Abstract
The escalating burden of diabetes is increasing the risk of contracting tuberculosis (TB) and has a pervasive impact on TB treatment outcomes. Therefore, we conducted this systematic review and meta-analysis to examine the burden of diabetes among TB patients and assess its impact on TB treatment in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). PubMed, Excerpta Medica Database (EMBASE), and CINAHL databases were systematically searched for observational (cross-sectional, case–control and cohort) studies that reported prevalence of diabetes in TB patients and published between 1 January 1980 and 30 July 2020. A random-effect model for computing the pooled prevalence of diabetes and a fixed-effect model for assessing its impact on TB treatment were used. The review was registered with PROSPERO number CRD42020167896. Of the 3463 identified studies, a total of 74 studies (47 studies from India, 10 from Pakistan, four from Nepal and two from both Bangladesh and Sri-Lanka) were included in this systematic review: 65 studies for the prevalence of diabetes among TB patients and nine studies for the impact of diabetes on TB treatment outcomes. The pooled prevalence of diabetes in TB patients was 21% (95% CI 18.0, 23.0; I2 98.3%), varying from 11% in Bangladesh to 24% in Sri-Lanka. The prevalence was higher in studies having a sample size less than 300 (23%, 95% CI 18.0, 27.0), studies conducted in adults (21%, 95% CI 18.0, 23.0) and countries with high TB burden (21%, 95% CI 19.0, 24.0). Publication bias was detected based on the graphic asymmetry of the funnel plot and Egger’s test (p < 0.001). Compared with non-diabetic TB patients, patients with TB and diabetes were associated with higher odds of mortality (Odds Ratio (OR) 1.7; 95% CI 1.2, 2.51; I2 19.4%) and treatment failure (OR 1.7; 95% CI 1.1, 2.4; I2 49.6%), but not associated with Multi-drug resistant TB (OR 1.0; 95% CI 0.6, 1.7; I2 40.7%). This study found a high burden of diabetes among TB patients in South Asia. Patients with TB-diabetes were at higher risk of treatment failure and mortality compared to TB alone. Screening for diabetes among TB patients along with planning and implementation of preventive and curative strategies for both TB and diabetes are urgently needed.
Highlights
Tuberculosis (TB) is the largest infectious disease killer in the world[1]
Of the 3463 articles retrieved (3295 articles for estimating the prevalence of diabetes among TB patients and 168 articles for assessing the impact of diabetes among TB treatment outcome), 65 articles were found eligible for assessing the prevalence of diabetes among TB patients and nine for assessing the impact of diabetes on TB treatment outcomes as shown in the figures. (Supplementary Fig. 1)
65 studies with 49,792 TB patients were included in the pooled prevalence for diabetes in tuberculosis patient, out of which 47 studies were from I ndia[13,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67, 10] from Pakistan[68,69,70,71,72,73,74,75,76,77], four from Nepal[78,79,80,81] and two studies each from Bangladesh[82,83] and Sri-Lanka[84,85]
Summary
Tuberculosis (TB) is the largest infectious disease killer in the world[1]. The South Asian region which consists of eight low and middle-income nations, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka alone shares for nearly 44% of the world TB cases[1] and a high burden of TB mortality (681,975 deaths), 38% of the worldwide burden[2]. World Health Organization member countries have agreed upon an ambitious target to achieve 25% reduction in TB incidence and 75% reduction in TB mortality between 2015 and 2025, and 90% reduction in TB incidence and 95% reduction in TB mortality by 2 03520 This ambitious target cannot be achieved unless the escalating burden of risk factors such as diabetes is properly addressed. Previous systematic review by Noubiap et al which reported global prevalence of diabetes among TB patients, did not provide comprehensive evidence from South Asian countries; failing to include many studies from India and reporting no studies from Afghanistan, Bhutan, Maldives and N epal[3]. This study will, examine the existing literature on the prevalence of diabetes and its impact on treatment outcomes among TB patients which can inform policymakers in devising strategies for integrated care of TB and diabetes at the national and regional levels
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