Socio-demographic and clinical differences in subjects with tuberculosis with and without diabetes mellitus in Brazil--a multivariate analysis

Health Status and Treatment Outcome of Tuberculosis with Diabetes Mellitus Cases, Rajkot City, Gujarat - A Longitudinal Study

Background

India, with the highest number of tuberculosis (TB) cases in the world, is also facing epidemic growth in diabetes mellitus (DM). TB is curable while DM is a metabolic and incurable disease that if not controlled will affect the health status of a person. This study was conducted to assess the health status and treatment outcome of TB with DM cases.

Materials and Methods

We selected a total of 64 newly registered pulmonary TB (PTB) with DM cases from five tuberculosis units (TUs) in Rajkot city from October 2019 to December 2020. At the end of treatment, 64 cases were analyzed for treatment outcome and 56 cases (5 deaths; 3 lost to follow-up) were followed up to observe progression in health status. The information was collected in pretested proforma by interview.

Results

There was a significant improvement in TB symptoms (cough, weight loss, weakness, anorexia, evening rise of temperature, dyspnea, chest pain, hemoptysis), DM symptoms (frequent urination, excessive thirst and hunger, tingling and numbness), symptoms of mental health (fatigue, sleep disturbance, negative emotions, socially inactive), and adverse drug reactions (ADRs) on consecutive visits (McNemar's test, P < 0.001) and at the end of treatment (Cochran's Q test, P < 0.001). Improvement of nutritional status was also found statistically significant on consecutive visits (Wilcoxon test, P < 0.001) and at the end of treatment (Friedman's test, P < 0.001). The cure rate was 82.8% and 4.7% of cases had completed treatment.

Conclusion

At the end of treatment, there was a significant improvement in health status and treatment outcome; also good cure rate was reported among cases.

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

Objetivo.

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

Métodos.

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

Resultados.

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

Conclusão.

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

Tuberculosis and comorbidities: treatment challenges in patients with comorbid diabetes mellitus and depression

Tuberculosis is one of the leading causes of death worldwide, primarily affecting low- and middle income countries and individuals with limited-resources within fractured health care systems. Unfortunately, the COVID-19 pandemic has only served to aggravate the already existing diagnostic gap, decreasing the number of people who get diagnosed and thereby complete successful treatment. In addition to this, comorbidities act as an external component that when added to the TB management equation, renders it even more complex. Among the various comorbidities that interact with TB disease, diabetes mellitus and depression are two of the most prevalent among non-communicable diseases within the TB population and merits a thoughtful consideration when the healthcare system provides care for them. TB patients with diabetes mellitus (TB-DM) or depression both have an increased risk of mortality, relapse and recurrence. Both of these diseases when in presence of TB present a ‘vicious-circle-like’ mechanism, meaning that the effect of each disease can negatively add up, in a synergistic manner, complicating the patient’s health state. Among TB-DM patients, high glucose blood levels can decrease the effectiveness of anti-tuberculosis drugs; however, higher doses of anti-tuberculous drugs could potentially decrease the effects of DM drugs. Among the TB-depression patients, not only do we have the adherence to treatment problems, but depression itself can biologically shift the immunological profile responsible for TB containment, and the other way around, TB itself can alter the hormonal balance of several neurotransmitters responsible for depression. In this paper, we review these and other important aspects such as the pharmacological interactions found in the treatment of TB-DM and TB-depression patients and the implication on TB care and pharmacological considerations.

Detailed epidemiological analysis as a strategy for evaluating the actual behavior of tuberculosis in an apparently low-incidence region

Tuberculosis control in developing regions with apparent low incidence, like the low-income Mexican state of Michoacán, with mean annual incidence rates below 10/100,000 inhabitants, requires knowledge of the actual behavior of the disease. This can be determined using an epidemiological profile at sub-regional level, allowing disclosure of the clinical and social factors that may be hampering efforts to control tuberculosis. In this work, a detailed epidemiological profile was outlined using data of all new monthly cases registered in the National System of Epidemiological Surveillance Database for Michoacán municipalities from 2000 to 2012. Cases were grouped by gender and age, and sociodemographic data were obtained both from the National Institute of Statistics and Geography and from the United Nations Development Programme. Correlations were calculated by Chi-square, Mann-Whitney U, and Kruskal-Wallis H tests. We observed no statistically significant differences between notification rates for the years 2000, 2005 and 2010 (χ² = 0.222, p = 0.895). The percentage of cases is similar between all age groups older than 15, while some regions had low notification rates but high proportions of pediatric cases. Higher proportions of cases of extrapulmonary tuberculosis were observed in municipalities in northern Michoacán. No correlation was found between municipal Human Development Index values and municipal notification rates. Michoacán is undergoing an epidemiological transition with three regions having different epidemiological profiles and particular needs for effective prevention and containment of tuberculosis. Our work shows the importance of the spatial scale of epidemiological profiles for determining specific regional needs of surveillance and containment.

Tuberculosis and diabetes: association with sociodemographic characteristics and diagnosis and treatment of tuberculosis. Brazil, 2007-2011

INTRODUCTION

Tuberculosis and diabetes comorbidity remains a challenge for global public health.

OBJECTIVE

To analyze the sociodemographic profile and the diagnostic and treatment characteristics of tuberculosis cases with and without diabetes in Brazil.

METHODS

This is a cross-sectional study with data from the Notifiable Diseases Information System and the Hypertension and Diabetes Mellitus Primary Care Clinical Management System, from 2007 to 2011. We adopted a Poisson regression model with robust variance to estimate the prevalence ratios (PR) and their respective confidence intervals.

RESULTS

We found the studied comorbidity in 7.2% of cases. The hierarchical model showed a higher PR among women (PR=1.31; 95% confidence interval - 95%CI 1.27-1.35); a greater association in the age groups 40-59 years and ≥ 60 years (PR=11.70; 95%CI 10.21-13.39, and PR=17.49; 95%CI 15.26-20.05), and in those with positive sputum smear microscopy results - 1st sample (PR=1.40; 95%CI 1.35-1.47). Return after treatment discontinuation and treatment discontinuation were inversely associated with comorbidity (PR=0.66; 95%CI 0.57-0.76 and PR=0.79; 95%CI 0.72-0.87).

CONCLUSION

The findings, such as the inverse relationship with tuberculosis treatment discontinuation in the group of people with comorbidity, reinforce the importance of integrated actions in health services to change the scenario of this challenging comorbidity.

Burden of diabetes among patients with tuberculosis: 10-year experience from a tertiary care referral teaching hospital in South India

Context

Tuberculosis (TB) and diabetes mellitus (DM) are converging epidemics, each worsening the morbidity of the other. A study of the prevalence of DM in TB patients assumes great importance.

Aims

The study aims to evaluate the association between DM and TB over a 10-year period in a tertiary care hospital.

Settings and Design

A retrospective observational study in a southern Indian tertiary care teaching hospital was conducted.

Materials and Methods

All patients with TB diagnosed and treated during the 10-year study period were identified from the hospital database. All relevant clinical, microbiological, and laboratory results pertaining to diagnosis of DM were collected. The diagnosis of TB and DM was made as per the standard criteria.

Statistical Analysis

Categorical variables were analyzed using Chi-square test while continuous variables using independent sample t-test.

Results

From 2001 to 2012, we studied 1979 TB patients among whom data on DM were available. The prevalence of DM was 29%, 21%, and 14%, in smear positive, smear negative and extrapulmonary TB respectively (overall 24%). Diabetics were more likely to be men (77.3% vs. 61%;P = 0.001); >40 years of age (81.7% vs. 38.9%;P < 0.001); heavier (59.96 vs. 50.37;P = 0.004); tobacco smokers (16.1% vs. 8.1%;P < 0.001); and alcohol consumers (6.8% vs. 4%;P = 0.02). They were less likely to be HIV coinfected (1.8% vs. 6.1%;P < 0.001). HIV coinfection was seen in 5% of patients and was substantially higher in extrapulmonary TB group (19.4%). Multidrug-resistant TB was lower in DM (11.7%) compared to non-DM (15.9%) (P = 0.02). Overall, 48% of the DM patients were diagnosed at the time of TB diagnosis. Over 10 years, no obvious changes in the trend were evident.

Conclusions

Over a 10-year study period, 24% of the TB patients were diabetic, nearly half were detected at the time of TB diagnosis. There may be a good case for screening all TB patients for DM.

Prevalence of diabetes mellitus among tuberculosis patients in Sub-Saharan Africa: a systematic review and meta-analysis of observational studies

BACKGROUND

Tuberculosis and diabetes mellitus are significant global public health challenges. In Sub-Saharan Africa, study findings regarding prevalence of diabetes mellitus amongst tuberculosis patients have been inconsistent and highly variable. Therefore, this systematic review and meta-analysis estimates the overall prevalence of diabetes mellitus among tuberculosis patients in Sub-Saharan Africa.

METHODS

Four international databases (PubMed, Google Scholar, Science Direct and Cochrane Library) were systematically searched. We included all observational studies reporting the prevalence of DM among TB patients in Sub-Saharan Africa. All necessary data for this review were extracted using a standardized data extraction format by two authors (CT and AA1). STATA Version 14 statistical software was employed to conduct meta-analysis. The Cochrane Q test statistics and I2 test were used to assess the heterogeneity of the studies. Finally, a random effects meta-analysis model was computed to estimate the pooled prevalence of diabetes mellitus in TB patients. Besides, subgroup analysis was done based on different factors.

RESULTS

In the meta-analysis, sixteen studies fulfilled the inclusion criteria and were included. The findings of these 16 studies revealed that the pooled prevalence of diabetes mellitus among tuberculosis patients in Sub-Saharan Africa was 9.0% (95% CI: 6.0, 12.0%). The highest prevalence of diabetes mellitus among tuberculosis patients was found in Nigeria (15%), followed by Tanzania (11%), and then Ethiopia (10%). Besides, the prevalence of diabetes mellitus among HIV infected TB patients was (8.9%) which is slightly higher than HIV uninfected (7.7%) TB patients.

CONCLUSION

Diabetes mellitus among tuberculosis patients in Sub-Saharan Africa was significantly high. Moreover, this study found that there was a high prevalence of DM among HIV infected than uninfected TB patients. It is strongly recommended to screen for DM among TB patients and special emphasis should be given for early screening of DM among TB/HIV co-infected patients.

Early death by tuberculosis as the underlying cause in a state of Southern Brazil: Profile, comorbidities and associated vulnerabilities

AIM

To know the profile of adults who died by tuberculosis as the main cause, the time interval between the diagnosis and death, associated comorbidities and vulnerabilities.

METHOD

Observational study of secondary data regarding deaths by tuberculosis that occurred in the State of Paraná, Brazil, from 2008 to 2015. A linkage between the databases of mortality and tuberculosis notification system was conducted for data enrichment. Frequency tables, Exact Fisher test and Z test have identified statistical associations.

RESULTS

Linkage points out 12.1% (115/944) of under-reporting in the 944 deaths identified. Early deaths accounted for 74.6% (705/944). The male sex (75.8%) was associated with the early death group. Almost half of the deaths reported in notification system (414/829) had one or more vulnerabilities. Early death were associated with respiratory system diseases and symptoms (p=0.0001) and mental and behavioral disorders (p=0.0001).

CONCLUSION

High number of early deaths due TB indicate the need to seek out the respiratory symptomatic and use faster diagnostic methods. Strategies for treatment adherence, adequate monitoring of comorbidities and multisectorial support may prevent early and late death. The presence of vulnerabilities indicates that efforts beyond the health sector are needed in order to eliminate tuberculosis as public health problem.

[Co-management of tuberculosis and diabetes: an integrative reviewManejo integrado de la tuberculosis y la diabetes: revisión integrativa]

Objetivo.

Identificar as evidências sobre manejo integrado de tuberculose e diabetes disponíveis na literatura para o contexto latino-americano.

Métodos.

Foi realizada uma revisão integrativa da literatura com busca nas bases de dados LILACS, Web of Science e PubMed. A estratégia utilizou como termos de busca “tuberculose”, “diabetes mellitus” e “manejo integrado”. Foram incluídos artigos científicos sobre estudos realizados na América Latina, publicados de 2011 a 2017, com acesso livre ao texto integral e publicação em inglês, espanhol ou português. Foram coletados dados relativo aos autores, delineamento, amostra, principais resultados, país e ano da publicação. Finalmente, os estudos foram classificados em níveis de evidência.

Resultados.

Foram incluídos 20 estudos, dos quais 60% apresentaram baixa evidência científica (nível IV). Conforme esses estudos, os pacientes com diabetes possuem maior risco de desenvolver tuberculose, especialmente aqueles com controle glicêmico ineficaz. Além disso, pacientes com tuberculose-diabetes apresentam atraso na conversão do escarro e maior probabilidade de falha terapêutica e morte. Há maior prevalência da associação tuberculose-diabetes no sexo masculino. Em relação aos registros de tuberculose e diabetes em prontuários ou fichas eletrônicas de informação nos serviços de saúde, há falhas ou ausência de anotações. Foi identificado alto custo financeiro do manejo clínico em indivíduos com a comorbidade. A equipe multidisciplinar possui papel imprescindível na prevenção e promoção em saúde, nos três níveis de atenção.

Conclusão.

O rastreamento bidirecional de tuberculose-diabetes poderá implicar em melhor controle desses agravos, principalmente em países em desenvolvimento e em áreas endêmicas para tuberculose.

Risk of active tuberculosis among people with diabetes mellitus: systematic review and meta-analysis

OBJECTIVE

To assess the risk of active TB in people with DM and the factors associated with this risk.

METHODS

Systematic review and meta-analysis. We searched the literature for studies that reported the effect of DM on TB controlled for the effect of age. Studies that had not established the diagnosis of DM prior to detecting active TB were excluded. Study quality was assessed by Newcastle-Ottawa scale and we conducted a meta-analysis using random-effects models.

RESULTS

Of 14 studies (eight cohort and six case-control studies) that involved 22 616 623 participants met the selection criteria and were included in the analysis. There was substantial variation between studies in the estimates of the effect of DM on TB. However, the pooled estimates from seven high-quality studies showed that diabetic people have a 1.5-fold increased risk of developing active TB vs. those without DM (95%CI 1.28-1.76), with relatively small heterogeneity (I²  = 44%). The increased risk of TB was observed predominantly among DM populations with poor glycaemic control.

CONCLUSION

There is evidence suggesting an increased risk of developing TB among people with DM, and that improving glycaemic control in DM patients would reduce the risk of developing TB. An integrated approach is needed to control the dual burden of DM and TB.

Prevalence of diabetes mellitus amongst hospitalized tuberculosis patients at an Indian tertiary care center: A descriptive analysis

Background

India has a high prevalence of tuberculosis (TB) as well as diabetes mellitus (DM). DM is a chronic disease caused by deficiency of insulin production by the pancreas. The risk of TB amongst DM patients is three times higher than those without. The estimated national prevalence of DM is 7.3%. Despite the growing burden of DM, there are limited studies describing the prevalence of TB-DM in India.

Objective

Our study estimated the prevalence of DM amongst adult hospitalized TB patients at Kasturba Hospital, Manipal and determined factors associated with the likelihood of DM-TB co-prevalence.

Methods

We conducted a retrospective cohort study at Kasturba Hospital, Manipal Academy of Higher Education. All hospitalized adult patients diagnosed with pulmonary TB (PTB) and extrapulmonary TB (EPTB) between June 1^st 2015 and June 30^th 2016 were eligible for inclusion. Pediatric and pregnant TB patients were excluded from our study. Data were extracted from medical charts. Descriptive and multivariate analyses were performed in R. Multivariate analysis adjusted for age, gender, type of TB, history of TB, and nutrition (body mass index (BMI)) status.

Results

A total of 728 patients met the eligibility criteria, 517 (71%) were male, 210 (29%) female, 406 (56%) had PTB and 322 (44%) had EPTB. Amongst those with a nutritional status, 36 (30%) patients were underweight (BMI <18.4 kg/m²), 73 (40%) had a normal BMI (18.5kg/m²–24.9 kg/m²), 15 (8%) were overweight (BMI 25.0 kg/m²–29.9 kg/m²) and 9 (5%) were obese (BMI >30.0 kg/m²). A total of 720 (98.9%) of TB patients had at least one blood sugar test result. The overall prevalence of DM (n = 184) amongst TB patients was 25.3% (95% CI 22.2%, 28.6%). When stratified, it was 35.0% (30.4%, 39.9%) and 13.0% (9.7%, 17.3%) amongst PTB and EPTB patients respectively. TB patients aged 41–60 years had 3.51 times higher odds (aOR 3.51 (2.08, 6.07)) of having DM than patients 40 years or younger. Patients aged 60 years or older had 2.49 times higher odds (aOR 2.49 (1.28, 4.85)) of having DM than younger patients (<40 years). Females had lower odds (aOR 0.80 (0.46, 1.37)) of developing DM than male TB patients and patients with a history of TB had lower odds (aOR 0.73 (0.39, 1.32)) than newly diagnosed TB patients. Additionally, EPTB patients had significantly lower odds (aOR 0.26 (0.15, 0.43)) compared to PTB patients. Underweight patients also had significantly lower odds (aOR 0.25 (0.14, 0.42)) of having DM than normal weight patients.

Conclusion

Our study found a higher prevalence of TB-DM than the national average. TB-DM co-prevalence was significantly associated with age, type of TB and undernutrition. As India’s DM prevalence is expected to rise, TB-DM will become an increasingly important part of the TB epidemic requiring specialized study and care.

Genotyping and spatial analysis of pulmonary tuberculosis and diabetes cases in the state of Veracruz, Mexico

Background

Genotyping and georeferencing in tuberculosis (TB) have been used to characterize the distribution of the disease and occurrence of transmission within specific groups and communities.

Objective

The objective of this study was to test the hypothesis that diabetes mellitus (DM) and pulmonary TB may occur in spatial and molecular aggregations.

Material and methods

Retrospective cohort study of patients with pulmonary TB. The study area included 12 municipalities in the Sanitary Jurisdiction of Orizaba, Veracruz, México. Patients with acid-fast bacilli in sputum smears and/or Mycobacterium tuberculosis in sputum cultures were recruited from 1995 to 2010. Clinical (standardized questionnaire, physical examination, chest X-ray, blood glucose test and HIV test), microbiological, epidemiological, and molecular evaluations were carried out. Patients were considered “genotype-clustered” if two or more isolates from different patients were identified within 12 months of each other and had six or more IS6110 bands in an identical pattern, or < 6 bands with identical IS6110 RFLP patterns and spoligotype with the same spacer oligonucleotides. Residential and health care centers addresses were georeferenced. We used a Jeep hand GPS. The coordinates were transferred from the GPS files to ArcGIS using ArcMap 9.3. We evaluated global spatial aggregation of patients in IS6110-RFLP/ spoligotype clusters using global Moran´s I. Since global distribution was not random, we evaluated “hotspots” using Getis-Ord Gi* statistic. Using bivariate and multivariate analysis we analyzed sociodemographic, behavioral, clinic and bacteriological conditions associated with “hotspots”. We used STATA® v13.1 for all statistical analysis.

Results

From 1995 to 2010, 1,370 patients >20 years were diagnosed with pulmonary TB; 33% had DM. The proportion of isolates that were genotyped was 80.7% (n = 1105), of which 31% (n = 342) were grouped in 91 genotype clusters with 2 to 23 patients each; 65.9% of total clusters were small (2 members) involving 35.08% of patients. Twenty three (22.7) percent of cases were classified as recent transmission. Moran`s I indicated that distribution of patients in IS6110-RFLP/spoligotype clusters was not random (Moran`s I = 0.035468, Z value = 7.0, p = 0.00). Local spatial analysis showed statistically significant spatial aggregation of patients in IS6110-RFLP/spoligotype clusters identifying “hotspots” and “coldspots”. GI* statistic showed that the hotspot for spatial clustering was located in Camerino Z. Mendoza municipality; 14.6% (50/342) of patients in genotype clusters were located in a hotspot; of these, 60% (30/50) lived with DM. Using logistic regression the statistically significant variables associated with hotspots were: DM [adjusted Odds Ratio (aOR) 7.04, 95% Confidence interval (CI) 3.03–16.38] and attending the health center in Camerino Z. Mendoza (aOR18.04, 95% CI 7.35–44.28).

Conclusions

The combination of molecular and epidemiological information with geospatial data allowed us to identify the concurrence of molecular clustering and spatial aggregation of patients with DM and TB. This information may be highly useful for TB control programs.

Molecular clustering of patients with diabetes and pulmonary tuberculosis: A systematic review and meta-analysis

Introduction

Many studies have explored the relationship between diabetes mellitus (DM) and tuberculosis (TB) demonstrating increased risk of TB among patients with DM and poor prognosis of patients suffering from the association of DM/TB. Owing to a paucity of studies addressing this question, it remains unclear whether patients with DM and TB are more likely than TB patients without DM to be grouped into molecular clusters defined according to the genotype of the infecting Mycobacterium tuberculosis bacillus. That is, whether there is convincing molecular epidemiological evidence for TB transmission among DM patients. Objective: We performed a systematic review and meta-analysis to quantitatively evaluate the propensity for patients with DM and pulmonary TB (PTB) to cluster according to the genotype of the infecting M. tuberculosis bacillus.

Materials and methods

We conducted a systematic search in MEDLINE and LILACS from 1990 to June, 2016 with the following combinations of key words “tuberculosis AND transmission” OR “tuberculosis diabetes mellitus” OR “Mycobacterium tuberculosis molecular epidemiology” OR “RFLP-IS6110” OR “Spoligotyping” OR “MIRU-VNTR”. Studies were included if they met the following criteria: (i) studies based on populations from defined geographical areas; (ii) use of genotyping by IS6110- restriction fragment length polymorphism (RFLP) analysis and spoligotyping or mycobacterial interspersed repetitive unit-variable number of tandem repeats (MIRU-VNTR) or other amplification methods to identify molecular clustering; (iii) genotyping and analysis of 50 or more cases of PTB; (iv) study duration of 11 months or more; (v) identification of quantitative risk factors for molecular clustering including DM; (vi) > 60% coverage of the study population; and (vii) patients with PTB confirmed bacteriologically. The exclusion criteria were: (i) Extrapulmonary TB; (ii) TB caused by nontuberculous mycobacteria; (iii) patients with PTB and HIV; (iv) pediatric PTB patients; (v) TB in closed environments (e.g. prisons, elderly homes, etc.); (vi) diabetes insipidus and (vii) outbreak reports. Hartung-Knapp-Sidik-Jonkman method was used to estimate the odds ratio (OR) of the association between DM with molecular clustering of cases with TB. In order to evaluate the degree of heterogeneity a statistical Q test was done. The publication bias was examined with Begg and Egger tests. Review Manager 5.3.5 CMA v.3 and Biostat and Software package R were used.

Results

Selection criteria were met by six articles which included 4076 patients with PTB of which 13% had DM. Twenty seven percent of the cases were clustered. The majority of cases (48%) were reported in a study in China with 31% clustering. The highest incidence of TB occurred in two studies from China. The global OR for molecular clustering was 0.84 (IC 95% 0.40–1.72). The heterogeneity between studies was moderate (I² = 55%, p = 0.05), although there was no publication bias (Beggs test p = 0.353 and Eggers p = 0.429).

Conclusion

There were very few studies meeting our selection criteria. The wide confidence interval indicates that there is not enough evidence to draw conclusions about the association. Clustering of patients with DM in TB transmission chains should be investigated in areas where both diseases are prevalent and focus on specific contexts.

Diabetes and Tuberculosis

The increase in type 2 diabetes mellitus (DM) patients in countries where tuberculosis (TB) is also endemic has led to the reemerging importance of DM as a risk factor for TB. DM causes a 3-fold increase in TB risk and a 2-fold increase in adverse TB treatment outcomes. Given the sheer numbers of DM patients worldwide, there are now more TB patients with TB-DM comorbidity than TB-HIV coinfection. There is an urgent need to implement strategies for TB prevention and control among the millions of DM patients exposed to Mycobacterium tuberculosis. This chapter summarizes the current epidemiological, clinical, and immunological knowledge on TB and DM and their clinical and public health implications. These include the underlying mechanisms for TB risk in DM patients and their clinical and sociodemographic characteristics that distinguish them from TB patients without DM. TB-DM comorbidity is posing a new challenge for integrating the short-term care for TB with the long-term care for DM, particularly in low- and middle-income countries.

IL-6 and IL-18 cytokine gene variants of pulmonary tuberculosis patients with co-morbid diabetes mellitus and their household contacts in Hyderabad

PURPOSE

Association of cytokine genes reflects their susceptibility towards infection and disease in household contacts (HHC) of pulmonary tuberculosis (PTB) patients. Hyperglycemia, a common factor in diabetics might influence their risk towards mycobacterium tuberculosis infection and disease development. This study determines the association of IL-6 and IL-18 cytokine gene variants of TB patients with diabetes mellitus (TBDM) and their HHC in Hyderabad.

METHODS

Single nucleotide polymorphisms of IL-6 (-174 G>C and -572 G>C) and IL-18 (-137 G>C and -607 C>A) cytokine genes were genotyped by Amplification Refractory Mutation System and Restriction Fragment Length polymerase chain reaction in total of 705 subjects comprising of TBDM, their HHC, PTB, DM and Healthy controls (HC).

RESULTS

At IL-6 -174G>C variant, GG genotype, G allele in TBDM and TBDM HHC, at -572G>C variant, C allele in TBDM and GG haplotype in TBDM HHC were showing positive association, however DM have not shown any association at IL-6 polymorphic sites. With respect to the IL-18 gene polymorphisms, at -137 G>C variant, GG genotype was positively associated in PTB while at -607 C>A variant positive association was shown with AC genotype in TBDM, their HHC and DM; GACC diplotype in TBDM and GCGC in PTB.

CONCLUSION

Our findings suggest that susceptible combination of IL-6 and IL-18 cytokine genes associated with disease in the HHCs highlight their risk of inclination towards the disease.

Prevalence and associated factors of tuberculosis and diabetes mellitus comorbidity: A systematic review

Introduction

The dual burden of tuberculosis (TB) and diabetes mellitus (DM) has become a major global public health concern. There is mounting evidence from different countries on the burden of TB and DM comorbidity. The objective of this systematic review was to summarize the existing evidence on prevalence and associated/risk factors of TBDM comorbidity at global and regional levels.

Methods

Ovid Medline, Embase, Global health, Cochrane library, Web of science and Scopus Elsevier databases were searched to identify eligible articles for the systematic review. Data were extracted using standardized excel form and pilot tested. Median with interquartile range (IQR) was used to estimate prevalence of TBDM comorbidity. Associated/risk factors that were identified from individual studies were thematically analyzed and described.

Results

The prevalence of DM among TB patients ranged from 1.9% to 45%. The overall median global prevalence was 16% (IQR 9.0%-25.3%) Similarly, the prevalence of TB among DM patients ranged from 0.38% to 14% and the overall median global prevalence was 4.1% (IQR 1.8%-6.2%). The highest prevalence of DM among TB patients is observed in the studied countries of Asia, North America and Oceania. On the contrary, the prevalence of TB among DM patients is low globally, but relatively higher in the studied countries of Asia and the African continents. Sex, older age, urban residence, tobacco smoking, sedentary lifestyle, poor glycemic control, having family history of DM and TB illness were among the variables identified as associated/risk factors for TBDM comorbidity.

Conclusion

This systematic review revealed that there is a high burden of DM among TB patients at global level. On the contrary, the global prevalence of TB among DM patients is low. Assessing the magnitude and risk/associated factors of TBDM comorbidity at country/local level is crucial before making decisions to undertake TBDM integrated services.

Effects of diabetes mellitus on the clinical presentation and treatment response in tuberculosis

BACKGROUND AND OBJECTIVE

With the colliding global epidemics of diabetes mellitus (DM) and tuberculosis (TB), we studied the effects of DM on the presentation of TB and its response to treatment.

METHODS

Consecutive TB patients from 2006 to 2010 in a territory-wide treatment programme offering 9-month extended treatment for TB patients with DM were examined and followed up prospectively to assess their treatment response. Successful treatment completers were tracked through the TB registry and death registry for relapse, death or till 31 December 2014, whichever was the earliest.

RESULTS

DM was independently associated with more chest symptoms (adjusted OR (AOR): 1.13) and systemic symptoms (AOR: 1.30) but less with other site-specific symptoms (AOR: 0.58) at TB presentation. There was more frequent pulmonary involvement (AOR: 1.69), with more extensive lung lesion (AOR: 1.25), lung cavity (AOR: 2.00) and positive sputum smear (AOR: 1.83) and culture (AOR: 1.38), but no difference in the proportion of retreatment cases or isoniazid and/or rifampicin resistance. After treatment initiation, there was higher overall incidence (AOR: 1.38) of adverse effects (mainly gastrointestinal symptoms, renal impairment and peripheral neuropathy but less fever and skin hypersensitivity reactions), more smear non-conversion (AOR: 1.59) and culture non-conversion (AOR: 1.40) at 2 months, and lower combined cure/treatment completion rate at 12 months (AOR: 0.79), but no difference in the relapse rate after having successfully completed treatment.

CONCLUSION

DM adversely affected the clinical presentation and treatment response of TB, but there was no difference in the drug resistance and relapse rates.

Clinical and epidemiological characteristics associated with unfavorable tuberculosis treatment outcomes in TB-HIV co-infected patients in Brazil: a hierarchical polytomous analysis

Background

TB patients co-infected with HIV have worse treatment outcomes than non-coinfected patients. How clinical characteristics of TB and socioeconomic characteristics influence these outcomes is poorly understood. Here, we use polytomous regression analysis to identify clinical and epidemiological characteristics associated with unfavorable treatment outcomes among TB-HIV co-infected patients in Brazil.

Methods

TB-HIV cases reported in the Brazilian information system (SINAN) between January 1, 2001 and December 31, 2011 were identified and categorized by TB treatment outcome (cure, default, death, and development of MDR TB). We modeled treatment outcome as a function of clinical characteristics of TB and patient socioeconomic characteristics by polytomous regression analysis. For each treatment outcome, we used cure as the reference outcome.

Results

Between 2001 and 2011, 990,017 cases of TB were reported in SINAN, of which 93,147 (9.4%) were HIV co-infected. Patients aged 15–19 (OR = 2.86; 95% CI: 2.09–3.91) and 20–39 years old (OR = 2.30; 95% CI: 1.81–2.92) were more likely to default on TB treatment than those aged 0–14 years old. In contrast, patients aged ≥60 years were more likely to die from TB (OR = 2.22; 95% CI: 1.43–3.44) or other causes (OR = 2.86; 95% CI: 2.14–3.83). Black patients were more likely to default on TB treatment (OR = 1.33; 95% CI: 1.22–1.44) and die from TB (OR = 1.50; 95% CI: 1.29–1.74). Finally, alcoholism was associated with all unfavorable outcomes: default (OR = 1.94; 95% CI: 1.73–2.17), death due to TB (OR = 1.46; 95% CI: 1.25–1.71), death due to other causes (OR = 1.38; 95% CI: 1.21–1.57) and MDR-TB (OR = 2.29; 95% CI: 1.46–3.58).

Conclusions

Socio-economic vulnerability has a significant effect on treatment outcomes among TB-HIV co-infected patients in Brazil. Enhancing social support, incorporation of alcohol abuse screening and counseling into current TB surveillance programs and targeting interventions to specific age groups are interventions that could improve treatment outcomes.

Diabetes mellitus in patients with pulmonary tuberculosis in an aging population in Shanghai, China: Prevalence, clinical characteristics and outcomes

AIMS

To determine the prevalence of diabetes mellitus among pulmonary tuberculosis patients and the difference of clinical characteristics and outcomes between pulmonary tuberculosis patients with and without diabetes mellitus in an aging population in Shanghai, China.

METHODS

This is a retrospective population-based study. 201 newly diagnosed pulmonary tuberculosis patients in Changning District, Shanghai during 2007-2008 were included. Clinical characteristics and outcomes were collected. Determination of diabetes mellitus was based on the medical records before pulmonary tuberculosis was diagnosed.

RESULTS

The prevalence of diabetes mellitus among pulmonary tuberculosis patients was 19.9% (40/201). Pulmonary tuberculosis patients with diabetes mellitus were more likely to be old (≥50, OR=5.23, 95% CI=2.07-13.25), to have pulmonary cavities (OR=3.02, 95% CI=1.31-6.98), to be sputum smear positive (OR=2.90, 95% CI=1.12-7.51), and to have extension of anti-tuberculosis treatment duration (OR=2.68, 95% CI 1.17-6.14). Besides, they had a higher 2nd month sputum smear positive proportion (OR=2.97, 95% CI 1.22-7.22) and a higher 5-year recurrence rate (OR=5.87, 95% CI 1.26-27.40).

CONCLUSIONS

High prevalence, severe clinical characteristics and poor outcomes of pulmonary tuberculosis patients with diabetes mellitus highlight the necessity of early bi-directional screening and co-management of these two diseases in Shanghai, China.

Prevalence and Associated Factors of Diabetes Mellitus among Tuberculosis Patients in South-Eastern Amhara Region, Ethiopia: A Cross Sectional Study

Background

The association between diabetes mellitus (DM) and tuberculosis (TB) is re-emerging worldwide. Recently, the prevalence of DM is increasing in resource poor countries where TB is of high burden. The objective of the current study was to determine the prevalence and analyze associated factors of TB and DM comorbidity in South-Eastern Amhara Region, Ethiopia.

Methods

This was a facility based cross-sectional study. All newly diagnosed TB patients attending selected health facilities in the study area were consecutively screened for DM. DM was diagnosed based on the World Health Organization diagnostic criteria. A pre-tested semi-structured questionnaire was used to collect socio-demographic, lifestyles and clinical data. Logistic regression analysis was performed to identify factors associated with TB and DM comorbidity.

Result

Among a total of 1314 patients who participated in the study, the prevalence of DM was estimated at 109 (8.3%). Being female [odds ratio (OR) 1.70; 95% confidence interval (CI) (1.10–2.62)], patients age [41–64 years (OR 3.35; 95% CI (2.01–5.57), 65–89 years (OR 3.18; 95% CI (1.52–6.64)], being a pulmonary TB case [(OR 1.69; 95% CI 1.09–2.63)] and having a family history of DM [(OR 4.54; 95% CI (2.36–8.73)] were associated factors identified with TB and DM comorbidity.

Conclusion

The prevalence of DM among TB patients in South-Eastern Amahra Region is high. Routine screening of TB patients for DM is recommended in the study area.

[What are the causes of death of patients with tuberculosis: multiple causes of death in a cohort of cases and a research proposal of presumed causes]

The objective of this study was to analyze the multiple causes of death in a cohort of patients with tuberculosis (TB) and to introduce an investigation proposal death for TB from a list of presumable causes. We performed a probabilistic record linkage with the databases of the Information System for Notifiable Diseases (SINAN) 2006 and the Mortality Information System (SIM) 2006-2008. There were 825 deaths, of which 23% for death for TB, deaths due to TB with 16% and 61% without mention of TB. Two hundred and fifteen (42.7%) deaths occurred within the period of treatment, whose profile differed from the pattern of causes when TB was an associated cause, with high frequency of respiratory diseases, AIDS and ill-defined causes. We elaborated a proposal for correction of associated causes of death and an investigation proposal death for TB from a list of presumable causes. According to the proposal, 26 deaths could have modified the underlying cause. This study highlights the importance of record linkage to TB surveillance and improvement of information the SIM and SINAN.

Effect of diabetes on tuberculosis presentation and outcomes in Kiribati

OBJECTIVES

To determine the association between diabetes and the clinical features and treatment outcomes of TB in Kiribati.

METHODS

We enrolled consecutive patients with TB who presented from August 2010 to February 2012 and compared clinical features and TB treatment outcomes for patients with and without diabetes, as measured by haemoglobin A1c assay. Poor outcome was defined as death, default or treatment failure, and good outcome as treatment success or cure.

RESULTS

Two hundred and seventy-five eligible persons with TB disease were enrolled; 101 (37%) had diabetes. TB patients with diabetes were more likely to have acid-fast bacilli (AFB) seen on sputum smear microscopy (RR: 1.3; 95% CI: 1.03-1.62). The risk of poor outcome did not differ between patients with or without diabetes (RR: 1.1; 95% CI: 0.5-2.7).

CONCLUSION

TB patients with diabetes are more likely than those without to have sputum with AFB on microscopy. This could increase transmission in the community. Early detection of TB by screening patients with diabetes, and the converse, could be important public health interventions where diabetes and TB are prevalent.

Type 2 diabetes mellitus and its influence in the development of multidrug resistance tuberculosis in patients from southeastern Mexico

AIMS

To determine the factors associated with the presence of pulmonary tuberculosis in patients with type 2 diabetes mellitus and the effect in the development of drug and multi-drug resistance, in a population with tuberculosis from the southeast of Mexico.

METHODS

This is a case-control study including 409 individuals, 146 with the binomial tuberculosis-type 2 diabetes mellitus and 263 individuals with tuberculosis. Demographic, epidemiological and outcome variables were collected. Risks were calculated.

RESULTS

The factors associated with the presence of type 2 diabetes mellitus were age ≥35years, (OR=9.7; CI: 5.2-17.8), previous contact with a person infected with tuberculosis (OR=1.7; CI: 1.1-3.1). Body mass index ≥25 kg/m(2) (OR=2.2; CI: 1.1-4.3), and inherited family history of diabetes (OR=5.4; CI: 3.2-9.2). It was also found that patients with tuberculosis-type 2 diabetes mellitus presented a 4.7-fold (CI: 1.4-11.3) and 3.5-fold (CI: 1.1-11.1) higher risk of developing drug- and multidrug resistance tuberculosis, respectively. By last, individuals with tuberculosis-type 2 diabetes had a 2.3-fold (CI: 1.5-4.1) greater chance of persisting as tuberculosis-positive by the second month of treatment, delaying the resolution of the tuberculosis infection.

CONCLUSIONS

Type 2 diabetes exerts a strong influence on the presentation and evolution of tuberculosis within the analyzed population and displays remarkable particularities, necessitating the development of dedicated tuberculosis-diabetes surveillance systems that consider the particular epidemiological characteristics of the population affected.

Impact of diabetes on the natural history of tuberculosis

Tuberculosis (TB) is the number one bacterial killer worldwide and the current increase in type 2 diabetes mellitus patients (DM), particularly in countries where TB is also endemic, has led to the re-emerging importance of DM2 as a risk factor for TB. There is an urgent need to implement strategies for TB prevention among the millions of DM patients exposed to Mycobacterium tuberculosis (Mtb) worldwide, but knowledge is limited on how and when DM2 alters the natural history of this infection. In this review we summarize the current epidemiological, clinical and immunologic studies on TB and DM and discuss the clinical and public health implications of these findings. Specifically, we evaluate the mechanisms by which DM patients have a higher risk of Mtb infection and TB development, present with signs and symptoms indicative of a more infectious TB infection, and are more likely to have adverse TB treatment outcomes, including death. Emphasis is placed on type 2 DM given its higher prevalence in contemporary times, but the underlying role of hyperglycemia and of type 1 DM is also discussed.

Clinical management of concurrent diabetes and tuberculosis and the implications for patient services

Diabetes triples the risk for active tuberculosis, thus the increasing burden of type 2 diabetes will help to sustain the present tuberculosis epidemic. Recommendations have been made for bidirectional screening, but evidence is scarce about the performance of specific tuberculosis tests in individuals with diabetes, specific diabetes tests in patients with tuberculosis, and screening and preventive therapy for latent tuberculosis infections in individuals with diabetes. Clinical management of patients with both diseases can be difficult. Tuberculosis patients with diabetes have a lower concentration of tuberculosis drugs and a higher risk of drug toxicity than tuberculosis patients without diabetes. Good glycaemic control, which reduces long-term diabetes complications and could also improve tuberculosis treatment outcomes, is hampered by chronic inflammation, drug-drug interactions, suboptimum adherence to drug treatments, and other factors. Besides drug treatments for tuberculosis and diabetes, other interventions, such as education, intensive monitoring, and lifestyle interventions, might be needed, especially for patients with newly diagnosed diabetes or those who need insulin. From a health systems point of view, delivery of optimum care and integration of services for tuberculosis and diabetes is a huge challenge in many countries. Experience from the combined tuberculosis and HIV/AIDS epidemic could serve as an example, but more studies are needed that include economic assessments of recommended screening and systems to manage concurrent tuberculosis and diabetes.

Factors associated with tuberculosis by HIV status in the Brazilian national surveillance system: a cross sectional study

Background

Over the last decade tuberculosis (TB) incidence and mortality in Brazil have been steadily declining. However, this downward trend has not been observed among HIV-infected patients. We describe the epidemiological and clinical profile of TB patients by HIV status using the Brazilian National Surveillance System.

Methods

All TB diagnoses with HIV status information between January 1, 2007 and December 31, 2011 were categorized as either HIV or non-HIV at time of TB diagnosis. Co-infected patients (TB-HIV) were compared to TB patients with no HIV-infection using a hierarchical logistic regression model using Stata 13.0.

Results

The prevalence of TB-HIV co-infection was 19% among adults ≥ 15 years of age. We analyzed data from 243,676 individuals, of whom 46,466 were TB-HIV and 197,210 were only TB cases. The following factors increased risk of co-infection: male sex (OR: 1.06, 95% CI 1.03-1.10), 20 to 39 years of age (OR = 4.82, 95% CI 4.34-5.36), black (OR = 1.08, 95% CI 1.04-1.13), 4–7 years of education (OR = 1.13, 95% CI 1.19-1.28), diagnosed following default (OR = 2.65, 95% CI 1.13-6.25), presenting with pulmonary and extra-pulmonary forms of TB simultaneously (OR = 2.80, 95% CI 1.56-5.02), presenting with histopathologic examination suggestive of TB (OR = 2.15, 95% CI 1.13-4.07). Co-infected patients were less likely to live in rural areas (OR = 0.45, 95% CI 0.42-0.48), have diabetes (OR = 0.45, 95% CI 0.40-0.50) and be smear positive (OR = 0.55, 95% CI 0.32-0.95), and co-infected patients had higher risk of default (OR = 2.96, 95% CI 2.36-3.71) and death from TB (OR = 5.16, 95% CI 43.04-5.77).

Conclusions

The prevalence of co-infection with HIV among TB patients is 19% in Brazil. By identifying predictors of co-infection targeted interventions can be developed to prevent both TB and HIV, and to diagnose each disease earlier and ultimately decrease poor treatment outcomes and death.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-415) contains supplementary material, which is available to authorized users.

Treatment outcomes in tuberculosis patients with diabetes: a polytomous analysis using Brazilian surveillance system

BACKGROUND

The impact of non-communicable diseases on tuberculosis incidence has received significant attention. It has been suggested that the risk of tuberculosis is higher among subjects with diabetes and these subjects also has poor TB treatment outcomes.This study was aimed at assessing the socio-demographic and clinical factors that may influence different outcome of TB in patients with DM (TB-DM) identified in the Brazilian national database from 2001 to 2011.

METHODS

TB-DM cases reported in the Brazilian information system were identified and compared.Covariates associated with the outcomes of interest (cure, default, deaths, and development of TB MDR) were included in a hierarchical regression model.

RESULTS

TB-DM cases increased from 380/100,000/year in 2001 to 6,150/100,000/year in 2011. Some of the main associations found are pointed. The odds of default was higher among those in the age group 20-39 years (OR = 2.07, 95%CI 1.32-3.24); alcoholics (OR = 2.17, 95%CI 1.86-2.54), and HIV/AIDS (OR = 2.16, 95%CI 1.70-2.74);positive monitoring smear (OR = 1.94, 95%CI 1.55-2.43); prior default (OR = 5.41, 95%CI 4.47-6.54), and unknown type of treatment (OR = 3.33, 95%CI 1.54-7.22). The odds of death was greater for subjects ≥60 years old (OR = 2.74, 95%CI 1.74-4.29); institutionalized in shelter (OR = 2.69, 95%CI 1.07-6.77); alcoholics (OR = 2.70, 95%CI 2.27-3.22); HIV/AIDS (OR = 2.87, 95%CI 2.13-3.86); pulmonary+extrapulmonary TB (OR = 2.49, 95%CI 1.79-3.46); with unknown type of treatment (OR = 14.12, 95%CI 7.04-28.32).Development of MDR TB was more related to relapse (OR = 9.60, 95%CI 6.07-15.14);previous default (OR = 17.13, 95%CI 9.58-30.63); and transfer of treatment center (OR = 7.87, 95%CI 4.74-13.07).

CONCLUSIONS

Older subjects and those with comorbidities and with a previous treatment of TB had poorest outcomes. TB control program in Brazil will need to expand efforts to focus on treatment of TB-DM patients to improve their cure rates in order to achieve the goals of tuberculosis elimination.

Is there an effect of glucose lowering treatment on incidence and prognosis of tuberculosis? A systematic review

The association between diabetes and incidence of tuberculosis is well established, and observational studies have shown poor treatment outcome in tuberculosis related to hyperglycemia. The WHO recommends screening for diabetes among all patients with tuberculosis and optimized glycemic control aiming at improving tuberculosis outcome. However, no intervention studies support this notion. Patients with tuberculosis are often vulnerable with high degree of comorbidity, and, therefore, at high risk of adverse effects of intensive glucose control. Controlled intervention studies of the effect of glucose lowering treatment on tuberculosis outcomes are clearly warranted to justify screening for- and tight control of diabetes.

Host-pathogen interactions in tuberculosis patients with type 2 diabetes mellitus

Tuberculosis (TB) is known to be fueled by HIV as well as social and economic factors. With progression of the diabetes mellitus (DM) pandemic in countries where TB is also endemic, focus is increasing on the potential links between DM and TB. Despite the magnitude of the DM-TB association worldwide, it is striking how little we know about the underlying biology that promotes this association which is a major concern to public health. In this review we summarize current findings regarding the alterations in the innate and adaptive immune responses of DM patients to Mycobacterium tuberculosis (Mtb). Current findings suggest underperforming innate immunity followed by a hyper-reactive cellular response to Mtb, but the contribution of these altered responses to TB susceptibility or to the more adverse clinical outcomes of TB patients with DM remains unclear. Elucidating the basic mechanisms underlying the higher susceptibility of DM patients to TB should lead to a strategy for stratification of the millions of DM patients worldwide into those with the highest TB risk for targeted TB prevention.

Prevalence and patterns of multimorbidity among tuberculosis patients in Brazil: a cross-sectional study

Introduction

The number of subjects with tuberculosis (TB) presenting with co-occurrence of multiple chronic medical conditions, or multimorbidity (MM) is increasing in Brazil. This manuscript aimed to characterize subjects with TB, according to their MM status and to analyse factors associated with TB treatment outcomes.

Methods

This is a cross-sectional study that included 39,881 TB subjects reported in Brazil, in 2011. MM were defined as any (two or more) occurrence of chronic medical conditions in a TB patient (TB–MM). Data analysis was performed by hierarchical logistic regression models comparing TBMM with those with only TB.

Results

Of the reported TB cases in 2011, 454 (1.14%) had MM. The subjects in the age group 40–59 years (OR: 17.89; 95% CI, 5.71-56.03) and those ≥ 60 years (OR: 44.11; 95% CI, 14.09-138.06) were more likely to develop TB–MM. The TB–MM subjects were less likely to be male (OR: 0.63; 95% CI, 0.52-0.76), institutionalized (OR: 0.59; 95% CI, 0.23-0.80) and live in rural areas (OR: 0.63; 95% CI, 0.42-0.95). Death from causes other than TB was higher among TB–MM subjects (OR: 1.76; 95% CI, 1.36-2.28). Of 454 TB–MM subjects 302 (66.5%) were cured and 152 (33.5%) were not cured. The odds of not being cured was 1.55 (95% CI, 1.04-2.32) among males, 2.85 (95% CI, 1.12-7.28) among institutionalized subjects, and 3.93 (IC 95%, 1.86-8.30) among those who were infected with HIV. TB retreatment after previous abandonment (OR: 7.53; 95% CI, 2.58-21.97) and transfer from a treatment site (OR: 2.76; 95% CI, 1.20-6.38) were higher for subjects not cured compared to those who were cured.

Conclusions

While TB is well recognized to be a disease engendered by social inequity, we found that even among TB patients, those who have MM have greater inequity in terms of socioeconomic status and adverse clinical outcomes. Addressing the problem of TB and TB–MM requires a multisectorial approach that includes health and social service organizations.