ReacciónTuberculosis (TB) remains a major cause of ill-health and disability in many low- and middle-income countries and is a leading cause of death due to an infectious agent globally (1). The risk of TB is elevated in people with diabetes mellitus (DM). In studies in which the type of diabetes was not specified, people with diabetes were found to have a 1.9 (95% confidence interval, 1.5 ; 2.4) times higher risk of developing TB than those without diabetes (2). One study found a 4.2 (95% confidence interval, 2.4–7.4) times increased risk in people with type 1 diabetes (3). Irrespective of the type of diabetes, both longer duration of diabetes and more severe hyperglycaemia have also been linked to a greater risk of TB disease (4,5). Having diabetes is further associated with a higher risk of multidrug-resistant TB (MDR-TB) (6,7). The prevalence of diabetes is estimated to increase globally by 50% between 2019 and 2045, with a median increase of 99% (interquartile range: 69–151%) in countries with a high burden of TB (8,9). In 2023, an estimated 380 000 (95% uncertainty interval: 280 000 ; 500 000) new episodes of TB were attributable to diabetes (1). One systematic review reported that, in 2019, 15.3% of people with TB were estimated to have diabetes globally, as compared with 9.3% among the general adult population (aged 20–79 years) (8,10). This equates to about 1.65 million people with TB who required coordinated care and follow-up to optimize management of both conditions in 2023 (1,10). Concomitant diabetes can complicate the management of TB and may adversely affect adherence to TB treatment (11–14). People with TB and diabetes are also at increased risk of dying during TB treatment and of TB relapse after treatment completion, as compared with people without diabetes (15).
In response to the increased diabetes burden, the World Health Organization (WHO) launched the Global Diabetes Compact in 2021 (16), with the vision of reducing the risk of diabetes and ensuring that all people who are diagnosed with diabetes have access to equitable, comprehensive, affordable, high-quality treatment and care. The WHO End TB Strategy, endorsed by the World Health Assembly in May 2014, provides strategic direction for achievement of the TB targets within the United Nations Sustainable Development Goals. Integrated patient-centred prevention and care and social protection for people with TB and diabetes are key components of the End TB Strategy. The strategy outlines a range of medical and socioeconomic interventions to address TB morbidity and mortality and the social determinants of TB (17). The End TB Strategy has a clear focus on the association between TB and comorbidities – including diabetes – under pillar 1 of the Strategy, namely integrated patient-centred care and prevention. The importance of protecting human rights when delivering integrated people-centred services was reiterated in the political declarations of the respective United Nations high-level meetings on the fight against TB and on noncommunicable diseases (NCDs) (18–20). The political declaration of the 2023 UN high-level meeting on the fight against TB recognizes that TB disproportionately affects people living with diabetes, and Member States commit themselves in the declaration to “integrate within primary health care, including community based services, systematic screening, prevention, treatment and care of TB and for related health conditions”, such as diabetes (20).
To help countries address TB and diabetes, WHO, in collaboration with the International Union Against Tuberculosis and Lung Disease, published the Collaborative framework for care and control of tuberculosis and diabetes in 2011 (21). The recommended collaborative activities for the prevention and care of diabetes and TB, also known as collaborative TB/DM activities, include establishment of mechanisms for collaboration, for detection and management of TB in people living with diabetes and for the detection and management of diabetes in people with TB. Systematic uptake of these recommendations by countries has, however, been limited (9,22,23).
This section of the operational handbook, hereinafter referred to as the “TB/DM section”, supports implementation of the recommendations on interventions developed in line with Grading of Recommendations Assessment, Development and Evaluation (GRADE). The included recommendations comprise those that are still valid in the Collaborative framework for care and control of tuberculosis and diabetes as well as related recommendations outlined in guidelines on the WHO TB Knowledge Sharing Platform (https://tbksp.org/) and in the latest WHO guidelines on the diagnosis and management of diabetes, such as HEARTS-D¹ (24–34). The TB/DM section also draws on the Framework for collaborative action on tuberculosis and comorbidities, in particular in relation to establishment and strengthening of collaboration among health programmes and sectors for peoplecentred services for TB and diabetes (35). In addition, it outlines some outstanding research priorities for collaborative TB/DM activities. The original recommendations from the Collaborative framework for care and control of tuberculosis and diabetes that were not developed in line with GRADE are included as part of general implementation guidance in the TB/DM Operational Handbook (21).
1 HEARTS-D is an acronym based on the modules of the technical package, H: Health–lifestyle counselling; E: Evidence-based protocols; A: Access to essential medicine and technology; R: Risk-based cardiovascular disease management; T: Team-based care; S: System for monitoring; D: diagnosis and management of type 2 diabetes.
