International Journal of Diabetes and Endocrinology

2020; 5(2): 23-33

http://www.sciencepublishinggroup.com/j/ijdee
doi: 10.11648/j.ijde.20200502.12
ISSN: 2640-1363 (Print); ISSN: 2 (Online)

TUBERCULOSIS AMONG PATIENTS WITH DIABETES MELLITUS IN PORT

HARCOURT
1Nwalozie R. M. 2Esiere, R. K. 3George-Opuda I. M.
1
Department of Pathology, Rivers State University Teaching Hospital, Port Harcourt, Nigeria
2
Dept of Medical Microbiology / Parasitology. University of Calabar Teaching Hospital
Calabar, Nigeria.
3
Department of Medical Laboratory Science Rivers State University, Port Harcourt, Nigeria.
Email address:
rhodanwalozie@gmail.com.
To cite this article:
Nwalozie R. M. Esiere, R. K. George-Opuda I. M. Tuberculosis Among Patients with Diabetes
Mellitus in Port Harcourt. International Journal of Diabetes and Endocrinology. Special Issue:
Hypoglycemia in Diabetes. Vol. 5, No. 2, 2020, pp. 23-26. doi: 10.11648/j.ijde.20200502.12

Abstract: The occurrence of Tuberculosis was assessed among subjects diagnosed of Diabetes Mellitus.
One hundred and twenty-five subjects that have been diagnosed of TB attending the Rivers State University
Teaching Hospital were selected for the study by simple random sampling. Diagnoses of TB was done
according to standard methods. The mean age of the subjects was 56.05±14.58 years. The results showed
that 73 (58.40%) had DM for less than 1 year, 24 (19.20%) had DM between 1 – 5 years, 21 (16.80%) had
DM for 6 – 10 years and 7 (5.60%) had DM for more than 10 years. There was a 5.60% (7/125) prevalence
of Tuberculosis (TB) among the subjects, while 94.40% (118/125) did not have TB. The prevalence of
Drug resistant TB (DR-TB) among the subjects showed that 4 (3.20%) of the subjects had DR-TB. Among
the subjects with TB, drug resistant tuberculosis was found to be significantly high, as 57.14% (4/7) of the
subjects with TB had DR-TB (c2 = 69.65, p = 0.0001). The risk factors for the occurrence of TB include;
contact with people coughing for more than 2 weeks (OR: 51.1, 7.7 - 336, p = 0.0001), coughing blood
(OR: 19.5, 1.0 – 351.1, p = 0.0059). Coughing for more than two weeks (OR; 44.5, 4.9 – 397.9, p =
0.00001).
Keywords: Tuberculosis, Diabetes, Drug Resistance, Risk

1. Introduction dependent on how insulin is produced, regulated

or both. There are two types of DM, type 1,
Diabetes is a group of metabolic disorders formerly known as insulin dependent diabetes
marked by high blood glucose levels. It is entirely mellitus and type 2 DM, formerly known as

23
International Journal of Diabetes and Endocrinology
2020; 5(2): 23-33
http://www.sciencepublishinggroup.com/j/ijdee
doi: 10.11648/j.ijde.20200502.12
ISSN: 2640-1363 (Print); ISSN: 2 (Online)
noninsulin dependent DM (WHO). They both
present with a similar range of complications,
however, the significant difference is their time
of onset or diagnosis (Zumla, 2015). This
research focused on diabetes mellitus without
disaggregating the type among patients with TB,
exploring their characteristics as well as their risk
of drug resistant TB. Type 2 DM accounts for 90-
95% of all DM diagnosed cases and the most
observed in TB/DM comorbidity. It is associated
with old age, obesity, lifestyle practices and race.
Blacks and Hispanics are most at risk (Zumla,
2015). Tuberculosis (TB) has been recognized by
the World Health Organization (WHO) as the
most common cause of death among people with
Human Immune Deficiency Virus (HIV),
responsible for a reported 25% mortality of
global Acquired Immune Deficiency Syndrome
(AIDS) death in 2013 (Zumla, 2015). Notably,
the prevalence of Diabetes Mellitus (DM) has
increased in countries with a high burden of TB
(Martinez and Kornfeld, 2014). The
physiological link between the two epidemics has
been recognized throughout history (Ruslami,
2010).
The prevalence of TB among diabetics is high
and has been since ancient history as documented
by Root, (2010). This article observed that TB is
much more common amongst patients whose
diabetes is poorly managed (Root, 2010). A
major limitation amongst the growing body of
studies looking at the association between TB and
Diabetes is the use of active TB cases in studies
compared to latent TB infection which may either
overestimate of underestimate the strength of
association between TB and DM. The
interactions between Diabetes and TB is most
critical at analyzing TB/DM comorbidity. The
observed correlation between TB and diabetes
could have a negative impact on TB control
programs (Restrepo et al., 2017). Patients with
diabetes have a weak immunity and are prone to
getting infections including TB which dents
global TB control initiative (Martinez and
24
Kornfeld, 2014). The study was carried out to
examine the distribution of TB among diabetic
patients and explore the risk of Drug-resistant TB
in Diabetics who are also infected with TB in Port
Harcourt.
2. Methods
2.1 Study design
The study was based on a cross-sectional
descriptive study design to determine the
occurrence of tuberculosis among patients
diagnosed with Diabetes mellitus.
2.2 Ethical Consideration
Ethical approval to carry out the study was
obtained from the Ethics committees of the
Rivers State ministry of Health. Written informed
consent were obtained from prospective
participants prior to the commencement of the
study.
2.3 Sample size and Sampling
The sample size will be calculated based on the
prevalence of 9% as reported by Alebel et al.
(2019) with the sample size for proportions as
stated by Araoye (2008) below
n = Z2pq/d2
where;
n = sample size for Case and Control
Z = 95% confidence interval= 1.96
P = proportion of the target population
used=78%
q = 1.0 – p = 1.0 – 0.09 = 0.91
d = degree of accuracy desired (usually set
at 0.05)
n = {(1.96)2 x (0.09) (1.0 - 0.09)} / 0.052
=125
International Journal of Diabetes and Endocrinology
2020; 5(2): 23-33
http://www.sciencepublishinggroup.com/j/ijdee
doi: 10.11648/j.ijde.20200502.12
ISSN: 2640-1363 (Print); ISSN: 2 (Online)
Sample size = 125
Therefore, a total of 125 patients presenting with
DM were selected as subjects the study. The
subjects were selected via random sampling
based on random number generated with MS
Excel software.
2.4 Specimen Collection
Sterile screw-cap containers were given to the
patients to cough into. Collection of samples were
done in a secluded and open-air area. All
collections were done in the morning and
immediately screened. The screw-cap containers
were labelled carefully and appropriately as
described (Jorgenson et al., 2015). This sputum
samples were assessed microscopically as
described by Ekrakene and Igeleke, (2010).
2.5 Data Collection
A structured questionnaire was interviewer-
administered to the recruited subjects. This
structured questionnaire involves 15 questions,
divided into two sections, as follows: ‘Section A’
contained the demographic data of the
respondent, while ‘Section B’ contained the
respondents’ relative history with tuberculosis.
2.6 Statistical Analysis of Data
The data collected was imputed in excel
spreadsheets and exported to SPSS 25 for
analysis. 95 % confidence intervals were
obtained using SPSS. The acceptable level of
error was 0.05 and p-values of <0.05 was
25
significant when a two-tailed T-Test was applied
for the continuous variables. Since two
significant groups was analysed, the TB/DM
group and TB without DM. Only group, a chi
square test was performed for the categorical
variables. Data was summarized using
descriptive statistics.
3. Results
Table 4.1 shows the sociodemographic
distribution of the subjects. The data presented
shows that 49 (39.20%) were male and 76
(60.80%). The age distribution showed that 6
(4.80%) were between 20 -29 years, 15 (12.00%)
were between 30 – 39 years, 22 (17.60%) were
between 40 – 49 years, 25 (20.00) were between
50 – 59 years, 23 (18.40%) were 70 years and
above and 34 (27.20%) were between 60 – 69
years. The mean age of the subjects was
56.05±14.58 years. Among the subjects, 6
(4.80%) were divorced, 12 (9.60%) were single,
36 (26.80%) were widowers/widowed and 71
(56.80%) were married. The highest educational
qualifications were as follows; 13 (10.40%) had
no formal education, 27 (21.60%) had primary
education only, 31 (24.80%) had secondary
education and 54 (43.20%) had tertiary
education. The occupations of the subjects as
distributed include; 2 (1.60%) teachers, 4
(3.20%) drivers, 17 (13.60%) civil servants, 19
(15.20%) unemployed persons, 26 (20.80%)
retired persons and 57 (45.60%) self-employed
persons
International Journal of Diabetes and Endocrinology
2020; 5(2): 23-33
http://www.sciencepublishinggroup.com/j/ijdee
doi: 10.11648/j.ijde.20200502.12
ISSN: 2640-1363 (Print); ISSN: 2 (Online)

Table 1: Sociodemographic Information of the Respondents

Variable Frequency (n = 125) Percentage
Male 49 39.20%
Gender
Female 76 60.80%
20 - 29 years 6 4.80%
30 - 39 years 15 12.00%
40 - 49 years 22 17.60%
Age Group
50 - 59 years 25 20.00%
60 - 69 years 34 27.20%
70 and above 23 18.40%
Mean Age ±SD 56.05±14.58
Divorced 6 4.80%
Married 71 56.80%
Marital Status
Single 12 9.60%
Widow/widower 36 28.80%
No formal education 13 10.40%
Primary 27 21.60%
Education
Secondary 31 24.80%
Tertiary 54 43.20%
Teacher 2 1.60%
Civil servant 17 13.60%
Driver 4 3.20%
Occupation
Retired 26 20.80%
Self employed 57 45.60%
Unemployed 19 15.20%

7, 5.60%

118, 94.40% NEGATIVE

POSITIVE

Figure 1: Prevalence of Tuberculosis in Subjects

26
International Journal of Diabetes and Endocrinology
2020; 5(2): 23-33
http://www.sciencepublishinggroup.com/j/ijdee
doi: 10.11648/j.ijde.20200502.12
ISSN: 2640-1363 (Print); ISSN: 2 (Online)

Figures 1 shows that there was a 5.60% (7/125) prevalence of Tuberculosis (TB) among the
subjects, while 94.40% (118/125) did not have TB.

Table 3: Distribution of Tuberculosis and Duration of Diabetes among Study Subjects

Duration of DM TB Positive TB Negative Chi-square
(p-value)
(n, %) (n, %)
< 1 Year 5 (71.43) 68 (57.63)
1 - 5 Years 2 (28.57) 22 (18.64)
2.21
6 - 10 Years 0 (0.00) 21 (17.80)
(0.5289)**
Above 10 Years 0 (0.00) 7 (5.93)
Total 7 (100.00) 118 (100.00)

Table 3 shows the distribution of TB by the duration of DM among the subject. Among the 7
subjects that had TB, 5 (71.43%) had DM for < 1 year, and 2 (28.57%) had DM between 1 – 5
years. Chi-square analysis showed that the distribution of TB by the years of DM diagnosis was
not statistically significant (c2 = 2.21, p = 0.5289).
Table 4: Distribution of Drug Resistant TB in the study subjects
Drug-resistant TB TB positive TB negative Chi-square
(p-value)
(n, %) (n, %)
Yes 4 (57.14) 0 (0.00)
69.65
No 3 (42.86) 118 (100.00)
(0.0001)*
Total 7 (100.00) 118 (100.00)
*Distribution is statistically significant (p <0.05)
**Distribution is not statistically significant (p > 0.05)
Table 4 shows that distribution of Drug resistant TB in the study subjects, among the subjects that
were positive for TB, 4 (57.14%) had DR-TB and 3 (42.86%) did not have DR-TB. While the
distribution of DR-TB among the subjects was found to be statistically significant (c2 = 69.65, p =
0.0001).
27
 International Journal of Diabetes and Endocrinology
2020; 5(2): 23-33
http://www.sciencepublishinggroup.com/j/ijdee
doi: 10.11648/j.ijde.20200502.12
ISSN: 2640-1363 (Print); ISSN: 2 (Online)

Table 5 Logistic regression of risk factors and TB among the subjects

Variables TB Positive TB Negative Chi- p-value OR (95% CI)
square
(n = 7) (n = 118)

Contact with people Yes 4 (57.14) 3 (2.54) 37.26 0.0001* 51.1 (7.7 - 336.7)
coughing for more
No 3 (42.86) 115 (97.46)
than 2 weeks

Alcohol consumption Yes 3 (42.86) 20 (16.95) 2.95 0.0856** 3.6 (0.7 - 17.7)
No 4 (57.14) 98 (83.05)

Fever Yes 5 (71.43) 43 (36.44) 3.41 0.0644** 4.3 (0.8 – 23.4)

No 2 (28.57) 75 (63.56)

Coughing blood Yes 1 (14.29) 1 (0.85) 7.57 0.0059* 19.5 (1.0 – 351.1)
No 6 (85.71) 117 (99.15)

Having cough for Yes 6 (85.71) 14 (11.86) 26.81 0.0001* 44.5 (4.9 – 397.9)
more than 2 weeks
No 1 (14.29) 104 (88.14)

NA: Not Applicable

*Distribution is statistically significant (p <0.05)
**Distribution id not statistically significant (p > 0.05)

28
International Journal of Diabetes and Endocrinology
2020; 5(2): 23-26
http://www.sciencepublishinggroup.com/j/ijdee
doi: 10.11648/j.ijde.20200502.12
ISSN: 2640-1363 (Print); ISSN: 2 (Online)
4. Discussion
The results showed a 5.60% prevalence of
Tuberculosis (TB) among the subjects. This
is similar to the findings of Wild et al which
reported a 5 – 7% prevalence of TB among
individuals with DM. Similarly, Kozeil et al.,
(2015) reported a 6% prevalence of TB
among subjects with diabetes in Tanzania.
However, in contrast to the findings of these
study, studies across Europe and North
America have reported a <2% prevalence of
TB among subjects with DM (Aguiree et al.,
2013; Zumla, 2013; Martinez and Kornfeld,
2014). Although TB doesn’t seem to be a
common complication of diabetes, these
occurrence of TB among diabetics may most
likely be attributed to the burden of TB in the
local environment. It has been reported that
the prevalence of TB in high-burden
countries corresponds to the occurrence of
TB as a comorbid condition among
individuals with Non-communicable
diseases such as DM (Magee et al., 2015;
Van et al., 2018; Jeon et al., 2018). In this
study, the distribution of the duration DM
among the subjects was not found to be
associated with the occurrence of TB among
the subjects (c2 = 2.21, p = 0.5289). This is
consistent with the reports of Zumla, (2013)
and Martinez and Kornfeld, (2014) which
reported that the occurrence of duration of
DM is not a significant factor in the
occurrence of TB among subjects with DM.
Among the subjects, the occurrence of TB
was found to be significantly higher among
subjects between 20 – 39 years (57.14%) (c2
= 14.44, p = 0.0131). This is consistent with
the findings of other studies which reported
the occurrence of TB to be significantly
29
higher among subjects between 20 – 40 years
old especially in high TB burden countries
such as Nigeria (Chiang, 2015; Dooley and
Chaisson, 2018; Tanrikutu, 2018).
There was a 3.20% prevalence of drug
resistant TB (DR-TB) among the study
subjects. This is lower than the national
prevalence of DR-TB reported to be between
6 – 11% (Lawson et al., 2012). The relatively
low prevalence of DR-TB among the subjects
may be attributed to the relatively low
occurrence of TB among the subjects. There
have been reports of <1.0% occurrence of
DR-TB among diabetics in studies carried
out in advanced countries (Corbett et al.,
2013; Rkpttonirina et al., 2014; Mathers and
Loncar, 2016). The occurrence of DR-TB
among the subjects may not be unrelated to
the current concerns of drug resistant TB
reported in many of the high TB burden
countries (Wild et al., 2014; Workneh et al.,
2016). Similarly, there may also be a
likelihood that most of the subjects had been
diagnosed and treated for tuberculosis in the
past year and may have had a recurring
infection of DR-TB as reported in other
studies (Lawson et al., 2012; Mboussa et al.,
2013; Magee et al., 2015). Among the
subjects with TB, drug resistant tuberculosis
was found to be significantly high, as 57.14%
(4/7) of the subjects with TB had DR-TB (c2
= 69.65, p = 0.0001). This is consistent with
the findings of Ottmani et al., (2014) which
showed that the occurrence of TB is a vital
risk for the occurrence of DR-TB, especially
in countries with a high burden of
tuberculosis.
International Journal of Diabetes and Endocrinology
2020; 5(2): 23-26
http://www.sciencepublishinggroup.com/j/ijdee
doi: 10.11648/j.ijde.20200502.12
ISSN: 2640-1363 (Print); ISSN: 2 (Online)
The study showed that significant risk factors
for the occurrence of TB among the subjects
include; contact with people coughing for
more than 2 weeks (OR: 51.1, 7.7 - 336, p =
0.0001), coughing blood (OR: 19.5, 1.0 –
351.1, p = 0.0059). Coughing for more than
two weeks (OR; 44.5, 4.9 – 397.9, p =
0.00001). These factors have been reported to
be significant risk factors for the occurrence
of TB in various studies (Blanc et al., 2011;
Scott et al., 2015; Dooley and Chaisson,
2018; WHO, 2018). The occurrence of cough
for more than 2 weeks is consistently been
advised to be reported to health care
professionals in countries with high burden
of TB (Lawson et al., 2012). Similarly,
coughing of blood and contact with people
consistently coughing for more than 2 weeks
have been reported as a risk factor for
contracting TB (Chiang, 2015). Tanrikulu
(2018) have also reported that recurrent fever
is one of the most common symptoms among
the newly diagnosed TB patients.
5. Conclusion
The study showed a relatively low prevalence
of TB of 5.60% among the subjects with
diabetes mellitus. However, the duration of
DM was not shown to be significantly
associated with the occurrence of TB among
the subjects. Also, DR-TB was found to
occurrence among the patients. Although, TB
was prevalent among subjects with DM, there
was no indication that DM was a
predisposing factor for the occurrence of TB
among the subjects. The occurrence of TB
among the subjects could be attributed to the
high burden of TB currently in Nigeria.
30
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