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Tuberculosis - a reminder to our vision

Dr Murugan S. Rajan, Resident Consultant General Medicine and Physician of KPJ Sabah Specialist Hospital What is Tuberculosis (TB) Tuberculosis (TB) is caused by bacteria (Mycobacterium tuberculosis) and it most often affects the lungs, but can impacts other parts of the body also. TB is curable but if left untreated can result in deaths – making it the world's top infectious killer. A Vision for a TB-Free World The vision of the Malaysian Tuberculosis (TB) Control Programme is for Malaysia to be a TB-free country by the year 2035 (<1/1,000,000 population). To achieve this, it is vital to ensure timely universal access to quality-assured diagnosis and treatment for all forms of TB. The challenges we face in our TB control programme are from delays in the diagnosis of TB especially of smear negative PTB, extra pulmonary TB (EPTB) and TB in children to treatment default and non-adherence. While healthcare agencies including public and private sectors are responsible for the early diagnosis and effective treatment, it cannot be overemphasized that the community has a definite role to help avoid defaulting the treatment and by strict adherence to the treatment protocols set by the experts in the field. The World Health Organization (WHO) proposed the End TB Strategy to improve TB management with targets of a 90% decrease in TB incidence and 95% decrease in TB mortality by 2035. TB is endemic in Malaysia and continues to be a major public health concern. The TB incidence for Malaysia in 2015 was 79.0/100,000 population. In 2020, the TB incidence in Malaysia was reduced to 72.4/100,000 population but it was still below the End TB Strategy target. There were 1,696 TB deaths in 2015 (TB mortality rate of 5.5/100,000 population) and the figure increased to 2,320 deaths in 2020 (7.1/100,000 population). By 2035, Malaysia aims to reduce TB death to fewer than 85 deaths per year. Symptoms Adults with productive cough, coughing out blood (hemoptysis), unexplained weight loss, fever especially in evenings, night sweats and fatigue should be screened for pulmonary TB (PTB). However, typical symptoms may be absent in the immunocompromised or elderly patients. TB in children is mostly with non-specific signs and symptoms. Young children with anorexia, failure to thrive, poor feeding and decreased activities or playfulness should be suspected for the disease. Diagnosis Tuberculin skin test is performed via the Mantoux technique, which consists of intradermal injection of purified-protein derivative on the inner aspect of the forearm. This stimulates a delayed T-lymphocyte mediated hypersensitivity response in patients with prior mycobacterial exposure. The test must be read between 48 – 72 hours later. Laboratory Investigations – All patients suspected of having PTB should submit at least two sputum specimens for microscopic examination. When possible, at least one early morning specimen should be obtained as sputum collected at this time has the highest yield. For patients who are unable to expectorate sputum spontaneously, sputum induction may be done. Sputum should be sent for mycobacterial culture at the initiation of TB treatment to confirm the presence of mycobacterium tuberculosis and to exclude drug-resistant TB. Chest Radiography should be used as the primary imaging modality to aid the diagnosis and management of PTB. In a centre where radiography facilities are not available, diagnosis of PTB can be made based on clinical findings and positive sputum smear results. All patients should be routinely screened for HIV and diabetes mellitus. TB Treatment The aims of Tuberculosis (TB) treatment are to reduce morbidity, reduce mortality, prevent relapse, decrease transmission and prevent emergence of drug-resistant TB. Only daily anti-tuberculosis regimen should be used throughout the treatment of PTB Fixed dose combination tablets are available for easy administration Active TB must be ruled out before starting latent TB infection treatment. Shorter Latent TB Infection treatment regimens are preferred in suitable individuals. The standard treatment regimens for drug susceptible TB are: Pulmonary Tuberculosis (PTB) – 2 months of 4 types of TB medicines followed by 4 month of 2 types of TB medicines Tuberculosis Meningitis – 2 months of 4 types of TB medicines followed by 10 months of 2 types of TB medicines (HR) Bone & Joint Tuberculosis – 2 month of 4 types of TB medicines followed by 4-7 months of 2 types of TB medicines Other forms of extrapulmonary TB is the same as PTB TB treatment should be observed directly (DOT). Alternately, video observed treatment (VOT) may be used. Self-administered treatment should be reserved for patients who are unable to undergo Direct Observed Treatment (DOT) or Video Observed Treatment (VOT). Recurrent TB Patients exposed to anti-TB drugs are at risk of drug resistance. Hence, all patients who are suspected to have recurrent TB should be investigated using rapid molecular tests e.g Xpert Ultra and mycobacterial culture. If the rapid molecular test results are negative, the patients should be treated with a standard regimen for drug susceptible TB pending drug culture and susceptibility results. Special Situations Patients having chronic kidney disease and patients on hemodialysis – should be treated with standard anti-TB regimen and have dosage adjusted Patients with liver cirrhosis – should be managed at an experienced specialist center Pregnant & lactating women – should receive the same treatment regimen for TB as for non-pregnant women Women on rifampicin based anti-TB treatment – should use alternative contraception methods other than oral contraceptive pills TB in children – the TB treatment regimen in children for both Pulmonary Tuberculosis (PTB) and Extrapulmonary Tuberculosis (EPTB) are the same as in adults. Anti-TB dose in children should be calculated in mg/kg and the total dose must not exceed the maximum dose Anti-TB drug adverse reaction & drug interaction Adverse drug reactions should be recognized early and managed well to reduce treatment related morbidity and mortality. Anti-TB drug adverse drug reaction may affect any organ/system and they vary in severity. The following are adverse reaction on Anti-TB drugs: Isoniazid – skin rash, jaundice, hepatitis, anorexia, nausea, abdominal pain, burning/numbness/tingling sensation in hands or feet Rifampin – skin rash, jaundice, hepatitis, anorexia, nausea, abdominal pain, orange/red urine, flu syndrome (fever, chills, malaise, headache, bone pain) Ethambutol – visual impairment Pyrazinamide – skin rash, jaundice, hepatitis, anorexia, nausea, abdominal pain, joint pain Drug induced liver injury is one of the commonest serious Adverse Drug Reactions due to first-line anti-TB drugs. Patients with suspected severe Adverse Drug Reactions, including Drug Induced Liver Injury should have their TB treatment stopped immediately or switched to an alternative anti-TB regimen. All patients with Adverse Drug Reactions should be treated compassionately, offered symptomatic treatment and given reassurance of getting good medical care. They should be referred to specialists for drug challenge/dechallenge or drug desensitization when indicated. Certain TB drugs may interact with broad range of commonly used medications and may need to have their dose adjusted. The management of TB should be guided by an evidence-based approach, in order to provide quality care to the TB patients. Dr. Murugan S. Rajan, Resident Consultant General Medicine and Physician of KPJ Sabah Specialist Hospital advised patients who completed TB treatment to watch out for recurrence of TB symptoms and if present to contact the nearest healthcare providers. We shall remember that achieving our goal of controlling this disease by 2035 is not an impossible task provided all of us, healthcare providers and community together put our efforts sincerely. 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