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Current Issues International Health and Diabetes
injection of tuberculin, which is read 48–72 hours later, or the more Millennium Development Goal 6, target 8, specifies that the incidence of
expensive interferon-gamma release assays (IGRAs), which are costly and infectious diseases such as TB should be halted and reversed by 2015. The
require specific laboratory equipment. If these results are positive, how goal for TB elimination is a global incidence of less than one case per
should the progression of latent infection to disease be monitored or what million by 2050. To achieve these targets in resource-poor countries it is
should be done to prevent TB? Should these patients be given a course of important to focus not only on improved access to TB diagnosis and
isoniazid preventive therapy? Should patients with TB and diabetes be treatment and on HIV/AIDS, but also on the burgeoning epidemic of
treated with a different drug regimen from the regimen used to treat those diabetes as a significant epidemiological risk factor. The link between TB
with TB alone? Simple screening algorithms currently used in HIV-infected and diabetes has been established; what is needed now is good-quality
patients in high HIV–TB burden countries evaluate patients for cough, implementation research to screen for, care for, prevent, and monitor this
fever, night sweats, weight loss, and chest pain. A positive response dual burden of disease.
indicates the need for further assessment by sputum smear examination
and chest radiography. The value of such screening tools in the diabetes
Anil Kapur, MD, is Managing Director of the World Diabetes Foundation. He specializes in
clinics of developing countries is not known.
Moreover, sputum smear is
internal medicine and has written books on diabetes for both medical professionals and lay
highly insensitive; given the propensity of people with diabetes for people, and has published more than 60 papers in international journals in the areas of
reactivation, do negative smears in people with diabetes have the same
internal medicine, clinical pharmacology, and diabetes. Dr Kapur has co-ordinated several
large studies, including the DiabCare Asia India study, Cost of Diabetes Care in India, and the
significance as in those without diabetes? Finally, in most developing
National Urban Diabetes Survey.
countries there are no systematic ways of monitoring or evaluating
patients with non-communicable diseases. This has to change. The directly Anthony D Harries, MD, is Senior Advisor at the International Union Against Tuberculosis
observed treatment short-course (DOTS) framework for TB control, which
and Lung Disease and an Honorary Professor at the London School of Hygiene and Tropical
Medicine. He worked in Malawi for 20 years, where he held the posts of physician,
was developed by the International Union against Tuberculosis and Lung
Foundation Professor of Medicine, National Technical Advisor to the Malawi Tuberculosis
Disease and WHO, has allowed structured, well-monitored services to be Control Programme, and National Advisor in HIV Care and Support at the Ministry of Health.
delivered to millions of TB patients in some of the poorest countries. This
model can be adapted for non-communicable diseases such as diabetes.
Knut Lönnroth, MD, PhD, is a Medical Officer in the Tuberculosis Department at the World
Health Organization (WHO), where he is the focal point for work on tuberculosis risk factors
Need for Action
and social determinants. Dr Lönnroth is involved in international health research with a
focus on health systems and social factors, particularly in relation to tuberculosis control.
There is a misconception among policy-makers, multilateral donors, and
even public health experts, particularly in the developed world, that
Ib C Bygbjerg, MD, is a Professor in the Department of International Health, Immunology, and
diabetes is a rich man’s disease. However, the fact is that the low- and
Microbiology at the University of Copenhagen. He teaches international health, trains
middle-income countries undergoing rapid urbanization are witnessing the
healthcare professionals, and conducts research in Denmark, Ghana, India, Tanzania, and
Vietnam. Professor Bygbjerg founded the Centre for International Health and Development
fastest growth in diabetes rates, and the worst affected are the urban poor
and Cluster in International Health, which carries out research in diabetes, HIV/AIDS,
in these countries. In this context, diabetes shares many risk factors and
tuberculosis, malaria, and their interactions.
socioeconomic determinants of poor health outcomes with TB, and may
therefore be found in the same sub-populations. In most developing and
Pierre Lefèbvre, MD, PhD, is Emeritus Professor of Medicine, Past Chairman of Medicine, and
Head of the Division of Diabetes, Nutrition, and Metabolic Disorders at the University of
low-resource countries there are few healthcare resources available for
Liège. He serves as Chairman of the Board of Directors of the World Diabetes Foundation
diabetes prevention and care. Can a common health system approach and was President of the International Diabetes Federation from 2003–2006.
to diabetes and TB be adapted to address prevention and care?
1. Canci A, Minozzi S, Borgognini Tarli S, New evidence of 11 .Jeon CY, Murray MB, Diabetes mellitus increases the risk of patients on the Bellevue Chest Service, 1987 to 1997, Chest,
tuberculous spondylitis from Neolithic Liguria (Italy), Int J active tuberculosis: a systematic review of 13 observational 2001;120:1514–19.
Osteoarchaeol, 1996;6:497–501. studies, PLoS Med, 2008;5:e152. 19. Fisher-Hoch SP, Whitney E, Mccormick JB, et al.; and The
2. Dixon B, Diabetes and tuberculosis: an unhealthy 12. Stevenson CR, Forouhi NG, Roglic G, et al., Diabetes and Nuevo Santander Tuberculosis Trackers, Type 2 diabetes and
partnership. Availablle at: tuberculosis: the impact of the diabetes epidemic on multidrug-resistant tuberculosis, Scand J Infect Dis, 2008;1–6:I.
3. Gupta A, Shah A, Tuberculosis and diabetes: an appraisal, Ind tuberculosis incidence, BMC Public Health, 2007;7:234. 20. Nijland HM, Ruslami R, Stalenhoef JE, et al., Exposure to
J Tub, 2000;47:3. 13. Stevenson CR, Critchley JA, Forouhi NG, et al., Diabetes and rifampicin is strongly reduced in patients with tuberculosis
4. Root HF, The association of diabetes and tuberculosis, N Engl the risk of tuberculosis: a neglected threat to public health, and type 2 diabetes, Clin Infect Dis, 2006;43:848–54.
J Med, 1934;1:210. Chronic Illn, 2007;3:228–45. 21. Park JY, Kim KA, Park PW, et al., Effect of rifampin on the
5. Younger D, Hadley WB. In: Marble A, White P, Bradley RF, Krall 14. Restrepo BI, Fisher-Hoch SP, Pino PA, et al., Tuberculosis in pharmacokinetics and pharmacodynamics of gliclazide, Clin
LP (eds), Joslin’s diabetes mellitus. 11th ed, Philadelphia: Lea and poorly controlled type 2 diabetes: altered cytokine Pharmacol Ther, 2003;74:334–40.
Febiger, 1971;628–31. expression in peripheral white blood cells, Clin Infect Dis, 22. Mugusi F, Swai AB, Alberti KG, McLarty DG, Increased
6. Luntz G, Tuberculous diabetics: the Birmingham Regional 2008;47(5):634–41. prevalence of diabetes mellitus in patients with pulmonary
Service, Lancet, 1954;266(6819):973–4. 15. Restrepo BI, Fisher-Hoch SP, Crespo JG, et al., Type 2 tuberculosis in Tanzania, Tubercle, 1990;71:271–6.
7. Global TB Control, 2009, Geneva: World Health Organization, diabetes and tuberculosis in a dynamic bi-national border 23. Surya Kirani KRL, Santha Kumari V, Lakshmi Kumari R,
2009. population, Epidemiol Infect, 2007;135:483–91. Co-existence of pulmonary tuberculosis and diabetes
8. Harries AD, Billo N, Kapur A, Links between diabetes mellitus 16. Singla R, Khan N, Al-Sharif N, et al., Influence of diabetes on mellitus: some observations, Ind J Tub, 1998;45:47–8.
and tuberculosis: should we integrate screening and care?, manifestations and treatment outcome of pulmonary TB 24. Restrepo BI, Convergence of the Tuberculosis and Diabetes
Trans R Soc Trop Med Hyg, 2009;103:1–2 patients, Int J Tuberc Lung Dis, 2006;10:74–9. Epidemics: Renewal of Old Acquaintances, Clin Infect Dis,
9. Lönnroth K, Raviglione M, Global Epidemiology of 17. Guler M, Unsal E, Dursun B, et al., Factors influencing sputum 2007;45:436–8.
Tuberculosis: Prospects for Control, Semin Respir Crit Care Med, smear and culture conversion time among patients with new 25. Harries AD, Jahn A, Zachariah R, Enarson D, Adapting the
2008;29:481–91. case pulmonary tuberculosis, Int J Clin Pract, 2007;61:231–5. DOTS framework for tuberculosis control to the
10. Kant L, Diabetes Mellitus–Tuberculosis: The Brewing Double 18. Bashar M, Alcabes P, Rom WN, Condos R, Increased management of non-communicable diseases in sub-
Trouble, Indian J Tuberc, 2003;5:183–4. incidence of multidrug-resistant tuberculosis in diabetic Saharan Africa, PLoS Med, 2008;5:e124.
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