The global relationship between the prevalence of diabetes mellitus and incidence of tuberculosis: 2000-2012

The association between type 2 diabetes and pulmonary cavitation revealed among IGRA-positive tuberculosis patients

The co-occurrence of tuberculosis (TB) and diabetes mellitus (DM) presents a significant obstacle to TB eradication. Pulmonary cavitation can occur in severe cases of TB, particularly in patients with DM. From 1 May 2014 through 30 June 2019, we conducted a cross-sectional study of 1,658 smear- or culture-confirmed pulmonary TB (PTB) patients at the Second Department of Pulmonary Medicine and Tuberculosis, Shenzhen, China. A total of 861 participants who satisfied the criteria (chest CT scan for cavitation, interferon-gamma release assay (IGRA), diagnosis of diabetes mellitus), with the median age of 36.7 years, 63.6% of male, 79.7% IGRA positive, 13.8% with diabetes, and 40.8% with pulmonary cavitation, were included in the study. The association between diabetes and pulmonary cavitation was confirmed in these TB patients (adjusted OR, 2.54; 95% CI, 1.66-3.94; p < 0.001). No associations were observed between diabetes and IGRA, as well as between lung cavitary and IGRA. Based on the criteria of IGRA+/-, pulmonary cavitation+/-, and DM+/-, the further analysis with univariate and multivariate logistic regression were conducted in six subgroups. The significant association between diabetes and pulmonary cavitation was further confirmed in the IGRA+ subgroup (adjusted OR, 3.07; 95% CI, 1.86-5.16; p < 0.001) but not observed in IGRA- individuals. This observation suggests that different immunological mechanisms of pulmonary cavitary/DM may be employed in IGRA+ TB patients from IGRA- TB patients.

Prevalence and predictors of tuberculosis infection among people living with HIV in a high tuberculosis burden context

BACKGROUND

Tuberculosis (TB) disease is the leading cause of mortality among people living with HIV (PLHIV). Interferon-gamma release assays (IGRAs) are approved for TB infection ascertainment. However, current IGRA data on the prevalence of TB infection in the context of near-universal access to antiretroviral therapy (ART) and TB preventive therapy (TPT) are lacking. We estimated the prevalence and determinants of TB infection among PLHIV within a high TB and HIV burden context.

METHODS

This cross-sectional study included data from adult PLHIV age ≥18 years in whom QuantiFERON-TB Gold Plus (QFT-Plus) assay, an IGRA, was performed. TB infection was defined as a positive or indeterminate QFT-Plus test. Participants with TB and those who had previously used TPT were excluded. Regression analysis was performed to identify independent predictors of TB infection.

RESULTS

Of 121 PLHIV with QFT-Plus test results, females were 74.4% (90/121), and the mean age was 38.4 (SD 10.8) years. Overall, 47.9% (58/121) were classified as TB infection (QFT-Plus test positive and indeterminate results were 39.7% (48/121) and 8.3% (10/121), respectively). Being obese/overweight (body mass index ≥25 kg/m²; p=0.013, adjusted OR (aOR) 2.90, 95% CI 1.25 to 6.74) and ART usage for >3 years (p=0.013, aOR 3.99, 95% CI 1.55 to 10.28) were independently associated with TB infection.

CONCLUSION

There was a high TB infection prevalence among PLHIV. A longer period of ART and obesity were independently associated with TB infection. The relationship between obesity/overweight and TB infection may be related to ART use and immune reconstitution and requires further investigation. Given the known benefit of test-directed TPT among PLHIV never exposed to TPT, its clinical and cost implications for low and middle-income countries should be explored further.

Prevalence of Diabetes Mellitus and its Related Factors in Patients with Tuberculosis

BACKGROUND

Considering the high prevalence of tuberculosis (TB) in developing countries and the fact that comorbidity with diabetes mellitus (DM) imposes a higher burden on the society, this study was carried out to assess the prevalence of diabetes and its related factors in patients with TB in Mashhad, Iran.

METHODS

In this study, we enrolled 405 patients over the age of 18 who had been diagnosed with TB between the years 2015 and 2016 according to the documents of the ministry of health. The participants were selected randomly from five health center domains based on the stratified sampling method. The patients were screened for diabetes according to HbA1c over 6.5% or a fasting blood sugar (FBS) level over 126 mg/dL at different time points and the patient's self-report of having DM.

RESULTS

The mean age of participants was 51.14±20.52 (19-92 years). The prevalence of DM in patients with TB was 21.2%, of whom 3.5% were newly diagnosed. Among potential factors, age with OR=3.786 (1.183, 12.113), body mass index with OR=9.149 (3.182, 26.302), nationality with OR=2.149 (1.122, 4.117) and TB type with 3.328 (1.44, 7.689) were associated with DM in patients with TB.

CONCLUSION

The prevalence of DM in our study was higher than that observed in other countries. Our study showed associated factors like age, body mass index, and TB type to be very important. Also, the prevalence of DM was different in patients with different nationality.

The cumulative dose-dependent effects of metformin on the development of tuberculosis in patients newly diagnosed with type 2 diabetes mellitus

BACKGROUND

Diabetes mellitus (DM) is a well-known risk factor for tuberculosis (TB). Metformin, which is an essential anti-diabetic drug, has been shown to exhibit anti-TB effects in patients with DM. Its effect on preventing the development of TB among patients who are newly diagnosed with DM remains unclear.

METHODS

This was a retrospective cohort study using the claims database of the Korean Health Insurance Review and Assessment Service. The study population included patients who were newly diagnosed with type 2 DM and who were treated with anti-diabetic drugs between 1 January 2003 and 31 March 2011. A patient was defined as a metformin user if he/she had taken metformin for more than 28 days within 6 months since cohort entry, and as a metformin non-user if he/she had never been treated with metformin. The development of TB within 2 years after the index date was compared by Cox proportional hazard regression models between metformin users and 1:1 propensity score (PS)-matched non-users.

RESULTS

Among 76,973 patients who were newly diagnosed with type 2 DM, 13,396 were classified as metformin users, 52,736 were classified as metformin non-users, and 10,841 were excluded from the final analysis. PS-matched Cox proportional hazard regression models revealed that metformin use was not associated overall with the prevention of TB development (HR 1.17; 95% CI 0.75-1.83; P = 0.482). There was a trend, however, towards a reduction in the development of TB among patients taking a higher cumulative dose of metformin. Patients who were in the highest quartile (Q4) of cumulative metformin dose had only a 10% risk of developing TB compared to metformin non-users. In contrast, during the early phases of metformin treatment, patients in the second quartile (Q2) of cumulative metformin use had a higher risk of developing TB than patients in the first quartile (Q1).

CONCLUSIONS

Only the highest cumulative doses of metformin were protective against the development of TB among patients who were newly diagnosed with type 2 DM; lower cumulative doses of metformin did not appear to reduce the incidence of active TB infection.

Comparative Evaluation of Standard E TB-Feron ELISA and QuantiFERON-TB Gold Plus Assays in Patients with Tuberculosis and Healthcare Workers

Recently, the American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention advised against performing the interferon-γ-release assay (IGRA) test for individuals with a low risk of TB, and also recommended retesting low-risk individuals with an initial positive IGRA result. However, to evaluate both sensitivity and specificity of available tests, we compared the performance of the Standard E TB-Feron (TBF) and QuantiFERON-TB Gold Plus (QFT-Plus) assays in healthcare workers (HCWs) and tuberculosis (TB) patients. We also retrospectively investigated diabetes mellitus (DM) comorbidity among the enrolled TB patients. We prospectively collected samples from 177 HCWs and 48 TB patients. The TBF and QFT-Plus tests were performed and analyzed according to the manufacturers’ instructions. We also defined IGRA results between 0.2 and 0.7 IU/mL as ‘borderline’. The agreement rate between TBF and QFT-Plus was 92.0% (207/225) with a Cohen’s kappa value of 0.77 (95% CI, 0.68–0.87). While the majority (26/31, 83.9%) of borderline TBF results were in HCWs, the majority (14/19, 73.7%) of borderline QFT-Plus results were in TB patients. Discordant results were found in 18 samples, with TBF-positive/QFT-Plus-negative or indeterminate results in 11 HCWs and seven TB patients. After resampling from 10 HCWs (seven borderline-positive and three positive results, all <1.0), six reverted to negative. The prevalence of DM comorbidity was very high (35.4%). In summary, TBF showed substantial agreement with the QFT-Plus assay but had a higher positivity rate in both HCWs and TB patients. The negative conversion rate was high (60%) among HCWs whose initial (TB Ag-nil) result was <1.0.

Artificial neural network to predict the effect of obesity on the risk of tuberculosis infection

BACKGROUND

Body weight has been implicated as a risk factor for latent tuberculosis infection (LTBI) and the active disease.

DESIGN AND METHODS

This study aimed to develop artificial neural network (ANN) models for predicting LTBI from body weight and other host-related disease risk factors. We used datasets from participants of the US-National Health and Nutrition Examination Survey (NHANES; 2012; n=5,156; 514 with LTBI and 4,642 controls) to develop three ANNs employing body mass index (BMI, Network I), BMI and HbA1C (as a proxy for diabetes; Network II) and BMI, HbA1C and education (as a proxy for socioeconomic status; Network III). The models were trained on n=1018 age- and sex-matched subjects equally distributed between the control and LTBI groups. The endpoint was the prediction of LTBI.

RESULTS

When data was adjusted for age, sex, diabetes and level of education, odds ratio (OR) and 95% confidence intervals (CI) for risk of LTBI with increased BMI was 0.85 (95%CI: 0.77 - 0.96, p=0.01). The three ANNs had a predictive accuracy varied from 75 to 80% with sensitivities ranged from 85% to 94% and specificities of approximately 70%. Areas under the receiver operating characteristic curve (AUC) were between 0.82 and 0.87. Optimal ANN performance was noted using BMI as a risk indicator.

CONCLUSION

Body weight can be employed in developing artificial intelligence-based tool to predict LTBI. This can be useful in precise decision making in clinical and public health practices aiming to curb the burden of tuberculosis, e.g., in the management and monitoring of the tuberculosis prevention programs and to evaluate the impact of healthy weight on tuberculosis risk and burden.

Obesity and Prevalence of Latent Tuberculosis: A Population-Based Survey

OBJECTIVE

Diminution in body weight is a known risk factor that increases the burden of active tuberculosis (TB). However, conflicting evidence exists for the effect of body weight on the risk of latent tuberculosis infection (LTBI). The objective of the present study is to examine the prevalence of LTBI at different body weights, evaluate the extent of association between body mass index (BMI) and LTBI and identify factors mediating this relationship in an adult population.

METHODS

We conducted a cross-sectional study to estimate the relationship between BMI and LTBI in participants from the US-National Health and Nutrition Examination Survey (NHANES; 2012, n = 5156; 514 with LTBI and 4642 controls).

RESULTS

The association between BMI and levels of cardiometabolic risk markers in both LTBI and control groups had a similar profile. When adjusted for age and sex, BMI was significantly inversely correlated with the prevalence of LTBI (r = -0.147, P < .001). Effect of BMI on the risk of LTBI was evaluated using multivariate logistic regression models adjusted for age, sex, diabetes, and level of education. In this model, increasing BMI was significantly associated with lower risk of LTBI (OR = 0.85; 95%CI: 0.77-0.96, P < .01).

CONCLUSION

This study further establishes an inverse relationship between BMI and prevalence of LTBI. Decreased BMI can be considered as a risk factor in LTBI, the reservoir for active TB cases.

A stochastic threshold of a delayed epidemic model incorporating Lévy processes with harmonic mean and vaccination

The aim of this paper is to investigate a stochastic threshold for a delayed epidemic model driven by Lévy noise with a nonlinear incidence and vaccination. Mainly, we derive a stochastic threshold [Formula: see text] which depends on model parameters and stochastic coefficients for a better understanding of the dynamical spreading of the disease. First, we prove the well posedness of the model. Then, we study the extinction and the persistence of the disease according to the values of [Formula: see text]. Furthermore, using different scenarios of Tuberculosis disease in Morocco, we perform some numerical simulations to support the analytical results.

Systematic analysis for the relationship between obesity and tuberculosis

OBJECTIVES

Underweight or low body mass index (BMI) is an established risk factor for active tuberculosis. Recent evidence, however, suggests that overweight is associated with lower incidence of tuberculosis. The objective of this systematic review and meta-analysis is to understand the relationship between obesity and tuberculosis and document the extent of association between the two conditions over the range of BMI from underweight to obesity.

METHODS

A comprehensive literature search was conducted to identify studies reporting prevalence of the different BMIs in patients with tuberculosis and controls. Thirty studies of adult humans reporting the incidence of tuberculosis at different weight categories were selected for inclusion for meta-analysis in the present study.

RESULTS

In tuberculosis, the prevalence of underweight was 3-fold higher than that in controls (P = 0.001) whereas the proportion of overweight and obesity was 2-fold lower (P = 0.001). One unit increase in BMI was associated with 2% reduction in tuberculosis incidence (P < 0.001). Adjusted odds ratio of tuberculosis was 4.96 (95% confidence interval: 4.87-5.05) in underweight and 0.26 in obesity.

CONCLUSION

This study further establishes low body weight as a risk factor for tuberculosis whilst overweight and obesity are associated with lower disease risk. Body weight can be considered as a prognostic indictor in the clinical course of tuberculosis.

Geographic Variation and Associated Covariates of Diabetes Prevalence in India

IMPORTANCE

Diabetes is a severe metabolic disorder affecting human health worldwide, with increasing prevalence in low- and middle-income countries. Gaps in knowledge regarding factors that lead to diabetes and its association with tuberculosis (TB) endemicity at the national scale still exist, mainly because of the lack of large-scale dual testing and appropriate evaluation methods.

OBJECTIVES

To identify locations in India where diabetes prevalence is concentrated, examine the association of diabetes with sociodemographic and behavioral covariates, and uncover where high regional TB endemicity overlaps with diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 803 164 men aged 15 to 54 years and women aged 15 to 49 years who participated in the Demographic Health Survey (2015-2016), carried out by the India Ministry of Health and Family Welfare using a 2-stage clustered sampling, which included a diabetes estimation component. The survey was conducted from January 2015 to December 2016, and data analysis was conducted from July 2018 to January 2019.

EXPOSURES

Self-reported diabetes status.

MAIN OUTCOMES AND MEASURES

Self-reported diabetes status was used to estimate the association of covariates, including educational level, sex, age, religion, marital status, alcohol use, tobacco use, obesity status, and household socioeconomic level, with diabetes prevalence. Additionally, regional tuberculosis endemicity level, estimated using the India TB report for 2014 from the Revised National TB Program, was included to evaluate the national extent of the spatial overlap of diabetes and TB.

RESULTS

Among 803 164 sampled individuals (691 982 [86.2%] women; mean [SD] age, 30.09 [9.97] years), substantial geographic variation in diabetes prevalence in India was found, with a concentrated burden at the southern coastline (cluster 1, Andhra Pradesh and Telangana: prevalence, 3.01% [1864 of 61 948 individuals]; cluster 2, Tamil Nadup and Kerala: prevalence, 4.32% [3429 of 79 435 individuals]; cluster 3, east Orissa: prevalence, 2.81% [330 of 11 758 individuals]; cluster 4, Goa: prevalence, 4.43% [83 of 1883 individuals]). Having obesity and overweight (odds ratio [OR], 2.44; 95% CI, 2.18-2.73; P < .001; OR, 1.66; 95% CI, 1.52-1.82; P < .001, respectively), smoking tobacco (OR, 3.04; 95% CI, 1.66-5.56; P < .001), and consuming alcohol (OR, 2.01; 95% CI, 1.37-2.95; P < .001) were associated with increased odds of diabetes. Regional TB endemicity and diabetes spatial distributions showed that there is a lack of consistent geographical overlap between these 2 diseases (eg, TB cluster 4: 60 213 TB cases; 186.79 diabetes cases in 20 183.88 individuals; 0.93% diabetes prevalence; TB cluster 8: 47 381 TB cases; 180.53 diabetes cases in 22 449.18 individuals; 0.80% diabetes prevalence; TB cluster 9: 37 620 TB cases, 601.45 diabetes cases in 12 879.36 individuals; 4.67% diabetes prevalence).

CONCLUSIONS AND RELEVANCE

In this study, identifying spatial clusters of diabetes on the basis of a nationally representative survey suggests that India may face different levels of disease severity, and each region might need to implement control strategies that are more appropriate for its unique epidemiologic context.

Detrimental association between diabetes and tuberculosis: An unresolved double trouble

Despite significant efforts made to control tuberculosis (TB) through DOTS program, the increasing burden of diabetes mellitus (DM) threatens the progress in reducing TB-related mortality, particularly in developing countries. In recent years, TB-DM comorbidity continues to remain high in countries where DM is on rampant. DM increases the risk of TB, reactivates the dormant TB and worsens the TB treatment outcome. The present review highlights the current findings regarding the prevalence and association of TB-DM comorbidity along with their public health implications. This review will increase the awareness among researchers, policymakers and clinicians, regarding the current scenario of TB-DM association.

Tuberculosis and viral hepatitis infection in Eastern Europe, Asia, and Latin America: impact of tumor necrosis factor-α inhibitors in clinical practice

Tumor necrosis factor-α (TNF-α) inhibitors are increasingly becoming the standard of care for treating a number of inflammatory diseases. However, treatment with TNF-α inhibitors carries an inherent risk of compromising the immune system, resulting in an increased susceptibility to infections and malignancies. This increased risk of infection is of particular concern in Asia, Eastern Europe, and Latin America where tuberculosis (TB) and viral hepatitis are endemic. In this brief review, we examine the literature and review the impact of TNF-α inhibitors on the incidence and the reactivation of latent disease with respect to TB, hepatitis C infection, and hepatitis B infection. Our findings show that TNF-α inhibitors are generally safe, if used with caution. Patients should be screened prior to the initiation of TNF-α inhibitor treatment and given prophylactic treatment if needed. In addition, patients should be monitored during treatment with TNF-α inhibitors and after treatment has stopped to ensure that infections, if detected, are treated promptly and effectively. Our analysis is consistent with other reports and guidelines.

Metabolic relationship between diabetes and Alzheimer's Disease affected by Cyclo(His-Pro) plus zinc treatment

BACKGROUND

Association of Alzheimer's Disease (AD) with Type 2 Diabetes (T2D) has been well established. Cyclo(His-Pro) plus zinc (Cyclo-Z) treatment ameliorated diabetes in rats and similar improvements have been seen in human patients. Treatment of amyloid precursor protein (APP) transgenic mice with Cyclo-Z exhibited memory improvements and significantly reduced Aβ-40 and Aβ-42 protein levels in the brain tissues of the mice.

SCOPE OF REVIEW

Metabolic relationship between AD and T2D will be described with particular attention to insulin sensitivity and Aβ degradation in brain and plasma tissues. Mechanistic effect of insulin degrading enzyme (IDE) in decreasing blood glucose and brain Aβ levels will be elucidated. Cyclo-Z effects on these biochemical parameters will be discussed.

MAJOR CONCLUSION

Stimulation of IDE synthesis is effective for the clinical treatment of metabolic diseases including AD and T2D.

GENERAL SIGNIFICANCE

Cyclo-Z might be the effective treatment of AD and T2D by stimulating IDE synthesis.

Metabolic relationship between diabetes and Alzheimer's Disease affected by Cyclo(His-Pro) plus zinc treatment

BACKGROUND

Association of Alzheimer's Disease (AD) with Type 2 Diabetes (T2D) has been well established. Cyclo(His-Pro) plus zinc (Cyclo-Z) treatment ameliorated diabetes in rats and similar improvements have been seen in human patients. Treatment of amyloid precursor protein (APP) transgenic mice with Cyclo-Z exhibited memory improvements and significantly reduced Aβ-40 and Aβ-42 protein levels in the brain tissues of the mice.

SCOPE OF REVIEW

Metabolic relationship between AD and T2D will be described with particular attention to insulin sensitivity and Aβ degradation in brain and plasma tissues. Mechanistic effect of insulin degrading enzyme (IDE) in decreasing blood glucose and brain Aβ levels will be elucidated. Cyclo-Z effects on these biochemical parameters will be discussed.

MAJOR CONCLUSION

Stimulation of IDE synthesis is effective for the clinical treatment of metabolic diseases including AD and T2D.

GENERAL SIGNIFICANCE

Cyclo-Z might be the effective treatment of AD and T2D by stimulating IDE synthesis.

The global dynamics of diabetes and tuberculosis: the impact of migration and policy implications

The convergence between tuberculosis (TB) and diabetes mellitus (DM) will represent a major public health challenge in the near future. DM increases the risk of developing TB by two to three times and also increases the risk of TB treatment failure, relapse, and death. The global prevalence of DM is predicted to rise significantly in the next two decades, particularly in some of the low- and middle-income countries with the highest TB burden. Migration may add further complexity to the effort to control the impact on TB of the growing DM pandemic. Migration may increase the risk of DM, although the magnitude of this association varies according to country of origin and ethnic group, due to genetic factors and lifestyle differences. Migrants with TB may have an increased prevalence of DM compared to the native population, and the risk of TB among persons with DM may be higher in migrants than in autochthonous populations. Screening for DM among migrants, screening migrants with DM for active and latent TB, and improving access to DM care, could contribute to mitigate the effects of DM on TB.

Association between diabetes mellitus and active tuberculosis in Africa and the effect of HIV

OBJECTIVE

To determine current evidence for the association between diabetes and active tuberculosis in Africa, and how HIV modifies, or not, any association between diabetes and active tuberculosis.

METHODS

We conducted a systematic review by searching the EMBASE, Global Health and MEDLINE databases. Studies were eligible for inclusion if they explored the association between diabetes mellitus prevalence and active tuberculosis incidence or prevalence, used a comparison group, were conducted in an African population and adjusted the analysis for at least age. Study characteristics were compared, and risk of bias was assessed. The range of effect estimates was determined for the primary association and for effect modification by HIV.

RESULTS

Three eligible studies were identified: two investigated the primary association and two investigated HIV as a potential effect modifier. All studies were case-control studies, including a combined total of 1958 tuberculosis cases and 2111 non-tuberculosis controls. Diabetes diagnostic methods and analysis strategies varied between studies. Individual study adjusted odds ratios of active tuberculosis for the effect of diabetes mellitus (unstratified) ranged from 0.88 (95% CI 0.17-4.58) to 10.7 (95% CI 4.5-26.0). Individual study P-values for HIV interaction ranged from 0.01 to 0.83. Quantitative synthesis of individual study data was not performed due to heterogeneity between studies.

CONCLUSIONS

Few data currently exist on the association between diabetes and active tuberculosis in Africa, and on the effect of HIV on this association. Existing data are disparate. More regional research is needed to guide policy and practice on the care and control of tuberculosis and diabetes in Africa.

Prevalence of Diabetes in the 2009 Influenza A (H1N1) and the Middle East Respiratory Syndrome Coronavirus: A Systematic Review and Meta-Analysis

Over the past two decades a number of severe acute respiratory infection outbreaks such as the 2009 influenza A (H1N1) and the Middle East respiratory syndrome coronavirus (MERS-CoV) have emerged and presented a considerable global public health threat. Epidemiologic evidence suggests that diabetic subjects are more susceptible to these conditions. However, the prevalence of diabetes in H1N1 and MERS-CoV has not been systematically described. The aim of this study is to conduct a systematic review and meta-analysis of published reports documenting the prevalence of diabetes in H1N1 and MERS-CoV and compare its frequency in the two viral conditions. Meta-analysis for the proportions of subjects with diabetes was carried out in 29 studies for H1N1 (n=92,948) and 9 for MERS-CoV (n=308). Average age of H1N1 patients (36.2±6.0 years) was significantly younger than that of subjects with MERS-CoV (54.3±7.4 years, P<0.05). Compared to MERS-CoV patients, subjects with H1N1 exhibited 3-fold lower frequency of cardiovascular diseases and 2- and 4-fold higher prevalence of obesity and immunosuppression, respectively. The overall prevalence of diabetes in H1N1 was 14.6% (95% CI: 12.3-17.0%; P<0.001), a 3.6-fold lower than in MERS-CoV (54.4%; 95% CI: 29.4-79.5; P<0.001). The prevalence of diabetes among H1N1 cases from Asia and North America was ~two-fold higher than those from South America and Europe. The prevalence of diabetes in MERS-CoV cases is higher than in H1N1. Regional comparisons suggest that an etiologic role of diabetes in MERS-CoV may exist distinctive from that in H1N1.