Time to manage diabetes and latent TB

Roger Paul Kamugasha, CNS Correspondent, Uganda
Research has proved that people with diabetes are at high risk of developing active TB disease. This calls for global attention to focus on specific action in order to shift the paradigm of the escalating TB-diabetes burden. These actions should focus on earmarking resources for investment into research, advocacy communication and social mobilization.

Diabetes has also been found to be associated with a small but statistically significant risk for latent TB infection (LTBI). In a webinar hosted by CNS, Dr Leonardo Martinez of Stanford University, shared the findings of the first ever population based study (of which he was the lead researcher) that diabetes (and pre-diabetes) increases risk of latent TB infection. Usually the risk for people with diabetes to get latent TB goes up two times, but higher risk was found for those with poor glycaemic control.

Advocacy for LTBI screening among people with diabetes is pertinent. Latent TB is a major impediment hindering complete elimination of TB, even in low-risk countries. Many cases of TB arise from reactivation of latent TB; this is particularly evident in high –risk groups or vulnerable subpopulations. The WHO estimates that one in three people in the world has LTBI and is at risk of TB reactivation.

Diabetes is a disease where blood glucose levels are above normal because the body is either not making enough insulin or is not able to fully utilise insulin made in order to prevent build-up of glucose in the blood and to help distribute it to the cells of the body. Diabetes is also one of the few chronic diseases listed as a risk factor for TB.

At the same webinar, Dr Anil Kapur, of the World Diabetes Foundation, said that globally 415 million people are affected with diabetes and there are another about 330 million odd people with pre-diabetics. So we are talking about a population of about 700 million people who are highly vulnerable to acquire TB infection, and many of these are living in countries where TB is quite endemic. In fact 80% of people with diabetes live in low and middle income countries and about 95% of the TB burden is also in those countries.

So diabetes is indeed fueling the spread of TB. Diabetes is also more difficult to manage in people who have TB. And a person sick with both diseases is likely to have complications that do not typically exist when either one is present on its own. Addressing the increasing TB- diabetes burden therefore requires a coordinated response to both diseases at all levels of the health system— from the crafting and implementation of national policies, to the management of disease control programes, to the delivery of services to individual patients.

This calls for specific investment demands to implement the recommendations within the Collaborative Framework for Care and Control of TB and diabetes. There is a need to establish policies at local and global levels that call for, and enable, coordination between public health programs currently tasked with controlling TB and responding to diabetes. Countries with a high burden of TB and escalating rates of diabetes should institute such policies as priority. Funds have to be made available to implement a robust research and development agenda.

Guidance that the Global Fund to Fight AIDS, Tuberculosis and Malaria has issued for the inclusion of coordinated TB-HIV activities within its funding proposals could serve as a good precedent for similar guidance for TB-diabetes activities.

The link between TB and diabetes breaks the centuries’ old myth that linked TB to poverty and associated diabetes with the well-to-do. To me this is an opportunity to mitigate all the risks related to how a non communicable disease impacts an infectious disease, bringing the poor and rich on the same table. This will eliminate the fallacy of social determinants of TB that seem to have missed the point of TB being an airborne disease that can infect the rich and poor in equal measures.

There is need to impart advocacy, communication and social mobilization skills to clinicians who treat clients for TB and/or diabetes; make patients aware of the risks and promote referrals; educate policymakers, large-scale public health program implementers about TB-diabetes and work to shape policies and mobilize resources to implement the Collaborative Framework. Countries should also develop a media agenda for advocates in low- and middle-income countries where TB- diabetes is a growing challenge; wage campaigns to educate decision makers and the public, and call for the implementation of the TB-Diabetes Collaborative Framework within their countries.

Political will is vital to have in place ministerial agendas in order to not only provide a cross border continuum of care for people living with both diseases, but also to ensure that the spiraling of the two diseases is halted. It is timely and innovative to take joint decisions  at the upcoming Moscow Ministerial Conference for curbing TB and diabetes in the post 2015 sustainable development era.

Roger Paul Kamugasha, Citizen News Service - CNS
November 3, 2017