TUBERCULOSIS in diabetic patients has appeared as a silent public health concern while the number of diabetic patients is increasing.
Tuberculosis and diabetes have for long been considered major public health concerns but the convergence of the two has thrown a new challenge to the health care delivery system as tuberculosis is separately dealt with by the National TB control programme, DGHS, ministry of health and family welfare while diabetes patients are treated by the Bangladesh Diabetic Samiti through its healthcare network.
Against this backdrop, the Diabetic Association of Bangladesh has taken a project with financial support from the USAID and the guidance of National TB Control Programme with technical support of TB Care II and MSH Challenge TB Project, Bangladesh ‘Integrated approach to increase access to TB services for diabetic patients’ for screening, treatment, prevention and awareness of TB-DM co-morbidity.
To increase awareness and prevention of TB-DM co-morbidity, the project organised a roundtable, ‘Tuberculosis and diabetes control and prevention: our responsibilities’, with support of National Tuberculosis Control Programme in partnership with New Age on April 25.
Below are the noteworthy comments of noted public health experts, specialists, government officials and representatives of local and international NGOs who took part in roundtable.
Professor Dr Md Delwar Hossain, Programme Director, BADAS-USAID Challenge TB Project & Head Respiratory Medicine, BIRDEM General Hospital & Ibrahim Medical College
TUBERCULOSIS continues to be a major public health problem. A third of the world population are infected with mycobacterium tuberculosis. WHO lists tuberculosis as one of the top 10 causes of death worldwide. In 2016, 10.4 million people fell ill with TB and 1.7 million died from the disease. Over 95 per cent of TB deaths occurred in low- and middle-income countries like Bangladesh.
TB is endemic in Bangladesh, having incidence of 221/100,000 a year and death of TB 40/100,000 a year. Bangladesh ranks seventh in the world’s 30 high TB-burdened countries.
About 7 million people in Bangladesh suffer from diabetes and the estimated number of diabetic patients with tuberculosis is almost 35,000. Tuberculosis in diabetic patients has appeared as a silent public health concern.
Under the BADAS-USAID Challenge TB Project, Bangladesh, 31,12,965 patients were screened, about 28,990 patients were advised sputum examinations and 4000 patients were diagnosed as active tuberculosis patients and put on treatment in BIRDEM and other 93 affiliated associations of Bangladesh Diabetic Samiti throughout Bangladesh in the project period of June 2013–March 2018.
Diabetic and tuberculosis patients need to be addressed in a special way as diabetic patients with tuberculosis may not have typical tuberculosis symptoms. Strict control of blood sugar is essential for a successful treatment; moreover, diabetic patients often have complications like kidney diseases, eye problems, liver diseases and neurological diseases which need special attention and dose modification of anti-tubercular drugs for the treatment of tuberculosis in diabetic patients.
Mohammad Hossain, Senior technical adviser, Challenge TB, Management Sciences for Health
DIABETES with tuberculosis is a double-pronged problem. The BADAS-USAID Challenge TB Project has been initiated to face the challenge.
Globally, we have seen a preparation to tackle tuberculosis and diabetes. Now tuberculosis and diabetes are merging. The government has made it mandatory to notify incidence of tuberculosis. But it is not practised yet. We have developed an easy procedure so that the patients can notify incidence of tuberculosis.
Brig Gen (retd) Abdul Majid Bhuian, Director, Bangladesh Institute of Health Sciences
THE number of tuberculosis patients coming to hospital is just the tip of an iceberg. There are countless others who have not been diagnosed. We we have to find out how to prevent tuberculosis. We have to expand institutional healthcare network like the one of the Diabetic Association of Bangladesh.
Professor Bashir Ahmed, President, Asthma Association of Bangladesh and Professor of Respiratory Medicine at National Institute of Diseases of the Chest and Hospital
TUBERCULOSIS screening for diabetic patients should be made mandatory for better outcome. The National Tuberculosis Control Programme should incorporate the idea.
Professor ABM Abdullah, Dean, faculty of medicine, Bangabandhu Sheikh Mujib Medical University
Tuberculosis and diabetes have similar symptoms, which makes detection and treatment difficult. Diabetic patients with tuberculosis sometime do not show common symptoms of tuberculosis.
Doctors should go for a thorough analysis of patients’ history to detect if the patient had suffered from tuberculosis or diabetes previously.
Diabetic patients in rural areas have a problem taking insulin. Patients visiting me say that it is difficult to inject insulin. Besides, patients in rural areas find it difficult to preserve insulin for lack of refrigerator. We have to think about safe oral medicine for diabetic patients, especially in rural areas.
Professor Billal Alam, Principal and head of department of medicine, Sir Salimullah Medical College and President, Bangladesh Society of Medicine
BOTH diabetes and tuberculosis affect 100 trillion body cells. Both types of patients develop many complications in different organs.
Tuberculosis and diabetes are now coming together. The BADAS-USAID project considering these diseases from a single point of view is praiseworthy.
Patients suffering from either diabetes or tuberculosis should be treated taking their whole complications into consideration. The guideline developed by the Diabetic Association of Bangladesh for treatment of diabetic patients with tuberculosis should be distributed to doctors across the county.
Professor Abid Hossain Mollah, Head, department of paediatrics, BIRDEM
USUALLY diabetic patients do not undergo tuberculosis screening. They do it only when the doctors suspect the development of tuberculosis although tuberculosis symptoms are not always visible in diabetic patients.
A large number of children with tuberculosis remain out of diagnosis. But what is more concerning is that under-15 children suffering from tuberculosis remain out of diagnosis because the symptoms of tuberculosis are not specific to this age group. The diagnosis of tuberculosis in adult diabetic patients is a bit easy.
Professor M Ali Hossain, Former director and professor of respiratory medicine, National Institute of Diseases of the Chest and Hospital
TUBERCULOSIS patients who go to DOTS centres get only tuberculosis medicines free but those suffering from tuberculosis and diabetes do not get diabetes medicines free. To treat tuberculosis and diabetes together, we should offer diabetes medicines as well from DOTS centres.
Professor Jalaluddin Ashraful Haq, Principal, Ibrahim Medical College and Microbiologist
MEDICAL students who will take the responsibility of the nation’s health should be taught about the convergence of diabetes and tuberculosis.
The medical education curriculum has not been updated for years and the curriculum is still filled with outdated issues. The curriculum should incorporate issues like the convergence of diabetes and tuberculosis.
Professor MA Rashid, Cardiologist & CEO, Ibrahim Cardiac Hospital and Research Institute
EXPANSION of health network like that of Diabetic Association of Bangladesh is needed to stop diabetes and tuberculosis.
Awareness is essential. If health networks could reach community level, it would help not only to stop diseases like diabetes and tuberculosis but also reduce the national healthcare expenses.
Diabetes has many health hazards and the convergence of tuberculosis and diabetes only adds to patients’ sufferings. We have also found that extrapulmonary tuberculosis is occurring. For a better treatment of patients of diabetes with tuberculosis, we have to adopt total treatment approach. And as tuberculosis treatment is free, diabetes treatment should also be free.
Professor M Rashidul Hassan, Former director of National Institute of Diseases of the Chest and Hospital and President of Bangladesh Lung Foundation
DIABETIC patients are three times more likely to be infected with tuberculosis because diabetes reduces immunity. We have lack of awareness of how to prevent diabetes and tuberculosis. Unhealthy way of life are responsible for diabetes while coughing and sneezing can spread tuberculosis.
While many tuberculosis patients visit doctors with symptoms of diabetes, many diabetic patients do so with tuberculosis symptoms; but they are not treated in an integrated way and they are not even screened for other diseases.
Vitamins, especially A and D, are crucial for diabetes with tuberculosis patients. These two vitamins increase immunity against diabetes and tuberculosis.
Dr Kazi Saifuddin Bennoor, Associate professor, National Institute of Disease of Chest & Hospital
TUBERCULOSIS and diabetes are two major public health concerns and their convergence has challenged the traditional health service mechanism of tackling tuberculosis and diabetes separately.
We must have a guideline that will direct physicians on how to treat tuberculosis patients with diabetes and diabetes patients with tuberculosis. I think this project has put a significant and substantial impact on tackling the diseases
Dr Fatema Khatun, Senior manager, BRAC
BRAC has been operating Directly Observed Treatment Short-course (DOTS) centres with NTCP support across the country since 2005. Besides, the NTCP has started the Gene Xpert diagnosis for tuberculosis detection, but tuberculosis patients are often unaware of the issue. We should inform people about testing facilities.
Dr Muhammad Murtaza Khair, Consultant, Bangladesh Specialised Hospital
THERE are some medicines for patients with tuberculosis, but not available on local market. The medicines can only be found with DOTS centres. So, people cannot buy them. Such medicines should be available with pharmacies and sold to
Mohammad Abdus Shakur Khan, Associate professor, NIDCH
WE earlier had problems in detecting tuberculosis; now the problem has reduced a bit. But providing individual patient with medicine has become a new challenge.
The BADAS-USAID project should introduce a facility unit at all centres where the patients’ medicine record will be maintained, which will later help healthcare providers to deal with patients individually as per their needs. Besides, maintaining the patients’ record will also be of much help.
Sabera Sultana, National professional officer, World Health Organisation
PEOPLE with diabetes have tuberculosis risk three times higher than people with no diabetes. The BADAS-USAID project guideline has helped in tackling patients with both diseases. From WHO, we also want to support the project.
MA Hamid Salim, Adviser to National Tuberculosis Control Programme, USAID-GFATM, Bangladesh
CHALLENGES still are there in tuberculosis detection and the correlation between tuberculosis and diabetes has not been assessed yet. We have to have a proper screening of diabetic patients to learn how many of them are prone to tuberculosis.
And for tackling the issue, DOTS centres for tuberculosis patients should be equipped with glucose testing mechanism.
We have talked to USAID and requested them to continue with the BADAS-USAID project and the response has been positive.
Ahmedul Kabir, General secretary, Bangladesh Society of Medicine and Associate Professor of Medicine, Dhaka Medical College Hospital
INCIDENCES of diabetes with tuberculosis increased in the past decades when controlling HIV with tuberculosis was in focus. We failed to have proper strategy to deal with the patients affected by both tuberculosis and diabetes.
Many changes and modifications are required for tuberculosis-diabetic patients as the symptoms are often complicated. Weight loss is often seen as a good indicator of a diabetic patient but physicians must not forget that tuberculosis can have the same symptom.
As per WHO, the incidence rates of tuberculosis-diabetic patients could be reduced by 95 per cent by 2035, but for that, we must fight both the diseases in an integrated
Tuberculosis detection process can be hampered by the lack of awareness among people as they do not come to the testing centres.
Insulin cannot be the only treatment for diabetes patients as insulin has been costlier these days. Physicians must think of other ways.
Sohael M Arafat, Professor, department of medicine, BSMMU
TUBERCULOSIS for patients with diabetes does not appear as co-morbidity; it rather counts as a complication of diabetes.
Mujibur Rahman, Associate professor, Bangladesh University of Health Sciences and coordinator former National TB Control Programme
DIABETIC patients have a high risk of being infected with tuberculosis and tuberculosis patients also have the risk of getting affected with diabetes.
To tackle the situation, we must ensure an early detection of both the diseases and treat the patients accordingly.
Diabetes is not only a medical problem; rather, it has other social implications while tuberculosis has environmental impact. So, social and environmental strategies have to be formulated to fight the diseases.
Children and elderly people should be tested for tuberculosis thoroughly as they are at risk of the disease while tuberculosis screening for patients with HIV and lung diseases needs to be made compulsory.
AKM Mosharraf Hossain, Chairman, respiratory medicine, Bangabandhu Sheikh Mujib Medical University
DIABETES rate is very high not only in Bangladesh but all over South East Asia. The main cause of the problem is lack of efforts in controlling diabetes. And tuberculosis prevalence is high because of high prevalence of diabetes. We have to control diabetes if we want to control tuberculosis.
Abu Jamil Faisal, Consultant, IRD
SEARCH, treat and prevent are the three options in tackling tuberculosis but unfortunately in Bangladesh, the first stage has not been reached properly yet.
The main challenge for tackling tuberculosis is its high incidence, with around 39 per cent still remaining undetected. We have to concentrate on screening and prevention options.
Professor Md Samiul Islam, Director for mycobacterium disease control and line director for TB-Leprosy, Directorate General of Health Services
THE government is working with NGOs to control tuberculosis. It is an endless job because we have a huge population.
The government is now buying the first-line tuberculosis drugs which were previously donated. The government will buy all the tuberculosis drugs gradually. Many countries are yet to take the responsibility of buying tuberculosis drugs, which shows the government’s seriousness about tuberculosis.
Still 30 per cent of tuberculosis patients remain undetected but the detection rate is increasing. I would say that the NTP has progressed. We are doing well in treating multi-drug resistant tuberculosis and in short-regimen tuberculosis treatment medicine course.
Zafar Ahmed Latif, Additional director general, BIRDEM
TWENTY per cent of rural people suffer from glucose intolerance. In Dhaka, 14 per cent of people are in a pre-diabetic condition and 12 per cent in frank diabetic condition.
Diabetes is increasing by 10 per cent every decade. With that, tuberculosis has come as an added problem. We have to be more cautious about coincidence of diabetes and tuberculosis.
BIRDEM has formulated a guideline for doctors on treating patients of diabetes with tuberculosis. The Diabetic Association of Bangladesh has trained 14,000 health personnel through distant learning about diabetes and tuberculosis.
People often think that diabetes is a disease of morning. They check blood sugar level after breakfast but the blood sugar level go high after lunch and dinner. This practice shoud stop.
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