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Public Health Action Screening Patients with Tuberculosis For InternaƟ onal Union Against Tuberculosis and Lung Disease Public Health Action Health soluƟ ons for the poor VOL 3 SUPPLEMENT 1 PUBLISHED 4 NOVEMBER 2013 EDITORIAL Taking on the diabetes-tuberculosis epidemic in India: paving the way through operational research Srinath Satyanarayana,1 Ajay M. V. Kumar,1 Nevin Wilson,1 Anil Kapur,2 Anthony D. Harries,3,4 Rony Zachariah5 http://dx.doi.org/10.5588/pha.13.0039 n September 2011, a national stakeholders meeting of the two diseases, treatment of persons with dual AFFILIATIONS 1 International Union 5 Iwas held in Delhi, India, to discuss how to move for- disease and prevention of TB in persons with DM. For Against Tuberculosis and ward with bi-directional screening of tuberculosis (TB) each of these challenges, the knowledge gaps are high- Lung Disease (The Union), South-East Asia Office, and diabetes mellitus (DM). Agreement was reached lighted along with the research questions that need to New Delhi, India about how to 1) implement screening at hospitals and be answered if care and control of the dual burden of 2 World Diabetes Founda- tion, Gentofte, Denmark peripheral health institutions, 2) monitor and record disease are to be achieved. The second review article 3 The Union, Paris, France the process and outcomes of screening for each indi- looks at existing and new technologies for screening 4 London School of Hygiene vidual patient and 3) report on aggregate data at quar- and diagnosing type 2 DM that may be more suitable & Tropical Medicine, London, UK terly intervals. The meeting was followed by training for TB patients in low- and middle-income countries.6 5 Médecins Sans Frontières, of health care personnel involved in the work, imple- As pointed out, these new technologies should be low Medical Department, Operational Research Unit, mentation of screening and a reconvening of im- cost, rapid, easy to use, non-invasive, requiring mini- Brussels Operational plementing partners to share data and discuss chal- mal additional infrastructure and able to differentiate Center, Luxembourg, Luxembourg lenges. This body of work culminated in two published between transient and longer term hyperglycaemia. papers presenting the process and aggregate data on Several tools in development, such as point-of-care CORRESPONDENCE e-mail: ssrinath@theunion. 1,2 bi-directional screening of TB and DM in India. glycated haemoglobin and glycated albumin assays, org; [email protected] These pilot projects, conducted within the routine non-invasive advanced glycation end (AGE) product health services, produced good quality evidence that readers and sudomotor function-based screening de- has led to changes in policy and practice. A policy di- vices, are discussed. rective has been issued that all patients registered with The eight operational research papers assess 1) bi- TB in India should be screened for DM. Patient TB directional screening of the two diseases in one facil- treatment cards and TB registers have been modifi ed to ity,7 2) screening of DM patients for TB in one facility,8 accommodate these new parameters, recording whether and 3) screening of TB patients for DM in the other fa- screening has taken place for DM, whether the patient cilities,9–14 with one of these facilities also evaluating has received a diagnosis of DM and the results of blood treatment outcomes.13 A few key messages that are glucose measurements during TB treatment. A Minis- consistent across sites emerge. First, the yield of diabe- try of Health Training Manual on screening TB pa- tes was high among TB patients, with higher yields tients for DM has also been developed for health care seen among patients aged more than 35–40 years, pa- workers in the fi eld.3 Importantly, a policy directive tients with smear-positive pulmonary TB, current ciga- from the Directorate General of Health Services now rette smokers and those with recurrent TB. The pro- links India’s Revised National TB Control Programme portion with newly diagnosed DM as a result of blood to the National Programme for Non-Communicable test screening was higher among TB patients man- Diseases (NCD) at the sub-centre level so that data on aged in peripheral health facilities compared to ter- TB patients screened for DM are reported to the NCD tiary care centres, highlighting the need to prioritise programme. The NCD programme is in a nascent phase active screening efforts at the peripheral level. Second, in the country, but it is also evolving rapidly, and this the yield of TB among DM patients was relatively low, model of convergence, adapting and incorporating the and further research is required to optimise the screen- DOTS framework with its ‘cohort reviews’, is impor- ing criteria and diagnostic algorithms for diagnosing tant for this evolution. This bi-directional approach TB. One study showed that DM patients who were will be the fi rst of its kind to be implemented at na- male, older, had a longer duration of DM, required tional level, with such initiatives recently being en- combined oral hypoglycaemic drugs and insulin medi- dorsed by the 66th World Health Assembly Resolution cation and had poorly controlled DM were more likely on 25 May 2013.4 to have TB.7 Third, while the results reported are use- In this context, the current supplement on DM and ful, the one study that assessed treatment outcomes TB is timely and important. It consists of two review was not adequately powered to answer the question articles and eight operational research papers. The fi rst about whether DM adversely affects outcomes.12 There review article provides an up-to-date international per- was a statistically non-signifi cant trend towards failure spective on the epidemiology of and interaction be- of DM-TB patients to smear convert at 2 months, but tween DM and TB, and examines three important op- this whole area requires adequately powered, prospec- PHA 2013; 3(S1): S1–S2 erational challenges for care—bidirectional screening tive cohort research. © 2013 The Union Public Health Action Editorial S2 The interaction between DM and TB is rapidly becoming a hot 6 Adepoyibi T, Weigl B, Greb H, Neogi T, McGuire H. New screening technolo- topic for research, with projects examining the biological and mo- gies for type 2 diabetes mellitus appropriate for use in tuberculosis patients. Public Health Action 2013; 3 (Suppl): S10–S17. lecular reasons for the linkages and addressing questions about 7 Prakash B C, Ravish K S, Prabhakar B, et al. Tuberculosis-diabetes mellitus bi- how best to manage and integrate care. These operational research directional screening at a tertiary care centre, South India. Public Health Ac- studies from various sites in India will begin to pave the way to- tion 2013; 3 (Suppl): S18–S22. 8 Kumpatla S, Sekar A, Achanta S, et al. Characteristics of patients with diabe- wards a better understanding of the two diseases, in addition to tes screened for tuberculosis in a tertiary care hospital in South India. Public better care and, ultimately, better health outcomes. Health Action 2013; 3 (Suppl): S23–S28. 9 Dave P, Shah A, Chauhan M, et al. Screening patients with tuberculosis for References diabetes mellitus in Gujarat, India. Public Health Action 2013; 3 (Suppl): S29–S33. 1 India Tuberculosis-Diabetes Study Group. Screening of patients with tubercu- 10 Naik B, Kumar A M V, Satyanarayana S, et al. Is screening for diabetes among losis for diabetes mellitus in India. Trop Med Int Health 2013; 18: 636–645. tuberculosis patients feasible at the fi eld level? Public Health Action 2013; 3 2 India Diabetes Mellitus-Tuberculosis Study Group. Screening of patients with (Suppl): S34–S37. diabetes mellitus for tuberculosis in India. Trop Med Int Health 2013; 18: 11 Nair S, Kumari A K, Subramonianpillai J, et al. High prevalence of undiag- 646–654. nosed diabetes among tuberculosis patients in peripheral health facilities in 3 Central Tuberculosis Division, Ministry of Health and Family Welfare, Gov- Kerala. Public Health Action 2013; 3 (Suppl): S38–S42. ernment of India. Screening of tuberculosis patients for diabetes mellitus— 12 Achanta S, Tekumalla R R, Jaju J, et al. Screening tuberculosis patients for di- training module for the staff of the Revised National Tuberculosis Control abetes in a tribal area in South India. Public Health Action 2013; 3 (Suppl): Programme. New Delhi, India: Directorate General of Health Services, Minis- S43–S47. try of Health and Family Welfare, Government of India, 2013. 13 Khanna A, Lohya S, Sharath B N, Harries A D. Characteristics and treatment 4 World Health Organization. Sixty-Sixth World Health Assembly, Agenda response in patients with tuberculosis and diabetes mellitus in Delhi, India. Item 13. Follow-up to the Political Declaration of the High-level Meeting of Public Health Action 2013; 3 (Suppl): S48–S50. the General Assembly on the Prevention and Control of Non-Communicable 14 Jali M V, Mahishale V K, Hiremath M B, et al. Diabetes mellitus and smoking Diseases. A66/A/CONF./1 Rev.1 (25 May 2013). Geneva, Switzerland: WHO, among tuberculosis patients in a tertiary care centre in Karnataka, India. 2013. http://apps.who.int/gb/e/e_wha66.html Accessed August 2013. Public Health Action 2013; 3 (Suppl): S51–S53. 5 Harries A D, Satyanarayana S, Kumar A M V, et al. Epidemiology and inter- action of diabetes mellitus and tuberculosis and the challenges for care: a re- view. Public Health Action 2013; 3 (Suppl): S3–S9. Public Health Action (PHA) The voice for operational research. e-ISSN 2220-8372 Published by The Union (www.theunion.org), PHA provides a platform to Editor-in-Chief: Donald A Enarson, MD, Canada fulfi l its mission, ‘Health solutions for the poor’. PHA publishes high-quality Contact: [email protected] scientifi c research that provides new knowledge to improve the accessibility, PHA website: http://www.theunion.org/index.php/en/journals/pha equity, quality and effi ciency of health systems and services.
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