Diabetes mellitus and TB: Can we avert a looming co-epidemic?

Catherine Mwauyakufa, CNS Correspondent, Zimbabwe
Photo credit: CNS: citizen-news.org
Diabetes mellitus (DM) and tuberculosis (TB) have a link, even though many people have not really taken time to see that this co-infection is on the increase. In 2013 4% of the global DM burden was in Africa. In the same year, the continent reported 29% of the TB burden. As per the Diabetes Atlas, worldwide 387 million people have DM today and this figure could rise to 552 million in 2030.

Globally there is a large number of people who have DM but do not know their status and there are many thousands more who are not yet diagnosed. 50% of those with DM remain undiagnosed and there is also the challenge that 37% of the estimated TB patients have not been notified.

The risk of acquiring TB increases in people with DM. Other causes that suppress the immune system, like HIV/AIDS, increase the risk to getting TB or suffering a relapse of the disease. The issue that DM increases risk of TB had been recognised even during the Roman times. But, previously there was little interest in TB-diabetes comorbidity, but this has changed in the last ten years. DM increases the risk of TB by 2 to 3 times. Patients with DM have impaired immunity and poor lung defences against TB and multi drug resistance TB (MDR-TB), which makes them more prone to the risk.

The world is committed to achieve an 80% decline in TB incidence by 2030 as compared to 2015 but this cannot be achieved if DM diagnosis and treatment is not accelerated. In Zimbabwe, which is my home country, we still have deaths due to TB, as well as recurrent TB infection. In Zimbabwe there is a collaborative framework for care and control of TB and diabetes, in the same manner as there is collaborative framework for control of TB and HIV co-infection. Patients with DM and TB are treated simultaneously.

The Harare City Department Director of Health Services, Dr Prosper Chonzi said that they were coping well in handling the co-infection. “We treat diabetes at the same time when we commence a patient on TB medication if they are found to have the co-infection. We have managed to have both under control and we have a framework policy in our clinics on managing such patients,” said Dr Prosper Chonzi in a telephonic interview.

“TB is treated for six months with a cocktail of medications but we mainly use isoniazad and rifampicin. After six months a patient is screened to check if any TB remains and if so the treatment is extended until no trace of the TB bacteria is found. TB patients with DM must note that even when they are cleared of TB, they have to continue taking DM medication because it is life-long treatment,” he added.

“Diabetes medication is life-long but you find patients may get tired of taking the pills . This is pill fatigue and it can occur either when a patient is feeling much better or else develops side effects from taking the medication,” he said. People who have been diagonsed with TB recoil into a shell at times, and find it difficult to disclose that they are on TB treatment. This self stigma could be due to lack of understanding of TB disease.

“TB is highly infectious when one is not on treatment and it is during this crucial time, when one does not even know that they have, TB that they are infectious. Usually with correct taking of anti TB medicines one is no longer infectious 72 hours after commencing TB treatment, in case of drug sensitive TB. So there is no fear of transmission once one is on TB treatment. People on TB treatment have been stigmatised because of this lack of information”, said Dr Charles Sandy who heads the AIDS and TB unit in the Ministry of Health and Child Care in Zimbabwe.

Early identification of TB and treatment results in manageable outcomes. TB can present itself with HIV, diabetes and even hypertension. So as all HIV patients are screened for TB, all TB patients should be screened for DM and vice versa, as the co-infection may cause havoc if left unchecked.

Random blood glucose tests are carried out mostly at private institutions. There is no cohort analysis and recording of DM in public institutions.Treating patients with DM and TB co-infection has to be high on the health agenda as leaving it too late may result in what we experienced with TB and HIV in the 90s to mid 2000.

“In the late 90s it was noted that the HIV-TB co-infection was an emergency and many lives were lost due to the co-infection,” said Dr Sandy. “As health personnels we are alert and offer diabetes and TB treatment simultaneously. I am hopeful that TB-DM coinfection will not get to the levels as TB/HIV co-infection did, because we now have the know-how and effective medicines,” he said.

With Zimbabwe geographically located in sub Saharan Africa, which has a heavy burden of HIV and TB co-infection, it has to take the DM-TB infection with the urgency it deserves. With committed leadership and support from governments as outlined in the Abuja Declaration whereby 15% of national budgets have to be channelled to the health sector, TB-DM  infection will be managed. But in scenarios where this is not met, then a gaping hole, which can be a health disaster, looms.

Catherine Mwauyakufa, Citizen News Service - CNS
November 15, 2015