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Hamada Y, Quartagno M, Law I, Malik F, Bonsu FA, Adetifa IM, Adusi-Poku Y, D'Alessandro U, Bashorun AO, Begum V, Lolong DB, Boldoo T, Dlamini T, Donkor S, Dwihardiani B, Egwaga S, Farid MN, Celina G.Garfin AM, Mae G Gaviola D, Husain MM, Ismail F, Kaggwa M, Kamara DV, Kasozi S, Kaswaswa K, Kirenga B, Klinkenberg E, Kondo Z, Lawanson A, Macheque D, Manhiça I, Maama-Maime LB, Mfinanga S, Moyo S, Mpunga J, Mthiyane T, Mustikawati DE, Mvusi L, Nguyen HB, Nguyen HV, Pangaribuan L, Patrobas P, Rahman M, Rahman M, Rahman MS, Raleting T, Riono P, Ruswa N, Rutebemberwa E, Rwabinumi MF, Senkoro M, Sharif AR, Sikhondze W, Sismanidis C, Sovd T, Stavia T, Sultana S, Suriani O, Thomas AM, Tobing K, Van der Walt M, Walusimbi S, Zaman MM, Floyd K, Copas A, Abubakar I, Rangaka MX. Association of diabetes, smoking, and alcohol use with subclinical-to-symptomatic spectrum of tuberculosis in 16 countries: an individual participant data meta-analysis of national tuberculosis prevalence surveys. EClinicalMedicine 2023; 63:102191. [PMID: 37680950 PMCID: PMC10480554 DOI: 10.1016/j.eclinm.2023.102191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/24/2023] [Accepted: 08/16/2023] [Indexed: 09/09/2023] Open
Abstract
Background Non-communicable diseases (NCDs) and NCD risk factors, such as smoking, increase the risk for tuberculosis (TB). Data are scarce on the risk of prevalent TB associated with these factors in the context of population-wide systematic screening and on the association between NCDs and NCD risk factors with different manifestations of TB, where ∼50% being asymptomatic but bacteriologically positive (subclinical). We did an individual participant data (IPD) meta-analysis of national and sub-national TB prevalence surveys to synthesise the evidence on the risk of symptomatic and subclinical TB in people with NCDs or risk factors, which could help countries to plan screening activities. Methods In this systematic review and IPD meta-analysis, we identified eligible prevalence surveys in low-income and middle-income countries that reported at least one NCD (e.g., diabetes) or NCD risk factor (e.g., smoking, alcohol use) through the archive maintained by the World Health Organization and by searching in Medline and Embase from January 1, 2000 to August 10, 2021. The search was updated on March 23, 2023. We performed a one-stage meta-analysis using multivariable multinomial models. We estimated the proportion of and the odds ratio for subclinical and symptomatic TB compared to people without TB for current smoking, alcohol use, and self-reported diabetes, adjusted for age and gender. Subclinical TB was defined as microbiologically confirmed TB without symptoms of current cough, fever, night sweats, or weight loss and symptomatic TB with at least one of these symptoms. We assessed heterogeneity using forest plots and I2 statistic. Missing variables were imputed through multi-level multiple imputation. This study is registered with PROSPERO (CRD42021272679). Findings We obtained IPD from 16 national surveys out of 21 national and five sub-national surveys identified (five in Asia and 11 in Africa, N = 740,815). Across surveys, 15.1%-56.7% of TB were subclinical (median: 38.1%). In the multivariable model, current smoking was associated with both subclinical (OR 1.67, 95% CI 1.27-2.40) and symptomatic TB (OR 1.49, 95% CI 1.34-1.66). Self-reported diabetes was associated with symptomatic TB (OR 1.67, 95% CI 1.17-2.40) but not with subclinical TB (OR 0.92, 95% CI 0.55-1.55). For alcohol drinking ≥ twice per week vs no alcohol drinking, the estimates were imprecise (OR 1.59, 95% CI 0.70-3.62) for subclinical TB and OR 1.43, 95% CI 0.59-3.46 for symptomatic TB). For the association between current smoking and symptomatic TB, I2 was high (76.5% (95% CI 62.0-85.4), while the direction of the point estimates was consistent except for three surveys with wide CIs. Interpretation Our findings suggest that current smokers are more likely to have both symptomatic and subclinical TB. These individuals can, therefore, be prioritised for intensified screening, such as the use of chest X-ray in the context of community-based screening. People with self-reported diabetes are also more likely to have symptomatic TB, but the association is unclear for subclinical TB. Funding None.
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Affiliation(s)
- Yohhei Hamada
- Institute for Global Health, University College London, United Kingdom
| | - Matteo Quartagno
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, United Kingdom
| | - Irwin Law
- Global Tuberculosis Programme, World Health Organization, Switzerland
| | - Farihah Malik
- UCL Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | | | - Ifedayo M.O. Adetifa
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Gambia
- Department of Infectious Diseases Epidemiology, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Yaw Adusi-Poku
- National Tuberculosis Programme, Ghana Health Service, Ghana
| | - Umberto D'Alessandro
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Gambia
| | - Adedapo Olufemi Bashorun
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Gambia
| | | | | | - Tsolmon Boldoo
- Tuberculosis Surveillance and Research Department, National Center for Communicable Disease, Mongolia
| | - Themba Dlamini
- Eswatini National Tuberculosis Program, Ministry of Health, Eswatini
| | - Simon Donkor
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Gambia
| | - Bintari Dwihardiani
- Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Indonesia
| | - Saidi Egwaga
- Tuberculosis and Leprosy Programme, Ministry of Health and Social Welfare, United Republic of Tanzania
| | | | | | | | | | - Farzana Ismail
- Centre for Tuberculosis, National Institute for Communicable Diseases, A Division of the National Health Laboratory Services, South Africa
- Department of Medical Microbiology, University of Pretoria, South Africa
| | - Mugagga Kaggwa
- World Health Organization, Country Office for Uganda, Uganda
| | - Deus V. Kamara
- Tuberculosis and Leprosy Programme, Ministry of Health and Social Welfare, United Republic of Tanzania
| | - Samuel Kasozi
- National Tuberculosis Control Programme, Ministry of Health, Uganda
| | | | | | - Eveline Klinkenberg
- Department of Global Health, Amsterdam University Medical Center, Netherlands
| | - Zuweina Kondo
- Tuberculosis and Leprosy Programme, Ministry of Health and Social Welfare, United Republic of Tanzania
| | - Adebola Lawanson
- National Tuberculosis and Leprosy Control Programme, Federal Ministry of Health, Nigeria
| | - David Macheque
- National Tuberculosis Program, Ministry of Health, Mozambique
| | - Ivan Manhiça
- National Tuberculosis Program, Ministry of Health, Mozambique
| | | | - Sayoki Mfinanga
- Institute for Global Health, University College London, United Kingdom
- National Institute for Medical Research, Muhimbili Medical Research Centre, United Republic of Tanzania
- Liverpool School of Tropical Medicine, United Kingdom
- Alliance for Africa Health and Research, United Republic of Tanzania
| | - Sizulu Moyo
- Human Sciences Research Council, South Africa
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - James Mpunga
- National Tuberculosis Programme, Ministry of Health, Malawi
| | | | | | | | | | | | | | - Philip Patrobas
- World Health Organization, Country Office for Nigeria, Nigeria
| | - Mahmudur Rahman
- Institute of Epidemiology, Disease Control and Research (IEDCR), Bangladesh
| | - Mahbubur Rahman
- Institute of Epidemiology, Disease Control and Research (IEDCR), Bangladesh
| | | | | | | | | | - Elizeus Rutebemberwa
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Uganda
| | | | - Mbazi Senkoro
- National Institute for Medical Research, Muhimbili Medical Research Centre, United Republic of Tanzania
| | | | - Welile Sikhondze
- Eswatini National Tuberculosis Program, Ministry of Health, Eswatini
| | | | | | | | - Sabera Sultana
- World Health Organization, Country Office for Bangladesh, Bangladesh
| | | | | | | | | | | | | | - Katherine Floyd
- Global Tuberculosis Programme, World Health Organization, Switzerland
| | - Andrew Copas
- Institute for Global Health, University College London, United Kingdom
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, United Kingdom
| | - Molebogeng X. Rangaka
- Institute for Global Health, University College London, United Kingdom
- Division of Epidemiology and Biostatistics & CIDRI-AFRICA, University of Cape Town, South Africa
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