Double burden of TB-diabetes: Are we ready?

Carolyn Kavita Tauro, CNS Special Correspondent
Diabetes has been long seen as a disease of the rich. Today, however, it is clear that the disease is also prevalent in low- and middle-income countries, affecting the rich and the poor alike. Like malnutrition and HIV infection that compromise a person’s immunity, chronic conditions like diabetes, have also shown to impair a person’s defense system against tuberculosis (TB).

While diabetes has for long been focused as one of the non-communicable diseases, this disease seems to quietly augment the spread of TB. Dr Ramesh Pawar, a consultant diabetologist in Mumbai, says, “If a patient has diabetes, the TB is fulminant or spreads rapidly. It is a vicious cycle – one neglected aggravates the other. Any stress, be it psychological or pathological, increase blood glucose levels and tuberculosis does just that”.

According to the International Diabetes Federation (IDF)'s Diabetes Atlas, while 382 million people were affected with diabetes in 2013, this number is projected to increase to about 592 million in the year 2035. One and a half million have said to have died due to tuberculosis in the year 2013 (Global Tuberculosis Report 2014). Patients with diabetes are three times more likely to get active TB. There is much evidence of high rates of diabetes in people with TB and of a significant number of diabetics being diagnosed with TB. Various studies in India show a prevalence of diabetes between 25 to 44 % in TB patients (Figure 1).

Prevalence of Diabetes in TB patients: Recent Studies
Region                           TB Patients w/Diabetes    Year Published
Karnataka State, India                 32%                              2011
Kerala State, India                      44%                               2012
Tamil Nadu State, India              25%                              2012
Texas, USA                                 39%                               2011
Mexico                                        36%                               2011
Tanzania                                      17%                               2011
Pakistan                                       16%                              2012
South Pacific                         40-45%                              2013
Figure 1: Prevalence of Diabetes in TB patients: Recent studies (Source: The Looming Co-epidemic of TB Diabetes: A Call to Action, page 7).

India is classified as being a “high TB burden, high MDR-TB burden & High HIV burden country” (WHO country fact sheet), and now it is projected to be one of the five countries with half of the world’s diabetics by 2030, the others being China, Indonesia, Pakistan and Brazil.  With about 61.3 million adults with diabetes in India in 2011 (IDF, Diabetes Atlas), there is increased risk that persons with diabetes will become sick with TB.

Managing TB-Diabetes
Diabetes is more difficult to manage in people with TB, due to interactions between anti-tubercular drugs and anti-diabetic medications, and likely to manifest with more complications. Also, among those with diabetes, the likelihood that the person will die or get TB again after they have been successfully treated is also significantly higher. They also remain infectious for far longer than those without diabetes.

 “The difficulty with treating a patient with tuberculosis who also has diabetes is that more often than not he or she has uncontrolled diabetes. This along with extensive tuberculosis (usually one lung completely diseased etc.) makes it a very challenging case to treat, even more so if thoracic surgery is required”, says Dr Lalit Kumar Anande, Chief Medical Officer, Group of TB Hospitals (also known as Sewri Hospital), Mumbai. While he says it is still possible (to treat diabetes) in an inpatient setting, the problem heightens when the patient leaves the hospital and there is no one who can treat them for the diabetes at the DOTS centers. “DOTS providers are not trained in treating diabetes, they do not have anti-diabetic medications and are not able to keep insulin because of cold chain issues etc. This means while there is follow up with tuberculosis, there is none with diabetes, and this does not help either condition”, he adds.

“A patient with TB and Diabetes together needs the attention of two specialists so that the disease is fought together and aggressively. By the time one disease is controlled, the other may go haywire, if treated separately”, stressed Dr Pawar. The number of diabetologists in India is very small and most patients are treated by physicians, usually not trained in managing diabetes. “The problem lies in the fact that physicians do not have the time to counsel patients when extensive counseling is most essential in these conditions”, says Dr Pawar. “Patients need to be told what their status is, how it will be treated and that their treatment will be a long term, even lifelong one”, he emphasizes.

Patients suffering from tuberculosis usually come from a lower socio economic background. Dr Anande mentions how they are usually unprepared to be diagnosed with yet another disease, this time a life-long one, when they had come to get their TB treated in the first place. “They tend to stop medications, do not get them on time and even refuse to take treatment such as insulin therapy”, says Dr Pawar.

A familiar co-epidemic: TB-HIV
The world has faced a very similar story with another co-epidemic of TB and HIV. Like diabetes, infection with HIV decreased immunity levels in HIV increases the chances of acquiring and complicating tuberculosis. The approach to both epidemics, however, is different as in most countries treatment for TB and HIV is borne by the government while treatment for diabetes is usually an out of pocket expenditure. In India, this might not apply completely. Even though HIV and TB treatment is provided free of cost by the government, it is a known fact that most TB patients seek medical care from private practitioners before and after being diagnosed with TB. The out-of-pocket expenditure in these cases is already sky high, adding to which the cost of anti-diabetics and follow up makes it difficult for someone from a low economic background to comply by.

With increase in case detection and treatment, expenditures will increase for the individual as well as for governments. With the rate of diabetics in India only rising, this means a significant increase in the number of patients newly detected with TB, this usually being only the tip of the iceberg. With diminishing international funds for TB and private practitioners further referring patients to the public sector, what will become of the already burdened government health system? The Tuberculosis units, both urban and rural, will have a massive increase in the number of patients with absolutely no extra resources. There has been no separate funding for TB-HIV within the national tuberculosis program and if the same is applied to TB-Diabetes, very little will be possible in practice to overcome the challenges to respond to this dual condition.

Besides this, we already face the issue of TB and HIV programs being vertical entities, with TB and HIV clinics functioning separately. This increases the number of patients on either side that are lost to follow up or dead before the co-morbidity is detected. The same is true for TB-diabetes, where diabetes is dealt with separately under the National Program on Prevention and Control of Cancer, Diabetes, Cardio-vascular Diseases and Stroke (NPCDCS). “In TB hospitals, our doctors only focus on the chest”, says Dr Anande. “They do not, many a time suspect, or treat other conditions like diabetes. If diagnosed, the process of referral to another hospital usually leads to many issues and the process takes much longer. This then leads to improper follow up”. He stresses that the need for diabetes to be treated along with TB at the DOTS center level.

The challenges with this dual burden seem immense. Increasing financial costs on an already burdened health system, lack of training of DOTS providers as well as physicians and the effect on the individual all point towards a looming epidemic in the making. Many a steps need to be taken towards controlling this dynamic duo of diseases.

Carolyn Kavita Tauro, Citizen News Service - CNS
1 November 2014