Abstract
BackgroundSystematic reviews suggest that the incidence of diagnosed tuberculosis is two- to- three times higher in those with diabetes mellitus than in those without. Few studies have previously reported the association between diabetes or hyperglycaemia and the prevalence of active tuberculosis and none in a population-based study with microbiologically-defined tuberculosis. Most have instead concentrated on cases of diagnosed tuberculosis that present to health facilities. We had the opportunity to measure glycaemia alongside prevalent tuberculosis. A focus on prevalent tuberculosis enables estimation of the contribution of hyperglycaemia to the population prevalence of tuberculosis.MethodsA population-based cross-sectional study was conducted among adults in 24 communities from Zambia and the Western Cape (WC) province of South Africa. Prevalent tuberculosis was defined by the presence of a respiratory sample that was culture positive for M. tuberculosis. Glycaemia was measured by random blood glucose (RBG) concentration. Association with prevalent tuberculosis was explored across the whole spectrum of glycaemia.ResultsAmong 27,800 Zambian and 11,367 Western Cape participants, 4,431 (15.9%) and 1,835 (16.1%) respectively had a RBG concentration ≥7.0 mmol/L, and 405 (1.5%) and 322 (2.8%) respectively had a RBG concentration ≥11.1 mmol/L. In Zambia, the prevalence of tuberculosis was 0 · 5% (142/27,395) among individuals with RBG concentration <11.1 mmol/L and also ≥11.1 mmol/L (2/405); corresponding figures for WC were 2 · 5% (272/11,045) and 4 · 0% (13/322). There was evidence for a positive linear association between hyperglycaemia and pulmonary prevalent tuberculosis. Taking a RBG cut-off 11.1 mmol/L, a combined analysis of data from Zambian and WC communities found evidence of association between hyperglycaemia and TB (adjusted odds ratio = 2 · 15, 95% CI [1 · 17–3 · 94]). The population attributable fraction of prevalent tuberculosis to hyperglycaemia for Zambia and WC combined was 0.99% (95% CI 0 · 12%–1.85%) for hyperglycaemia with a RBG cut-off of 11.1 mmol/L.ConclusionsThis study demonstrates an association between hyperglycaemia and prevalent tuberculosis in a large population-based survey in Zambia and Western Cape. However, assuming causation, this association contributes little to the prevalence of TB in these populations.
Highlights
Systematic reviews suggest that the incidence of diagnosed tuberculosis is two- to- three times higher in those with diabetes mellitus than in those without
Associations between diabetes and tuberculosis are increasingly recognised: systematic reviews and metaanalyses suggest that the incidence of active diagnosed tuberculosis is two- to- three times higher in those with diabetes compared to those without diabetes; [8,9,10] that diabetes increases the risk of death from diagnosed tuberculosis [11], and that diabetes may increase the risk of tuberculosis relapse [9, 11]
Studies from Africa have shown even stronger associations between diabetes and active diagnosed TB; a four-fold increase in diabetes prevalence was seen in TB patients in Dar es Salaam compared to the general population; [12] an odds ratio for TB of 8 · 33 was seen in the Congo comparing those with diabetes to those without diabetes [13]
Summary
Systematic reviews suggest that the incidence of diagnosed tuberculosis is two- to- three times higher in those with diabetes mellitus than in those without. The number of adults with diabetes mellitus globally is predicted to rise from 382 million in 2013 to 592 million in 2035 [1,2,3,4,5,6] Of those in the world who currently have diabetes, four out of five live in a low or middle income country [6]. Associations between diabetes and tuberculosis are increasingly recognised: systematic reviews and metaanalyses suggest that the incidence of active diagnosed tuberculosis is two- to- three times higher in those with diabetes compared to those without diabetes; [8,9,10] that diabetes increases the risk of death from diagnosed tuberculosis [11], and that diabetes may increase the risk of tuberculosis relapse [9, 11]. As the prevalence of diabetes rises in locations with a high burden of tuberculosis, a deeper understanding of these associations is increasingly important
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