Health & Medical Public Health

Alcohol Use as a Risk Factor for Tuberculosis -- A Systematic Review

Alcohol Use as a Risk Factor for Tuberculosis -- A Systematic Review

Abstract and Background


Background: It has long been evident that there is an association between alcohol use and risk of tuberculosis. It has not been established to what extent this association is confounded by social and other factors related to alcohol use. Nor has the strength of the association been established. The objective of this study was to systematically review the available evidence on the association between alcohol use and the risk of tuberculosis.
Methods: Based on a systematic literature review, we identified 3 cohort and 18 case control studies. These were further categorized according to definition of exposure, type of tuberculosis used as study outcome, and confounders controlled for. Pooled effect sizes were obtained for each sub-category of studies.
Results: The pooled relative risk across all studies that used an exposure cut-off level set at 40 g alcohol per day or above, or defined exposure as a clinical diagnosis of an alcohol use disorder, was 3.50 (95% CI: 2.01–5.93). After exclusion of small studies, because of suspected publication bias, the pooled relative risk was 2.94 (95% CI: 1.89–4.59). Subgroup analyses of studies that had controlled for various sets of confounders did not give significantly different results and did not explain the significant heterogeneity that was found across the studies.
Conclusion: The risk of active tuberculosis is substantially elevated in people who drink more than 40 g alcohol per day, and/or have an alcohol use disorder. This may be due to both increased risk of infection related to specific social mixing patterns associated with alcohol use, as well as influence on the immune system of alcohol itself and of alcohol related conditions.


It has been evident for decades that there is a strong association between alcohol use and risk of tuberculosis (TB). Prevalence of alcohol use disorders among TB patients have ranged from 10% to 50% in studies carried out in Australia, Canada, Russia, Switzerland, and the USA. Similar evidence of a strong link emerges from studies in which population groups with high prevalence of alcohol use disorders have been screened for TB. Jones et al found that the prevalence of active pulmonary TB among social service clients (among whom alcohol use disorders was the main problem) in the USA in the 1950s was 55 times the prevalence of the general population (2,220/100,000 vs. 40/100,000). Friedman et al reported a 46 times higher prevalence among people with alcohol use disorders (who did not abuse other drugs) in New York in the early 1980s (1,500/100,000 vs. 32/100,000). In a cohort of persons with alcohol use disorders who were followed prospectively for 8 years, the TB incidence was 464/100,000 person-years, which was 9 times the age-matched incidence among the general population in New York. However, these studies did not control for potential confounders.

Possible causal pathways include specific social mixing patterns among people with alcohol use disorders, leading to higher risk of infection, or weakened immune system leading to higher risk of break down from infection to TB disease. The latter may be through direct toxic effects of alcohol on the immune system, or indirectly through micro- and macronutrient deficiency, or other alcohol-related medical conditions such as malignancies and depression.

This paper reviews analytical epidemiological studies with individual-level data on alcohol exposure and TB disease status, with the aim to determine if there is a likely causal association between alcohol use and risk of TB disease. The paper also attempts to estimate the strength of such an association.

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