The double burden of diabetes and global infection

77% of people with diabetes mellitus now live in low and middle-income countries (LMIC), and the incidence of diabetes is accelerating in poorer communities. The majority of people with diabetes are thought to have Type 2 diabetes mellitus (T2DM) although further research on diabetes subtypes in LMIC is needed. Diabetes increases susceptibility to infection and / or worsens outcomes for major global infections such as tuberculosis (TB), dengue, influenza and Gram-negative sepsis including Salmonella species and the neglected tropical disease melioidosis. Melioidosis is caused by the soil bacterium Burkholderia pseudomallei, has a 40% hospitalised case fatality rate in LMIC, and an estimated 89,000 global death toll. People with diabetes have a twelve-fold increased risk of melioidosis compared to non-diabetics, and up to two-thirds of melioidosis patients have T2DM. There is a large overlap between populations at risk of diabetes and those at risk of melioidosis, resulting in an estimated 280 million people with diabetes now living in melioidosis-endemic countries across the world. In addition, people with diabetes bear a disproportionate burden of drug-resistant infections from bacteria with antimicrobial resistance (AMR).

This talk will give an overview of what is known about the epidemiology of diabetes and infection, and discuss potential mechanisms for the increased risk of infection, and in particular for the exquisite susceptibility of people with diabetes to melioidosis. International treatment guidelines for T2DM are based on research conducted in high-income countries focussed on preventing adverse cardiovascular outcomes and early death. There is a lack of evidence on which to base treatment guidelines for people living in LMIC, where there is an increased burden of infectious diseases. The literature to date on the impact of treatment on infection risk and outcomes will be discussed. Finally, the role of vaccination of people with diabetes will be discussed. It is noted that a public health vaccine for melioidosis would be targeted at people with diabetes in the first instance, as this group represents a well-defined and accessible population for evaluation of a melioidosis vaccine.