49 3 Epidemiology and control of DM-TB Comorbidity (14, 15). People with DM have a greater risk of developing TB. This increased risk is possibly due to poor glycemic control resulting in abnormal metabolism in macrophages and lymphocytes, which impacts the immune function of these cells. This predisposes to new TB infection or reactivation of latent TB in those who were previously infected (12, 14). On the contrary, the causes of impaired blood glucose during TB treatment are not clear. Current evidence points to an impaired glucose tolerance during TB treatment which may or may not resolve once treatment is completed (16-18). This may be due to undiagnosed DM, stress response from infection which elevates stress hormones or abnormal functioning of the liver which results in abnormal endocrine function (16, 19). Among known diabetics undergoing treatment for TB, there have been concerns of DM delaying sputum conversion leading to a poor outcome. This is yet to be fully confirmed (12, 14). A recent study from Ghana shows significantly fewer patients with hyperglycemia had sputum conversion at two months of TB treatment compared to normoglycemic patients, but not at six months (20). Other factors that could impact TB treatment outcomes amongst people with DM include the non-integration of services that causes non-adherence, psychosocial factors such as stigma and increased economic burden of treatment for the two conditions which are paid for out-of-pocket in most low-income countries (12, 15). More recently, the COVID-19 pandemic impacted all service delivery and access to essential care. This was due to disruption in the supply of essential health commodities, widespread infection of healthcare workers with COVID-19 and restriction of movement which limited TB patients from visiting health facilities. The impact of the pandemic and the different measures adopted to limit COVID-19 infection on access to TB services and treatment outcomes is yet to be quantified. The Syndemics concept has been used to describe the symbiotic coexistence of diseases with associated inequity in access to health and social services, poverty and malnutrition resulting in increased morbidity and mortality in at-risk populations (15, 21). The Syndemics concept originated from high-income countries’ observations that different disease conditions coexist and affect the communities, notably the minority populations and those with low socioeconomic status. Meanwhile, the concept has been extended to describe the comorbid conditions which exist in low and middle-income countries, like TB/HIV and non-communicable diseases (15, 21). With a gradual increase in lifespan in low- and middle-income countries, the impact of NCDs particularly DM and hypertension, has become obvious. Morbidity and mortality due to TB and HIV have reduced because patients now access life-saving medications and observed morbidity and mortality is due to NCDs (22-24).
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