Mortality among hospitalised HIV-negative TB patients was extremely high in poor urban areas in the Philippines.
Diabetes and undernutrition are common risk factors for tB, associated with poor treatment outcomes and exacerbated by tB. We aimed to assess non-communicable multimorbidity (co-occurrence of two or more medical conditions) in filipino tB outpatients, focusing on malnutrition and diabetes. in a crosssectional study, 637 adults (70% male) from clinics in urban Metro Manila (N = 338) and rural Negros occidental (n = 299) were enrolled. Diabetes was defined as HbA1c of ≥6.5% and/or current diabetes medication. Study-specific HIV screening was conducted. The prevalence of diabetes was 9.2% (54/589, 95%CI: 7.0-11.8%) with 52% newly diagnosed. Moderate/severe undernutrition (body mass index (BMi) <17 kg/ 2) was 20.5% (130/634, 95%CI: 17.4-23.9%). Forty percent of participants had at least one co-morbidity (diabetes, moderate/severe undernutrition or moderate/severe anaemia (haemoglobin <11 g/dL)). HIV infection (24.4%, 74/303) was not associated with other co-morbidities (but high refusal in rural clinics). central obesity assessed by waist-to-hip ratio was more strongly associated with diabetes (Adjusted odds Ratio (AoR) = 6.16, 95%CI: 3.15-12.0) than BMI. Undernutrition was less common in men (AoR = 0.44, 95%CI: 0.28-0.70), and associated with previous history of TB (AoR = 1.97, 95%CI: 1.28-3.04) and recent reduced food intake. The prevalence of multimorbidity was high demonstrating a significant unmet need. HIV was not a risk factor for increased non-communicable multimorbidity.
Bacterial co-infection is common and contributes to an increased risk of early mortality among HIV-negative PTB patients.
Background The Philippines is ranked 3 rd globally for tuberculosis incidence (554/100,000 population). The tuberculosis ward at San Lazaro Hospital, Manila receives 1,800–2,000 admissions of acutely unwell patients per year with high mortality. Objectives of this prospective cohort study were to quantify the association of under-nutrition (primary) and diabetes (secondary) with inpatient mortality occurring between 3–28 days of hospital admission in patients with suspected or previously diagnosed TB. Methods and results We enrolled 360 adults (≥18 years); 348 were eligible for the primary analysis (alive on day 3). Clinical, laboratory, anthropometric and enhanced tuberculosis diagnostic data were collected at admission with telephone tracing for mortality up to 6 months post-discharge. In the primary analysis population (mean age 45 years, SD = 15.0 years, 70% male), 58 (16.7%) deaths occurred between day 3–28 of admission; 70 (20.1%) between day 3 and discharge and documented total post-day 3 mortality including follow-up was 96 (27.6%). In those in whom it could be assessed, body mass index (BMI) ranged from 11.2–30.6 kg/m 2 and 141/303 (46.5%) had moderate/severe undernutrition (BMI<17 kg/m 2 ). A sex-specific cut-off for mid-upper arm circumference predictive of BMI<17 kg/m 2 was associated with inpatient Day 3–28 mortality in males (AOR = 5.04, 95% CI: 1.50–16.86; p = 0.009; p = 0.032 for interaction by sex). The inability to stand for weight/height for BMI assessment was also associated with mortality (AOR = 5.59; 95% CI 2.25–13.89; p<0.001) as was severe compared to normal/mild anaemia (AOR = 9.67; 95% CI 2.48–37.76; p<0.001). No TB specific variables were associated with Day 3–28 mortality, nor was diabetes (HbA1c ≥6.5% or diabetes treatment). Similar effects were observed when the same multivariable model was applied to confirmed TB patients only and to the outcome of all post-day 3 in-patient mortality. Conclusion This research supports the use of mid-upper arm circumference for triaging acutely unwell patients and the design and testing of nutrition-based interventions to improve patient outcomes.
Body mass index (BMI) kg/m 2 is a key screening tool for under-nutrition in adults, but difficult to obtain in immobile or unwell patients, particuarly in low resource settings, due to inability to accurately measure both weight and height. Mid-upper arm circumference (MUAC) is used to assess under-nutrition in children under 5 years but no standardised cut-off values exist for adults. In a cohort of adult Filipino patients admitted to a tuberculosis ward we assessed (i) cut-offs for MUAC to predict moderate under-nutrition (BMI <17kg/m 2 ), (ii) the performance of limb lengths to predict height and; (iii) associations of body fat percentage from skinfolds and hand grip-strength with BMI. In 303 patients with MUAC and BMI at admission, aged 18–80 years (mean = 45.5, SD:14.8), BMI ranged from 11.2–30.6 kg/m 2 and 141 (46.5%) had BMI <17.0 kg/m 2 . Using receiver operator curves, MUAC cut-offs were identified as <20.5cm for males (sensitivity: 89%, specificity: 84%) and <18.5cm for females (sensitivity: 91%, specificity: 89%), for BMI<17.0 kg/m 2 . Using published equations, knee height had the lowest mean difference between predicted and measured heights compared to ulnar or demi-span: (-0.98 cm, 95% CI: -1.51/-0.44). Both grip-strength and body fat percentage were positively associated with BMI, in separate linear regression models with exposure-age-sex interactions (adjusted-R-squared values: 0.15, 0.66, respectively). MUAC can predict moderate acute under-nutrition with high positive predictive value. Further research is required to determine the performance of alternative measures to BMI to predict mortality or adverse outcomes in acutely unwell patients.
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