People with diabetes are at a high risk of tuberculosis (TB). According to several studies and systematic reviews, people with diabetes might have 2 to 3 fold higher risk of getting tuberculosis (TB). In the lead up to the World Diabetes Day (14 November), and 41st Union World Conference on Lung Health, Berlin, Germany (11-15 November 2010), it might be wise to see one of the key outcomes of a TB and poverty meeting that brought deadly synergy between diabetes and TB to the fore. The linkage of TB and diabetes came out very prominently when different TB programme managers from Nepal, Thailand, India and those from different Indian states shared their experience at the recently concluded consultative workshop of the TB and poverty sub-working group of the Stop TB Partnership (29-30 October 2010). Read more
The secretariat of TB and poverty sub-working group is housed in the South-East Asia office of the International Union Against Tuberculosis and Lung Disease (The Union) in New Delhi, India.
"The other important non-communicable disease (NCD) that will impact TB control in India and countries in the region is diabetes - the prevalence of this in the general population is high and early studies already suggest that about a fifth of incident sputum positive TB are co-morbid with diabetes. This will require coordinated and urgent measures. There is already a rural predominance in the distribution of diabetes in India, and of course the poor are disproportionately affected. Together with TB, this combination will impoverish already poor people and push them into greater poverty. The upcoming UN NCD summit (September 2011) is an opportunity to focus government attention to the magnitude of this problem and attract donor funding. TB programmes must engage with their counterparts in NCD and specifically diabetes control and management and urgently review mechanisms to identify and manage co-morbidity through coordinated programming" commented Dr Nevin Wilson, Regional Director of The Union's South East Asia office in response to a post "Poor people are most hard hit by TB, COPD and tobacco."
"The risk of mortality is much higher in TB patients who have co-existing diabetes. There are also evidences to suggest that when there is co-existing diabetes it takes longer for the sputum to become negative (for TB) with anti-tubercular treatment" said Dr Anil Kapur, President of the World Diabetes Foundation (WDF).
"There are also suggestions that there are interactions between drugs that are used for treating tuberculosis and managing diabetes, which would affect both the treatment of TB and diabetes. Also there is an issue that because of TB, people who are at risk of diabetes and are not at this stage dealing with diabetes (although they may be having pre-diabetes), so when there is a serious infection like TB, this temporarily leads to a phase where blood sugar levels are up, of course blood sugar levels come down when TB is brought under control. But none-the-less these people (with TB) remain at high risk of getting diabetes in the future" further explained Dr Anil Kapur.
According to a research study done by the University of Texas School of Public Health Brownsville Regional Campus, people with type-II diabetes might be at greater risk for contracting TB. This study also further suggested that:
- Type-II diabetes, especially type-II diabetes involving chronic high blood sugar, is associated with altered immune response to TB, and this was particularly marked in patients with chronically high blood sugar
- Patients with diabetes and TB take longer to respond to anti-TB treatment
- Patients with active TB and type-II diabetes are more likely to have multi-drug resistant TB.
"The other problem is that if in a family if somebody has diabetes, and another person in same family has TB, then the chance of the person with diabetes acquiring TB becomes high" said Dr Kapur.
"As with TB, which often occurs in social-economically less well-off people, people living in crowded places, in urban environments where they don’t have access to care, and are often smoking and they also consume alcohol, many of these same risks apply to diabetes" said Dr Kapur. "So what is starting to happen is that diabetes is much more often seen in people who are poor in the developing countries and also in countries where there is a high burden of TB" further added Dr Kapur.
Also the environment in which TB happens is the one where diabetes is occurring. "This has very dangerous portents especially for countries like India where we have a very high level of diabetes and a very high level of TB" said Dr Kapur. In fact there have been studies that have been published which estimate that the level of tuberculosis caused by diabetes might be quite substantial in India.
"Similarly people with diabetes who complain of persistent cough for more than two weeks, the doctors should be aware of the double risk (for TB and diabetes) and therefore should investigate these people for potential risk for TB. So this is something we are working with the International Union Against Tuberculosis and Lung Disease (The Union) and also with Stop TB programme of WHO. In addition to that we have funded programmes where we are doing this kind of screening and training of community healthcare workers who are working in areas with TB to look for diabetes. One such programme is right now ongoing in Tamil Nadu, India, with diabetes research centre and National TB Research Institute in Chennai. There is another one being undertaken in China" said Dr Kapur.
Such collaborative public health approach will yield positive public health outcomes, keeping fingers crossed for a healthy future.
Bobby Ramakant – CNS
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