The Bali Declaration aims to prevent diabetes from fuelling TB

Dr Amitava Acharyya, CNS Correspondent, India
Photo credit: CNS:
The duel problem of TB and diabetes mellitus (DM) is a major public health dilemma today.  Like in the case of TB-HIV, it has taken several years to focus the attention of the public health community and others on this crucial issue. According to estimates, 6 of the 10 high-TB-burden countries are also expected to have the highest numbers of people living with diabetes by 2035.

India presently has the highest number of TB cases and is also deemed to be the future capital of diabetes. If timely and proper steps are not taken, this will create another back breaking burden on the Indian health system. Reports on the association between DM and TB date back to 1000 A.D. when Avicenna the Greek noted that ‘phthisis’ (Greek for TB), often caused complications in people living with diabetes and that diabetes increased a person’s risk of developing TB. Another description is seen in the works of Yugimahamuni, a traditional Indian saint. He described the association of DM and TB by a combination of symptoms called ‘meganoikal’. These symptoms included obesity,  thirst, respiratory symptoms and unconsciousness.

During the last decade, new evidence about the public health links between the two have re-emerged. In 2009, experts on TB and diabetes gathered in Paris to review the available evidence and determine whether TB diabetes duel burden was strong enough to justify and inform the creation of international guidelines for the care and control of the dual disease. Thus was born the Collaborative Framework for Care and Control of Tuberculosis and Diabetes in 2011 due to the joint efforts of the International Union Against Tuberculosis and Lung Disease (The Union) and the World Health Organization. This document provides evidence-based guidance for policymakers and health programme implementers to begin addressing the growing epidemic of diabetes and TB. Recently, a few days ago ‘The Bali Declaration’ was signed the first international summit on the looming DM-TB co-epidemic. This declaration another step forward to guide the policy makers, health specialists and the community to deal with the situation that merits immediate attention.

The co-morbid state of diabetes and TB is affecting treatment outcomes for both the diseases.  It has been observed that the recurrence of TB and mortality due to TB are much higher among co-morbid diabetes patients, even after being successfully treated for TB. Research also shows that TB patients with DM, remain contagious for a longer period (after treatment begins) than those who do not have diabetes.

The pathology of TB is itself responsible for temporarily increase the level of blood sugar, a condition known as ‘impaired glucose tolerance’, which is a risk factor for developing diabetes. TB and diabetes drugs’ interaction is another concerning issue—rifampicin, a drug used to treat TB, can make it more difficult to control diabetes. Some researcher believe that oral hypoglycaemic agents (OHA) decrease the effectiveness of anti tubercular drugs.

Normally diabetes increases the chance of development to any type of infections. Just like HIV, diabetes also impairs the immune system (though not to the same extent), thus diminishing the body’s ability to fight the TB bacteria within the body. So bi-directional screening is much more applicable to deal with this duel problem. A study done in the Indian state of Kerala found nearly 44% TB patients to be suffering with diabetes also. Timely screening, as well as continued medication and care could increase positive outcomes. There is need to establish greater collaboration between national TB and NCDs (non communicable diseases) control programmes. It would make a lot of economic sense in the long run to incorporate good quality diabetes treatment in the public health programme, just as that exists for TB. Of course, we need to focus attention on prevention programmes as well because as the old adage truly says--prevention is better than cure.

Hopefully, the ‘The Bali Declaration’ will help in galvanizing action to implement comprehensive solutions to deal with this duel burden of TB-DM.

Dr Amitava Acharyya, Citizen News Service - CNS
November 13, 2015