TB and Diabetes
Programme Coordinator, Emilie Kirstein
NCD-CD seminar, 23rd April 2013
WDF was founded in 2002
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Initiated by a grant from Novo Nordisk A/S of DKK 1.1 Billion. / USD 195 mill.
Registered in Denmark as an independent trust
Six board members – majority external of Novo Nordisk
Chairman: Professor Pierre Lefèbvre (Former President of IDF)
279 projects funded to date in 100 countries / 15 projects based on fundraising
Key diabetes focus areas
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The diabetic foot (prevention of amputations)
Eye care (detection of diabetes, prevention of blindness)
Children with diabetes (prevention, education, treatment)
Mothers and diabetes (nutrition, prevention, education)
The Coming Generation – primary prevention
TB & DM – prevention, capacity building and Care
Access to diabetes care
Advocacy – building a global alliance
WDF Distribution of project funding
Regional burden of diabetes.
(Source: IDF 4th Edition)
WDF distributions per region
2002-2011
Western
Pacific
16%
Africa
32%
Africa 6% Europe and
Central Asia
5%
Western
Pacific 31%
Latin
America
and
Caribbean
14%
South East
Asia
25%
Middle East
and North
Africa
10%
Europe and
Central Asia
4%
Global
4%
Latin
America and
Caribbean
9%
Middle East
and North
Africa 13%
South East
Asia 31%
WDF distributions by focus areas
2002-2011
TB
1%
Advocacy Foot
4%
8%
Eye
13%
Prevention
10%
Gen. care
40%
Mothers
7%
Awareness
12%
Children
5%
Training of health care professionals
• WDF has supported the training of 37.675 doctors
• 39.709 nurses trained
• 65.199 paramedics trained
Clinics and access to care
• More than 15.162 screening camps has been organised
• To date, more than 7.5 million people have been screened for diabetes
• 4.900 clinics and micro clinics has been funded by WDF
• 1.3 million documented cases of people have been treated
Mobile diabetes Care and Diabetic
Retinopathy
• Since 2005, the WDF has supported the funding of 16 mobile diabetes care vans
• To date, more than 782.922 people have been screened for diabetes
• More than 235.485 have been detected with diabetic retinopathy
• 61.069 of these have been given sight saving laser treatment on site
• Mobile vans operate in India, Kenya, Sudan and Thailand
Saving feet, saving futures
• WDF has trained 8.089 health care professionals in the area of diabetic foot care
• These specially trained health care professionals have screened more than
370.692 patients and their feet, thus rescuing thousands from certain disability
• 43 Foot Care projects supported by WDF in 26 Countries
• Step by Step a very successful and often replicated model in WDF projects
Gestational Diabetes Screening and Care
• Screening saves two lifes
• More than 77.324 women have been screened and 1.663 cases of GDM detected
2.240 Clinics strenthened with gestational diabetes services
WDF support for children and youth
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1.3 million school children in China, India, South Africa and Caribbean benefit
from school based program for awareness and prevention of obesity
and type 2 diabetes.
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WDF is supporting the “Changing Diabetes in Children” programme in
collaboration with Novo Nordisk A/S and Roche for type 1 children
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WDF support is granted towards capacity building, funding of clinics,
education & awareness material, camps for children and essential equipment
DM & tuberculosis
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2% of WDF funding for DM and
TB (incl. advocacy)
% of total distributions
2002-2011
DM and TB projects include the
following areas:
DM & TB
2%
– Screening for DM
– Training of HCPs
– Testing of DOTS model for
monitoring
– Development of guidelines
– Advocacy / raising
awareness of links between
DM & TB
Other
focus
areas
WDF distributions to focus area regional segmentation 2002-2011
Effect of DM & TB projects
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9 projects focussing on improving
detection and care of diabetes
among TB patients in 9 countries
1,427 HCPs trained in diabetes
diagnosis
WDF distributions to DM & TB
2002-2011
Western
Pacific
28%
10,487 TB patients screened for
diabetes
India: Preliminary results show
crude prevalence of 25.3% in TB
patients and that 16% were known
to have diabetes and 9.3% were
newly diagnosed. The prevalence of
pre-diabetes was 24.6% among TB
patients
Africa
12%
Global
22%
South
East Asia
20%
Latin
America
and
Caribbean
18%
Collaborative framework for TB and DM
• The WDF, which has joined forces with the World Health
Organisation and the International Union Against Tuberculosis and
Lung Disease, is keen to encourage “bidirectional” screening, where
those diagnosed with TB would be checked for diabetes and vice
versa.
• In 2011, the three organisations launched a collaborative framework
for care and control of tuberculosis and diabetes – a guide to
detecting and managing diabetes and TB together, and further
investigating the links between the two diseases. “We wanted to
help build evidence of the ‘double burden’ of diabetes and TB,” Dr
Kapur says.
The TB / Diabetes Framework
Circulated to the WHO
and The Union
networks, and other
partners in TB control
Presented in the UN
Summit on NCDs
• NCD Alliance
September
2011
• PAHO Partners Forum 20th
September 2011
17th
Field testing in
countries:
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Document available at:
Sri Lanka
Mexico
China
India etc…
Presentations at the
Union conference in
Lille & Diabetes
Congress in Dubai
Research, including
operational research
linked to field testing
http://www.who.int/tb/publications/2011/en/index.html
TB and DM burdens
DM Burden
TB Burden
• 366 million
people living
with DM in 2011
• 8,8 million
people living
with TB in 2010
• 6 million new
cases each year
• 9.4 million new
cases each year
• 4.6 million
people died of
DM in 2011
• 1.4 million
people died of
TB in 2010
Global distribution
TB
DM
• South East Asia 20%
• South East Asia 35%
• Western Pacific 23%
• Western Pacific 20%
• Africa
• Africa
5%
80% in LIC and MIC
30%
95% in LIC and MIC
Diabetes and Tuberculosis - the converging pandemics
Risk factors for diabetes and TB
Why the link, when DM is a metabolic disorder and TB is an infectious disease?
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Tobacco smoking and alcoholism may both predispose for diabetes
and TB.
DM patients:
• Poorly controlled diabetes can lead to increased susceptibility of
infection, such as TB, at a cellular and immunological levels.
– DM patients have evidence of impaired cell-mediated immunity, micronutrient
deficiency, pulmonary micro-angiopathy and renal insufficiency, all of which
predispose to TB.
TB patients
• TB patients have a higher risk of developing diabetes, but it is
unclear if TB can directly cause diabetes → glucose intolerance /
diabetes may have been undiagnosed
Public health relevance of the association
How does TB affect diabetes patients?
 TB is associated with worsening glycaemic control in people
with diabetes:
- The risk is related to how the blood glucose levels varies,
i.e. uncontrolled diabetes and the length of period of
uncontrolled diabetes.
- Higher hyperglycaemia, the higher the risk – for example
T1DM patients are likely to be more underweight and
typically have uncontrolled diabetes.
 Medications for TB may interfere with the treatment of diabetes
through drug interactions.
 The onset of diabetes may be triggered by TB.
 TB infection may progress at a faster rate in people with
diabetes than in those without diabetes.
Public health relevance of the association
How does diabetes affect TB patients?
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People with diabetes have a 2-3 times higher risk of developing TB
disease compared to people without diabetes.
People with TB and coexisting diabetes have 4 times higher risk of
death during TB treatment and higher risk of TB relapse after
treatment.
People with TB and coexisting diabetes are more likely to be
sputum positive and take longer to become sputum negative.
Diabetes may adversely affect TB treatment outcomes by delaying
the response time to treatment.
The emergence of drug-resistant TB may be accelerated by
diabetes.
Diabetes may interfere with the activity of TB medications.
The three areas of recommendations
Document available at: http://www.who.int/tb/publications/2011/en/index.html
Determining number of
patients to be screened
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Number of TB cases needed to be screened to find one DM case is
generally low (<10), and in some settings the DM prevalance among
TB patients is 40-50% (e.g. Mexico, Pacific Islands, and growing
number of middle income countries).
Appropriateness of TB screening in people with DM depends on
local TB burden. If TB prevalence is less than 25 per 100,000
persons, at least 1000 people with DM would need to be screened
to diagnose one case of TB, whereas in high TB burden countries
the number needed to be screened is about 100-300.
Only in high TB burden countries is it economically efficient to
screen people with diabetes for TB.
Screening recommendation for diabetes in TB patients
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Screen at time of registration with random blood glucose
(RBG)
If RBG > 6.1 mmol/l (110mg/dl), then conduct fasting
blood glucose at next visit (during initial phase of antituberculosis treatment)
If fasting blood glucose > 7.0 mmol/l (126 mg/dl), then
diagnosis = DM
Refer to DM care if FBG > 7.0 mmol/l
Screening recommendation for TB in diabetes patients
Symptom based inquiry:
• Is there a current cough and has the cough lasted for > 2
weeks; Is there unintentional and significant weight loss
in last 4 weeks; Has there been night sweats in last 4
weeks; Has there been fever in last 4 weeks; Is there a
suspicion of tuberculosis
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TB symptom screening should be done every time the
patient comes to clinic
If positive to any one of the 5 symptoms then this is a
positive screen
If symptom screen is positive,
refer to TB investigations
WDF distributions to DM & TB
2002-2011 (incl. advocacy)
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WDF08-380 China
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WDF08-385 India
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WDF09-451 Malawi
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WDF10-567 Nigeria
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WDF10-530 Mexico and Brazil
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WDF10-585 India and China
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WDFI08-371 Advocacy (incl. meetings
in Paris , Cancun & Kuala Lumpur and
publications)
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WDF12-621 Indonesia
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WDF12-706 South Africa
WDF distributions to DM & TB
2002-2011
Western
Pacific
28%
Africa
12%
Global
22%
South
East Asia
20%
Latin
America
and
Caribbean
18%
7
7,523
6
136
30,537
1 million
2%
USD 2,270.084
98%
Epidemiological results from WDF projects
• TB patients screened for diabetes
– In India, results have shown that prevalence of diabetes among TB
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patients ranges between 13-25%, the highest being the particularly in
the South → this fits well the 3-fold risk (WDF08-385 & WDF10-585).
In China results have shown that the prevalence of diabetes among
TB patients has shown to be 12.4% (WDF10-585).
In Nigeria results have shown that the prevalence of diabetes among
TB patients has shown to be 12% (WDF10-567).
Diabetes patients screened for TB:
– In India, results have shown that
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the incidence rate of TB among
diabetes patients was almost 8 timer higher, as compared to TB
cases in general population (WDF10-585).
In China results have shown that the that the incidence rate of TB
among diabetes patients was almost 5.5 timer higher, as compared
to TB cases in general population(WDF10-585).
Prevalence rates dependant on two major factors:
Prevalence rate in population and the screening methodology (RBG, FBG or OGTT).
Lesson learnt & challenges
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Cross-referral between TB and DM care - Who is responsible? → It is unlikely
that diagnosis and treatment of both conditions will be managed in the same
clinic.
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Screening TB patients for DM is easier than vice versa → screening DM
patients for TB requires proxy questions for TB symptoms upon every visit.
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Creating linkages between care networks of TB and DM is imperative, but
challenging:
– TB and DM programmes have different sources of funding
– Vertical programming frame of mind is still prevailing
WDF funded projects are not research studies but are operational research
studies which illustrate how routine screening can be done in practice.
Lesson learnt & challenges, cont
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TB clinics / units are available at most PHC, secondary and tertiary care
levels are more often quite well established (funding + resources + existence),
which have proven easier to set up / integrate diabetes screening → HIV / TB
experience.
DM clinics often do not exist at PHC level and if they do, they do not always
run on a weekly basis - they are often weaker as compared to TB units
(limited funding and / or resources) → lack of systematic approach.
Articles recommended for reading
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Ottmani SE, Murray MB, Jeon CY, Baker MA, Kapur A, Lönnroth K Harries AD.
Consultation Meeting on Tuberculosis and Diabetes Mellitus: Meeting summary and
recommendations. Int J Tuberc Lung Dis 2010.
Harries AD, Murray MB, Jeon CY, Ottmani SE, Lönnroth, K, et al. Defining the research
agenda to reduce the joint burden of disease from Diabetes mellitus and Tuberculosis.
Trop Med Int Health 2010; 15: 659–663.
Jeon CY, Harries AD, Baker MA, Hart JE, Kapur A, Lönnroth K, Ottmani SE,
Goonesekera S, Murray M. Bi-directional screening for tuberculosis and diabetes: a
systematic review. TMIH 2010.
Harries AD, Lin Y, Satyanarayana S, Lönnroth K, Li L, Wilson N, et al.. The looming
epidemic of diabetes-associated tuberculosis: learning lessons from HIV-associated
tuberculosis. Int J Tuberc Lung Dis 2011.
Dooley KE, Chaisson RE:Tuberculosis and diabetes mellitus: convergence of two
epidemics. Lancet Infect Dis. 2009 Dec;9(12):737-46.
In preparation: Kapur A & Harries AD. The double burden of diabetes and tuberculosis
– public health implications.
Thank you!
www.worlddiabetesfoundation.org