Incidence of pulmonary tuberculosis in Chinese adults with type 2 diabetes: a retrospective cohort study in Shanghai

Abstract

To estimate the incidence of pulmonary tuberculosis (PTB) in Chinese diabetes patients and to evaluate the effect of blood glucose on PTB risk, a retrospective cohort study was built based on the diabetes management system in Shanghai and included 240,692 adults aged 35 or above. Incidences of PTB in all diabetes patients and by subgroups were calculated and compared. Multivariable Cox regression models with restricted cubic splines were used to evaluate the association of fasting plasma glucose (FPG) with the risk of PTB. A total of 439 incident PTB cases were identified in the cohort after an average of 3.83 years of follow-up. The overall PTB incidence rate was 51.3/100,000 in diabetes patients, and annual incidence remained higher than that in general population. The PTB incidence rate of diabetes patients was higher in men than in women (86.2 vs. 22.1 per 100,000) and was highest in patients with body mass index (BMI) < 18.5 kg/m 2 (215.2/100,000) or FPG ≥ 10 mmol/L (143.2/100,000). Our results suggest that the risk of tuberculosis may be greater at higher levels of FPG in diabetes patients of normal weight. Specific tuberculosis screening strategies for different characteristic diabetes population should be provided to prevent and control tuberculosis in China. Tuberculosis (TB) remains a major global public health issue despite its slowly decreased incidence, particularly in developing countries. The World Health Organization (WHO) reported that an estimated 10 million people developed TB and 1.6 million people died of TB worldwide in 2017 1. At the same time, type 2 diabetes mellitus (T2DM) is a global epidemic. It is estimated that there were around 425 million prevalent diabetes patients worldwide in 2017, and the number is expected to be almost 700 million by 2045 2. The associations of T2DM with the incidence, severity and clinical outcome of TB have been well documented 3-7. The estimated number of incident TB attributable to T2DM increased from 10% in 2010 to 15% in 2013, globally, and almost 17% of diabetes-associated TB cases occurred in China 8. A recent meta-analysis demonstrated that T2DM was associated with a two-to four-fold increased risk of active TB 9. Shanghai, a typical megacity of China, experiencing rapid population aging, urbanization, industrialization and changes in lifestyle, is bearing heavy dual burden of prevention and control for diabetes and TB. Although TB incidence rate is relatively low in Shanghai, approximately 26.9 per 100,000 in 2015, the prevalence of diabetes is dramatically increasing. A cross-sectional investigation in 2013 reported that overall weighted prevalence of diabetes was 17.6% among Shanghai residents aged 35 or above, which was much higher than the nationwide average level 10. Therefore, to realize the WHO's END TB Strategy, which was approved by the 67 th World Health Assembly in 2014 11 , the Shanghai Municipal Commission of Health and Family Planning launched "Plan for Hierarchical

Prevalence, Incidence, and Characteristics of Tuberculosis Among Known Diabetes Patients — A Prospective Cohort Study in 10 Sites, 2013–2015

“…The analyses for both TB prevalence and TB incidence in several subgroups showed significant differences. Male DM patients with lower BMI had higher TB prevalence and incidence rates; these findings were like those identified in the general population and could be found in retrospective cohort study conducted in Shanghai ( 6 ). A history of previous TB was identified as a high-risk factor for developing TB by many studies ( 9 ).…”

“…The study also observed a higher prevalence of bacteriologically-confirmed TB in known DM patients than that for the general population based on data obtained from the Fifth National Tuberculosis Prevalence Survey. Compared with a retrospective cohort study conducted in Shanghai ( 6 ), our study obtained a much higher TB incidence rate in larger areas. Our active TB incidence was also higher than that obtained in a cohort study conducted in the Republic of Korea ( 7 ) and lower than that obtained in Indonesia ( 8 ).…”

Mechanisms of ag85a/b DNA vaccine conferred immunotherapy and recovery from Mycobacterium tuberculosis‐induced injury

“…This study found for the first time that the significant increases of these three genes may be related to the inflammatory reaction after MTB infection, and also play important roles in the pathogenesis of various types of diabetes 96,97 . The current research showed that the risk of pulmonary TB in T2DM patients was about two to three times that of the general population, 98 and the results of this study suggest that TB may also increase the incidence rate of diabetes. Amy2a5 is an amylase alpha 2 that catalyzes the hydrolysis of starch into sugar, providing energy for the body 44 .…”

Risk factors for multidrug resistance in tuberculosis patients with diabetes mellitus

“…Inclusion criteria: Patients diagnosed with TB and DM. Inclusion criteria of TB dependedon the Chinese guidelines for the diagnosis and treatment of TB (2020 version) [11]: (1) The sputum smear was positive for acid-fast bacilli; (2) Mycobacterium tuberculosis cogroup was cultured in sputum, bronchoalveolar lavage fluid or pleural effusion; (3) The nucleic acid of Mtb and/or Mtb culture was positive in sputum, bronchoalveolar lavage fluid, or pleural effusion; (4) the pathological staining of lung tissue specimens was positive for acid-fast bacilli, or the nucleic acid of Mtb was positive in lung tissue specimens from the lesion site. The diagnosis of pulmonary TB could be clarified if any of the above four items were met.…”

“…The growing prevalence of diabetes mellitus (DM) has emerged as one of the major global health challenges and may lead to an increase in the burden of TB. China has a heavy burden of TB with DM (patients had both tuberculosis and diabetes) [ 1 ]. Studies have shown that due to the impaired immune function of DM patients, the risk of active TB increases by 3 times [ 2 ].…”