Tuberculosis (TB) and Diabetes mellitus (DM) are major global health challenges. TB is responsible for over one million deaths each year, and DM affects 463 million adults globally; a rate that has more than tripled over the past two decades.[1, 2] A double burden of TB and DM is of growing concern, especially in low- and middle-income countries (LMICs) with high burdens of TB.[3] Studies have found that TB and DM can each increase the incidence of the other,[4] and DM can triple the risk of developing TB.[5] Results from bi-directional TB and DM screening all over the world have found large variations of TB prevalence in DM and DM prevalence in TB, ranging from less than 2% to over 35% for both rates. This variation is due to the wide variety in prevalence of each disease.[6] A systematic review of studies in South Asia suggested that DM prevalence among TB patients is higher in countries with a high TB burden.[7] Moreover, TB patients with DM are more likely to have adverse treatment outcomes such as relapse or even death, and potentially show a higher risk of developing multi-drug resistant TB.[7–9] Uncontrolled diabetes (plasma HbA1C level ≥ 7.0%) has been identified in studies as a risk factor for poor TB treatment outcomes, or even treatment failure.[10, 11] In 2011, the World Health Organization (WHO) and the International Union against Tuberculosis and Lung Disease released the “Collaborative framework for care and control of tuberculosis and diabetes”. This framework recognized the close correlation between TB and DM, and called for increased efforts to establish collaboration in TB-DM co-management.[12] The detection and treatment of TB-DM cases are crucial to reaching the end TB target of Sustainable Development Goals (SDG).[13] Achieving this target is a critical challenge, especially for LMICs with a high burden of TB and rising prevalence of DM.
The technical guidelines for the detection and clinical management of TB-DM co-morbidities have been widely covered in the current literature. Previous studies have discussed the technical validity and feasibility of TB-DM bi-directional screening. A two-stage approach including random plasma glucose (RPG) screening plus glycosylated hemoglobin A1C testing for RPG > 6.1 mm/L has been verified as an accurate approach to detect DM in TB patients in a multi-site large study;[14] the first step of which includes the use of fasting blood glucose and urine dipstick.[6, 14] The WHO recommends a five-point questionnaire on TB symptoms to screen for suspected TB cases before administering diagnostic tests such as sputum smear test, culture tests or X-rays.[15] Although recent studies on TB and DM in LMICs supported the need for DM screening among all TB patients or at least high-risk patients;[7, 11, 16–21] studies on the feasibility and impact of TB screening among DM patients have showed mixed-results even in countries with a high TB burden like India.[22–26] Nevertheless, the WHO still recommends active screening of TB among DM patients in countries with high TB prevalence (over 100/100 000).[27] The clinical management of concurrent TB-DM cases requires more effort, as TB patients with DM are more susceptible to the toxicity of TB drugs and to drug-drug reaction, which could result in poor treatment adherence.[28] Glycemic levels also need continuous monitoring during TB treatment to avoid adverse clinical outcomes.
Indonesia suffers from a high burden of TB and DM. According to a 2020 WHO report, Indonesia accounted for the second largest number (8.5%) of global TB incidence.[2] Over 6% of adults aged 20–79 in Indonesia have DM, a significant number given the large population of Indonesia.[1] A recent study estimated an age-standardized DM prevalence rate of 11.3% among Pulmonary TB patients in Indonesia,[20] another study from 2013–2016 found that over 13% of DM cases in Indonesia ever had TB or were diagnosed as TB.[29] In 2015, the Indonesian Ministry of Health issued a Consensus on the Management of Tuberculosis and Diabetes Mellitus (TB-DM) to support comprehensive TB-DM co-management in health care facilities. This consensus included bi-directional screening algorithms, diagnosis pathways and referral requirements for TB-DM cases, and was intended as a reference for health workers on TB-DM management services in all primary health care facilities in Indonesia.[30] In 2016, the first official statement of collaborative TB-DM co-management was included in National TB Control Program (NTP) and these co-management activities were initiated across Indonesia in 2017.[31] Since its implementation, there has been little evaluation on the success of the TB-DM co-management program in real-life settings. This study aims to examine the case-detection and treatment outcomes of TB-DM patients in Jakarta, Indonesia after implementing the co-management activities, and to identify factors associated with the detection and treatment outcomes of TB-DM co-morbidities. This study will also provide new evidence regarding the impact of the TB-DM co-management program on overall TB-DM care, as well as implications for implementing such programs in similar resource-limited settings in other LMICs.