Prevalence and factors associated with tuberculosis infection among diabetic patients in the northeast state of Peninsular Malaysia
DOI:
https://doi.org/10.63719/imrj.2026.12.01.004Abstract
The link between tuberculosis and diabetes mellitus is a significant public health concern. This study aimed to determine the prevalence of tuberculosis and its associated risk factors among diabetic patients in Kemaman, Malaysia. In this cross-sectional study, we analysed secondary data from 225 diabetic patients randomly sampled from the National Diabetes Mellitus Registry (2015-2019) in Kemaman. Tuberculosis status was verified using the national surveillance registry, and data were analysed with logistic regression. The prevalence of tuberculosis was 17.0%. A longer duration of diabetes mellitus significantly increased tuberculosis risk (adjusted odds ratio 1.28; 95% CI: 1.14–1.44), while older age at diagnosis (adjusted odds ratio 0.86; 95% CI: 0.82–0.91) and being overweight or obese (adjusted odds ratio 0.20; 95% CI: 0.07–0.63) were significantly protective. Our findings reveal a complex interplay between metabolic health and immunity to tuberculosis. The paradoxical protective effect of a higher body mass index and older age at diagnosis, contrasted with the risk from prolonged diabetes mellitus, highlights the need for nuanced risk assessment to refine screening protocols. The 17.0% prevalence and the identification of age, body mass index, and duration of diabetes mellitus as crucial associated factors underscore the need for targeted public health strategies. Screening those diagnosed at a younger age.
References
World Health Organization. Tuberculosis [Internet]. 2020 (cited 2024 Aug 18). Available from: https://www.who.int/health-topics/tuberculosis#tab=tab_1
World Health Organization. Malaysia Country Fact Sheet Public Health Data at a Glance (Internet). Geneva: WHO; 2019 (cited 2024 Aug 18). Available from: https://www.who.int/docs/default-source/wpro---documents/countries/malaysia/fact-sheet-malaysia/who-my-factsheet-fa-09042020.pdf?sfvrsn=db2f8b32_2
World Health Organization. Diabetes (Internet). 2023 (cited 2024 Aug 18). Available from: https://www.who.int/news-room/fact-sheets/detail/diabetes
Ministry of Health Malaysia. NCDs-Non-Communicable Diseases: Risk factors and other health problems (Internet). 2019 (cited 2024 Aug 18). Available from: https://iku.moh.gov.my/images/IKU/Document/REPORT/NHMS2019/Report_NHMS2019-NCD_v2.pdf
World Health Organization. TB and Diabetes (Internet). 2024 (cited 2024 Aug 18). Available from: https://www.who.int/publications/digital/global-tuberculosis-report-2021/featured-topics/tb-diabetes#:~:text=The%20prevalence%20of%20diabetes%20influences,)%20(2%2D4%20(2%2D4))
Syed Suleiman SA, Ishaq Aweis DM, Mohamed AJ, Razak Muttalif A, Moussa MA. Role of diabetes in the prognosis and therapeutic outcome of tuberculosis. Int J Endocrinol. 2012;2012:645362. doi: 10.1155/2012/645362.
Jeon CY, Murray MB. Diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. PLoS Med. 2008;5(7):e152. doi:10.1371/journal.pmed.0050152.
Suhairi MH, Mohamad M. Risk factors for tuberculosis-related death among adults with drug-sensitive pulmonary tuberculosis in Selangor, Malaysia from 2013 to 2019: a retrospective cohort study using surveillance data. BMJ Open. 2024;14(2):e080144. doi: 10.1136/bmjopen-2023-080144.
Mohidem NA, Osman M, Hashim Z, Muharam FM, Elias S, Shaharudin R. Identifying Hotspots of Tuberculosis Cases in Gombak, Selangor, Malaysia [Internet]. ResearchGate; 2023 [cited 2025 Aug 13]. Available from: https://www.researchgate.net/publication/372717981_Identifying_Hotspots_of_Tuberculosis_Cases_in_Gombak_Selangor_Malaysia
Khor L, Wahid U, Ling L, Liansim S, Oon J, Balakrishnan M, et al. Prevalence and associated factors of delayed sputum smear conversion in patients treated for smear positive pulmonary tuberculosis: A retrospective follow up study in Sabah, Malaysia. PLoS One. 2023;18(3):e0282733. doi: 10.1371/journal.pone.0282733.
Baskaran N, Lian LS, Jamludin NA. Factors influencing delay in sputum conversion in smear-positive pulmonary tuberculosis patients in primary care in Kuala Lipis Pahang. Int J Health Sci. 2022;6(S7):13077-90. doi:10.53730/ijhs.v6nS7.13077.
Ahmad SR, Yaacob NA, Jaeb MZ, Hussin Z, Wan Mohammad WMZ. Effect of Diabetes Mellitus on Tuberculosis Treatment Outcomes among Tuberculosis Patients in Kelantan, Malaysia. Iran J Public Health. 2020;49(8):1485-93. doi: 10.18502/ijph.v49i8.3892.
Husain NF, Yusoff HM, Hassan NM, Aziz AA. Prevalence of Latent Tuberculosis Infection and its Associated Factors Among Diabetic Patients Availing Primary Health Care in Terengganu State, Malaysia. Oman Med J. 2023;38(5):e546. doi: 10.5001/omj.2023.97.
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(1):6. doi: 10.1186/2049-9957-2-6.
Lin YH, Chen CP, Chen PY, Huang JC, Ho C, Weng HH, et al. Screening for pulmonary tuberculosis in type 2 diabetes elderly: a cross-sectional study in a community hospital. BMC Public Health. 2015;15:3. doi: 10.1186/1471-2458-15-3.
Castellanos-Joya M, Delgado-Sánchez G, Ferreyra-Reyes L, Cruz-Hervert P, Ferreira-Guerrero E, Ortiz-Solís G, et al. Results of the implementation of a pilot model for the bidirectional screening and joint management of patients with pulmonary tuberculosis and diabetes mellitus in Mexico. PLoS One. 2014;9(9):e106961. doi: 10.1371/journal.pone.0106961.
Amin S, Khattak MI, Shabbier G, Wazir MN. Frequency of pulmonary tuberculosis in patients with diabetes mellitus. Gomal J Med Sci. 2011;9(2). Available from: https://gjms.com.pk/index.php/journal/article/download/366/363
Workneh MH, Bjune GA, Yimer SA. Prevalence and associated factors of tuberculosis and diabetes mellitus comorbidity: a systematic review. PLoS One. 2017;12(4):e0175925. doi: 10.1371/journal.pone.0175925.
Ministry of Health Malaysia. Clinical Practice Guideline Management of Tuberculosis (Fourth Edition) (Internet). 2021 (cited 2024 Aug 17). Available from: https://www.moh.gov.my/moh/resources/Penerbitan/CPG/Respiratory/CPG-Management_of_Tuberculosis(4th_Edition).pdf
Wang L, Wang W. Temporal Trends in Notification and Mortality of Tuberculosis in China, 2004–2019: A Joinpoint and Age–Period–Cohort Analysis. Int J Environ Res Public Health. 2021;18(11):5607. doi:10.3390/ijerph18115607.
Cheng J, Sun YN, Zhang CY, Yu YL, Tang LH, Peng H, et al. Incidence and risk factors of tuberculosis among the elderly population in China: a prospective cohort study. Infect Dis Poverty. 2020;9(1):13. doi: 10.1186/s40249-019-0614-9.
Hauer B, Brodhun B, Altmann D, Fiebig L, Loddenkemper R, Haas W. Tuberculosis in the elderly in Germany. Eur Respir J. 2011;38(2):467-70. doi: 10.1183/09031936.00199910.
Kumar NP, Babu S. Impact of diabetes mellitus on immunity to latent tuberculosis infection. Front Clin Diabetes Healthc. 2023;4:1095467. doi: 10.3389/fcdhc.2023.1095467.
Ministry of Health Malaysia. National Diabetic Registry Report 2020 [Internet]. 2020. Available from: https://www.moh.gov.my/moh/resources/Penerbitan/Rujukan/NCD/Diabetes/National_Diabetes_Registry_Report_2020.pdf
Araia ZZ, Mesfin AB, Mebrahtu AH, Tewelde AG, Osman R, Tuumzghi HA. Diabetes mellitus and its associated factors in tuberculosis patients in maekel region, eritrea: analytical cross-sectional study. Diabetes Metab Syndr Obes. 2021;14:515-23. doi: 10.2147/DMSO.S293557.
Lin HH, Wu CY, Wang CH, Fu H, Lönnroth K, Chang YC, et al. Association of Obesity, Diabetes, and Risk of Tuberculosis: Two Population-Based Cohorts. Clin Infect Dis. 2018;66(5):699-705. doi: 10.1093/cid/cix852.
Berkowitz N, Okorie A, Goliath R, Levitt N, Wilkinson RJ, Oni T. The prevalence and determinants of active tuberculosis among diabetes patients in Cape Town, South Africa, a high HIV/TB burden setting. Diabetes Res Clin Pract. 2018;138:16-25. D[oi: 10.1016/j.diabres.2018.01.018.
Soh A, Chee C, Wang Y, Yuan J, Koh W. Diabetes and body mass index in relation to risk of active tuberculosis: a prospective population-based cohort. Int J Tuberc Lung Dis. 2019;23(12):1277-82. doi: 10.5588/ijtld.19.0094.
Matarese G, Moschos S, Mantzoros CS. Leptin in immunology. J Immunol. 2005;174(6):3137-42. doi: 10.4049/jimmunol.174.6.3137.
Neyrolles O, Hernández-Pando R, Pietri-Rouxel F, Fornès P, Tailleux L, Payán JAB, et al. Is adipose tissue a place for Mycobacterium tuberculosis persistence? PLoS One. 2006;1(1):e43. doi: 10.1371/journal.pone.0000043.
Yang S, Wang S, Yang B, Zheng J, Cai Y, Yang Z. Weight loss before a diagnosis of type 2 diabetes mellitus is a risk factor for diabetes complications. Medicine (Baltimore). 2016;95(49):e5618. doi: 10.1097/MD.0000000000005618.
Yoo JE, Kim D, Han K, Rhee SY, Shin DW, Lee H. Diabetes Status and Association With Risk of Tuberculosis Among Korean Adults. JAMA Netw Open. 2021;4(9):e2126099. doi: 10.1001/jamanetworkopen.2021.26099.
Leal ML, Maciel ELN, Cade NV. Factors associated with tuberculosis in a population of diabetics: A case-control study. Cien Saude Colet. 2019;24(9):3247-56. doi: 10.1590/1413-81232018249.30392017.
Pealing L, Wing K, Mathur R, Prieto-Merino D, Smeeth L, Moore DAJ. Risk of tuberculosis in patients with diabetes: population based cohort study using the UK Clinical Practice Research Datalink. BMC Med. 2015;13:135. doi: 10.1186/s12916-015-0381-9.
Shim WS, Kim SK, Kim HJ, Kang ES, Ahn CW, Lim SK, et al. Decrement of postprandial insulin secretion determines the progressive nature of type-2 diabetes. Eur J Endocrinol. 2006;155(4):615-22. doi: 10.1530/eje.1.02249.
Tsai S, Clemente-Casares X, Zhou AC, Lei H, Ahn JJ, Chan YT, et al. Insulin receptor-mediated stimulation boosts T cell immunity during inflammation and infection. Cell Metab. 2018;28(6):922-34.e4. doi: 10.1016/j.cmet.2018.08.003.
