Diabetes Mellitus Among Pulmonary Tuberculosis Patients From 4 Tuberculosis-endemic Countries: The TANDEM Study

[Association between treatment outcome and age in tuberculosis and diabetes patients: a population analysis]

BACKGROUND

The undoubted importance of this work lies in the fact that for the first time in the Republic of Kazakhstan, an analysis is being made of the relationship between age and treatment outcome in patients with a comorbid diagnosis of tuberculosis and diabetes mellitus.

PURPOSE OF THE STUDY

Identification of the correlation between the age of patients with tuberculosis with diabetes mellitus and the outcome of treatment.

MATERIALS AND METHODS

Cross-sectional retrospective study of 2,125 patients with TB and diabetes mellitus out of a total of 43,807 of all patients diagnosed with TB (2017-2019). The study analyzed the data of patients with comorbidity from all regions of Kazakhstan (data from 14 regions and 3 cities of republican significance) (2017-2019).

RESULTS

A high prevalence of tuberculosis morbidity with a concomitant diagnosis of diabetes mellitus in the age group from 45 to 64 years was revealed. This group consisted of 1193 patients out of 2115 (56.4% of the total number of patients with tuberculosis and diabetes mellitus). The average age of all studied patients with DM was 54.7±13.4 years. There is a positive correlation between age and treatment outcome in TB patients. Mortality was higher in the age group over 45 years old - OR95%CI = 0.213 [0.019-2.362], p - 0.0000015 (p < 0.05).

Prevalence of cardiovascular risk factors in active tuberculosis in Africa: a systematic review and meta-analysis

People with tuberculosis (TB) are at risk of major adverse cardiovascular events. We estimated the prevalence of cardiovascular risk (CVR) factors among people with active TB in Africa. This was a systematic review and meta-analysis of studies from Africa. We searched EMBASE, MEDLINE through PubMed, Web of Science, the Cochrane Central Register of Controlled Trials, mRCTs, Clinical trials.gov, and International Clinical Trials Registry Platform from inception to 31st December 2021. Among 110 eligible studies, 79 (238,316 participants) were included in the meta-analysis for smoking, 67 (52,793 participants) for current alcohol use, 30 (31,450 participants) for hazardous alcohol use, 51 (37,879 participants) for diabetes mellitus (DM), 19 (18,211 participants) for hypertension and 18 (13,910 participants) for obesity. The pooled prevalence was 26.0% (95% confidence interval 22.0–29.0) for smoking, 30.0% (25.0–35.0) for any current alcohol use, 21.0% (17.0–26.0) for hazardous alcohol use, 14.0% (9.0–18.0) for hypertension, 7.0% (6.0–9.0) for DM, and 4.0% (2.0–5.0) for obesity. Cost-effective strategies are needed to screen for CVR factors among people with active TB in Africa.

Cigarette smoking is associated with an increase in blood monocytes in people with tuberculosis: A cross-sectional study

The effect of smoking on immune responses in people with tuberculosis (TB) is not well elucidated. We aimed to compare peripheral blood counts of CD4+ and CD87 + T-lymphocytes, monocytes, and neutrophils and the CD4:CD8 ratio in TB patients with and without history of cigarette smoking. We further determined factors associated with current smoking. Participants with TB were consecutively enrolled in a cross-sectional study at a national TB treatment center in Uganda in 2018. We compared cell counts and the CD4:CD8 ratio using the median test among never smokers, past smokers (>6 months ago) and current smokers (≤6 months). Factors associated with current smoking were determined using logistic regression. A post hoc analysis for factors associated with an increase in the monocytes was also performed. Of 363 participants, there were 258 (71.1%) never smokers, 50 (13.8%) past smokers, and 55 (15.2%) current smokers. Most current smokers (49.1%) had a high sputum mycobacterial load. They also had the lowest body mass index and the highest axillary temperature. The median (interquartile range [IQR]) monocyte count among current smokers was 815 (540-1425) cells/mm3 and was significantly higher than that among past smokers (610 (350-900) cells/mm3, P = .017) and never smokers (560 [400-800] cells/mm3, P = .001). The monocyte counts positively correlated with the number of cigarettes smoked per day among current smokers (R = 0.43, P = .006). Current smokers also had higher neutrophil and CD4+ T-cell counts than never smokers. In a multivariable logistic regression model, an increase in the monocyte count was associated with current cigarette smoking (adjusted odds ratio [aOR] = 4.82, 95% confidence interval 1.61-14.39, P = .005). Similarly, current cigarette smoking was independently associated with an increase in the monocyte count (aOR = 1.80, 95% CI 1.39-2.32, P < .001). Cigarette smoking is associated with an increase in the blood monocytes in people with TB in a dose- and time-dependent manner. Further, current smoking is associated with an increase in neutrophils and CD4+ T-lymphocytes. The findings suggest that current smokers have systemic inflammation that is not necessarily beneficial to TB control in TB patients.

The Impact of Diabetes and Prediabetes on Prevalence of Mycobacterium tuberculosis Infection Among Household Contacts of Active Tuberculosis Cases in Ethiopia

Background

It is uncertain whether diabetes affects the risk of developing latent tuberculosis infection (LTBI) following exposure to Mycobacterium tuberculosis (Mtb). We assessed the relationship of diabetes or prediabetes and LTBI among close and household contacts (HHCs) of patients with active pulmonary tuberculosis (TB) disease in Addis Ababa, Ethiopia.

Methods

In this cross-sectional study, we performed interferon-γ release assays, TB symptom screening, and point-of-care glycolated hemoglobin (HbA1c) testing among HHCs of active TB cases. Diabetes status was classified into diabetes (HbA1c ≥6.5% or self-reported diagnosis), prediabetes (5.7%-6.4%), and euglycemia (≤5.6%). Multivariable logistic regression was used to determine the association of diabetes with LTBI.

Results

Among 597 study participants, 123 (21%) had dysglycemia including diabetes (n = 31) or prediabetes (n = 92); 423 (71%) participants were diagnosed with LTBI. Twelve of 31 (39%) HHCs with diabetes were previously undiagnosed with diabetes. The prevalence of LTBI among HHCs with diabetes, prediabetes, and euglycemia was 87% (27/31), 73% (67/92), and 69% (329/474), respectively. In multivariable analysis adjusted for age, sex, and HIV status, the odds of LTBI among HHCs with diabetes were 2.33 (95% confidence interval [CI], .76-7.08) times the odds of LTBI without diabetes. When assessing interaction with age, the association of diabetes and LTBI was robust among participants aged ≥40 years (adjusted odds ratio [aOR], 3.68 [95% CI, .77-17.6]) but not those <40 years (aOR, 1.15 [95% CI, .22-6.1]).

Conclusions

HHCs with diabetes may be more likely to have LTBI than those with euglycemia. Further investigations are needed to assess mechanisms by which diabetes may increase risk of LTBI after Mtb exposure.

[Tuberculosis and diabetes comorbidity in Brazil, 2012-2018: exploratory spatial data analysis and statistical modelingLa comorbilidad tuberculosis-diabetes en Brasil, 2012-2018: análisis exploratorio de la distribución espacial y modelización estadística]

Objetivo.

Descrever a distribuição espacial da comorbidade tuberculose-diabetes e identificar os determinantes sociais da dupla carga no período de 2012 a 2018 no Brasil.

Métodos.

Este estudo ecológico utilizou os municípios como unidade de análise. Incluíram-se todos os casos de tuberculose notificados de 2012 a 2018 ao Sistema de Informação de Agravos de Notificação. Como determinantes, foram analisadas variáveis socioeconômicas de emprego, renda e desenvolvimento e o indicador de cobertura da atenção básica. O índice de Moran global foi calculado para verificar a existência de autocorrelação espacial da comorbidade. O índice de Moran local foi utilizado para delimitar clusters de tuberculose-diabetes: alto/alto (municípios com alta proporção de tuberculose-diabetes cujos vizinhos também apresentaram altas proporções) e baixo/baixo (municípios com proporção abaixo da média, cercados por municípios com baixas proporções).

Resultados.

Observou-se elevação na proporção de tuberculose-diabetes na maioria das regiões brasileiras. Constatou-se autocorrelação espacial da comorbidade tuberculose-diabetes e identificou-se um cluster alto-alto de tuberculose-diabetes reunindo 88 municípios, pertencentes principalmente às regiões Nordeste, Sudeste e Sul, com média de prevalência da comorbidade de 28,04%. As variáveis “percentual da população que vive em domicílios com densidade superior a duas pessoas por dormitório”, “percentual de desemprego de pessoas maiores de 18 anos” e “renda per capita” relacionaram-se à ocorrência da comorbidade.

Conclusão.

Os resultados mostraram uma distribuição não aleatória da comorbidade tuberculose-diabetes, com áreas de alto risco e variáveis explicativas de sua ocorrência. Esses achado reforçam a necessidade de operacionalizar a colaboração entre programas de tuberculose e diabetes, com vistas ao controle tanto de cada agravo isoladamente quanto da sindemia.

The co-management of tuberculosis-diabetes co-morbidities in Indonesia under the National Tuberculosis Control Program: results from a cross-sectional study from 2017 to 2019

Background

Indonesia suffers from a high burden of tuberculosis (TB) and diabetes (DM). The government initiated national TB-DM co-management activities under the National TB Control Program in 2017. This study investigates the detection and treatment outcomes of TB-DM in Jakarta after implementing these activities, and identifies the main factors associated with these outcomes.

Methods

A cross-sectional study was conducted using TB registry data in two districts of Jakarta, East Jakarta (low-income) and South Jakarta (high-income). A 5-step cascade analysis was used: diagnosed TB patients; TB patients tested for DM; diagnosed TB-DM patients; and patients received and completed TB treatment/cured. We conducted descriptive analyses to understand the characteristics of TB and TB-DM patients, and used a two-level mixed-effect logistic regression to explore factors associated with having a DM test and completing TB treatment/being cured.

Results

Over the study period (2017–2019) 50.8% of the new pulmonary TB patients aged over 15 were tested for DM. The percentage increased from 41.7% in 2017–2018 to 60.1% in 2019. Of the TB patients tested for DM, 20.8% were diagnosed with DM. Over 90% of the detected TB-DM patients received standard TB treatment, 86.3% of whom completed treatment/were cured. Patients in East Jakarta were more likely to be tested for DM and to complete standard TB treatment/be cured than patients in South Jakarta (P <  0.001). Bacteriologically positive TB patients were more likely to be tested for DM (OR = 1.37, 95% CIs 1.17,1.60). Patients diagnosed in sub-district level healthcare centers had a higher likelihood of being tested for DM than those in government and private hospitals (P <  0.05). Receiving DM treatment was associated with a higher likelihood of completing TB treatment/being cured (OR = 1.82, 95% CIs 1.20, 2.77).

Conclusions

TB-DM case detection significantly improved in 2019 after introducing TB-DM co-management activities in Jakarta, while gaps in TB-DM co-management existed between bacteriologically positive and clinically diagnosed TB patients, and across different types of health facilities. Collaboration between TB and DM departments should be strengthened, and more resources need to be mobilized to further improve the co-management of TB-DM in Indonesia.

Epidemiological Characteristics and Their Influencing Factors Among Pulmonary Tuberculosis Patients With and Without Diabetes Mellitus: A Survey Study From Drug Resistance Surveillance in East China

Background

The burden of pulmonary tuberculosis (TB) and diabetes mellitus (DM) have become serious global concerns, while the comprehensive evaluations of DM status and drug resistance in TB patients are still lacking.

Methods

All details of TB cases were collected from drug resistance monitoring sentinels in Zhejiang province. Fisher's exact test or Pearson chi-square test (χ²) was used to compare the baseline characteristics among TB with different DM statuses. The logistic regression model was used to estimate the relationship between DM and different drug resistance spectra. Univariate analysis and multivariate logistic model were used to explore the possible risk factors of drug resistance in TB patients with DM and no DM.

Results

936 TB cases with smear-positive in Zhejiang province were collected, in which 76 patients (8.12%) owned the co-morbidity of DM. TB-DM prevalence was higher in older, Han nationality, employed, accompanied by no health insurance and hepatitis B status. Among 860 cases of TB-no DM and 76 cases of TB-DM, drug resistance-TB accounted for 31.51% and 23.68% (P > 0.05), MR-TB accounted for 15.93% and 14.47% (P > 0.05), respectively. MDR-TB was 4.88% and 6.58% (P > 0.05). The incidence of poly-drug resistant tuberculosis (PDR-TB) in TB-no DM patients (10.70 vs. 2.63%, OR: 4.43; 95% CI, 1.07–18.36) was higher than that in the TB-DM group (P < 0.05). In univariate and multivariate analysis, none of the basic factors were statistically significant with drug resistance among TB-DM cases (all P > 0.05). Retreatment was the risk factor of drug resistance among TB-no DM cases.

Conclusions

Our results showed that the drug resistance rate of the TB-DM group was not higher than that of the TB-no DM group. Patients with TB-no DM were at a higher risk for PDR-TB, but not for MDR-TB, MR-TB, and drug resistance-TB. Special attention should be paid to TB-no DM patients who have been previously treated. In the future, large-scale and well-designed prospective studies are needed to clarify the impact of DM on the drug-resistance among TB.

Bidirectional screening and treatment outcomes of diabetes mellitus (DM) and Tuberculosis (TB) patients in hospitals with measures to integrate care of DM and TB and those without integration measures in Malawi

INTRODUCTION

There are efforts in low and middle-income countries (LMICs) to integrate Tuberculosis (TB) and Diabetes mellitus (DM) healthcare services, as encouraged by WHO and other international health organizations. However, evidence on actual effect of different integration measures on bidirectional screening coverages and or treatment outcomes for both diseases in LMICs is scarce.

OBJECTIVES AND METHODS

Retrospective chart review analysis was conducted to determine effects of integrated care on bidirectional screening and treatment outcomes for both TB patients and people with DM (PWD) recruited in eight Malawian hospitals. Data of ≥ 15 years old patients registered between 2016 to August 2019 were collected and analysed.

RESULTS

557 PWDs (mean age 54) and 987 TB patients (mean age 41) were recruited. 64/557 (11.5%) PWDs and 105/987 (10.6%) of TB patients were from an integrating hospital. 36/64 (56.3%) PWDs were screened for TB in integrated healthcare as compared to 5/493 (1.0%) in non-integrated care; Risk Difference (RD) 55.2%, (95%CI 43.0, 67.4), P < 0.001, while 10/105 (9.5%) TB patients were screened for DM in integrated healthcare as compared to 43/882 (4.9%) in non-integrated care; RD 4.6%, (95%CI - 1.1, 10.4), P = 0.065. Of the PWDs screened, 5/41 (12.2%) were diagnosed with TB, while 5/53 (9.4%) TB patients were diagnosed with DM. On TB treatment outcomes, 71/508 (14.8%) were lost to follow up in non-integrated care and none in integrated care were lost to follow-up; RD - 14.0%, (95%CI: - 17.0,-11.0), p < 0.001. Among PWDs, 40/493 (8.1%) in non-integrated care and 2/64 (3.1%) were lost to follow up in integrated care; RD - 5.0%, (95%CI:-10.0, - 0.0); P = 0.046. After ≥ 2 years of follow up, 62.5% PWDs in integrated and 41.8% PWDs in non-integrated care were retained in care, RD 20.7, (95%CI: 8.1, 33.4), P = 0.001.

CONCLUSION

We found higher bidirectional screening coverage and less loss to follow-up in one centre that made more efforts to implement integrated measures for TB and DM care than in 7 others that did not make these efforts. Decisions on local programs to integrate TB/DM care should be taken considering currently rather weak evidence and barriers faced in the local context as well as existing guidelines.

Genomic signatures of pre-resistance in Mycobacterium tuberculosis

Recent advances in bacterial whole-genome sequencing have resulted in a comprehensive catalog of antibiotic resistance genomic signatures in Mycobacterium tuberculosis. With a view to pre-empt the emergence of resistance, we hypothesized that pre-existing polymorphisms in susceptible genotypes (pre-resistance mutations) could increase the risk of becoming resistant in the future. We sequenced whole genomes from 3135 isolates sampled over a 17-year period. After reconstructing ancestral genomes on time-calibrated phylogenetic trees, we developed and applied a genome-wide survival analysis to determine the hazard of resistance acquisition. We demonstrate that M. tuberculosis lineage 2 has a higher risk of acquiring resistance than lineage 4, and estimate a higher hazard of rifampicin resistance evolution following isoniazid mono-resistance. Furthermore, we describe loci and genomic polymorphisms associated with a higher risk of resistance acquisition. Identifying markers of future antibiotic resistance could enable targeted therapy to prevent resistance emergence in M. tuberculosis and other pathogens.

Differentiating transient from persistent diabetic range hyperglycemia in a cohort of people completing tuberculosis treatment in Dhaka, Bangladesh

BACKGROUND

In recent non-pandemic periods, tuberculosis (TB) has been the leading killer worldwide from a single infectious disease. Patients with DM are three times more likely to develop active TB and poor treatment outcomes. Single glycemic measurements at TB diagnosis may inaccurately diagnose or mischaracterize DM severity. Data are limited regarding glycemic dynamics from TB diagnosis through treatment.

METHODS

Prospective study of glycemia dynamics in response to TB treatment measured glycosylated haemoglobin (HbA1c) in patients presenting to TB screening centres in Bangladesh to determine the prevalence and risk factors of hyperglycemia before and at TB treatment completion.

RESULTS

429 adults with active TB disease were enrolled and divided into groups based on history of DM and initial HbA1c range: normoglycemia, prediabetes, and DM. DM was diagnosed in 37%. At treatment completion,14(6%) patients from the normoglycemia and prediabetes groups had HbA1c>6.5%, thus increasing the prevalence of DM to 39%. The number needed to screen to diagnose one new case of DM at TB diagnosis was 5.7 and 16 at treatment completion in the groups without DM. Weight gain>5% at treatment completion significantly increased the risk of hyperglycemia in the groups without DM at TB diagnosis (95% CI 1.23-26.04, p<0.05).

CONCLUSION

HbA1c testing prior to and at TB treatment completion found a high prevalence of prediabetes and DM, including a proportion found at treatment completion and commonly in people with a higher percentage of weight gain. Further longitudinal research is needed to understand the effects of TB disease and treatment on insulin resistance and DM complications.

Implementation of the WHO's collaborative framework for the management of tuberculosis and diabetes: a scoping review

OBJECTIVE

To map evidence on the implementation of the WHO's collaborative framework for the management of tuberculosis (TB) and diabetes mellitus (DM) comorbidity, globally.

DESIGN

Scoping review.

METHODS

Guided by Arksey and O'Malley's scoping review framework, this review mapped literature on the global implementation of the framework for the management of TB and DM comorbidity, globally. An extensive literature search for peer-reviewed studies, theses, studies in the press and a list of references from the selected studies was conducted to source-eligible studies. PubMed, Google Scholar, Web of Science, Science Direct, the EBSCOhost platform (academic search complete, health source: nursing/academic edition, CINAHL with full text), Scopus and the WHO library were used to source the literature. We performed title screening of articles using keywords in the databases, after which two independent reviewers (RS and PV) screened abstracts and full articles. Studies from August 2011 to May 2021 were included in this review and the screening was guided by the inclusion and exclusion criteria. Findings were analysed using the thematic content analysis approach and results presented in the form of a narrative report. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension was used as a checklist and for explaining the scoping review process.

RESULTS

This review found evidence of the WHO TB-DM collaborative framework's implementation in 35 countries across the globe. TB-DM comorbidity was identified in patients through bidirectional screening of both patients with TB and patients with DM in rural and urban settings.

CONCLUSION

Due to the paucity of evidence on mechanisms of collaboration, we recommend further research in other implementing countries to identify techniques used for diagnosis and integration of TB and DM services, in order to ensure that effective and joint management of TB-DM comorbidity in populations is achieved.

Diabetes-Associated Susceptibility to Tuberculosis: Contribution of Hyperglycemia vs. Dyslipidemia

Diabetes is a major risk factor for tuberculosis (TB). Diabetes increases the risk of the progression from latent tuberculosis infection (LTBI) to active pulmonary TB and TB patients with diabetes are at greater risk of more severe disease and adverse TB treatment outcomes compared to TB patients without co-morbidities. Diabetes is a complex disease, characterised not only by hyperglycemia but also by various forms of dyslipidemia. However, the relative contribution of these underlying metabolic factors to increased susceptibility to TB are poorly understood. This review summarises our current knowledge on the epidemiology and clinical manifestation of TB and diabetes comorbidity. We subsequently dissect the relative contributions of body mass index, hyperglycemia, elevated cholesterol and triglycerides on TB disease severity and treatment outcomes. Lastly, we discuss the impact of selected glucose and cholesterol-lowering treatments frequently used in the management of diabetes on TB treatment outcomes.

Exploring the Clinical Utility of Metagenomic Next-Generation Sequencing in the Diagnosis of Pulmonary Infection

INTRODUCTION

We aimed to explore the real-world clinical application value and challenges of metagenomic next-generation sequencing (mNGS) for pulmonary infection diagnosis.

METHODS

We retrospectively reviewed the results of mNGS and conventional tests from 140 hospitalized patients with suspected pulmonary infections from January 2019 to December 2020. The sample types included bronchoalveolar lavage fluid, lung tissue by transbronchial lung biopsy, pleural effusion, blood, and bronchial sputum. Apart from the mNGS reports that our patients received, an extra comprehensive and thorough literature search was conducted.

RESULTS

Significant differences were noticed in the positive detection rates of pathogens between mNGS and conventional diagnostic testing (115/140, 82.14% vs 50/140, 35.71%, P < 0.05). The percentage of mNGS-positive patients was significantly higher than that of conventional testing-positive patients with regard to bacterial detection (P < 0.01), but no significant differences were found with regard to fungal detection (P = 0.67). Significant statistical differences were found between mixed infection cases (15, 22.70%) and single infection cases (4, 7.84%) in terms of diabetes (P = 0.03). The most frequent pattern of mixed infection was bacteria and fungi mixed infection (40, 40/89 = 44.94%), followed by bacteria mixed infection (29, 29/89 = 32.58%). The sensitivity of mNGS in pulmonary infection diagnosis was much higher than that of conventional test (89.17% vs 50.00%; P < 0.01), but the specificity was the opposite (75.00% vs 81.82%; P > 0.05).

CONCLUSION

mNGS is a valuable tool for the detection of pulmonary infections, especially mixed pulmonary infections. The most common combinations we found were bacterial-fungal coinfection and bacterial-bacterial coinfection. Still, there are many challenges in the clinical application of mNGS in the diagnosis of pulmonary infections. There is still a lot of work to be done in interpreting the mNGS reports, because both clinical judgment and literature analysis strategy need to be refined.

Diabetes and tuberculosis: a syndemic complicated by COVID-19

Tuberculosis (TB) is the leading cause of infectious mortality in the world, affecting mainly developing countries (DC), while diabetes (DM) is one of the most prevalent chronic diseases. This review analyzes the fact that diabetes is currently an important risk factor for developing TB, also presenting more complicated TB, more relapses and higher mortality. The DCs and the fourth world of the large cities are those with the highest incidence of TB and an increase in DM, which will make it difficult to control tuberculosis disease. At the same time, the COVID-19 pandemic is complicating the management of both diseases due to the difficulty of access to control and treatment and the worsening of socioeconomic inequalities. It is necessary to establish a bidirectional screening for TB and DM and promote recommendations for the joint management of both diseases.

Impact of Diabetes and Low Body Mass Index on Tuberculosis Treatment Outcomes

BACKGROUND

Diabetes was identified as a tuberculosis (TB) risk factor mostly in retrospective studies with limited assessments of metabolic variables. The prospective Effects of Diabetes on Tuberculosis Severity study compared adults with pulmonary TB in Chennai, India, who were classified as having either diabetes or a normal glucose tolerance at enrollment.

METHODS

Baseline TB severity, sputum conversion, and treatment outcomes (cure, failure, death, or loss to follow-up) were compared between groups with respect to glycemic status and body mass index (BMI).

RESULTS

The cohort of 389 participants included 256 with diabetes and 133 with a normal glucose tolerance. Low BMIs (<18.5 kg/m2) were present in 99 (74.4%) of nondiabetic participants and 85 (33.2%) of those with diabetes. Among participants with normal or high BMIs, rates of cure, treatment failure, or death did not vary by glycemic status. Participants with low BMIs had the highest radiographic severity of disease, the longest time to sputum culture conversion, and the highest rates of treatment failure and death. Among participants with low BMIs, poorly controlled diabetes (glycohemoglobin [HbA1c] ≥8.0%) was unexpectedly associated with better TB treatment outcomes. A high visceral adiposity index was associated with adverse outcomes and, despite an overall correlation with HbA1c, was elevated in some low-BMI individuals with normal glucose tolerance.

CONCLUSIONS

In this South Indian cohort, a low BMI was significantly associated with an increased risk for adverse TB treatment outcomes, while comorbid, poorly controlled diabetes lessened that risk. A high visceral adiposity index, either with or without dysglycemia, might reflect a novel TB susceptibility mechanism linked to adipose tissue dysfunction.

Prevalence of tuberculosis and diabetes comorbidity in patients attending secondary healthcare hospital in south India: A retrospective study

Background and Objectives:

Tuberculosis, a communicable disease and diabetes, a non-communicable disease together has a bidirectional relationship toward each other withsignificant morbidity and delayed treatment outcome. Therefore, there is a need to identify the prevalence of both these diseases in a community. A retrospective study was planned to identify the prevalence of both diseases among the patients attending secondary hospitals for 3 years.

Methods:

The study was conducted in the chest diseases department in a secondary care hospital after obtaining approval from the institute ethics committee and RNTCP. The retrospective data in the hospital register was used to identify various parameters. The data for basic demographic characteristics, number of new cases, previously treated cases, pulmonary/extrapulmonary cases, drug resistance cases, and DM/TB cases were entered in Microsoft excel and were analyzed.

Results:

The prevalence of TB among the patients attending the chest diseases department was 2.9%, 2.5%, and 3% for the years 2016, 2017, and 2018, respectively. The prevalence of DM/TB ranged between 8.5–11%, which is a lesser range when compared with many other studies.

Interpretations and Conclusion:

There was no significant difference in the prevalence between the years. The screening of one disease in the presence of the other can reduce the prevalence and improve the prognosis.

Prior undernutrition and insulin production several years later in Tanzanian adults

BACKGROUND

The prevalence, pathology, and existence of malnutrition-associated diabetes remain uncertain, especially with respect to adult-acquired undernutrition.

OBJECTIVE

The aim was to investigate the association of prior undernutrition (low BMI, in kg/m2), acquired in adulthood and insulin during an oral glucose tolerance test (OGTT).

METHODS

We followed up 630 adults recruited 7-14 y previously for other studies. Plasma insulin was measured fasting and at 30 and 120 min during an OGTT. The main exposure was BMI measured 7-14 y prior. The main outcome of interest was plasma insulin, controlling for time during the OGTT using generalized estimating equations, and exploratory outcomes were early insulin response (relative change in insulin and glucose from 0-30 min) and relative insulin and glucose AUCs from 0 to 120 min. Current confounding factors were age, sex, BMI, HIV, socioeconomic status, and physical activity.

RESULTS

In unadjusted analyses, increasing severity of prior malnutrition was associated with lower insulin concentration. In multivariate adjusted analyses, only current BMI was a strong predictor of overall insulin concentration. Associations with prior BMI of insulin responses accounting for glucose were also seen in unadjusted but not adjusted analyses. For insulin concentration but not the outcomes accounting for glucose, there was a sex interaction with prior BMI such that only men had lower insulin if previously malnourished: insulin (pmol/L) at 120 min was 311 (95% CI: 272, 351) for prior BMI ≥18.5, 271 (95% CI: 221, 321) for prior BMI 17.0-18.5, and 237 (95% CI: 194, 297) for prior BMI <17.0; P = 0.03. HIV status showed limited and variable associations with insulin.

CONCLUSIONS

Insulin concentration, fasting and during an OGTT, was normalized in women more than in men several years after adult malnutrition. Chronic malnutrition, as indicated by low prior and current BMI, may contribute to diabetes through low insulin secretion.

The effect of a structured clinical algorithm on glycemic control in patients with combined tuberculosis and diabetes in Indonesia: A randomized trial

AIMS

Diabetes mellitus (DM) is associated with worse tuberculosis (TB) treatment outcomes, especially among those with poor glycemic control. We examined whether a structured clinical algorithm could improve glycemic control in TB patients with DM.

METHODS

In an open label randomized trial, TB-DM patients were randomized to scheduled counselling, glucose monitoring, and adjustment of medication using a structured clinical algorithm (intervention arm) or routine DM management (control arm), with glycated hemoglobin (HbA1c) at month 6 as the primary end point.

RESULTS

We randomized 150 pulmonary TB-DM patients (92% culture positive, 51.3% male, mean age 53 years). Baseline mean HbA1c was 11.0% in the intervention arm (n = 76) and 11.6% in the control arm (n = 74). At 6 months, HbA1c had decreased more in the intervention arm compared with the control arm (a difference of 1.82% HbA1c, 95% CI 0.82-2.83, p < 0.001). Five patients were hospitalized in the intervention arm and seven in the control arm. There was more hypoglycemia (35.0% vs 11.8%; p = 0.002) in the intervention arm. Two deaths occurred in the intervention arm, one due to cardiorespiratory failure and one because of suspected septic shock and multiorgan failure.

CONCLUSION

Regular monitoring and algorithmic adjustment of DM treatment led to improved glycemic control.

Phenotype Definition for "Resisters" to Mycobacterium tuberculosis Infection in the Literature-A Review and Recommendations

Tuberculosis (TB) remains a worldwide problem. Despite the high disease rate, not all who are infected with Mycobacterium Tuberculosis (Mtb) develop disease. Interferon-γ (IFN-γ) specific T cell immune assays such as Quantiferon and Elispot, as well as a skin hypersensitivity test, known as a tuberculin skin test, are widely used to infer infection. These assays measure immune conversion in response to Mtb. Some individuals measure persistently negative to immune conversion, despite high and prolonged exposure to Mtb. Increasing interest into this phenotype has led to multiple publications describing various aspects of these responses. However, there is a lack of a unified "resister" definition. A universal definition will improve cross study data comparisons and assist with future study design and planning. We review the current literature describing this phenotype and make recommendations for future studies.

Factors affecting outcome of longer regimen multidrug-resistant tuberculosis treatment in West Java Indonesia: A retrospective cohort study

Background

Multidrug-resistant tuberculosis had high treatment failure and mortality. Success rate of treatment currently 56% at global level, 48% in Indonesia and 36% in West Java province, the most populated province and surround Jakarta, the capitol of Indonesia.

Objective

This study aimed to evaluate factors affecting success of multidrug-resistant tuberculosis treatment in patients using longer treatment regimen in West Java Indonesia.

Methods

This was a retrospective cohort study of multidrug-resistant tuberculosis patients treated with longer regimen at Hasan Sadikin General Hospital from January 2015 to December 2017. Potential risk factors associated with the treatment outcome were analyzed using multiple logistic regression.

Results

A total of 492 patients were enrolled during the study period. Fifty percents multidrug-resistant tuberculosis patients had successful treatment outcome. Age ≤45 years, male, normal body mass index, no previous tuberculosis treatment, culture conversion ≤2 months, acid fast bacilli sputum smear ≤+1 were independent factors associated with increased treatment success. Sputum culture conversion ≤2 months was the major factor affecting successful outcome (RR 2.79; 95% CI: 1.61–4.84; p-value<0.001). Human Immunodeficiency Virus infection, chronic kidney disease, and cavitary lesion were independent risk factors for unfavourable outcome.

Conclusion

Age, gender, body mass index, tuberculosis treatment history, time of sputum conversion, acid fast bacilli sputum smear, HIV infection, chronic kidney disease, and cavitary lesion can be used as predictors for longer multidrug-resistant tuberculosis treatment regimen outcome.

Dysglycemia is associated with Mycobacterium tuberculosis lineages in tuberculosis patients of North Lima-Peru

This study was performed to investigate the role of dysglycemia on the genetic diversity of Mycobacterium tuberculosis (MTB) among pulmonary tuberculosis (TB) patients to build scientific evidence about the possible mechanisms of TB transmission. MTB isolates obtained of patients affected by pulmonary tuberculosis from health care facilities of North Lima-Peru, were analyzed using whole genome sequencing and 24-locus mycobacterial interspersed repetitive-unit -variable-number tandem repeats (MIRU-VNTR). Subsequently, clinical and epidemiological characteristics were associated with clustering, lineages and comorbid conditions. The analysis carried out 112 pulmonary TB patients from various health centers in North Lima, 17 (15%) had diabetes mellitus (DM) and 33 (29%) had pre-diabetes (PDM). Latin American-Mediterranean, Haarlem and Beijing were the most frequent MTB lineages found in those patients. Previous TB (adjusted odds ratio [aOR] = 3.65; 95%CI: 1.32-17.81), age (aOR = 1.12; 95%CI: 1.03-1.45) and Beijing lineage (aOR = 3.53; 95%CI: 1.08-13.2) were associated with TB-DM comorbidity. Alcoholism (aOR = 2.92; 95%CI: 1.10-8.28), age (aOR = 1.05; 95%CI: 1.03-1.12) and Haarlem lineage (aOR = 2.54; 95%CI: 1.04-6.51) were associated with TB-PDM comorbidity. Beijing and Haarlem lineages were independently associated with TB-DM and TB-PDM comorbidities, respectively. Although these findings may be surprising, we must be cautious to suggest that dysglycemia could be associated with a highly clustering and predisposition of MTB lineages related to a serious impact on the severity of TB disease, which requires further research.

Impact of Intermediate Hyperglycemia and Diabetes on Immune Dysfunction in Tuberculosis

BACKGROUND

People with diabetes have an increased risk of developing active tuberculosis (TB) and are more likely to have poor TB-treatment outcomes, which may impact on control of TB as the prevalence of diabetes is increasing worldwide. Blood transcriptomes are altered in patients with active TB relative to healthy individuals. The effects of diabetes and intermediate hyperglycemia (IH) on this transcriptomic signature were investigated to enhance understanding of immunological susceptibility in diabetes-TB comorbidity.

METHODS

Whole blood samples were collected from active TB patients with diabetes (glycated hemoglobin [HbA1c] ≥6.5%) or IH (HbA1c = 5.7% to <6.5%), TB-only patients, and healthy controls in 4 countries: South Africa, Romania, Indonesia, and Peru. Differential blood gene expression was determined by RNA-seq (n = 249).

RESULTS

Diabetes increased the magnitude of gene expression change in the host transcriptome in TB, notably showing an increase in genes associated with innate inflammatory and decrease in adaptive immune responses. Strikingly, patients with IH and TB exhibited blood transcriptomes much more similar to patients with diabetes-TB than to patients with only TB. Both diabetes-TB and IH-TB patients had a decreased type I interferon response relative to TB-only patients.

CONCLUSIONS

Comorbidity in individuals with both TB and diabetes is associated with altered transcriptomes, with an expected enhanced inflammation in the presence of both conditions, but also reduced type I interferon responses in comorbid patients, suggesting an unexpected uncoupling of the TB transcriptome phenotype. These immunological dysfunctions are also present in individuals with IH, showing that altered immunity to TB may also be present in this group. The TB disease outcomes in individuals with IH diagnosed with TB should be investigated further.

The Interaction of Diabetes and Tuberculosis: Translating Research to Policy and Practice

Diabetes Mellitus increases the risk of developing Tuberculosis (TB) disease by about three times; it also doubles the risk of death during TB treatment and other poor TB treatment outcomes. Diabetes may increase the risk of latent infection with Mycobacterium tuberculosis (LTBI), but the magnitude of this effect is less clear. Whilst this syndemic has received considerable attention, most of the published research has focussed on screening for undiagnosed diabetes in TB patients or observational follow-up of TB treatment outcomes by diabetes status. There are thus substantial research and policy gaps, particularly with regard to prevention of TB disease in people with diabetes and management of patients with TB-diabetes, both during TB treatment and after successful completion of TB treatment, when they likely remain at high risk of TB recurrence, mortality from TB and cardiovascular disease. Potential strategies to prevent development of TB disease might include targeted vaccination programmes, screening for LTBI and preventive therapy among diabetes patients or, perhaps ideally, improved diabetes management and prevention. The cost-effectiveness of each of these, and in particular how each strategy might compare with targeted TB prevention among other population groups at higher risk of developing TB disease, is also unknown. Despite research gaps, clinicians urgently need practical management advice and more research evidence on the choice and dose of different anti-diabetes medication and effective medical therapies to reduce cardiovascular risks (statins, anti-hypertensives and aspirin). Substantial health system strengthening and integration may be needed to prevent these at risk patients being lost to care at the end of TB treatment.

Household Contacts of Leprosy Patients in Endemic Areas Display a Specific Innate Immunity Profile

Leprosy is a chronic infectious disease, caused by Mycobacterium leprae, that can lead to severe life-long disabilities. The transmission of M. leprae is continuously ongoing as witnessed by the stable new case detection rate. The majority of exposed individuals does, however, not develop leprosy and is protected from infection by innate immune mechanisms. In this study the relation between innate immune markers and M. leprae infection as well as the occurrence of leprosy was studied in household contacts (HCs) of leprosy patients with high bacillary loads. Serum proteins associated with innate immunity (ApoA1, CCL4, CRP, IL-1Ra, IL-6, IP-10, and S100A12) were determined by lateral flow assays (LFAs) in conjunction with the presence of M. leprae DNA in nasal swabs (NS) and/or slit-skin smears (SSS). The HCs displayed ApoA1 and S100A12 levels similar to paucibacillary patients and could be differentiated from endemic controls based on the levels of these markers. In the 31 households included the number (percentage) of HCs that were concomitantly diagnosed with leprosy, or tested positive for M. leprae DNA in NS and SSS, was not equally divided. Specifically, households where M. leprae infection and leprosy disease was not observed amongst members of the household were characterized by higher S100A12 and lower CCL4 levels in whole blood assays of HCs in response to M. leprae. Lateral flow assays provide a convenient diagnostic tool to quantitatively measure markers of the innate immune response and thereby detect individuals which are likely infected with M. leprae and at risk of developing disease or transmitting bacteria. Low complexity diagnostic tests measuring innate immunity markers can therefore be applied to help identify who should be targeted for prophylactic treatment.

Forecasting tuberculosis using diabetes-related google trends data

Online activity-based data can be used to aid infectious disease forecasting. Our aim was to exploit the converging nature of the tuberculosis (TB) and diabetes epidemics to forecast TB case numbers. Thus, we extended TB prediction models based on traditional data with diabetes-related Google searches. We obtained data on the weekly case numbers of TB in Germany from June 8^th, 2014, to May 5^th, 2019. Internet search data were obtained from a Google Trends (GTD) search for 'diabetes' to the corresponding interval. A seasonal autoregressive moving average (SARIMA) model (0,1,1) (1,0,0) [52] was selected to describe the weekly TB case numbers with and without GTD as an external regressor. We cross-validated the SARIMA models to obtain the root mean squared errors (RMSE). We repeated this procedure with autoregressive feed-forward neural network (NNAR) models using 5-fold cross-validation. To simulate a data-poor surveillance setting, we also tested traditional and GTD-extended models against a hold-out dataset using a decreased 52-week-long period with missing values for training. Cross-validation resulted in an RMSE of 20.83 for the traditional model and 18.56 for the GTD-extended model. Cross-validation of the NNAR models showed a mean RMSE of 19.49 for the traditional model and 18.99 for the GTD-extended model. When we tested the models trained on a decreased dataset with missing values, the GTD-extended models achieved significantly better prediction than the traditional models (p < 0.001). The GTD-extended models outperformed the traditional models in all assessed model evaluation parameters. Using online activity-based data regarding diabetes can improve TB forecasting, but further validation is warranted.

Patterns and predictors of co-morbidities in Tuberculosis: A cross-sectional study in the Philippines

Diabetes and undernutrition are common risk factors for TB, associated with poor treatment outcomes and exacerbated by TB. We aimed to assess non-communicable multimorbidity (co-occurrence of two or more medical conditions) in Filipino TB outpatients, focusing on malnutrition and diabetes. In a cross-sectional study, 637 adults (70% male) from clinics in urban Metro Manila (N = 338) and rural Negros Occidental (N = 299) were enrolled. Diabetes was defined as HbA1c of ≥6.5% and/or current diabetes medication. Study-specific HIV screening was conducted. The prevalence of diabetes was 9.2% (54/589, 95%CI: 7.0-11.8%) with 52% newly diagnosed. Moderate/severe undernutrition (body mass index (BMI) <17 kg/2) was 20.5% (130/634, 95%CI: 17.4-23.9%). Forty percent of participants had at least one co-morbidity (diabetes, moderate/severe undernutrition or moderate/severe anaemia (haemoglobin <11 g/dL)). HIV infection (24.4%, 74/303) was not associated with other co-morbidities (but high refusal in rural clinics). Central obesity assessed by waist-to-hip ratio was more strongly associated with diabetes (Adjusted Odds Ratio (AOR) = 6.16, 95%CI: 3.15-12.0) than BMI. Undernutrition was less common in men (AOR = 0.44, 95%CI: 0.28-0.70), and associated with previous history of TB (AOR = 1.97, 95%CI: 1.28-3.04) and recent reduced food intake. The prevalence of multimorbidity was high demonstrating a significant unmet need. HIV was not a risk factor for increased non-communicable multimorbidity.

A public-private model to scale up diabetes mellitus screening among people accessing tuberculosis diagnostics in Dhaka, Bangladesh

Background:

Data are scarce regarding the prevalence of diabetes mellitus (DM) among tuberculosis (TB) patients in Bangladesh. This study was undertaken to estimate the number needed to screen (NNS) to identify a case of DM among those with TB symptoms and those with confirmed TB disease, and to identify factors predicting treatment outcomes of TB patients with and without DM.

Methods:

Persons attending public–private model screening centres in urban Dhaka for the evaluation of TB were offered free blood glucose testing in addition to computer-aided chest X-ray and sputum Xpert MTB/RIF.

Results:

Among 7647 people evaluated for both TB and DM, the NNS was 35 (95% confidence interval (CI) 31–40) to diagnose one new case of DM; among those diagnosed with TB, the NNS was 21 (95% CI 17–29). Among those with diagnosed TB, patients with DM were more likely to have cavitation on chest X-ray compared to those without DM (31% vs 22%). Treatment failure (odds ratio (OR) 18.9, 95% CI 5.43–65.9) and death (OR 2.08, 95% CI 1.11–3.90) were more common among TB patients with DM than among TB patients without DM. DM was the most important predictor of a poor treatment outcome in the classification analysis for TB patients aged 39 years and above.

Conclusions:

A considerable burden of DM was found among patients accessing TB diagnostics through a public–private model in urban Bangladesh, and DM was associated with advanced TB disease and a high rate of poor treatment outcome.

[Prevalence of comorbidity tuberculosis and diabetes mellitus in Paraguay, 2016 and 2017Prevalência de comorbidade tuberculose-diabetes mellitus no Paraguai, 2016 e 2017]

Objetivo.

Estimar la prevalencia nacional y regional de la comorbilidad tuberculosis (TB) y diabetes mellitus (DM) e identificar los factores asociados con esta comorbilidad en Paraguay.

Métodos.

Estudio transversal en pacientes con TB notificada en 2016 y 2017 y registrados en la base de datos del Programa Nacional de Control de la TB. La prevalencia de DM, definida por autonotificación, se estimó en pacientes con TB. Para conocer los factores asociados con la comorbilidad TB-DM se empleó un modelo multivariante de regresión binomial para ajustar las razones de prevalencia (RP) según los errores estándar por el clúster de región sanitaria.

Resultados.

Entre 2016 y 2017 se notificaron 5 315 casos de TB. La prevalencia de la comorbilidad TB-DM fue 6,3% en 2016, 6,0% en 2017 y 6,2% en ambos años. Fue más alta en Itapúa (9,2%), Alto Paraguay (8,0%), Alto Paraná (7,5%), Central (7,4%) y Asunción (7,2%). La mediana de edad de personas con DM fue más alta que la de las que no tenían DM (55 y 33 años; P < 0,001). Tener una edad mayor de 45 años (RP = 18,3), el sexo femenino, antecedente de hipertensión arterial (HTA) (RP = 2,17), baciloscopía de diagnóstico de tres cruces (RP 1,98), y antecedente de enfermedad pulmonar obstructiva crónica (EPOC) (RP 1,68) estuvieron asociados con mayor comorbilidad. En cambio, se asociaron con menor comorbilidad pertenecer a la población indígena (RP = 0,26), la infección por el virus de la inmunodeficiencia humana (RP = 0,44), historia de adicción a drogas (RP = 0,49), el sexo masculino (RP = 0,64), y la TB extrapulmonar (RP = 0,75).

Conclusiones.

La prevalencia de la comorbilidad de TB y DM en Paraguay, por autonotificación, fue 6,2% en el periodo 2016-2017 y varió entre las regiones sanitarias. La edad, una alta carga bacilar al diagnóstico y la comorbilidad con HTA y EPOC se asociaron a una mayor comorbilidad. Estos hallazgos permitirán priorizar grupos de población para aumentar rendimiento del cribado, diagnóstico, tratamiento y prevención de la comorbilidad TB-DM en Paraguay.

Plasma metabolomics in tuberculosis patients with and without concurrent type 2 diabetes at diagnosis and during antibiotic treatment

Tuberculosis (TB) and type 2 diabetes mellitus (DM), a major TB risk factor, are both accompanied by marked alterations in metabolic processes. Dissecting the specific metabolic changes induced by disease through metabolomics has shown potential to improve our understanding of relevant pathophysiological mechanisms of disease, which could lead to improved treatment. Targeted tandem liquid chromatography–mass spectrometry (LC-MS/MS) was used to compare amine and acylcarnitine levels in plasma samples of patients with TB or TB-DM from Indonesia at time of diagnosis and during antibiotic treatment. Partial least squares discrimination analysis (PLS-DA) showed good separation of patient groups. Amine levels were strongly altered in both disease groups compared to healthy controls, including low concentrations of citrulline and ornithine. Several amino acid ratios discriminated TB from controls (phenylalanine/histidine; citrulline/arginine; kynurenine/tryptophan), possibly reflecting changes in indoleamine-pyrrole 2,3-dioxygenase (IDO) and nitric oxide synthase (NOS) activity. Choline, glycine, serine, threonine and homoserine levels were lower in TB-DM compared to TB, and, in contrast to other analytes, did not normalize to healthy control levels during antibiotic treatment. Our results not only provide important validation of previous studies but also identify novel biomarkers, and significantly enhance our understanding of metabolic changes in human TB and TB-DM.

An Inflammatory Story: Antibodies in Tuberculosis Comorbidities

Mycobacterium tuberculosis (Mtb) resides in a quarter of the world's population and is the causative agent for tuberculosis (TB), the most common infectious reason of death in humans today. Although cellular immunity has been firmly established in the control of Mtb, there is growing evidence that antibodies may also modulate the infection. More specifically, certain antibody features are associated with inflammation and are divergent in different states of human infection and disease. Importantly, TB impacts not just the healthy but also those with chronic conditions. While HIV represents the quintessential comorbid condition for TB, recent epidemiological evidence shows that additional chronic conditions such as diabetes and kidney disease are rising. In fact, the prevalence of diabetes as a comorbid TB condition is now higher than that of HIV. These chronic diseases are themselves independently associated with pro-inflammatory immune states that encompass antibody profiles. This review discusses isotypes, subclasses, post-translational modifications and Fc-mediated functions of antibodies in TB infection and in the comorbid chronic conditions of HIV, diabetes, and kidney diseases. We propose that inflammatory antibody profiles, which are a marker of active TB, may be an important biomarker for detection of TB disease progression within comorbid individuals. We highlight the need for future studies to determine which inflammatory antibody profiles are the consequences of comorbidities and which may potentially contribute to TB reactivation.

High prevalence and heterogeneity of Dysglycemia in patients with tuberculosis from Peru: a prospective cohort study

BACKGROUND

The accuracy of different laboratory tests for diagnosis of diabetes mellitus (DM) and prediabetes (preDM) in populations exposed to tuberculosis (TB) remains poorly understood. Here, we examined the prevalence of DM and preDM in TB affected people in Lima, Peru.

METHODS

A prospective cohort study of patients affected TB and their household contacts (HHC), was conducted between February and November 2017 in Lima, Peru. Fasting plasma glucose (FPG), HbA1c and oral glucose tolerance test (OGTT) were used to detect DM and preDM in a prospective cohort of TB patients (n = 136) and household contacts (n = 138). Diagnostic performance of the laboratory tests was analyzed. Potential effects of sociodemographic and clinical factors on detection of dysglycemia were analyzed.

RESULTS

In TB patients, prevalence of DM and preDM was 13.97 and 30.88% respectively. Lower prevalence of both DM (6.52%) and preDM (28.99%) were observed in contacts. FPG, HbA1c and OGTT had poor agreement in detection of preDM in either TB cases or contacts. TB-DM patients had substantially lower hemoglobin levels, which resulted in low accuracy of HbA1c-based diagnosis. Classic sociodemographic and clinical characteristics were not different between TB patients with or without dysglycemia.

CONCLUSION

High prevalence of DM and preDM was found in both TB patients and contacts in Lima. Anemia was strongly associated with TB-DM, which directly affected the diagnostic performance of HbA1c in such population.

Primary drug resistance among tuberculosis patients with diabetes mellitus: a retrospective study among 7223 cases in China

Background

Given the high burden of tuberculosis (TB) and diabetes mellitus (DM) in China and the worse outcome of TB-DM cases (refers to TB patients with diabetes), and drug-resistant tuberculosis cases (DR-TB), it is of great significance to explore the association between diabetes and primary DR-TB for TB elimination target in China. We assessed the clinical characteristics, drug-resistance profile, and increased risk of resistance among TB-DM patients across China from 2004 to 2017.

Method

7223 cases with drug-susceptibility data were collected from Shandong, China. Categorical baseline characteristics of new TB cases were compared by DM status using Fisher's exact or Pearson Chi-square test. Univariable analysis and multivariable logistic models were used to estimate the association between diabetes and different drug-resistance profiles and the risk factors of primary drug resistance among TB-DM cases.

Result

Of 7223 newly diagnosed TB patients, 426 (5.90%) were TB-DM cases. TB-DM csaes were more likely to be older，accompanied by higher body mass index (BMI) and hypertension than TB-no DM cases (refers to TB patients without diabetes). The rates of DR-TB (21.83% vs 16.96%), polydrug resistant TB (PDR-TB, 6.10% vs 3.80%), isoniazid (INH)+streptomycin (SM)-resistant TB (4.93% vs 3.13%), and SM-resistant TB (16.20% vs 11.7%) among TB-DM group were higher than TB-no DM group, P<0.05. DM was significantly associated with any DR-TB (adjusted (aOR):1.30; 95% CI, 1.02-1.65), SM-related resistance (aOR: 1.43; 95% CI, 1.08-1.88), PDR-TB (OR: 1.57; 95% CI, 1.04-2.36; aOR: 1.59; 95% CI, 1.04-2.44), compared with pan-susceptible TB patients (P<0.05).

Conclusion

Our study indicated that TB-DM groups had a higher proportion of drug resistance than TB groups, and diabetes was identified as a risk factor of total DR, PDR, SM resistance and INH+SM resistance among newly diagnosed TB cases. Good management of diabetes and TB infection screening program among DM patients might be necessary for improving TB control in China.