What will it take to avert the looming TB-Diabetes co-epidemic?

Shobha Shukla, CNS (Citizen News Service)
As per latest data, 9.6 million people fell ill with TB and 387 million people were living with diabetes mellitus (DM) in 2014. One person dies of TB every 22 seconds, while diabetes takes a toll of one life every 7 seconds. Six of the 10 countries projected to have the greatest numbers of people living with diabetes by the year 2035 - China, India, Brazil, Indonesia, Pakistan and the Russian Federation—are also classified as high TB-burden countries by the World Health Organization.

What is more frightening is that the disease of poverty (TB) seems to have joined hands with the disease of plenty (DM) and wreak havoc in the form of a co-epidemic. The world’s first International Summit on TB and Diabetes, held in Bali marked the first major effort to mount defense against the looming DM-TB co-epidemic, in an effort to avert a global health crisis. At the end of the two day meet, the organizers of the summit - Indonesian Ministry of Health, the International Union Against Tuberculosis and Lung Disease (The Union) and the World Diabetes Foundation (WDF) - along with more than 100 global health officials and experts, signed the Bali Declaration. It aims to bring the co-epidemic to the attention of governments across the globe and spearhead a global campaign to fight the twin scourge of TB and diabetes.

Bi-directional screening is a key component of this fight. It is a strategy that ensures optimal care is provided to patients with both diseases by diagnosing TB early in people with DM, and DM in people with TB.

Here is what some of the experts had to say:

Dr Lily Sulistyowati, Ministry of Health, Indonesia: Non communicable diseases (NCDs) are now moving from developed countries to emerging economies. Purpose of this summit is to demonstrate that TB-DM is a series public health threat. We need to synthesize evidence and fill the knowledge gaps and act accordingly. Indonesia has taken steps to promote bi-directional screening.

Dr Knut Lonnroth, Senior Medical Officer, WHO: There must be a joint approach to focus on NCDs and communicable diseases (CDs) together. We need to focus more on prevention. DM prevention will result in TB prevention. We will have to link health with development. Health is a beneficiary of development, and more so in TB. Universal Health Coverage is important. We will have to address social determinants of TB like poverty, hunger, environment, and of DM like good health seeking behaviour.

Dr Anil Kapur, Chairman, WDF: the 2030 Sustainable Development Goals (SDGs) have given us a platform to bridge the gap between NCDs and CDs. Let us cut the artificial divide between them. We need to scale up implementation of the Collaborative Framework For Care and Control of TB and DM, that was jointly produced by the WHO and The Union. While the TB world is taking it seriously, the diabetes world is yet to focus enough on this dual problem. Urban slums are hot beds of TB-DM co-morbidity. We will have to make treatment available at point of care level, ensure adequate supply of drugs and also ensure good infection control in DM clinics lest they become centres of TB transmission.

Dr Anthony Harries, senior advisor and Director, Department of Research, The Union: There is very little public health response to this problem. While TB decline is slow, DM is flourishing mainly in the urban poor. Risk of TB is highest in the 1st two years of DM, perhaps when the latter is in its uncontrolled stage.

Dyah Erti Mustikawan, Director of NCD Control, Indonesia: There are an estimated 1 million new TB cases every year in Indonesia, but only less than 33% are notified. Estimated prevalence of DM is 12 million cases, two thirds of which were undiagnosed. In 2014, DM ranked as the 3rd biggest cause of death followed by TB. 13-15% of TB patients in the country also suffer from DM. This rapidly growing pandemic of DM could threaten TB control and sustainable development due to increasing number of cases,increasing mortality and increasing risk of relapse after treatment.

Consensus and guidance for bidirectional screening have been produced to be gradually implemented at all levels of healthcare delivery system. Funding should be made available to implement a robust TB-DM research agenda for development of new tools.

Dr Richard Brostrom, CDC
CNS file photo (08/2015)
Dr Richard Brostrom, DM Control Programme Manager, CDC: Diabetes is the 'HIV of the Pacific'. TB-DM combine is devastating Pacific Islanders where it is more of a rule rather than exception for people to have both. Diabetes complicates TB care. The region also has a high rate of premature deaths due to NCDs.

But there has been a paradigm change in DM management with help from TB DOTS staff. TB staff has at least 100 meetings with TB patients during their course of TB treatment. During these intercations nurses/healthcare workers talk to them about DM and its management.

TB-DM framework: Ensure that blood glucose of the patient is under control during TB treatment. Give DM education at DOTS centres; refer TB-DM cases to DM centres; keep diabetes medicines with DOTS centres. This will result not only in improved TB treatment outcomes but also improved life long DM control.

Professor Susan Fisher Hoch, University of Houston: Burden of DM has increased as people have moved from food insecurity to food security. DM is a continuum of metabolic impairment that increases risk of TB. DM prevention is a tool to control TB. Intensive life style adjustments and use of Metformin in DM patients have shown clear benefits. Diabetes prevention programme should begin at pre-diabetes stage.

The way forward:
  • Address the issue of food that is low in nutrients and high in calories.
  • Educate healthcare personnel in DM and other clinics.
  • Empower DM patients to understand their risk for TB and other infections. Engage communities and partner with them to address the vast pool of undiagnosed DM cases.
  • Engage the media and use modern social media tools to communicate messages.
  • Interventions need to be ethnicity and genetically specific. More well designed studies on tailored interventions are needed.
Anand Madhab, Chief Executive Officer, Jagran: There is very little knowledge in the people about this problem. So there is need to create awareness and sensitize them. The media should be involved from the very beginning as a partner in this process and not as a watchdog. Currently there is no such partnership between media and CSOs to address this co-epidemic. Messages/stories conveyed through the media become the Bible  for the common people.

Jose Luis Castro (Executive Director, The Union and Chair of the NCD Alliance): Convergence of these two diseases can be catastrophic. We have to unite our efforts and create a global strategy to address this imminent crisis. The problem is more severe in low and middle income countries. Healthcare systems will have to be strengthened to deal with this challenge and become more accessible to patients suffering from the dual burden. We have to take action now!

Shobha Shukla, CNS (Citizen News Service)
4 November 2015