The conundrum of TB, tobacco use and NCDs in Asia Pacific

Shobha Shukla / Bobby Ramakant *

Asia Pacific region had over 6.7 million new TB cases and over 883,000 people died of TB in 2021, as per the latest Global TB Report of the World Health Organization (WHO). The top 5 biggest risk factors that caused TB disease in 2021 in Asia Pacific region were undernourishment (1.2 million new cases), tobacco use (502,000 new TB cases), alcohol (486,000 new TB cases), diabetes (234,000 new TB cases), and HIV (209,000 new TB cases).

Preventing TB risk factors is also TB prevention

“Breaking the chain of infection transmission is one of the critical cog-in-the-wheel towards ending TB. Alongside making latest treatment therapies of latent TB infection accessible to those who are at a higher risk of progressing to active TB disease, we also need to focus on stronger tobacco and alcohol control, diabetes prevention and care, TB-HIV collaborative activities, as well as ensuring food security for everyone in the region. TB is preventable – but each of the 6.7 million people who got TB disease in Asia Pacific in 2021, is a grim reminder that we could have done better to prevent TB,” said Dr Tara Singh Bam, Asia Pacific Director of International Union Against Tuberculosis and Lung Disease (The Union) and Board Director of Asia Pacific Cities Alliance for Health and Development (APCAT).

If we are to end TB by 2030, we need urgent and stronger collaborative actions so that while we scale up TB prevention, diagnosis, treatment and care services to all those who need it, we also reduce (with a goal to eliminate) TB risk factors such as tobacco, alcohol, and undernourishment, prevent and reduce NCDs, among other vital steps to strengthen health systems.

Local actions are key to achieve global goals

In many countries in Asia and the Pacific region, despite policies for collaborative activities between national programmes of TB, tobacco, NCDs, or food security, an alarming number of people have suffered due to active TB disease, and quite a significant number died. “At the local level, it is paramount for frontline workers and other local leaders who work on TB, and prevention of tobacco, alcohol, NCDs or undernourishment, to join forces effectively. Local or sub-national governments have a critical responsibility to ensure forging of stronger partnerships between these programmes that address TB risk factors. Reaching out to every case of TB disease and those who need treatment for latent TB is as important as reducing (and eliminating) risk factors that cause the disease,” said Dr Tara Singh Bam.

That is why sub-national government leaders (such as Mayors, Governors or Members of Parliament) of over 80 cities across 12 countries of Asia Pacific who co-lead APCAT had adopted a strong Declaration at the 7th Asia Pacific Summit of Mayors last December calling for stronger united action towards eventually ending tobacco, TB, viral hepatitis, and preventing the avoidable burden of non-communicable diseases (NCDs), among other decision points.

Tobacco use is one of the major risk factors for NCDs as a whole. Tobacco is one of the major risk factors for cardiovascular diseases, chronic respiratory diseases, cancers, and diabetes. One in six deaths by NCDs are related to tobacco. According to the first edition of the Tobacco Atlas (2020) for WHO Southeast Asia region, 20% of deaths due to tobacco use occurred in the southeast Asia region which covers 11 countries: Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste. With 26% of the world’s population in this region, it reported the highest prevalence of tobacco use (28%) amongst all WHO regions in 2020.

According to the latest Diabetes Atlas, 1 in 11 adults (90 million people ) are living with diabetes in Southeast Asia alone. More alarming is that more than half of them are undiagnosed. Over 747,000 people died of diabetes in 2021 in southeast Asia region with over US$ 10 billion spent on diabetes. In Western Pacific region, 1 in 8 adults (206 million people) are living with diabetes with over half of them undiagnosed. 2.3 million deaths were caused by diabetes in 2021 and US$ 241 billion was spent on diabetes that year in the region.

Studies have shown that poorly controlled diabetes presents a higher risk for latent TB infection. Prevalence of latent TB infection was 4.1% in people without diabetes, 5.5% in people with pre-diabetes condition, and 7.6% in people with diabetes. Alarmingly, it also showed that people with diabetes, with poor glycemic control (or diabetes control) were even more likely to have latent TB infection. For example, people with undiagnosed diabetes (who often have uncontrolled diabetes) had 12 percent prevalence of latent TB infection; a rate 3-4 times higher than the general population. People with diabetes with high levels of fasting plasma glucose, a biomarker of poor glycemic control also had significantly higher rates of latent TB infection.

Tobacco use increases the risk of contracting TB, increases the risk of recurrent TB, and impairs the response to treatment of the disease.

“Neglecting TB risk factors are threatening to reverse the progress made in the fight against TB. Neither can we afford to wither away the gains made in the fight against TB, nor can we ignore the mountainous disease and untimely death burden caused by TB risk factors. United responses on the ground are must,” said Dr Bam. Latest TB diagnostics and full cascade of TB care services much reach everyone who needs them, and no one can be left behind if we are to end TB by 2030. No less important is to work committedly and collaboratively to reduce (and eliminate where possible) TB risk factors and strengthen health systems and other development indices.