Cough, Cough, Go Away

We are familiar with it as a disease portrayed in movies – seemingly distant and removed from everyday life. But tuberculosis is much closer to our realities than we think. Prof Dr James Koh, Head of Division of Medicine, School of Medicine, International Medical University, shares about tuberculosis to raise awareness about the disease many of us don’t think about.

It’s a scene on screen we know all too well: the lonely figure with a chronic cough, slowly wasting away day after day, with a sickly pallor attributed to getting older or working too hard. Until the day the coughs get more violent and bring up blood – then there’s no mistaking it. Something is seriously wrong.

Tuberculosis (TB), or “the consumption” as it was known because of the weight loss it caused, is a debilitating disease that we might erroneously think was left behind in the past. It’s true that the disease is 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 in this country – 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 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 what we may not know is that its effectiveness wanes over the years and by the time we are adults, many of us no longer have immunity.

The 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. In patients who are immunosuppressed such as those living 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.

Prof Dr James Koh, Head of Division of Medicine, School of Medicine

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,” says Prof James. 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 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. Taking into account your general state of health, the doctor will know whether to test you for TB or not. Do the same if you have unexplained night sweats and weight loss together with 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,” Prof James adds.

He explains that 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,” says Prof James. Some examples of close contacts would be immediate carers, office mates or those living in the same house.

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,” says Prof James. 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,” he says.

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 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 that someone, because the bacteria is already resistant, it becomes very hard to treat. These cases will need a lot of alternative medications involving injections and much longer therapy for up to two years. It gets very, very complicated,” warns Prof James. To prevent such lapses, the public health system has a check-in protocol where those undergoing treatment are regularly monitored to ensure proper administration of the drugs.

Once the treatment is started, a person will be non-infective in ten to 14 days. In hospitals, a patient will be put in isolation but there is no prescribed quarantine period. “The most important thing is to wear a mask and wash your hands frequently,” Prof James says.

TB in Numbers
While Malaysia is not on the World Health Organisation’s top 30 high-burden countries for TB,[1] it is still considered a country with a high incidence rate, estimated at 92 per 100,000 population.[2] Every year, between 20,000 to 25,000 cases of TB are recorded, resulting in an average of 1,500 to 2,000 deaths.[3] (To put things in perspective: there are 50,000 to 100,000 dengue cases a year, with about 100 recorded deaths.[4])

Recently, there have been reports that cases have been on the rise. However, Prof James explains that the trend in TB cases correlates with the implementation of COVID-19 protocols.

Pre-pandemic, in 2018, Malaysia recorded 25,837 cases.[5] During the pandemic, in 2020 and 2021, the cases decreased to 23,644 and 21,727 respectively. “We were wearing masks, social distancing, and adhering to movement control orders – all of which helped to dampen the spread of TB,” explains Prof James.

With the relaxation of these SOPs, the incidence of TB has risen back to pre-pandemic levels – 2022 recorded 25,391 cases,[6] although WHO’s incidence rate estimates actual cases as around 30,000.[7]

What Do We 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 with a good immune system should be able to fight off TB on their own,” says Prof James.

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, don’t smoke. You can get re-infected with TB and that can be quite bad,” says Prof James.

Education of the disease is also pertinent to avoid stigmatising those with TB. Perhaps not helped by 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 rising from a sense of helplessness, fear of isolation and rejection by society. Remember: the disease is curable and it can happen to anyone.

Cough, cough, not going away? Head to the doctor. Don’t wait for it to come back for another day.


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