THE HEALTH | MAY , 2023

The disease is indeed old – it was discovered in the 1880s . However , it is still very much around today . 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 consider the existence and threat of TB in the community .

We only need to look at our upper arms to remind ourselves – Malaysians carry the scar of the BCG ( i . e . Bacille Calmette-Guerin ) vaccine given as babies and at primary school . This shot protects us against TB . This may be why we feel a sense of security , but we may not know that its effectiveness wanes over the years and many of us no longer have immunity by the time we are adults .

THE BASICS OF TB

The bacteria Mycobacterium tuberculosis causes TB . 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 . In immunosuppressed patients such as those with HIV , it can attack the brain .

Those most susceptible to the infection are the elderly , those with lowered immunity such as diabetics , people who are immunosuppressed , such as those on chronic steroid therapy and people living with HIV . Young children are also more at risk because their immune systems would still be developing and that is why they are given the 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 a chronic cough , profuse night sweats , loss of weight , and a 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 doesn ’ t 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 . The slow and subtle onset of the symptoms is also unlikely to set off alarm bells until the disease has advanced such as 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 telling sign of TB . There is also a saliva test and a skin test ; in cases of EPTB , a biopsy of the bone or swelling

BY PROF DR JAMES KOH

might need to be done . When do you need to see a doctor ? The rule of thumb is : Don ’ t wait to cough up blood . See a doctor if you have had a persistent cough for two weeks . Do the same if you have unexplained night sweats , weight loss , swollen lymph nodes , or chronic back pain .

If you are aware that you ’ ve been exposed to someone with TB , someone you share a working or living space with , then you might also want to see a doctor to be screened . A good notification system is in place in the public health sector .

When a patient is detected with 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 we experienced with Covid-19 . Similarly , to all respiratory diseases , it is spread by water droplets that come 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 in a situation where there ’ s prolonged exposure , generally more than eight hours a day . A person with latent or dormant TB is not infectious , and neither are those who present only with 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 to a year , depending on which part of the body is affected . For PTB , it is generally within six months . EPTB needs nine to 12 months .

Newer medications can potentially treat TB within three months , but Malaysia does not have the facility yet . At the moment , we ’ re still using the old regime . It is crucial , however 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 multidrugresistant TB ( MDR TB ) – commonly known as superbugs . Those with MDR / XDR TB can spread it to others and unfortunately for that someone , because the bacteria is already resistant , it becomes very hard to treat . 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 the drugs .

CASES ON THE RISE

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 , the trend in TB cases correlates with the implementation of Covid-19 protocols .

Pre-pandemic , in 2018 , Malaysia recorded 25,837 cases . During the pandemic , in 2020 and 2021 , the cases decreased to 23,644 and 21,727 respectively . With the relaxation of these SOPs , the incidence of TB has risen back to pre-pandemic levels – 2022 recorded 25,391 cases , although WHO ’ s incidence rate estimates actual cases as around 30,000 .

WHAT DO WE DO ?

There is no “ booster shot ” to raise immunity levels against TB . Ensuring a healthy lifestyle is the best way to keep it at bay . Generally , a person who is healthy with a good immune system should be able to fight off TB on their own .

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 rising from a sense of helplessness , fear of isolation and rejection by society . Remember : the disease is curable , and it can happen to anyone .

Prof Dr James Koh is Head of the Division of Medicine , School of Medicine , International Medical University .