Defining a Research Agenda to Address the Converging Epidemics of Tuberculosis and Diabetes

Abstract

There is growing interest in the interaction between type 2 diabetes mellitus (DM) and TB, but many research questions remain unanswered. Epidemiologists, basic scientists, and clinical experts recently convened and identified priorities. This is the first of two reviews on this topic, summarizing priority areas of research regarding epidemiology, clinical management, and public health. First, from an epidemiologic point of view, more study is needed to determine the importance of transient hyperglycemia in patients with TB and on the importance of DM for the global epidemic of multidrug resistant (MDR)-TB. Second, regarding the screening and clinical management of combined TB and DM (TB-DM), clinical trials and large cohort studies should examine the benefits of improved DM care as well as prolonged or intensified TB treatment on the outcome of TB-DM and investigate the cost-effectiveness of screening methods for DM among patients newly diagnosed with TB. Third, from a public health and health systems point of view, the population health impact and cost-effectiveness of different interventions to prevent or treat DM and TB in high-burden populations should be examined, and health-system interventions should be developed for routine TB-DM screening, management of DM after completion of TB treatment, and better access to DM services worldwide. Studies are needed across different ethnicities and settings given the heterogeneity of metabolic perturbations, inflammatory responses, medications, and access to health care. Finally, studies should address interactions between TB, DM, and HIV because of the convergence of epidemics in sub-Saharan Africa and some other parts of the world.

The burden of common infections in children and adolescents with diabetes mellitus: A Pediatric Health Information System study

“…Similar to adults, the PHIS database shows that children and adolescents with DM routinely seek medical attention for respiratory infections, skin and soft tissue infections, UTI, and gastrointestinal infections. Prior studies suggest that both common and uncommon infections are prevalent among patients with DM . The following paragraph briefly reviews the infectious etiologies of these 4 common infections in people with DM.…”

Epidemiological, clinical and mechanistic perspectives of tuberculosis in older people

“…In diabetic patients, there is more severe pulmonary disease radiologically and bacteriologically, more adverse drug effects, delayed smear and culture conversion, and unfavourable 1‐year outcome with higher mortality . DM has been associated with treatment failure, relapse and drug resistance in some studies, However, with prolonged treatment duration of 9 months for TB patients with DM in Hong Kong, the relapse rate was not found to be significantly increased . Despite the large cohort size, no association was seen between DM and bacillary resistance to isoniazid or rifampicin, likely due to the good programmatic performance locally …”

“…Apart from possible ethnic differences, differing degrees of diabetic control may contribute to the heterogeneous effect size, as poor metabolic control was found to increase the risk of TB in a cohort study among the geriatric population in Hong Kong . On the other hand, active TB also adversely affects glycaemic control . Furthermore, DM is predominantly associated with pulmonary TB, rather than extra‐pulmonary disease .…”

Stress Hyperglycemia in Patients with Tuberculosis Disease: Epidemiology and Clinical Implications

“…Such patients may experience prolonged proinflammatory response including stress hyperglycemia. This chronic hyperglycemia during TB disease may be a catalyst for some patients with pre-existing pre-diabetes which advances the disease toward overt diabetes [79] during or after TB treatment. A cohort study conducted in Chennai, India reported that patients with TB and newly diagnosed diabetes had significantly lower HbA1c levels compared to those with known diabetes (i.e., previously diagnosed diabetes) [20], suggesting that TB disease alone might progress patients with elevated blood glucose level prior to TB infection into a diabetes classification at the time of TB treatment initiation.…”

“…Risk scores for diabetes incidence among patients with TB will help to target specific diabetes prevention interventions. Bi-directional screening for TB – diabetes (i.e., screening for TB among patients with diabetes and screening for diabetes among patients with TB) has been proposed and may improve disease management for both TB and diabetes [14, 79], but to date has not included systematic screening of patients with history of TB for diabetes. The optimal time and laboratory measure to screen for diabetes among patients with a history of TB is unclear but will likely differ by setting.…”