Co-morbidities

Several medical conditions like diabetes, malnutrition, HIV, tobacco-smoking and alcohol-use are risk factors for TB and for poor TB treatment results. Therefore, it is important to identify these co-morbidities in people diagnosed with TB in order to ensure early diagnosis and improve co-management. When these conditions are highly prevalent in the general population they can be important contributors to the TB burden. Consequently, reducing the prevalence of these conditions can help prevent TB.

TB and HIV

People living with HIV are 29 times (26–31) more likely to develop tuberculosis (TB) disease compared with people without HIV and living in the same country. TB is a leading cause of hospitalization and death among adults and children living with HIV, accounting for one in five HIV-related deaths globally. Integration of HIV and tuberculosis services reduced the annual number of people dying from HIV-associated TB globally from over 500 000 in 2000 to 300 000 – a 40% decline in 2017. In the SEA Region in 2017, 55% of notified TB patients had documented HIV test results and ART coverage was 68%. The Regional Response Plans for TB -HIV 2017-2021 lays down strategies for enhanced action in this regard.

TB and tobacco smoking

The burden of tobacco use in the South-East Asia Region is one of the highest among the WHO regions, and tobacco use is a growing public health problem. Countries in the South-East Asia Region, such as India, Bangladesh and Indonesia, have a high burden of both TB and tobacco use, which requires immediate concerted action in order to have effective impact on the global epidemic. The Region is home to over 400 million tobacco users and in particular, prevalence of smoking among men in many countries of the Region is high and among females, smokeless tobacco use is popular. Smokers are almost twice as likely to be infected with TB and progress to active disease. Smoking interferes with TB at every stage of the disease. Secondly, it increases the risk of latent TB infection, culture conversion, sputum smear positivity, cavitary disease, treatment delay, treatment default, poor treatment outcomes and transmission of the disease. Some of these effects are mediated by a higher bacillary load among smokers. Thirdly, smokers are also twice as likely to die from TB.

The TB and Tobacco Regional Response Plan for South -East Asia 2017-2021 has three pronged strategy to address the issue.

TB and diabetes

Diabetes triples the risk of TB. The association between diabetes and TB has been known for many years but studies in the last 10–15 years have highlighted that diabetes  increases the risk of active TB and that patients with dual disease have worse TB treatment outcomes compared with those who have just TB alone. Strategies are needed to ensure that optimal care is provided to patients with both diseases. Diabetes prevalence is increasing globally including in SEA Region due to socio-economic and lifestyle factors. Further increase in the number of diabetes-associated TB cases risks jeopardizing progress that has been made in the global fight against TB. Therefore, it is essential to have cross-screening, all adult TB patients should be screening for diabetes and all  diabetes patients should be offered systematic screening for TB in high TB burden countries.

TB and nutrition

Malnutrition increases the risk of TB and TB can lead to malnutrition. Malnutrition is therefore often highly prevalent among people with TB. While appropriate TB treatment often helps normalize nutritional status, many TB patients are still malnourished at the end of TB treatment. Therefore, nutritional assessment and counselling, and management of malnutrition based on the nutritional status are an important part of the TB treatment package. Under-nutrition, and underlying food insecurity, are among the most important determinants of TB. Improving nutritional status at population level is important for TB prevention. This should be part of broader actions on social determinants.