Tuberculosis and diabetes: bidirectional association in a UK primary care data set

HIV co-infection increases the risk of post-tuberculosis mortality among persons who initiated treatment for drug-resistant tuberculosis

Little is known regarding the relationship between common comorbidities in persons with tuberculosis (TB) (including human immunodeficiency virus [HIV], diabetes, and hepatitis C virus [HCV]) and post-TB mortality. We conducted a retrospective cohort study among persons who initiated treatment for rifampicin-resistant or multi/extensively drug-resistant (RR or M/XDR) TB reported to the country of Georgia's TB surveillance during 2009-2017. Exposures included HIV serologic status, diabetes, and HCV status. Our outcome was all-cause post-TB mortality determined by cross-validating vital status with Georgia's death registry through November 2019. We estimated adjusted hazard rate ratios (aHR) and 95% confidence intervals (CI) of post-TB mortality among participants with and without comorbidities using cause-specific hazard regressions. Among 1032 eligible participants, 34 (3.3%) died during treatment and 87 (8.7%) died post-TB treatment. The median time to post-TB death was 21 months (interquartile range 7-39) after TB treatment. After adjusting for confounders, the hazard rates of post-TB mortality were higher among participants with HIV co-infection (aHR = 3.74, 95%CI 1.77-7.91) compared to those without HIV co-infection. In our cohort, post-TB mortality occurred most commonly in the first 3 years post-TB treatment. Linkage to care for common TB comorbidities post-treatment may reduce post-TB mortality rates.

Prior tuberculosis, radiographic lung abnormalities and prevalent diabetes in rural South Africa

BACKGROUND

Growing evidence suggests that chronic inflammation caused by tuberculosis (TB) may increase the incidence of diabetes. However, the relationship between post-TB pulmonary abnormalities and diabetes has not been well characterized.

METHODS

We analyzed data from a cross-sectional study in KwaZulu-Natal, South Africa, of people 15 years and older who underwent chest X-ray and diabetes screening with hemoglobin A1c testing. The analytic sample was restricted to persons with prior TB, defined by either (1) a self-reported history of TB treatment, (2) radiologist-confirmed prior TB on chest radiography, and (3) a negative sputum culture and GeneXpert. Chest X-rays of all participants were evaluated by the study radiologist to determine the presence of TB lung abnormalities. To assess the relationships between our outcome of interest, prevalent diabetes (HBA1c ≥6.5%), and our exposure of interest, chest X-ray abnormalities, we fitted logistic regression models adjusted for potential clinical and demographic confounders. In secondary analyses, we used the computer-aided detection system CAD4TB, which scores X-rays from 10 to 100 for detection of TB disease, as our exposure interest, and repeated analyses with a comparator group that had no history of TB disease.

RESULTS

In the analytic cohort of people with prior TB (n = 3,276), approximately two-thirds (64.9%) were women, and the average age was 50.8 years (SD 17.4). The prevalence of diabetes was 10.9%, and 53.0% of people were living with HIV. In univariate analyses, there was no association between diabetes prevalence and radiologist chest X-ray abnormalities (OR 1.23, 95%CI 0.95-1.58). In multivariate analyses, the presence of pulmonary abnormalities was associated with an 29% reduction in the odds of prevalent diabetes (aOR 0.71, 95%CI 0.53-0.97, p = 0.030). A similar inverse relationship was observed for diabetes with each 10-unit increase in the CAD4TB chest X-ray scores among people with prior TB (aOR 0.92, 95%CI 0.87-0.97; p = 0.002), but this relationship was less pronounced in the no TB comparator group (aOR 0.96, 95%CI 0.94-0.99).

CONCLUSIONS

Among people with prior TB, pulmonary abnormalities on digital chest X-ray are inversely associated with prevalent diabetes. The severity of radiographic post-TB lung disease does not appear to be a determinant of diabetes in this South African population.

Tuberculosis-diabetes comorbidities: Mechanistic insights for clinical considerations and treatment challenges

Tuberculosis (TB) remains a leading cause of death among infectious diseases, particularly in poor countries. Viral infections, multidrug-resistant and ex-tensively drug-resistant TB strains, as well as the coexistence of chronic illnesses such as diabetes mellitus (DM) greatly aggravate TB morbidity and mortality. DM [particularly type 2 DM (T2DM)] and TB have converged making their control even more challenging. Two contemporary global epidemics, TB-DM behaves like a syndemic, a synergistic confluence of two highly prevalent diseases. T2DM is a risk factor for developing more severe forms of multi-drug resistant-TB and TB recurrence after preventive treatment. Since a bidirectional relationship exists between TB and DM, it is necessary to concurrently treat both, and promote recommendations for the joint management of both diseases. There are also some drug-drug interactions resulting in adverse treatment outcomes in TB-DM patients including treatment failure, and reinfection. In addition, autophagy may play a role in these comorbidities. Therefore, the TB-DM comorbidities present several health challenges, requiring a focus on multidisciplinary collaboration and integrated strategies, to effectively deal with this double burden. To effectively manage the comorbidity, further screening in affected countries, more suitable drugs, and better treatment strategies are required.

HIV co-infection increases the risk of post-tuberculosis mortality among persons who initiated treatment for drug-resistant tuberculosis

Little is known regarding the relationship between common comorbidities in persons with tuberculosis (TB) (including human immunodeficiency virus [HIV], diabetes, and hepatitis C virus [HCV]) with post-TB mortality. We conducted a retrospective cohort study among persons who initiated treatment for rifampicin-resistant and multi/extensively drug-resistant (RR and M/XDR) TB reported to the country of Georgia's TB surveillance during 2009-2017. Exposures included HIV serologic status, diabetes, and HCV status. Our outcome was all-cause post-TB mortality determined by cross-validating vital status with Georgia's death registry through November 2019. We estimated adjusted hazard rate ratios (aHR) and 95% confidence intervals (CI) of post-TB mortality among participants with and without comorbidities using cause-specific hazard regressions. Among 1032 eligible participants, 34 (3.3%) died during treatment and 87 (8.7%) died post-TB treatment. Among those who died post-TB treatment, the median time to death was 21 months (interquartile range 7-39) post-TB treatment. After adjusting for confounders, the hazard rates of post-TB mortality were higher among participants with HIV co-infection (aHR=3.74, 95%CI 1.77-7.91) compared to those without HIV co-infection. In our cohort, post-TB mortality occurred most commonly in the first three years post-TB treatment. Linkage to care for common TB comorbidities post-treatment may reduce post-TB mortality rates.

Insulin resistance, and not β-cell impairment, mediates association between Mycobacterium tuberculosis sensitization and type II diabetes mellitus among US adults

Type 2 diabetes mellitus (T2DM) may be a long-term sequela of infection with Mycobacterium tuberculosis (M.tb) by mechanisms that remain to be fully explained. We evaluated association between M.tb sensitization and T2DM among U.S adults and, via formal mediation analysis, the extent to which this association is mediated by insulin resistance and/or β-cell failure. These evaluations accounted for demographic, socio-economic, behavioral and clinical characteristics. T2DM was assessed by fasting plasma glucose, 2-hour oral glucose tolerance testing and HbA1c; homoeostasis model assessment 2 (HOMA2) was used to estimate β-cell dysfunction (HOMA2-B) and insulin resistance (HOMA2-IR); while M.tb sensitization status was ascertained by tuberculin skin testing (TST). Exposure to M.tb was associated with increased risk for T2DM, likely driven by an increase in insulin resistance. Definitive prospective studies examining incident T2DM following tuberculosis are warranted.

Research in Context

What is already known about this subject?: Accumulating evidence suggests that pre-diabetes and new-onset type 2 diabetes mellitus (T2DM) may be a long-term complication of exposure to Mycobacterium tuberculosis ( M.tb ) via mechanisms that remain to be unraveled What is the key question?: To what extent do insulin resistance and β-cell failure mediate the association between M.tb sensitization with T2DM among US adults? What are the new findings?: M.tb sensitization is characterized by distinct glucose metabolic disturbances manifesting as increased risk of T2DM and isolated impaired fasting glucose (IFG) Insulin resistance, and not β-cell impairment, likely independently mediate the observed diabetogenic effects of M.tb sensitization How might this impact on clinical and/or public health practice in the foreseeable future?: If corroborated by prospective studies, both TB programs and individual clinical care must incorporate monitoring of serum glucose and long-term metabolic outcomesThis will be particularly urgent in sub-Saharan Africa and South-East Asia where scarce health resources coincide with overlapping endemic TB and epidemic T2DM.

Association between prior tuberculosis disease and dysglycemia within an HIV-endemic, rural South African population

OBJECTIVE

Tuberculosis (TB) may predispose individuals to the development of diabetes. Such a relationship could have an outsized impact in high-prevalence TB settings. However, few studies have explored this relationship in populations heavily burdened by diabetes and TB.

METHODS

We analyzed data from a community-based population cohort that enrolled adults in rural South Africa. Individuals were considered to have prior TB if they self-reported a history of TB treatment. We fitted sex-specific logistic regression models, adjusted for potential clinical and demographic confounders, to estimate relationships between dysglycemia (HBA1c ≥6.5%) and prior TB. Propensity score-matched cohorts accounted for the differential age distributions between comparator groups. We examined the interactions between sex, prior TB, and HIV status.

RESULTS

In the analytic cohort (n = 17,593), the prevalence of prior TB was 13.8% among men and 10.7% among women. Dysglycemia was found in 9.1% of the population, and HIV prevalence was 34.0%. We found no difference in dysglycemia prevalence by prior TB (men OR 0.96, 95% CI 0.60-1.56: women OR 1.05, 95% CI 0.79-1.39). However, there was a qualitative interaction by HIV serostatus, such that among men without HIV, those with a history of TB had a greater prevalence of dysglycemia than those without prior TB (10.1% vs. 4.6%, p = 0.0077). An inverse relationship was observed among men living with HIV (prior TB 3.3% vs. no TB 7.3%, p = 0.0073).

CONCLUSIONS

Treated TB disease was not associated with dysglycemia in an HIV-endemic, rural South African population. However, we found a significant interaction between prior TB and HIV status among men, suggesting distinct pathophysiological mechanisms between the two infections that may impact glucose metabolism. Longitudinal studies are needed to better establish a causal effect and underlying mechanisms related to resolved TB, HIV, and diabetes.

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

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

Subjects With Diabetes Mellitus Are at Increased Risk for Developing Tuberculosis: A Cohort Study in an Inner-City District of Barcelona (Spain)

Background

Tuberculosis is the leading cause of mortality from lung infectious disease worldwide in recent years, and its incidence has re-emerged in large cities in low-incidence countries due to migration and socioeconomic deprivation causes. Diabetes mellitus and tuberculosis are syndemic diseases, with diabetes being considered a risk factor for developing tuberculosis.

Objective

To investigate whether diabetic patients were at increased risk of tuberculosis living in an inner-district of a large city of northeastern Spain.

Methods

Observational matched retrospective cohort study based on clinical records from the population of the lowest socioeconomic status in Barcelona (Ciutat Vella district). A cohort including patients with type 1 and type 2 diabetes mellitus in 2007 and new cases until 2016 (8004 subjects), matched 1:1 by sex and age with a non-diabetic cohort. Follow-up period was until December 31st 2018. We evaluated the risk of developing tuberculosis in diabetic patients compared to non-diabetic patients during the follow up period. We used time-to-event analysis to estimate the incidence of tuberculosis, and competing risks regression by clusters and conditional Cox regression models to calculate the hazard ratio (HR) and its 95% confidence intervals (CI).

Results

Among the 16,008 included subjects, the median follow-up was 8.7 years. The mean age was 57.7 years; 61.2% men and 38.8% women in both groups. The incidence of tuberculosis was 69.9 per 100,000 person-years in diabetic patients, and 40.9 per 100,000 person-years in non-diabetic patients (HR = 1.90; CI: 1.18-3.07). After adjustment for the country of origin, chronic kidney disease, number of medical appointments, BMI, alcoholism and smoking, the risk remained higher in diabetic patients (1.66: CI 0.99-2.77). Additionally, subjects from Hindustan or with a history of alcohol abuse also showed a higher risk of developing tuberculosis (HR = 3.51; CI:1.87-6.57, and HR = 2.73; CI:1.22-6.12 respectively).

Conclusion

People with diabetes mellitus were at higher risk of developing tuberculosis in a large cohort recruited in an inner-city district with a high incidence for this outcome, and low socioeconomic conditions and high proportion of migrants. This risk was higher among Hindustan born and alcohol abusers.

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

OBJECTIVE

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

DESIGN

Scoping review.

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Diabetes and tuberculosis: A syndemic complicated by COVID-19

Tuberculosis (TB) is the leading cause of infectious mortality in the world, affecting mainly developing countries (DC), while diabetes (DM) is one of the most prevalent chronic diseases.

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

Diabetes and tuberculosis: a syndemic complicated by COVID-19

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

Evaluation of the Host Genetic Effects of Tuberculosis-Associated Variants Among Patients With Type 1 and Type 2 Diabetes Mellitus

Background

Understanding the link between tuberculosis (TB) and diabetes is increasingly important as public health responds to the growing global burden of noncommunicable diseases. Genetic association studies have identified numerous host genetic variants linked to TB; however, potential host genetic mechanisms linking TB and diabetes remain unexplored.

Methods

We used genetic and phenotypic data from the UK Biobank to evaluate the association of 6 previously reported TB-related host genetic variants (genome-wide significant associations from published studies) with diabetes. The study included 409692 adults of European ancestry including 2177 with type 1 diabetes mellitus (T1DM) and 13976 with type 2 diabetes mellitus (T2DM), defined by ICD-10 diagnosis codes.

Results

Of the 6 TB-associated single nucleotide polymorphisms (SNPs), 2 were associated with T1DM and 3 with T2DM, after adjusting for age, sex, body mass index, smoking, alcohol use, and population structure. After correction for multiple testing, SNPs rs2894257 and rs3135359 (HLA-DRA-DQA1) were associated with T1DM (rs2894257: odds ratio [OR], 1.32; 95% confidence interval [CI], 1.21–1.45; rs3135359: OR, 1.72; 95% CI, 1.57–1.88) and T2DM (rs2894257: OR, 1.11; 95% CI, 1.08–1.15; rs3135359: OR, 1.06; 95% CI, 1.025–1.096). The associations with T2DM weakened for rs2894257 and rs3135359 after further exclusion of probable T1DM cases defined by International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes. SNP rs4733781 on chromosome 8 (ASAP1 gene) was associated with T2DM after exclusion of T1DM cases.

Conclusions

Our findings suggest that common host genetic effects may play a role in the molecular mechanism linking TB and diabetes. Future large genetic studies of TB and diabetes should focus on developing countries with high burdens of infectious and chronic diseases.

Diabetes Mellitus and Tuberculosis Comorbidity and Associated Factors Among Bale Zone Health Institutions, Southeast Ethiopia

BACKGROUND

Globally, tuberculosis and diabetes mellitus co-morbidity is higher than tuberculosis and human immunodeficiency virus comorbidity. Considering this, the World Health Organization and the International Union against tuberculosis and lung disease recommend bi-directional screening of the two diseases. However, in Ethiopia, bi-directional screening has not been started yet.

OBJECTIVE

The objective of this study was to assess the prevalence of diabetes mellitus and tuberculosis comorbidity and its predictors among adult tuberculosis patients in Bale Zone Health Institutions, Southeastern Ethiopia.

MATERIALS AND METHODS

Institutional-based cross-sectional study carried out using interviewer administered questionnaire, registration review, anthropometric and blood glucose level measurement from March, 30, 2019 to April, 30, 2019. Three hundred twenty-one tuberculosis patients were selected from tuberculosis registration log book using lottery methods. The collected data were checked for completeness, coded and entered in to EpiData3.0.2 and exported to SPSS version 20. Independent variables that had p value less 0.25 were used as candidates for multiple logistic regressions to control confounders. Variables that had significant association were identified by calculating odds ratio, with 95% confidence interval, and p value less than 0.05 used to declare statistical significance.

RESULTS

Diabetes mellitus and tuberculosis comorbidity among adult tuberculosis patients was 5.1% (95% CI: 2.7%, 7.5%). Age with ≥50 years (AOR=3.98, 95% CI: 1.13, 14.36), having extra pulmonary tuberculosis (AOR=3.31, 95% CI: 1.16, 9.44) and being females (AOR=3.8, 95% CI: 1.17, 12.33) were significantly associated with the comorbidity of the two diseases.

CONCLUSION AND RECOMMENDATION

The prevalence of diabetes mellitus and tuberculosis comorbidity was high. Female tuberculosis patients, tuberculosis patients with age ≥50 years and those having extra pulmonary tuberculosis patients should be screened for diabetes mellitus.

[Loss to follow-up in patients treated for multidrug-resistant tuberculosis in EcuadorA Perda de seguimento de pacientes tratados para tuberculose multirresistente a medicamentos no Equador]

OBJECTIVE

Determine the incidence of loss to follow-up (LTFU) in patients treated for rifampicin-resistant tuberculosis (RR-TB) or multidrug-resistant tuberculosis (RR/MDR-TB), and the factors associated with this discharge status in Ecuador.

METHODS

Retrospective cohort study of patients with RR/MDR-TB who followed the World Health Organization's 18-24-month treatment regimen in 2014 and 2015, as reported by the Ministry of Health of Ecuador. The incidence of LTFU was determined, and clinical and epidemiological manifestations of cases discharged as LTFU were compared with those discharged as successfully treated. Survival was analyzed with Cox regression in order to evaluate factors associated with LTFU.

RESULTS

Of 328 cases, 270 (82.3%) were analyzed because they had a reported discharge status. Discharge as LTFU accounted for 39.6% of cases, and as successfully treated, 50.4%. The risk factors associated with LTFU were: previous discharge as LTFU in a previous TB episode [hazard ratio (HR): 2.96 (1.53-5.73), P < 0.001]; addiction to alcohol or drugs [HR: 2.82 (1.10-7.23), P = 0.031]; and having an Xpert® diagnosis (TB-RR) [HR: 1.53 (1.0-2.35), P = 0.048]. Of the total LTFU, 43% occurred after nine months of treatment.

CONCLUSION

The incidence of LTFU in patients with RR/MDR-TB in Ecuador is above the average for the Region of the Americas. The three identified factors support implementation of shorter regimens and patient-centered care, in line with the End TB Strategy.

The re-emerging association between tuberculosis and diabetes: Lessons from past centuries

The association between tuberculosis (TB) and diabetes mellitus (DM) had a common place in the literature up to the first half of the 20th century, but virtually disappeared with the discovery of insulin to treat DM and antibiotics to cure TB. In the late 1990s the literature began to re-emerge with the worldwide increase in type 2 DM, particularly in TB-endemic countries. Today, type 2 DM is the most prevalent comorbidity among TB patients and the World Health Organization considers it a threat to TB control. We summarize the literature on TB and DM up to the 1960s. Then we evaluate unique aspects of this comorbidity in older times, such as the frequent diabetic comas that suggest challenges for proper DM management as insulin was being implemented, or the absence of antibiotics to cure TB. Despite the unique aspects of each study period, the literature across times is consistent in key aspects of the association. Namely, a higher TB prevalence among DM (versus non-DM patients), the importance of glucose control and chronic DM on TB susceptibility and the higher risk of death among patients with the co-morbidity. From the older literature, we can infer the likely contribution of type 1 DM to TB (in addition to type 2), regardless of their differing autoimmune or metabolic pathophysiology, respectively. Furthermore, in the older literature there was a notable reporting of DM development among TB patients, even though DM usually preceded TB. This observation deserves further epidemiological and basic studies to elucidate this intriguing aspect of the relationship between TB and DM.