[COLUMNIST] Ending Tuberculosis: Enhancing Prevention, Improving Diagnosis, and Incentivizing Treatment

Despite our commitment to Sustainable Development Goals (SDGs), specifically the target under SDG 3 (Good health and well-being) to end tuberculosis by 2030, our progress has stagnated. According to the report, Malaysia has recorded 26,781 cases of tuberculosis in 2023, which is a 5.47% increase compared to 2022.

Tuberculosis is hard to tackle. For one, there are two main types of tuberculosis conditions: active tuberculosis and latent tuberculosis infection (LTBI), which might develop into active tuberculosis over time. The emergence of drug-resistant strains further complicates treatment efforts.

However, difficult does not mean impossible. While the number of cases may have risen over the year, we have avoided a major outbreak of the disease. With enhanced prevention, improved diagnosis and incentivised treatment, the target of ending tuberculosis is achievable.

When we speak of contagious disease prevention, vaccines are the first thing that comes to mind. Currently, the only vaccine against tuberculosis is the BCG vaccine, which is required to be administered shortly after birth.

Unfortunately, the protection the BCG vaccine offers does not last long. According to Martinez et al. (2022), the vaccine only offers significant protection for people who are younger than 5 years old. While other vaccines currently undergoing clinical trials, do not expect them to be available anytime soon.

Hence, it is crucial to identify the susceptible groups and prevent tuberculosis from developing and spreading in these populations.

It is widely agreed that tuberculosis cases are more prevalent in low-income groups. Noykhovich and Mookherji (2019) found that individuals living in urban slums are three to five times more likely to develop tuberculosis. However, tuberculosis is not exclusive to low-income populations.

Mohidem et al. (2021) discovered a positive correlation between sociodemographic and environmental factors with tuberculosis in Gombak, where income status was strongly associated with tuberculosis, and the cases were higher in more developed and urban areas as well.

Mohidem et al. (2021) also found an association between smoke containing Nitrogen Dioxide, Carbon Monoxide, Sulfur Dioxide, and PM10 particulate matter and tuberculosis. These pollutants are abundant in industrial areas.

To address this issue, we can increase tuberculosis awareness in areas where the susceptible groups reside via public awareness campaigns and have proactive health screening initiatives instead of reactive ones. Additionally, educating children about the dangers of tuberculosis will certainly help since there are still people who do not fully understand the disease.

A patient interviewed by Tok et al. (2023) in their qualitative study initially expressed disbelief upon receiving her diagnosis, as she was unaware that tuberculosis could manifest with extrapulmonary involvement.

Other than the low-income group and people living in urbanised industrial areas, smokers are also considered a susceptible group. Obore et al. (2020) have identified a two-fold increase in the risk of developing tuberculosis in both active and second-hand tobacco smokers alike. Altet et al. (2022) echo this study, further stating that tuberculosis patients who were exposed to tobacco had a higher instance of false-negative results in IGRA diagnosis, meaning they were misdiagnosed as healthy persons.

Multiple studies have suggested a possibility that nicotine might be disrupting the immune response to a host of Mycobacterium tuberculosis, thereby favouring disease progression (Davies et al., 2006; Kolappan & Gopi, 2002).

Our government has tried its best to follow the WHO Framework Convention on Tobacco Control (FCTC), including banning tobacco product advertisements. However, there is more to be done, especially with the recent rise of e-cigarettes.

Although e-cigarettes are under similar regulation as traditional cigarettes, such as restrictions on selling to minors or promotional activities, the government have removed nicotine liquid from the Poison List. Additionally, a proposed law aimed at banning people born after January 1, 2007, from buying smoking products under the “Generation Endgame” was scrapped before the passage of Control of Smoking Products for Public Health Bill 2023.

It is advised to revisit “Generation Endgame” as soon as possible since this not only reduces the risk of developing tuberculosis or other tobacco-related illnesses among the younger population but also aligns with the SDG 3 target 3.A to strengthen the implementation of WHO FCTC. Increasing the number of smoke-free areas and better enforcement will also protect people from second-hand smoke exposure.

The Ministry of Health (MoH) has a comprehensive guideline on managing tuberculosis patients, the Management of Tuberculosis 4th Edition. This guideline highlights multiple diagnostic tools for active tuberculosis and LTBI.

However, the diagnosis of tuberculosis can be tricky, and the various conventional methods can be suboptimal. For example, a false-positive is commonly observed in the tuberculin skin test when the patient has the BCG vaccine (Acharya et al., 2020). Although the IGRA is more specific in diagnosing LTBI, MoH’s guideline mentioned that it is not widely available and requires a prior appointment because it is costly and needs to be tested in a reference lab. Instead, Acharya et. al (2020) have proposed a potential diagnostic method named Volatile Organic Compound (VOC) test, which they claimed to be inexpensive and non-invasive.

Badola et al. (2023) hypothesised that tuberculosis may alter VOC in breath. After their experiment evaluating a breath analyser for detecting tuberculosis, they discovered a sensitivity of 95.7% and specificity of 91.3%, which is highly accurate.

Another group of researchers who tried to detect LTBI by using a mass spectrometer to analyse breath has reported a sensitivity of 80% and specificity of 80.8% (Fu et al., 2023).

Obviously, further studies are needed to verify the reliability of these methods. Badola et al. (2023) listed their study as being a quasi-experimental pilot study as a limitation, and Fu et al. (2023) mentioned that more extensive cohort studies are required before clinical application. However, it is undeniable that VOC tests have shown potential in tuberculosis diagnosis. We should seize this opportunity not only to advance our capabilities in medical research but also to improve our tuberculosis diagnostic methods.

The treatment of tuberculosis is just a combination of several antibiotic medications, and it is commendable that our government provides free diagnosis and treatment for eligible patients. However, there are still cases of loss to follow-up (LTFU) among patients, indicating that they stop treatment without permission from their doctor. This often occurs because while the treatment is not complicated, it typically lasts for six months and sometimes even longer.

Considering the low-income group is more susceptible to tuberculosis, the financial burden of tuberculosis treatment can be detrimental to them, as they may need to take frequent leave for their treatment or fork out extra for transportation, both of which can negatively impact their income.

Among the patients interviewed by Tok et al. (2023), financial issues were cited as a reason for discontinuing treatment, while other factors, such as work obligations or lack of transportation, also influenced their treatment adherence. One patient expressed a desire to seek treatment but simply couldn’t afford it.

At the end of the interview, some patients provided recommendations on how to improve the treatment programme. Suggestions included giving weekly doses of medication, establishing healthcare centres that operate outside working hours to accommodate patients who need to work, and providing transport allowances to help patients get their treatment.

Positively for the patients residing in Selangor, the state government does provide a RM800 incentive is to be paid out in three phases to the patient who successfully completed treatment. This incentive programme was introduced in 2020, and in 2022, 903 patients have benefitted from it.

Expanding the programme nationwide or simplifying the application process by utilising MySejahtera (currently only accessible via e-mail) could greatly benefit patients with lower incomes and encourage more patients to keep up with their treatment.

Tackling tuberculosis is no small feat that requires considerable effort, but it is imperative that we prioritise the health of our communities. By enhancing our prevention scale, improving and investing in newer diagnostic methods, and providing incentives for treatment among low-income patients, we can make a dent in the rising cases of tuberculosis and hopefully work towards its eventual eradication.

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