TUBERCULOSIS (TB), also known as “the consumption” because of the weight loss it causes, is a debilitating disease that we may assume is a thing of the past. However, it still affects millions of people worldwide. It is indeed an old disease – it was discovered in the 1880s. TB is endemic in Malaysia – a disease we live with – just like dengue and, recently, Covid-19. While awareness is high for the latter two, many of us rarely spare a thought to the existence and threat of TB in the community.
We only need to remind ourselves by looking at our arms – Malaysians are vaccinated with BCG (i.e. Bacille Calmette-Guerin) as babies and in primary school. This shot protects us against TB. This may be the reason we feel a sense of security but we do not realise that its effectiveness wanes over the years and many of us no longer have immunity as adults.
Basics of TB
TB is caused by the bacteria Mycobacterium tuberculosis. It can attack different parts of the body, with the lungs – referred to as pulmonary tuberculosis (PTB) – being the most common. Extrapulmonary tuberculosis (EPTB) is a term used to categorise TB when it manifests in other parts of the body, including the lymph nodes, bones (usually the spine), in rare cases, the gut. It can also attack the brain of immunosuppressed patients, especially those having HIV.
Those with the highest risk are the elderly, individuals with lowered immunity, such as diabetics and those undergoing chronic steroid therapy, and people living with HIV. Young children are also more at risk because their immune systems are still developing and that is why they are given BCG. Others include those who live in overcrowded living spaces – making it easier for the bacteria to pass on – such as migrant workers and the poor.
The four cardinal symptoms of PTB are chronic cough, profuse night sweats, weight loss and recurrent rise in body temperature in the evenings. In EPTB manifestations, the disease presents itself as swollen lymph nodes, chronic back pain and fragile bones, a sensitive gut and if in the brain, it can cause seizures, headaches, confusion and even alterations in personality.
One of the challenges in detecting TB is that it does not present symptoms immediately. “You could have been exposed long ago and the bacteria will stay latent or dormant in the body and hibernate. Symptoms can come up months or even years later,” says the Head of Division of Medicine, School of Medicine, International Medical University, Prof Dr James Koh. The slow and subtle onset of the symptoms are also unlikely to set off alarm bells until the disease has advanced, when you find yourself coughing up blood.
Testing for TB
TB is diagnosed through a few tests. For PTB, an X-ray of the lungs will show “cavities”, a telltale sign of TB. There is also a saliva test and a skin test; in cases of EPTB, a biopsy of the bone or swelling may need to be done.
When do you need to see a doctor? The rule of thumb is: Do not wait to cough up blood. See a doctor if you have had persistent cough for two weeks. Taking into account your general state of health, the doctor will know whether to test you for TB. Do the same if you have unexplained night sweats and weight loss, along with swollen lymph nodes or chronic back pain.
“If you are aware that you have been exposed to someone with TB, someone you share a working or living space with, then you may also want to see a doctor to be screened,” adds Koh.
He explains that a good notification system is in place in the public health sector. When a patient is detected as having TB, the doctor has to notify the public health officer. The officer will then initiate contact tracing to identify the possible people who have been exposed. Arrangements will then be made for these people to be tested.
Contagious or not?
The good news is that while TB is contagious, it is not as contagious as Covid-19. Similar to all respiratory diseases, it spreads through water droplets from coughing or spitting. However, unlike the coronavirus, the bacteria is heavy, so these need to be significant water droplets.
“You have to be in quite close contact and there is prolonged exposure. Generally, more than eight hours,” says Koh. Some examples of close contacts would be immediate carers, colleagues or those living in the same house.
A person with latent or dormant TB is not infectious and neither are those who have EPTB, without the infection settling in the lungs.
What to expect for treatment
TB treatment is straightforward but long. A combination of four antibiotics will be prescribed for anything between six months and a year, depending on which part of the body is affected.
“For PTB, it is generally six months. EPTB needs nine to 12 months,” says Koh. Newer medications can potentially treat TB within three months but Malaysia does not have them yet. “At the moment, we are still using the old regime,” he adds.
However, it is crucial to take the medication on time and as prescribed. If a patient does not complete the course or misses doses, the bacteria can become resistant to the drug. This can escalate into extensively drug-resistant TB (XDR TB) and multidrug-resistant TB (MDR TB) – or what is commonly known as superbugs.
“Those with MDR/XDR TB can spread it to others and, unfortunately for the infected person, it can become hard to treat because the bacteria is already resistant. In this case, alternative medications involving injections and a much longer therapy of up to two years is necessary. It can get complicated,” warns Koh. To prevent such lapses, the public health system has a check-in protocol where those undergoing treatment are regularly monitored to ensure the proper administration of drugs.
Once treatment is started, a person will be non-infective in 10 to 14 days. Patients in hospitals are put in isolation but there is no prescribed quarantine period. “The most important thing is to wear a mask and wash your hands frequently.”
TB numbers
While Malaysia is not on the World Health Organisation’s top 30 high-burden countries for TB, it is still considered a country with a high incidence rate, estimated at 92 per 100,000 population. Every year, between 20,000 and 25,000 cases of TB are recorded, resulting in an average of 1,500 to 2,000 deaths. (To put things in perspective: There are 50,000 to 100,000 dengue cases a year, with about 100 recorded deaths.)
Recently, there have been reports that cases have been on the rise. However, Koh explains that the trend in TB cases correlates with the implementation of Covid-19 protocols.
Malaysia recorded 25,837 cases pre-pandemic in 2018. During the pandemic, in 2020 and 2021, the cases decreased to 23,644 and 21,727, respectively. “We were wearing masks, observing social distancing and adhering to movement control orders – all of which helped to dampen the spread of TB,” explains Koh.
With the relaxation of these standard operating procedures, the incidence of TB has risen back to pre-pandemic levels – 25,391 cases were recorded in 202 – although the World Health Organisation’s incidence rate estimates actual cases at around 30,000.
What to do?
There is no “booster shot” to raise immunity levels against TB. The best way to keep it at bay is to ensure a healthy lifestyle.
“Generally, a person who is healthy and has a good immune system should be able to fight off TB on their own,” says Koh.
It also pays to be aware of symptoms as early treatment is crucial. If left for too long, even after recovery, TB can leave scarring on the lungs that will forever curb a person’s lung capacity.
“When a person has recovered, maintain a good diet, exercise and do not smoke. You can get reinfected with TB and that can be quite bad,” he advises.
Education on the disease is also crucial to prevent stigmatisation of those with TB. Perhaps, due to the portrayal of the disease in movies, TB is often seen as a “dirty disease” and a confirmed death note. It is far from this, and this perception can lead to delays in seeking treatment, arising from a sense of helplessness, fear of isolation and rejection by society. Remember that the disease is curable and that it can happen to anyone.
This article was contributed by the International Medical University. Comments: letters@thesundaily.com
