• Fatima Mukhtar
  • Zahid A Butt


With the global increase in the diabetic population there is a resurgence of interest in the dual epidemic of diabetes mellitus (DM) and tuberculosis (TB), which have a bidirectional detrimental relationship with negative consequences for co-infected patients. Pakistan is feared to be hit the hardest, occupying fifth position amidst the 22 high burden TB countries, and ranking seventh in the global diabetic burden. The diabetes tuberculosis treatment outcome (DITTO) study was undertaken to determine the impact of diabetes on tuberculosis treatment outcome in Pakistan. The generation of such scientific evidence is useless if it is not utilized for policy making and practice, especially in a developing country like ours with a dearth of resources. In this paper, we have developed a framework for the transfer of scientific evidence regarding the impact of diabetes on TB treatment outcomes into policy and practice. The framework is divided into three components namely; generation of scientific evidence harnessing international and national efforts, informing health policy and practice and addressing other concerns such as social protection, health education and future research.Keywords:Diabetis, Tuberculosis, Policy, epidemic

Author Biography

Fatima Mukhtar

Associate ProfessorDept. of Community Medicine


WHO. Millennium Development Goals (MDGs) [Internet]. [cited 2016 May 1st]. Available from: http://www.who.int/topics/millennium_development_goals/en/

Magee MJ, Blumberg HM, Narayan KMV. Commentary: Co-occurrence of tuberculosis and diabetes: new paradigm of epidemiological transition. Inter J Epi 2011;40(2):428–31.

Transforming our world: the 2030 Agenda for Sustainable Development:. Sustainable Development Knowledge Platform [Internet]. United Nations. [cited 2016 May 1st]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld

Dooley KE, Chaisson RE. Tuberculosis and diabetes mellitus: convergence of two epidemics. Lancet Infect Dis 2009;9(12):737–46.

Guidelines for diagnosis and management of tuberculosis in Pakistan 2012. [Internet]. [cited 2015 Aug 25]. Available from: http://ntp.gov.pk/uploads/ntp_1369815695_NATIONAL_GUIDELINES.pdf

WHO EMRO. Stop Tuberculosis. Support for TB control in Pakistan [Internet]. [cited 2014 Dec 18]. Available from: http://www.emro.who.int/pak/programmes/stop-tuberculosis.html

National Tuberculosis Control Program. [Internet]. [cited 2014 10th]. Available from: http://ntp.gov.pk/index.php

National diabetes prevention programme [Internet]. [cited 2016 May 1st]. Available from: http://clahrc-gm.nihr.ac.uk/our-work/exploiting-technologies/national-diabetes-prevention-programme/

Faurholt-Jepsen D. The Double Burden. Dan Med J 2013;60(7):B4673.

Uplekar M, Weil D, Lonnroth K, Jaramillo E, Lienhardt C, Dias HM, et al. WHO’s new End TB Strategy. Lancet 2015;385(9979):1799–801.

The Mexico statement on health research. Knowledge for better health: strengthening health systems. [Internet]. from the ministerial summit on health research mexico city; 2004 [cited 2016 May 1]. Available from: http://www.who.int/rpc/summit/agenda/Mexico_Statement-English.pdf

Sutcliffe S, Court J. Overseas Development Institute (London E, Research and Policy Development Programme. A toolkit for progressive policymakers in developing countries. London: Overseas Development Institute; 2006.

Oxman AD. Lavis JN, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 1: What is evidence-informed policymaking?. Health Res Policy Syst 2009:7(Suppl 1):S1

Orem JN, Mafigiri D, Marchal B, Ssengooba F, Macq J, Criel B. Research, evidence and policymaking: the perspectives of policy actors on improving uptake of evidence in health policy development and implementation in Uganda. BMC Public Health 2012;12:109.

Moynihan R. Using Health Research in Policy and Practice: Case Studies from Nine Countries [Internet]. Co-Published with AcademyHealth; 2004 [cited 2016 May 1st]. Available from: http://www.milbank.org/uploads/documents/0409Moynihan/0409Moynihan.htm

Baker MA, Harries AD, Jeon CY, Hart JE, Kapur A, Lonnroth K, et al. The impact of diabetes on tuberculosis treatment outcomes: A systematic review. BMC Med 2011;9:81.

WHO, International Union Against Tuberculosis and Lung Disease. Collaborative Framework for Care and Control of Tuberculosis and Diabetes. WHO/HTM/TB/2011.15. Geneva: World Health Organization; 2011.

Satyanarayana S, Kumar AMV, Wilson N, Kapur A, Harries AD, Zachariah R. Taking on the diabetes-tuberculosis epidemic in India: paving the way through operational research. Public Health Action 2013;3(Suppl 1):S1–2.

Restrepo BI, Fisher-Hoch SP, Smith B, Jeon S, Rahbar MH, McCormick JB. Mycobacterial clearance from sputum is delayed during the first phase of treatment in patients with diabetes. Am J Trop Med Hyg 2008;79(4):541–4.

Oni T, Unwin N. Why the communicable/non-communicable disease dichotomy is problematic for public health control strategies: implications of multimorbidity for health systems in an era of health transition. Int Health 2015;7(6):390–9.

Bhattacharya PK, Roy A. Tuberculosis and Diabetes Mellitus: A Double Whammy for the Developing Nations. J Med Diagn Methods 2015;4:177.

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 2013;3(Suppl 1):S3–9.

WHO. Global Strategy and Targets for Tuberculosis Prevention, Care, and Control After 2015. WHO 67th World Health Assembly 2014. Geneva: World Health Organization; 2014.

Walugembe DR, Kiwanuke SN, Matovu JKB, Rutebemberwe E, Reichenbach L. Utilization of research findings for health policy making and practice: evidence from three case studies in Bangladesh. Health Res Policy Syst 2015;13:26.

Kumar AMV, Satyanarayana S, Wilson NC, Chadha SS, Gupta D, Zachariah R, et al. Operational research leading to rapid national policy change: tuberculosis-diabetes collaboration in India. Public Health Action 2014;4(2):85–8.

ExpandNet, WHO. Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up. Geneva, Switzerland: 2011. [Internet]. [cited 2016 May 1st]. Available from: http://www.expandnet.net/PDFs/ExpandNet-WHO%20-%20Beginning%20with%20the%20end%20in%20mind%20-%202011.pdf

Non-Communicable Diseases (NCD’s) policy brief-Pakistan. The World Bank, South Asia Human Development, Heath, Nutrition, and Population. February 2011. [Internet]. [cited 2016 May 1st]. Available from: http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/223546-1296680097256/7707437-1296680114157/NCD_PK_Policy_Feb_2011.pdf

Kilbourne AM, Neumann MS, Pincus HA, Bauer MS, Stall R. Implementing evidence-based interventions in health care: application of the replicating effective programs framework. Implement Sci 2007;9:2:42.

Hargreaves JR, Boccia D, Evans CA, Adato M, Petticrew M, Porter JDH. The Social Determinants of Tuberculosis: From Evidence to Action. Am J Public Health 2011;101(4):654–62.

National Health Program in Pakistan. Prime Minister National Health Program Wiki, Information & Guide [Internet]. [cited 2016 May 1st]. Available from: http://www.pakistantimes.com/topics/national-health-program/

WHO. The End TB Strategy. Geneva: World Health Organization [Internet]. 2015 [cited 2016 May 1st]. Available from: http://www.who.int/tb/post2015_TBstrategy.pdf

Ranganath TS, Shivaraj BM. A study on tuberculosis treatment outcome in known diabetic patients treated under Revised National Tuberculosis Control Program in Bengaluru. Int J Med Public Health 2015;5(1):32–4.

Reid MJ, McFadden N, Tsima BM. Clinical challenges in the co-management of diabetes mellitus and tuberculosis in southern Africa. J Endocrinol Metab Diabetes South Afr 2013;18(3):135–40.

Balasubramanian R, Ramanathan U, Thyagarajan K, Ramachandran R, Rajaram K, Bhaskar D, et al. Evaluation of an intermittent six-month regimen in new pulmonary tuberculosis patients with diabetes mellitus. Indian J Tuberc 2007;54(4):168–76.

Wang JY, Lee MC, Shu CC, Lee CH, Lee LN, Chao KM, et al. Optimal duration of anti-TB treatment in patients with diabetes: nine or six months? Chest 2015;147(2):520–8.

Tatar D, Senol G, Alptekin S, Karakurum C, Ayin M, Coskunol I. Tuberculosis in diabetics: features in an endemic area. Jpn J Infect Dis 2009;62(6):423–7.

Sullivan T, Ben Amor Y. The co-management of tuberculosis and diabetes: challenges and opportunities in the developing world. PLoS Med 2012;9(7):e1001269.




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