TB AROUND YOU

"Doc, one of my house staff/friends has tuberculosis! What do I do? How serious is it? Will I get it ,too? How about my family? What protection medicine can I take? When can TB patients go back to work? Etc. etc.

By N Macalintal Jr MD 2024

So, say your driver or maid has in his/her chest x-ray film features of one of the most prevalent and contagious disease in the country and in the world. And you probably want to send him home or away right now, as in now, but you worry about the time he was there driving for you or your children during the last several months.

Before we answer what you can do, let’s first talk about what is TB, how one gets it, and then how our body responds to getting exposed to it.   Tuberculosis, or TB, (also called Koch’s in the old times), is a disease caused by a bacteria belonging to a family of Mycobacteria.

It has several relatives and for our purposes, we shall not deal with them further here. The TB bacteria is airborne and therefore one can get it by simply by inhalation.   People still don’t learn – that when they cough or sneeze, they can spread germs to others.  And when one inhales it, few things can happen - it can be totally destroyed by our body defense system , or it can stimulate our body's immune response or it can lead to actual disease. When a body gets exposed to a bacteria, the defense response it creates allow our system to remember the bacteria, in this case the TB bacteria, and this explains why a TB Skin Test can become positive.  

Let’s pause for a while and talk about the TB Skin test (PPD in medical terms) as things may get complicated later in our discussion. A positive TB Skin Test does NOT always mean the person has active TB - it only means the person with positive TB skin on has an intact immune response to TB. However, both those who were just exposed and those who have active disease will generally show positive skin test, but those with active disease will have abnormal chest x-ray while those who were just exposed and got infected, will not have an abnormal chest x-ray.  

Question: Why would somebody turn out to have TB?  

Getting or not getting TB is not always related to where he works. Family health history is important. Did any of his parents / relatives living with him before had TB? Previous health history of the person is also just as important. A previously diagnosed TB subject should have undergone a six-month treatment composed of three to four drugs, otherwise he risks worsening the disease or having a relapse.   Even in the absence of positive family or personal past health history, being in a place endemic for the disease is a risk factor (the disease is very prevalent in the country). It might interest you to know that in various conferences on lung disease about TB and Immigration, there are  countries whose immigrants are on the very close monitoring by their immigration offices.  

Question: Just how common and serious is TB?  

TB is very common both in the Philippines and in the world. Worldwide prevalence has it somewhere at 1.7BILLION with 20M of them active cases, with 3million deaths per year - that's equivalent to 1 commercial airline crashing every hour!! "TB has been a major medical threat in the Philippines and continues to be so. Local government estimates that 1/3 of our population has been infected. The local medical community believes this is not correct - and that it is actually much more since the statistics do not include the patients from the private medical sectors and those who self-medicate. To date, TB ranks within the country’s 10 leading causes of death (and that has been so for over about half a century).  

Question: How contagious is TB? They say it has to be treated for months, is it true – why that long??!??  

TB bacteria spreads easily. One contagious person, on average, infects 10-15 people with TB each year, according to the WHO Global TB Programme estimates.   Unlike other ‘ordinary bacteria’, the TB bacteria has a very thick fatty wall. Also there are about 4 TB populations in the body, with some of them doing nothing but grow and multiply, grow and multiply… They do not die easily, and has the tendency to mutate if treated transiently. Worldwide experience with the disease dictates TB has to be treated  for 6 months, no less, otherwise, patient’s treatment often just goes to waste.   Question: Now, what do I do with my driver or my househelper with PTB?   Have him/her see a lung doctor, preferably. He may need to go on leave, not because he cannot do the job, but because he poses as a health hazard to others in the workplace.   A new gray zone appears here and the question like "How about the time we were together? Could I have gotten the disease?" is a valid concern. But then, nothing can be done about it. My opinion on this is that this patient you know has TB is far better than the others who have the same illness and are not aware of it. And employers of such subjects are actually not that unlucky since such patient you know has TB is aware he is sick and is getting the treatment. What about those whom you fall in line with in movies, in malls - and who may have the disease and not aware of it and not even on treatment? As you can see, the impact of such reality is far more worrisome than we can imagine.  

Now, the leave from work - how much should you impose / offer / give ?  

Basic knowledge has it that after about two weeks of intensive phase treatment, sputum generally converts from positive to negative, thus making the subject fit to resume work, provided full treatment regimen is complied and completed. Yes, the patient can go back to work after about two weeks of TB treatment, but while this may for 'minimal PTB' cases only, the patient must have a negative sputum MTB GenXpert test, preferably twice , before allowing them to return to work. For moderate and far-advanced ones, a two-month rest from work at least is recommended (and sputum culture for TB bacteria should be done ideally 2-3x while treatment is being started, since by the time the culture result is ready [4-8 weeks], it is time to evaluate the patient for possible resumption to work). (Shorter periods of rest can be considered if GenXpert test is negative)   To be sure the subject does not infect others, sputum tests are ideal, although there are other things which remained unsettled in this issue. One, the sputum studies needed to grow TB in culture takes time, about 6-8 weeks using the conventional methods.

Newer methods like DNA studies ,e.g., PCR or polymerase chain reaction method, can give results in a few days - but costly (~PHP5000). Other newer methods include a process where a specimen with positive TB will fluoresce, or light up or glow , and results can also be available earlier than when using the conventional methods. (This may also be at an extra cost. At the moment, I am not aware of its availability locally.) (Now, you realize the extreme importance of our fireflies - that's where this technology came from, in case you would like to know …)   There is an advantage of one over the other and it certainly would depend on the urgency of the patient's needs to have his/her results. For those who may want to use such report on immigration-related matters, it is best to consult the embassy-accredited clinic regarding the result as they may have other preferences on the type of test and where it should be done.

  Question: What about drug-resistant TB?

  Sometimes ,  there are TB patients who do not complete their treatment, and incomplete treatment is the principal cause of drug resistance, because by making treatment incomplete, the bacteria is being given time to learn the antibiotics and given time to create their protection from the medicine. And there’s a new alarming issue – the XDR, the extremely-drug resistant TB, which are resistant to 2 or more second-line drugs!!! Hopefully, we don’t see PANresistant strains especially with the advent of newer anti-TB drugs!!  

There are various reasons why treatment could not be completed. 

First, a lot of them could not afford the cost of therapy per month and for these groups of patients , it may be prudent to advise them to check with their respective health centers for stocks. Second, a denial attitude is often instant! "Oh no, it cannot be! It's my evaluation for regularization in my job next week? I've got my interview at the embassy tomorrow!" are indeed very common outburst of patients who are often asymptomatic upon discovery of TB in their chest x-rays. So they seek second or third opinions, surf the net, or worse , seek neighbors' advice who invariably scare them by giving stories of either people who reportedly had some reactions while taking medicines or who amplify their denial stance by giving stories of people who became better taking nothing. Third, some TB patients do not take medications and simply refuse to believe they are sick because they 'never had any symptoms'.Valid? Yes, but maybe. You see, not all disease have symptoms, that's why x-rays are needed to screen certain illness, and TB is one of them. It may also help defiant patients to know that the surface area of our lung is about 70 square meters (that's the size of a tennis court!), if you care to know), and that a sizable portion has to be destroyed first before a symptom can be felt by the patient.  

Some patients take the medicines but stop sometime in the middle of the course, say two or three months after starting therapy, because they became fed up taking the medicines. This duration of treatment may be enough to control the infectiousness of the disease, but certainly not enough to prevent relapse. Several studies done with regards to these show that any current treatment regimen shorter than 6months risks a high relapse rate, specially over the next 2-3 years. Obviously, the need for in-depth understanding of the diseaseby the patient is important for compliance to improve.

The realities of TB in the Philippines need not be over-emphasized: [1] it has one of the highest TB prevalence rate in Asian countries; [2] over the last quarter of a century, our mortality/morbidity from the disease of TBhas to improve further;[3] 80% of cases are asymptomatic AND are not on any treatment; [4] more than 40% are resistant to at least 1 drug, with 15% being multi-drug-resistant.   One of the ways we can help solve this gargantuan medical crisis is for each TB case to be treated adequately and FULLY.

Finally, it does not have to be only every March 24th , the World TB Day, that our concerns should fill our dailies and news columns. It's an everyday calling to be aware and be concerned.

Why TB refuses to die and what can we do … (and what we should not do…)

NAZARIO A. MACALINTAL JR., MD,FPCP, FPCCP   v2024

 The TB bacteria, in contrast to other germs, have a much thicker wall or cover – this makes them difficult to be penetrated by antibiotics.  TB has 3 types of population – ONE, those that live inside the cells and do nothing but grow and multiply. TWO, those living outside the cell and multiply episodically, and THREE those that live outside the cell and also multiply episodically. There is actually a FOURTH group, that “sleeps” and gets awakened when our resistance goes lower and lower. All these groups have to be eradicated by the antibiotics, and the antibiotics at times are good only on certain areas.  

A very disturbing extent of TB infection among humans is that Tuberculosis resides within the very core with of our immune or defense system, like the terrorists residing inside an opponent nation’s GHQ. Worse , they are able to manifest themselves as friends, and are not recognized as invaders. “Good morning, Sir, please feel at home!” may be the way how our immune system will greet TB bacteria when they meet. How is that possible????!!?   Ordinarily, a germ or infecting agent has some marks in their coats or cover that makes them very easy to identify. Doctors for example is easily identified by their white gowns and stethoscopes and a police officers by their handguns and uniforms. The  wall of TB bacteria have little of those invader marks and as such it allows them to pass unnoticed by our immune system. TB would change  their coats or covers depending on the stress situations they will be exposed to. Not only would their wall’s physical structure changed, but it occurred down to the DNA level, and showed to us how even their genetic makeup would change. (At this point during that 1995 international  convention , I  paused for a while and wondered whether I chose the right subspecialty!). In the words of the speaker in that forum, she said “TB has perfected the way to survive the human body”.   Nowadays, we do have the grave threat of TB, which is killing 3 million a year worldwide – that’s equivalent to about the size of a jumbo jet crashing every hour, and can you see who  cares? We now even have multi-drug resistant strains that do not respond anymore to routine set of medications, aside from the superimposing problem of AIDS on those who have TB. (to make matters worse, there IS now such a thing as XDR-TB – these are the extremely drug-resistant TB that even the second-generation treatment regimens do not work!!)While the medical research community are exhausting ways to win the battle against them, patients need to be treated soonest and fully and aggressively once they develop TB, and this is one way we can help – to have them treated fully.

The way we should treat TB is extremely important – that should be SIX months at the least, with 3-4 drugs on the first two months for the so-called intensive phase, and 2-3 drugs for the next 4 months for the so-called maintenance phase. It can be more than 6 months especially for complicated cases, but definitely NOT LESS, even if the patient does not feel anything. Any deviation from this should be clarified from the patient’s doctors, as it IS the inadequate treatment that teaches the TB bacteria on how to outsmart mankind , that’s why for several decades we haven’t won the battle against TB.   The way the patients handle the prescribed treatment is another story. Relief of symptoms is being equated to cure, and most would stop their medications prematurely, and worse, they may only see the doctors once TB has worsened. By that time, TB bacteria had been given already ample time to learn to outsmart  the antibiotic given, then resistance to treatment follows. Our country has consistently won one of the top ten positions in having the worst TB prevalence worldwide – Bow! That is why our immigrants have to go through the strict processes of evaluation and treatment by accredited clinics of embassies. Ask your friends about it. They have their stories.   Today’s approaches to improve treatment compliance include the famous DOTS, or Directly Observed Therapy System, and are already in the national healthcare programs globally. Additionally and on a more personal point of view, I find requiring the submission of the foils of used medications (and counting them!) effective in checking compliance (and refusing to accept them on their next visit if foils submitted are incomplete, with the view in mind that it is only in helping them go through the course of treatment that doctors can really help them) I read about and found this technique while I was in my college years in a 1970s AudioDigest tape from my sister who was then in a residency training program  - and it works.   Lastly, there is the need for TB patients to be properly educated on why they need to be on the mask..  TB patients should wear disposable masks especially on the first two weeks and as long as they as they are sputum positive ) since this is the time when they are most infectious that their sputum carry significant loads of TB bacteria. Worn disposable masks should be changed daily, and burned after use. The most common scenario in the local setting is that right after the patients exit from the door of the doctor’s clinics, they would suddenly rip the mask off their face and pocket them I think it is our responsibility as doctors to make them realize that there are uncomfortable but extremely necessary steps to help prevent spread of the disease to other people, which includes those even in their homes.   LASTLY, IT SHOULD BE A MORAL OBLIGATION OF THE RELATIVES TO COOPERATE AND ALLOWED THEMSELVES TO BE SCREENED AND MAKE SURE NO ONE ELSE IS INFECTED WITH THE SAME DISEASE IN THE SAME HOME.   … Just imagine a family of seven, ALL under treatment for active TB …or a family of 19 in one compound, all infected, with 5 active cases from 1 far-advanced tb case who refused any consult not until breathlessness hit her .. Similar stories go on, and on.. and on.. and refusals after refusals. … “Wala naman akong nararamdaman ehh. Si ate na lang muna (ang mag-pa xray) !!” – this attitude has no place at all, and for the benefit of the family members – this defiant stance has to stop. It is NOT for the physicians welfare after all – it’s for your family.

"Why can't anyone stop my coughing?!!?

“Doc, I’ll out of the country in a week and have been having asthma  attack despite my meds! What do I do” ®v2010 2024 By Dr. Mac

 First - are you in remission before you left? Never assume mild attacks before your intended travel will subside without your doctor’s follow-up care. When it occurs while you are in a far away place, not much can be done by your MD back home, and your local prescription may not even be honored in a foreign land. Include the pre-travel pulmonary check-up in your list of priorities.   Check your peak flow. What was your best blow? And do you have a recent one? Was it 15% or more lower than your best? If it is so, SEE YOUR DOCTOR before your fly.  

Second, when you travel, find out first How’s the weather. The sad thing about checking today’s weather is that it is becoming as unpredictable as today’s typhoons and floods! Get more recent weather update as travel date nears – check it even the day before flight date. I once had a Suisse-bound travel and we were advised light clothings only a week earlier but on the day pre-flight, layers of warmers were advised!!!  

Check natural turmoil / local epidemics possibly currently occurring in the place of interest. If there is one, can you cancel your trip? Remember, about 80% of asthma attacks are caused by respiratory infections and if you decide to pursue your travel, you should be ready for its exacerbation – even for confinement! And stocks of meds!  

Third, ask "What should you avoid? Whatever makes you worse locally is probably what can also make you worse over there.   A very common and almost certain observation is that going to less polluted areas relieve patients of their symptoms , at times they are able to taper their medications. (Reminder: if you do so, you must put them back about few days before traveling back  to a densely populated place where pollution is a problem.) Don’t forget to ask your doctor what to take before you arrive back. For my patients, there is a Travel Prescription being issued – go get a check-up BEFORE your travel date  

Fourth, know what your doctor can do before you fly/cruise.   What I do to my patients is provide them  an extended prescription of their maintenance medications (assuming they may extend their travel plans). Under these prescriptions are Optional meds that include:[a] acute relievers for acute attack’ [b] 2 sets of broad-spectrum antibiotics; [c] some steroid tablets;[d] a pack of anti-flu like Oseltamivir – among other meds – with explicit notes on what those meds are for , and advice to see local MD if symptoms persist. Buying these medicines before travel is not cheap – but having to go to an Emergency Room and get slapped Euro 300 or more is certainly more expensive!

If on-line consult is available, do a teleconsult with your MD – the assumption however is that stocks of the necessary medications are with you the patient.  

Fifth, now comes your problem – you have asthma attacks despite your meds! What are your options?   DO NOT FORGET - DO NOT PANIC! Why? because if a patient with obstructive airways problem breathes fast during attacks, they will TRAP MORE air, and will worsen asthma attack. Breathing out should be looonnnger than breathing in – this should minimize air trapping. How do you it? Try it with a pursed lip.   Then – SIT UP , BEND FORWARD, with ELBOWS ON YOUR KNEES. Do not lie down. Why? From our middle chest bone structure, we have a long muscle called Rectus Abdominis that stretches all the way down to our lower belly area , and this muscle aids the chest muscle in breathing out – like a bellows system. For a muscle to work best, it should be allowed to contract or shorten in the most optimum position. Lying down prevents this muscle from shortening at its best.   Also, use the doctor-prescribed acute relievers - those airways maintenance meds are generally NOT rapid relievers and are therefore NOT for acute attacks. Some long-acting meds like formoterol are also rapid relievers!  

Better bring a portable nebulizer With today’s technology, in your palm will fit a portable battery-operated unit, neb kit and mouthpiece included.   IF you opt to bring the old reliable AC-plugged nebulizer -

Check your hotel socket requirement because they vary in configuration depending on the countries. Get that multiple adapter from the local home depot, or find them at the airport duty-free shops before heading for your hotel. Note that before you can use this, you may also need another adapter for your nebulizer which was converted to local applicability.

Remember as well that some adapters allow you to use US or European equipments in Asia, but not necessarily vice-versa.   If your machine has a 220-110-volt option, you’ve may have no problem about power supply needs. (But, if it needs to be reset every time you change places of stay, recheck setting before plugging while abroad. Also, do not forget to reset the machine to local applicability  when you bring it back!)  Most gadgets today though are auto-volt.    

NOW, ANTIBIOTICS. You may have to bring some. In most countries, you cannot get over-the-counter antibiotics other than erythromycins, (and apart from paracetamols and some decongestants). The rest needs at least a hundred-fifty dollar consult (make it three or more times if you’re in a hotel). Your doctor will prescribe which will suit your needs.  

If in case, you happen to be so short of breath despite your meds, remember 911. Also, remember that if you’re using a cellphone (at least for Motorola) in USA, pressing “1” for a few seconds automatically connects you to 911 service. (I was told it’s two thousand green bucks per 911 service, wheww!!!!).  

If cost is not an issue, bringing a portable oxygen concentrator can be opted – but for those buying, make sure it is airline-approved (and make sure dealer does that clearing for you before you buy) and mind you, different carrier airlines may have different clearing approvals (so stick to one carrier)  

Finally, Do you have a comprehensive health insurance coverage? There are local insurance companies that offer reimbursement types, in case you got confined but make sure it includes health, not just accident. Others are more comprehensive. (Schengen states  require a Euro30,000 health insurance cover for each trip).Watch out for Pre-existing conditions? Be prepared. There is no substitute for getting ready  of cash or plastic money - just in case.   If winter season is coming, don't forget to have those flu vaccine shots, and the pneumonia shots too! They are best received two weeks before the travel date.  

Other than the above, enjoy your stay. Have fun!       (Oh,, by the way , your doctor collects Music CDs/Tshirts from various countries , or cap,  etc.) Joke