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Paul Jensen, Senior Advisor (Policy),

International Union Against Tuberculosis and

Lung Disease (The Union)
- Remarks on TB-Diabetes
CNS Webinar July 2015
TB-diabetes is an example of a public health challenge that will
become more serious unless action is taken now to prevent it. This is
relevant for the post-2015 sustainable development goals, because the
goals aim to end the TB epidemic by 2030. The TB epidemic will not be
eliminated in the absence to a response to TB-diabetes.
Until recently, TB-diabetes wasnt taken seriously because it was
believed that in countries where TB is common, diabetes is not; and in
countries where diabetes is common, TB is not.
But this is not true.
According to researchers, its estimated that more than 80 percent of
diabetes-related deaths happen in low and middle income countries
not in high income countries as previously believed.
A large proportion of people with diabetes as well as TB is not
diagnosed, or is diagnosed too late. Early detection can help improve
care and control of both.
Now, this is important for TB, because people with diabetes are two to
three times more likely to develop TB than people who do not have
diabetes. (The underlying causes for this are not even known yet
because there hasnt been enough research - but it has something to
do with the fact that diabetes has the potential to weaken the immune
Whats more is that people with diabetes have worse TB treatment
outcomes. People with diabetes who also have TB are more likely to die
from TB compared to people who dont have diabetes. And theyre
more likely to get TB again in the future.
What this means is that right now, its estimated that 15 percent of all
people with TB worldwide also have diabetes. This comes out to be
1,042,000 adults who have TB and who are also living with diabetes.
This is only slightly less than the number of people with TB who are
living with HIV infection.
Whats more is that diabetes is increasing globally. Its predicted that

diabetes prevalence the number of people who are living with

diabetes is going to increase by 50 percent by 2030.
And these increases are happening primarily in low and middle income
1. Its common that for people who have diabetes and TB, theyre
forced to receive care at different clinics. The health workers who treat
TB are different from the health workers who treat diabetes, and they
dont really talk to each other.
2. A lot of global resources and political attention have gone into TB in
the last 10-20 years. Not enough, but more than in the past. If we
ignore diabetes and dont stop its impact, then it could start to
eliminate the progress made against TB in countries where TB is
Lessons from History:
TB-HIV. For years, the public health community knew that HIV was a
major risk factor for TB and that TB-HIV was killing large numbers of
people. WHO issued a policy framework for addressing TB-HIV through
collaborative activities. But the implementation of these policies at the
country level was slow and took years to scale up. The result was large
numbers of avoidable deaths. We do not want to repeat this history
when it comes to TB-diabetes.
WHO/Union recommendations
All people with TB should be screened for diabetes
Screening for TB in people with diabetes should be considered,
particularly in settings with high TB prevalence
People with diabetes who are diagnosed with TB have a higher
risk of death during TB treatment and of TB relapse after
treatment. WHO-recommended treatments should be rigorously
implemented for people with TB/diabetes
Diabetes is complicated by the presence of infectious diseases,
including TB. It is important that proper care for diabetes is
provided to those that are suffering from TB/diabetes
This sounds simple but Lessons for the post-2015 development
Addressing TB and diabetes in an integrated way will challenge health
systems - in part because the conventional approach is for infectious
diseases and chronic illnesses to be seen as two different types of

health challenges. There isnt much interaction between infectious

disease experts and NCD experts - inside of countries or internationally.
So part of the challenge will be to break down barriers and to open
communication among different groups of public health experts.
Coordinated planning and service delivery across communicable and
non-communicable disease programs is now necessary. This is
something that needs to happen at different levels of the health
system - national level, perhaps district level, city level for urban areas.
Investments in human resources health workers are going to be
important for being able to deliver integrated care for both TB and
One simple, inexpensive, and as yet unevaluated method is to
implement a major education programme for care givers and patients,
so that persons with diabetes understand the risks of TB, recognise the
symptoms and present to health care services when they think they
might have TB. Such an approach might also help mitigate the risk of
person-to-person TB transmission within DM clinics.