Tuberculosis continues to be a major public health challenge, affecting 9 million people and claiming 1.5 million lives annually.
Several risk factors have been associated with TB including HIV, smoking, malnutrition, poverty, and others. A fast emerging addition to this list is diabetes, which significantly increases the risk of TB.
With rapid urbanization, economic development and related lifestyle changes, diabetes is on the rise. It is estimated that around 600 million people will be affected by diabetes in the next two decades — and most of these will be from lower- and middle-income countries, which are already struggling with around 80 percent of all the world’s TB cases.
What threats does diabetes pose to TB control and what can be done to address this issue?
The Millennium Development Goals have been successful in halving the prevalence and mortality and reversing the incidence of TB in most regions of the world. This has been possible with the efforts of the national TB programs supported by various technical agencies — including the World Health Organization and The Union — and donor agencies — including The Global Fund, World Bank and others.
However, this is not sufficient to control the TB epidemic, which continues to affect millions of people globally and causes economic losses in the billions. The forthcoming sustainable development goals will build on the MDGs and propose ambitious and holistic targets to address poverty and hunger; ensure education, health, gender equality, human rights, environmental sustainability, global partnerships and economic development; and provide a framework for U.N. member states to develop their agendas and policies for the next 15 years.
TB remains an important component of this agenda and the post-2015 global framework — the End TB Strategy, which focuses on integrated patient-centered TB care and prevention, supportive system, and intensified research and innovation — aims for a world free of TB, with targets to reduce TB deaths by 95 percent, to cut new cases by 90 percent and to ensure that no family is burdened with catastrophic expenses due to TB by 2035.
But are we facing down a TB-diabetes co-epidemic?
The International Diabetes Foundation estimates the prevalence of diabetes to increase to 10 percent in the next couple of decades. This could result in a situation similar to the rising incidence of HIV in the 1990s, which fuelled the TB epidemic in several African countries and led to unimaginable mortality, morbidity and financial losses from which these countries are yet to recover.
The similarities with the HIV-TB co-epidemic are striking. Like HIV, diabetes weakens the immune system and accelerates the breakdown of those infected with TB to active disease. Diabetes, while causing significant morbidity by itself, is likely to flare up the TB incidence further in rapidly developing countries like India, China, Indonesia, Pakistan and Brazil, which already have high TB burden.
However, unlike the TB-HIV epidemic, where delayed response took its toll, there is still an opportunity to control the TB-diabetes co-epidemic — provided we act rapidly.
The first step is to implement the The Union-WHO recommended collaborative framework on prioritizing countries at higher risk and advocates for collaboration of the national programs on TB and diabetes at all levels of the health system. All patients should be screened for diabetes and all the diabetes patients should be screened for symptoms of TB periodically — and managed accordingly.
So what are the challenges of implementing this framework?
First, it will require institution of policies by countries to provide a platform to integrate diabetes and TB control programs as a priority.
Second, while most of the countries have a robust and well-functioning TB program, many diabetes programs are still rudimentary. The diagnostic and treatment services for TB are widely available at little or no cost to the patients, whereas those for diabetes are limited and expensive which makes bidirectional screening and management of those with both diseases challenging. Additional resources will be required for strengthening the diabetes programs, including developing standardized protocols for management, training of health staff, providing test kits and drugs, and establishing a recording, reporting and follow up mechanism.
There are several opportunities in these challenges. The strengths of the already established TB programs can be leveraged to serve as an entry point for identification of diabetes patients and create the demand that diabetes programs can match gradually as they scale up.
TB programs can also pragmatically allocate resources for collaborative activities to serve as seed money to strengthen diabetes programs. This will encourage further investment from conventional and nonconventional donors as they begin to see the value. The success of the TB program anchors on the simple and standardized management protocol, decentralized services and a robust recording, reporting and follow-up mechanism — something that diabetes programs can learn from and replicate.
So what is our call to action for the global development community?
The implementation of the collaborative framework will require commitment and resources. During the last World Lung Conference in Barcelona in 2014, a historic report on the looming TB-diabetes co-epidemic synthesized the scientific evidence on how TB and diabetes are linked, promoting the global policy framework as a way to address the two diseases together. This scientific document can be the starting point for advocating the integration of TB and diabetes control programs.
The upcoming third International Financing for Development conference in Addis Ababa in July is an opportunity to discuss how multilateral development agencies can assist governments in aligning TB and diabetes programs in LICs and MICs — and encourage investment of funds and other resources towards strengthened collaboration along the same lines as the TB-HIV implementation model. This will be a major leap towards ensuring ending TB for good.