The Dangerous Communion of Tuberculosis and Diabetes

(CNS): In 2011 India had 61.3 million people living with diabetes (17% of the global incidence of 366 million) with 983,000 deaths (20% of the global figure of 4.6 million) attributable to the disease. India also accounts for 21% of the global incidence of tuberculosis (TB) with 1.98 million people developing TB and nearly 300,000 dying of it every year. Diabetes Mellitus is a non-curable, non-communicable metabolic disease that occurs when either the pancreas fail to produce sufficient insulin, (the hormone that regulates blood sugar), or when the body cannot use the insulin it produces effectively. It can be treated and controlled effectively although, over a period of time, it does increase the risk of heart disease and stroke and can cause kidney failure, blindness and nerve damage.

Tuberculosis, on the other hand, is a curable airborne disease caused by the Mycobacterium TB that spreads from one person to another through airborne particles. However, in people with strong immune systems the bacteria are quickly destroyed once they enter the body. Some may develop latent TB infection and carry the bacteria but may not be contagious. But those having low immunity are at high risk of becoming contagiously sick with TB.

Diabetes has a proven relationship with tuberculosis. Studies have shown that diabetes triples the risk of contracting TB and can worsen the course of TB. TB in its turn can worsen glycaemic control in people with diabetes. Hence strategies are needed for managing people with both diseases, for screening TB patients for diabetes and people with diabetes for TB. Early diagnosis is critical for both diseases.

Professor (Dr) Surya Kant, Head of the Pulmonary Medicine Department, King George's Medical University (KGMU), said to Citizen News Service (CNS) that 3% to 4% of his TB patients are found with hitherto undiagnosed diabetes. He cautions that, “Ideally before starting Anti Tuberculosis Treatment (ATT) in patients having diabetes, they should be put on injectable insulin therapy for smooth control of blood sugar levels. Once the treatment is successfully completed, they can switch back to oral therapy. Also, doctors must rule out diabetes in all pulmonary TB patients over 40 years of age who have symptoms like significant weight loss, increased appetite, and increased thirst. Similarly, any person who does not respond to ATT within 2 to 4 weeks should be tested for diabetes.”

Razia Begum (name changed), a 55 years old widow living in Lucknow, had no idea as for how long she had been living with diabetes and TB. Her eye sight had steadily deteriorated over the past 10 years. But it was only in April, 2012 when she really became very sick with high fever accompanied by vomiting, severe loss of appetite and weakness, that she became concerned about her health. Her blood sugar levels were very high at 500mg/dl and her chest X-Ray showed some lung infection. She took insulin injections for one month, but her condition did not improve. Neither her sugar levels nor her fever went down. Since August, 2012 she is under the treatment of her present doctor who also diagnosed her with TB. Now she is taking treatment for both diabetes and TB—one pill for TB (on an empty stomach) and two pills for diabetes every day. Her fever is gone, her appetite has returned, there is no nausea or vomiting, and her health is almost back to normal. However she is finding it difficult to shell out Rs 400 ($8) per week to buy medicines from the open market. She admits being very short tempered and mentally stressed all the time due to family problems.

Professor (Dr) Anthony Harries of the International Union Against Tuberculosis and Lung Disease (The Union), avers that, “We now know that if the diabetes is out of control one is more at risk of getting TB than when the diabetes is under control. So this is a clear message that if one has diabetes the blood sugar levels should be kept down. Diabetes upsets the immune system in different ways and if the immune system is down, the risk of contracting TB as well as other infections increases. So in patients with diabetes we need to think about TB and screen them and in patients with TB we need to think about diabetes. If we do not seriously think about the link between TB diabetes, it may begin to derail some of the good advances made in TB control, especially in countries like China and India.”

The example of Naresh Misra (name changed), a 54 years old farmer who is an ex TB patient and is also living with diabetes, validates Professor Anthony's fears. Naresh's health deteriorated over a period of time and 4 years ago he started feeling very weak and vomited blood on walking and even talking a little bit. But the doctors could not diagnose his problem. One day he fell down suddenly due to excessive weakness. The tests revealed a very high blood sugar level of 495 mg/dl. He sought treatment in the private sector, but got no relief. Eventually he showed himself to his present doctor in a Government Medical College who suspected TB as well, which was confirmed by a chest X-Ray. His TB and diabetes medication started together around three years ago. He has since been cured of TB after one year of a daily dose regimen of TB treatment, but has to continue taking one pill daily to keep his diabetes under control. He admits being very irregular in getting his sugar levels tested periodically as he is scared of the amount of blood which is drawn at every testing.

Naresh admits that, “I have been a smoker since long and still smoke a few cigarettes every day. I was off smoking during my TB treatment, but have resumed it again. When there is more tension, my smoking also goes up. It is like an addiction and difficult to leave, though I want to quit. I want to take some medicine which will help in cessation.”

Professor Anthony warns that, “Smoking in its own right increases the risk of TB. So if one has diabetes and is also a smoker one has a higher risk, maybe 5 times higher risk of getting TB. Smoking is no good for diabetes (and for TB) because smoking hardens and narrows the arteries and so does diabetes.”

The increasing incidence of diabetes, particularly in low- and middle-income countries, is a crisis that is now receiving global attention. It threatens to have a negative impact on TB control, and vice versa. Strategies are therefore needed for managing people with both diseases as one exacerbates the other. The World Health Assembly set the “25 by 25” target at its May 2012 meeting. This target aims to reduce deaths from preventable non-communicable diseases (NCDs) such as diabetes, by 25% by 2025.

The World Health Organization and The Union have come out with a Collaborative Framework on the Care and Control of Tuberculosis and Diabetes published in August 2011. This provisional framework aims to guide national programmes, clinicians and others, engaged in care of patients and prevention and control of diabetes and TB, on how to establish a coordinated response to both diseases at organisational and clinical levels. Also, last year The Union and its partners in China carried out a 9-month first bi-directional screening initiative, screening TB patients for diabetes and diabetes patients for TB in a few hospitals. A similar initiative is also underway in India.

People will have to make life style modifications in order to lessen the impact of NCDs. Losing weight, increasing physical exercise, reducing mental stress and quitting smoking can, not only prevent/delay the onset of Type 2 diabetes but also strengthen the immune response of the body to fight the bacteria of TB and other infections. (CNS)

Shobha Shukla - CNS
(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She received her editing training in Singapore, has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: [email protected], website: http://www.citizen-news.org)