|Year : 2022 | Volume
| Issue : 2 | Page : 159-165
Prevalence estimation of diabetes mellitus among tuberculosis cases, its risk factors, and treatment outcome in Rajkot city
Pooja N Ranpariya, Harsha M Solanki, Rajesh K Chudasama
Community Medicine Department, P. D. U. Government Medical College, Rajkot, Gujarat, India
|Date of Submission||08-Jan-2022|
|Date of Decision||07-Feb-2022|
|Date of Acceptance||07-Mar-2022|
|Date of Web Publication||21-Jul-2022|
Dr. Harsha M Solanki
Department of Community Medicine, P. D. U. Government Medical College, Rajkot 360001, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Tuberculosis (TB) and diabetes mellitus (DM) are the world’s leading public health issues. TB with DM co-morbidity adversely affects prognosis of individual diseases and its treatment outcome. Materials and Methods: A cross-sectional study was conducted at five TB units of Rajkot city for five quarters. Newly registered pulmonary TB (PTB) patients having DM during the study period were included as cases. All cases were followed up at the end of treatment to observe outcomes. Information was collected in a pretested proforma using the interview technique. Results: The prevalence of DM among PTB cases was 5%. Maximum cases were in 51–60 years (34.4%), male: female ratio was 3:1, living in urban slum (53.1%), literate (81.2%), and from middle socio-economic class (65.6%). One-fourth of the cases had family (28.1%) and past history (28.1%) of TB, and more than one-third (37.5%) of the cases had family history of DM. All cases were on daily drug adherence, and most of them (83%) were on regular follow-up. Significant association was observed with urban slum (P = 0.03) and family history of diabetes (P = 0.04) among cases. At the end of continuation phase, 82.8% of the cases were cured and 4.7% of the cases had completed treatment. Conclusion: The study reported 5% of DM among newly registered TB cases and family history of DM as its significant risk factor.
Keywords: Diabetes mellitus, prevalence, risk factors, treatment outcome, tuberculosis
|How to cite this article:|
Ranpariya PN, Solanki HM, Chudasama RK. Prevalence estimation of diabetes mellitus among tuberculosis cases, its risk factors, and treatment outcome in Rajkot city. J Diabetol 2022;13:159-65
|How to cite this URL:|
Ranpariya PN, Solanki HM, Chudasama RK. Prevalence estimation of diabetes mellitus among tuberculosis cases, its risk factors, and treatment outcome in Rajkot city. J Diabetol [serial online] 2022 [cited 2022 Nov 29];13:159-65. Available from: https://www.journalofdiabetology.org/text.asp?2022/13/2/159/351758
| Introduction|| |
Diabetes mellitus (DM) and tuberculosis (TB) are major public health problems for mankind across the globe. About 95% of the TB and 75% of the DM cases live in low- and middle-income countries. India is the highest TB-burden country in the world having an estimated incidence of 18.1 lakh cases in 2020. As a consequence of urbanization, socio-economic development, and lifestyle changes, there is also a rising epidemic of DM. India reported the second largest number of DM people in the world, having 74.2 million people in 2021. The profile of TB with DM patients vs. TB only is strikingly different. TB with DM patients are likely to be older, obese, females, more likely to have lower education and higher unemployment, and have family history of DM, which complicates TB and DM management. These socio-demographic factors are associated with less access to health care and poorer glucose control. A systematic review of bidirectional screening for TB with DM co-morbidity reported high prevalence of DM among TB patients ranging from 1.9% to 35%.
During TB treatment, people with DM have 8.99 times higher risk of treatment failure, 1.64 times higher risk of relapse, and 1.88 times higher risk of death when compared with those without DM. Due to lack of early detection and treatment, complications from TB with DM co-morbidity lead to high cost of treatment and out-of-pocket expenditure. The poor TB treatment outcomes became a major threat to global TB control program. Hence, the study was conducted to estimate the prevalence of DM among TB patients, to study the role of risk factors and treatment outcome of TB with DM cases.
| Materials and Methods|| |
A cross-sectional study was conducted from October 1, 2019 to December 31, 2020 at five tuberculosis units (TUs) of Rajkot city after obtaining approval from the Institutional Ethics Committee. Newly registered pulmonary TB (PTB) patients with newly diagnosed or known cases of DM were included as cases during the study period. Based on the last year’s newly registered cases in the government sector, approximately 125 cases were expected during the study period.
A total of 1384 PTB patients were newly registered at five TUs of Rajkot city during the study period. All patients were screened for DM by random blood sugar at TU, of which a total of 64 (53 were known cases of DM and 11 were newly diagnosed) cases had fulfilled all the criteria of standard case definition of TB with DM and were included in the study. All 64 cases were then screened by fasting blood glucose, post-prandial plasma glucose at TU, and HbA1c at PDU, Civil Hospital, Rajkot, Gujarat. However, 32 patients turned up for HbA1c and rest did not undergo HbA1c investigation because of fear of COVID and COVID lockdown. As only half of the cases tested for HbA1c, their findings were excluded in the analysis. A person was defined as a case of PTB with DM if the following criteria were satisfied: (1) Mycobacterium tuberculosis is in sufficient numbers to be detected in the sputum by diagnostic tests; (2) M. tuberculosis cannot be detected in the sputum but patients have persistent symptoms with chest radiograph shadows suggestive of TB disease; (3) single fasting plasma glucose ≥126 mg/dL, a post-prandial plasma glucose ≥200 mg/dL in newly diagnosed symptomatic cases; (4) fasting plasma glucose ≥126 mg/dL, a post-prandial plasma glucose ≥200 mg/dL on two separate occasions in newly diagnosed asymptomatic cases; and (5) known cases of DM on anti-diabetic treatment. Extra-pulmonary TB, multi-drug resistant TB, and extensive drug-resistant TB cases having a long duration of treatment were excluded. All cases were followed up at the end of their treatment to observe outcome.
Information was collected in a preformed, pretested, and semi-structured questionnaire by the interview technique. The questionnaire included information regarding the socio-demographic details, information related to TB, DM, and outcome after completion of the treatment. The modified Prasad’s socio-economic classification was used considering All India Consumer Price Index of October 2019. Data entry was done in Microsoft Office Excel 2016, and analysis was done using the software package Epi Info (version 126.96.36.199) from CDC, Atlanta, USA. Appropriate statistical tests such as Fisher’s exact test and χ2 test were used.
| Results|| |
The prevalence of DM among PTB patients was 5% (64/1384) [Figure 1]. Among them, 17% of the (11/64) cases were TB with newly diagnosed DM and 83% (53/64) were TB with known case of DM. The present study reported a maximum number of TB with DM cases in the age group of 51–60 years [22 (34.4%)]. Out of the total TB with DM cases, 48 (75%) were male and 16 (25%) were female with a male–female ratio of 3:1. Socio-demographic details revealed that 34 (53.1%) cases were living in urban slum area; the majority were literate [52 (81.2%)] and belong to the middle socio-economic class [43 (67.2%)] [Table 1].
|Figure 1: Prevalence of diabetes mellitus among pulmonary tuberculosis cases|
Click here to view
|Table 1: Baseline characteristics of tuberculosis with diabetes mellitus cases|
Click here to view
Family history of TB was present in 18 (28.1%) cases and past history of TB was also present in 18 (28.1%) cases. More than half [38/64 (59.4%)] of the cases were tobacco-addicted. Among tobacco users, more than three-fourth of the cases [29/38 (76.4%)] were using it for more than 10 years. Positive family history of DM was present in 24 (37.5%) cases [Table 2]. More than half [59 (54.7%)] of the cases suffered from DM for less than 5 years and 24 (45.3%) for more than or equal to 5 years. At the time of diagnosis of TB, DM screening was carried out and if found diabetic among new cases, they were put on anti-diabetic treatment. So, at the time of first interview, among newly diagnosed diabetics (n=11), 9 patients had started treatment (oral hypoglycemic drugs), whereas 2 patients had not started treatment. Among newly diagnosed diabetics (n = 11), the majority [9 (72.7%)] were on oral hypoglycemic drugs and 2 cases were not taking any diabetic medication. Among known cases of DM (n=53), five were on insulin and rest were on oral hypoglycemic drugs. After detection of TB, three more cases were started on insulin. Hence, in total, eight patients were on insulin. All known diabetics were on regular daily medication, 44 (83%) cases were doing regular follow-up, and one-third [18 (34%)] of the cases were getting their blood sugars tested once in 3 months [Table 3].
|Table 2: Information related to tuberculosis and diabetes mellitus among cases|
Click here to view
|Table 3: Health-seeking behavior for diabetes management among tuberculosis with known diabetic cases|
Click here to view
The occurrence of TB with newly diagnosed DM was significantly high in urban slum population (P = 0.03). Family history of DM was significantly associated among TB with DM cases (P = 0.04) [Table 4]. The treatment success rate found was 87%, which includes 82.8% cure rate and 4.7% treatment completed rate among TB with DM cases [Table 5].
| Discussion|| |
India is facing the dual problem of being the highest TB-burden country having a large number of people with diabetes. In the present study, the prevalence of DM among PTB patients was 5% (public sector). In India, among all notified TB patients in the public and private sectors, 8% were found to have DM. This finding is comparable with the results of studies carried out in India and Indonesia, which reported 15.3% and 14.8% prevalence rates, respectively., A probable explanation for this variation in prevalence is the different study area and population characteristics. In the current study, majority of the cases (34.4%) were belonging to the age group of 51–60 years. A study conducted at Chandigarh and Kerala found that “TB diabetes co-morbidity” was higher, 63.9% and 61.1% in those aged 50 years and above, respectively., TB with DM cases were reported to be higher (54%) in more than 50 years of age, and it was found to be statistically significant in a study conducted at Bhopal. Age is linked with both diseases, as increasing age is actually advancing toward type 2 diabetes and low immunity results in active TB.
Around half (52.8%) of the TB with known case of DM were coming from the urban area, whereas 81.8% of the TB with newly diagnosed DM cases were coming from the urban slum. This difference was found to be statistically significant (P = 0.03). A study conducted in India reported that prevalence of TB-DM is 15.2% higher in urban areas when compared with rural areas. A study done in Chandigarh revealed that 36.1% of TB with DM cases were illiterate. Different studies from Madhya Pradesh reported more number of literate TB with DM cases when compared with illiterate cases., In the present study, 17% TB with known case of DM and 27.3% TB with newly diagnosed DM cases were illiterate, whereas other cases were literate.
More number of unemployed or retired cases (52.2%) were reported in the study conducted at Bangladesh. In the current study, 23.4% of TB with DM cases were retired/unemployed. A study conducted at Gwalior reported that sedentary occupation was the common risk factor associated with diabetes among TB cases.
Various studies conducted at Bhopal revealed that TB with DM cases were more common among middle socio-economic class., Similar findings were observed in the present study that more cases were belonging to middle socio-economic class (67.2%) when compared with lower (21.9%) and upper (10.9%) socio-economic classes. Positive family history of TB was present in 13.8% and 11.8% of cases in studies conducted at Chandigarh and Nepal, respectively., Similar finding was observed in a study conducted at South Delhi. In the present study, 28.1% of the cases gave the past family history of TB. Family history of TB was 2.7 times more likely to be associated with TB with DM (odds ratio 2.7 [confidence interval=1.447–5.186]). The present study reported approximately one-fifth (19.7%) of the cases with past history of TB. A hospital-based cohort study also reported similar findings as 19.7% of cases had a past history of TB. The frequency of MDR-TB is increasing among previously treated cases.
More than half of the cases (59.4%) were consuming tobacco. Out of all tobacco users, 42.1% were smokers, whereas 44.7% were consuming smokeless form of tobacco and 13.2% of the cases consuming both, like various other studies.,, Smoking damages lungs and harms body’s immune system and reduces TB treatment effectiveness, which leads to longer period of infection. Less than one-fifth (14.1%) of the cases were exposed to second-hand smoking in this study. Approximately 33.3% of the cases were exposed to second-hand smoking at home or workplace reported in a study conducted at Chandigarh. The study done in Bhopal reported that 20.6% of the cases were alcoholic in their study. Similar to this, 17.1% and 19.7% alcoholics were found in the study conducted at Madhya Pradesh and Karnataka, respectively., In the present study, 7.8% of the cases were giving a history of alcohol consumption. The study conducted in South India reported that 6.8% of the cases were consuming alcohol. More numbers of TB with known case of DM (83.3%) were consuming tobacco for more than 10 years in the present study. Statistically significant difference was not found between both the groups of TB with DM and duration of tobacco consumption. Duration of smoking was associated with the development of PTB in comparison to quantity bidis or cigarettes.
Sedentary occupational status and smoking were more prevalent in males and put them at higher risk of co-infection. A study done at Nepal and Northeast Ethiopia reported that 66.7% and 78.6% of the cases were males, respectively., The association of sex with active TB infection was not statistically significant in a study done in Chandigarh city. Similarly, more numbers of male cases (75%) were found when compared with female cases (25%) in the present study, and this difference was not found to be statistically significant. Family history of DM (risk is higher if one or more first-degree relatives, for example, parents, siblings, and children, are affected with the disease) is one of the key non-modifiable risk factors for DM and hence those with family history of diabetes are likely to develop diabetes in future. There is strong evidence that DM increases the risk of TB disease two- to three-fold because of immunosuppression. Further, TB is an airborne disease that is transferred from one person to another through aerosol formation. Only 30% of the population gets successfully infected when coming in contact with M. tuberculosis, whereas in the remaining 70% of the population it remains latent because of good immunity. People with diabetes, which is being a chronic disease, are likely to have a weak immune system, and hence they are at a higher risk of progressing from latent to active TB. Hence, early diagnosis of DM and early initiation of appropriate DM care will result in better outcomes. In the current study, 43.4% of the TB with DM cases had a positive family history of DM and it was statistically significant (P = 0.04). Similar findings were observed in a study conducted at Tamil Nadu and Pakistan and reported significant association between positive family history of DM and DM among TB cases., Out of the all known cases of DM, 50% of the cases were diabetic for more than 5 years and rest of the cases (50%) were having the disease for less than 5 years in this study. Those patients who had DM for more than 10 years had a higher proportion of TB than those who had shorter durations (<5 years) of DM, which is consistent with a study done in Pakistan.
A study done in Chandigarh reported that 64% of the cases tested their blood sugar monthly and 84% with known DM were on daily medication adherence. In the present study, 34% of the cases were getting blood sugar tested every 3 monthly, and all the cases were on daily drug adherence. The success rate of TB treatment among TB with DM cases was 89.9% in a study at Tamil Nadu. Similar to this finding, the current study also found 87.5% success rate of TB treatment. In contrast to this finding, the study conducted at Indonesia reported no difference of positive sputum smear at the end of intensive phase, but reported some delay in conversion in the TB with DM group.
There was a chance of selection bias in the present study as TB with DM cases were selected from the government sector only. The study was restricted to only PTB patients. Desired sample size was not achieved due to Covid-19 pandemic occurrence during the study period.
| Conclusion|| |
The study reported 5% of DM among newly registered TB cases and family history of DM as its significant risk factor. Hence, similar studies with larger sample size may help to understand the magnitude and associated risk factors of TB with DM co-morbidity. This will further help in making appropriate policy decision of bi-directional screening and integrated services for TB with DM.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Workneh MH, Bjune GA, Yimer SA Prevalence and associated factors of tuberculosis and diabetes mellitus comorbidity: A systematic review. PLoS One 2017;12:e0175925.
Central TB Division—Directorate General of Health Services. India TB Report 2021. Available from: https://tbcindia.gov.in/showfile.php?lid=3587
. [Last accessed on July 14, 2021].
International Diabetic Federation Diabetes Atlas. 10th ed. Brussels: International Diabetes Foundation; 2021. Available from: https://diabetesatlas.org/idfawp/resource-files/2021/07/IDF_Atlas_10th_Edition_2021.pdf
. [Last accessed on December 16, 2021].
Jeon CY, Harries AD, Baker MA, Hart JE, Kapur A, Lönnroth K, et al
. Bi-directional screening for tuberculosis and diabetes: A systematic review. Trop Med Int Health 2010;15:1300-14.
Lin Y, Harries AD, Kumar AM, Critchley JA, Crevel RV, Owiti P, et al
. Management of Diabetes Mellitus–Tuberculosis: A Guide to the Essential Practice. 1st ed. Paris: World Diabetes Foundation; 2019. Available from: theunion.org/sites/default/files/2020-11/TheUnion_DMTB_Guide.pdf.
Debnath DJ, Kakkar R Modified BG Prasad socio-economic classification, updated—2020. Indian J Comm Health 2020;32:124-25.
Mansuri S, Chaudhari A, Singh A, Malek R, Viradiya R Prevalence of diabetes among tuberculosis patients at Urban Health Centre, Ahmedabad. Int J Sci Study 2015;3:115-8. Available from: https://DOI:10.17354/ijss/2015/318
Alisjahbana B, Sahiratmadja E, Nelwan EJ, Purwa AM, Ahmad Y, Ottenhoff TH, et al
. The effect of type 2 diabetes mellitus on the presentation and treatment response of pulmonary tuberculosis. Clin Infect Dis 2007;45:428-35.
Sharma D, Goel NK, Sharma MK, Walia DK, Thakare MM, Khaneja R Prevalence of diabetes mellitus and its predictors among tuberculosis patients currently on treatment. Indian J Community Med 2018;43:302-6.
Nair S, Kumari AK, Subramonianpillai J, Shabna DS, Kumar SM, Balakrishnan S, et al
. High prevalence of undiagnosed diabetes among tuberculosis patients in peripheral health facilities in Kerala. Public Health Action 2013;3:S38-42.
Nagar V, Prasad P, Gour D, Singh AR, Pal DK Screening for diabetes among tuberculosis patients registered under revised National Tuberculosis Control Program, Bhopal, India. J Family Med Prim Care 2018;7:1401-5.
Noureen. Diabetes mellitus and associated risk factors among tuberculosis patients in Rawalpindi, Pakistan. Anat Physiol Biochem Int J 2017;1:1-8. Available from: https://doi:10.19080/apbij.2017.01.555570
Sharma P, Visnegarwala F, Tripathi V Burgeoning double burden of tuberculosis and diabetes in India: Magnitude of the problem—Strategies and solutions. Clin Epidemiol Glob Heal 2014;2:107-16. Available from: https://doi:10.1016/j.cegh.2013.03.002
Sembiah S, Nagar V, Gour D, Pal DK, Mitra A, Burman J Diabetes in tuberculosis patients: An emerging public health concern and the determinants and impact on treatment outcome. J Family Community Med 2020;27:91-6.
Sarker M, Barua M, Guerra F, Saha A, Aftab A, Latif AH, et al
. Double trouble: Prevalence and factors associated with tuberculosis and diabetes comorbidity in Bangladesh. PLoS One 2016;11:e0165396.
Agarwal A, Agarwal N, Mahore R A comparative study of clinical variables in tuberculosis patients with coexisting diabetes. J Diabetol 2018;9:81-7. Available from: http://www.journalofdiabetology.org/text.asp?2018/9/3/81/239566
Mahato RK, Laohasiriwong W, Koju R, Kaen K, Kaen K, Hospital D The role of type 2 diabetes mellitus on the clinical manifestation of pulmonary tuberculosis: A study from Nepal. J Clin Diagn Res 2019;9:1-13. Available from: https://doi:10.7860/JCDR/2019/42353.13122
Siddiqui AN, Khayyam KU, Sharma M Effect of diabetes mellitus on tuberculosis treatment outcome and adverse reactions in patients receiving directly observed treatment strategy in India: A prospective study. Biomed Res Int 2016;2016:7273935.
Pande T, Huddart S, Xavier W, Kulavalli S, Chen T, Pai M, et al
. Prevalence of diabetes mellitus amongst hospitalized tuberculosis patients at an Indian tertiary care center: A descriptive analysis. PLoS One 2018;13:e0200838.
Christopher DJ, Jeyaseelan L, Michael JS, Veeraraghavan B, Manipadam MT, David T, et al
. Burden of diabetes among patients with tuberculosis: 10-year experience from a tertiary care referral teaching hospital in South India. Lung India 2020;37:232-7.
] [Full text]
Prasad R, Garg R, Singhal S, Dawar R, Agarwal GG, Suryakant. A case–control study of tobacco smoking and tuberculosis in India. Ann Thorac Med 2009;4:208-10.
] [Full text]
Amare H, Gelaw A, Anagaw B, Gelaw B Smear positive pulmonary tuberculosis among diabetic patients at the Dessie Referral Hospital, Northeast Ethiopia. Infect Dis Poverty 2013; 2:6.
Pal R, Ansari MA, Hameed S, Fatima Z Diabetes mellitus as hub for tuberculosis infection: A snapshot. Int J Chronic Dis 2016;2016:5981574.
Viswanathan V, Kumpatla S, Aravindalochanan V, Rajan R, Chinnasamy C, Srinivasan R, et al
. Prevalence of diabetes and pre-diabetes and associated risk factors among tuberculosis patients in India. PLoS One 2012;7:e41367.
Jabbar A, Hussain SF, Khan AA Clinical characteristics of pulmonary tuberculosis in adult Pakistani patients with co-existing diabetes mellitus. East Mediterr Health J 2006;12:522-7.
Viswanathan AA, Gawde NC Effect of type II diabetes mellitus on treatment outcomes of tuberculosis. Lung India 2014;31: 244-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]