Diabetes and Tuberculosis Co-Management in High-Burden Settings: A Narrative Review of Integrated Service Models
DOI:
https://doi.org/10.5281/zenodo.22261632Keywords:
Tuberculosis, Diabetes, Bidirectional screening, Integrated care, Low- and middle-income countriesAbstract
International guidance recommends bidirectional screening for tuberculosis and diabetes where both are prevalent, and
integrated services have been established in several countries to deliver it. The evidence that integration works is weaker and
more one-sided than the recommendation implies. In a comparison of eight Malawian hospitals, of which one had integration
measures, tuberculosis screening among people with diabetes increased and loss to follow-up in both diseases fell, but the
evidence for increased diabetes screening among people with tuberculosis was limited. The yields differ by a wide margin in the
same direction: screening people with diabetes for tuberculosis in a multi-province Chinese study found active disease in 0.80 per
cent, while screening people with tuberculosis for diabetes in a Kerala programme found a prevalence of 44 per cent. A scoping
review of the collaborative framework concluded that evidence that diabetes is a risk factor for tuberculosis remains inconclusive.
Keywords: International guidance recommends bidirectional screening for tuberculosis and diabetes where both are prevalent, and
integrated services have been established in several countries to deliver it. The evidence that integration works is weaker and
more one-sided than the recommendation implies. In a comparison of eight Malawian hospitals, of which one had integration
measures, tuberculosis screening among people with diabetes increased and loss to follow-up in both diseases fell, but the
evidence for increased diabetes screening among people with tuberculosis was limited. The yields differ by a wide margin in the
same direction: screening people with diabetes for tuberculosis in a multi-province Chinese study found active disease in 0.80 per
cent, while screening people with tuberculosis for diabetes in a Kerala programme found a prevalence of 44 per cent. A scoping
review of the collaborative framework concluded that evidence that diabetes is a risk factor for tuberculosis remains inconclusive.
References
World Health Organization. "Global tuberculosis report 2024". World Health Organization, Geneva (2024).
Harries AD, Kumar AMV, Satyanarayana S, Lin Y, Zachariah R, Lonnroth K, et al. "Addressing diabetes mellitus as part of the strategy for ending TB". Trans R Soc Trop Med Hyg 110(2016):173-179.
Lonnroth K, Roglic G, Harries AD. "Improving tuberculosis prevention and care through addressing the global diabetes epidemic: from evidence to policy and practice". Lancet Diabetes Endocrinol 2(2014):730-739.
Malawi comparison authors. "Bidirectional screening and treatment outcomes of diabetes mellitus and tuberculosis patients in hospitals with measures to integrate care of diabetes and tuberculosis and those without integration measures in Malawi". BMC Infect Dis 22(2022):11.
Implementation determinants authors. "Implementation determinants of integrated tuberculosis and diabetes care". medRxiv (2025).
Lin Y, Innes A, Xu L, Li L, Chen J, Hou J, et al. "Screening of patients with diabetes mellitus for tuberculosis in community health settings in China". Trop Med Int Health 20(2015):1073-1080.
Balakrishnan S, Vijayan S, Nair S, Subramoniapillai J, Mrithyunjayan S, Wilson N, et al. "High diabetes prevalence among tuberculosis cases in Kerala, India". PLoS One 7(2012):e46502.
Kapur A, Harries AD. "The double burden of diabetes and tuberculosis: public health implications". Diabetes Res Clin Pract 101(2013):10-19.
Delhi integration authors. "Integrating screening for non-communicable diseases and their risk factors in routine tuberculosis care in Delhi, India: a mixed-methods study". PLoS One 13(2018):e0202256.
Rural India pilot authors. "Integrated management of diabetes and tuberculosis in rural India: results from a pilot study". Front Public Health 10(2022):766847.
Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, et al. "Task shifting for non-communicable disease management in low and middle income countries: a systematic review". PLoS One 9(2014):e103754.
Eswatini integration authors. "Tuberculosis and diabetes in Eswatini: addressing suboptimal treatment outcomes through integrated services". PLoS One 20(2025):e0323145.
World Health Organization. "Eswatini STEPS survey for noncommunicable disease risk factors". World Health Organization, Geneva (2014).
Restrepo BI. "Diabetes and tuberculosis". Microbiol Spectr 4(2016):TNMI7-0023-2016.
Critchley JA, Restrepo BI, Ronacher K, Kapur A, Bremer AA, Schlesinger LS, et al. "Defining a research agenda to address the converging epidemics of tuberculosis and diabetes". Chest 152(2017):165-173.
Riza AL, Pearson F, Ugarte-Gil C, Alisjahbana B, van de Vijver S, Panduru NM, et al. "Clinical management of concurrent diabetes and tuberculosis and the implications for patient services". Lancet Diabetes Endocrinol 2(2014):740-753.
Ruslami R, Aarnoutse RE, Alisjahbana B, van der Ven AJAM, van Crevel R. "Implications of the global increase of diabetes for tuberculosis control and patient care". Trop Med Int Health 15(2010):1289-1299.
Workneh MH, Bjune GA, Yimer SA. "Prevalence and associated factors of tuberculosis and diabetes mellitus comorbidity: a systematic review". PLoS One 12(2017):e0175925.
Foe-Essomba JR, Kenmoe S, Tchatchouang S, Ebogo-Belobo JT, Mbaga DS, Kengne-Nde C, et al. "Diabetes mellitus and tuberculosis, a systematic review and meta-analysis with sensitivity analysis for studies comparing prevalence". PLoS One 16(2021):e0261246.
Odone A, Houben RMGJ, White RG, Lonnroth K. "The effect of diabetes and undernutrition trends on reaching 2035 global tuberculosis targets". Lancet Diabetes Endocrinol 2(2014):754-764.
Harries AD, Satyanarayana S, Kumar AMV, Nagaraja SB, Isaakidis P, Malhotra S, et al. "Epidemiology and interaction of diabetes mellitus and tuberculosis and challenges for care: a review". Public Health Action 3(2013):S3-S9.
Jorgensen ME, Faurholt-Jepsen D. "Is there an effect of glucose lowering treatment on incidence and prognosis of tuberculosis? A systematic review". Curr Diab Rep 14(2014):505.
Bailey SL, Grant P. "The tubercular diabetic: the impact of diabetes mellitus on tuberculosis and its threat to global tuberculosis control". Clin Med 11(2011):344-347.
Dooley KE, Chaisson RE. "Tuberculosis and diabetes mellitus: convergence of two epidemics". Lancet Infect Dis 9(2009):737-746.
Nair S, Kumari AK, Subramonianpillai J, Shabna DS, Kumar SM, Balakrishnan S, et al. "High prevalence of undiagnosed diabetes among tuberculosis patients in peripheral health facilities in Kerala". Public Health Action 3(2013):S38-S42.
Kumar A, Gupta D, Nagaraja SB, Singh V, Sethi GR, Prasad J. "Updated national guidelines for pediatric tuberculosis in India". Indian Pediatr 50(2013):301-306.
Marais BJ, Lonnroth K, Lawn SD, Migliori GB, Mwaba P, Glaziou P, et al. "Tuberculosis comorbidity with communicable and non-communicable diseases: integrating health services and control efforts". Lancet Infect Dis 13(2013):436-448.
Prakash BC, Ravish KS, Prabhakar B, Ranganath TS, Naik B, Satyanarayana S, et al. "Tuberculosis-diabetes mellitus bidirectional screening at a tertiary care centre, South India". Public Health Action 3(2013):S18-S22.
