TB-Diabetes: "An issue relevant all over"

Babs Verblackt, CNS Special Correspondent
The international action against the looming co-epidemic of diabetes and TB should speed up, avoiding a slow response like the one that had happened to the other co-epidemic of TB and HIV years ago. Dr. Anil Kapur, member of the Board of Directors  of the World Diabetes Foundation, explains why - and elaborates on the double burden of diabetes and TB in an exclusive interview with Citizen News Service (CNS).

The world faces a looming co-epidemic of TB-diabetes, a serious health risk that needs to be addressed urgently, emphasizes the report released by the International Union Against Tuberculosis and Lung Disease (The Union) and the World Diabetes Foundation (WDF) at the 45th Union World Conference On Lung Health. According to this report, ‘Diabetes is quietly fueling the spread of TB'. It is escalating, especially in countries where large numbers of people are infected with TB. As diabetes spreads, it will cause more and more people to develop TB’.

Strategies to combat the double burden
The public health response to TB and diabetes should apply the same strategy as the playing strategy of Canadian ice hockey player Wayne Gretzky. "His objective was not to skate to where the puck was on the ice, but always to skate to where the puck was heading," says Dr. Anil Kapur. "We need to use the same approach to TB-diabetes."

"Five years back when the WDF and The Union started working on the issue there was very little information on the double burden from the developing world. But since then many studies and projects have built robust database to support action," says Kapur. "However there are still many missing links – we do not know whether patients with TB and diabetes require a more aggressive or a different treatment regimen. We do not have good quality point of care tools to diagnose diabetes and TB in the primary healthcare settings which are economical to be scaled up on a large scale. While treatment for TB is to a great extent subsidized or free, treatment for diabetes is not readily available in the primary care setting."

"Healthcare providers at the primary care level need training to address the double burden and, in particular, the treatment of diabetes. Also the lack of knowledge about the dual burden amongst policy makers, care providers and patients is a huge challenge," Kapur continues. "On the other hand there are huge opportunities as both diseases share common risk factors – smoking, poor nutrition, harmful use of alcohol, lack of outdoor physical activity, overcrowding, lack of exposure to sunlight and stress. Addressing these common risk factors will help control both conditions and provide an opportunity to share resources and communications."

Screening diabetes patients for TB and screening TB patients for diabetes - or 'bi-directional screening' - is recognized as an important tool in the fight against the looming co-epidemic. Dr. Kapur takes the example of China and India, two countries with the highest burden of TB and diabetes.

"Studies show that in China about a third to half of diabetes cases in TB patients are discovered on screening. About 3% to 6% of TB cases may have previously undiagnosed diabetes  which is detected on screening during TB treatment," Kapur says. "If all 1 million TB cases in China were screened for diabetes it will lead to annually diagnosing at least 30,000 to 60,000 cases of diabetes who otherwise may remain undiagnosed for long periods and have poor outcomes for both TB and diabetes."

Similarly, in India between a third and half of diabetes cases in TB patients are newly discovered on screening, Kapur stresses. "About 6% to 10 % of TB cases may have previously undiagnosed diabetes  which is first detected on screening during TB treatment. If all 2.3 million cases of TB were screened for diabetes about 135,000 to 230,000 cases of diabetes would be identified and receive care," he says.

"A similar situation may be prevailing in other high TB burden countries such as Indonesia, Pakistan, Bangladesh, Brazil, Nigeria and Mexico--countries that have high rates of both diabetes and TB. These 6 countries, along with India and China, account for about 67% of the global burden of both TB and diabetes."

The double burden and risks of TB and diabetes are specifically relevant in countries throughout the world where diabetes is increasing rapidly and TB continues to be present. "Yet the issue is also significant for the developed world because of forced economic or conflict migrations, wherein people from the developing world infected with latent TB may migrate and develop diabetes on migration, triggering the onset of TB disease," Kapur explains. "Migrant populations in general have poor access to health which may delay diagnosis and contribute to its spread in the host country. So it is an issue relevant all over but is particularly relevant in the developing countries and socio-economically challenged populations in the developed world."

Babs Verblackt, Citizen News Service - CNS
29 October 2014
(The author is reporting for CNS from 45th Union World Conference on Lung Health in Barcelona, Spain, with support from the Global Alliance for TB Drug Development (TB Alliance). Email: babs@citizen-news.org)

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