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Greater community support needed in fight against TB

As first reported in TODAY, the recent Ang Mo Kio cluster of multi-drug-resistant tuberculosis (MDR-TB) cases is an extension of the MDR-TB outbreak that involved patrons of three cybercafes at Parklane shopping mall in 2012. The interviewee in TODAY’s report, a young man who was a friend and contact of one of the patients from the cybercafe cluster, had unfortunately developed side effects from the treatment of MDR-TB that compelled him to quit his job and remain unemployed for a year.

A resident of Block 203 Ang Mo Kio Avenue 3 undergoing TB screening last week. It is in the interest of businesses and society that MDR-TB does not take root in Singapore. Photo: Jason Quah

A resident of Block 203 Ang Mo Kio Avenue 3 undergoing TB screening last week. It is in the interest of businesses and society that MDR-TB does not take root in Singapore. Photo: Jason Quah

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As first reported in TODAY, the recent Ang Mo Kio cluster of multi-drug-resistant tuberculosis (MDR-TB) cases is an extension of the MDR-TB outbreak that involved patrons of three cybercafes at Parklane shopping mall in 2012. The interviewee in TODAY’s report, a young man who was a friend and contact of one of the patients from the cybercafe cluster, had unfortunately developed side effects from the treatment of MDR-TB that compelled him to quit his job and remain unemployed for a year.

In the cybercafe outbreak, contact tracing was particularly difficult and the health authorities had to resort to media publicity — in addition to serving legal orders and health advisories to cybercafe employees and patrons — in an attempt to attract potentially exposed contacts to go for TB screening. The index case from the Parklane cluster could not recall prior close contact with any person with TB, and it was only via molecular fingerprinting of the TB bacterium, coupled with the TB Control Unit’s (TBCU’s) extensive database, that the original source patient — who was diagnosed with the disease in 2008 — could be identified.

This extended outbreak highlights several pertinent issues pertaining to how TB is managed in general, and MDR-TB, in particular. It is worthwhile emphasising that TB is a slow infection — infected persons typically develop an active infection months to year after exposure — and hence most do not remember who passed the infection to them. More importantly, this slow pace of spread seldom impinges on the public consciousness (the Ang Mo Kio cluster is a rare exception), lacking the immediacy of, say, Middle East Respiratory Syndrome (Mers) or an Ebola outbreak.

Hence, providing the resources for TB control in a population often takes a backseat to other, more seemingly emergent, crises. The fear of being stigmatised by friends and co-workers, losing one’s job, or — in the case of businesses — losing one’s customer base is very real and frequently poses an impediment to contact investigations and TB control efforts.

Actual treatment of TB is a long process: Six months with a multiple-drug regimen is typical for drug-sensitive TB, whereas twice that duration and more drugs are required for successful MDR-TB treatment, even with the new, shorter MDR-TB regimen proposed by the World Health Organization (WHO) this year. Side effects are not uncommon, especially with MDR-TB treatment, and the requirement in most cases that treatment be administered via Dots (directly observed therapy, short course) — where patients take their medication in front of a nurse from the polyclinics or the TBCU at Moulmein Road — imposes significant social and occupational inconvenience.

Professor Sonny Wang, longstanding director of TBCU, believes that if MDR-TB becomes the predominant type of TB in Singapore, our current system for TB control will be inadequate because of the tremendous additional medical and socioeconomic costs of treatment.

Dots is recommended by the WHO because adherence to extended courses of any drug treatment — if patients are left to take medications on their own — is poor, especially if side effects occur. The key difference for TB as opposed to chronic diseases such as diabetes mellitus and heart disease is that patients who default taking their medication harm not only themselves, but also potentially others if the disease is spread to them. TBCU and the Ministry of Health (MOH) have taken many steps to reduce the inconvenience of Dots, including providing drug treatment free, extending the hours of the Dots service for those with odd working hours, and implementing an “outreach Dots” service where a nurse will travel to the patients’ homes to witness them taking their medication. But there is a limit to governmental intervention, especially if the rest of the community remains apathetically unengaged.

 

HOW CAN THE COMMUNITY AND BUSINESSES HELP?

 

Many view TB control as the sole purview of the government and health services under the MOH. However, this was not always the case.

After World War II, when TB was one of the most significant causes of death in Singapore, there were two community ground-up initiatives that were critical for TB control locally. The first was the foundation of the Singapore Anti-Tuberculosis Association (Sata) as a charity organisation in 1947 — it still exists as Sata CommHealth today. Sata actively raised funds through charity events, channelling these into developing diagnostic and treatment facilities, including the iconic Sata mobile X-ray bus, as well as a rehabilitation centre built for cured TB patients to learn skills that would make them employable. The second initiative was the Rotary Clinic at Tan Tock Seng Hospital — funded in its construction by the Rotary Club in 1948 and matched dollar for dollar by the government of the day. More than 300 patients were treated there every day during its heyday, before it was demolished in the 1990s.

What can the community do today? Besides the eradication of the stigma associated with TB and provision of more resources for research, our society needs to work towards developing a culture of greater support of those who are on TB treatment, ensuring that most, if not all patients, will complete the entire course.

More businesses can endeavour to provide leave support and job security for their staff diagnosed with TB, adjusting their workload according to the employees’ state of health. Sata CommHealth has provided supermarket vouchers for low-income patients who adhere to TB treatment since 2009, lessening the burden on these patients and improving patient adherence. More of such charitable activities will help to make a difference.

It is ultimately in the interest of businesses and society that MDR-TB does not take root in Singapore, and that TB be contained and eradicated.

 

ABOUT THE AUTHOR:

Associate Professor Hsu Li Yang is Programme Leader, Antimicrobial Resistance Progamme at the NUS Saw Swee Hock School of Public Health.

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