An honest look at tuberculosis in Malaysia, with insights from a top expert
By Siti Salihah
Tuberculosis (TB) is a health issue that doesn’t always make the headlines, but it’s one we can’t afford to overlook. In Malaysia, TB continues to pose challenges, with reported cases steadily increasing. While better detection means more people can receive early treatment, the fight against TB is far from over.
To shed light on the topic of TB and the progress being made, we had an insightful conversation with Dr. Jamalul Azizi Abdul Rahaman, a Consultant in Respiratory Medicine and Physician from Thomson Medical Centre. Dr. Jamalul is a respected leader in the field, with special expertise in interventional bronchoscopy and pulmonary physiology.
From his training in Marseille, France, to pioneering key practices like rigid bronchoscopy in Malaysia, Dr. Jamalul’s career is nothing short of inspiring. In this conversation, we discussed the current efforts to combat TB and what we can learn from one of Malaysia’s top pulmonologists.
1Twenty80: How big of a challenge is TB in Malaysia today, and what makes it such a persistent health issue?
Dr Jamalul: Throughout my 35 years in practice, the disease remains persistent for several reasons:
- Late Presentation
A major factor is late presentation. Many patients delay seeking medical help, even after months of persistent coughing. By the time they come forward, the disease is often advanced and has spread beyond the lungs to affect other organs like the brain, liver, or kidneys. This delay makes treatment more challenging, and in some cases, it’s too late to save them.
I recall a case of a young boy from Kuala Lipis who waited three months for a CT scan at his local hospital. His condition worsened, and his family eventually brought him to me. On the same day, I diagnosed him with TB and started treatment, but the delay had already made his case more severe. This kind of scenario is common, especially among non-locals, such as migrant workers, who may hesitate to seek care due to fear of legal repercussions or cost barriers.
- Patient and Comorbidity Factors
Certain groups, like those with chronic conditions—such as uncontrolled diabetes, chronic obstructive pulmonary disease (COPD), or patients on immunosuppressive drugs—are particularly vulnerable to TB. These comorbidities complicate treatment outcomes and make it harder to achieve full recovery.
- Gaps in the Healthcare System:
There are also systemic issues, particularly in general practice (GP) settings. Some GPs lack access to chest X-ray facilities, which is crucial for diagnosing TB early. Patients often jump between GPs, receiving antibiotics for what is mistakenly thought to be a viral infection. By the time they’re referred to specialists or government hospitals, their condition has often deteriorated.
For example, in TB mortality meetings during my time in government service, we found that gaps in history-taking and thorough assessments by some GPs were common reasons for missed or delayed diagnoses. This is not to say all GPs are at fault—many do excellent work—but the lack of diagnostic resources in some clinics poses a significant challenge.
- Impact of Medical Tourism and Global Mobility:
Another issue is the influx of patients through medical tourism. Some of these individuals unknowingly carry TB and travel without proper precautions, potentially spreading the disease. While medical tourism benefits the healthcare sector, it adds complexity to controlling infectious diseases like TB.
The World Health Organisation (WHO) aims to eliminate TB by 2030, but based on my experience, this target will be difficult to achieve without addressing these persistent issues—particularly late presentations, vulnerable groups with comorbidities, and gaps in healthcare resources. Addressing these challenges is critical if we want to see meaningful progress in combating TB in Malaysia.
1Twenty80: How does the availability and quality of medical infrastructure impact the treatment outcomes for TB patients?
Dr. Jamalul: Of course, better health facilities play a role, but it’s not just about having advanced infrastructure. Skilled doctors who are aware of TB and able to identify it when a patient presents with a prolonged cough are equally important. Patients themselves need to understand the importance of seeking care early. This isn’t usually a problem in private hospitals, where patients come in promptly. In government settings, however, it’s common for patients to delay seeking help—even if they’ve been coughing for two weeks.
One major reason for this is overcrowding. Government hospitals are extremely busy, with long waiting times to see specialists. Even something like scheduling a CT scan can take months, delaying everything in the process. On top of that, these hospitals are severely understaffed. When doctors are seeing 100 patients a day, it’s impossible to provide the level of care patients need.
In private hospitals, things are very different. I’ve been working in one for two months now, and everything moves so much faster. I can spend time explaining things to my patients and answering their questions. That’s what’s missing in government hospitals, where doctors often only have five to ten minutes per patient. The specialists in government hospitals are good, but they’re stretched thin, which affects the overall quality of care.
The issue isn’t just limited to staff shortages. Administrative challenges, such as slow internet and outdated systems, make it harder to retrieve test results and patient records quickly. This adds to the delays and frustration for both patients and healthcare workers.
Ultimately, it’s not just about having the best facilities or equipment. If you don’t have enough doctors, nurses, and paramedics to support the system, it won’t work. That’s the most important factor for ensuring good treatment outcomes.
1Twenty80: How does living in urban areas with high air pollution affect the risk of contracting TB or worsening its severity?
Dr. Jamalul: Air pollution doesn’t directly increase the risk of contracting TB. Instead, it is more closely associated with conditions like COPD. You become vulnerable to TB when you’re exposed to someone with active TB who is coughing near you, which leads to infection, not because of air pollution.
That said, air pollution—both outdoor and indoor—can still have harmful effects on respiratory health, which makes it challenging to avoid altogether. Taking precautions, like wearing masks, is essential to mitigate exposure. However, in terms of TB specifically, air pollution isn’t a factor that increases vulnerability or worsens its severity.
1Twenty80: What are your thoughts on drug-resistant TB, and what challenges remain in managing this form of the disease?
Dr. Jamalul: Drug-resistant TB is an extremely challenging condition to treat. The good news is that in Malaysia, drug-resistant TB is still under control and not as widespread as in certain countries like those in Eastern Europe, where the incidence is high.
Globally, 88% of estimated multidrug-resistant TB (MDR-TB) cases occur in middle or high-income countries, with 60% found in Brazil, China, India, Russia, and South Africa. Malaysia, however, is not in that category, which is reassuring.
The main challenge with drug-resistant TB is that it requires complex treatment protocols, which are not only expensive but can also come with no guarantee of a cure. One significant reason drug-resistant TB develops is when TB is mismanaged by healthcare providers.
Proper TB treatment typically requires a combination of three or four drugs over six months. Resistance can develop if doctors prescribe inadequate dosages or limit the treatment to only one or two drugs. This mismanagement can lead to drug resistance and make the condition more difficult to treat.
Fortunately, doctors in Malaysia are generally good at managing TB, which has helped prevent drug resistance from becoming a major issue. “The best treatment for drug-resistant TB is to prevent it from happening,” which is why prevention remains the most effective strategy.
That said, if drug-resistant TB were to become a widespread problem, it would be a severe crisis. Managing such cases would be challenging, costly, and could lead to devastating outcomes. It’s an issue that needs to be taken seriously, as the consequences of a significant rise in drug-resistant TB would be catastrophic, something that I admit is difficult even to contemplate.
1Twenty80: How effective are the current diagnostic methods for TB in Malaysia, and do they meet the needs of the population in terms of speed and accuracy?
Dr. Jamalul: Diagnostic methods for TB in Malaysia are highly effective, whether in the public or private sector. Overall, the country’s TB diagnostics are superb. In private hospitals, the speed and efficiency of diagnostics are excellent, with results typically returned very quickly. Unfortunately, this level of service is difficult to match in government hospitals due to the sheer volume of patients they handle.
Despite TB remaining a priority in the public healthcare system and efforts to expedite diagnosis, delays are inevitable because of the patient load. It is nearly impossible to diagnose a patient with suspected TB on the same day in a government hospital. This discrepancy highlights a significant difference in the speed of service between the public and private sectors, though both are committed to providing accurate and timely diagnoses.
1Twenty80: What are some conditions that can mimic TB by presenting similar symptoms?
Dr. Jamalul: There are a few conditions that can mimic TB due to their similar symptoms, such as:
- Persistent cough
- Coughing up blood
- Weight loss
- Night sweats
The most significant condition that can present with symptoms similar to TB is lung cancer. It can be challenging to differentiate between the two on an X-ray, as they may appear similar. In some unfortunate cases, a patient may have both TB and lung cancer simultaneously. This can happen because TB is highly endemic in Malaysia, making co-occurrence possible.
The situation contrasts sharply with countries like Australia, where I spent a year working in a hospital. During that year, I only encountered one case of TB. The same can be said for countries in Europe, including the UK and the US, where TB is not as common. However, in Malaysia, TB cases are seen nearly every week, especially in government services, making it a prevalent health issue.
Diagnosing whether a patient has TB or lung cancer can be challenging due to their overlapping symptoms. To confirm a diagnosis, we often need to conduct further investigations, such as bronchoscopy, scans, or biopsies. The process is simplified if the sputum test shows TB, as this result is definitive. However, chest X-rays may sometimes suggest TB, but the results can be negative, necessitating additional tests.
Detecting lung cancer early is crucial due to its significant impact on health. While these investigations are typically not difficult in Malaysia, the challenge lies in distinguishing between TB and lung cancer, as they can appear very similar. Fortunately, we have the facilities and services available to accurately diagnose the condition.
1Twenty80: What are the preventive methods being taken to try and manage TB in Malaysia?
Dr. Jamalul: Managing and preventing TB, particularly in Malaysia, presents a significant challenge. In public spaces such as shopping malls, it is difficult to fully control exposure, and continuous mask-wearing is not practical for most people. As a result, the risk of exposure remains a concern.
Preventive Measures in Healthcare Settings
In a hospital setting, preventive measures are more comprehensive. When patients present with symptoms such as a persistent cough, precautions are taken immediately.
Medical staff wear masks before examining these patients, and in cases where TB is suspected, they are isolated from others to prevent the spread. Nurses, who are often the first point of contact for patients, are particularly vulnerable. Government data indicates that they have a higher incidence of contracting TB while on duty.
Hospitals use triage systems to identify and manage potential TB cases efficiently. For instance, in the emergency department, patients presenting with coughs are assessed and directed to separate areas for further evaluation. Isolation wards equipped with negative pressure are available to minimize the risk of transmission.
From a personal perspective, I ensure strict adherence to protective measures. When performing procedures on suspected TB patients, I wear a mask, and the assisting nurses use N95 masks for additional protection. If these precautions were not in place, it would be much easier for healthcare workers to contract TB. Despite these measures, cases can still occur if protective equipment is not used correctly. Early precaution, such as wearing a mask as soon as TB is suspected, is critical, as waiting for confirmation could lead to exposure.
Challenges Outside Healthcare Settings
Outside the hospital, prevention is more complex. Constant mask-wearing is not feasible, and after the COVID-19 pandemic, the practice has diminished. Public areas, such as shopping malls and busy city centres, pose challenges for individual protection. While some may choose to wear masks for added safety, it is not common practice, making it difficult to maintain comprehensive protection in everyday life.
“The BCG vaccination does not provide lifelong protection against TB, which is why people can still develop TB as they grow older”.
Dr. Jamalul
1Twenty80: Do you see significant differences in TB severity or treatment outcomes between those vaccinated with BCG and those who aren’t?
Dr. Jamalul: That’s an interesting question and one that comes up frequently. The simple answer is: no, the BCG vaccination does not provide lifelong protection against TB, which is why people can still develop TB as they grow older.
Purpose and Limitations of the BCG Vaccine
The BCG vaccine is primarily administered to protect children from severe forms of TB, such as TB of the brain. It does not offer immunity to adults. This is a critical point that many may not understand. Although the vaccine is effective at reducing the risk of serious TB in children, it does not prevent TB infection in adulthood.
Current Vaccine Development and Challenges
Unfortunately, we do not have a vaccine that provides comprehensive, long-term protection against TB for adults. Unlike the pneumococcal vaccine, which requires only one shot for long-term protection, or the influenza vaccine that is taken annually, TB remains a challenge. While a better BCG vaccine or an entirely new TB vaccine for adults would be beneficial, there has been no significant breakthrough yet. If a suitable vaccine existed, the WHO and governments worldwide would have already implemented it.
Conclusion and Hope for the Future
We are still waiting for advancements in TB vaccine research and development. While there is hope that scientists will one day create an effective vaccine for adults, there is still much work to be done in this field. Until then, the current BCG vaccine will continue to be used to protect children from severe TB cases.
Join our 1Twenty80 Broadcast Channel today! Be the first to receive interview updates, behind the scenes snippets and happenings in Malaysia’s health scene!
References: The Rakyat Post, Buku Garis Panduan NSPTB, Straits Times, New Straits Times, National Library of Medicine
