What is Tuberculosis (TB)?
Tuberculosis (TB) is an infectious disease which is spread through fine droplets in the air from an infected person to others. It is caused by a bacteria called Mycobacterium Tuberculosis and mainly affects the respiratory system, the lungs. Other parts of the body can be affected as well, such as the brain, lymph nodes, kidneys, bones, and joints.
When TB affects the lungs, it is called pulmonary tuberculosis, and when it affects other parts of the body, it is called extrapulmonary tuberculosis.
Most people who are exposed to TB are not infected with the disease. However, for those who are infected, most of them develop latent TB (LTBI). Individuals with LTBI do not have symptoms of TB such as cough, and are not able to spread TB to others. When the latent TB becomes active and the infected person starts to show symptoms like coughing, this is then known as active TB, and the person is then infectious and able to spread the condition to others. For healthy people with LTBI, 90% of them do not develop active TB and the bacteria remains dormant in them throughout their life. Ten percent of this group do go on to develop active TB within two years or more of contracting the bacteria.
Tuberculosis is a disease of public health concern as TB does not present with any immediate symptoms and can spread easily from person to person. According to a report by the World Health Organisation, an estimated nine million people have developed TB and 1.5 million died from the disease. About one-quarter of the world’s population has been infected with the TB bacteria in their body, but are not yet ill with it. As such, it leads to Issues like delayed detection and missed opportunities for treatment, which presents concerns for dealing with this disease.
Tuberculosis can affect either the lungs, or other parts of the body. Symptoms will manifest differently depending on the organs involved. For example, if TB affects the spine, it could cause back pains. TB in the kidneys could cause blood to appear in urine.
Symptoms of active TB at the lungs include:
- Coughing for three or more weeks
- Chest pains, or pains while breathing or coughing
- Fatigue and tiredness
- Coughing up blood or mucus
- Unexplained weight loss
- Fever chills
- Night sweats
- Loss of appetite
Early detection is especially important for TB. Consult a doctor immediately if there are signs and symptoms of TB present. The doctor may order a chest X-ray and referral to specialists for further clinical and laboratory investigations. Early detection can help to rule out other possible conditions as well. Symptoms of TB can look similar to lung cancer, so making the differentiation is important for the right treatment.
Risk Factors for Tuberculosis
Progression to active TB is more likely for certain individuals. These include those:
- Who have weakened immune systems due to medications or illness
- With underlying medical conditions such as HIV infection and diabetes
- Who have poor nutrition and live in squalid conditions
- Who use drugs and substances
- Who work in medical facilities and nursing homes
- Who work or live in certain areas, like Asia, Africa, Eastern Europe, Russia, and Latin America
TB is spread through prolonged and close contact with someone who is infected and has the active variant of TB. It cannot be spread through sharing utensils, food, or cigarettes. It is not transmitted through physical contact as well, such as shaking hands, kissing, or by touching bed linens or toilet seats.
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During the examination, the doctor will check the person’s lymph nodes for swelling, and listen to the sounds the lungs make while breathing by using a stethoscope.
Common test for TB are:
Tuberculin skin test
This is a test which shows if a person is likely to be infected with TB. A small amount of substance, called Tuberculin, is injected in the skin on the side of the forearm. Within 48 to 72 hours, the injected site will be assessed for any swelling. A hard, raised, red bump would mean the person is likely to have TB infection. The size of the bump determines whether the results are likely to be reliable.
Sputum is taken and tested for smear and culture of TB germs.
This can show whether TB has damaged the lungs.
These are becoming more common in the practice of assessing TB in an individual.
Treatment involves medication. The exact type of drug and length of treatment will depend on the person’s age, overall health, possible drug resistance, and the location of the TB infection in the body.
With active TB, a mix of anti-TB drugs are given to the person with TB. The course of medication lasts over six to nine months, and must be adhered to in this period. Active TB is considered to be non-infectious after two weeks of effective therapy. More than 95% of individuals who have active TB recover completely if they take all prescribed medications until completion. This is crucial to prevent resistance against anti-TB drugs, and also to prevent recurrence of TB.
When TB becomes drug-resistant, it becomes more difficult to treat as less effective drugs have to be used. This means that the drugs must be taken for a longer period of time to clear the infection. Also, the chances of recovery are considerably reduced. In Singapore, it is recommended to be treated under the Ministry of Health’s Directly Observed Therapy (DOT) programmes. This programme is recommended by the World Health Organization as the standard of care for all TB patients. In this programme:
- The person with TB takes each dose of medication given by a health care worker. The health care worker will watch the person taking the medication. This helps to ensure that the correct dosage and combination of TB medications are taken for the entire course of treatment.
- Response to the medication and adherence to treatment are closely monitored. This helps to avoid unsuccessful treatment, emergence of drug resistance, and spread of TB.
Serious side effects of TB drugs are uncommon but can be fatal when they occur. All TB medications can be toxic to the liver. Do inform a doctor immediately if any of the following side effects appear:
- Nausea or vomiting
- Appetite loss
- Easy bruising or bleeding
- Dark coloured urine
- Yellow tinge to the person’s skin (Jaundiced skin)
- Blurred vision
Active TB in the lungs will require hospitalisation. The person with TB will be isolated in a single room for at least two weeks after treatment starts. Staff attending to the person should wear protective gear to prevent infection. Visitors are allowed, but they will need to wear a mask to protect themselves before entering the patient’s room. They will also need to wash their hands with soap and water before entering and leaving the room. Children under the age of 12, or persons with low immunity are advised not to visit.
While the person with TB is completing treatment, having a strong support system is vital in encouraging and cheering them on in treatment completion. Employers can also help by granting flexibility for the employee to access DOT and aid in their completion of treatment. This will benefit the community at large, in protecting individuals against potential infection. For the person undergoing TB treatment, it is important that they:
- Regularly take their medication
- Avoid crowded places
- Cough and sneeze in a tissue, and throw them in a rubbish bin, and wash their hands properly afterwards with soap and water
- Ensure that any household surfaces contaminated with phlegm are cleaned with disinfectant
Masks are not necessary for anyone visiting the person’s home.
Potential Complications of Tuberculosis
If TB is not treated, it can be fatal. Untreated active TB usually affects the lungs, but if left untreated, it can move on to affect other parts of the body. Some complications include:
Damage to the joints.
Arthritis that results from TB usually affects the hips and knees.
Common complications of TB include back pain and stiffness.
This refers to the swelling of the membranes which cover your brain. It can cause a headache which occurs for weeks, and possible changes in mental state as well.
TB can infect the tissues surrounding the heart, causing inflammation or causing the heart to be inefficient in pumping effectively. This rare condition, called cardiac tamponade, can be fatal.
Liver and kidney problems
TB in the liver and kidney can impair the body’s ability to filter waste and impurities from the bloodstream.
Tuberculosis has a part to play in Singapore’s history. Early on, booming trade in Singapore during the 19th century attracted large numbers of immigrants from China and India. As this population grew, the number of cases of TB started to increase due to the overcrowded and unsanitary housing conditions migrants were exposed to. The Ministry of Health then launched the Singapore Tuberculosis Elimination Programme (STEP) in 1997 to curb the spread of TB in Singapore, aiming to detect, diagnose, and treat all infectious cases of TB in Singapore. This has been largely successful, leading to a decline in the rates of TB presently. Tuberculosis in Singapore declined to 33.9 cases per 100,000 resident populations in 2020, compared to 49 to 57 per 100,000 resident populations between 1987 to 1998.
When TB was widespread and of national concern, the Singapore Anti-Tuberculosis Association (SATA), a charity organisation, was set up by a group of businessmen to help in detecting and treating TB cases in Singapore. As the rates of TB declined, SATA shifted its focus on providing community healthcare instead, and was rebranded in 2009 as SATA CommHealth to reflect the shift in priorities.
In June 1949, SATA launched the Bacille Calmette-Guerin (BCG) vaccination drive for those aged 18 and below. This eventually became part of the national childhood immunisation programme. Under this programme, BCG was administered at birth, and revaccination carried out at ages 12 to 16. Revaccination has been stopped since July 2001 as there was no scientific evidence on the protective effectiveness of revaccination.
Tuberculosis Screening in Singapore
If a person contracts active TB, their close contacts like family and office colleagues will receive a letter from the TB control unit to inform them to go for a screening at TB Control Unit @ Moulmein Road. This is to check for any possible TB infection, so that necessary treatment can be administered to prevent it from becoming active TB. All screened close contacts found to have latent TB should be offered treatment, regardless of age and BCG vaccination status.
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- Mayo Clinic. (2021, April 3). Tuberculosis – Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/syc-20351250
- Ministry of Health. (n.d.). MOH | Tuberculosis. Retrieved June 30, 2021, from https://www.moh.gov.sg/diseases-updates/tuberculosis
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- World Health Organization. (2020, October 14). Tuberculosis (TB). Tuberculosis. https://www.who.int/news-room/fact-sheets/detail/tuberculosis