TB: early detection, treatment ensure better recovery

By Carol Aloysius

Once a widely prevalent and much feared infectious disease, TB has made a remarkable reverse turn over the past decade.

This dramatic decline of reported TB cases islandwide was largely due to sustained awareness raising on the part of the health ministry. Concerns however have now been raised on newly detected cases which have shown a slight increase last year compared with the provides week, while at present an estimated 13,000 new cases of TB are detected every year.

Given the availability of the drugs and modern diagnostic techniques, early detection and treatment of TB patients can reduce this number to zero level, says National Program Tuberculosis Control and Chest Diseases Deputy Director, Dr. Sudath Samaraweera in this discussion with the Sunday Observer.

Following are excerpts...

Q. TB was once widely prevalent in S.L. Is this the same today? If it has declined what is the percentage of the drop in the number of cases?

A. Tuberculosis is not as prevalent as it was in the past. However, recent estimates indicate that it is emerging again. For example, when compared with 2011 case findings, in 2012, there was a 9.5 percent case reduction. Again in 2013, there is a 1.6 percent increase in case finding. However, we are not happy about this case reduction in 2012. The reason is that according to the World Health Organisation estimates, there are around 13,000 case detections each year. Hence we have customised and adapted this year's world theme ‘Reach the three million’ to what we think are closer to the actual cases undetected in Sri Lanka and called it, ‘Reach four thousand undetected. A TB test, treatment and cure for all'.

Q. Has there been a national survey on TB patients in Sri Lanka? If so, are the figures hundred percent correct or are they only reported cases?

A. No surveys have been carried out in recent years to estimate the number of TB cases here. This is because, being a country which the WHO categorises as a ‘moderate burden country with TB,’ the WHO does not approve prevalence surveys since they are not cost effective. Instead, the WHO recommends to strengthen the existing case finding strategies to close the gap.

But we believe there are many more undetected cases to reach.

Q. Where is TB most widely prevalent in Sri Lanka?

A. 42.2 percent of all cases are reported from the Western province. Out of that more than half (i.e. 24.2 percent of all cases of the country) are from Colombo District. Around 10 percent of all cases are reported from the Colombo Municipal Council area. Highest TB burden is reported from Kolonnawa, Wellawatta, Grandpass, Mattakkuliya and Maradana areas. Apart from Western Province, Kandy and Ratnapura districts report high number of cases.

Q. What causes TB? Is it a virus or bacteria?
A. TB is an airborne bacterial infection. The causative organism is Mycobacterium tuberculosis.

Q. Is it inherited? Can one be born with it?
A TB is not inherited.

Q. Are there different types of TB?

A. Yes, TB can occur anywhere in the body except in nails, teeth and hair. Tuberculosis is classified according to the site of the disease.

If it is in the lungs, it is called pulmonary tuberculosis and if outside the lungs - extra pulmonary tuberculosis. Pulmonary tuberculosis is again divided as sputum smear positive TB and sputum smear negative TB based on whether the patient expel bacteria along with sputum.

Q. Which part of the body does TB mostly attack?
A. TB mostly attacks the lungs.

Q. What about other parts of the body?
A. Apart from the lung it frequently attacks lymph nodes.

It also affects bones, joints, kidneys, intestine, meninges (tissue around the brain causing tuberculosis meningitis).

Q. Are there specific medical terms to describe these conditions?

A. TB of the Lung is referred to as Pulmonary TB. TB of the Bones depends on the specific bone e.g. if it is in the spine it is called Spinal TB

Joints: Tuberculosis Arthritis
Kidney: Renal Tuberculosis
Intestine: Intestinal TB
Meninges: TB meningitis

Q. How does TB spread?

A. When a person with the disease coughs, sneezes, laughs etc, these organism are released into the air. If another person inhales these organisms, they will travel to the lung and get settled there. This is called TB infection.

Q. What is the percentage of the global population with TB?

A. Worldwide, one third of the population is estimated to infect with TB. However, due to the immune reaction of the body, TB infection does not progress in to the disease. The organism may remain dormant (inactive) for many years to reactivate and to cause the disease if the person becomes weak and has poor immunity.

Q. What age groups are most vulnerable to TB?

A. People in the extremes of age are more vulnerable. However, the BCG vaccination at birth prevents children from developing severe forms of the disease. In Sri Lanka, most patients are detected are between 15-45 years of age.

Q. Do young people have better resistance to the germ compared to older persons? If so why?

A. Yes, young people have better resistance because older people by nature are having poor immunity. They may also have other diseases that affect their immunity e.g. diabetes, renal disease, liver disease, cancer etc.

Q. Can constant infections, or chronic illness increase the risk of contracting TB? e.g. acute case of measles or diabetes?

A. Chronic illnesses such as diabetes, kidney disease, liver disease, cancer increase risk of developing tuberculosis. The most important single condition that aggravates TB is HIV infection.

Q. Why are people with HIV more vulnerable to TB?

A. HIV infected persons have a poor immune system. Therefore, they are more prone to any infection and TB is among them. In fact, TB is the single most important disease which causes HIV infected people to die.

Q. What about malnutrition? Is it a contributory factor?

A. Yes, malnourished people have a weaker immune system. Therefore, they are prone to get any infection and TB is no exception. Furthermore, if somebody gets TB, they lose their appetite. Wasting also leads to malnourishment.

In the 18th and 19th centuries, in the West, TB was called “Consumption”.

Q. How can one build up a strong immune system to resist the disease?

A. To build up a strong immune system, they should be healthy and well nourished and keep their other health conditions such as diabetes under control.

Q. How can one verify if he/she has TB? What are the methods used?

A. TB infection can be identified by a skin test called Mantoux.

There are also blood tests now that can identify TB infection. However, under normal circumstances, it is useless to know whether someone is infected or not. One third of the population will give positive results and it is not a condition that is necessary to treat. What is necessary to treat is TB disease.

Q. What are the symptoms?

A. Symptoms of TB disease are, cough for more than two weeks, fever, night sweating, loss of appetite, loss of weight, fatigue. If it is extra pulmonary TB, there may be no cough.

Instead, symptoms related to site can be observed. Eg: swelling of joints in TB arthritis.

Pain in the site, enlarged lymph nodes in TB lymphadenitis. Sputum can be tested for tuberculosis. Usually three consecutive samples should be tested as some may come as negative. The best is three early morning samples.

In addition, chest Xray shows changes in pulmonary TB. Sputum also can culture to grow the organism. In conventional culture methods for TB, it takes around eight weeks to give results.

Q. Have they changed in the past 10 years? If so what are the new methods used?

A. In recent years new methods to detect have been introduced. One is Xpert MTB/Rif where sputum sample is subjected to a molecular testing to identify TB and its resistance to rifampicin, one of the most potent anti-TB drugs. In addition, there are rapid culture methods where results can be obtained in 2-4 weeks time.

Q. Are all these methods available in Sri Lanka?

A. Yes, all the methods are available in Sri Lanka. However, newer methods are still available only in limited capacity.

Q. Is there a vaccine to prevent TB? When is it given?

A. Apart from BCG, there are no vaccines against TB. The BCG however, protects children against severe forms of TB only.

Q. When a person gets the BCG vaccine does it give him lifetime immunity to the disease? Or can it recur? If so, how and why?

A. BCG does not provide life long immunity.

Q. Are there drugs to control the disease or cure patients?

A. There are drugs to cure patients. They are called anti-TB drugs. Since the organism is very tough to kill, one needs to take a combination of four drugs for two months and then two drugs for another four months to cure the disease. If someone is getting the disease for a second time or later, he/she should be treated with five drugs and total duration of treatment will be eight months.

Q. What are their side effects?

A. The most common side effect would be allergy. Some may get their liver affected by anti-TB drugs.

Q. What is the DOTS program? When was it introduced and why?

A. DOTS program is an abbreviation for Directly Observed Treatment Short course. Sri Lanka commenced DOTS strategy which has five components in 1997 to detect, monitor and evaluate the progress made.

Q. What is the role of grass root level health workers who are often the first line of contact, in this program?

A. They help people get their daily drugs dosage administered under direct supervision. They also make early detections and monitor any side effects.

In addition they ensure that patients visit the chest clinic regularly for evaluation and repeat sputum examination at pre-determined intervals. Grass root health workers also trace TB symptomatics among contacts of TB and refer them for further investigation. Most importantly, they work to reduce stigma surrounding the disease.

Q. Are you close to achieving this year's goal of increasing case findings? If not, what are the obstacles?

A. The goal is to eliminate TB from Sri Lanka by 2050. For this, it is necessary to identify cases early and treat them to break the transmission. The main obstacle is that we are not still detecting all cases in time. Many are late detections. The main reason is that the treating physician does not suspect TB among symptomatics since this is now an uncommon disease. The other obstacle is high risk groups such as prisoners, urban slums, drug addicts, smokers alcoholics who are difficult to reach or difficult to investigate and put on treatment. Stigma against the disease is another obstacle.

To overcome the obstacles we have introduced the following activities: Regular screening of high risk groups, Improved awareness among general public and medical community, gradual introduction of new diagnostic methods and ensuring uninterrupted availability of anti-TB drugs.

Q. Future plans?

A. In June this year, there will be an evaluation of the national TB control program by international TB experts, funded by WHO and the Global Fund. Based on their findings, the National Strategic Plan for TB Control in Sri Lanka will be updated. Based on the revised National Strategic Plan, a concept note will be prepared to submit to the Global Fund for more funds in TB control.

Already, the Global Fund has pledged US $ 3 million for TB control in Sri Lanka. More funds will be announced in the course of this month.

It is expected that the new funds will be available by January 2015.

Q. Have you a message for the public?

A. Tuberculosis is curable. The best benefits are reaped when detected early.

Early detection and treatment not only provides early and better recovery, it prevents it being transmitted to others.

If you suspect symptoms of TB, especially a cough for more than two weeks, go to a District Chest Clinic or to a microscopy centre in a government hospital and get yourself checked for TB.

Q. What should you do if you are diagnosed with the disease?

A. You will be provided with all treatment and investigations free of charge.

The doctors and the staff at the District Chest Clinics will take care of you until you are fully recovered from the disease.

For more details contact the National Program for TB control at 555/5, Public Health Complex, Elvitigala Mawatha, Colombo 5.

Having trouble with your voice?

Exploring that “frog in the throat”:

by Rasangi Weerasekera

Have you found speaking to be tiring and effortful at times when having spoken continuously for a prolonged period? Think about the last time that you vigorously cheered and roared for your team during the big match cricket season, or how you shrilled with delight at a concert along with much loved artistes, and then you ended the day croaking like a frog or even worse - having lost your voice altogether. Does this sound all too familiar?

This is a common occurrence many of us experience from childhood on. Well what happened next? You may also have recall that your voice went back to normal after a while following a bit of rest. The good news is that such changes in voice and difficulty in speaking last only for a short period of time.

On the other hand, however, if such vocal behaviour continues for a considerably longer period, and you pay no heed to vocal exhaustion, you may be unknowingly damaging your voice box to an extent where the voice change would persist and give rise to a true voice disorder. This is why occupational voice users such as singers, teachers, lecturers, clergy, actors, lawyers, politicians, and salespeople are at more risk of developing voice problems.

Suddenly

Voice problems have the potential to emerge stealthily or suddenly. Their manifestation can be highly distressing especially for occupational voice users for whom the voice is an essential tool which, if damaged can also have a considerable economic and social impact on them. However, one should, never forget that voice problems can be just as overwhelming for any individual who relies on voice to get through day to day speaking situations such as sharing information, engaging in conversation, and speaking on the telephone. In view of these facts, it is important to understand that the practice of healthy vocal behaviours and vocal hygiene are the first steps for taking better care of your voice.

The voice box or the larynx is a complex structure which includes the vocal folds, a pair of bands which vibrate against each other and produce voice using exhaled breath.

Unhelpful vocal behaviours such as shouting and screaming can traumatise the vocal folds, causing swelling and even the formation of calluses on their surface, which typically results in a changed voice. For this reason, all of us must consciously make an effort to avoid speaking loudly and too long.

It is advisable to talk at a moderate volume, especially in a background with minimum noise, i.e. away from noisy traffic, television and radio, trains, noisy restaurants etc. Allow yourself to rest your voice for approximately 15 minutes for every two hours of talking. The sage saying “everything in moderation” certainly goes a long way with regard to voice usage.

Secondly, avoid throat clearing and harsh coughing as it is enormously traumatic to the vocal folds. By and large, most people form a habit of clearing their throat vigorously when faced with repeated sensation of bothersome mucous in the throat. However, it is important to try to suppress the need to cough and to clear the throat by swallowing hard or drinking a little water.

Dehydrated

Equally relevant is the fact that people are dehydrated, much more so than they often realise. The vocal folds are covered with a mucous membrane, like in the mouth, and dehydration causes the smooth lubricated functioning of the vocal folds to reduce.

The drying out effect may happen due to smoking and alcohol consumption which needless to say compromises vocal health. Inhaling smoke, dust and chemical fumes also intensifies dryness of the vocal folds. Moreover, food products such as coffee, tea,

chocolate, cola and energy drinks containing caffeine also cause dryness of the vocal folds internally. Finally, many medications have “dry mouth” and thus dry vocal folds as a side effect. Therefore, it is preferable to avoid or reduce consumption of such products and exposure to such vocal irritants, especially in the presence of vocal distress. It is helpful to wear a protective mask from dust and fumes whenever necessary.

So how do you rehydrate the vocal folds? The best way to achieve rehydration is through drinking plenty of water to keep the vocal folds moist. In fact, the best practice is to drink water in small amounts frequently, rather than gulp down a larger amount at once.

Forming a routine of carrying a bottle of water all through the day is helpful to meet the daily water requirement of 2.5 Liters as recommended for all healthy individuals.

Another way to rehydrate the vocal folds is by inhaling steam (hot-water vapour) for approximately 10 minutes twice per day.

It is advisable to avoid adding any substances such as menthol and eucalyptus to hot-water due to its consequent drying out effect within the throat.Another aspect to consider is the presence of gastroesophageal reflux, a condition where the stomach produced acids move back up the food pipe and into the throat where it could potentially inflame the vocal folds by causing voice problems. This condition needs to be managed with medication, diet and lifestyle changes. Existence of heart burn and/or a burning sensation in the back of the throat together with a persistent cough indicates the need to seek medical attention for gastroesophageal reflux.

Hoarseness

What is most important is to be aware is that persistent hoarseness of the voice suggests the need to consult an ENT doctor. Typically, the person's throat is scoped to view the structure and function of the vocal folds. In some cases, referral to a Speech and Language Therapist would allow for comprehensively assessing the voice and then implementing voice therapy in conjunction with the overall treatment plan which can also include medical and/or surgical interventions. The main message then is, do not hesitate, nor delay to seek help whenever your voice worries you.Begin taking care of your voice today in the best possible manner to protect and preserve your voice. Good vocal practices will ensure best possible outcomes and help you maintain the quality of your voice over time.

At least until the next big match or karaoke session!

The writer is Speech and Language Therapist, Sri Jayewardenepura General Hospital.