CNS: Bi-directional TB Diabetes Screening in India and China

The International Union Against Tuberculosis and Lung Disease (The Union), the World Health Organization (WHO) and the World Diabetes Foundation in association with the Indian government conducted a pilot project this year screening more than 8,000 tuberculosis patients for diabetes, and over 10,000 diabetes patients per quarter for TB. Fasting blood glucose tests for diabetes measured in TB patients at 7 tertiary hospitals and over 60 primary health care centres across the country showed that 13% of them had high blood sugar levels indicating diabetes, with higher rates in the south than in the north. Interim data from the project was presented to India's Revised National TB Control Programme in September 2012 and resulted in a national policy decision to scale up testing of all TB patients for diabetes in the country.

The TB testing in patients with diabetes was carried out in six tertiary hospitals; where on an average 10,000 people with diabetes are seen each quarter. A high rate of TB cases was detected in them, indicating that this is also a worthwhile activity that should be continued.

This bi-directional screening project was launched amidst growing concerns about the rising incidence of diabetes in low- and middle-income countries and the potentially deadly link between diabetes and TB. Research has shown that diabetes increases by two to three times the risk of tuberculosis, and patients who have both diabetes and TB have an increased risk of dying during TB treatment and of recurrent TB once anti-TB treatment is completed.

"Of the 366 million people with diabetes today, more than 150 million live in India and China," informs Professor Anthony D Harries, Director of Research for The Union. "This is a very large population at increased risk for TB, so determining how to manage the two diseases effectively is a high priority in both countries".

China was the first country to implement bi-directional screening within the routine health care system, using the approach outlined in the WHO/Union Collaborative Framework for the Care and Control of Tuberculosis and Diabetes, published in 2011. With the help of The Union, the WHO and the World Diabetes Foundation China developed a plan to conduct screening in 11 facilities. This project was completed in May 2012 and led to agreement that the project should be expanded to other facilities across the country. Two scientific papers about the project have been published in an effort to disseminate the results and lessons learnt.

According to Prof Harries, one-third of the world's population is infected with the bacillus that causes tuberculosis, although for most people the risk of developing active TB is very low. Nevertheless there were 8.7 million new cases of TB in 2011, and the increase in cases of diabetes - which is projected to reach 552 million by 2030 - will have implications for TB control.

"The link with TB means that diabetes could potentially destabilise TB control the way the HIV/AIDS epidemic did in the 1980s", says Prof Harries, "so all stakeholders in public health need to help health systems to prepare for and treat these patients successfully". The bi-directional screening projects in India and China were funded through a grant from the World Diabetes Foundation.