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      Diabetes, undernutrition, migration and indigenous communities: tuberculosis in Chiapas, Mexico

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          Abstract

          We investigated the distribution of comorbidities among adult tuberculosis (TB) patients in Chiapas, the poorest Mexican state, with a high presence of indigenous population, and a corridor for migrants from Latin America. Secondary analysis on 5508 new adult TB patients diagnosed between 2010 and 2014 revealed that the most prevalent comorbidities were diabetes mellitus (DM; 19.1%) and undernutrition (14.4%). The prevalence of DM in these TB patients was significantly higher among middle aged (41–64 years) compared with older adults (⩾65 years) (38.6% vs. 23.2%; P < 0.0001). The prevalence of undernutrition was lower among those with DM, and higher in communities with high indigenous presence. Immigrants only comprised 2% of all TB cases, but were more likely to have unfavourable TB treatment outcomes (treatment failure, death and default) when compared with those born in Chiapas (29.5% vs. 11.1%; P < 0.05). Unfavourable TB outcomes were also more prevalent among the TB patients with undernutrition, HIV or older age, but not DM ( P < 0.05). Our study in Chiapas illustrates the challenges of other regions worldwide where social (e.g. indigenous origin, poverty, migration) and host factors (DM, undernutrition, HIV, older age) are associated with TB. Further understanding of these critical factors will guide local policy makers and health providers to improve TB management.

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          The impact of diabetes on tuberculosis treatment outcomes: A systematic review

          Meghan A. Baker, Anthony D. Harries, Christie Y. Jeon … (2011)
          Background Multiple studies of tuberculosis treatment have indicated that patients with diabetes mellitus may experience poor outcomes. We performed a systematic review and meta-analysis to quantitatively summarize evidence for the impact of diabetes on tuberculosis outcomes. Methods We searched PubMed, EMBASE and the World Health Organization Regional Indexes from 1 January 1980 to 31 December 2010 and references of relevant articles for reports of observational studies that included people with diabetes treated for tuberculosis. We reviewed the full text of 742 papers and included 33 studies of which 9 reported culture conversion at two to three months, 12 reported the combined outcome of failure and death, 23 reported death, 4 reported death adjusted for age and other potential confounding factors, 5 reported relapse, and 4 reported drug resistant recurrent tuberculosis. Results Diabetes is associated with an increased risk of failure and death during tuberculosis treatment. Patients with diabetes have a risk ratio (RR) for the combined outcome of failure and death of 1.69 (95% CI, 1.36 to 2.12). The RR of death during tuberculosis treatment among the 23 unadjusted studies is 1.89 (95% CI, 1.52 to 2.36), and this increased to an effect estimate of 4.95 (95% CI, 2.69 to 9.10) among the 4 studies that adjusted for age and other potential confounding factors. Diabetes is also associated with an increased risk of relapse (RR, 3.89; 95% CI, 2.43 to 6.23). We did not find evidence for an increased risk of tuberculosis recurrence with drug resistant strains among people with diabetes. The studies assessing sputum culture conversion after two to three months of tuberculosis therapy were heterogeneous with relative risks that ranged from 0.79 to 3.25. Conclusions Diabetes increases the risk of failure and death combined, death, and relapse among patients with tuberculosis. This study highlights a need for increased attention to treatment of tuberculosis in people with diabetes, which may include testing for suspected diabetes, improved glucose control, and increased clinical and therapeutic monitoring.
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            A consistent log-linear relationship between tuberculosis incidence and body mass index.

            Knut Lonnroth, Brian Williams, Peter Cegielski … (2010)
            Low weight for height is an established risk factor for tuberculosis (TB), and recent studies suggest that overweight is a protective factor. No previous systematic review has been done to explore the consistency and establish the gradient of this apparent 'dose-response' relationship. A systematic literature review was carried out to identify cohort studies that collected data on weight and height at baseline and that used a diagnosis of active TB as the study outcome. Weight-for-height measures used in the original studies were transformed into body mass index (BMI). Exponential trend lines were fitted to each data set. Six studies were included. In all of them, there was a log-linear inverse relationship between TB incidence and BMI, within the BMI range 18.5-30 kg/m(2). The average slope gave a reduction in TB incidence of 13.8% [95% confidence interval 13.4-14.2] per unit increase in BMI. The dose-response relationship was less certain at BMI 30 kg/m(2). There is a strong and consistent log-linear relationship between TB incidence and BMI across a variety of settings with different levels of TB burden. More research is required to test the relationship at very low and very high BMI levels, to establish the biological mechanism linking BMI with risk of TB and to establish the potential impact on the global TB epidemic of changing nutritional status of populations.
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              Association between diabetes mellitus and active tuberculosis: A systematic review and meta-analysis

              Rami Al-Rifai, Fiona Pearson, Julia A Critchley … (2017)
              The burgeoning epidemic of diabetes mellitus (DM) is one of the major global health challenges. We systematically reviewed the published literature to provide a summary estimate of the association between DM and active tuberculosis (TB). We searched Medline and EMBASE databases for studies reporting adjusted estimates on the TB–DM association published before December 22, 2015, with no restrictions on region and language. In the meta-analysis, adjusted estimates were pooled using a DerSimonian-Laird random-effects model, according to study design. Risk of bias assessment and sensitivity analyses were conducted. 44 eligible studies were included, which consisted of 58,468,404 subjects from 16 countries. Compared with non-DM patients, DM patients had 3.59–fold (95% confidence interval (CI) 2.25–5.73), 1.55–fold (95% CI 1.39–1.72), and 2.09–fold (95% CI 1.71–2.55) increased risk of active TB in four prospective, 16 retrospective, and 17 case-control studies, respectively. Country income level (3.16–fold in low/middle–vs. 1.73–fold in high–income countries), background TB incidence (2.05–fold in countries with >50 vs. 1.89–fold in countries with ≤50 TB cases per 100,000 person-year), and geographical region (2.44–fold in Asia vs. 1.71–fold in Europe and 1.73–fold in USA/Canada) affected appreciably the estimated association, but potential risk of bias, type of population (general versus clinical), and potential for duplicate data, did not. Microbiological ascertainment for TB (3.03–fold) and/or blood testing for DM (3.10–fold), as well as uncontrolled DM (3.30–fold), resulted in stronger estimated association. DM is associated with a two- to four-fold increased risk of active TB. The association was stronger when ascertainment was based on biological testing rather than medical records or self-report. The burgeoning DM epidemic could impact upon the achievements of the WHO “End TB Strategy” for reducing TB incidence.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Epidemiol Infect
                Journal ID (iso-abbrev): Epidemiol. Infect
                Journal ID (publisher-id): HYG
                Title: Epidemiology and Infection
                Publisher: Cambridge University Press (Cambridge, UK )
                ISSN (Print): 0950-2688
                ISSN (Electronic): 1469-4409
                Publication date Collection: 2019
                Publication date (Electronic): 25 January 2019
                Volume: 147
                Electronic Location Identifier: e71
                Affiliations
                [1 ]University of Texas Health Houston, School of Public Health , Brownsville Campus, Brownsville, TX, 78520, USA
                [2 ]Research Network GRAAL (Research Groups for Africa and Latin America), The College of the South Border (ECOSUR), San Cristobal de Las Casas Chiapas, Mexico
                [3 ]Department of Physician Assistant, University of Texas Rio Grande Valley, College of Health Affairs , Edinburg campus, Edinburg, TX, 78541, USA
                [4 ]GRAAL, Prevention and Control Program of Tuberculosis in the Highlands Region of Chiapas, Ministry of Health of Chiapas , Chiapas, Mexico
                [5 ]Transmissible and Non-transmissible Diseases Department, Ministry of Health of Chiapas , Chiapas, Mexico
                [6 ]Advocate and International Public Health Consultant Fighting Tuberculosis, HIV/AIDS and other Neglected Diseases , San Diego, California, USA
                [7 ]Ministry of Health , Mexico City, Mexico
                [8 ]Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Centre at Houston , Houston, Texas, USA
                [9 ]Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, and The Centre for Clinical and Translational Sciences, University of Texas Health Science Centre at Houston , Houston, Texas, USA
                Author notes
                Author for correspondence: B. I. Restrepo, E-mail: blanca.i.restrepo@ 123456uth.tmc.edu ; blancares2008@ 123456gmail.com
                Article
                Publisher Item ID: S0950268818003461 Publisher ID: 00346
                DOI: 10.1017/S0950268818003461
                PMC ID: 6518577
                PubMed ID: 30869023
                SO-VID: ab878e50-73d5-48d5-b209-dbf509b94668
                Copyright © © The Author(s) 2019
                License:

                This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 09 May 2018
                Date revision received : 04 November 2018
                Date accepted : 23 November 2018
                Page count
                Figures: 4, Tables: 4, References: 57, Pages: 12
                Categories
                Subject: Original Paper

                ScienceOpen disciplines: Public health
                Keywords: diabetes mellitus (dm),indigenous,mexico,tuberculosis (tb),undernutrition
                Data availability:
                ScienceOpen disciplines: Public health
                Keywords: diabetes mellitus (dm), indigenous, mexico, tuberculosis (tb), undernutrition

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