Taking on the diabetes-tuberculosis epidemic in India: paving the way through operational research [Editorial]

Abstract

of the two diseases, treatment of persons with dual disease and prevention of TB in persons with DM. 5 For each of these challenges, the knowledge gaps are highlighted along with the research questions that need to be answered if care and control of the dual burden of disease are to be achieved. The second review article looks at existing and new technologies for screening and diagnosing type 2 DM that may be more suitable for TB patients in low-and middle-income countries. 6 As pointed out, these new technologies should be low cost, rapid, easy to use, non-invasive, requiring minimal additional infrastructure and able to differentiate between transient and longer term hyperglycaemia. Several tools in development, such as point-of-care glycated haemoglobin and glycated albumin assays, non-invasive advanced glycation end (AGE) product readers and sudomotor function-based screening devices, are discussed.The eight operational research papers assess 1) bidirectional screening of the two diseases in one facility, 7 2) screening of DM patients for TB in one facility, 8 and 3) screening of TB patients for DM in the other facilities, 9-14 with one of these facilities also evaluating treatment outcomes. 13 A few key messages that are consistent across sites emerge. First, the yield of diabetes was high among TB patients, with higher yields seen among patients aged more than 35-40 years, patients with smear-positive pulmonary TB, current cigarette smokers and those with recurrent TB. The proportion with newly diagnosed DM as a result of blood test screening was higher among TB patients managed in peripheral health facilities compared to tertiary care centres, highlighting the need to prioritise active screening efforts at the peripheral level. Second, the yield of TB among DM patients was relatively low, and further research is required to optimise the screening criteria and diagnostic algorithms for diagnosing TB. One study showed that DM patients who were male, older, had a longer duration of DM, required combined oral hypoglycaemic drugs and insulin medication and had poorly controlled DM were more likely to have TB. 7 Third, while the results reported are useful, the one study that assessed treatment outcomes was not adequately powered to answer the question about whether DM adversely affects outcomes. 12 There was a statistically non-signifi cant trend towards failure of DM-TB patients to smear convert at 2 months, but this whole area requires adequately powered, prospective cohort research. Interna onal Union Against Tuberculosis and Lung DiseaseHealth solu ons for the poor In September 2011, a national stakeholders meeting was held in Delhi, India, to discuss how to move forward with bi-directional screening of tuberculosis (TB) and diabetes mellitus (DM). Agreement was reached about how to 1) implement screening at hospitals and peripheral health institutions, 2) monitor and record the process and outcomes of screening for each individual patient and 3) report on aggregate data at quarterly intervals. The meetin...

Risk of adverse treatment outcomes among new pulmonary TB patients co-infected with diabetes in Pakistan: A prospective cohort study

“…No difference was found among the two groups i.e diabetic PTB and non-diabetic PTB regarding treatment outcome [ 35 ]. Satyanaray et al have attributed these results to inability of the study to achieve adequate power [ 36 ]. Another cohort study conducted in India showed no association of diabetes with treatment outcome among TB patients [ 37 ].…”

Comparative study of HbA1c and fasting plasma glucose vs the oral glucose tolerance test for diagnosis of diabetes in people with tuberculosis

“…The present study differs from that report by Kumpatla et al [8] by only screening individuals with active pulmonary tuberculosis who were aged ≥ 25 years. Previous screening programmes have chosen to screen individuals with tuberculosis for diabetes from 15-18 years of age, but the risk of diabetes and prediabetes is highest in individuals aged >35-40 years, and the diabetes yield was higher in individuals with a positive sputum smear [10]. In addition, a substantial number of individuals with tuberculosis and stress-related transient hyperglycaemia become normoglycaemic during tuberculosis treatment [9,11]; even though Asian people are at risk of developing diabetes and related complications at a younger age than European people [12], we do not believe that it is feasible to recommend screening for diabetes in tuberculosis in very young individuals because of the risk of a false-positive diagnosis in this low-risk age group.…”

Addressing policy needs for prevention and control of type 2 diabetes in India

“…23 A recent policy decision has been issued that all patients registered with TB in India should be screened for diabetes mellitus and vice versa and such a bidirectional screening thus links goals of the RNTCP and the national programme for NCDs. 24 Hopefully, the newly elected Government in India will be able to bring a radical change in policy decisions towards controlling both diabetes as well as TB, which are current major public health concerns for India. …”