Nigeria: Fresh concern over TB, diabetes co-morbidity link

As WDF, STRUHI seek new guideline for treatment

Reason: Researchers have found increasing link between TB and DM co-morbidity among Nigerians. A recent finding conducted in some parts of the country showed that no fewer than 12 per cent TB patients have also developed diabetes; 67 per cent of which has recently been diagnosed.

The specialists’ are more worried citing that people living with diabetes have two-to-three times higher risk of developing TB diseases compared to people without diabetes. More so, undiagnosed or poorly controlled diabetes worsens the outcome of TB treatment.

Consultant Endocrinologist/Diabetologist with the Lagos State University Teaching Hospital (LASUTH), Dr Anthonia Ogbera, observed that people with TB infection and coexisting diabetes are more likely to be sputum positive and take longer to become sputum negative. TB is associated with worsening glycemic control in people with diabetes. Yet, TB is infectious disease; every poorly managed active case would infect an average of 10 new cases in year.

Besides, the financial burden of managing this co-morbidity is huge and often unaffordable. Tuberculosis infection is bad enough and lifelong diabetes disorder is worst. “Where both combines without adequate care in any patient, it is like a marriage made in hell!” Ogbera said.

In recognition of the importance of policy change in addressing the twin-trauma, the World Diabetes Foundation (WDF) and Structured Healthcare Initiative (STRUHI) have advocated for new guideline that is in tune with the World Health Organisation (WHO) collaborative framework for care and control of TB and DM.

The bodies called for similar integrated policy in the treatment of HIV/TB, to be replicated in DM/TB, by at least making all TB Directly Observed Therapy (DOT) centres screen for DM, adding that government must support with capacity development.

Programme Coordinator WDF, Ulugbek Bekmukhamedov told The Guardian in Lagos that the new guideline was important because facts have it that people with TB and coexisting diabetes have four times higher risk of death during TB treatment and higher risk of TB relapse after treatment.

The association between TB and DM and their synergetic role in causing human disease and suffering has been recognized for centuries. Bekmukhamedov, however, said recent evidence has shown that there is a more significance link between diabetes and TB than previously thought.

He said the focus of the WDF in partnership with STRUHI is on the link between DM and TB, and WDF projects, about 300 in 100 developing countries including Nigeria, are contributing to the field.

“Solid data are emerging from China (13 to 25 per cent), India (12.4 per cent) and Nigeria (12 per cent) as countries under the TB/DM prevalence. The focus is very important because patients with TB have two-to-three times more likelihood to develop DM and vice versa than in normal population.

“Diabetes in TB patients is clear, but TB in DM is what we are exploring. The data so far also support that the link is strong,” he said.

Tuberculosis Supervisor at Ajeromi Ifelodun Local Government Area (LGA), Bashiru Ajose, 60, observed that DM incidence in TB patients is about 10:167 in the local government.

Ajose, who works at Tolu DOT centre, one of the 16 DOT centres in the LGA noted that there were more cases of TB infection that had refused to improve within the six months of care.

According to him: “We had a particular patient that kept getting worst with TB treatment. So, on one of the visits, we checked his blood pressure and found it to the dangerously high, such that the patient had to be referred immediately,” he said. The patient is one of several TB patients with undetected diabetes.

Giving the way TB presents, according to Ogbera, DM also presents in similar way especially when undetected and poorly controlled.

“The patient would not get better and people would think there is a relapse or he/she is not responding. Meanwhile, there is an underline problem that is still undetected. We’ve had such real case scenario of patients that have undergone treatment for so long and not gaining weight, only to later discover that they have diabetes.”

Ajose said the DOT centres (with TB patients as high as 150 in a week) had made it a duty to check for DM/TB like they do for HIV/TB. But the concern for many of their patients is the financial burden of coping with the co-morbidity, especially diabetes.

A mother of four, Basirat Quadri, was detected TB positive in December 2011 and barely a month later, also diagnosed with diabetes. Though her TB has been cured, and DM under control, the widow felt she was spending too much of her meagre earnings on diabetes drugs, besides coping with lifestyle modifications.

2010 TB fact sheet shows that 8.8 million people around the world fell ill with TB, 1.4 million of which died in the same year. Over 95 per cent of the deaths occurred in low and middle-income countries.

One-third of the world’s population is infected with latent TB. People infected with latent TB have a lifelong risk of developing and falling sick with active TB.

Bekmukhamedov said while TB prevalence was reducing globally, the increasing prevalence of DM might pose fresh risk to TB burden in the world.

There are about 366 million people estimated to have diabetes in 2011, with 80 per cent in developing countries. Global prevalence is expected to rise to 552 million by 2030.

Courtesy of an old data, Nigeria has 2.2 per cent DM prevalence rate. But recent findings in Lagos State pegged the burden at six per cent. Much more cases are feared undetected.

Bekmukhamedov added that it was important for Nigeria to domesticate the policy guideline designed by the International Union Against TB and lung Disease (IUATLD) and WHO; to at least ensure all TB patients are screened of diabetes.

“Efforts by the IUATLD has persuaded the Indian government to implement this policy of screening Dm in TB patients. It is worth the effort if we detect a case in every 10 that we screen.

“It is more challenging in Nigeria, which is why it is important to screen using the DOTs centre because they are already established, and the result quicker. The support by Nigerian government is crucial, to ensure that the test strips are covered by the health budget. Also ensure that the workers in the DOT centres are well motivated and instructed on how to do the test well,” he said.

Ogbera, who is also the Chief Executive Officer of STRUHI, an NGO and project partner of WDF in Lagos, added that there is need for a paradigm shift from the way TB is currently managed.

“Like they are doing with HIV/TB associated diagnosis, the same should be done for DM/TB. If it were coming from the government, other healthcare facilities would follow suit.

“We have very strong data to back up what we are advocating for Nigeria. So, if we are detecting 12 in 100, then we are saving 12 lives and I think that is a big deal. If that can influences the current policy, then it something worth doing by the government,” she said.

Source: The Guardian Nigeria