TB and diabetes are running into each other more often than we think - and our health system needs to keep up

Here’s something worth reflecting on for a moment. India bears approximately 25% of the world’s tuberculosis burden. It also has an estimated 101 million people living with diabetes, alongside another 136 million classified as pre-diabetic. And these two conditions? They share a clinically recognised, mutually damaging relationship.

A person with diabetes faces roughly three times the risk of developing active TB compared to someone without it, according to WHO. And TB, in turn, worsens glycaemic control, pushing blood sugar levels higher during and after treatment. It’s a cycle - sugar weakens immunity, the infection destabilises sugar. Dono ek doosre ko aur mushkil bana dete hain.

The scale of India’s TB progress, however, warrants proper recognition before we consider the complications. The WHO Global TB Report 2025, released on 12 November 2025, confirmed that India’s TB incidence fell by 21% between 2015 and 2024 - from 237 to 187 per lakh population. This is nearly twice the global decline of 12.3% over the same period. Treatment coverage increased from 53% to over 92%. The “missing cases” gap - people with TB who were never reported to the programme - reduced from 15 lakh in 2015 to less than one lakh in 2024. By any standard, these are notable achievements, supported by a nearly tenfold increase in government funding for the TB programme over nine years.

The Comorbidity Challenge

Indian studies report that the prevalence of diabetes among pulmonary TB patients ranges from 12% to 18%, depending on the region and study design. A cross-sectional study conducted across RNTCP centres in Madhya Pradesh identified TB-diabetes co-morbidity in 15.4% of patients. Research from the ICMR-supported RePORT India consortium has demonstrated that patients with both conditions experience delayed sputum conversion, higher relapse rates, and increased treatment failure. This is not a niche concern - it is a systemic issue, especially since India’s diabetes numbers continue to rise.

To its credit, India set up a National Framework for Joint TB-DM Collaborative Activities in 2017 - ahead of many other countries. The policy requires bidirectional screening: TB patients are tested for diabetes, and individuals attending NCD clinics with diabetes are checked for TB symptoms. The TB-HIV integration programme showed how effectively this model can operate when provided with dedicated resources and coordination.

The challenge exists at the district level, where the two programmes - NTEP for TB and NPCDCS (now NPNCD) for NCDs - often operate independently with separate logistics, separate reporting, and limited cross-programme coordination. A stakeholder study across Kerala and Bihar found that even when screening occurs, patients newly diagnosed with diabetes during TB treatment are often lost to follow-up once their six months of DOTS are completed. The TB gets treated. The diabetes? That’s a lifelong condition requiring ongoing care, monitoring, and medication. And that hand-off between programmes is where patients tend to fall through the cracks.

From the Patient’s Side of the Table

Consider how this affects a daily wage worker in a high-burden state. TB already carries stigma - family members keep their distance, employers become nervous. Add a diabetes diagnosis, and you face long-term medication costs, dietary changes that a Rs 200-a-day income cannot support, and a health system designed to handle one condition at a time. NCD-related out-of-pocket expenses already push Indian families into catastrophic health spending, with significant variation across states.

Then there’s the pharmacological complexity. Rifampicin, the cornerstone of TB treatment, interacts with some oral hypoglycaemics. Managing blood sugar levels during active TB treatment requires closer monitoring and dose adjustments than overstretched primary health centres can reliably provide.

What Can Be Done - Building on What Works

Firstly, strengthen integration at the final stage. India’s TB infrastructure is truly world-class - with 9,391 rapid molecular testing facilities, over 500 AI-enabled portable X-ray units, and 1.78 lakh Ayushman Arogya Mandirs bringing TB care directly to communities. The TB Mukt Bharat Abhiyan screened 19 crore people. These are substantial platforms. Incorporating systematic diabetes screening into these existing touchpoints - not as a separate activity but as an integral part of the protocol - would be a high-impact, low-cost measure.

Second, an ASHA-led bridge. The Community Based Assessment Checklist (CBAC) already includes risk assessment for common NCDs. Training frontline workers to link TB-cured patients to long-term NCD care - not just for detection but for ongoing follow-up - could close the gap that currently exists between cure and continued care.

Third, data linkage. Ni-kshay is a robust digital platform. If NCD data from NPNCD could be linked to Ni-kshay records at the patient level, clinicians and programme managers would have visibility on comorbidity patterns, treatment compliance, and outcomes that currently sit in silos.

India has shown it can accelerate progress on TB faster than nearly any other high-burden country. The next challenge is ensuring that the rising diabetes epidemic does not quietly undo those achievements. The policy framework is in place. The platforms are available. What is needed now is the operational effort to enable them to work together - at the PHC, at the district level, and in the lives of patients who require both programmes to function as one.

To know more about this and for support if any, call YRGMERF on 044 33125000 and do visit our website- yrgmerf.org

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