Q4-11 Interview: Link between diabetes and tuberculosis hits the global agenda The Collaborative Framework for Care and Control of Tuberculosis and Diabetes was launched in August this year. The framework document has been developed by the WHO and the International Union Against TB and Lung Disease (The Union). All along, the WDF has played an important role in catalysing the process. The Collaborative Framework and support material is available from WDF's thematic TB page.   We spoke to one of the driving forces behind the genesis of this framework document, Prof. Anthony Harries. He is Senior Advisor in The Union and focuses on the field of tuberculosis, HIV/AIDS, tropical medicine and operational research. What is the main message of the collaborative framework on tuberculosis and diabetes? "The main message is that there is strong evidence about a link between diabetes and tuberculosis. This evidence was not apparent five years ago. In brief, the evidence indicates that diabetes increases the risk of getting tuberculosis 2-3 times. And it indicates that tuberculosis can make diabetes worse. Furthermore, diabetes makes treatment of tuberculosis less efficient. In this framework document we demonstrate the evidence at this stage and suggest the ways forward." How will this message be promoted or communicated? "The provisional framework will be launched and disseminated globally by the WHO and The Union. All WHO regional offices will receive web and hard copy versions. It will be disseminated at the UN NCD Summit in New York in September. On this occasion, Dr. Nils Billo will present a few slides about the link during a short session on various aspects of NCDs. It will also be disseminated at the World Lung Conference to be held in Lille (France) in October accompanied by a press conference. Hopefully, the message will be picked up through some of these channels of communication." It seems that the global increase in diabetes and the link between diabetes and tuberculosis have pushed global tuberculosis agenda. How has this affected the process towards the collaborative framework? "Most of us feel that it would be a mistake to ignore the link. When HIV-TB became an issue we were very slow in responding to that threat, particularly in Africa and it took us a long time to get our act together and to get together collaborative activities to reduce the dual burden of those two diseases. We do not want to make that mistake with diabetes - tuberculosis. I think we learned from past mistakes here and we take the threat of the diabetes-tuberculosis association seriously. We must begin to act now in terms of screening patients and picking up these diseases early so that we can treat them early and hopefully get better outcomes." This framework has been on its way since the systematic review and the expert meeting in Paris in 2009. What will happen in the years to come? "It is important for me to emphasise that this is a provisional framework. What we mean by that is that there is strong evidence about the linkage and there is strong evidence about the adverse effects. But what we don't really know at the moment is how best we screen for those two diseases in routine systems and how best we offer better control. An example is ‘Do we need to extend the length of tuberculosis treatment in patients with diabetes?' We don't know that. Some people say we should do, but we have no evidence. So the way forward, as I see it between now and 2015 is for people to do operational research and clinical research; try to build the evidence for intervention. What the WHO has requested is in 2-3 years time to review that evidence and see whether we have a real framework instead of a provisional one. So the next few years will be about building the evidence around what sort of interventions we should do." Thematic page about diabetes and tuberculosis

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