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Year : 2013  |  Volume : 40  |  Issue : 2  |  Page : 59-60

Diabetes and tuberculosis: A reemerging epidemic

Department of Pulmonary Medicine, Jawaharlal Nehru Medical College Karnataka Lingayat Education University, Belgaum - 590 010, Karnataka, India

Date of Web Publication23-Jul-2013

Correspondence Address:
Vinay Mahishale
Department of Pulmonary Medicine, Jawaharlal Nehru Medical College Karnataka Lingayat Education University, Belgaum - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-5009.115470

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How to cite this article:
Mahishale V. Diabetes and tuberculosis: A reemerging epidemic. J Sci Soc 2013;40:59-60

How to cite this URL:
Mahishale V. Diabetes and tuberculosis: A reemerging epidemic. J Sci Soc [serial online] 2013 [cited 2021 Jul 26];40:59-60. Available from: https://www.jscisociety.com/text.asp?2013/40/2/59/115470

We are approaching a time and era where the terms communicable disease like tuberculosis (TB) and noncommunicable disease like diabetes mellitus (DM) are taking on a new meaning. Association between these two diseases is known since ages. Diabetes and TB have coexisted for thousands of years. Great physicians in the ancient civilizations of Egypt, India, Greece, and Rome described an illness that we now understand as diabetes. The earliest evidence of TB has been found in the skeleton of a 30-year-old woman in Italy, dated 5800 BC. [1] The great Indian physician Sushruta (600 CE) was aware of the association, and Avicenna (800 CE) commented that phthisis (TB) frequently complicated diabetes. [2] However, this was largely forgotten during the second half of the 20 th and beginning of 21 th century, with the advent of widely available treatment for both diseases. With the current global increase in cases of type 2 DM, the association between TB and DM is reemerging so much so that DM patients are doomed to die of TB rather than diabetic coma!

There is accelerating pandemic of type-2 DM worldwide. Diabetes affects 230 million worldwide, anticipated to reach 366 million by 2030; by that time 80% of those affected will be living in low- and middle-income countries where active tuberculosis is widespread. [3],[4] Eight of the ten countries with the highest incidence of diabetes are also classified as high burden countries for TB by the World Health Organization (WHO). [5] The consequences of these converging epidemics are likely to be substantial. Hence, WHO has declared both DM and TB as global epidemics. The idea that TB and DM share synergistic relationship has been creating growing concern around the world. Recently, WHO and the International Union Against TB and Lung Disease (Union) have acknowledged the need for international guidelines on the joint management and control of TB and DM and have published a provisional collaborative framework for the care and control of both diseases. [6]

The association is supported by the fact that diabetes patients have evidence of impaired cell-mediated immunity, micronutrient deficiency, pulmonary microangiopathy, and renal insufficiency, all of which predispose to TB. The effect is consistently and significantly more marked in diabetes patients with chronic hyperglycemia. The impaired and altered immune response is also likely to increase susceptibility to infection with multidrug-resistant (MDR) strains. [7] DM is a well-known risk factor for the development of active TB, increasing the risk by a factor of 2-3. [8] Diabetes patients with TB, also have worse TB treatment outcome, which includes delayed conversion from positive to negative sputum cultures, higher risk of death during TB treatment, and elevated risk of treatment failure and recurrence of disease after treatment has been successfully completed. [9]

In the past 50-60 years, India is undergoing rapid social and economic expansion. There has been a significant change in life style, food habits, decreasing physical activity, unhealthy diet, and obesity. Consequences of which, there has been an escalating epidemic of DM. [10],[11] DM prevalence rates have risen in both urban and rural populations and also among the poor. Increase in the prevalence of DM in rural and economically impoverished populations would further augment the risk of TB epidemics. Available data suggest that in 2011, there were an estimated 61.3 million adults with DM, a national adult prevalence of 8.3% in persons aged 20 years and above.

Although India has an excellent national TB control program and follows the 'DOTS' model for TB control, the disease is still a sizeable problem. In 2011, there were an estimated 2.2 million incident cases of TB (range 2.0-2.5 million) with case detection rates of just under 60%. Prevalence of TB in India is around 3.1 million cases, that is, 161-373 cases per 100,000 population. There is significant increase in MDR-TB cases as well. [12] A large population-based bilateral screening of TB patients for DM and DM patients for TB in India was completed between January and September 2012 to study the feasibility and operational challenges. This pilot project shows that it is important and feasible to screen patients with TB for DM in the routine setting, resulting in earlier identification of DM in some patients and opportunities for better management of comorbidity. This study was conducted by India Tuberculosis-Diabetes Study Group (current author is also member of this group). A policy decision has since been made by the National TB Control Program of India to implement this intervention countrywide. [13] In India, it is also feasible to screen all patients with DM for TB resulting in high rates of TB detection. [11]

In terms of absolute numbers and given the size of the population, India is one of the highest DM and TB burdened countries. The association is similar to the tuberculosis-human immunodeficiency virus (TB-HIV) coinfection. The escalated epidemic of DM in the country is significantly affecting the TB control program. Hence, it is imperative to screen all TB patients for DM and also DM patients for TB at all levels of healthcare facilities.

  References Top

1.Canci A, Minozzi S, Borgognini Tarli S. New evidence of tuberculous spondylitis from Neolithic Liguria (Italy). Int J Osteoarchaeol 1996;6:497-501.  Back to cited text no. 1
2.Gupta A, Shah A. Tuberculosis and diabetes: An appraisal. Ind J Tub 2000;47:3.  Back to cited text no. 2
3.Ruder K. Fighting the epidemic. A United Nations resolution on diabetes. Diabetes Forecast 2007;60:50-1.  Back to cited text no. 3
4.Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.  Back to cited text no. 4
5.WHO report 2007. Global tuberculosis control: Surveillance, planning, financing 2007. Available from: http://www.who.int/tb/publications/global_report/2007/pdf/full.pdf [Last accessed on 2013 May 24].  Back to cited text no. 5
6.World Health Organization and The International Union Against Tuberculosis and Lung Disease. Collaborative framework for care and control of tuberculosis and diabetes. Geneva: WHO, 2011. Ramachandran A, Ma RC, Snehalatha C. Diabetes in Asia. Lancet 2010;375:408-18.  Back to cited text no. 6
7.Restrepo BI, Fisher-Hoch SP, Pino PA, Salinas A, Rahbar MH, Mora F, et al. Tuberculosis in poorly controlled type 2 diabetes: Altered cytokine expression in peripheral white blood cells. Clin Infect Dis 2008;47:634-41.  Back to cited text no. 7
8.Jeon CY, Murray MB. Diabetes mellitus increases the risk of active tuberculosis: A systematic review of 13 observational studies. PLoS Med 2008;5:e152.  Back to cited text no. 8
9.Baker MA, Harries AD, Jeon CY, Hart JE, Kapur A, Lönnroth K, et al. The impact of diabetes on tuberculosis treatment outcomes: A systematic review. BMC Med 2011;9:81.  Back to cited text no. 9
10.Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, et al. Global burden of metabolic risk factors of chronic diseases collaborating group (Blood Glucose). National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: Systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet 2011;378:31-40.  Back to cited text no. 10
11.India Diabetes Mellitus: Tuberculosis Study Group. Screening of patients with diabetes mellitus for tuberculosis in India. Trop Med Int Health 2013;18:646-54.  Back to cited text no. 11
12.World Health Organization. Global Tuberculosis Report 2012. WHO, Geneva, Switzerland. Available from: http://www.who.int/tb/publications/global_report/en/[Last accessed on 2013 Mar 10].  Back to cited text no. 12
13.Screening all TB patients for diabetes mellitus: From pilot to policy change. Available from: www.theunion.org/index.php/en/newsroom/item/2310-screening-all-tbpatients-for-diabetes-mellitus-from-pilot-to-policy-change [Last accessed on 2013 May 26].  Back to cited text no. 13


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