The return of TB  



It's essential for TB patients to continue their treatment for the whole specified duration and not stop once they feel better.
CHEONG (not his real name) is looking forward to joining the National Service. You would be hard-pressed to find many 17-year-olds as keen as he is, especially when you consider the fact that Cheong just recovered from tuberculosis (TB) a year ago. 

The gangly teenager from Old Klang Road looks like any other boy his age as he jokes with the nurse during his check-up. He shows no signs of ailing health now, apart from the fact that he has not regained the weight lost during his bout of illness. 

“I’m okay now,” he shrugs cheerfully. But the same cannot be said for the other 1,500 Malaysians who die of tuberculosis every year. 

TB, a bacterial disease once feared as a deadly scourge and was even referred to as the “White Plague”, has been pushed to the fringes of our minds. We have been so busy battling the diseases of affluence, like obesity, cardiovascular disease and cancer, that we have forgotten how easily TB germs spread within overcrowded, unhygienic environments, or that this airborne disease used to be the number one cause of death in the 1950s.  

Today, few people are fully aware of the symptoms or consequences of TB. So when Cheong developed a cough two years ago, he paid little attention to it. Then people started commenting that he was losing weight. 

“I used to be very fat, you see, so it was very obvious. I also didn’t want to eat, and I wanted to sleep all the time. But I didn’t bother, and I didn’t want to see the doctor,” he says in fluent Cantonese. 

In the end, his mother took him to see a doctor, who then referred him to the hospital for a chest x-ray.  

When Cheong received the x-ray report with the initials “TB” written on it, he did not have a clue as to what it meant, until the doctor explained it to him. He admits that he went home later and cried. The thought of having to take so many types of medications for half a year daunted him at first.  

TB treatment consists of taking four different medications daily for two months, followed by three different medications twice a week for another four months. Some of these medications produce minor side effects, including dizziness, blurry vision and itchiness. 

“There’s one of them that makes your urine turn orange. I didn’t dare to use public urinals then, because people might think I’m peeing orange juice!” Cheong jokes. 

While most of his friends still treated him as before, there were some people who did not understand the disease and reacted bizarrely to him.  

“My little brother didn’t want to sleep in the same room with me. Sometimes he would sleep in the living room, sometimes I had to. I really felt like hitting him at that time. But he just didn’t understand what was going on.” 

On another occasion, one of Cheong’s friends accidentally ate some of his food and immediately rushed himself to the hospital for an x-ray. Little did he know that Cheong had already been rendered non-infectious the moment he began treatment. 

Today, Cheong is grateful that he had medicine to cure him, or as he says in his words, “I would be dead by now!” He is living proof that TB can be effectively treated. 

Fighting an age-old disease 

The question now is why does the World Health Organisation (WHO) continue to record as many as three million deaths from TB every year? This is an inordinately large number, given the fact that effective treatment is widely available. 

Dr Kuppusamy Iyawoo ... 'There is a general lack of awareness about TB among the public and the medical profession ... there is a sense of complacency.'
“That’s a very important question. If we have this kind of (effective) treatment for lung cancer, people will be clamouring for it ? cancer would be wiped out!” says Dr Kuppusamy Iyawoo, Head of the Institute of Respiratory Medicine, Hospital Kuala Lumpur. 

He believes that TB treatment fails because of a general lack of awareness among the public. “People do not know what TB is about. When they start coughing blood or losing weight, some of them still believe that it is because someone is doing some ‘harm’ to them, so they seek the help of a bomoh, medium or priest. This still happens, not just in rural areas but also in urban areas.” 

By seeking out the local medicine man, TB-infected people are depriving themselves of the right treatment. Another major problem stems from the fact that taking so many different tablets every day for six months can be cumbersome.  

“Initially, before starting treatment, patients feel very sick, with fever, cough and all that. After a few weeks on the treatment, they feel much better. There’s a tendency for them to stop the treatment on their own because they don’t realise a need to continue. This is one of the biggest problems,” says Dr Kuppusamy, also a senior consultant chest physician. 

This predictable habit among people worldwide has led WHO to devise a strategy called DOTS, or Directly Observed Treatment-Shortcourse. 

“It is a very interesting strategy to ensure that the patient completes all 88 doses of his medication. Instead of asking the patient to take his medication at home, a doctor or nurse takes over the responsibility of making sure that he takes his medication. The patient goes to the nearest health centre, where the tablets are kept. The doctor or nurse will administer the treatment and record it. If the patient doesn’t go to the health centre, the records will show this and the healthcare provider will go to him.” 

DOTS eliminates the likelihood of patients defaulting on treatment, which then reduces the risk of them developing resistant TB. 

“Resistant TB is where the germs are resistant to standard medication. We have to use completely different medication, which is very expensive, very toxic (a lot of side effects) and has to be given for a minimum of two years, if not longer. Patients with resistant TB also have to be isolated, unlike normal TB,” Dr Kuppusamy explains. 

Resistant TB increases the country’s healthcare costs by more than 100 times. Fortunately, resistant TB is not common in Malaysia, compared to neighbouring countries like Thailand, Cambodia, Vietnam, India and China. However, due to the proximity of these countries and the frequency of travellers crossing borders, resistant TB could be transmitted easily to Malaysia. 

Dr Kuppusamy stresses that the disease must be managed well by the healthcare professionals and the patients themselves to reduce the risk of developing resistant TB. 

Rise and fall of TB 

It is easy to see how TB gradually lost its prominence in the public eye. Back in the 1950s, when it first peaked in Malaysia, TB was so serious that it warranted the launching of a National TB Control Programme to reduce the disease as a major public health problem. Mass BCG vaccination, effective treatment, training activities and a case-finding drive succeeded in decreasing the incidence of TB, especially among children. 

“From 1950 to 1980, it came down quite a bit. Then from 1985 to 2000, it started to rise again, “ says Dr Kuppusamy. In 1995, 11,000 cases of TB were detected. This figure has risen to 14,500 cases in 2002.  

Even then, TB has been replaced by cardiovascular disease as the No. 1 cause of death in the country, while the infectious disease itself has fallen to the 11th ranking. With this, a sense of complacency has settled over the country. 

“When disease rates are low, people tend not to worry about it. There is a general lack of awareness among the public and the medical profession. The general public don’t know what TB is, while the medical profession have lost their diagnostic and management skills of TB. People forget about the disease and that is when it starts to rise again,” says Dr Kuppusamy. 

The industrialisation that descended upon Malaysia in the 1950s explains why TB rose to such heights then. “Rapid industrialisation gives rise to overcrowding and unhealthy living habits, which is one of the main reasons infectious diseases go up. TB, being an infectious disease, behaves in the same manner,” says Dr Kuppusamy. 

Similarly, TB rose to epidemic proportions during the Industrial Revolution in Europe in the 17th and 18th century. 

There are many reasons for the rise of TB again in the mid-1980’s, but Dr Kuppusamy singles out the HIV epidemic as the most important factor. 

“The HIV virus affects the immune system. It attacks and kills off all the cells in the body that protects against infectious disease, such as TB. Because HIV destroys the immune system, the patient with HIV becomes very vulnerable to infections. One of the most common infections amongst HIV-infected patients is TB. One-third of HIV-infected patients, which is 32%, die of TB. It is the single most important cause of death among HIV-infected patients,” Dr Kuppusamy explains. 

The HIV epidemic has also caused a rise in areas where TB has come down, like in the US. According to Dr Kuppusamy, diseases like TB show a predictable rise and fall. “TB has a typical ‘epidemic wave’, where it peaks and then drops within a couple of hundred years. The epidemic wave has declined in Europe, but here, we are probably somewhere in the peak, just like Africa and Latin America.” 

Although TB is no longer the menace it used to be, we should, nevertheless, continue to be on guard to check any “resurgence” of the disease. Improved living conditions and higher hygiene standards will go a long way towards reducing the spread of TB. 

“We need to increase awareness about the symptoms of TB, so that people will go for checkups. A healthy lifestyle is also very important. People who smoke and don’t eat well have reduced body resistance, so they have higher incidence of TB,” concludes Dr Kuppusamy.