling pathways such as insulin, AMPK and mToR. Thus, an altered balance between lipid metabolism and glucose metabolism in adipose tissue and other organs including the lungs may be an important component of the link between Mtb infection and subsequent metabolic syndrome.

Diabetes mellitus and tuberculosis, a systematic review and meta-analysis with sensitivity analysis for studies comparable for confounders

Introduction

Meta-analyses conducted so far on the association between diabetes mellitus (DM) and the tuberculosis (TB) development risk did not sufficiently take confounders into account in their estimates. The objective of this systematic review was to determine whether DM is associated with an increased risk of developing TB with a sensitivity analyses incorporating a wider range of confounders including age, gender, alcohol consumption, smoke exposure, and other comorbidities.

Methods

Pubmed, Embase, Web of Science and Global Index Medicus were queried from inception until October 2020. Without any restriction to time of study, geographical location, and DM and TB diagnosis approaches, all observational studies that presented data for associations between DM and TB were included. Studies with no abstract or complete text, duplicates, and studies with wrong designs (review, case report, case series, comment on an article, and editorial) or populations were excluded. The odds ratios (OR) and their 95% confidence intervals were estimated by a random-effect model.

Results

The electronic and manual searches yielded 12,796 articles of which 47 were used in our study (23 case control, 14 cross-sectional and 10 cohort studies) involving 503,760 cases (DM or TB patients) and 3,596,845 controls. The size of the combined effect of TB risk in the presence of DM was OR = 2.3, 95% CI = [2.0–2.7], I² = 94.2%. This statistically significant association was maintained in cohort (OR = 2.0, CI 95% = [1.5–2.4], I² = 94.3%), case control (OR = 2.4, CI 95% = [2.0–2.9], I² = 93.0%) and cross-sectional studies (OR = 2.5, CI 95% = [1.8–3.5], I² = 95.2%). The association between DM and TB was also maintained in the sensitivity analysis including only studies with similar proportions of confounders between cases and controls. The substantial heterogeneity observed was mainly explained by the differences between geographic regions.

Conclusions

DM is associated with an increased risk of developing latent and active TB. To further explore the role of DM in the development of TB, more investigations of the biological mechanisms by which DM increases the risk of TB are needed.

Review registration

PROSPERO, CRD42021216815.

Reactivation of latent tuberculosis through modulation of resuscitation promoting factors by diabetes

The evidence of an association between diabetes and latent tuberculosis infection (LTBI) remains limited and inconsistent. Thus, the study aims to delineate the role of diabetes in activation of latent tuberculosis infection. Murine model of latent tuberculosis and diabetes was developed, bacillary load and gene expression of resuscitation promoting factors (rpfA-E) along with histopathological changes in the lungs and spleen were studied. Treatment for LTBI [Rifampicin (RIF) + Isoniazid (INH)] was also given to latently infected mice with or without diabetes for 4 weeks. Diabetes was found to activate latent tuberculosis as the colony forming unit (CFU) counts were observed to be > 10⁴ in lungs and spleen. The gene expression of hspX was downregulated and that of rpfB and rpfD was observed to be upregulated in latently infected mice with diabetes compared to those without diabetes. However, no significant reduction in the CFU counts was observed after 4 weeks of treatment with RIF and INH. Diabetes helps in the progression of LTBI to active disease mainly through altered expression of resuscitation promoting factors rpfB and rpfD, which can serve as important targets to reduce the shared burden of tuberculosis and diabetes.

Tuberculosis: An Update on Pathophysiology, Molecular Mechanisms of Drug Resistance, Newer Anti-TB Drugs, Treatment Regimens and Host- Directed Therapies

Human tuberculosis (TB) is primarily caused by Mycobacterium tuberculosis (Mtb) that inhabits inside and amidst immune cells of the host with adapted physiology to regulate interdependent cellular functions with intact pathogenic potential. The complexity of this disease is attributed to various factors such as the reactivation of latent TB form after prolonged persistence, disease progression specifically in immunocompromised patients, advent of multi- and extensivelydrug resistant (MDR and XDR) Mtb strains, adverse effects of tailor-made regimens, and drug-drug interactions among anti-TB drugs and anti-HIV therapies. Thus, there is a compelling demand for newer anti-TB drugs or regimens to overcome these obstacles. Considerable multifaceted transformations in the current TB methodologies and molecular interventions underpinning hostpathogen interactions and drug resistance mechanisms may assist to overcome the emerging drug resistance. Evidently, recent scientific and clinical advances have revolutionised the diagnosis, prevention, and treatment of all forms of the disease. This review sheds light on the current understanding of the pathogenesis of TB disease, molecular mechanisms of drug-resistance, progress on the development of novel or repurposed anti-TB drugs and regimens, host-directed therapies, with particular emphasis on underlying knowledge gaps and prospective for futuristic TB control programs.

Diabetes in a TB and HIV-endemic South African population: Analysis of a virtual cohort using routine health data

BACKGROUND

It is widely accepted that people living with diabetes (PLWD) are at increased risk of infectious disease, yet there is a paucity of epidemiology studies on the relationship between diabetes and infectious disease in SSA. In a region with a high burden of infectious disease, this has serious consequences for PLWD.

METHODS AND FINDINGS

Using routinely collected longitudinal health data, we describe the epidemiology of diabetes in a large virtual cohort of PLWD who have a high burden of HIV and TB, from the Khayelitsha subdistrict in the Western Cape Province in South Africa. We described the relationship between previous TB, newly diagnosed TB disease and HIV infection on diabetes using HbA1c results as an outcome measure. The study population was predominately female (67%), 13% had a history of active TB disease and 18% were HIV positive. The HIV positive group had diabetes ascertained at a significantly younger age (46 years c.f. 53 years respectively, p<0.001) and in general had increased HbA1c values over time after their HIV diagnosis, when compared to the HIV-negative group. There was no evidence of TB disease influencing the trajectory of glycaemic control in the long term, but diabetes patients who developed active TB had higher mortality than those without TB (12.4% vs 6.7% p-value < 0.001). HIV and diabetes are both chronic diseases whose long-term management includes drug therapy, however, only 52.8% of the study population with an HIV-diabetes comorbidity had a record of diabetes treatment. In addition, the data suggest overall poor glycaemic control in the study population with only 24.5% of the participants having an HbA1c <7% at baseline despite 85% of the study population being on diabetes treatment.

CONCLUSION

The epidemiologic findings in this exploratory study highlight the need for further research into diabetes outcomes in a high TB and HIV burden setting and demonstrate that routine health data are a valuable resource for understanding disease epidemiology in the general population.

Demographic stratification of Type 2 diabetes and comorbidities in district healthcare in KwaZulu-Natal

Background

Diabetes has been reported as the second leading cause of death and the top leading cause of death amongst women in South Africa; it is important to evaluate any epidemiological or demographic transition related to diabetes. This study evaluated the demographically stratified prevalence of type 2 diabetes mellitus (T2DM) and existing comorbidities amongst an outpatient population in a district healthcare facility in Kwazulu-Natal (KZN).

Methods

This retrospective cross-sectional study was conducted at a district hospital, and a retrospective record review of all outpatients who reported to the hospital to be treated for T2DM between the period, August 2018–January 2019, was used. Data, such as age, sex, ethnicity and any coexisting morbidity, were collected from outpatient hospital registers and electronically captured using a record review tool.

Results

There were significantly more female patients (3072) compared to male patients (1050) (p < 0.001) with a mean age of 59.21 years. Hypertension (77.9%) and cardiovascular problems (11.16%) were most frequent. Approximately 84% of women presented with T2DM and either one or two morbidities simultaneously. Female patients were at significantly higher risk of presenting with hypertension (odds ratio [OR] = 1.44, 95% confidence interval [CI]: 1.20;1.71), whilst their risk for cardiovascular problems was significantly lower compared to male patients (OR = 0.67, 95% CI: 0.54;0.83).

Conclusion

The prevalence of T2DM and comorbidities differed by demographic factors, such as sex, ethnicity and age. There is a need for flexible and adaptive approaches for the prevention and management of T2DM cases in order to allocate medical resources efficiently and according to the true burden of disease because of T2DM complications.

Epidemiological characterization of symptomatic and asymptomatic COVID-19 cases and positivity in subsequent RT-PCR tests in the United Arab Emirates

The coronavirus disease 2019 (COVID-19) cases could be symptomatic or asymptomatic. We (1) characterized and analyzed data collected from the first cohort of reverse transcriptase polymerase chain reaction (RT-PCR)-confirmed COVID-19 cases reported in the Emirate of Abu Dhabi, United Arab Emirates, according to the symptomatic state, and (2) identified factors associated with the symptomatic state. The association between the symptomatic state and testing positive in three subsequent RT-PCR testing rounds was also quantified. Between February 28 and April 8, 2020, 1,249 cases were reported. Sociodemographic characteristics, working status, travel history, and chronic comorbidities of 791 cases were analyzed according to the symptomatic state (symptomatic or asymptomatic). After the first confirmatory test, the results of three subsequent tests were analyzed. The mean age of the 791 cases was 35.6 ± 12.7 years (range: 1-81). Nearly 57.0% of cases were symptomatic. The two most frequent symptoms were fever (58.0%) and cough (41.0%). Symptomatic cases (mean age 36.3 ± 12.6 years) were significantly older than asymptomatic cases (mean age 34.5 ± 12.7 years). Compared with nonworking populations, working in public places (adjusted odds ratio (aOR), 1.76, 95% confidence interval (95% CI): 1.11-2.80), healthcare settings (aOR, 2.09, 95% CI: 1.01-4.31), or in the aviation and tourism sectors (aOR, 2.24, 95% CI: 1.14-4.40) was independently associated with the symptomatic state. Reporting at least one chronic comorbidity was also associated with symptomatic cases (aOR, 1.76, 95% CI: 1.03-3.01). Compared with asymptomatic cases, symptomatic cases had a prolonged duration of viral shedding and consistent odds of ≥2 positive COVID-19 tests result out of the three subsequent testing rounds. A substantial proportion of the diagnosed COVID-19 cases in the Emirate of Abu Dhabi were asymptomatic. Quarantining asymptomatic cases, implementing prevention measures, and raising awareness among populations working in high-risk settings are warranted.

Barriers and facilitators to bidirectional screening of TB-DM in Ghana: Healthcare workers' perspectives

Background

The tuberculosis (TB) and diabetes mellitus (DM) co-epidemic continues to increase globally. Low-and middle-income countries bear the highest burden of co-epidemic, and Ghana is no exception. In 2011, the World Health Organisation (WHO) responded to this global challenge by launching a collaborative framework with a view to guide countries in implementing their DM and TB care, prevention and control plans. Subsequently, several countries, including Ghana, adopted this framework and began implementing bidirectional screening of TB and DM patients. Almost a decade later since the launch of the framework, the implementation of bidirectional screening in Ghana has not been subjected to empirical research. This study explored the barriers and facilitators to bidirectional screening through the lenses of the implementing healthcare workers.

Methods

This was an exploratory qualitative study conducted in three public health facilities offering both TB and DM services in Northern Ghana. In-depth interviews, document review and observations, were used to generate data. In total twenty-three healthcare workers (doctors, nurses, prescriber, health managers and TB task- shifting officers delivering care in TB and DM clinics) were interviewed, using semi-structured interview guides. The interview questions solicited information on the screening process, including knowledge of the collaborative framework, comorbidity, collaboration and workload.

Results

Six themes emerged from the analysis, of which two (Increase in staff capacity, and Institutionalisation of bidirectional screening) were facilitators, and four (Delays in screening, Fear and stigmatization of TB, Poor collaboration between TB and DM units, and Skewed funding for screening) were barriers.

Conclusions

The implementation of bidirectional screening at public health facilities in Ghana was evident in this study and increased staff capacity, funding and institutionalisation enhanced the policy implementation process. However, the screening of TB patients for DM is yet to be prioritised, and emphasis should be put on the design for cost-effective screening approaches for low- and middle-income countries.

Undiagnosed diabetes mellitus and tuberculosis infection: A population-based, observational study from eastern China

BACKGROUND

China has the largest dual diabetes and tuberculosis epidemic globally. No studies from mainland China have assessed the relationship between tuberculosis infection and diabetes. We conducted a population-based, observational study in eastern China to further explore this relationship.

METHODS

A blood glucose, Quantiferon, and tuberculin skin test were administered at baseline. We compared tuberculosis infection in nondiabetics and diabetics. The cohort was additionally screened for tuberculosis progression over 5 years.

RESULTS

Among 5405 participants, diabetics had elevated levels of Quantiferon and tuberculin positivity, largely driven by undiagnosed diabetics (compared with nondiabetics, adjusted odds ratios of 1.53; 95% confidence interval [CI], 1.05-2.23 and 1.58; 95% CI, 1.07-2.35 for tuberculin and Quantiferon positivity). During follow-up, the annual tuberculosis incidence was three times higher for diabetics compared with the entire cohort.

CONCLUSIONS

These results suggest improving diabetic control through rapidly identifying undiagnosed diabetes may have indirect benefits to tuberculosis control. Targeting of preventive therapy to newly diagnosed diabetics at high-risk for progressive tuberculosis in China should be considered.

Forecasting the impact of diabetes mellitus on tuberculosis disease incidence and mortality in India

Background

In context of the rapidly expanding diabetes mellitus (DM) epidemic in India and slowly declining tuberculosis (TB) incidence, we aimed to estimate the past, current, and future impact of DM on TB epidemiology.

Methods

An age-structured TB-DM dynamical mathematical model was developed and analyzed to assess the DM-on-TB impact. The model was calibrated using a literature review and meta-analyses. The DM-on-TB impact was analyzed using population attributable fraction metrics. Sensitivity analyses were conducted by accommodating less conservative effect sizes for the TB-DM interactions, by factoring the age-dependence of the TB-DM association, and by assuming different TB disease incidence rate trajectories.

Results

In 1990, 11.4% (95% uncertainty interval (UI) = 6.3%-14.4%) of new TB disease incident cases were attributed to DM. This proportion increased to 21.9% (95% UI = 12.1%-26.4%) in 2017, and 33.3% (95% UI = 19.0%-44.1%) in 2050. Similarly, in 1990, 14.5% (95% UI = 9.5%-18.2%) of TB-related deaths were attributed to DM. This proportion increased to 28.9% (95% UI = 18.9%-34.1%) in 2017, and 42.8% (95% UI = 28.7%-53.1%) in 2050. The largest impacts originated from the effects of DM on TB disease progression and infectiousness. Sensitivity analyses suggested that the impact could be even greater.

Conclusions

The burgeoning DM epidemic is predicted to become a leading driver of TB disease incidence and mortality over the coming decades. By 2050, at least one-third of TB incidence and almost half of TB mortality in India will be attributed to DM. This is likely generalizable to other Asian Pacific countries with similar TB-DM burdens. Targeting the impact of the increasing DM burden on TB control is critical to achieving the goal of TB elimination by 2050.

Burden of diabetes among patients with tuberculosis: 10-year experience from a tertiary care referral teaching hospital in South India

Context

Tuberculosis (TB) and diabetes mellitus (DM) are converging epidemics, each worsening the morbidity of the other. A study of the prevalence of DM in TB patients assumes great importance.

Aims

The study aims to evaluate the association between DM and TB over a 10-year period in a tertiary care hospital.

Settings and Design

A retrospective observational study in a southern Indian tertiary care teaching hospital was conducted.

Materials and Methods

All patients with TB diagnosed and treated during the 10-year study period were identified from the hospital database. All relevant clinical, microbiological, and laboratory results pertaining to diagnosis of DM were collected. The diagnosis of TB and DM was made as per the standard criteria.

Statistical Analysis

Categorical variables were analyzed using Chi-square test while continuous variables using independent sample t-test.

Results

From 2001 to 2012, we studied 1979 TB patients among whom data on DM were available. The prevalence of DM was 29%, 21%, and 14%, in smear positive, smear negative and extrapulmonary TB respectively (overall 24%). Diabetics were more likely to be men (77.3% vs. 61%;P = 0.001); >40 years of age (81.7% vs. 38.9%;P < 0.001); heavier (59.96 vs. 50.37;P = 0.004); tobacco smokers (16.1% vs. 8.1%;P < 0.001); and alcohol consumers (6.8% vs. 4%;P = 0.02). They were less likely to be HIV coinfected (1.8% vs. 6.1%;P < 0.001). HIV coinfection was seen in 5% of patients and was substantially higher in extrapulmonary TB group (19.4%). Multidrug-resistant TB was lower in DM (11.7%) compared to non-DM (15.9%) (P = 0.02). Overall, 48% of the DM patients were diagnosed at the time of TB diagnosis. Over 10 years, no obvious changes in the trend were evident.

Conclusions

Over a 10-year study period, 24% of the TB patients were diabetic, nearly half were detected at the time of TB diagnosis. There may be a good case for screening all TB patients for DM.

Unfavourable treatment outcomes in tuberculosis patients with different vitamin D status and blood glucose levels in a programme setting in China

OBJECTIVE

Tuberculosis (TB) treatment success rates are high in China, but there are still a considerable number of cases who have unfavourable treatment outcomes (UTO). We aimed to determine the proportion of TB patients with UTO and to assess whether baseline characteristics that included glycaemic status [normal fasting blood glucose (FBG), transient hyperglycaemia and diabetes mellitus (DM)] and vitamin D status were associated with UTO.

METHOD

Prospective cohort study conducted between November 2015 and July 2016 at six clinics within routine TB services in Jilin province, where persons with TB were consecutively recruited. Data analysis was performed using the chi-squared test and multivariate logistic regression.

RESULTS

Of the 306 recruited TB patients, 96 (31.4%) had smear-positive pulmonary TB, 187 (61.1%) had smear-negative pulmonary TB and 23 (7.5%) had extrapulmonary TB (EPTB). Of these, 95 (31.1%) had normal blood glucose, 83 (27.1%) had transient hyperglycaemia and 128 (41.8%) had DM. 227 (74.2%) patients had vitamin D deficiency/severe deficiency. There were 125 (40.8%) patients with UTO of whom the majority were lost to follow-up (57.6%) or not evaluated (28.8%). UTO was significantly associated with smear-negative pulmonary TB (P = 0.009), EPTB (P < 0.001) and DM (P = 0.007).

CONCLUSION

The proportion of TB patients with UTO increased with smear-negative pulmonary TB, EPTB and DM. TB programmes need to pay more attention to these issues and ensure intensive patient support to those at risk and early detection of DM.

Diabetes mellitus among patients attending TB clinics in Dar es Salaam: a descriptive cross-sectional study

Background

A bi-directional interaction between diabetes mellitus and tuberculosis is well established and has been likened to that between HIV and TB. Whereas HIV screening is standard of care test in sub Saharan Africa TB programs, the same is not true for diabetes mellitus (DM). Sub Saharan Africa, a region with high TB infection rates, is going through an epidemiological transition with rapidly rising prevalence of diabetes.

We aimed at characterizing TB patients with DM in order to identify factors associated with TB-DM dual disease among patients attending TB clinics in Dar es Salaam.

Methods

A cross-sectional study was conducted between September 2016 and January 2017 among patients attending TB clinics in Dar es Salaam. We collected socio-demographic characteristics, anthropometric measurements and screened for diabetes by measuring fasting blood glucose that was followed by a 2 h postprandial glucose for participants with impaired fasting blood glucose. We examined for socio-demographic and clinical factors associated with diabetes using logistic regression analysis.

Results

Of the 660 enrolled participants with TB, 25 (3.8%) were on treatment for diabetes while 39 (6.1%) and 147 (23%) of the remaining 635 participants were ultimately diagnosed with DM and impaired fasting blood glucose respectively. The overall prevalence of DM was 9.7% (64/660). Independent risk factors for diabetes included: age > 44 years {OR 4.52, 95% CI: [1.28–15.89]}; family history of diabetes {OR 3.42, 95% [CI 1.88–6.21]}.

HIV sero-positive TB patients were less likely to have DM compared to those who were HIV sero-negative {OR 0.35, 95% CI [0.17–0.73]}.

Conclusions

Screening for diabetes should be advocated for TB patients aged above 44 years and/or with a family history of diabetes. HIV sero-negative TB patients were more likely to have DM compared to those who were HIV sero-positive. Further studies are needed to confirm this observation and the underlying factors.

Diabetic lung disease: fact or fiction?

Diabetes mellitus is a chronic, progressive, incompletely understood metabolic disorder whose prevalence has been increasing steadily worldwide. Even though little attention has been paid to lung disorders in the context of diabetes, its prevalence has recently been challenged by newer studies of disease development. In this review, we summarize and discuss the role of diabetes mellitus involved in the progression of pulmonary diseases, with the main focus on pulmonary fibrosis, which represents a chronic and progressive disease with high mortality and limited therapeutic options.

Integrating TB and non-communicable diseases services: Pilot experience of screening for diabetes and hypertension in patients with Tuberculosis in Luanda, Angola

BACKGROUND

In the face of the rising burden of non-communicable diseases like diabetes mellitus (DM) and hypertension in sub-Saharan Africa, where infectious diseases like Tuberculosis (TB) are still endemic, the double burden of communicable and non-communicable diseases appears to be increasing rapidly. However, the size of the problem and what is the proper health system approach to deal with the double burden is still unclear. The aim of this project was to estimate the double burden of DM hypertension and TB and to pilot the integration of the screening for DM and hypertension in the TB national programs in six TB centers in Luanda, Angola.

METHODS

All newly diagnosed pulmonary TB (PTB) patients accessing six directly observed treatment (DOT) centers in Luanda were screened for diabetes and hypertension. TB diagnosis was made clinically and/or with sputum microscopy DM diagnosis was made through estimation of either fasting plasma glucose (FPG) (considered positive if ≥ 7∙0mmol/l) or random plasma glucose (considered positive if ≥ 11∙1mmol/l). Uncontrolled hypertension was defined as systolic blood pressure (SBP) of ≥ 140 mm of Hg and/or diastolic blood pressure (DBP) of ≥ 90 mm of Hg, irrespective of use of antihypertensive drug.

RESULTS

Between January 2015 and December 2016, a total of 7,205 newly diagnosed patients with PTB were included in the analysis; 3,598 (49∙9%) were males and 3,607 females. Among 7,205 PTB patients enrolled, blood pressure was measured in 6,954 and 1,352 (19∙4%) were found to have uncontrolled hypertension, more frequently in females (23%) compared to males (16%). In multivariate logistic regression analysis uncontrolled hypertension was associated with increasing age and BMI and ethnic group. The crude prevalence of DM among TB patients was close to 6%, slightly higher in males (6∙3%) compared to females (5∙7%). Age adjusted prevalence was 8%. Impaired fasting glucose (>6∙1 to <7∙0 mmol/L) was detected in 414 patients (7%). In multivariate logistic regression analysis DM prevalence was higher in males and increased with increasing age and BMI.

INTERPRETATION

TB patients have a considerable hypertension and diabetes co-morbidity. It is possible to screen for these conditions within the DOTs centres. Integration of health services for both communicable and non-communicable diseases is desirable and recommended.

The potential impact and cost-effectiveness of tobacco reduction strategies for tuberculosis prevention in Canadian Inuit communities

BACKGROUND

Tuberculosis (TB) remains a significant public health problem in Canadian Inuit communities. In 2016, Canadian Inuit had an incidence rate 35 times the Canadian average. Tobacco use is an important risk factor for TB, and over 60% of Inuit adults smoke. We aimed to estimate changes in TB-related outcomes and costs from reducing tobacco use in Inuit communities.

METHODS

Using a transmission model to estimate the initial prevalence of latent TB infection (LTBI), followed by decision analysis modelling, we conducted a cost-effectiveness analysis that compared the current standard of care for management of TB and LTBI without additional tobacco reduction intervention (Status Quo) with (1) increased tobacco taxation, (2) pharmacotherapy and counselling for smoking cessation, (3) pharmacotherapy, counselling plus mass media campaign, and (4) the combination of all these. Projected outcomes included the following: TB cases, TB-related deaths, quality-adjusted life years (QALYs), and health system costs, all over 20 years.

RESULTS

The combined strategy was projected to reduce active TB cases by 6.1% (95% uncertainty range 4.9-7.0%) and TB deaths by 10.4% (9.5-11.4%) over 20 years, relative to the status quo. Increased taxation was the only cost-saving strategy.

CONCLUSIONS

Currently available strategies to reduce commercial tobacco use will likely have a modest impact on TB-related outcomes in the medium term, but some may be cost saving.

Coprevalence of type 2 diabetes mellitus and tuberculosis in low-income and middle-income countries: A systematic review

Increasing coprevalence of diabetes mellitus (DM) and tuberculosis (TB) in low-income and middle-income countries (LMICs) indicates a rising threat to the decades of progress made against TB and requires global attention. This systematic review provides a summary of type 2 diabetes and tuberculosis coprevalence in various LMICs. We searched PubMed, Ovid Medline, Embase, and PsychINFO databases for studies that provided estimates of TB-DM coprevalence in LMICs published between 1990 and 2016. Studies that were non-English and exclusively conducted in multidrug resistant-tuberculosis or type 1 diabetes and inpatient settings were excluded. We reviewed 84 studies from 31 countries. There were huge diversity of study designs and diagnostic methods used to estimate coprevalence, and this precluded pooling of the results. Most studies (n = 78) were from small, localized settings. The DM prevalence among TB patients in various LMICs varied from 1.8% to 45%, with the majority (n = 44) between 10% and 30%. The TB prevalence among people with DM ranged from 0.1% to 6.0% with most studies (n = 9) reporting prevalences less than 2%. Coprevalence of TB-DM was higher than general population prevalence of either diseases in these countries. This study underscores the need for intervention and more focused research on TB DM bidirectional screening programs in low-income and middle-income countries as well as integrated chronic disease management.

Detrimental association between diabetes and tuberculosis: An unresolved double trouble

Despite significant efforts made to control tuberculosis (TB) through DOTS program, the increasing burden of diabetes mellitus (DM) threatens the progress in reducing TB-related mortality, particularly in developing countries. In recent years, TB-DM comorbidity continues to remain high in countries where DM is on rampant. DM increases the risk of TB, reactivates the dormant TB and worsens the TB treatment outcome. The present review highlights the current findings regarding the prevalence and association of TB-DM comorbidity along with their public health implications. This review will increase the awareness among researchers, policymakers and clinicians, regarding the current scenario of TB-DM association.

The change in blood glucose levels in tuberculosis patients before and during anti-tuberculosis treatment in China

Objective: We aimed to observe (i) changes in fasting blood glucose (FBG) in tuberculosis (TB) patients before and during anti-TB treatment, (ii) whether FBG levels were stable or unstable and (iii) baseline characteristics associated with an unstable FBG.

Method: TB patients consecutively attended six clinics or hospitals. FBG measurements were made at months 0, 2 and 6. Data analysis was performed using the chi-square test and multivariate logistic regression.

Results: Of 232 patients without diabetes mellitus (DM) whose initial FBG < 6.1 mmol/L, over 90% maintained FBG < 6.1 mmol/L during treatment and no patient developed DM. Of 17 patients without DM and initial FBG between 6.1 and 6.9 mmol/L, over half had FBG < 6.1 mmol/L during treatment and no patient had DM at the end of treatment. Eight DM patients with already known DM had their FBG controlled at < 7.0 mmol/L during treatment. There were 13 DM patients newly diagnosed with FBG ≥ 7.0 mmol/L, and 69% continued to have FBG ≥ 7.0 mmol/L. After adjustment for confounding, the odds for an unstable FBG were higher for HIV-positive status, already having DM, smoking and coming to hospitals rather than clinics.

Conclusion: TB patients who do not have DM based on FBG measurements do not develop DM during anti-TB treatment. Those newly diagnosed with DM on screening in general maintain their DM status with high FBG and need to be better managed.

Stress Hyperglycemia in Patients with Tuberculosis Disease: Epidemiology and Clinical Implications

PURPOSE OF REVIEW

The intersection of tuberculosis (TB) disease and type 2 diabetes mellitus is severely hindering global efforts to reduce TB burdens. Diabetes increases the risk of developing TB disease and negatively impacts TB treatment outcomes including culture conversion time, mortality risk, and TB relapse. Recent evidence also indicates plausible mechanisms by which TB disease may influence the pathogenesis and incidence of diabetes. We review the epidemiology of stress hyperglycemia in patients with TB and the pathophysiologic responses to TB disease that are related to established mechanisms of stress hyperglycemia. We also consider clinical implications of stress hyperglycemia on TB treatment, and the role of TB disease on risk of diabetes post-TB.

RECENT FINDINGS

Among patients with TB disease, the development of stress hyperglycemia may influence the clinical manifestation and treatment response of some patients and can complicate diabetes diagnosis. Research is needed to elucidate the relationship between TB disease and stress hyperglycemia and determine the extent to which stress hyperglycemia impacts TB treatment response. Currently, there is insufficient data to support clinical recommendations for glucose control among patients with TB disease, representing a major barrier for efforts to improve treatment outcomes for patients with TB and diabetes.

Meta-analysis of the prevalence of tuberculosis in diabetic patients and its association with cigarette smoking in African and Asian countries

Objective

This systematic review and meta-analysis was undertaken to estimate the prevalence of tuberculosis in diabetic patients and to determine the effect of cigarette smoking.

Results

A total of 15 studies was included in the meta-analysis. The pooled overall prevalence of tuberculosis in diabetes was 4.72% (95% CI 3.62–5.83%). In sub-group analyses, the prevalence was 5.13% (95% CI 4.34–5.92%) in Africa, followed by 4.16% (95% CI 2.9–5.4%) in Asia. The odd ratio of tuberculosis among diabetes patients was 7.6 (95% CI 1.46–39) in cigarette smokers as compared to nonsmokers. Publication bias was detected based on graphic asymmetry of fun-nel plots, Begg’s and Egger’s tests (p < 0.05). Tuberculosis is a common co-morbidity in diabetic patients. Tuberculosis-diabetes co-morbidity is significantly higher in cigarette smokers.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3390-x) contains supplementary material, which is available to authorized users.

Type I Interferons in the Pathogenesis of Tuberculosis: Molecular Drivers and Immunological Consequences

Tuberculosis (TB) remains a major global health threat. Urgent needs in the fight against TB include improved and innovative treatment options for drug-sensitive and -resistant TB as well as reliable biological indicators that discriminate active from latent disease and enable monitoring of treatment success or failure. Prominent interferon (IFN) inducible gene signatures in TB patients and animal models of Mycobacterium tuberculosis infection have drawn significant attention to the roles of type I IFNs in the host response to mycobacterial infections. Here, we review recent developments in the understanding of the innate immune pathways that drive type I IFN responses in mycobacteria-infected host cells and the functional consequences for the host defense against M. tuberculosis, with a view that such insights might be exploited for the development of targeted host-directed immunotherapies and development of reliable biomarkers.

Association between diabetes mellitus and active tuberculosis: A systematic review and meta-analysis

The burgeoning epidemic of diabetes mellitus (DM) is one of the major global health challenges. We systematically reviewed the published literature to provide a summary estimate of the association between DM and active tuberculosis (TB). We searched Medline and EMBASE databases for studies reporting adjusted estimates on the TB–DM association published before December 22, 2015, with no restrictions on region and language. In the meta-analysis, adjusted estimates were pooled using a DerSimonian-Laird random-effects model, according to study design. Risk of bias assessment and sensitivity analyses were conducted. 44 eligible studies were included, which consisted of 58,468,404 subjects from 16 countries. Compared with non-DM patients, DM patients had 3.59–fold (95% confidence interval (CI) 2.25–5.73), 1.55–fold (95% CI 1.39–1.72), and 2.09–fold (95% CI 1.71–2.55) increased risk of active TB in four prospective, 16 retrospective, and 17 case-control studies, respectively. Country income level (3.16–fold in low/middle–vs. 1.73–fold in high–income countries), background TB incidence (2.05–fold in countries with >50 vs. 1.89–fold in countries with ≤50 TB cases per 100,000 person-year), and geographical region (2.44–fold in Asia vs. 1.71–fold in Europe and 1.73–fold in USA/Canada) affected appreciably the estimated association, but potential risk of bias, type of population (general versus clinical), and potential for duplicate data, did not. Microbiological ascertainment for TB (3.03–fold) and/or blood testing for DM (3.10–fold), as well as uncontrolled DM (3.30–fold), resulted in stronger estimated association. DM is associated with a two- to four-fold increased risk of active TB. The association was stronger when ascertainment was based on biological testing rather than medical records or self-report. The burgeoning DM epidemic could impact upon the achievements of the WHO “End TB Strategy” for reducing TB incidence.

Molecular clustering of patients with diabetes and pulmonary tuberculosis: A systematic review and meta-analysis

Introduction

Many studies have explored the relationship between diabetes mellitus (DM) and tuberculosis (TB) demonstrating increased risk of TB among patients with DM and poor prognosis of patients suffering from the association of DM/TB. Owing to a paucity of studies addressing this question, it remains unclear whether patients with DM and TB are more likely than TB patients without DM to be grouped into molecular clusters defined according to the genotype of the infecting Mycobacterium tuberculosis bacillus. That is, whether there is convincing molecular epidemiological evidence for TB transmission among DM patients. Objective: We performed a systematic review and meta-analysis to quantitatively evaluate the propensity for patients with DM and pulmonary TB (PTB) to cluster according to the genotype of the infecting M. tuberculosis bacillus.

Materials and methods

We conducted a systematic search in MEDLINE and LILACS from 1990 to June, 2016 with the following combinations of key words “tuberculosis AND transmission” OR “tuberculosis diabetes mellitus” OR “Mycobacterium tuberculosis molecular epidemiology” OR “RFLP-IS6110” OR “Spoligotyping” OR “MIRU-VNTR”. Studies were included if they met the following criteria: (i) studies based on populations from defined geographical areas; (ii) use of genotyping by IS6110- restriction fragment length polymorphism (RFLP) analysis and spoligotyping or mycobacterial interspersed repetitive unit-variable number of tandem repeats (MIRU-VNTR) or other amplification methods to identify molecular clustering; (iii) genotyping and analysis of 50 or more cases of PTB; (iv) study duration of 11 months or more; (v) identification of quantitative risk factors for molecular clustering including DM; (vi) > 60% coverage of the study population; and (vii) patients with PTB confirmed bacteriologically. The exclusion criteria were: (i) Extrapulmonary TB; (ii) TB caused by nontuberculous mycobacteria; (iii) patients with PTB and HIV; (iv) pediatric PTB patients; (v) TB in closed environments (e.g. prisons, elderly homes, etc.); (vi) diabetes insipidus and (vii) outbreak reports. Hartung-Knapp-Sidik-Jonkman method was used to estimate the odds ratio (OR) of the association between DM with molecular clustering of cases with TB. In order to evaluate the degree of heterogeneity a statistical Q test was done. The publication bias was examined with Begg and Egger tests. Review Manager 5.3.5 CMA v.3 and Biostat and Software package R were used.

Results

Selection criteria were met by six articles which included 4076 patients with PTB of which 13% had DM. Twenty seven percent of the cases were clustered. The majority of cases (48%) were reported in a study in China with 31% clustering. The highest incidence of TB occurred in two studies from China. The global OR for molecular clustering was 0.84 (IC 95% 0.40–1.72). The heterogeneity between studies was moderate (I² = 55%, p = 0.05), although there was no publication bias (Beggs test p = 0.353 and Eggers p = 0.429).

Conclusion

There were very few studies meeting our selection criteria. The wide confidence interval indicates that there is not enough evidence to draw conclusions about the association. Clustering of patients with DM in TB transmission chains should be investigated in areas where both diseases are prevalent and focus on specific contexts.

Systems Immunology of Diabetes-Tuberculosis Comorbidity Reveals Signatures of Disease Complications

Comorbid diabetes mellitus (DM) increases tuberculosis (TB) risk and adverse outcomes but the pathological interactions between DM and TB remain incompletely understood. We performed an integrative analysis of whole blood gene expression and plasma analytes, comparing South Indian TB patients with and without DM to diabetic and non-diabetic controls without TB. Luminex assay of plasma cytokines and growth factors delineated a distinct biosignature in comorbid TBDM in this cohort. Transcriptional profiling revealed elements in common with published TB signatures from cohorts that excluded DM. Neutrophil count correlated with the molecular degree of perturbation, especially in TBDM patients. Body mass index and HDL cholesterol were negatively correlated with molecular degree of perturbation. Diabetic complication pathways including several pathways linked to epigenetic reprogramming were activated in TBDM above levels observed with DM alone. Our data provide a rationale for trials of host-directed therapies in TBDM, targeting neutrophilic inflammation and diabetic complication pathways to address the greater morbidity and mortality associated with this increasingly prevalent dual burden of communicable and non-communicable diseases.

[Antituberculosis-drug resistance in the border of Brazil with Paraguay and Bolivia]

Objetivo.

Estimar as taxas de resistência às drogas entre casos de tuberculose pulmonar (TBP) para o estado de Mato Grosso do Sul, Brasil, e especificamente para a região da fronteira com Paraguai e Bolívia, além de identificar fatores de risco associados.

Métodos.

O presente estudo epidemiológico, transversal, enfocou os casos de TBP registrados de janeiro de 2007 a dezembro de 2010 no Sistema de Informação de Agravos de Notificação da Secretaria de Estado de Saúde com resultados do teste de suscetibilidade a rifampicina, isoniazida, etambutol e estreptomicina. Definiram-se como variáveis dependentes o desenvolvimento de resistência a uma única droga e a qualquer combinação de drogas. As variáveis independentes foram ser caso novo ou tratado, residência em região de fronteira ou outra região, presença ou ausência de diabetes e história de alcoolismo.

Resultados.

Foram identificados 789 casos de TBP com teste de suscetibilidade. As características associadas à resistência foram: caso tratado (P=0,0001), região de fronteira (P=0,0142), alcoolismo (P=0,0451) e diabetes (P=0,0708). As taxas de resistência combinada, primária e adquirida no estado foram de 16,3%, 10,6% e 39,0%, e na fronteira, de 22,3%, 19,2% e 37,5%. As taxas de resistência a múltiplas drogas combinada, primária e adquirida no estado foram de 1,8%, 0,6% e 6,3%, e na fronteira, de 3,1%, 1,2% e 12,5%.

Conclusões.

O estado deve, na região de fronteira, realizar cultura em todos os sintomáticos respiratórios, investigar o padrão de resistência nos casos confirmados, adotar o tratamento diretamente observado nos casos de TBP e desencadear ações de saúde conjuntas com os países fronteiriços. Em todo o estado, é necessário monitorar os níveis de resistência adquirida, ampliar a investigação de resistência para todos os casos tratados e adotar o tratamento diretamente observado prioritariamente entre pacientes com alcoolismo e diabetes.

Syndemics and the biosocial conception of health

The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.

Early interventions for diabetes related tuberculosis associate with hastened sputum microbiological clearance in Virginia, USA

Background

Diabetes complicates tuberculosis (TB) treatment including a prolonged time of sputum culture conversion to negative growth. Since 2013 in Virginia, interventions early in the treatment course have used therapeutic drug monitoring and dose correction for isoniazid and rifampin after 2 weeks of TB treatment in patients with diabetes along with nurse manager initiated diabetes education and linkage to care.

Methods

A retrospective cohort study of the state TB registry was performed for patients initiating drug-susceptible pulmonary TB treatment that were matched for age, gender, chest imaging and sputum smear status to compare time to sputum culture conversion and other clinical outcomes in the pre-and post-intervention groups.

Results

Three hundred sixty-three patients had documented time to sputum culture conversion in the pre-and post-intervention periods, including 56 (15%) with diabetes. Seventy-four (57%) of all patients with diabetes were ≥60 years of age at treatment initiation. Twenty-six patients with diabetes were matched in each group. Mean time to sputum culture conversion in the post-intervention group was 42 ± 22 days compared to the pre-intervention group of 62 ± 31 days (p = 0.01). In the post-intervention group 21 (80%) of patients with diabetes had culture conversion by 2 months compared to 13 (50%) in the pre-intervention group (p = 0.04).

Conclusions

Early interventions for diabetes related TB in the programmatic setting may hasten sputum culture conversion.

Diabetes and pulmonary tuberculosis: a global overview with special focus on the situation in Asian countries with high TB-DM burden

BACKGROUND

The double burden of tuberculosis (TB) and diabetes mellitus (DM) is hitting certain Asian countries harder than other areas. In a global estimate, 15% of all TB cases could be attributable to DM, with 40% of those cases coming from India and China. Many other countries of South, East, and South-East Asia are of particular concern given their TB burdens, large projected increases in DM prevalence, and population size.

OBJECTIVE

In this narrative review, we aimed to: (i) give an overall insight into the evidence on TB-DM epidemiology from high double burden Asian countries, (ii) present the evidence on bi-directional screening implementation in this region, (iii) discuss possible factors related to higher TB susceptibility of Asian diabetic patients, and (iv) identify TB-DM comorbidity treatment challenges.

METHODS

The PubMed and Google Scholar databases were searched for all studies addressing DM/TB epidemiology, bi-directional screening and management in South, East and South-East Asia.

RESULTS

We identified the DM prevalences among TB patients as ranging from approximately 5% to more than 50%, whereas TB prevalences among diabetic patients were 1.8-9.5 times higher than in the general population in developing Asian countries. Evidence from studies designed to address diagnosis and treatment of the dual disease in these critical regions is scarce as well as the evidence related to possible DM patients' genetic and acquired predisposition for TB.

CONCLUSION

More prospective studies specifically designed to address adequate screening techniques, identify patients at risk, and define an adequate treatment of dual disease in this region are needed without delay.

Tuberculosis screening at a diabetes clinic in the Republic of the Marshall Islands

Setting

Tuberculosis (TB) and diabetes mellitus (DM) are prominent public health problems in the Republic of the Marshall Islands, a small island nation with high rates of tuberculosis and diabetes.

Objective

Evaluate the rate of active and latent TB in a Pacific Island DM clinic.

Design

In one DM clinic on the island of Ebeye, 213 adult patients aged 27–86 years completed tuberculin skin testing and TB work-up between April 2010 and March 2012.

Results

Screening for TB led to the diagnosis of 77 patients with TB infection and 11 patients with TB disease. From these data, the prevalence of TB disease among DM patients in the clinic exceeded 5% (95% CI 2.2%–8.1%). All patients who completed TB screening were at high risk of TB disease, and those with DM aged  ≤ 50 years had a higher risk of TB disease than those with DM over age 50 (RR 3.1, C.I. 1.0–9.7, p = 0.05).

Conclusion

The experience at the Ebeye Diabetes Clinic demonstrates that screening DM patients for TB can identify significant rates of TB infection and TB disease, and should be considered for other settings with a high background TB incidence. Further assessment of TB risks should explore age, gender, and level of diabetes control.

Tuberculosis-diabetes co-morbidity is characterized by heightened systemic levels of circulating angiogenic factors

BACKGROUND

Tuberculosis-diabetes co-morbidity (TB-DM) is characterized by increased inflammation with elevated circulating levels of inflammatory cytokines and other factors. Circulating angiogenic factors are intricately involved in the angiogenesis-inflammation nexus.

METHODS

To study the association of angiogenic factors with TB-DM, we examined the systemic levels of VEGF-A, VEGF-C, VEGF-D, VEGF-R1, VEGF-R2, VEGF-R3 in individuals with either TB-DM (n = 44) or TB alone (n = 44).

RESULTS

Circulating levels of VEGF-A, C, D, R1, R2 and R3 were significantly higher in TB-DM compared to TB individuals. Moreover, the levels of VEGF-A, C, R2 and/or R3 were significantly higher in TB-DM with bilateral or cavitary disease or with hemoptysis, suggesting an association with both disease severity and adverse clinical presentation. The levels of these factors also exhibited a significant positive relationship with bacterial burdens and HbA1c levels. In addition, VEGF-A, C and R2 levels were significantly higher (at 2 months of treatment) in culture positive compared to culture negative TB-DM individuals. Finally, the circulating levels of VEGF-A, C, D, R1, R2 and R3 were significantly reduced following successful chemotherapy at 6 months.

CONCLUSION

Our data demonstrate that TB-DM is associated with heightened levels of circulating angiogenic factors, possibly reflecting both dysregulated angiogenesis and exaggerated inflammation.

Glycemic Control and the Risk of Tuberculosis: A Cohort Study

BACKGROUND

Diabetes is a well-known risk factor for tuberculosis (TB) and is increasingly prevalent in low- and middle-income countries, where the burden of TB is high. Glycemic control has the potential to modify the risk of TB. However, there are few studies on the association between glycemic control and TB risk, and the results are inconsistent.

METHODS AND FINDINGS

We assembled a cohort using 123,546 individuals who participated in a community-based health screening service in northern Taiwan from 5 March 2005 to 27 July 2008. Glycemic control was measured using fasting plasma glucose (FPG) at the time of screening. The cohort was followed up to 31 December 2012 for the occurrence of TB by cross-matching the screening database to the national health insurance database. Multiple imputation was used to handle missing information. During a median follow-up of 4.6 y, 327 cases of TB occurred. In the multivariable Cox regression model, diabetic patients with poor glycemic control (FPG > 130 mg/dl) had a significantly higher hazard of TB (adjusted hazard ratio [aHR] 2.21, 95% CI 1.63-2.99, p < 0.001) compared to those without diabetes. The hazard of TB in diabetic patients with good glycemic control (FPG ≤ 130 mg/dl) did not differ significantly from that in nondiabetic individuals (aHR 0.69, 95% CI 0.35-1.36, p = 0.281). In the linear dose-response analysis, the hazard of TB increased with FPG (aHR 1.06 per 10-mg/dl increase in FPG, 95% CI 1.03-1.08, p < 0.001). Assuming the observed association between glycemic control and TB was causal, an estimated 7.5% (95% CI 4.1%-11.5%) of incident TB in the study population could be attributed to poor glycemic control. Limitations of the study include one-time measurement of fasting glucose at baseline and voluntary participation in the health screening service.

CONCLUSIONS

Good glycemic control could potentially modify the risk of TB among diabetic patients and may contribute to the control of TB in settings where diabetes and TB are prevalent.

Convergence of a diabetes mellitus, protein energy malnutrition, and TB epidemic: the neglected elderly population

BACKGROUND

On a global scale, nearly two billion persons are infected with Mycobacterium tuberculosis. From this vast reservoir of latent tuberculosis (TB) infection, a substantial number will develop active TB during their lifetime, with some being able to transmit TB or Multi-drug- resistant (MDR) TB to others. There is clinical evidence pointing to a higher prevalence of infectious diseases including TB among individuals with Diabetes Mellitus (DM). Furthermore, ageing and diabetes mellitus may further aggravate protein-energy malnutrition (PEM), which in turn impairs T-lymphocyte mediated immunologic defenses, thereby increasing the risk of developing active TB and compromising TB treatment. This article aims to a) highlight synergistic mechanisms associated with immunosenescence, DM and PEM in relation to the development of active TB and b) identify nutritional, clinical and epidemiological research gaps.

METHODS

To explore the synergistic relationship between ageing, DM, tuberculosis and PEM, a comprehensive review was undertaken. The MEDLINE and the Google Scholar databases were searched for articles published from 1990 to March 2015, using different MESH keywords in various combinations.

RESULTS

Ageing and DM act synergistically to reduce levels of interferon gamma (IFN- γ), thereby increasing susceptibility to TB, for which cell mediated immunity (CMI) plays an instrumental role. These processes can set in motion a vicious nutritional cycle which can predispose to PEM, further impairing the CMI and consequently limiting host defenses. This ultimately transforms the latent TB infection into active disease. A clinical diagnostic algorithm and clinical guidelines need to be established for this population.

CONCLUSION

Given the increase in ageing population with DM and PEM, especially in resource-poor settings, these synergistic tripartite interactions must be examined if a burgeoning TB epidemic is to be averted. Implementation of a comprehensive, all-encompassing approach to curb transmission is clearly indicated. To this end, clinical, nutritional and epidemiological research gaps must be addressed without a delay.

Diabetes mellitus and tuberculosis: programmatic management issues

In August 2011, the World Health Organization and the International Union Against Tuberculosis and Lung Disease launched the Collaborative Framework for Care and Control of Tuberculosis (TB) and diabetes mellitus (DM) to guide policy makers and implementers in combatting the epidemics of both diseases. Progress has been made, and includes identifying how best to undertake bidirectional screening for both diseases, how to provide optimal treatment and care for patients with dual disease and the most suitable framework for monitoring and evaluation. Key programmatic challenges include the following: whether screening should be directed at all patients or targeted at those with high-risk characteristics; the most suitable technologies for diagnosing TB and diabetes in routine settings; the best time to screen TB patients for DM; how to provide an integrated, coordinated approach to case management; and finally, how to persuade non-communicable disease programmes to adopt a cohort analysis approach, preferably using electronic medical records, for monitoring and evaluation. The link between DM and TB and the implementation of the collaborative framework for care and control have the potential to stimulate and strengthen the scale-up of non-communicable disease care and prevention programmes, which may help in reducing not only the global burden of DM but also the global burden of TB.

TB control: challenges and opportunities for India

India's TB control programme has treated over 19 million patients, but the incidence of TB continues to be high. TB is a major killer and drug-resistant TB is a growing threat. There are several likely reasons, including social conditions and co-morbidities that fuel the TB epidemic: under-investment by the government, weak programme implementation and management, suboptimal quality of care in the private sector, and insufficient advocacy around TB. Fortunately, India possesses the technical know-how, competence and resources to address these challenges. The End TB Strategy by WHO offers India an excellent blueprint to advance the agenda of TB control.

Cohort for Tuberculosis Research by the Indo-US Medical Partnership (CTRIUMPH): protocol for a multicentric prospective observational study

INTRODUCTION

Tuberculosis disease (TB) remains an important global health threat. An evidence-based response, tailored to local disease epidemiology in high-burden countries, is key to controlling the global TB epidemic. Reliable surrogate biomarkers that predict key active disease and latent TB infection outcomes are vital to advancing clinical research necessary to 'End TB'. Well executed longitudinal studies strengthening local research capacity for addressing TB research priorities and advancing biomarker discovery are urgently needed.

METHODS AND ANALYSIS

The Cohort for Tuberculosis Research by the Indo-US Medical Partnership (CTRIUMPH) study conducted in Byramjee Jeejeebhoy Government Medical College (BJGMC), Pune and National Institute for Research in Tuberculosis (NIRT), Chennai, India, will establish and maintain three prospective cohorts: (1) an Active TB Cohort comprising 800 adults with pulmonary TB, 200 adults with extrapulmonary TB and 200 children with TB; (2) a Household Contact Cohort of 3200 adults and children at risk of developing active disease; and (3) a Control Cohort consisting of 300 adults and 200 children with no known exposure to TB. Relevant clinical, sociodemographic and psychosocial data will be collected and a strategic specimen repository established at multiple time points over 24 months of follow-up to measure host and microbial factors associated with (1) TB treatment outcomes; (2) progression from infection to active TB disease; and (3) Mycobacterium tuberculosis transmission among Indian adults and children. We anticipate CTRIUMPH to serve as a research platform necessary to characterise some relevant aspects of the TB epidemic in India, generate evidence to inform local and global TB control strategies and support novel TB biomarker discovery.

ETHICS AND DISSEMINATION

This study is approved by the Institutional Review Boards of NIRT, BJGMC and Johns Hopkins University, USA. Study results will be disseminated through peer-reviewed journals and research conferences.

FUNDING

NIH/DBT Indo-US Vaccine Action Programme and the Indian Council of Medical Research.

Updates on the risk factors for latent tuberculosis reactivation and their managements

The preventive treatment of latent tuberculosis infection (LTBI) is of great importance for the elimination and control of tuberculosis (TB) worldwide, but existing screening methods for LTBI are still limited in predicting the onset of TB. Previous studies have found that some high-risk factors (including human immunodeficiency virus (HIV), organ transplantation, silicosis, tumor necrosis factor-alpha blockers, close contacts and kidney dialysis) contribute to a significantly increased TB reactivation rate. This article reviews each risk factor's association with TB and approaches to address those factors. Five regimens are currently recommended by the World Health Organization, and no regimen has shown superiority over others. In recent years, studies have gradually narrowed down to the preventive treatment of LTBI for high-risk target groups, such as silicosis patients, organ-transplantation recipients and HIV-infected patients. This review discusses regimens for each target group and compares the efficacy of different regimens. For HIV patients and transplant recipients, isoniazid monotherapy is effective in treating LTBI, but for others, little evidence is available at present.

Coincident diabetes mellitus modulates Th1-, Th2-, and Th17-cell responses in latent tuberculosis in an IL-10- and TGF-β-dependent manner

Type 2 diabetes mellitus (DM) is a risk factor for the development of active tuberculosis (TB), although its role in the TB-induced responses in latent TB (LTB) is not well understood. Since Th1, Th2, and Th17 responses are important in immunity to LTB, we postulated that coincident DM could alter the function of these CD4(+) T-cell subsets. To this end, we examined mycobacteria-induced immune responses in the whole blood of individuals with LTB-DM and compared them with responses of individuals without DM (LTB-NDM). T-cell responses from LTB-DM are characterized by diminished frequencies of mono- and dual-functional CD4(+) Th1, Th2, and Th17 cells at baseline and following stimulation with mycobacterial antigens-purified protein derivative, early secreted antigen-6, and culture filtrate protein-10. This modulation was at least partially dependent on IL-10 and TGF-β, since neutralization of either cytokine resulted in significantly increased frequencies of Th1 and Th2 cells but not Th17 cells in LTB-DM but not LTB individuals. LTB-DM is therefore characterized by diminished frequencies of Th1, Th2, and Th17 cells, indicating that DM alters the immune response in latent TB leading to a suboptimal induction of protective CD4(+) T-cell responses, thereby providing a potential mechanism for increased susceptibility to active disease.

Diabetes-related tuberculosis in the Middle East: an urgent need for regional research

OBJECTIVES

Diabetes mellitus (DM) triples the risk of tuberculosis (TB) disease, complicates TB treatment, and increases the risk of a poor TB outcome. As DM prevalence is increasing across the Middle East, this review was performed to identify regional gaps in knowledge and research priorities for DM/TB.

METHODS

Online databases were searched for studies published from Middle East countries on DM and TB and the studies summarized based on topic and major findings. Studies included had a principle hypothesis related to both diseases, or described TB patients with individual data on DM.

RESULTS

Fifty-nine studies from 10 countries met search criteria. No published studies were found from Lebanon, Bahrain, Syria, Jordan, Cyprus, or the United Arab Emirates. DM prevalence among TB patients was high, but varied considerably across studies. The vast majority of studies were not specifically designed to compare DM/TB and non-DM/TB patients, but many suggested worse treatment outcomes for DM/TB, in accordance with reports from other regions.

CONCLUSIONS

Opportunity exists for the regional study of bidirectional screening, management strategies for both DM and TB diseases, and whether such efforts could take place through the integration of services.

Integrating tuberculosis and HIV services in rural Kenya: uptake and outcomes

SETTING

Seventeen rural public health facilities in Western Kenya that introduced three models of integrated care for tuberculosis (TB) and human immunodeficiency virus (HIV) patients.

OBJECTIVE

To assess the uptake and timing of cotrimoxazole preventive therapy (CPT) and antiretroviral treatment (ART) as well as anti-tuberculosis treatment outcomes among HIV-infected TB patients before (March-October 2010) and after (March-October 2012) the introduction of integrated TB-HIV care.

DESIGN

A before-and-after cohort study using programme data.

RESULTS

Of 501 HIV-infected TB patients, 357 (71%) were initiated on CPT and 178 (39%) on ART in the period before the introduction of integrated TB-HIV care. Following the integration of services, respectively 316 (98%) and 196 (61%) of 323 HIV-infected individuals were initiated on CPT and on ART (P < 0.001). The median time to CPT and ART initiation dropped from 7 to 2 days and from 42 to 34 days during the pre- and post-integration phases, respectively. Overall TB success rates did not vary with integration or with type of model instituted.

CONCLUSION

Integration of TB and HIV services enhanced uptake and reduced delay in instituting CPT and ART in rural health facilities. There is a need to increase impetus in these efforts.