Glycemic Trajectories and Treatment Outcomes of Patients with Newly Diagnosed Tuberculosis: A Prospective Study in Eastern China

Prediabetes and the treatment outcome of tuberculosis: A meta-analysis

OBJECTIVES

Diabetes has been related to higher risk and poor prognosis of patients with tuberculosis, while the influence of prediabetes on the treatment outcome of patients with tuberculosis remains not determined. A meta-analysis was performed to evaluate the influence of prediabetes on treatment outcome of patients with tuberculosis.

METHODS

Relevant cohort studies were acquired through a search of Medline, Embase, and Web of Science databases. To minimise the influence of between-study heterogeneity, a randomised-effects model was used to pool the results.

RESULTS

Eight prospective cohort studies including 3001 patients with tuberculosis were available for the meta-analysis. Among them, 752 (25.1%) were with prediabetes at baseline, and the patients were followed for a mean duration of 17.7 months. It was shown that compared to patients with normoglycemia, those with prediabetes were associated with a higher incidence of unfavourable treatment outcome (risk ratio [RR]: 1.41, 95% confidence interval [CI]: 1.02 to 1.96, p = 0.04; I2 = 56%). Subgroup analysis did not support that difference in study country (Asian or non-Asian), diagnosis (pulmonary tuberculosis only or also with extrapulmonary tuberculosis), mean age, follow-up duration, or study quality score had significant influence on the results (p for subgroup difference all >0.05). However, prediabetes at baseline was not associated with an increased risk of all-cause mortality during follow-up (RR: 1.59, 95% CI: 0.75 to 3.38, p = 0.23; I2 = 54%).

CONCLUSIONS

Patients with tuberculosis and prediabetes may have a higher risk of unfavourable treatment outcome compared to patients with normoglycemia.

Altered hepatic metabolic landscape and insulin sensitivity in response to pulmonary tuberculosis

Chronic inflammation triggers development of metabolic disease, and pulmonary tuberculosis (TB) generates chronic systemic inflammation. Whether TB induced-inflammation impacts metabolic organs and leads to metabolic disorder is ill defined. The liver is the master regulator of metabolism and to determine the impact of pulmonary TB on this organ we undertook an unbiased mRNA and protein analyses of the liver in mice with TB and reanalysed published data on human disease. Pulmonary TB led to upregulation of genes in the liver related to immune signalling and downregulation of genes encoding metabolic processes. In liver, IFN signalling pathway genes were upregulated and this was reflected in increased biochemical evidence of IFN signalling, including nuclear location of phosphorylated Stat-1 in hepatocytes. The liver also exhibited reduced expression of genes encoding the gluconeogenesis rate-limiting enzymes Pck1 and G6pc. Phosphorylation of CREB, a transcription factor controlling gluconeogenesis was drastically reduced in the livers of mice with pulmonary TB as was phosphorylation of other glucose metabolism-related kinases, including GSK3a, AMPK, and p42. In support of the upregulated IFN signalling being linked to the downregulated metabolic functions in the liver, we found suppression of gluconeogenic gene expression and reduced CREB phosphorylation in hepatocyte cell lines treated with interferons. The impact of reduced gluconeogenic gene expression in the liver was seen when infected mice were less able to convert pyruvate, a gluconeogenesis substrate, to the same extent as uninfected mice. Infected mice also showed evidence of reduced systemic and hepatic insulin sensitivity. Similarly, in humans with TB, we found that changes in a metabolite-based signature of insulin resistance correlates temporally with successful treatment of active TB and with progression to active TB following exposure. These data support the hypothesis that TB drives interferon-mediated alteration of hepatic metabolism resulting in reduced gluconeogenesis and drives systemic reduction of insulin sensitivity.

Drug Exposure and Treatment Outcomes in Patients With Multidrug-Resistant Tuberculosis and Diabetes Mellitus: A Multicenter Prospective Cohort Study From China

BACKGROUND

The management of multidrug-resistant tuberculosis (MDR-TB) remains challenging. Treatment outcome is influenced by multiple factors; the specific roles of diabetes and glycemic control remain uncertain. This study aims to assess the impact of glycemic control on drug exposure, to investigate the association between drug exposure and treatment outcomes, and to identify clinically significant thresholds predictive of treatment outcome, among patients with diabetes.

METHODS

This multicenter prospective cohort study involved patients with confirmed MDR-TB and diabetes. Drug exposure level was estimated by noncompartmental analysis. The minimum inhibitory concentrations (MICs) were determined for the individual Mycobacterium tuberculosis isolates. The influence of poor glycemic control (glycated hemoglobin ≥7%) on drug exposure and the associations between drug exposure and treatment outcome were evaluated by univariate and multivariate analysis. Classification and regression tree analysis was used to identify the drug exposure/susceptibility thresholds.

RESULTS

Among the 131 diabetic participants, 43 (32.8%) exhibited poor glycemic control. Poor glycemic control was independently associated with decreased exposure to moxifloxacin, linezolid, bedaquiline, and cycloserine, but not clofazimine. Additionally, a higher ratio of drug exposure to susceptibility was found to be associated with a favorable MDR-TB treatment outcome. Thresholds predictive of 6-month culture conversion and favorable outcome were bedaquiline area under the concentration-time curve (AUC)/MIC ≥245 and moxifloxacin AUC/MIC ≥67, demonstrating predictive accuracy in patients, regardless of their glycemic control status.

CONCLUSIONS

Glycemic control and optimal TB drug exposure are associated with improved treatment outcomes. This dual management strategy should be further validated in randomized controlled trials of patients with MDR-TB and diabetes.

Glycemic control during TB treatment among Filipinos: The Starting Anti-Tuberculosis Treatment Cohort Study

Poor TB treatment outcomes are observed in patients with type 2 diabetes mellitus (DM) comorbidity and glycemic control throughout treatment may play a role. The objective of this study was to investigate glycemic control longitudinally among Filipino adults undergoing TB treatment using mixed-effects linear and logistic regression. Analyses were conducted in 188 DM-TB patients out of 901 enrolled in the Starting Anti-TB Treatment (St-ATT) cohort, with a median baseline glycosylated hemoglobin (HbA1c) of 8.2% (range 4.5-13.3%). Previous versus new DM diagnosis was associated with higher mean HbA1c (worse glycemic control) during treatment, with a smaller effect amongst those with central obesity (coefficient 0.80, 95% confidence interval [CI] 0.26, 1.57, P = 0.043) than amongst those without central obesity (coefficient 3.48, 95% CI 2.16, 4.80, P<0.001). In those with a new DM diagnosis, central obesity was associated with higher blood glucose (coefficient 1.62, 95% CI 0.72, 2.53, P = 0.009). Of 177 participants with ≥2 HbA1c results, 40% had uncontrolled glycemia (≥2 HbA1c results ≥8%). Of 165 participants with ≥3 HbA1c results, 29.9% had consistently-controlled glycemia, 15.3% had initially-uncontrolled glycemia, and 18.6% had consistently-uncontrolled glycemia. Previous versus new DM diagnosis and glucose-lowering medication use versus no use were associated with having uncontrolled versus controlled glycemia (adjusted odds ratio [aOR] 2.50 95%CI 1.61, 6.05, P = 0.042; aOR 4.78 95% CI 1.61,14.23, P<0.001) and more likely to have consistently-uncontrolled versus consistently-controlled glycemia (adjusted relative risk ratio [aRRR] 5.14 95% CI 1.37, 19.20, P = 0.015; aRRR 10.24 95% CI 0.07, 0.95, P = 0.003). Relapse cases of TB were less likely than new cases to have uncontrolled (aOR 0.20 95%CI 0.06, 0.63, P = 0.031) or consistently-uncontrolled (aRRR 0.25 95%CI 0.07, 0.95, P = 0.042) versus controlled glycemia. Those with long-term DM, suggested by previous diagnosis, glucose-lowering medication use and possibly central obesity, may require additional support to manage blood glucose during TB treatment.

Trends of type 2 diabetes with pulmonary tuberculosis patients,2013-2022, and changes after the coronavirus disease 2019 (COVID-19) pandemic

BACKGROUND

To describe the trends of Type 2 Diabetes with Pulmonary Tuberculosis (T2DM-TB) patients from 2013 to 2022 and to investigate the impact of COVID-19 lockdown on glycemic control and associated factors in T2DM-TB.

METHODS

In this population-based study of the First Affiliated Yijishan Hospital of Wannan Medical College in China, we described the 10-year trends of patients diagnosed with T2DM-TB. We included patients diagnosed with TB, T2DM-TB and T2DM-TB patients for comparative analysis, aged 15 years or older. Data were missing, and both multidrug-resistant (MDR) TB patients and non-T2DM patients were excluded from our study.

RESULTS

We pooled Type 2 Diabetes (T2DM) and Tuberculosis (TB) data from The First Affiliated Yijishan Hospital of Wannan Medical College in China, gathered between January 1, 2013, and December 31, 2022. The data included 14,227 T2DM patients, 6130 TB patients, and 982 T2DM-TB patients. During the past 10 years, the number of inpatients with TB decreased, while the number of patients with T2DM and T2DM-TB increased year by year. To rule out any influence factors, we analyzed the ratio of the three groups. The ratio of TB/T2DM decreased year by year (p < 0.05), while the ratio of TB-T2DM/TB increasing year by year (p = 0.008). During the COVID-19 epidemic period, there was no significant change in the ratio of TB-T2DM/T2DM (p = 0.156). There was no significant change in the proportion of male patients with TB and TB-T2DM (p = 0.325; p = 0.190), but the proportion of male patients with T2DM showed an increasing trend (p < 0.001). The average age of TB patients over the past 10 years was 54.5 ± 18.4 years and showed an increasing trend year by year (p < 0.001). However, there was no significant change in the age of T2DM or TB-T2DM patients (p = 0.064; p = 0.241). Patients data for the first (2013-2017) and the last (2018-2022) five years were compared. We found that the number of T2DM and TB-T2DM in the last five years was significantly higher than in the first five years, but the number of TB was significantly lower than in the first five years. There is a significant statistical difference in the proportion of TB/T2DM and TB-T2DM/TB, which is similar to the previous results. The average age (56.0 ± 17.6 years) of TB patients in the last five years is significantly higher than in the first five years (53.1 ± 18.9) (p < 0.001). The number of male patients with T2DM in the last five years is higher than that in the first five years, with significant difference (p < 0.001).

CONCLUSION

The trends of T2DM-TB among hospitalized TB patients have increased significantly over the past 10 years, which may be related to the increase in the number of T2DM cases. The COVID-19 pandemic has been effective in controlling the transmission of TB, but it has been detrimental to the control of T2DM. Male patients with T2DM and elderly TB patients are the key populations for future prevention and control efforts.

Global and regional estimates of tuberculosis burden attributed to high fasting plasma glucose from 1990 to 2019: emphasis on earlier glycemic control

BACKGROUND

Previous studies have shown subjects suffering from diabetes or persistent hyperglycemia were more likely to develop tuberculosis (TB). However, the global burden of TB attributed to high fasting plasma glucose (HFPG) remains unclear. This study aimed to characterize the global, regional, and national TB burden attributed to HFPG from 1990 to 2019.

METHODS

With Global Burden of Disease study 2019, the numbers and age-standardized mortality rates (ASMR) and age-standardized disability-adjusted life years (DALY) rates (ASDR) of TB attributed to HFPG at global, regional, and national levels from 1990 to 2019 were extracted. The locally weighted regression model was applied to estimate the TB burden for different socio-demographic index (SDI) regions.

RESULTS

Globally, the ASMR and ASDR attributed to HFPG were 2.70 (95% UI, 1.64-3.94) and 79.70 (95% UI, 50.26-112.51) per 100,000 population in 1990, respectively. These rates decreased to 1.46 (95% UI, 0.91-2.08) and 45.53 (95% UI, 29.06-62.29) in 2019. The TB burden attributed to HFPG remained high in low SDI and Central Sub-Saharan Africa regions, while it declined with most significantly in high SDI and East Asia regions. Additionally, the ASMR and ASDR of TB attributed to HFPG were significantly higher in the male and the elderly population.

CONCLUSIONS

The global TB burden attributable to HFPG decreased from 1990 to 2019, but remained high in low SDI regions among high-risk populations. Thus, urgent efforts are required to enhance the awareness of early glycemic control and TB treatment to alleviate the severe situation.

Glycated Hemoglobin Trajectories and Their Association With Treatment Outcomes Among Patients With Pulmonary TB in India: A Prospective Cohort Study

BACKGROUND

Transient hyperglycemia is seen commonly during TB treatment, yet its association with unfavorable treatment outcomes is unclear.

RESEARCH QUESTION

Does an association exist between glycated hemoglobin (HbA1c) trajectories and TB treatment outcomes?

STUDY DESIGN AND METHODS

Adults with pulmonary TB were evaluated prospectively for 18 months after the second HbA1c measurement. HbA1c trajectories during the initial 3 months of treatment were defined as follows: persistent euglycemia, HbA1c < 6.5% at baseline and 3-month follow-up; persistent hyperglycemia, HbA1c ≥ 6.5% at baseline and 3-month follow-up; transient hyperglycemia, HbA1c ≥ 6.5% at baseline and < 6.5% at 3-month follow-up; incident hyperglycemia, HbA1c < 6.5% at baseline and ≥ 6.5% at 3-month follow-up. Multivariable Poisson regression was used to measure the association between HbA1c trajectories and unfavorable treatment outcomes of failure, recurrence, and all-cause mortality.

RESULTS

Of the 587 participants, 443 participants (76%) had persistent euglycemia, 118 participants (20%) had persistent hyperglycemia, and 26 participants (4%) had transient hyperglycemia. One participant had incident hyperglycemia and was excluded. Compared with participants with persistent euglycemia, those with transient hyperglycemia showed a twofold higher risk of experiencing an unfavorable treatment outcome (adjusted incidence rate ratio [aIRR], 2.07; 95% CI, 1.04-4.15) after adjusting for confounders including diabetes treatment, and BMI; we did not find a significant association with persistent hyperglycemia (aIRR, 1.64; 95% CI, 0.71-3.79). Diabetes treatment was associated with a significantly lower risk of unfavorable treatment outcomes (aIRR, 0.38; 95% CI, 0.15-0.95).

INTERPRETATION

Transient hyperglycemia and lack of diabetes treatment was associated with a higher risk of unfavorable treatment outcomes in adults with pulmonary TB.

Mass Tuberculosis Screening Among the Elderly: A Population-Based Study in a Well-Confined, Rural County in Eastern China

BACKGROUND

Mass tuberculosis (TB) screening has been recommended in certain high-risk populations. However, population-based screening interventions have rarely been implemented. Whether mass screening improves health equity is unknown.

METHODS

We implemented a mass TB screening intervention among elderly persons (>60 years old) in Lanxi County, China. Standardized questionnaires, physical examinations, and chest radiographs (CXRs) were administered to all participants. Systematic testing with computed tomography, smear, culture, or Xpert was performed among persons with an abnormal CXR. We assessed TB prevalence per 100 000 persons and constructed multivariable regression models among subgroups that were and were not screened. Medical insurance was categorized as participation in either a basic program with limited coverage or a more comprehensive coverage program.

RESULTS

In total, 49 339 individuals (32% of the elderly population in Lanxi) participated in the screening. One hundred fifteen screened persons were diagnosed with TB (233 cases per 100 000 persons), significantly higher than persons not screened (168 cases among 103 979 person-years; prevalence-to-case notification ratio, 1.44 [95% confidence interval {CI}, 1.14-1.83]). This increase was largely driven by diagnosis of asymptomatic disease during mass screening (n = 57 [50% of participants with TB]). Participants with basic medical insurance were much more likely to be diagnosed through mass screening than by passive detection (adjusted odds ratio, 4.52 [95% CI, 1.35-21.28]).

CONCLUSIONS

In a population-based, mass TB screening intervention encompassing >30% of the elderly population in a county in rural China, case finding was 44% higher than background detection, driven by diagnosis of TB without recognized symptoms. Importantly, mass screening identified TB in people with limited healthcare options who were less likely to be found through background case detection.

How can tuberculosis services better support patients with a diabetes co-morbidity? A mixed methods study in the Philippines

BACKGROUND

People with diabetes mellitus (DM) have an estimated two- to three-times greater risk of adverse tuberculosis (TB) treatment outcomes compared to those without DM. Blood glucose control is a primary aim of managing DM during TB treatment, yet TB programmes are not generally adapted to provide DM services. The purpose of this study was to understand perceptions and the lived experiences of diabetic patients in TB treatment in the Philippines, with a view to informing the development of disease co-management strategies.

METHODS

This mixed methods study was conducted within a prospective cohort of adults newly-starting treatment for drug-sensitive and drug-resistant TB at 13 public TB clinics in three regions of the Philippines. Within the subset of 189 diabetic persons who self-reported a prior DM diagnosis, or were diagnosed by screenings conducted through the TB clinic, longitudinal blood glucose data were used to ascertain individuals' glycaemic control (controlled or uncontrolled). Univariable logistic regression analyses exploring associations between uncontrolled glycaemia and demographic and clinical factors informed purposive sampling of 31 people to participate in semi-structured interviews. All audio-recorded data were transcribed and thematic analysis performed.

RESULTS

Participants - both with controlled and uncontrolled blood glucose - were knowledgeable about diabetes and its management. However, a minority of participants were aware of the impact of DM on TB treatment and outcomes. Many participants newly-diagnosed with DM at enrolment in TB treatment had not perceived any diabetic symptoms prior and would have likely not sought clinical consult otherwise. Access to free glucose-lowering medications through TB clinics was a key enabling resource. However, participants expressed fear of side effects and interrupted access to glucose-lowering medications, and a preference for phytotherapy. Many participants felt that physical and financial impacts of TB and its treatment were challenges to DM management.

CONCLUSIONS AND RECOMMENDATIONS

Results of this study indicate that public TB clinics can provide diabetic patients with additional health care resources and education to address co-morbidity. TB programmes might consider identifying patients with complicated DM, and offering diabetic monitoring and management, as DM and diabetic complications may compound the burden of TB and its treatment.

Impaired resolution of blood transcriptomes through tuberculosis treatment with diabetes comorbidity

BACKGROUND

People with diabetes are more likely to develop tuberculosis (TB) and to have poor TB-treatment outcomes than those without. We previously showed that blood transcriptomes in people with TB-diabetes (TB-DM) co-morbidity have excessive inflammatory and reduced interferon responses at diagnosis. It is unknown whether this persists through treatment and contributes to the adverse outcomes.

METHODS

Pulmonary TB patients recruited in South Africa, Indonesia and Romania were classified as having TB-DM, TB with prediabetes, TB-related hyperglycaemia or TB-only, based on glycated haemoglobin concentration at TB diagnosis and after 6 months of TB treatment. Gene expression in blood at diagnosis and intervals throughout treatment was measured by unbiased RNA-Seq and targeted Multiplex Ligation-dependent Probe Amplification. Transcriptomic data were analysed by longitudinal mixed-model regression to identify whether genes were differentially expressed between clinical groups through time. Predictive models of TB-treatment response across groups were developed and cross-tested.

RESULTS

Gene expression differed between TB and TB-DM patients at diagnosis and was modulated by TB treatment in all clinical groups but to different extents, such that differences remained in TB-DM relative to TB-only throughout. Expression of some genes increased through TB treatment, whereas others decreased: some were persistently more highly expressed in TB-DM and others in TB-only patients. Genes involved in innate immune responses, anti-microbial immunity and inflammation were significantly upregulated in people with TB-DM throughout treatment. The overall pattern of change was similar across clinical groups irrespective of diabetes status, permitting models predictive of TB treatment to be developed.

CONCLUSIONS

Exacerbated transcriptome changes in TB-DM take longer to resolve during TB treatment, meaning they remain different from those in uncomplicated TB after treatment completion. This may indicate a prolonged inflammatory response in TB-DM, requiring prolonged treatment or host-directed therapy for complete cure. Development of transcriptome-based biomarker signatures of TB-treatment response should include people with diabetes for use across populations.

Temporal trends in mortality of tuberculosis attributable to high fasting plasma glucose in China from 1990 to 2019: a joinpoint regression and age-period-cohort analysis

Background

Nowadays, high fasting plasma glucose (HFPG) has been identified as the important risk factor contributing to the increased burden of diseases. But there remains a lack of research on tuberculosis (TB) mortality specifically attributable to HFPG. Thus, this study aims to explore the long-term trends in HFPG-related TB mortality in China from 1990 to 2019.

Methods

Data on HFPG-related TB mortality were obtained from the Global Burden of Disease (GBD) Study 2019. Analyzing the data using joinpoint regression and age-period-cohort methods adjusting for age, period, and cohort allowed us to assess the trends in TB mortality due to HFPG.

Results

The age-standardized mortality rates (ASMRs) of TB attributable to HFPG exhibited a downward trend in China from 1990 to 2019, with an average annual percentage change (AAPC) of -7.0 (95% CI, -7.5 to -6.6). Similar trends were found for male (AAPC of -6.5 [95% CI, -7.0 to -6.0]) and female (AAPC of -8.2 [95% CI, -8.5 to -7.9]), respectively. Local drifts curve with a U-shaped pattern reflected the AAPC of TB mortality due to HFPG across age groups. The greatest decline was observed in the age group of 60-64 years. The mortality rates related to HFPG first increased and then decreased with increasing age, peaking in the 55-59 age group. Our analysis of the period and cohort effects found that the rate ratios of TB mortality due to HFPG have decreased over the past three decades, more prominently in women. It is noteworthy that while both genders have seen a decline in HFPG-attributable TB mortality and risk, men have a higher risk and slightly less significant decline than women.

Conclusion

The present study shows that HFPG-related ASMRs and risk of TB in China decreased over the last 30 years, with similar trends observed in both men and women. In order to attain the recommended level set by the WHO, the effective strategies for glycemic control and management still needed to be implemented strictly to further decrease the burden of TB.

Rethinking the syndemic of tuberculosis and dysglycaemia: a Kenyan perspective on dysglycaemia as a neglected risk factor for tuberculosis

Background

The END TB 2035 goal has a long way to go in low-income and low/middle-income countries (LICs and LMICs) from the perspective of a non-communicable disease (NCD) control interaction with tuberculosis (TB). The World Health Organization has identified diabetes as a determinant for, and an important yet neglected risk factor for tuberculosis. National guidelines have dictated testing time points, but these tend to be at an isolated time point rather than over a period of time. This article aims to give perspective on the syndemic interaction of tuberculosis and dysglycaemia and how the gaps in addressing the two may hamper progress towards END TB 2035.

Main text

Glycated haemoglobin (HbA1C) has a strong predictive association with the progression to subsequent diabetes. Therefore, screening using this measure could be a good way to screen at TB initiation therapy, in lieu of using the random blood sugar or fasting plasma glucose only. HbA1C has an observed gradient with mortality risk making it an informative predictor of outcomes. Determining the progression of dysglycaemia from diagnosis to end of treatment and shortly after may offer information on the best time point to screen and follow-up. Despite TB and Human Immunodeficiency Virus (HIV) disease care being free, hidden costs remain. These costs are additive if there is accompanying dysglycaemia. Regardless of receiving TB treatment, it is estimated that almost half of persons affected by pulmonary TB develop post-TB lung disease (PTLD) as an outcome and the contribution of dysglycaemia is not well described.

Conclusions

Establishing costs of treating TB with diabetes/prediabetes alone and in the additional context of HIV co-infection will inform policy makers on what it takes, financially, to treat these patients and subsidize dysglycaemia care. In Kenya, cardiovascular disease is only rivalled by infectious disease as a cause of mortality, and diabetes is a well-described risk factor for cardiac disease. In poor countries, communicable diseases are responsible for majority of the mortality burden, but societal shifts and rural-urban migration may have contributed to the observed increase of NCDs.

Longitudinal trends in glycated hemoglobin during and after tuberculosis treatment

AIMS

To investigate the impact of pulmonary TB on glycemic status during and after TB treatment, and associations of glycemic trends with antidiabetic therapy and TB outcomes.

METHODS

Data from two prospective cohort studies of adults in Chennai, India, with pulmonary TB were combined for this analysis. Participants were classified by baseline hemoglobin A1_c (A1C) as having normoglycemia (NG; n = 74), prediabetes (pre-DM; n = 110), or diabetes (DM; n = 244). Repeat A1C measurements were performed at TB treatment months 3 and 6, and then 6 and 12 months after TB treatment completion.

RESULTS

Median A1C at baseline declined after TB treatment initiation in all groups. No baseline NG or pre-DM participants progressed to DM by end of study, while 16.7% of baseline DM participants shifted to pre-DM or NG levels of A1C. In the baseline DM group, rising A1C after the intensive phase of TB treatment was significantly associated with adverse TB outcomes.

CONCLUSIONS

Incident TB promotes transient glucose elevation but was not conclusively shown to promote chronic dysglycemia. Rising A1C during and after TB treatment may predict unfavorable treatment response in persons presenting with A1C ≥ 6.5 % at the time of TB diagnosis.

Differential Role of Type 2 Diabetes as a Risk Factor for Tuberculosis in the Elderly versus Younger Adults

The elderly are understudied despite their high risk of tuberculosis (TB). We sought to identify factors underlying the lack of an association between TB and type 2 diabetes (T2D) in the elderly, but not adults. We conducted a case-control study in elderly (≥65 years old; ELD) vs. younger adults (young/middle-aged adults (18-44/45-64 years old; YA|MAA) stratified by TB and T2D, using a research study population (n = 1160) and TB surveillance data (n = 8783). In the research study population the adjusted odds ratio (AOR) of TB in T2D was highest in young adults (AOR 6.48) but waned with age becoming non-significant in the elderly. Findings were validated using TB surveillance data. T2D in the elderly (vs. T2D in younger individuals) was characterized by better glucose control (e.g., lower hyperglycemia or HbA1c), lower insulin resistance, more sulphonylureas use, and features of less inflammation (e.g., lower obesity, neutrophils, platelets, anti-inflammatory use). We posit that differences underlying glucose dysregulation and inflammation in elderly vs. younger adults with T2D, contribute to their differential association with TB. Studies in the elderly provide valuable insights into TB-T2D pathogenesis, e.g., here we identified insulin resistance as a novel candidate mechanism by which T2D may increase active TB risk.

Impact of Positive Interferon-Gamma Release Assay on IVF-ET Pregnancy Outcomes in Infertile Patients With Untreated Prior Tuberculosis: A Prospective Cohort Study

Introduction: Tuberculosis (TB) is a major infectious disease that seriously endangers human health and female reproduction. In our previous study, 10.4% of infertile patients preparing for In vitro fertilization and embryo transfer (IVF-ET) had prior pulmonary TB (PTB) as detected on chest X-ray (CXR) screening. Among them, 81.8% did not receive anti-TB treatment. It remains unclear whether infertile women with untreated prior PTB have latent TB infection (LTBI) and whether LTBI affects IVF-ET outcomes. In this study, we aim to analyze the relationship between LTBI and pregnancy outcomes following IVF-ET in patients with untreated prior PTB.

Methods and Analysis: We designed a prospective cohort study of 1,200 infertile women with CXR findings suggestive of old-healed untreated TB, who are preparing for IVF-ET. Patients with a history of active TB and anti-TB treatment will be excluded. Interferon-gamma release assay (IGRA) will be used in patients with CXR findings suggestive of old-healed untreated TB to construct a cohort of IGRA-positive and IGRA-negative patients. Participants will undergo IVF-ET. General information, including age, body mass index, infertility causes, and controlled ovarian hyperstimulation protocol, will be recorded. Participants will be followed up during pregnancy. The primary outcome is live birth. Secondary outcomes include the numbers of retrieved oocytes, high-quality embryo rate, clinical pregnancy, number of active TB cases during pregnancy, and miscarriage.

Ethics and Dissemination: The study was approved by the Ethics Committee of Peking University Third Hospital [approval number (2020)218-01; approval date: June 19, 2020]. The research results will be disseminated through scientific/medical conferences and published in academic journals.

Trial Registration:ClinicalTrials.gov; identifier: NCT04443283.

Diabetes Status and Association With Risk of Tuberculosis Among Korean Adults

IMPORTANCE

The risk of tuberculosis (TB) associated with diabetes status, considering impaired fasting glucose or duration of diabetes, has not been well established.

OBJECTIVE

To evaluate the association of diabetes status with the development of TB in the general population.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used data from the Korean National Health Insurance System database. Adult participants without a history of TB who underwent a health screening in 2009 were included. Eligible participants were followed up for incident TB cases from 1 year after the day of health screening until December 31, 2018. Data analysis was performed from September 2019 to September 2020.

EXPOSURES

Five levels of diabetes status were evaluated: normal glucose, impaired fasting glucose (considered as without diabetes), new-onset diabetes, diabetes duration less than 5 years, and diabetes duration 5 years or longer (considered as having diabetes).

MAIN OUTCOMES AND MEASURES

Newly diagnosed TB.

RESULTS

Among 4 423 177 participants, the mean (SD) age was 46.5 (13.9) years, and there were 2 597 142 men (58.7%). A total of 26 458 participants (0.6%) received a diagnosis of TB within a median (interquartile range) of 8.3 (8.1-8.6) years of follow-up. An increased risk of TB was observed in participants with diabetes compared with those without diabetes (adjusted hazard ratio [aHR], 1.48; 95% CI, 1.42-1.53). Although participants with impaired fasting glucose did not show an increased risk of TB incidence (aHR, 0.97; 95% CI, 0.93-1.01), the risk of TB incidence increased with diabetes duration (new-onset diabetes, aHR, 1.32; 95% CI, 1.23-1.42; diabetes duration <5 years, aHR, 1.45; 95% CI, 1.36-1.54; diabetes duration ≥5 years, aHR, 1.57; 95% CI, 1.48-1.66). Among participants with new-onset diabetes, compared with those in the lowest decile (fasting plasma glucose [FPG] level ≥126 but <128 mg/dL), the risk of TB was significantly increased for those in the highest decile (FPG level ≥202 mg/dL, aHR, 1.79; 95% CI, 1.42-2.26).

CONCLUSIONS AND RELEVANCE

These findings suggest that longer diabetes duration is associated with development of TB, showing a dose-response association. Among participants with new-onset diabetes, incident TB was more common among those with FPG levels greater than or equal to 202 mg/dL.

A risk score for prediction of poor treatment outcomes among tuberculosis patients with diagnosed diabetes mellitus from eastern China

Persons living with diabetes (PLWD) with newly diagnosed tuberculosis are at greater risk of poor treatment outcomes. Identifying and prioritizing high-risk subgroups of PLWD and tuberculosis for tuberculosis programs to target has been rarely performed. We investigated risk factors for poor tuberculosis treatment outcomes among PLWD and developed a predictive risk score for tuberculosis control prioritization. Among PLWD diagnosed with tuberculosis, demographic, clinical, and tuberculosis treatment outcome data were collected. Poor treatment outcomes included treatment failure, death, default, and transfer. Multivariable logistic regression modeling was used to analyze risk factors of poor treatment outcomes. Risk scores were derived based on regression coefficients to classify participants at low-, intermediate-, and high-risk of poor treatment outcomes. Among 335 PLWD newly diagnosed with tuberculosis, 109 were cured and 172 completed treatment. Multivariable logistic regression found that risk factors of poor treatment outcomes included bacteriologically-positivity, low body mass index, no physical activity, and pulmonary cavitation. Rates of poor treatment outcomes in low- (0-2), intermediate- (3-4), and high-risk (5-8) groups were 4.2%, 10.5%, and 55.4% (Ptrend < 0.0001), respectively. The risk score accurately discriminated poor and successful treatment outcomes (C-statistic, 0.85, 95% CI 0.78-0.91). We derived a simple predictive risk score that accurately distinguished those at high- and low-risk of treatment failure. This score provides a potentially useful tool for tuberculosis control programs in settings with a double burden of both tuberculosis and diabetes.