On 23 Mar, 2024, Seniors Today hosted their weekly Health Live Webinar with Dr Anita Mathew who spoke in and answered questions about Incidence of Tuberculosis in the Elderly on the occasion of World Tuberculosis Day.
Dr Anita Mathew, Director-Internal Medicine at Fortis Hospital Mulund brings with her years of dedicated service in internal medicine, especially in the treatment of patients with infectious diseases, including Covid-19. Her deep understanding of the varied spectrum of health conditions affecting different organs and the challenging field of infectious diseases, has often seen her help delicate immuno-compromised patients, combat life-threatening infections such as Tuberculosis, Hepatitis C, and certain forms of Pneumonia.
Dr Mathew’s comprehensive knowledge of internal medicine and the complex, often chronic, nature of the health conditions has put her in the league of top physicians in the city. Her excellence in her vast experience of handling a broad range of long-term conditions at Fortis Hospital Mulund is evident in her apt diagnosis and her approach to the treatment modality. She begins with the diagnosis of the root of the underlying diseases, in-depth analysis of the medical test reports, and monitoring each condition with an eagle eye to optimise symptom management. In cases that require more clinical research, she ensures it is conducted under her impeccable tutelage.
Armed with proficiency in the diagnosis and treatment of all health conditions affecting different organs, including cancers, Dr Mathew is a revered name among her counterparts, and the medical students she tutors at Mumbai University. Dr Mathew underwent rigorous training in Thailand in the domain of HIV/AIDs, one of the most long-term infectious diseases afflicting mankind.
India has one of the highest tuberculosis burdens in the world. We account for 25% of the number of cases of tuberculosis.
Tuberculosis has always been a cause for concern, if you look at the graph, there has only been a rise in the number of tuberculosis cases; the number has only progressively increased. It is only in the last few years that there has been a significant visible change in the TB programmes in the nation to train in this particular disease.
In 2022, which was a milestone year, the TB surveillance efforts in India had a record notification of 24.2 lakh cases.
We have a huge burden of multi drug resistant tuberculosis in our country. In the last year, we had about 63,000 patients who were diagnosed with MDR TB (MultiDrug Resistant Tuberculosis).
Tuberculosis causes a huge amount of morbidity. Morbidity is the reduction in quality life. And also mortality, wherein we have lost a lot of youngsters and elderly folk to this disease, both stages wherein the immune system/ immunity of the individual is low.
Tuberculosis is a curable disease which we can easily control, but this requires a lot of resources, not just from the government sector and the healthcare sector, but also from the people to keep this disease at bay, at least to have a reduction in the number of cases that we are seeing in the country.
We are in the slow process of demographic transition, which means that we also have an increasing burden of the elderly, i.e. above the age of 60.
In the elderly population, there has been an increasing trend in the number of tuberculosis cases over the last few years, baring the last year, which has been slightly better than the years that preceded it.
Persistence of increase in the number of cases in this particular age group is also an important factor for us to say that our younger population might also get infected from us, and that the elderly population is the pool of infection for that community. Which is why it is important for us to see that we have fewer cases, for our own health and the health of our future citizens.
The older TB patients that we have are among the pool of whatever numbers that we have, as of now, we have 10-15% of which 50% are known to be sputum positive. These patients have a 40% higher risk of unfavourable outcome because of tuberculosis. Unfavourable outcomes mean high risk of morbidity and mortality.
Risk factors of unfavourable outcomes due to Tuberculosis:
- Age over 70 years
- Male > Female
- History of tuberculosis in the past, also known as re treatment patients
- Patients who have received a direct observation therapy (DOTS Therapy) in the past
Tuberculosis in the elderly is a concern is due to the following reasons:
- Comorbidities: Patients who is elderly are also at a risk of suffering from other diseases which in turn increases the risk of tuberculosis and complications.
- Physiological and cellular changes in the lungs as age progresses leads to a phase of persistent low grade inflammatory stage and also to cause an oxidative stage and stress. This is why you are also advised to anti- oxidants such as Vit E and Vit C
- Immuno- sensence: as we age, our immune system also grows old thereby increasing the risk of tuberculosis and its reactivation.
- Diabetes: as we get older, we can be diagnosed with diabetes. Diabetes itself is a risk factor for tuberculosis, increasing the risk by 1.5 fold.
- Chronic smokers, chronic asthmatics and people suffering from chronic respiratory diseases
- Alcohol abuse also increases the risk of tuberculosis
- Nutrition: many senior citizens in our country do not consume adequate nutritious food- both over and undernutrition, leading to an increase in the risk of tuberculosis.
- Elderly with immunocompromised conditions such as cancer, autoimmune diseases, HIV AIDS and patients undergoing treatment for the same. These are all also comorbidities which increase the risk of tuberculosis.
At both the extremes of age, which is infancy, early childhood (<5 years if age) and older age group, their immune system is not capable of handling infections too well, so you may not have fever as one of the major symptoms.
Presenting signs and symptoms include:
- Prolonged cough
- Blood in sputum (hemoptysis and hemetemesis)
- Night sweats
- Chills
- Fatigue
- Loss of appetite
- TB lung lesions- they can occasionally be misdiagnosed as pneumonia in some patients
We are all aware of TB of the lung, but there is also something known as extra pulmonary TB, ie TB which is in the other organs other than the lungs which includes tuberculosis of the lymph node, TB of the eye, ear, skin, abdomen, genitourinary tract TB in women. Thus symptoms pertaining to extra pulmonary TB depends on the affected organ.
Disseminated TB, wherein the TB spreads with the help of the sputum, through the lung which allows it to spread, which if your immune system is compromised can be disseminated from the lungs trough the blood. It is the worst for of TB wherein the TB is spread to every single organ and the chances of the patient succumbing to the disease is extremely high.
Diagnosis of tuberculosis:
- Tuberculin screening test (IGRA) which is a blood test. This is for patients with latent TB. This may come positive for most of the people, but you need to treat the patient only if there is a close family member suffering from an active TB infection.
- Sputum sample
- Lymph node sample
Every patient of TB is also screened for diabetes and HIV
A BCG roll out programme is going to be initiated, targeting the elderly population, over 60 years of age.
Individuals who take adequate supplementation, nutrition and a good fresh air have a lower incidence of TB infection.
Lifestyle intervention such as diet restriction, consuming adequate amounts of protein are simple things that help in managing and preventing TB.
National Tuberculosis Elimination Programme and Ni-kshay Mitra Programme are excellent government programmes which work exceedingly well.
Under the National Tuberculosis programme there are designated areas with designated Tuberculosis Centres which provide you with Anti TB medication, completely free of cost.
Treatment for MDR TB and RR This best taken from these centres, because they have drugs which are not easily available in the private sector.
The treatment of tuberculosis is a long one, because the bacteria takes a long time to multiply and replicate in your body post infection, unlike other infections which replicate at a rapid pace.
Most of us are infected with tuberculosis by the age of 5, it is our immune system which does not let the bacteria replicate and allows us to fight it out, thus, it is an immune related mechanism. Which means, the amount of time it takes for the infection to manifest as a disease is a couple of years. And there is no way that it can be said that the treatment will clear 100% of the bacteria out of your body.
Once the treatment start, in the first 15 days, you will be able to reduce a of the burden of disease but the rest of the time is taken to reduce it back to 1-2 bacilli which should not be able to harm you.
Treatment programmes for TB are the same for everyone since they are guideline based.
However, with the elderly population with starting the Anti TB protocol, there is the risk of developing toxicity such as liver toxicity when the patient is on standard treatment.
2nd line treatment can cause symptoms and side effects in the brain, skin, etc.
