Check that cough

by Carol Aloysius

Despite the stepped up efforts of the Ministry of Health to wipe out Tuberculosis (TB), once a dreaded scourge in this country, officials are concerned that a rise in the number of new cases could lead to the spread of the disease once again.

This in spite of the fact that patients now have easy access to treatment and drugs are freely available at all government hospitals and clinics. Poverty, overcrowded dwellings, drug addiction, refusal to continue treatment and the rise in non-communicable diseases have collectively contributed to its re-emergence. Here, Consultant Respiratory Physician, National Hospital for Respiratory Diseases, Welisara, Dr. Saman Kularatne, answers some pertinent questions about the disease and why it is important for TB patients to seek early treatment once diagnosed.

Excerpts...

Q: TB has reached a new high in Sri Lanka. What causes TB? What are the signs and symptoms?

A: Tuberculosis (TB) is caused by a germ, a bacterium known as Mycobacterium Tuberculosis. It is an infectious disease that mainly affects the lungs. TB can also affects almost all the other organs of the body (skin, bones, joints, intestines, Lymph nodes, kidneys, nervous system). When TB involves the lungs, the disease is known as Pulmonary TB (PTB) and when it involves the other organs, the disease is labelled as Extra Pulmonary TB (EPTB). Most of the PTB patients may show TB germs on sputum examination (PTB + ve Cases) and others may not (PTB -ve Cases).

Q: How does it spread?

A: Patients with Pulmonary TB can release large number of germs in to the environment when they cough, sneeze or even when speaking.

A single cough may produce more than two thousand sputum droplets containing TB germs. Good ventilation and sunlight can destroy the germs in the environment. You can get infected when you inhale these droplets.

Q: Will everyone who inhales these droplets become infected?

A: AL Not all who get infected will develop the TB. Whether you are going to develop the TB depends on two things, the number of germs you inhale and how strong your immune system is.

If your immune system is weak (e.g. due to poorly controlled diabetes, HIV, malnutrition, cirrhosis, immunosuppressive drugs, cancers) you may develop TB even with a small number of inhaled germs.

If your immune system is good, still you can develop the disease with persistent exposure to large number of germs. (e.g. close contact with a PTB +ve patient).

Symptoms of Pulmonary TB includes persistent cough, fever, especially low grade night fever, night sweating, blood in the sputum, loss of weight and loss of appetite.

Extra Pulmonary TB patients may have symptoms depending on the organ involved.

Q: Why is it on rise now?

A: The number of new TB cases detected annually is still high. Several factors such as overcrowding, poor housing in some areas, poor nutrition, rising incidence of diabetes and HIV, drug abuse, alcoholism, overcrowding in prisons are contributing to this.

Q: What is the age group of the high risk groups today?

A: Mainly in physically active group. It remains static. Our paediatric TB is low (3% of all TB) compared to South East Asia region (SEAR 8%)

Q: Why is it important to control the disease? What is the danger of it spreading?

A: TB is an infectious disease and if not detected early and treated properly patients can die of TB and those who survive can have long term breathing problems. Improper and interrupted treatment may lead to emergence of drug resistant TB (MDR TB), which is a big problem in some other developing countries.

Sri Lanka is a low MDR TB prevalent country (13 MDR TB cases per year in 2014 & 2015), as our health system is well established and TB is managed only in state sector.

Q: What measures are being taken by the National Programme for TB Control to bring down the figures?

A: It is multi-disciplinary task, and done by coordinating with other Health Institutions, Other government ministries, private - public mix with NGOs and volunteers. It contains

1. Increase case detection through awareness programs for staff and public, screening of high risk groups (ex- drug addicts, prisoners),

2. Proper patient managements through DOTs program

3. Contact tracing and defaulter tracing (those who lost to follow up) through MOH and range PHIs attached to MOH offices

4. Infection prevention and control by health education, promoting cough etiquette, and providing personnel protective appliances (PPAs) for PTB patients

Q: What has been the outcome of this treatment?

A: We have achieved the WHO outcome targets in our country with regards to treatment of TB.

Q: Is it correct that over 3,000 patients are said to refuse treatment? What do you do in their case? What is the danger of them spreading the disease?

A: We don't see patients refusing treatment but some may interrupt/ default the treatment especially drug addicts, alcoholics, smokers and those who have no proper place to live. Tracing some of these patients is very difficult. Our Public Health Inspectors (PHI) are always alert and they do home visits when a patient fails to attend clinic or DOTS centre on due date.

Do you have problems identifying TB cases? If so what are they?

A: Delay in seeking medical advice is a big problem. Especially, drug addicts, and alcoholics. Since the symptoms are not severe at the early stages of the disease, patients always try various other measures without seeking proper medical attention. Therefore, conducting continuous medical awareness programs to general public is very important.

Q: Do you have problems with regard to reporting cases?

A: So far we don't have problems with reporting cases.

Q: What are the current trends in the disease?

A: Current trend of the disease is static but we may see more patients in future due rise in number of HIV and diabetic patients.

Are there gaps in relation to lab network?

A: Pulmonary TB is diagnosed by examining sputum samples of possible TB patients and this facility is now freely available in all the bigger hospitals and all the chest clinics and also in most of the district and rural hospitals.

Q: What about treatment?

A: TB is treated with oral medicine for six months but some may need injections and longer duration of treatment. These medicines are freely available in district chest clinics. Patients are given directly observed therapy (DOTS) to prevent defaulting. Most of the patients are managed as out-patients at a place closer to the patient (DOTS centres). Regular assessment of patients with repeated sputum analysis and attending the side effects of medicine are important. Interrupted treatment may lead to drug resistant TB. Inward treatment facilities are available for ill patients.

Q: When distributing anti TB drugs and supplies are there problems you encounter from hospital to hospital?

A: TB control activities of our country are conducted by the National Program for Tuberculosis control and Chest Diseases (NPTCCD). We don't have any problems in conducting diagnostic tests and distributing TB drugs at present.

Q: What about their care providers?

A. We see reasonable family support in village population in the management of TB patients but it is poor in overcrowded city areas.

Q: Is TB a notifiable disease? Are there delays in doctors notifying the Campaign in time?

A. Yes. TB is a notifiable disease and there is no delay in notifying this at presents.

Q: Your advice to the public?

A. Tuberculosis is an infectious but a curable disease and facilities for diagnosis and treatment are freely available in Sri Lanka.

Patients with cough more than two weeks duration, and also having persistent fever, loss of weight, loss of appetite, blood in sputum should meet a doctor and get checked for TB. Patients with TB should continue the treatment as advised and take measures to minimize the spread (proper sputum disposal, using a mask).Society has a great responsibility of looking after TB patients. We can eradicate TB from our country only by early detection and proper treatment of TB patients.