Health Programmes must collaboratively address TB–Diabetes. By Bobby Ramakant

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With growing strong evidence on the dangerous communion between tuberculosis (TB) and diabetes in India, government health programmes must no longer delay implementing TB-diabetes collaborative activities. “Like the HIV/AIDS epidemic, the diabetes epidemic threatens to cause an escalation in TB incidence. China and India constitute 40% of the world’s diabetes population of 400 million people which is likely to go up to half a billion by 2020. If we do not seriously think about the link between TB diabetes my feeling is that it may begin to derail some of the good advances made in India and China on TB control” said Professor (Dr) Anthony D Harries, Senior Advisor, International Union Against Tuberculosis and Lung Disease (The Union) to Citizen News Service (CNS).
"In 2011 India had 6.13 crore people living with diabetes with 983,000 deaths attributable to the disease. India also accounts for 21% of the global incidence of tuberculosis (TB) with 19.8 lakh people developing TB and nearly 300,000 dying of it every year" said Shobha Shukla, Director, CNS Diabetes Media Initiative (DMI) and former senior faculty, Loreto Convent College.
Diabetes Mellitus is a non-curable, non-communicable metabolic disease that occurs when either the pancreas fail to produce sufficient insulin, (the hormone that regulates blood sugar), or when the body cannot use the insulin it produces effectively. It can be treated and controlled effectively although, over a period of time, it does increase the risk of heart disease and stroke and can cause kidney failure, blindness and nerve damage. TB, on the other hand, is a curable airborne disease caused by the Mycobacterium TB that spreads from one person to another through airborne particles.
TB-DIABETES - The Dangerous Communion
Diabetes has a proven relationship with TB. Studies have shown that diabetes triples the risk of contracting TB (risk of developing active TB disease goes up to five times if person has diabetes and also smokes) and can worsen the course of TB. TB in its turn can worsen glycaemic control in people with diabetes. Research has also shown that people with diabetes respond to anti-tuberculosis treatment at a much slower rate. People with a weak immune system, due to chronic diseases such as diabetes, are at a higher risk of progressing from latent to active TB. Diabetes too is complicated by the presence of infectious diseases, including TB.
Professor (Dr) Surya Kant, Head of the Pulmonary Medicine Department, King George’s Medical University (KGMU), said that 3-4% of his TB patients are found with hitherto undiagnosed diabetes. He cautions that, “Ideally before starting Anti TB Treatment (ATT) in patients having diabetes, they should be put on injectable insulin therapy for smooth control of blood sugar levels. Once the treatment is successfully completed, they can switch back to oral therapy. Also, doctors must rule out diabetes in all pulmonary TB patients over 40 years of age who have symptoms like significant weight loss, increased appetite, and increased thirst. Similarly, any person who does not respond to ATT within 2 to 4 weeks should be tested for diabetes.”
Diabetes can be treated and managed, but, over time, it increases the risk of heart disease and stroke and can cause kidney failure, blindness and nerve damage. In 2011, there were an estimated 4.6 million diabetes-related deaths, 80% of them in low- and middle-income countries. This number is expected to double by 2030. The World Health Organization and The Union have published in August 2011 a provisional framework to guide national programmes on how to establish a coordinated response to both diseases at organisational and clinical levels. Also, last year The Union and its partners in China carried out a 9-month first bi-directional screening initiative, screening TB patients for diabetes and diabetes patients for TB in a few hospitals.
Informs Dr S Srinath, Senior Operations Research Fellow, The Union's South East Asia Regional Office, in Delhi: "In India, we are testing one of the components of the WHO and The Union's 'Collaborative Framework on the Care and Control of Tuberculosis and Diabetes' called bi-directional screening, review meeting of which is later this month."
Diabetes and TB represent a critical intersection between communicable and non-communicable diseases. The link between these two diseases may become even more meaningful in coming years, as the prevalence of obesity and diabetes are expected to rise dramatically in the resource-poor areas where TB thrives. With growing evidence, government of India must consider implementing a rational and evidence-based TB and diabetes collaborative programme.
(The transcripts of interviews with some of the above-mentioned key experts and people dealing with TB and diabetes were played as key resource before the discussions took place at Media Dialogue organized on 11th October 2012 in Lucknow, India, by Vote For Health campaign, Citizen News Service (CNS), Asha Parivar and National Alliance of People's Movements - NAPM).

(The author serves as the Director (Policy and Programmes), Citizen News Service (CNS) and received the World Health Organization (WHO) Director-General’s WNTD Award 2008. He writes extensively on health and development through CNS. Email: bobby@citizen-news.org, website: www.citizen-news.org)

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