Tuberculosis Disability Adjusted Life Year (DALY) Rank of Cause Within Country (both sexes) Source: IHME 2015
Tuberculosis (TB) infected over 9 million people, killing 1.5 million of them, in 2013. The Asia Pacific region carries 56% of this global TB burden, accounting for around 5 million TB cases, and more than half a million TB related deaths in 2013. According to the Diabetes Atlas 2014, diabetes affects 387 million people worldwide out of which 213 million are in the Asia Pacific region. In 2014, diabetes killed 4.9 million people worldwide out of which 3 million (60%) were in the Asia Pacific Region.
About 15% of all TB cases are linked to diabetes. During the recently concluded 5th Asia Pacific Region Conference on Lung Health of the International Union Against Tuberculosis and Lung Disease (The Union), Dr Richard Brostrom, State TB Branch Chief and Pacific Regional Medical Officer of Centers for Disease Control and Prevention (CDC), gave some very interesting but grim statistics regarding the nexus between TB and diabetes. He said that, “People with diabetes on being infected with TB have a 2 times higher risk of remaining culture positive; 3 times higher risk of progression to active TB disease from latent infection; 4 times higher risk of relapse after completing standard TB treatment; and 5 times higher risk of death during TB treatment, as compared to those without diabetes.”
TB-diabetes co-morbidities are now one of the priorities both in clinical and public health aspects. Several studies confirm the necessity of taking this issue seriously if we aim to have a TB free world.
One such study on ‘Detection of TB among diabetes patients to reduce the burden of TB – diabetes mellitus (TB-DM) co-morbidities in Bangladesh’ was presented by Dr Mohammed Sayeedur Rahman at the aforesaid conference. Dr Rahman informed that:
There are 5.9 million people suffering from diabetes in Bangladesh and their number is increasing by 5%–6% each year. Considering the increasing number of populations at risk of both diseases, the combination of TB and DM signifies a health warning for Bangladesh.
Disability Adjusted Life Years (DALYS) Bangladesh 2010 Source: IHME 2015
The objective of the study was to implement collaborative activities to reduce the burden of TB-DM by increasing early case detection and management of TB among DM patients and developing knowledge and awareness on TB- DM co-morbidities among the health professionals.
The USAID TB CARE II project, Bangladesh has been supporting Diabetic Association of Bangladesh (DAB) to increase access to TB services for diabetes patients by improving prevention, early case detection and quality of care, thereby contributing to reduction in mortality and morbidity rates due to TB-diabetes by integrating TB services into diabetes delivery services.
The key activities include early detection of TB in diabetes patients through active screening of diabetes patients and quality of care for patients with TB-DM. As a result, total case notification of all forms of TB among diabetes patients increased manifold – from 337 cases notified during April-December in 2013 to 1119 cases in January – December 2014.
Moreover, DAB (i) oriented 811 health professionals from BIRDEM and affiliated hospitals on screening and management of TB among diabetes patients; (ii) developed a National guideline on management of TB-DM co- morbidities; (iii) provided regular counseling to diabetes patients to sensitize them about increased risks of TB infection and early care seeking for TB services.
Another study presented by Dr Abdul Razak Muttalif of Institute of Respiratory Medicine, Kuala Lumpur Hospital, Malaysia, compared treatment outcomes among TB patients in four states (Penang, Sabah, Sarawak and Selangor) with and without diabetes. The study results showed that:
– 24.4% of the TB patients had diabetes also, which was twice as high as reported by a previous study.
Diabetes Disability Adjusted Life Year (DALY) Rank of Cause Within Country (both sexes) Source: IHME 2015
– A very high percentage of TB-DM patients had poorer treatment success rate with the odd ratio for treatment success rate among them being 0.63 with 95% confidence interval.
– TB-DM patients were found to be at 8% increased risk for TB treatment failure.
– Treatment non-compliance rate and death rate (at 5.8% each) was also high in this group.
Thus diabetes has a strong influence on treatment success rate and hence is a contributing risk factor for mortality among TB patients. Even though Malaysia is a moderate TB burden country, the increasing level of diabetes enhances the chances of an escalating number of TB patients in future. It is because of this reason that all TB patients in Malaysia are screened for diabetes.
TB-Diabetes in Asia Pacific
In an interview, Dr Anthony D Harries, Director, Department of Research, International Union Against Tuberculosis and Lung Disease (The Union), said that TB-diabetes problem is indeed a formidable challenge in the Asia Pacific region. TB is a big problem in many West Asian countries and diabetes is a looming epidemic globally, more so in many West Asian countries, as a result of urbanization, changing life styles and TB. When these two epidemics meet and overlap, it causes a significant problem.
Dr Harries reiterated that, “It is a two-way system. Studies show that people with both type-1 (insulin dependent) and type-2 (related to obesity, high blood pressure) diabetes have 2-3 times higher risk of getting TB compared to normal people, perhaps because diabetes suppresses immunity and these people cannot contain infection as well as normal people – one of them being TB. On the other hand, while TB does not cause diabetes, it stresses the system and in the process increases the body’s blood sugar levels, thus unmasking diabetes in people who are borderline cases.”
While there is already a collaborative TB-diabetes framework produced by the World Health Organization (WHO) and The Union, Anthony feels that it is high time there is more action on the ground.
“All TB patients should be tested for diabetes, even if the patient says he/she does not have diabetes (50% of the people in the world who have diabetes do not know their status). There needs to be a policy decision on this for all countries of the region. At the same time we would advocate that in diabetes clinics of those countries, which have high incidence of TB, it would worthwhile screening diabetes patients for TB. Studies done in China and India have shown that if we screen for TB in diabetes clinics, we are likely to pick up more TB than in normal population. So it would be worthwhile to do this, as diabetes clinics are one of the many hotspots where we can find some of the 3 million missing TB cases that are currently lost by national TB programmes. But this may be easier said than done. We have to be careful while screening diabetes patients for TB, as still there is a lot of stigma attached with TB. So one can casually ask people with diabetes if they have symptoms like coughing for more than 2 weeks, fever, weight loss, night sweat, and then take the matter up further if need be. So bi-directional screening must be done – put policy into action,” he said.
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