Diabetes mellitus and the risk of multidrug resistant tuberculosis: a meta-analysis

Diabetes and infection: review of the epidemiology, mechanisms and principles of treatment

An association between diabetes and infection has been recognised for many years, with infection being an important cause of death and morbidity in people with diabetes. The COVID-19 pandemic has re-kindled an interest in the complex relationship between diabetes and infection. Some infections occur almost exclusively in people with diabetes, often with high mortality rates without early diagnosis and treatment. However, more commonly, diabetes is a complicating factor in many infections. A reciprocal relationship occurs whereby certain infections and their treatments may also increase the risk of diabetes. People with diabetes have a 1.5- to 4-fold increased risk of infection. The risks are the most pronounced for kidney infection, osteomyelitis and foot infection, but are also increased for pneumonia, influenza, tuberculosis, skin infection and general sepsis. Outcomes from infection are worse in people with diabetes, with the most notable example being a twofold higher rate of death from COVID-19. Hyperglycaemia has deleterious effects on the immune response. Vascular insufficiency and neuropathy, together with altered skin, mucosal and gut microbial colonisation, contribute to the increased risk of infection. Vaccination is important in people with diabetes although the efficacy of certain immunisations may be compromised, particularly in the presence of hyperglycaemia. The principles of treatment largely follow those of the general population with certain notable exceptions.

Risk factors associated with multidrug-resistant tuberculosis in areas with a moderate tuberculosis burden

BACKGROUND

The emergence of multidrug-resistant tuberculosis (MDR-TB) or rifampicin-resistant (RR) TB poses a significant challenge for TB control initiatives on a global scale. This study's aim was to estimate the incidence of MDR-/RR-TB and identify the risk factors associated with their incidence in four provinces in northern Iran.

METHODS

Drug susceptibility testing was conducted using the proportion method on Lowenstein-Jensen media. The demographic and clinical data were collected from the Iranian TB registry.

RESULTS

Among 1083 individuals diagnosed with TB, 27 (2.5%) were identified as having MDR-/RR-TB, while 73 cases (6.7%) were any drug resistant (ADR). The statistical analysis revealed a significant association between marital status and MDR-/RR-TB (p=0.003). In addition, significant associations were observed between ADR-TB and gender (p=0.035) and previous treatment for TB (p=0.02).

CONCLUSIONS

Our findings provide important information on the drug resistance pattern of Mycobacterium tuberculosis strains, as well as risk factors in northern Iran. Given the identified risk factors, creative approaches to promote treatment adherence in TB patients, particularly divorced/widowed women and individuals with a previous history of TB treatment, are required.

Impact of hyperglycemia on tuberculosis treatment outcomes: a cohort study

Hyperglycemia is prevalent and closely associated with pulmonary tuberculosis (PTB). This study aimed to investigate the effects of hyperglycemia on the outcomes of PTB treatment. This study comprised 791 patients with PTB in total. Patients with fasting plasma glucose levels of ≥ 6.1 mmol/L were diagnosed with hyperglycemia. Anthropometric and baseline demographic data were also collected. The treatment response was assessed based on clinical symptoms (sputum production, cough, chest pain, fever, hemoptysis, night sweats, loss of appetite, and fatigue), sputum smear, chest computed tomography (CT), and adverse gastrointestinal responses (vomiting, nausea, abdominal distension, diarrhea, and constipation). A generalized estimating equation (GEE) was used to evaluate these relationships. Hyperglycemia affected 266 (33.6%) of the 791 patients with PTB. In GEE analyses, patients with hyperglycemia exhibited a greater incidence of elevated tuberculosis (TB) scores (odds ratio (OR) 1.569; 95% CI 1.040-2.369), cough (OR 1.332; 95% CI 1.050-1.690), and night sweats (OR 1.694; 95% CI 1.288-2.335). Hyperglycemia was linked with a higher risk of positive sputum smears (OR 1.941; 95% CI 1.382-2.727). During therapy, hyperglycemia was also associated with an increased incidence of vomiting (OR 2.738; 95% CI 1.041-7.198), abdominal distension (OR 2.230; 95% CI 1.193-4.171), and constipation (OR 2.372; 95% CI 1.442-3.902). However, the CT results indicated that hyperglycemia did not affect pulmonary lesions in patients with TB. Patients with TB and hyperglycemia are at a higher risk of severe clinical manifestations, positive sputum smears, and adverse gastrointestinal effects and, therefore, the special situation of hyperglycemic patients should be considered in the prevention and treatment of TB.

Global burden of MDR-TB and XDR-TB attributable to high fasting plasma glucose from 1990 to 2019: a retrospective analysis based on the global burden of disease study 2019

PURPOSE

High fasting plasma glucose (HFPG) has been identified as a risk factor for drug-resistant tuberculosis incidence and mortality. However, the epidemic characteristics of HFPG-attributable multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) remain unclear. We aimed to analyze the global spatial patterns and temporal trends of HFPG-attributable MDR-TB and XDR-TB from 1990 to 2019.

METHODS

Utilizing data from the Global Burden of Disease 2019 project, annual deaths and disability-adjusted life years (DALYs) of HFPG-attributable MDR-TB and XDR-TB were conducted from 1990 to 2019. Joinpoint regression was employed to quantify trends over time.

RESULTS

From 1990 to 2019, the deaths and DALYs due to HFPG-attributable MDR-TB and XDR-TB globally showed an overall increasing trend, with a significant increase until 2003 to 2004, followed by a gradual decline or stability thereafter. The low sociodemographic index (SDI) region experienced the most significant increase over the past 30 years. Regionally, Sub-Saharan Africa, Central Asia and Oceania remained the highest burden. Furthermore, there was a sex and age disparity in the burden of HFPG-attributable MDR-TB and XDR-TB, with young males in the 25-34 age group experiencing higher mortality, DALYs burden and a faster increasing trend than females. Interestingly, an increasing trend followed by a stable or decreasing pattern was observed in the ASMR and ASDR of HFPG-attributable MDR-TB and XDR-TB with SDI increasing.

CONCLUSION

The burden of HFPG-attributable MDR-TB and XDR-TB rose worldwide from 1990 to 2019. These findings emphasize the importance of routine bi-directional screening and integrated management for drug-resistant TB and diabetes.

Antibiotic Resistance in Salmonella typhi Strains Isolated From Patients in Pakistan: A Hospital Database Study

BACKGROUND

The surge in antibiotic-resistant Salmonella enterica serotype Typhi strains has led to heightened morbidity, mortality, and treatment expenses. This study aims to assess the resistance patterns of Salmonella Typhi to diverse antibiotics among patients seeking care at a tertiary hospital in Pakistan.

METHODS

A database from a tertiary care hospital in Pakistan was reviewed, and data on blood cultures that isolated Salmonella enterica serotype Typhi were collected. Data were collected and analyzed using Microsoft Excel (Microsoft Corporation, USA) and IBM SPSS software (IBM Corp., Armonk, NY).

RESULTS

Demographic information of the selected data was retrieved from the hospital database, and the results showed that 63.7% were male, 36.1% were female, and 0.2% were categorized as neutered. Regarding antibiotic resistance, ampicillin exhibited the highest resistance rate (91.50%), while meropenem demonstrated the lowest (3.00%). Antibiotic sensitivity patterns also varied across different age groups, although statistical analysis indicated no significant differences. Significant associations were found between antibiotic resistance and comorbidities, as well as previous antibiotic use.

CONCLUSION

 Salmonella enterica serotype Typhi showed a high resistance to ampicillin and fluoroquinolones, such as ciprofloxacin. The emergence of resistance and decreased sensitivity to current first-line antibiotics necessitates a shift towards alternative options, such as third-generation cephalosporins, azithromycin, and newer antibiotics like meropenem.

Diabetic Pneumopathy- A Novel Diabetes-associated Complication: Pathophysiology, the Underlying Mechanism and Combination Medication

BACKGROUND

The "diabetic lung" has been identified as a possible target organ in diabetes, with abnormalities in ventilation control, bronchomotor tone, lung volume, pulmonary diffusing capacity, and neuroadrenergic bronchial innervation.

OBJECTIVE

This review summarizes studies related to diabetic pneumopathy, pathophysiology and a number of pulmonary disorders including type 1 and type 2 diabetes.

METHODS

Electronic searches were conducted on databases such as Pub Med, Wiley Online Library (WOL), Scopus, Elsevier, ScienceDirect, and Google Scholar using standard keywords "diabetes," "diabetes Pneumopathy," "Pathophysiology," "Lung diseases," "lung infection" for review articles published between 1978 to 2023 very few previous review articles based their focus on diabetic pneumopathy and its pathophysiology.

RESULTS

Globally, the incidence of diabetes mellitus has been rising. It is a chronic, progressive metabolic disease. The "diabetic lung" may serve as a model of accelerated ageing since diabetics' rate of respiratory function deterioration is two to three-times higher than that of normal, non-smoking people.

CONCLUSION

Diabetes-induced pulmonary dysfunction has not gained the attention it deserves due to a lack of proven causality and changes in cellular properties. The mechanism underlying a particular lung illness can still only be partially activated by diabetes but there is evidence that hyperglycemia is linked to pulmonary fibrosis in diabetic people.

Diabetes and Multiple Long-term Conditions: A Review of Our Current Global Health Challenge

Use of effective treatments and management programs is leading to longer survival of people with diabetes. This, in combination with obesity, is thus contributing to a rise in people living with more than one condition, known as multiple long-term conditions (MLTC or multimorbidity). MLTC is defined as the presence of two or more long-term conditions, with possible combinations of physical, infectious, or mental health conditions, where no one condition is considered as the index. These include a range of conditions such as cardiovascular diseases, cancer, chronic kidney disease, arthritis, depression, dementia, and severe mental health illnesses. MLTC has major implications for the individual such as poor quality of life, worse health outcomes, fragmented care, polypharmacy, poor treatment adherence, mortality, and a significant impact on health care services. MLTC is a challenge, where interventions for prevention and management are lacking a robust evidence base. The key research directions for diabetes and MLTC from a global perspective include system delivery and care coordination, lifestyle interventions and therapeutic interventions.

The impact of diabetes mellitus on the emergence of multi-drug resistant tuberculosis and treatment failure in TB-diabetes comorbid patients: a systematic review and meta-analysis

Background

The existence of Type 2 Diabetes Mellitus (DM) in tuberculosis (TB) patients is very dangerous for the health of patients. One of the major concerns is the emergence of MDR-TB in such patients. It is suspected that the development of MDR-TB further worsens the treatment outcomes of TB such as treatment failure and thus, causes disease progression.

Aim

To investigate the impact of DM on the Emergence of MDR-TB and Treatment Failure in TB-DM comorbid patients.

Methodology

The PubMed database was systematically searched until April 03, 2022 (date last searched). Thirty studies met the inclusion criteria and were included in this study after a proper selection process.

Results

Tuberculosis-Diabetes Mellitus patients were at higher risk to develop MDR-TB as compared to TB-non-DM patients (HR 0.81, 95% CI: 0.60-0.96, p < 0.001). Heterogeneity observed among included studies was moderate (I2 = 38%). No significant change was observed in the results after sub-group analysis by study design (HR 0.81, 95% CI: 0.61-0.96, p < 0.000). In the case of treatment failure, TB-DM patients were at higher risk to experience treatment failure rates as compared to TB-non-DM patients (HR 0.46, 95% CI: 0.27-0.67, p < 0.001).

Conclusion

The results showed that DM had a significant impact on the emergence of MDR-TB in TB-diabetes comorbid patients as compared to TB-non-DM patients. DM enhanced the risk of TB treatment failure rates in TB-diabetes patients as compared to TB-non-DM patients. Our study highlights the need for earlier screening of MDR-TB, thorough MDR-TB monitoring, and designing proper and effective treatment strategies to prevent disease progression.

Lineage classification and antitubercular drug resistance surveillance of Mycobacterium tuberculosis by whole-genome sequencing in Southern India

Whole-genome sequencing has created a revolution in tuberculosis management by providing a comprehensive picture of the various genetic polymorphisms with unprecedented accuracy. Studies mapping genomic heterogeneity in clinical isolates of Mycobacterium tuberculosis using a whole-genome sequencing approach from high tuberculosis burden countries are underrepresented. We report whole-genome sequencing results of 242 clinical isolates of culture-confirmed M. tuberculosis isolates from tuberculosis patients referred to a tertiary care hospital in Southern India. Phylogenetic analysis revealed that the isolates in our study belonged to five different lineages, with Indo-Oceanic (lineage 1, n = 122) and East-African Indian (lineage 3, n = 80) being the most prevalent. We report several mutations in genes conferring resistance to first and second line antitubercular drugs including the genes rpoB, katG, ahpC, inhA, fabG1, embB, pncA, rpsL, rrs, and gyrA. The majority of these mutations were identified in relatively high proportions in lineage 1. Our study highlights the utility of whole-genome sequencing as a potential supplemental tool to the existing genotypic and phenotypic methods, in providing expedited comprehensive surveillance of mutations that may be associated with antitubercular drug resistance as well as lineage characterization of M. tuberculosis isolates. Further larger-scale whole-genome datasets with linked minimum inhibition concentration testing are imperative for resolving the discrepancies between whole-genome sequencing and phenotypic drug sensitivity testing results and quantifying the level of the resistance associated with the mutations for optimization of antitubercular drug and precise dose selection in clinics. IMPORTANCE Studies mapping genetic heterogeneity of clinical isolates of M. tuberculosis for determining their strain lineage and drug resistance by whole-genome sequencing are limited in high tuberculosis burden settings. We carried out whole-genome sequencing of 242 M. tuberculosis isolates from drug-sensitive and drug-resistant tuberculosis patients, identified and collected as part of the TB Portals Program, to have a comprehensive insight into the genetic diversity of M. tuberculosis in Southern India. We report several genetic variations in M. tuberculosis that may confer resistance to antitubercular drugs. Further wide-scale efforts are required to fully characterize M. tuberculosis genetic diversity at a population level in high tuberculosis burden settings for providing precise tuberculosis treatment.

Comparative safety of bedaquiline and delamanid in patients with multidrug resistant tuberculosis: A nationwide retrospective cohort study

BACKGROUND/PURPOSE(S)

Bedaquiline and delamanid were recently approved for multidrug resistant tuberculosis (MDR-TB). Bedaquiline carries a black box warning of increased risk of death compared to the placebo arm, and there is a need to establish the risks of QT prolongation and hepatotoxicity for bedaquiline and delamanid.

METHODS

We retrospectively analyzed data of MDR-TB patients retrieved from the South Korea national health insurance system database (2014-2020) to assess the risks of all-cause death, long QT-related cardiac event, and acute liver injury associated with bedaquiline or delamanid, compared with conventional regimen. Cox proportional hazards models were used to estimate hazard ratios (HR) with 95% confidence intervals (CI). Stabilized inverse probability of treatment weighting based on propensity score was used to balance characteristics between the treatment groups.

RESULTS

Of 1998 patients, 315 (15.8%) and 292 (14.6%) received bedaquiline and delamanid, respectively. Compared with conventional regimen, bedaquiline and delamanid did not increase risk of all-cause death at 24-month (HR 0.73 [95% CI, 0.42-1.27] and 0.89 [0.50-1.60], respectively). Bedaquiline-containing regimen increased risk of acute liver injury (1.76 [1.31-2.36]), while delamanid-containing regimen increased risk of long QT-related cardiac events (2.38 [1.05-3.57]) within 6 months of treatment.

CONCLUSION

This study adds to the emerging evidence refuting the higher mortality rate observed in the bedaquiline trial population. Association between bedaquiline and acute liver injury needs careful interpretation considering for other background hepatotoxic anti-TB drugs. Our finding on delamanid and long QT-related cardiac events suggest careful risk-benefit assessment in patients with pre-existing cardiovascular disease.

Assessment of risk factors associated with drug-resistant tuberculosis in pulmonary tuberculosis patients

INTRODUCTION

Tuberculosis remains a global health problem worldwide and the risk progression of Tuberculosis to Drug Resistant Tuberculosis is influenced by various factors. These include immunocompromised status, past history of tuberculosis, life style and nutritional level. Hence, identifying the population at risk of multidrug-resistant tuberculosis is essential and may help in developing appropriate case-finding strategies. Therefore, the present study was designed to study the contributing risk-factors associated with Drug resistant Tuberculosis.

MATERIALS AND METHODS

In this prospective observational study, we assessed 189 Pulmonary tuberculosis diagnosed patients during the period of 2 years at government recognized tertiary care centers. Data was collected from all these patients checked to investigate risk factors associated with Drug resistant tuberculosis development by multivariant analysis.

RESULTS

Of the 189 participants, 36 were diagnosed with drug resistant tuberculosis and 153 with drug sensitive tuberculosis. Factors associated with drug resistant tuberculosis include low-weight (OR 8.50; p = 0.0008430991), low-BMI (p = 0.0000527166), lower economic status (OR-2.1351; p = 0.048608696) and tobacco (OR-4.5192; p = 0.0023003189) were found clinically and statistically significant in development of drug resistant tuberculosis. Binary logistic regression was performed to ascertain the effects of various statistically significant factors. Drug resistant tuberculosis patients were 7.77 times more likely to be tobacco users than drug sensitive tuberculosis.

CONCLUSIONS

Our study suggests that, there is a compelling and urgent need for increasing public awareness, initiating better nutrition and food programs, regular screening, and better management & control of MDR-TB.

Managing Comorbidities, Determinants and Disability at Start and End of TB Treatment under Routine Program Conditions in China

Many patients with tuberculosis (TB) have comorbidities, risk determinants and disability that co-exist at diagnosis, during and after TB treatment. We conducted an observational cohort study in 11 health facilities in China to assess under routine program conditions (i) the burden of these problems at the start and end of TB treatment and (ii) whether referral mechanisms for further care were functional. There were 603 patients registered with drug-susceptible TB who started TB treatment: 84% were symptomatic, 14% had diabetes, 14% had high blood pressure, 19% smoked cigarettes, 10% drank excess alcohol and in 45% the 6 min walking test (6MWT) was abnormal. Five patients were identified with mental health disorders. There were 586 (97%) patients who successfully completed TB treatment six months later. Of these, 18% were still symptomatic, 12% had diabetes (the remainder with diabetes failed to complete treatment), 5% had high blood pressure, 5% smoked cigarettes, 1% drank excess alcohol and 25% had an abnormal 6MWT. Referral mechanisms for the care of comorbidities and determinants worked well except for mental health and pulmonary rehabilitation for disability. There is need for more programmatic-related studies in other countries to build the evidence base for care of TB-related conditions and disability.

Correlation expression Toll-like receptor 4 with multidrugs resistant tuberculosis in diabetes mellitus condition

BACKGROUND

Toll-like receptor (TLR) are ligand homologous protein in the APC cell membrane that has functions as a receptor to triger leukocytes and innate immune responses. When there is a Microbacterium tuberculosis (MTB) infection enters from droplets to the lungs, the alveolar macrophages perform a phagocytic function. The interaction between M. tuberculosis and the TLR macrophage receptors produces chemokines which induce migration of monocytes and dendrite cells for destruction. Diabetes militus (DM) has become risk factor for developing tuberculosis. DM condition will reduce immunity and the ability of immune cell phagocytes bactery and triger severe infections. The consequences of more severe infection and metabolic disorders that occur make a person more likely to experience Multidrugs resistant MTB. Not much data that reports on the expression of TLR4 as a ligand that triggers an immune response in conditions of MDR and DM. We try to find out correlation between TLR-4 in MDR MTB, diabetes and level of MTB bacteria in experimental animals.

METHODS

We conducted an experimental study on 30 experimental mice weighing 25 grams consisting of negative control grub, infected with MTB, infected with MDR MTB, negative control diabetes, MTB DM, MDR MTB DM. DM animals were induced by streptozosin to experience DM, then in the treatment of infection, intraperitoneal MTB and MDR MTB bacterial injections were given. Termination was carried out on day 14. We count number of bacteria level in the lungs and perform evaluation TLR4 from blood sampel.

RESULTS

The negative control group had mean TLR value of 1.47 (± 0.46) while the MTB group showed an increase in TLR 9.22 (± 0.39) followed by MDR MTB 9.50 (± 0.29), DM negative control 9, 21 (± 0.24) and more increasing in conditions of DM MTB 13.36 (± 0.32) and DM MDR MTB 13.35 (± 0.34). ANOVA analysis showed a significant difference (P = 0.00). pearson correlation analysis find strong correlation TLR4 in MTB and MDR MTB with diabetes.

CONCLUSION

there were a significant difference level TLR4 between MTB and MDR TB infection with diabetes. higher TLR4 level higher in DM MTB, DM MDR MTB. TLR 4 strong correlates with an increase in the number of MTB bacteria.

Risk factors on healthcare-associated infections among tuberculosis hospitalized patients in China from 2001 to 2020: a systematic review and meta-analysis

Background

China has been still suffering from high burden attributable to tuberculosis (TB) and healthcare-associated infections (HAIs). TB patients are at high risk to get HAIs. Evidence-based guidelines or regulations to constrain the rising HAIs among TB hospitalized patients are needed in China. The aim of this systematic review and meta-analysis is to investigate the risk factors associated with HAIs among TB hospitalized patients in Chinese hospitals.

Methods

Medline, EMBASE and Chinese Journals Online databases were searched. The search was limited to studies published from January 1st 2001 to December 31st 2020. Meta-analyses of ORs of the risk factors between patients with HAIs and patients without HAIs among TB hospitalized patients were estimated. Heterogeneity among studies was assessed based on the \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{{\uptau }}$$\end{document}τ^² and I² statistics to select the meta-analysis model. Review Manager 5.3 was employed and P < 0.05 was considered as statistical significance.

Results

851 records were filtered from the databases, of which 11 studies were included in the quantitative meta-analysis. A total of 11,922 TB patients were included in the systematic review and meta-analysis, of which 1133 were diagnosed as having HAIs. Age older than 60 years (OR: 2.89 [2.01–4.15]), complications (OR: 3.28 [2.10–5.13]), diabetes mellitus (OR: 1.63 [1.22–2.19]), invasive procedure (OR: 3.80 [2.25–6.42]), longer than 15 hospitalization days (OR: 2.09 [1.64–2.64]), secondary tuberculosis (OR: 2.25 [1.48–3.42]), smoking (OR: 1.40[1.02–1.93]), underlying disease (OR: 2.66 [1.53–4.62]), and use of antibiotics (OR: 2.77 [2.35–3.27]) were the main risk factors associated with HAIs among TB hospitalized patients with a statistical significance (P < 0.05).

Conclusions

Age older than 60 years, presence of complications, presence of diabetes mellitus, invasive procedure, longer than 15 hospitalization days, secondary tuberculosis, smoking, presence of underlying disease, and use of antibiotics were the main risk factors which had a negative impact on HAIs among TB hospitalized patients in Chinese hospitals. These findings provided evidence for policy makers and hospital managers to make effective infection prevention and control measures to constrain the rising HAIs. It is also required that more cost-effective infection prevention and control measures should be widely applied in routinely medical treatment and clinical management to reduce the occurrence of HAIs among TB hospitalized patients.

Supplementary information

The online version contains supplementary material available at 10.1186/s12879-022-07364-9.

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.

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.

A Saudi Arabian Public Health Perspective of Tuberculosis

Tuberculosis is a global health challenge due to its spreading potential. The Kingdom of Saudi Arabia (KSA) faces a challenge in the spread of tuberculosis from migrant workers, but the foremost threat is the huge number of pilgrims who travel to visit sacred sites of the Islamic world located in the holy cities of Makkah and Al Madina. Pilgrims visit throughout the year but especially in the months of Ramadan and Zul-Hijah. The rise of resistance in Mycobacterium tuberculosis is an established global phenomenon that makes such large congregations likely hotspots in the dissemination and spread of disease at a global level. Although very stringent and effective measures exist, the threat remains due to the ever-changing dynamics of this highly pathogenic disease. This overview primarily highlights the current public health challenges posed by this disease to the Saudi health system, which needs to be highlighted not only to the concerned authorities of KSA, but also to the concerned global quarters since the pilgrims and migrants come from all parts of the world with a majority coming from high tuberculosis-burdened countries.

Effect of Diabetes Mellitus on Renal and Audiology Toxicities in Patients with Drug-Resistant Pulmonary Tuberculosis

Background: People with diabetes mellitus (DM) have a higher risk for drug-resistant tuberculosis (DR-TB). DR-TB patients with comorbidity of DM were also vulnerable to experience adverse effects of DR-TB treatment. Management of DR-TB with comorbidity of DM is complicated. Also, DM may affect TB response treatment and cause more adverse effects. Objectives: This study was conducted on DR pulmonary TB (DR-PTB) patients to evaluate the effect of DM on adverse effects, especially renal function impairment and audiology impairment, as well as treatment outcomes due to treatment regimens containing kanamycin. Methods: A retrospective study was conducted from 2016 to 2017 at Dr. Soetomo Hospital. Patients who received DR-TB regimens containing kanamycin were included in this study. HbA1c >7 was used to define DM. The adverse effects in this study were impaired renal function (increased serum creatinine) and audiology impairment. Results: Patients who experienced increased serum creatinine were 28/82 (34.1%) with DM and 20/120 (16.7%) without DM, audiology impairment were 22/82 (26.8%) with DM and 19/120 (15.8%) without DM, and unfavorable outcome were 37/82 (45%) with DM and 46/120 (38%) without DM. Moreover, DM is associated with adverse effects and treatment outcomes. Patients with DM have a risk ratio (RR) for increased serum creatinine, audiology impairment, and unfavorable outcome with RR 2.049 (95% CI: 1.242 – 3.379), RR 1.694 (95% CI: 0.982 – 2.925), and RR 1.177 (95% CI: 0.847 – 1.636), respectively. Conclusions: Diabetes mellitus increases the risk of adverse effects, increased serum creatinine, and audiology impairment. Also, it increases the risk of unfavorable treatment outcomes in patients with DR-PTB who receive DR-TB regimens containing kanamycin.

Association of IL-4 rs2243250 polymorphism with susceptibility to tuberculosis: A meta-analysis involving 6794 subjects

BACKGROUND

Interleukin-4 (lL-4) is a critical negative cytokine in tuberculosis (TB) immune process, acting through modulating macrophages activation and Th1/Th2 balance. rs2243250 has been demonstrated to be associated with enhanced promoter strength in IL-4 expression. We performed a meta-analysis to assess the association between IL-4 rs2243250 polymorphism and TB risk.

METHODS

We identified relevant studies by a comprehensive search of PubMed, Web of Science, and Embase databases, published up to February 10, 2021. The pooled odds ratios (ORs) and its 95% confidential intervals (95%CIs) were used to evaluate the associations under five genetic models. All statistical analyses were conducted with STATA 12.0 software.

RESULTS

Totally 11 qualified studies involving 3097 TB cases and 3697 controls were enrolled in this meta-analysis. Overall, we didn't detect any significant association between IL-4 rs2243250 polymorphism and TB risk (T vs. C: OR = 1.05, 95% CI = 0.85-1.30, p = 0; 65; TT + TC vs. CC: OR = 1.05, 95% CI = 0.73-1.50, p = 0.81; TT vs. TC + CC: OR = 1.10, 95% CI = 0.81-1.50, p = 0.54; TT vs. CC: OR = 1.17, 95% CI = 0.71-1.94, p = 0.54; TC vs. CC: OR = 1.03, 95% CI = 0.73-1.45, p = 0.88). Significant heterogeneity was identified in analyses under all genetic models. However, in the subgroup of European population, the recessive model provided an OR of 2.54 (1.30-4.96), with no significant between-study heterogeneity.

CONCLUSION

In conclusion, our meta-analysis indicated that IL-4 rs2243250 may increase TB risk in European population in recessive genetic model. Further research is needed to clarify the cause of ethnic difference in genetic association study.

Analysis of the efficacy and safety of iodine-125 seeds implantation in the treatment of patients with inoperable early-stage non-small cell lung cancer

Purpose

To evaluate the efficacy and safety of iodine-125 (¹²⁵I) seeds implantation for inoperable early-stage non-small cell lung cancer (NSCLC).

Material and methods

PubMed, Cochrane Library, Embase, China Biology Medicine disc (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang Data were searched from inception until April 2020. Data were collected concerning overall survival, short-term efficacy, and complications. Meta-analysis was performed using R software (version 3.6.3).

Results

Nine studies involving 308 patients were included. Meta-analysis showed that the 1-, 2-, and 3-year survival rates were 0.98% (95% CI: 0.95-0.99%), 0.83% (95% CI: 0.77-0.89%), and 0.65% (95% CI: 0.55-0.75%), respectively; short-term local control rate (LCR) and effective rates were 0.99% (95% CI: 0.98-1.00%) and 0.92% (95% CI: 0.83-0.98%), respectively; 1-, 2-, and 3-year LCRs were 0.96% (95% CI: 0.83-1.00%), 0.94% (95% CI: 0.85-0.99%), and 0.95% (95% CI: 0.76-1.00%), respectively. Sub-group analysis of the prescribed dose found that when the prescribed dose was > 120 Gy, short-term efficacy and 1-year LCR were increased significantly (p < 0.01). The incidence of bleeding, pneumothorax, and radiation lung injury was 0.14% (95% CI: 0.07-0.21%), 0.19% (95% CI: 0.11-0.28%), and 0.00% (95% CI: 0.00-0.03%), respectively. Two studies involving 106 patients compared ¹²⁵I seeds combined with chemotherapy versus chemotherapy alone for NSCLC. Results showed that compared with chemotherapy alone, ¹²⁵I seeds combined with chemotherapy could improve short-term LCR (RR = 1.34, 95% CI: 1.09-1.65%, p = 0.005) and short-term effective rate (RR = 1.49, 95% CI: 1.14-1.96%, p = 0.004).

Conclusions

¹²⁵I seeds implantation is safe and effective approach for the treatment of inoperable early-stage NSCLC, but high-quality clinical research is still needed to further confirm the findings.

Trends, Characteristics and Treatment Outcomes of Patients with Drug-Resistant Tuberculosis in Uzbekistan: 2013-2018

Uzbekistan has a high burden of drug-resistant tuberculosis (TB). Although conventional treatment for multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) has been available since 2013, there has been no systematic documentation about its use and effectiveness. We therefore documented at national level the trends, characteristics, and outcomes of patients with drug-resistant TB enrolled for treatment from 2013–2018 and assessed risk factors for unfavorable treatment outcomes (death, failure, loss to follow-up, treatment continuation, change to XDR-TB regimen) in patients treated in Tashkent city from 2016–2017. This was a cohort study using secondary aggregate and individual patient data. Between 2013 and 2018, MDR-TB numbers were stable between 2347 and 2653 per annum, while XDR-TB numbers increased from 33 to 433 per annum. At national level, treatment success (cured and treatment completed) for MDR-TB decreased annually from 63% to 57%, while treatment success for XDR-TB increased annually from 24% to 57%. On multivariable analysis, risk factors for unfavorable outcomes, death, and loss to follow-up in drug-resistant TB patients treated in Tashkent city included XDR-TB, male sex, increasing age, previous TB treatment, alcohol abuse, and associated comorbidities (cardiovascular and liver disease, diabetes, and HIV/AIDS). Reasons for these findings and programmatic implications are discussed.

Active screening of patients with diabetes mellitus for pulmonary tuberculosis in a tertiary care hospital in Sri Lanka

End TB strategy by the WHO suggest active screening of high-risk populations for tuberculosis (TB) to improve case detection. Present study generates evidence for the effectiveness of screening patients with diabetes mellitus (DM) for Pulmonary TB (PTB). A study was conducted among 4548 systematically recruited patients over 45 years attending DM clinic at the National Hospital of Sri Lanka. The study units followed an algorithm specifying TB symptom and risk factor screening for all, followed by investigations and clinical assessments for those indicated. Bacteriologically confirmed or clinically diagnosed PTB were presented as proportions with 95% CI. Mean (SD) age was 62·5 (29·1) years. Among patients who completed all indicated steps of algorithm, 3500 (76·9%) were investigated and 127 (2·8%) underwent clinical assessment. Proportion of bacteriologically confirmed PTB patients was 0·1% (n = 6,95%CI = 0·0-0·3%). None were detected clinically. Analysis revealed PTB detection rates among males aged ≥60 years with HbA1c ≥ 8 to be 0·4% (n = 2, 95%CI = 0·0-1·4%). The study concludes that active screening for PTB among all DM patients at clinic settings in Sri Lanka, to be non-effective measure to enhance TB case finding. However, the sub-category of diabetic males with uncontrolled diabetics who are over 60 years of age is recommended as an option to consider for active screening for PTB.

New Developments and Insights in the Improvement of Mycobacterium tuberculosis Vaccines and Diagnostics Within the End TB Strategy

PURPOSE OF REVIEW

The alignment of sustainable development goals (SDGs) with the End Tuberculosis (TB) strategy provides an integrated roadmap to implement key approaches towards TB elimination. This review summarizes current social challenges for TB control, and yet, recent developments in TB diagnosis and vaccines in the context of the End TB strategy and SDGs to transform global health.

RECENT FINDINGS

Advances in non-sputum based TB biomarkers and whole genome sequencing technologies could revolutionize TB diagnostics. Moreover, synergistic novel technologies such as mRNA vaccination, nanovaccines and promising TB vaccine models are key promising developments for TB prevention and control.

SUMMARY

The End TB strategy depends on novel developments in point-of-care TB diagnostics and effective vaccines. However, despite outstanding technological developments in these fields, TB elimination will be unlikely achieved if TB social determinants are not fully addressed. Indeed, the End TB strategy and SDGs emphasize the importance of implementing sustainable universal health coverage and social protection.

Tuberculosis: An Overview of the Immunogenic Response, Disease Progression, and Medicinal Chemistry Efforts in the Last Decade toward the Development of Potential Drugs for Extensively Drug-Resistant Tuberculosis Strains

Tuberculosis (TB) is a slow growing, potentially debilitating disease that has plagued humanity for centuries and has claimed numerous lives across the globe. Concerted efforts by researchers have culminated in the development of various strategies to combat this malady. This review aims to raise awareness of the rapidly increasing incidences of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis, highlighting the significant modifications that were introduced in the TB treatment regimen over the past decade. A description of the role of pathogen-host immune mechanisms together with strategies for prevention of the disease is discussed. The struggle to develop novel drug therapies has continued in an effort to reduce the treatment duration, improve patient compliance and outcomes, and circumvent TB resistance mechanisms. Herein, we give an overview of the extensive medicinal chemistry efforts made during the past decade toward the discovery of new chemotypes, which are potentially active against TB-resistant strains.

Prevalence and associated factors of diabetes mellitus among tuberculosis patients in Brunei Darussalam: A 6-year retrospective cohort study

OBJECTIVES

To determine the prevalence and associated factors of diabetes mellitus (DM) among tuberculosis (TB) cases in Brunei Darussalam.

METHODS

We conducted a retrospective cohort study among all TB patients registered between 2013 and 2018. Collected data include sociodemographics, comorbidities, and information related to their TB diagnosis and treatment outcomes. Associated factors of having DM among TB patients were investigated using logistic regression analyses.

RESULTS

We identified a total of 1362 TB patients, among which 462 (33.9% [95%CI: 31.4%,36.5%]) also have DM. 70.6% (n = 326) were diagnosed with DM at least six months prior to their TB diagnosis. The incidence of newly diagnosed DM among TB patients was 74.2 per 1000 population. Significant factors of having TB and DM comorbidity were age (adjusted OR (adj. OR) = 1.04 [95%CI: 10.3,1.05]), classified as smear-positive pulmonary TB (adj. OR = 5.77 [95%CI: 3.71,9.22]), having the following underlying conditions: hypertension/heart disease (adj. OR = 24.05 [95%CI: 5.80,100.05]), renal disease (adj. OR = 7.34 [95%CI: 2.88,20.22]) and chronic obstructive pulmonary disease/asthma (adj. OR = 0.38 [95%CI: 0.22,0.64]).

CONCLUSION

About one-third of TB cases in Brunei were also diagnosed with DM. Bi-directional screening could be a good strategy to facilitate early detection and treatment of both diseases.

Interim Effectiveness and Safety Comparison of Bedaquiline-Containing Regimens for Treatment of Diabetic Versus Non-Diabetic MDR/XDR-TB Patients in China: A Multicenter Retrospective Cohort Study

INTRODUCTION

Diabetes mellitus (DM), a common tuberculosis (TB) comorbidity, is associated with delayed bacillary clearance during anti-TB treatment and unfavorable outcomes. Bedaquiline (BDQ), when used as part of multidrug regimen for multidrug-resistant/extensively drug-resistant tuberculosis (MDR/XDR-TB), has been shown to be effective and safe although treatment outcome and risks for patients with MDR/XDR-TB and DM are unknown. A multicenter retrospective study was conducted to compared the safety and effectiveness of 24-week BDQ-containing anti-TB treatment for patients with MDR/XDR-TB with and without DM.

METHODS

The study of patients with MDR/XDR-TB with or without DM (enrolled February 2018-September 2019, 21 Chinese hospitals) was supervised by the New Drug Introduction and Protection Program (NDIP). Of 640 patients with MDR/XDR-TB receiving BDQ-containing anti-TB treatments, two propensity score-matched groups (107 DM/107 non-DM) were compared for cumulative culture conversion rate, time to culture conversion, adverse events, and corrected QT interval.

RESULTS

Body mass index was higher in patients with DM than patients without DM (23.29 ± 3.9 vs. 20.5 ± 3.6, P < 0.001); lung cavity prevalence (86.9% vs. 72.9%, P = 0.037) was also higher in patients with DM; the non-DM group had higher hepatitis prevalence (29.0% vs. 15.9%, P = 0.022). No significant intergroup differences were found for sputum culture conversion rate at week 8 (80.0% vs. 81.4%, P = 0.884), at week 24 (95.6% vs. 98.2%, P = 0.629), or for median time to sputum culture conversion [56 days (IQR 28-63) vs. 56 days (IQR 28-84) (P = 0.687)]. Favorable post-24-week treatment outcomes were presented by 90.7% and 93.5% in the DM group and non-DM group, respectively, without significant intergroup differences (P = 0.448). The DM adverse event rate exceeded non-DM rate (77.6% vs. 64.5%, P = 0.035).

CONCLUSION

Despite some differences in baseline characteristics, Chinese patients with MDR/XDR-TB with or without DM had similar sputum culture conversion rates and favorable treatment outcomes post-24-week BDQ-containing anti-TB treatment. Low BMI but not DM is risk factor associated with unfavorable outcome of patients with MDR/XDR-TB.

Diabetes among tuberculosis patients and its impact on tuberculosis treatment in South Asia: a systematic review and meta-analysis

The escalating burden of diabetes is increasing the risk of contracting tuberculosis (TB) and has a pervasive impact on TB treatment outcomes. Therefore, we conducted this systematic review and meta-analysis to examine the burden of diabetes among TB patients and assess its impact on TB treatment in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). PubMed, Excerpta Medica Database (EMBASE), and CINAHL databases were systematically searched for observational (cross-sectional, case-control and cohort) studies that reported prevalence of diabetes in TB patients and published between 1 January 1980 and 30 July 2020. A random-effect model for computing the pooled prevalence of diabetes and a fixed-effect model for assessing its impact on TB treatment were used. The review was registered with PROSPERO number CRD42020167896. Of the 3463 identified studies, a total of 74 studies (47 studies from India, 10 from Pakistan, four from Nepal and two from both Bangladesh and Sri-Lanka) were included in this systematic review: 65 studies for the prevalence of diabetes among TB patients and nine studies for the impact of diabetes on TB treatment outcomes. The pooled prevalence of diabetes in TB patients was 21% (95% CI 18.0, 23.0; I2 98.3%), varying from 11% in Bangladesh to 24% in Sri-Lanka. The prevalence was higher in studies having a sample size less than 300 (23%, 95% CI 18.0, 27.0), studies conducted in adults (21%, 95% CI 18.0, 23.0) and countries with high TB burden (21%, 95% CI 19.0, 24.0). Publication bias was detected based on the graphic asymmetry of the funnel plot and Egger's test (p < 0.001). Compared with non-diabetic TB patients, patients with TB and diabetes were associated with higher odds of mortality (Odds Ratio (OR) 1.7; 95% CI 1.2, 2.51; I2 19.4%) and treatment failure (OR 1.7; 95% CI 1.1, 2.4; I2 49.6%), but not associated with Multi-drug resistant TB (OR 1.0; 95% CI 0.6, 1.7; I2 40.7%). This study found a high burden of diabetes among TB patients in South Asia. Patients with TB-diabetes were at higher risk of treatment failure and mortality compared to TB alone. Screening for diabetes among TB patients along with planning and implementation of preventive and curative strategies for both TB and diabetes are urgently needed.

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.

Combined Tuberculosis and Diabetes Mellitus Screening and Assessment of Glycaemic Control among Household Contacts of Tuberculosis Patients in Yangon, Myanmar

Background: This study aimed to identify the prevalence of diabetes mellitus (DM) and tuberculosis (TB) among household contacts of index TB patients in Yangon, Myanmar. Method: Household contacts were approached at their home. Chest X-ray and capillary blood glucose tests were offered based on World Health Organization and American Diabetes Association guidelines. Crude prevalence and odds ratios of DM and TB among household contacts of TB patients with and without DM were calculated. Results: The overall prevalence of DM and TB among household contacts were (14.0%, 95% CI: 10.6–18.4) and (5%, 95% CI: 3.2–7.6), respectively. More than 25% of DM cases and almost 95% of TB cases among household contacts were newly diagnosed. Almost 64% of known DM cases among household contacts had poor glycaemic control. The risk of getting DM among household contacts of TB patients with DM was significantly higher (OR—2.13, 95% CI: 1.10–4.12) than those of TB patients without DM. There was no difference in prevalence of TB among household contacts of TB patients with and without DM. Conclusion: Significant proportions of the undetected and uncontrolled DM among household contacts of index TB patients indicate a strong need for DM screening and intervention in this TB–DM dual high-risk population.

A novel risk factor for predicting anti-tuberculosis drug resistance in patients with tuberculosis complicated with type 2 diabetes mellitus

OBJECTIVES

This study aimed to explore the relationship between glycosylated hemoglobin (HbA1c) and the risk of anti-tuberculosis (TB) drug resistance for TB-type 2 diabetes mellitus (T2DM) patients.

METHODS

From March 2014 to June 2019, medical records from multiple centers were searched. Logistic regression analyses were performed. A predictive model for multidrug-resistance (MDR) was developed and validated. Calibration and discrimination of the model were assessed.

RESULTS

Inconsistent results were found in the systemic review. A multicenter chart review with 657 records was thus conducted. The HbA1c <7% group and HbA1c ≥7% group had 390 and 267 patients, respectively. The HbA1c<7% group had a lower risk of developing rifampicin resistance, isoniazid resistance and MDR, with odd ratios (ORs) of 1.904 (p=0.001), 2.896 (p<0.001) and 3.228 (p<0.001), respectively. The between-group differences in the risk of anti-TB drug resistance were analyzed based on data from three provinces in China. After adding HbA1c grading, the predictive model for MDR (https://mengyuan.shinyapps.io/Shinyapp/) showed excellent capacity with an AUC of 75.4% in the training set (Sichuan and Gansu) and 73.9% in the internal validation set (Henan). The performances in calibration, prediction probabilities and net clinical benefit were significantly improved by HbA1c grading.

CONCLUSIONS

HbA1c grading was an independent risk factor for isoniazid resistance and MDR in TB-T2DM patients.

Determinants of multidrug-resistant tuberculosis in São Paulo-Brazil: a multilevel Bayesian analysis of factors associated with individual, community and access to health services

Objective

Multidrug‐resistant tuberculosis (MDR‐TB) remains a serious public health problem worldwide. Accordingly, this study sought to identify individual, community and access to health services risk factors for MDR‐TB.

Methods

Retrospective cohort of all TB cases diagnosed between 2006 and 2016 in the state of São Paulo. A Bayesian spatial hierarchical analysis with a multilevel design was carried out.

Results

It was identified that the history of previous TB treatment (Odds Ratios [OR]:13.86, 95% credibility interval [95% CI]:12.06–15.93), positive sputum culture test (OR: 5.26, 95% CI: 4.44–6.23), diabetes mellitus (OR: 2.34, 95% CI: 1.87–2.91), residing at a standard address (OR: 2.62, 95% CI: 1.91–3.60), positive sputum smear microscopy (OR: 1.74, 95% CI: 1.44–2.12), cavitary pulmonary TB (OR: 1.35, 95% CI: 1.14–1.60) and diagnosis performed due to spontaneous request (OR: 1.26; 95% CI: 1.10–1.46) were associated with MDR‐TB. Furthermore, municipalities that performed HIV tests in less than 42.65% of patients with TB (OR: 1.50, 95% CI: 1.25–1.79), that diagnosed TB cases only after death (OR: 1.50, 95% CI: 1.17–1.93) and that had more than 20.16% of their population with income between ¼ and ½ of one minimum wage (OR: 1.56, 95% CI: 1.30–1.87) were also related to the MDR‐TB.

Conclusions

Knowledge of these predictive factors may help to develop more comprehensive disease prevention strategies for MDR‐TB, avoiding the risks expressed regarding drug resistance expansion.

Immunometabolism during Mycobacterium tuberculosis Infection

Over a quarter of the world's population is infected with Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis (TB). Approximately 3.4% of new and 18% of recurrent cases of TB are multidrug-resistant (MDR) or rifampicin-resistant. Recent evidence has shown that certain drug-resistant strains of Mtb modulate host metabolic reprogramming, and therefore immune responses, during infection. However, it remains unclear how widespread these mechanisms are among circulating MDR Mtb strains and what impact drug-resistance-conferring mutations have on immunometabolism during TB. While few studies have directly addressed metabolic reprogramming in the context of drug-resistant Mtb infection, previous literature examining how drug-resistance mutations alter Mtb physiology and differences in the immune response to drug-resistant Mtb provides significant insights into how drug-resistant strains of Mtb differentially impact immunometabolism.

BCG and BCGΔBCG1419c protect type 2 diabetic mice against tuberculosis via different participation of T and B lymphocytes, dendritic cells and pro-inflammatory cytokines

Comorbidity between Tuberculosis (TB) and type 2 diabetes (T2D) is one of the greatest contributors to the spread of Mycobacterium tuberculosis (M. tuberculosis) in low- and middle-income countries. T2D compromises key steps of immune responses against M. tuberculosis and it might affect the protection afforded by vaccine candidates against TB. We compared the protection and immune response afforded by the BCGΔBCG1419c vaccine candidate versus that of wild-type BCG in mice with T2D. Vaccination with both BCGΔBCG1419c, BCG or infection with M. tuberculosis reduced weight loss, hyperglycemia, and insulin resistance during T2D progression, suggesting that metabolic changes affecting these parameters were affected by mycobacteria. For control of acute TB, and compared with non-vaccinated controls, BCG showed a dominant T CD4⁺ response whereas BCGΔBCG1419c showed a dominant T CD8⁺/B lymphocyte response. Moreover, BCG maintained an increased response in lung cells via IFN-γ, TNF-α, and IL-4, while BCGΔBCG1419c increased IFN-γ but reduced IL-4 production. As for chronic TB, and compared with non-vaccinated controls, both BCG strains had a predominant presence of T CD4⁺ lymphocytes. In counterpart, BCGΔBCG1419c led to increased presence of dendritic cells and an increased production of IL-1 β. Overall, while BCG effectively reduced pneumonia in acute infection, it failed to reduce it in chronic infection, whereas we hypothesize that increased production of IL-1 β induced by BCGΔBCG1419c contributed to reduced pneumonia and alveolitis in chronic TB. Our results show that BCG and BCGΔBCG1419c protect T2D mice against TB via different participation of T and B lymphocytes, dendritic cells, and pro-inflammatory cytokines.

Tuberculosis associated with diabetes mellitus by age group in Brazil: a retrospective cohort study, 2007–2014

Diabetes mellitus (DM) has important implications for tuberculosis (TB), as it increases the risk for disease activation and is associated with unfavorable TB treatment outcomes. This study analyzed the association between TB and DM (TBDM) in Brazil from 2007 to 2014. This was a retrospective cohort study carried out in 709,429 new cases of TB reported to the national disease notification system of the Brazilian Ministry of Health. Sociodemographic and clinical data, test results, and treatment outcomes were analyzed. TBDM was found in 6.0% of TB cases, mostly in men aged 18-59 years. The lethality rate was 5.1% higher in all age groups with diabetes, except in those older than 60 years of age. The frequency of multi-drug-resistant tuberculosis (MDR-TB) in patients with DM was higher in those without DM, with a 1.6- to 3.8-fold increase in the odds of MDR-TB. The elderly showed an increase in the prevalence of TBDM from 14.3% to 18.2%. Women were more likely to have DM, and elderly women had 41.0% greater chance of having DM. Relapse was significant among patients younger than 17 years of age. TBDM was high in Brazil, affected all age groups, and was associated with unfavorable TB treatment outcomes. We emphasize the need for strategies for the clinical management of diabetic tuberculosis patients in Brazil aiming at minimizing relapses, deaths, and MDR-TB.

Shortened treatment regimens versus the standard regimen for drug-sensitive pulmonary tuberculosis

BACKGROUND

Tuberculosis causes more deaths than any other infectious disease worldwide, with pulmonary tuberculosis being the most common form. Standard first-line treatment for drug-sensitive pulmonary tuberculosis for six months comprises isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE) for two months, followed by HRE (in areas of high TB drug resistance) or HR, given over a four-month continuation phase. Many people do not complete this full course. Shortened treatment regimens that are equally effective and safe could improve treatment success.

OBJECTIVES

To evaluate the efficacy and safety of shortened treatment regimens versus the standard six-month treatment regimen for individuals with drug-sensitive pulmonary tuberculosis.

SEARCH METHODS

We searched the following databases up to 10 July 2019: the Cochrane Infectious Diseases Group Specialized Register; the Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE (PubMed); Embase; the Latin American Caribbean Health Sciences Literature (LILACS); Science Citation Index-Expanded; Indian Medlars Center; and the South Asian Database of Controlled Clinical Trials. We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform, ClinicalTrials.gov, the Clinical Trials Unit of the International Union Against Tuberculosis and Lung Disease, the UK Medical Research Council Clinical Trials Unit, and the Clinical Trials Registry India for ongoing trials. We checked the reference lists of identified articles to find additional relevant studies.

SELECTION CRITERIA

We searched for randomized controlled trials (RCTs) or quasi-RCTs that compared shorter-duration regimens (less than six months) versus the standard six-month regimen for people of all ages, irrespective of HIV status, who were newly diagnosed with pulmonary tuberculosis by positive sputum culture or GeneXpert, and with presumed or proven drug-sensitive tuberculosis. The primary outcome of interest was relapse within two years of completion of anti-tuberculosis treatment (ATT).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed risk of bias for the included trials. For dichotomous outcomes, we used risk ratios (RRs) with 95% confidence intervals (CIs). When appropriate, we pooled data from the included trials in meta-analyses. We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included five randomized trials that compared fluoroquinolone-containing four-month ATT regimens versus standard six-month ATT regimens and recruited 5825 adults with newly diagnosed drug-sensitive pulmonary tuberculosis from 14 countries with high tuberculosis transmission in Asia, Africa, and Latin Ameria. Three were multi-country trials that included a total of 572 HIV-positive people. These trials excluded children, pregnant or lactating women, people with serious comorbid conditions, and those with diabetes mellitus. Four trials had multiple treatment arms. Moxifloxacin replaced ethambutol in standard four-month, daily or thrice-weekly ATT regimens in two trials; moxifloxacin replaced isoniazid in four-month ATT regimens in two trials, was given daily in one trial, and was given with rifapentine instead of rifampicin daily for two months and twice weekly for two months in one trial. Moxifloxacin was added to standard ATT drugs for three to four months in one ongoing trial that reported interim results. Gatifloxacin replaced ethambutol in standard ATT regimens given daily or thrice weekly for four months in two trials. Follow-up ranged from 12 months to 24 months after treatment completion for the majority of participants. Moxifloxacin-containing four-month ATT regimens Moxifloxacin-containing four-month ATT regimens that replaced ethambutol or isoniazid probably increased the proportions who experienced relapse after successful treatment compared to standard ATT regimens (RR 3.56, 95% CI 2.37 to 5.37; 2265 participants, 3 trials; moderate-certainty evidence). For death from any cause, there was probably little or no difference between the two regimens (2760 participants, 3 trials; moderate-certainty evidence). Treatment failure was rare, and there was probably little or no difference in proportions with treatment failure between ATT regimens (2282 participants, 3 trials; moderate-certainty evidence). None of the participants given moxifloxacin-containing regimens developed resistance to rifampicin, and these regimens may not increase the risk of acquired resistance (2282 participants, 3 trials; low-certainty evidence). Severe adverse events were probably little or no different with moxifloxacin-containing four-month regimens that replaced ethambutol or isoniazid, and with three- to four-month regimens that augmented standard ATT with moxifloxacin, when compared to standard six-month ATT regimens (3548 participants, 4 trials; moderate-certainty evidence). Gatifloxacin-containing four-month ATT regimens Gatifloxacin-containing four-month ATT regimens that replaced ethambutol probably increased relapse compared to standard six-month ATT regimens in adults with drug-sensitive pulmonary tuberculosis (RR 2.11, 95% CI 1.56 to 2.84; 1633 participants, 2 trials; moderate-certainty evidence). The four-month regimen probably made little or no difference in death compared to the six-month regimen (1886 participants, 2 trials; moderate-certainty evidence). Treatment failure was uncommon and was probably little or no different between the four-month and six-month regimens (1657 participants, 2 trials; moderate-certainty evidence). Acquired resistance to isoniazid or rifampicin was not detected in those given the gatifloxacin-containing shortened ATT regimen, but we are uncertain whether acquired drug resistance is any different in the four- and six-month regimens (429 participants, 1 trial; very low-certainty evidence). Serious adverse events were probably no different with either regimen (1993 participants, 2 trials; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Evidence to date does not support the use of shortened ATT regimens in adults with newly diagnosed drug-sensitive pulmonary tuberculosis. Four-month ATT regimens that replace ethambutol with moxifloxacin or gatifloxacin, or isoniazid with moxifloxacin, increase relapse substantially compared to standard six-month ATT regimens, although treatment success and serious adverse events are little or no different. The results of six large ongoing trials will help inform decisions on whether shortened ATT regimens can replace standard six-month ATT regimens. 9 December 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (10 Jul, 2019) were included.

Epidemiology of drug-resistant tuberculosis in Chongqing, China: A retrospective observational study from 2010 to 2017

China is one of the top 30 countries with high multidrug-resistant tuberculosis (MDR-TB) and rifampin-resistant tuberculosis (RR-TB) burden. Chongqing is a southwest city of China with a large rural population. A retrospective observational study has been performed based on routine tuberculosis (TB) surveillance data in Chongqing from 2010 to 2017. The MDR/RR-TB notification rate increased from 0.03 cases per 100,000 population in 2010 to 2.1 cases per 100,000 population in 2017. The extensively drug-resistant TB (XDR-TB) notification rate has increased to 0.09 cases per 100,000 population in 2017. There was a decreasing detection gap between the number of notified MDR/RR-TB cases and the estimate number of MDR/RR-TB cases in new TB cases. The treatment success rate of MDR/RR-TB was 59% (95% confidence interval [CI], 53%-65%) in this period. Despite the progress achieved, the prevalence of MDR/RR-TB was still high facing challenges including detection gaps in new TB cases, the regional disparity, and the high risk for MDR/RR-TB in elderly people and farmers. Sustained government financing and policy support should be guaranteed in the future.

Treatment for latent tuberculosis infection in low- and middle-income countries: progress and challenges with implementation and scale-up

Introduction: Treatment of latent tuberculosis infection (LTBI) is a crucial but neglected component of global tuberculosis control. The 2018 United Nations High-Level Meeting committed world leaders to provide LTBI treatment to at least 30 million people, including 4 million children<5 years, 20 million other household contacts and 6 million HIV-infected people by 2022.Areas covered: This review searched MEDLINE between 1990 and 2019 and discussed: i) high-risk groups to be prioritized for diagnosis and treatment of LTBI; ii) challenges with diagnosing LTBI in programmatic settings; iii) LTBI treatment options including isoniazid monotherapy, shorter regimens (rifampicin-monotherapy, rifampicin-isoniazid and rifapentine-isoniazid) and treatments for contacts of drug-resistant patients; iv) issues with programmatic scale-up of treatment including policy considerations, ruling out active TB, time to start treatment, safety, uninterrupted drug supplies and treatment adherence; and v) recording and reporting.Expert opinion: In 2017, <1.5 million persons were reported to be treated for LTBI. This must rapidly increase to 6 million persons annually. If HIV programs focus on HIV-infected people already accessing or about to start antiretroviral therapy and TB programs focus on household contacts, these targets could be achieved. Isoniazid remains the current treatment of choice although shorter courses of rifapentine-isoniazid are possible alternatives.

Changes in Host Response to Mycobacterium tuberculosis Infection Associated With Type 2 Diabetes: Beyond Hyperglycemia

Tuberculosis (TB) remains as the first cause of death among infectious diseases worldwide. Global incidence of tuberculosis is in part coincident with incidence of type 2 diabetes (T2D). Incidence of T2D is recognized as a high-risk factor that may contribute to tuberculosis dissemination. However, mechanisms which favor infection under T2D are just starting to emerge. Here, we first discuss the evidences that are available to support a metabolic connection between TB and T2D. Then, we analyze the evidences of metabolic changes which occur during T2D gathered thus far for its influence on susceptibility to M. tuberculosis infection and TB progression, such as hyperglycemia, increase of 1AC levels, increase of triglycerides levels, reduction of HDL-cholesterol levels, increased concentration of lipoproteins, and modification of the activity of some hormones related to the control of metabolic homeostasis. Finally, we recognize possible advantages of metabolic management of immunity to develop new strategies for treatment, diagnosis, and prevention of tuberculosis.

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.

Diabetes in developing countries

There has been a rapid escalation of type 2 diabetes (T2D) in developing countries, with varied prevalence according to rural vs urban habitat and degree of urbanization. Some ethnic groups (eg, South Asians, other Asians, and Africans), develop diabetes a decade earlier and at a lower body mass index than Whites, have prominent abdominal obesity, and accelerated the conversion from prediabetes to diabetes. The burden of complications, both macro- and microvascular, is substantial, but also varies according to populations. The syndemics of diabetes with HIV or tuberculosis are prevalent in many developing countries and predispose to each other. Screening for diabetes in large populations living in diverse habitats may not be cost-effective, but targeted high-risk screening may have a place. The cost of diagnostic tests and scarcity of health manpower pose substantial hurdles in the diagnosis and monitoring of patients. Efforts for prevention remain rudimentary in most developing countries. The quality of care is largely poor; hence, a substantial number of patients do not achieve treatment goals. This is further amplified by a delay in seeking treatment, "fatalistic attitudes", high cost and non-availability of drugs and insulins. To counter these numerous challenges, a renewed political commitment and mandate for health promotion and disease prevention are urgently needed. Several low-cost innovative approaches have been trialed with encouraging outcomes, including training and deployment of non-medical allied health professionals and the use of mobile phones and telemedicine to deliver simple health messages for the prevention and management of T2D.

Diabetes mellitus comorbidity in patients enrolled in tuberculosis drug efficacy trials around the world: A systematic review

AIMS

With a prevalence of 16%, diabetes mellitus (DM) is one of the most frequent non-communicable comorbidities of tuberculosis (TB). DM is a major risk factor for adverse TB outcomes and may require personalized TB drug dosing regimens. However, information on the inclusion of DM in TB drug trials is lacking. We aimed to assess the percentage of recent TB drug efficacy trials that included DM patients.

METHODS

A systematic review was performed and reported according to PRISMA guidelines. PubMed, Science Direct, and ClinicalTrials.gov databases were systematically searched for TB drug trials published between 1 January 2012 and 12 September 2017. Primary outcome was the percentage of TB drug trials performed around the world that included DM patients.

RESULTS

Out of the included 41 TB drug trials, 12 (29.3%) reported DM comorbidity among the study participants. Nine trials (21.9%) excluded all patients with DM comorbidity, ten (24.4%) excluded only insulin-dependent or uncontrolled DM, and 10 (24.4%) did not mention whether DM was included or excluded. Of the 12 trials that included DM comorbidity, the majority did not report the diagnostic criteria for DM and none reported outcomes in the DM subpopulation. Inclusion of DM was higher in drug-resistant-TB trials (67%, P = .003, vs drug-susceptible) and trials performed in Asia (60%, P = .006, vs Africa).

CONCLUSIONS

Fewer than 1/3 recent TB drug trials reported the inclusion of DM. To better reflect real-world DM prevalence and differential TB drug effectiveness, inclusion of DM patients requires increased attention for future TB drug trials.

Screening tuberculosis patients for diabetes mellitus in a routine program setting in Kampala, Uganda: a cross-sectional study

Background: Uganda is located in East Africa and is among the countries with the lowest income globally. The ten health centres in this project serve populations in the under-privileged communities of Kampala. The objective of the study was to implement diabetes mellitus (DM) screening among tuberculosis (TB) patients in a routine program setting with limited resources and high human immunodeficiency virus (HIV) prevalence. Methods: A descriptive cross-sectional observational study was conducted in ten health centres in Kampala, Uganda. As part of a project to implement DM screening in a routine setting, TB patients were screened for DM by trained health workers. A fasting blood glucose (FBG) value ≥7.0mmol/l was considered to indicate DM. For this study, aggregate data was collected and analysed using SPSS for Windows, version 13.0. Results:  Among 4,590 TB patients registered, 4,016 (88.0%) were screened with random blood glucose (RBG). Of those with RBG ≥6.1mmol/l, 1,093 (83.3%) were screened with FBG. In total, 92 (2.3%) patients were diagnosed with DM and 66 (71.8%) of them were newly diagnosed. The proportion of TB patients screened with FBG in the health centres varied from 58.2% to 100%. The proportion of patients screened with FBG and the prevalence of DM were significantly higher in private health centres compared with public health centres. The health centres in peri-urban areas screened more patients with RBG than those in urban areas. Health centres without DM services screened a larger number of patients with RBG and FBG than those with DM services. Conclusions: It appears feasible to implement screening TB patients for DM in routine program settings with limited resources and high HIV prevalence. Its introduction requires close collaboration between TB and DM services. The challenges identified need government attention and certain institutional and service-related factors need to be better managed at times.

Screening tuberculosis patients for diabetes mellitus in a routine program setting in Kampala, Uganda: a cross-sectional study

Background: Uganda is located in East Africa and is among the countries with the lowest income globally. The ten health centres in this project serve populations in the under-privileged communities of Kampala. The objective of the study was to implement diabetes mellitus (DM) screening among tuberculosis (TB) patients in a routine program setting with limited resources and high human immunodeficiency virus (HIV) prevalence. Methods: A descriptive cross-sectional observational study was conducted in ten health centres in Kampala, Uganda. As part of a project to implement DM screening in a routine setting, TB patients were screened for DM by trained health workers. A fasting blood glucose (FBG) value ≥7.0mmol/l was considered to indicate DM. For this study, aggregate data was collected and analysed using SPSS for Windows, version 13.0. Results:  Among 4,590 TB patients registered, 4,016 (88.0%) were screened with random blood glucose (RBG). Of those with RBG ≥6.1mmol/l, 1,093 (83.3%) were screened with FBG. In total, 92 (2.3%) patients were diagnosed with DM and 66 (71.8%) of them were newly diagnosed. The proportion of TB patients screened with FBG in the health centres varied from 58.2% to 100%. The proportion of patients screened with FBG and the prevalence of DM were significantly higher in private health centres compared with public health centres. The health centres in peri-urban areas screened more patients with RBG than those in urban areas. These health centres without DM services screened a larger number of patients with RBG and FBG than those with DM services. Conclusions: It appears feasible to implement screening TB patients for DM in routine program settings with limited resources and high HIV prevalence. Its introduction requires close collaboration between TB and DM services. The challenges identified need government attention and certain institutional and service-related factors need to be better managed at times.

High treatment success rate among multidrug-resistant tuberculosis patients in Myanmar, 2012-2014: a retrospective cohort study

Background

Since 2011, Myanmar has adopted domiciliary care for multidrug-resistant tuberculosis (MDR-TB) patients and implemented several patient-support measures such as community-based directly observed treatment, nutritional support and financial incentives for patients and providers. We assessed treatment outcomes among MDR-TB patients registered for treatment in the Yangon and Mandalay Regions of Myanmar during 2012-2014 and factors associated with unfavourable treatment outcomes.

Methods

We performed a retrospective cohort study involving secondary analysis of routine programmatic data extracted from the electronic MDR-TB treatment registries. We calculated the adjusted risk ratio (aRR) and 95% confidence interval (CI).

Results

Of 2185 MDR-TB patients (75% HIV tested, 14% HIV positive with 70% of them receiving antiretroviral therapy), 1746 (80%) were successfully treated (cured and treatment completed) and 20% had unfavourable outcomes (14% died, 3% lost to follow-up, 2% failure and 1% not evaluated). Compared with young patients (<25 y), patients 25-54 y of age (aRR 2.0 [95% CI 1.3 to 2.9]) and >55 y (aRR 3.2 [95% CI 2.1 to 4.8]) were more likely to have unfavourable outcomes. HIV-positive patients (especially not receiving ART; aRR 2.2 [95% CI 1.4 to 3.6]) and patients with 'unknown HIV status' (aRR 1.9 [95% CI 1.5-2.4]) had a higher risk of unfavourable outcomes compared with HIV-negative patients.

Conclusions

Treatment success was high and deaths accounted for three-fourths of unfavourable outcomes. Joint care and management of MDR-TB and HIV co-infected patients should be strengthened.

Association between diabetes mellitus and multi-drug-resistant tuberculosis: evidence from a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM) poses a significant risk for the development of active tuberculosis (TB) and complicates its treatment. However, there is inconclusive evidence on whether the TB-DM co-morbidity is associated with a higher risk of developing multi-drug-resistant tuberculosis (MDR-TB). The aim of this meta-analysis was to summarize available evidence on the association of DM and MDR-TB and to estimate a pooled effect measure.

METHODS

PubMed, Excerpta Medica Database (EMBASE), Web of Science, World Health Organization (WHO), and Global Health Library database were searched for all studies published in English until July 2018 and that reported the association of DM and MDR-TB among TB patients. To assess study quality, we used the Newcastle-Ottawa Scale for cohort and case-control studies and the Agency for Healthcare Research and Quality tool for cross-sectional studies. We checked the between-study heterogeneity using the Cochrane Q chi-squared statistic and I² and examined a potential publication bias by visual inspection of the funnel plot and Egger's regression test statistic. The random-effect model was fitted to estimate the summary effects, odds ratios (ORs), and 95% confidence interval (CIs) across studies.

RESULTS

This meta-analysis of 24 observational studies from 15 different countries revealed that DM has a significant association with MDR-TB (OR = 1.97, 95% CI = 1.58-2.45, I² = 38.2%, P value for heterogeneity = 0.031). The significant positive association remained irrespective of country income level, type of DM, how TB or DM was diagnosed, and design of primary studies. A stronger association was noted in a pooled estimate of studies which adjusted for at least one confounding factor, OR = 2.43, 95% CI 1.90 to 3.12. There was no significant publication bias detected.

CONCLUSIONS

The results suggest that DM can significantly increase the odds of developing MDR-TB. Consequently, a more robust TB treatment and follow-up might be necessary for patients with DM. Efforts to control DM can have a substantial beneficial effect on TB outcomes, particularly in the case of MDR-TB.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016045692 .

What can National TB Control Programmes in low- and middle-income countries do to end tuberculosis by 2030?

The international community has committed to ending the tuberculosis (TB) epidemic by 2030. This will require multi-sectoral action with a focus on accelerating socio-economic development, developing and implementing new tools, and expanding health insurance coverage. Within this broad framework, National TB Programmes (NTPs) are accountable for delivering diagnostic, treatment, and preventive services. There are large gaps in the delivery of these services, and the aim of this article is to review the crucial activities and interventions that NTPs must implement in order to meet global targets and milestones that will end the TB epidemic. The key deliverables are the following: turn End TB targets and milestones into national measurable indicators to make it easier to track progress; optimize the prompt and accurate diagnosis of all types of TB; provide rapid, complete, and effective treatment to all those diagnosed with TB; implement and monitor effective infection control practices; diagnose and treat drug-resistant TB, associated HIV infection, and diabetes mellitus; design and implement active case finding strategies for high-risk groups and link them to the treatment of latent TB infection; engage with the private-for-profit sector; and empower the Central Unit of the NTP particularly in relation to data-driven supportive supervision, operational research, and sustained financing. The glaring gaps in the delivery of TB services must be remedied, and some of these gaps will require new paradigms and ways of working which include patient-centered and higher-quality services. There must also be fast-track ways of incorporating new diagnostic, treatment, and prevention tools into program activities so as to rapidly reduce TB incidence and mortality and meet the goal of ending TB by 2030.

Association between tobacco smoking and drug-resistant tuberculosis

Background

Tobacco smoking is a risk factor for tuberculosis but little is known about the relationship between tobacco smoking and drug-resistant tuberculosis (DR-TB). We undertook a systematic review and meta-analysis to quantitatively assess the association between DR-TB and tobacco smoking.

Methods

We searched for relevant studies in the Ovid MEDLINE, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, WANFANG, and WEIPU data-bases from inception to September 1, 2017. Results were expressed as odds ratios (ORs) with accompanying 95% CIs, and subgroup analyses were performed by study design, smoking type, DR-TB type, and multivariate analysis.

Results

Thirty-three studies related to tobacco smoking and DR-TB were included. We found substantial evidence that tobacco smoking is associated with an increased risk of DR-TB (OR 1.57, 95% CI 1.33–1.86). Associations were also found in subgroup analyses: for multidrug-resistant tuberculosis (OR 1.49, 95% CI 1.19–1.86) and for any DR-TB (OR 1.70, 95% CI 1.3–2.23); the pooled OR was 1.45 (95% CI 1.11–1.90) for current smoking, 2.25 (95% CI 1.46–3.47) for past smoking, and 1.56 (95% CI 1.22–1.98) for smoking history; and similar ORs were also observed in study design and multivariate analysis subgroup analysis.

Conclusion

This study demonstrated that tobacco smoking is an independent risk factor for DR-TB.