Professional Documents
Culture Documents
Diabetes Mellitus and Tuberculosis (Dr. Anthony Harries)
Diabetes Mellitus and Tuberculosis (Dr. Anthony Harries)
Tuberculosis: 2009
14.0 million people living with TB 9.4 million new cases each year 1.7 million people died of TB during the year
[WHO- Global TB Control 2010]
Tuberculosis: 2009
South East Asia 35% Western Pacific 20% Africa 30%
2030
Diabetes mellitus
Jeon CY, Murray MB. Diabetes Mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. PLoS Medicine 2008; 5: e152
Search of PubMed and EMBASE databases: studies reporting age-adjusted quantitative estimate of association between DM and active TB
RESULTS
1,786,212 participants with 17,698 TB cases
DM associated with increased risk of TB [Cohort studies = RR 3.1, 95% CI 2.3 4.3]
[Case control studies = OR 1.2 7.8]
Higher risks in young people and communities with high background TB incidence
India
[Stevenson et al BMC Public Health 2007]
Epidemiological model constructed based on 21M adults with DM and 900,000 new TB cases in 2000 DM accounted for: 15% PTB (7% - 23%) : 20% smear+ve PTB (8% - 42%) Urban areas more affected than rural areas
Diabetes mellitus makes substantial contribution to burden of new TB in India
ALSO:Diabetes Mellitus associated with: Pulmonary microangiopathy Renal failure Increased risk of TB
Micronutrient Deficiency
Objectives of Meeting
1. Discuss an updated systematic review conducted by Harvard University between May Aug 2009, and identify knowledge gaps
2. Develop a prioritised research agenda 3. Decide on policy recommendations
PUBMED, EMBASE, Bibliographies, Conference proceedings from IUATLD in 2007 and 2008
Knowledge gaps:
Little evidence from low-income countries, especially Africa Need more data on the effect of DM control on risk of TB
2. Diagnosis of TB and DM
Two main problems: In patients with TB, DM is not suspected or recognised In patients with DM, TB may present differently and may not be diagnosed
Risk of remaining sputum culture positive after 2-3 months of treatment for DM patients with TB versus non-DM patients with TB
DM positive sputum culture 2-3 months/ Total DM Non-DM positive sputum culture 2-3 months/ Total Non-DM
Study
Country
RR (95% CI)
11/71 (15.5%) 32/93 (34.4%) 14/90 (15.6%) 7/41 (17.1%) 8/69 (11.6%)
33/449 (7.3%) 43/301 (14.3%) 16/334 (4.8%) 68/372 (18.3%) 10/68 (14.7%) 13/85 (15.3%) 88/262 (33.6%) 50/163 (30.7%)
2.11 (1.12, 3.98) 2.41 (1.62, 3.57) 3.25 (1.65, 6.40) 0.93 (0.46, 1.90) 0.79 (0.33, 1.88) 2.01 (0.77, 5.24) 2.17 (1.69, 2.78) 0.98 (0.54, 1.77)
Alisjahbana (2007) Indonesia Banu Rekha (2007) India Blanco (2007) Guler (2007)* Dooley (2009)
Canary Islands,Spain 4/13 (30.8%) Turkey USA 32/44 (72.7%) 9/30 (30%)
.3
Country
Japan 3/71 (4.2%) 3/32 (9.4%) 4/50 (8.0%) 1/40 (2.5%) 5/56 (8.9%) 7/50 (14%) 2/40 (5%) 13/22 (59.1%) 8/18 (44.4%) 8/32 (25%) 34/172 (19.8%) 5/20 (25%) 8/44 (18.2%) 8/73 11.0%) 14/449 (3.1%) 29/746 3.9%) 19/773 (2.5%) 43/667 (6.4%) 49/1044 (4.7%) 1/105 (0.95%) 26/852 (3.1%) 29/152 (19.1%) 14/108 (13.0%) 8/100 (8%) 61/409 (14.9%) 87/440 19.8%) 175/1872 (9.3%) 97/1438 (6.7%) 3/383 (0.8%) 0/540 (0%) 86/537 (16.0%) 112/1022 (11%) 6/44 (13.6%) 137/886 (15.5%) 20/255 (7.8%) 0/82 (0%) 11/143 (7.7%)
1.36 (0.40, 4.60) 2.41 (0.78, 7.50) 3.25 (1.15, 9.20) 0.39 (0.05, 2.74) 1.90 (0.79, 4.59) 14.70 (1.86, 116.27) 1.64 (0.40, 6.66) 3.10 (1.92, 4.99) 3.43 (1.68, 6.98) 3.13 (1.28, 7.65) 1.33 (0.91, 1.94) 1.26 (0.58, 2.76) 1.94 (1.02, 3.70) 1.62 (0.82, 3.21) 0.95 (0.10, 9.08) 28.47 (1.38, 588.46) 1.49 (0.99, 2.26) 1.07 (0.78, 1.48) 3.67 (1.23, 10.93) 1.40 (1.05, 1.86) 1.82 (0.78, 4.27) 7.16 (0.35, 146.29) 2.28 (1.08, 4.85) 1.85 (1.50, 2.28)
Ambrosetti (1995 Report) Italy Ambrosetti (1996 Report) Italy Ambrosetti (1997 Report) Italy Centis (1998 Report) Bashar (2001) Centis (1999 Report) Fielder (2002) Oursler (2002) Mboussa (2003) Ponce d Leon (2004) Kourbatova (2006) Mathew (2006) Pina (2006) Singla (2006) Alisjahbana (2007) Vasankari (2007) Fisher-Hoch (2008) Hasibi (2008) Chiang (2009) Dooley (2009) Maalej (2009) Wang (2009) Italy USA Italy USA USA Congo Mexico Russia Russia Spain
Saudi Arabia 1/134 (0.7%) Indonesia Finland USA Iran Taiwan USA Tunisia Taiwan 2/94 (2.1%) 22/92 (23. 9%) 46/391 (11.8%) 3/6 (50.0%) 52/241 (21.6%) 6/42 (14.3%) 2/57 (3.5%) 13/74 (17.6%)
Summary Heterogeneity I-squared = 44% (9, 66) Weights are from random effects analysis .3 1 1.85 7
Adjusted odds of death for diabetic patients with TB compared to non-diabetic patients with TB
[adjusted for age and other confounders]
Study
Country
OR (95% CI)
Fielder (2002)
USA
8/18 (44.4%)
14/108 (13.0%)
6/42 (14.3%)
20/255 (7.8%)
Wang (2009)
Taiwan
Summary
4.95
15
40
Study
Country
RR (95% CI)
Wada, 2000
Japan
7/61 (11%)
4/284 (1%)
6/17 (35%)
9/77 (12%)
Singla, 2006
3/367 (1%)
Maalej, 2009
Tunisia
4/55 (7%)
1/82 (1%)
Zhang, 2009
China
33/165 (20%)
9/170 (5%)
Summary
Heterogeneity I-squared = 0% (0,79) Weights are from random effects analysis .3 1 3.89 15 60
4. Preventing TB in DM
Two observational studies in 1958 and 1969 showing that isoniazid prophylaxis in DM patients reduces risk of TB Knowledge gaps:
Very poorly conducted studies and therefore evidence base still weak
Proportion of TB burden attributable to some major risk factors in high TB burden countries
Relative risk for active TB disease
HIV infection Malnutrition Diabetes Alcohol use (>40g / d) Active smoking Indoor Air Pollution
PAF
P RR 1 P RR 1 1
Sources: Lnnroth K, Castro K, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, Raviglione M. Tuberculosis control 2010 2050: cure, care and social change. Lancet 2010 DOI:10.1016/s0140-6736(10)60483-7.
3. Policy Recommendations
The recommendations