Is resistance to anti-tuberculosis drugs associated with type 2 diabetes mellitus? A register review in Beijing, China

Drug resistance in drug-resistant tuberculosis patients with and without diabetes mellitus: a comparative analysis

BACKGROUND

This dual burden of tuberculosis (TB) and diabetes mellitus (DM) has become a global public health concern. This study aims to compare drug resistance in drug-resistant tuberculosis (DR-TB) patients with and without DM and analyse the risk factors of multidrug-resistant tuberculosis (MDR-TB).

METHODS

A total of 893 DR-TB patients were admitted to Wenzhou Central Hospital between January 2018 and December 2022. After excluding 178 cases with incomplete clinical and laboratory data, 715 patients were included in the study. These patients were then categorized into two groups based on the presence of type 2 DM: the DM group (160 cases) and the non-DM group (555 cases). Demographic information, baseline clinical characteristics, laboratory and imaging test results, clinical diagnoses, and other relevant data were collected for analysis. Statistical analysis was conducted on demographic information, clinical parameters, drug resistance spectrum, and risk factors for multidrug resistance.

RESULTS

In both the DM and non-DM groups, the order of resistance to first-line anti-tuberculosis drugs is isoniazid, streptomycin, rifampicin, and ethambutol. There is no significant difference in the proportion of mono-resistant tuberculosis, polydrug-resistant tuberculosis, and multidrug-resistant tuberculosis between the two groups (P > 0.05). The prevalence of MDR-TB in both groups shows a downward trend between 2018 and 2022, but the trend is not statistically significant (P > 0.05). Among patients without DM, residence in rural areas, retreatment of tuberculosis, pulmonary cavity, and uric acid ≥ 346 µmol/L are identified as independent risk factors for MDR-TB. Among patients with DM, residence in rural areas, retreatment of tuberculosis, pulmonary cavity, and HbA1c ≥ 9.8% were identified as independent risk factors for MDR-TB.

CONCLUSION

Isoniazid is the most resistant drug among DR-TB patients with and without DM. There is no statistically significant difference in drug resistance patterns between the two groups. Some progress has been made in the prevention and control of DR-TB in this area, but the effect is not very significant. There are differences in the risk factors of MDR-TB between patients with and without DM.

Mutational Dynamics Related to Antibiotic Resistance in M. tuberculosis Isolates from Serial Samples of Patients with Tuberculosis and Type 2 Diabetes Mellitus

Genetic variation in tuberculosis is influenced by the host environment, patients with comorbidity, and tuberculosis-type 2 diabetes mellitus (TB-T2DM) and implies a higher risk of treatment failure and development of drug resistance. Considering the above, this study aimed to evaluate the influence of T2DM on the dynamic of polymorphisms related to antibiotic resistance in TB. Fifty individuals with TB-T2DM and TB were initially characterized, and serial isolates of 29 of these individuals were recovered on day 0 (diagnosis), 30, and 60. Genomes were sequenced, variants related to phylogeny and drug resistance analyzed, and mutation rates calculated and compared between groups. Lineage X was predominant. At day 0 (collection), almost all isolates from the TB group were sensitive, apart from four isolates from the TB-T2DM group showing the mutation katG S315T, from which one isolate had the mutations rpoB S450L, gyrA A90G, and gyrA D94G. This pattern was observed in a second isolate at day 30. The results provide a first overview of the dynamics of mutations in resistance genes from individuals with TB-T2DM, describing an early development of resistance to isoniazid and a rapid evolution of resistance to other drugs. Although preliminary, these results help to explain the increased risk of drug resistance in individuals with TB and T2DM.

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

Background

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

Aim

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

Methodology

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

Results

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

Conclusion

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

Prevalence and factors associated with diabetes mellitus among tuberculosis patients in South India-a cross-sectional analytical study

OBJECTIVE

To determine the prevalence and determinants of diabetes mellitus (DM) among tuberculosis (TB) patients and to assess the additional yield and number needed to screen (NNS) to obtain a newly diagnosed DM among TB patients.

DESIGN

We undertook a cross-sectional analysis of the cohort data under Regional Prospective Observational Research for Tuberculosis-India consortium. Newly diagnosed TB patients recruited into the cohort between 2014 and 2018 were included. Pretested standardised questionnaires and tools were used for data collection. Prevalence of DM among TB patients was summarised as proportion with 95% CI. Type II DM was diagnosed if random blood sugar level was >200 mg/dL or if the participant had a documented history of DM. NNS by blood glucose testing to diagnose one new DM case among TB patients was also calculated.

SETTING

Three districts of South India: Puducherry, Cuddalore and Villupuram SUBJECTS: Newly diagnosed sputum smear positive pulmonary TB patients aged ≥16 years RESULTS: In total, 1188 TB patients were included. Prevalence of DM among TB patients was 39% (95% CI: 36.2% to 41.8%). In unadjusted analysis, elderly TB, marital status, caste, gender, higher education level, household income and obesity had a significant association with DM. However, in adjusted analysis, only marital status (currently married aPR; 3.77 (95 CI: 2.20 to 6.49), widowed/separated/divorced aPR; 3.66 (95 CI: 1.96 to 6.83)) and body mass index category (normal weight aPR; 3.26 (95 CI: 2.55 to 4.16), overweight aPR; 3.86 (95 CI: 2.69 to 5.52), obesity aPR; 4.08 (95 CI: 2.81 to 5.94)) were found to be significant determinants. The number of TB patients needed to be screened to find a new DM case was 12.

CONCLUSION

We found that one in three TB patients had coexisting DM. The number of TB patients needed to be screened to obtain a newly diagnosed DM patients was also determined. The study supports and highlights the need of RNTCP's effort in bidirectional screening of TB and DM.

Diabetes comorbidities in low- and middle-income countries: An umbrella review

Background

Diabetes mellitus, particularly type 2 diabetes, is a major public health burden globally. Diabetes is known to be associated with several comorbidities in high-income countries. However, our understanding of these associations in low- and middle-income countries (LMICs), where the epidemiological transition is leading to a growing dual burden of non-communicable and communicable disease, is less clear. We therefore conducted an umbrella review to systematically identify, appraise and synthesise reviews reporting the association between diabetes and multiple key comorbidities in LMICs.

Methods

We searched Medline, Embase, Global Health, and Global Index Medicus from inception to 14 November 2020 for systematic reviews, with or without meta-analyses, of cohort, case-control or cross-sectional studies investigating the associations between diabetes and cardiovascular disease (CVD), chronic kidney disease (CKD), depression, dengue, pneumonia, and tuberculosis within LMICs. We sought reviews of studies focused on LMICs, but also included reviews with a mixture of high-income and at least two LMIC studies, extracting data from LMIC studies only. We conducted quality assessment of identified reviews using an adapted AMSTAR 2 checklist. Where appropriate, we re-ran meta-analyses to pool LMIC study estimates and conduct subgroup analyses.

Results

From 11 001 articles, we identified 14 systematic reviews on the association between diabetes and CVD, CKD, depression, or tuberculosis. We did not identify any eligible systematic reviews on diabetes and pneumonia or dengue. We included 269 studies from 29 LMICs representing over 3 943 083 participants. Diabetes was positively associated with all comorbidities, with tuberculosis having the most robust evidence (16 of 26 cohort studies identified in total) and depression being the most studied (186 of 269 studies). The majority (81%) of studies included were cross-sectional. Heterogeneity was substantial for almost all secondary meta-analyses conducted, and there were too few studies for many subgroup analyses.

Conclusions

Diabetes has been shown to be associated with several comorbidities in LMICs, but the nature of the associations is uncertain because of the large proportion of cross-sectional study designs. This demonstrates the need to conduct further primary research in LMICs, to improve, and address current gaps in, our understanding of diabetes comorbidities and complications in LMICs.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of polymorphisms at -174 in IL-6, and -308 and -238 in TNF-α, in the development of tuberculosis and type 2 diabetes mellitus in the Mexican population

Polymorphisms at -176 in IL-6, and -238 and -308 in TNF-α have been described as risk factors for developing tuberculosis (TB) and type 2 diabetes mellitus (T2DM). However, it is not known how these changes influence the development of TB-T2DM comorbidity. The objective of this work was therefore to analyze the impact of these polymorphisms in the Mexican population. This is a cross-sectional study of cases and controls in which polymorphisms at -174 in IL-6, -238 and -308 in TNF-α were identified in healthy subjects, those with TB, T2DM and carriers of the comorbidity, each group consisted of 30 individuals. Descriptions of the population, frequency of genotypes and risk association were calculated, and a reduction of multifactorial dimensionality between groups (MDR) was determined. Genotype 174 G/G-of IL-6 was observed in 78% of individuals, while -308 G/G and -238 G/G of TNF-α occurred in 90% and 91% of individuals, respectively. The -174 G/G IL-6 in individuals with T2DM increased five-fold (p = .02) the risk of developing the comorbidity. The MDR analysis showed that the association of -174 G/G IL-6 and -308 G/G TNF-α in healthy individuals increased the risk of developing the comorbidity up to six-fold (p = .019), while in individuals with T2DM, this risk augmented 14-fold (p = .0002). The -174 G/G IL-6 genotype increases the risk of developing comorbidity in the T2DM population and this risk is raised when associated with -308 G/G TNF-α. These findings have implications for understanding the epidemiological dynamics of the TB-T2DM comorbidity, promoting prevention strategies and inhibiting the development of this co-morbidity.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016045692 .

Primary multidrug-resistant tuberculosis versus drug-sensitive tuberculosis in non-HIV-infected patients: Comparisons of CT findings

Background

Multidrug-resistant tuberculosis has emerged as a global threat. The aim of this work was to compare the CT findings of primary multidrug-resistant tuberculosis and drug-sensitive tuberculosis in non-AIDS adults.

Material and methods

From January 2012 to February 2016, 89 patients with primary multidrug-resistant tuberculosis were retrospectively reviewed, and 89 consecutive drug sensitive TB patients with no history of anti-tuberculous chemotherapy from January 2014 to November 2014 were enrolled as control group. All patients were seronegative for HIV. The patients’ demographic data and the locations, frequency and patterns of lung lesions on chest CT were compared.

Results

Gender and frequency of diabetes were similar between the two groups. The mean age of primary multidrug-resistant tuberculosis patients was younger than that of drug-sensitive tuberculosis (39.0 vs 47.5, P = 0.005). Lung cavitary nodules or masses were more frequently observed and also showed greater extent in primary multidrug-resistant tuberculosis compared with drug-sensitive tuberculosis. The extent of bronchiectasis was significantly greater in primary multidrug-resistant tuberculosis than in drug-sensitive tuberculosis. Calcification, large nodules and calcified lymph nodes were more frequent in drug-sensitive tuberculosis.

Conclusion

Characteristic chest CT findings may help differentiate between primary multi-drug resistant tuberculosis and drug-sensitive tuberculosis in patients without HIV infection.

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

The high prevalence of diabetes mellitus (DM) among multidrug resistant tuberculosis (MDR-TB) patients is a serious cause for concern. We conducted a meta-analysis to determine whether DM is an independent risk factor for MDR-TB. Electronic literature searches of the PubMed, Web of Science and EMBASE databases up to July 12, 2016 were conducted. The pooled adjusted odds ratio (OR) and 95% confidence intervals (CIs) were calculated using the random effects model with STATA 12.0 software. In total 13 studies, including 9289 individuals with TB, were included in this meta-analysis. Significant association between DM and MDR-TB (OR = 1.71; 95% CI = 1.32, 2.22) was identified. Subgroup analyses showed that: 1) Pooled OR was 1.25 (95% CI: 0.82-1.91) for cross-sectional studies, and was 2.14 (95% CI: 1.51-3.02) for longitudinal studies; 2) The pooled OR was 1.69 (95% CI:1.09-2.62) for primary MDR-TB, 1.94 (95% CI:1.42-2.65) for any MDR-TB, and 0.85 for secondary MDR-TB (95% CI: 0.29-2.54); 3) DM was significantly associated with MDR-TB in both Caucasian (OR = 2.26, 95% CI: 1.66-3.07) and Asian (OR = 1.40, 95% CI: 1.01-1.95) subgroups. No evidence of publication bias was identified. In conclusion, the pooling analysis indicated that DM was an independent risk factor for MDR-TB, especially for primary MDR-TB.

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.

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

INTRODUCTION

Multi-drug-resistant tuberculosis (MDR-TB) has emerged as a challenge to global tuberculosis (TB) control and remains a major public health concern in many countries. Diabetes mellitus (DM) is an increasingly recognized comorbidity that can both accelerate TB disease and complicate its treatment. The aim of this study is to summarize available evidence on the association of DM and MDR-TB among TB patients and to provide a pooled estimate of risks.

METHODS

All studies published in English before October 2016 will be searched using comprehensive search strings through PubMed, EMBASE, Web of Science, and WHO Global Health Library databases which have reported the association of DM and MDR-TB in adults with TB (age > =15). Two authors will independently collect detailed information using structured data abstraction form. The quality of studies will be checked using Newcastle-Ottawa Scale for cohort and case-control studies and the Agency for Healthcare Research and Quality tool for cross-sectional studies. Heterogeneity between included studies will be assessed using the I² statistic. We will check potential publication bias by visual inspection of the funnel plot and Egger's regression test statistic. We will use the random effects model to compute a pooled estimate.

DISCUSSION

Increases in the burden of non-communicable diseases and aging populations are changing the importance of different risk factors for TB, and the profile of comorbidities and clinical challenges for people with TB. Although classic risk factors and comorbidities such as overcrowding, under-nutrition, silicosis, and HIV infection are crucial to address, chronic conditions like diabetes are important factors that impair host defenses against TB. Thus, undertaking integrated multifaceted approach is remarkably necessary for reducing the burden of DM and successful TB treatment outcome.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016045692 .

Diabetes and pulmonary tuberculosis: a global overview with special focus on the situation in Asian countries with high TB-DM burden

BACKGROUND

The double burden of tuberculosis (TB) and diabetes mellitus (DM) is hitting certain Asian countries harder than other areas. In a global estimate, 15% of all TB cases could be attributable to DM, with 40% of those cases coming from India and China. Many other countries of South, East, and South-East Asia are of particular concern given their TB burdens, large projected increases in DM prevalence, and population size.

OBJECTIVE

In this narrative review, we aimed to: (i) give an overall insight into the evidence on TB-DM epidemiology from high double burden Asian countries, (ii) present the evidence on bi-directional screening implementation in this region, (iii) discuss possible factors related to higher TB susceptibility of Asian diabetic patients, and (iv) identify TB-DM comorbidity treatment challenges.

METHODS

The PubMed and Google Scholar databases were searched for all studies addressing DM/TB epidemiology, bi-directional screening and management in South, East and South-East Asia.

RESULTS

We identified the DM prevalences among TB patients as ranging from approximately 5% to more than 50%, whereas TB prevalences among diabetic patients were 1.8-9.5 times higher than in the general population in developing Asian countries. Evidence from studies designed to address diagnosis and treatment of the dual disease in these critical regions is scarce as well as the evidence related to possible DM patients' genetic and acquired predisposition for TB.

CONCLUSION

More prospective studies specifically designed to address adequate screening techniques, identify patients at risk, and define an adequate treatment of dual disease in this region are needed without delay.

Tuberculosis-associated mortality in Shanghai, China: a longitudinal study

Objective

To determine excess mortality in a cohort of people with tuberculosis in Shanghai.

Methods

Participants were local residents in 4 (of 19) districts in Shanghai, registered in one of four tuberculosis clinics between January 1, 2004 and December 31, 2008. Baseline data were collected at the most recent diagnosis of tuberculosis and mortality was assessed between March and May of 2014. We calculated standardized mortality ratios (SMR) and case-fatality rates for all participants and for subgroups. Univariate and multivariate Cox regression models were used to quantify associations between co-morbidities and mortality from all causes and from tuberculosis.

Findings

We registered 4569 subjects in the cohort. Overall, the cohort had an SMR for deaths from all causes of 5.2 (95% confidence interval, CI: 4.8–5.6). Males had a higher SMR than females (6.1 versus 3.0). After adjustment for age and sex, hazard ratios (HR) for deaths from all causes were significantly greater in previously treated people (HR: 1.26; 95% CI: 1.08–1.49) and sputum smear-test positive people (HR: 1.55; 95% CI: 1.35–1.78). The risk of death from tuberculosis was also significantly greater for previously treated people (HR: 1.88; 95% CI: 1.24–2.86) and smear positive people (HR: 3.16; 95% CI: 2.06–4.87).

Conclusion

People with tuberculosis in Shanghai have an increased risk of mortality. Earlier diagnosis and more vigilant follow-up may help to reduce mortality in this group.