While tuberculosis (TB) may not be a commonly discussed medical condition these days, it certainly was during the 19th century, when it affected almost 90 per cent of the people living in the United States and Europe.
During that period, nearly one in seven people died of TB every day.
TB is an airborne disease caused by a bacteria known as Mycobacterium tuberculosis. This means the bacteria can spread through the air, when a person with pulmonary TB disease coughs, sneezes, or talks to others.
Pulmonary TB is the most common type of TB, and it affects the lungs. It causes symptoms such as prolonged cough (for more than two weeks), coughs with bloody phlegm, fever, night sweats, loss of appetite, and severe loss of weight.
Other than pulmonary TB, the TB bacteria can also invade other parts of the body, such as the lymph nodes, bones, brain, and kidneys. These are known as extrapulmonary TB.
TB is a treatable, curable, and preventable medical condition. The mainstay of TB treatment lies with medications.
However, in recent years, TB bacteria has developed resistance to the first and second-line TB treatments, leading multi-drug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) to be a critical concern to health care professionals worldwide.
What Are The Impacts Of TB?
Before the emergence of Covid-19, TB was the largest infectious disease killer. The latest Global TB Report estimated that 10.6 million people around the world were affected by TB, with 1.6 million deaths due to TB in 2021.
Despite the Southeast Asian region having contributed up to 43 per cent of the global TB burden, Malaysia has successfully maintained its status as a country with intermediate TB incidence with efforts through the National TB Control Programme by the Ministry of Health (MOH).
The MOH received a total of 21,727 TB case notifications and 2,288 death reports in 2021. This means there was an average of 60 people who fell ill with TB every day, with six deaths occurring daily.
TB has brought about detrimental health and wellbeing impacts, as well as financial burden on those affected by it. In general, TB patients will suffer from symptoms which may persist until treatment is administered.
In cases of pulmonary TB, it could cause irreversible scarring in the lungs after recovery, leading to symptoms such as shortness of breath. In cases of extrapulmonary TB, it could pose a challenge in the diagnosis with delayed treatments to cure the infection.
TB has also been known to affect the mental health and wellbeing of patients. Generally, patients with pulmonary TB have to be quarantined upon confirmation of diagnosis.
While most patients will no longer be infectious within two weeks upon treatment initiation, they are encouraged to refrain from interacting with others.
As they are unable to go to work while they undertake quarantine, this could result in a loss of productivity and income, especially for those who are on hourly or daily wages.
These, when coupled with societal stigma against TB, may precipitate a sense of loneliness, with worries about their medical and financial conditions, leading to distress and psychological consequences to the patient and family.
What Are The Myths And Facts About TB?
Myth 1: Only people from low socio-economic background get TB.
Fact: TB can affect anyone and everyone. Since TB is an airborne disease, TB bacteria can be transmitted in the form of droplets as the person coughs, sneezes or talks.
Therefore, it is important for us to take precautions to prevent TB infection. These include wearing a mask when feeling unwell, trying to avoid crowded and confined spaces, and practising hand hygiene regularly.
Moreover, it is also important for us to go to the doctor for a check-up if we feel unwell or if we are a close contact to a person who is newly diagnosed with TB.
Myth 2: We have taken the Bacillus Calmette–Guérin (BCG) vaccine, hence we will not get TB for life.
Fact: In Malaysia, it is mandatory for every new-born to receive the BCG vaccine. BCG vaccine aims to protect the children against severe forms of TB, such as TB meningitis.
However, BCG vaccine does not protect against the adult forms of TB, such as pulmonary TB.
Myth 3: All forms of TB are infectious.
Fact: There are types of TB which are non-infectious, for example, extrapulmonary TB and latent TB infection.
Extrapulmonary TB is a form of TB that affects other parts of the body apart from the lungs. Meanwhile, latent TB infection is a dormant form of TB where people who are diagnosed with latent TB infection will not experience any symptoms of sickness nor transmit the infection to others.
Latent TB infection happens when a healthy individual is infected by TB bacteria, but his or her immune system is strong enough to suppress the bacteria and keep the bacteria in the inactive form.
However, some people have weaker immune systems, for example people living with Human Immunodeficiency Virus (PLHIV) and children (below 5 years old) who are close contacts with a TB patient.
They will have a higher risk of getting latent TB infection, which can subsequently develop into active TB with symptoms. Therefore, preventive treatment is recommended to these populations to prevent TB infection.
Myth 4: As TB symptoms get better, we can stop taking TB medications.
Fact: TB patients will have to complete a full course of multiple antibiotic medications for at least six months, or as prescribed by their doctor. The symptoms will usually resolve within two weeks of treatment initiation. However, TB patients are required to continue the medications until they complete the whole course of medications as prescribed. This is to ensure TB bacteria are completely killed besides preventing the risk of developing MDR-TB or XDR-TB.
Myth 5: If we get TB once and recovered, we will not get TB again.
Fact: There is a 5 to 30 per cent of risk for TB survivors to get recurrent TB after recovery. Therefore, it is important for them to have regular follow-up with doctors for check-ups to identify if there is occurrence of subsequent TB or health complication resulted from TB.
How Do We Manage Tuberculosis?
The World Health Organization (WHO) has launched the END TB Strategy as a global commitment to eradicate TB by 2035. In Malaysia, the National TB Control Programme and the National Strategic Plan for TB Control are in place to continue strengthening TB management and outcomes.
Our public health care facilities, i.e public hospitals, health clinics (klinik kesihatan), and district health offices (pejabat kesihatan daerah or PKD) are equipped with excellent resources in screening, diagnosing, and treating TB.
Thorough contact tracing will be conducted for each diagnosed TB patient where close contacts to the patients, including the family members who stay together, close friends and colleagues will be notified to attend TB screening at the clinics. TB treatment will also be provided through directly-observed treatment (DOT), as recommended by the WHO.
DOT is a process where TB patients will take medications under the supervision and observation of a family member, community volunteer, or health care provider at a TB clinic on a daily basis.
Depending on the doctors’ evaluations, some TB patients will be enrolled in the DOT programme. DOT is useful to ensure TB patients have full adherence to the long course of antibiotic treatment.
This is significant as non-adherence with TB treatment could increase the risk of TB transmission and the development of MDR-TB or XDR-TB.
What Are Some Initiatives To Improve TB Management?
Public health care facilities in Malaysia are well-equipped with qualified professionals and effective tools in managing TB. Even during the Covid-19 pandemic, several initiatives were implemented to ensure the continuity of quality TB services.
These include the introduction of online appointment systems for clinical services, drive-through sputum collection, and enhancement of mobile radiography tools in handling TB cases. In addition, we can now track and trace the reports of active TB cases in the surrounding area through the Infectious Diseases Tracker in the MySejahtera mobile application.
Furthermore, Malaysia has started implementing video-observed treatment (VOT) in selected health care facilities since 2019. VOT is an alternative to the physical DOT programme by using online platforms (video call) to observe TB patients for their daily medication consumption.
VOT has been proven to improve TB treatment adherence and completion as it is a time- and cost-saving service that provides convenience and flexibility to TB patients.
Besides VOT, the WHO has also recommended another strategy known as the public-private mix (PPM) to scale up TB care and prevention. PPM is an effort to provide a more accessible and holistic care for TB patients through the collaboration between the National TB Control Programme and health care providers from the private sector, primary health care providers, non-governmental organisations, and faith-based organisations, which are more accessible to the public.
In PPM, the private sector, primary health care providers, and community-based organisations share the commitment in supplementing TB services such as identification of TB symptoms, referral and treatment monitoring in the community settings.
PPM has greatly improved TB case detection and TB treatment completion in numerous countries namely Cambodia, India, Indonesia, Myanmar, Pakistan, the Philippines, South Korea, the United States, Vietnam, and others.
On top of clinical services, it is also important to ensure timely mental health and psychological support, as well as financial assistance for TB patients and their family or caregivers. This is where the private sector, non-governmental organisations, and faith-based organisations can step in to provide additional support to those in need.
In addition, PPM is also useful for joint efforts to facilitate community engagement and deliver public education about TB, so as to enhance public awareness about TB and break stigma around TB.
As a multifaceted approach is required in managing TB, expansion of the current PPM model in Malaysia could be a potential stepping stone for us to achieve the status of a country with a low incidence of TB.
What Can We Do To End TB?
As guided by the WHO END TB strategy, we aim to be a TB-free world by 2035. All of us must commit to create a safe and non-judgemental environment to support communities who are affected by TB.
It is also essential for the members of community to have timely access to holistic TB care. In addition to the use of digital health technologies in improving the accessibility to quality TB management, multidisciplinary collaboration through PPM could be a considerable channel to multiply the efforts in TB control and prevention programmes.
Let us work hand in hand to live up to the theme of World TB Day 2023: “Yes! We Can End TB!”
Wong Yen Jun (PhD) is a pharmacist/ assistant lecturer at the School of Pharmacy, Monash University Malaysia.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.