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, 12 (11), e0187967

Association Between Diabetes Mellitus and Active Tuberculosis: A Systematic Review and Meta-Analysis


Association Between Diabetes Mellitus and Active Tuberculosis: A Systematic Review and Meta-Analysis

Rami H Al-Rifai et al. PLoS One.


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.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.


Fig 1
Fig 1. Flow diagram of study selection.
Published studies were retrieved from the MEDLINE-PubMed and EMBASE databases. TB: tuberculosis; DM: diabetes mellitus.
Fig 2
Fig 2. Forest plot of the meta-analyses.
Pooled findings of 44 studies reporting adjusted estimates of the association between TB and DM, stratified according to study design. Size of the square is proportional to the precision (weight) of the study-specific effect estimates. Circle is the study–specific effect point estimate. Arrows indicate that the bars are truncated to fit the plot. The diamond is centered on the summary effect estimate, and the width indicates the corresponding 95% CI. RRs: relative risk; RR: rate ratio; OR: odds ratio; HR: hazard ratio.

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Grant support

This publication was made possible by NPRP grant number 7-627-3-167 from the Qatar National Research Fund (a member of Qatar Foundation). The findings achieved herein are solely the responsibility of the authors. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.