COVID and diabetes become a threat to tuberculosis eradication; Virtual observation also required


Anu Solomon



Part 3

Representative Image| Photo: Gettyimages

In India, there are an estimated 2.7 million incident TB cases. As a consequence of urbanization as well as sociao economic development, there has been an escalating epidemic of Diabetes Mellitus. Available evidence and modeling studies indicate that nearly 20 percentage of all TB cases in India may also suffer from Diabetes.

Some facts

  • patients with Type 2 Diabetes have a 3 fold increased risk of developing TB.
  • Patients with TB have a 2 fold increased risk of developing Diabetes.
  • TB causes glucose intolerance
  • diabetes may alter the clinical presentation of TB.
  • Diabetes may increase the time of sputum culture conversion.
  • Double risk of development of drug resistance TB among Diabetes patients
  • Odds of having treatment failure, relapse and death was 8.99, 1.64, 1.88 times higher among TB patients with diabetes.
  • Due to lack of early detection and treatment, complications from TB-Diabetes co-morbidity lead to high cost of treatment and out of pocket expenditure
In 2020, 82 percentage of all the notified TB patients in the public and private sector have been screened for blood sugar and 8 percentage were found to have Diabetes. Out of this 54 percentage co morbid patients were referred to the NCD clinic and linked to anti-diabetic treatment.

Among the NCD clinic attendees with diabetes, about 15 percentage have been screened for Tuberculosis, and referred for TB testing.

Among the tuberculosis patients reported in Kerala, which is known as the Diabetic capital of India, 90 percent have diabetes. When diabetic patients were examined, 31 percent were found to have tuberculosis, as per the India TB report of 2021.

A representative image | Photo: Gettyimages

How COVID and diabetes lead to tuberculosis?
Dr Jayasree P. R, Consultant Pulmonologist at Kozhikode TB Centre, says that the most important reason for COVID and diabetes leading to tuberculosis is inadequate immunity power of the body.
COVID as well as the drugs used for treating COVID, especially steroid drugs, affects the immunity power of the body in a major way.

When immunity decreases, the dormant TB germs in the body becomes active. So it leads to tuberculosis disease. Because of these reasons, those who have been affected by COVID have higher chances of getting tuberculosis.

Dr Jayasree P R

Post-COVID complications and tuberculosis
Many lung-related health problems are found among those who have been cured of COVID. Post-COVID symptoms mostly affect lungs. Eighty percent of the patients are found to have persistent cough and breathing difficulty.

These symptoms, known as Long COVID Syndrome, will be present in patient for two to eight weeks after recovering from COVID. Those who have such problems should definitely undergo a sputum test to make sure that they are not affected by tuberculosis.

Tests like chest X-ray should also be undertaken along with the sputum test.

When diabetes adds to problems
Proneness to diabetes is also found among COVID patients. It means, diabetes has been found in those who did not have this disease earlier, after being affected by COVID. The reason is that the corona virus that causes COVID affects pancreas just like it affects all other organs in the body.

There is a section called vulnerable group among tuberculosis patients. One of the most important section in this group are diabetics. Similarly, those who have lung-related diseases, smokers, alcoholics, those who undergo dialysis, those who use drugs like steroid and those who take medicine for cancer come under the vulnerable group for TB.

The chance for being affected by TB is high among these people. Such patients who belong to the vulnerable group are identified as part of tuberculosis eradication program and their sputum test is taken in every three months because of their proneness to tuberculosis. Thus, those who have tuberculosis can be identified.

The tuberculosis symptoms in diabetic patients are the same as that of normal diabetic patients. A cough that persists longer than two weeks, blood in sputum, fever, body pain, breathing difficulty etc. are the symptoms of tuberculosis that affects lungs.

The chances of diabetic patients being affected by extra pulmonary TB are also significantly high. Diabetes is also a reason for reduction in body weight and immunity power. The symptoms of extra pulmonary TB appear depending on which organ in the body is affected.

Pulmonary TB is the one which is can be diagnosed most easily. If it is extra-pulmonary, it is difficult to diagnose. The symptoms will depend on which organ is affected. Normal symptoms of TB will also appear along with it. So, diagnosis should be made by conducting tests for all these.

A representative image | Photo: Gettyimage

Diagnosis
The most important diagnosis method is sputum test. It is of different types. One type is testing sputum and finding germs. Some other methods are nucleic acid tests like CB-NAAT(Nucleic acid amplification test), TrueNAT etc. These can diagnose tuberculosis accurately.

Nucleic acid tests like CB-NAAT and TrueNAT are used to diagnose tuberculosis among COVID patients.

This test helps to diagnose not only tuberculosis but also drug resistant TB. The same test is used in those who are cured of COVID.

TB Management
A diabetic tuberculosis patient is treated in the same way as a normal tuberculosis patient. Tuberculosis treatment is done at the respective TB centres and diabetes management is done under the supervision of a diabetes specialist. For the treatment of Tuberculosis, a treatment that includes medicines like INH, Rifampin, Pyrazinamide and Ethambutol are given in the first two months.

Then for the next four months, medicines such as INH, Rifampin and Ethambutol will be given.

Normally, a sputum test will be done 56 days after the treatment begins. Normally, the sputum test result will be negative in two months for those who undergo treatment. But the chance for sputum test becoming negative is less among those who have diabetes. Especially if, diabetes is not under control.

Not controlling diabetes properly and not taking medicines properly are the reasons for this condition. Like this, if the result is again positive, a sputum culture will be effective.

It will also help to find out if the medicines that are currently being given to the patient are effective or if they have resistance to any medicine.

If there is resistance, medicines can be changed accordingly and the treatment can be continued. Thus, after six months of treatment, the test usually becomes negative and the patient is completely cured of tuberculosis.

The total recovery from tuberculosis like this will be possible if there is proper diabetes control. In tuberculosis patients with diabetes, insulin will be more effective than tablets for diabetes control, added Dr. Jayasree.

Virtual IP necessary for managing diabetes in tuberculosis patients
During this pandemic period in which telemedicine has become common, Dr. Jyothidev Keshavadev, a prominent diabetes specialist and Chairman and Managing Director of Jyothidev's Diabetes and Research Centre, Thiruvananthapuram, is sharing a successful model of providing diabetes treatment through virtual IP.

Dr. Jyothidev Keshavadev

In the research conducted by Jyothidev’s Diabetes Research Centre in relation to treating COVID at homes in the state of Kerala, it has been found that death can be prevented in hundred percent of patients. The results of this study were presented in the international conference on Advanced Technologies & Treatment for Diabetes.

This was also published in Index Medical Journal. This project, named Virtual COVID IP, envisages admitting COVID patients at their own homes just like hospitals and a medical team comprising doctors, nurses and dieticians treating and monitoring them.

The patient checks their six vital parameters, which are pulse rate, blood oxygen, respiratory rate, glucose, temperature and blood pressure through self-observation once in every four hours and shares the same with the medical team through telemedicine. The medical team will be on duty for 24 hours, just like they are in the hospital.

In COVID patients, chances for the sugar level to increase are high, even if they are not diabetic. Diabetic treatment should be administered strictly to those who have diabetes so that COVID does not become serious.

As steroids are used in the treatment, sugar level should not exceed 180mg/dL or come down below 70mg/dL. This is very difficult. But it was made possible with virtual COVID IP. It was done by administering quick-acting insulin in small doses, four to ten times.

Continuous glucose monitoring was also done in 80 percent of patients for whom steroids had to be used for treatment. This was made possible with the help of technology and active participation of patients.

The same method can be used for managing diabetes in tuberculosis patients. At present, the treatment for tuberculosis is provided through TB Centres and that for diabetes management is given under the direct supervision of diabetes specialists.

Both these should be taken forward successfully to complete treatment effectively. So, the patients should also wholeheartedly cooperate to take forward both the treatments at the same pace, added Dr. Jyothidev.

All lifestyle diseases including diabetes can make a person vulnerable to tuberculosis and other diseases. So, what we should do is to take efforts to control lifestyle diseases. Not only tuberculosis patients, all should bring diabetes under strict control. Follow the instructions of the diabetes specialist and undergo treatment.

Proper exercise, nutritious food in proper measures, proper treatment—there should not be any negligence with regard to these. Remember, failing to control diabetes will create obstacles in tuberculosis eradication too.

(Concluded)

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