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SUMMARY
A review of the epidemiology of tuberculosis, its
contributing risk factors (excluding HIV) and the role of
screening latent tuberculosis infection in Malaysia was
done. Despite the global and domestic decrease in
prevalence rates of tuberculosis in the past decade, there is
an alarming increase in the trend of non communicable
diseases in the country. High prevalence rates of major risk
factors leading to reactivation of tuberculosis were seen
within the population, with diabetes mellitus being in the
forefront. The rising numbers in the ageing population of
Malaysia poses a further threat of re-emergence of
tuberculosis in the years to come. Economically, screening
of diabetic patients with comorbidities for latent
tuberculosis infection (LTBI) using two major techniques,
namely tuberculin sensitivity (TST) and Interferon gamma
release assay tests (IGRA) could be a viable option. The role
of future research in the detection of LTBI in the Malaysian
setting might be necessary to gauge the disease reservoir
before implementing prophylactic measures for high risk
groups involved.
KEY WORDS:
Latent tuberculosis infection, Non communicable diseases, TST,
IGRA, Prophylactic treatment, Risk factors
INTRODUCTION
This article reviews the prevailing trends in risk factors related
to tuberculosis in Malaysia and the latest developments in
screening LTBI. With the increase in risk factors relevant to
LTBI, mainly diabetes mellitus in the country, the feasibility
of a screening LTBI in high risk groups (excluding HIV
infection) becomes even more crucial. The aim of this article
is to highlight the possibility of devising a targeted latent
tuberculosis screening model amongst diabetic patients who
have compounding risk factors (ageing population, chronic
renal failure, smoking and dyslipidaemia). Data obtained
from the review of articles were utilized to point out the
significance of screening latent tuberculosis in view of the
rising trends in the related risk factors in Malaysia.
MATERIALS AND METHODS
A search was made on the relationship between tuberculosis
and its relevant risk factors (mainly non communicable
diseases). Extensive research was done on analyzing the
467
Review Article
468
Smoking
Malaysia is ranked as the country with the highest number of
smokers in South East Asia7. Scientific research has shown
that mucociliary clearance is crucial as a primary innate
defense in the airways28. Smoking therefore leads to impaired
mucociliary clearance that impedes the ability of the lungs to
combat attacks against Mycobacterium tuberculosis and
other infections29.
This evidence is consistent with clinical studies that have
demonstrated higher prevalence of tuberculosis amongst
smokers in comparison to non smokers30-32. Smokers also have
30-50% chance greater to contract the disease than non
smokers33. The risk of reactivation of latent tuberculosis in a
smoking adult is two fold that of a non smoker34.
Ageing
Over a duration of just 5 years (2000 2005), the elderly
population (aged above 60) grew from 1.4 million to 1.7
million in Malaysia11. At present, Malaysia is in the Window
Of Opportunity phase, where there is a large working age
population (aged 25 to 64) and the decline of young aged
persons (aged 15 to 24)35. This trend will persist up to the year
2020 and thereafter, the country will inherit a generation of
increasing old age burden which is likely to have an average
life expectancy up to the age of 7236. Projections made by the
United Nations reveal that there will be a rise of 22% in the
older generation of the population in 205011.
Ageing results in a decline in T-cell mediated immunity that
hampers the ability to combat tuberculosis infection
effectively37-39. This increases the host susceptibility to the
illness. In tandem with this evidence, surveys have shown
that tuberculosis is predominant in the ageing population in
comparison to their younger counterparts40,41. In one study,
mortality was higher in elderly patients at 20% when
compared to younger subjects (3%)42.
A high index of suspicion is required to detect prevailing
tuberculosis cases in the elderly as they present with atypical
presentation and symptoms maybe be masked by underlying
age related comorbidities 42-45. A more vigilant and targeted
screening of tuberculosis in this age group could be viable
option.
Dyslipidaemia
The role of dyslipidaemia as a risk factor in tuberculosis
remains controversial and further investigative studies in this
field is ongoing. A landmark finding in a recent study implies
that hypercholesterolemia leads to a defectively inefficient
innate adaptive mechanism which reduces resistance against
tuberculosis46.
Several studies, however, dispute the role of
hypercholesterolemia as a risk factor in tuberculosis. Patients
with higher cholesterol levels seem to possess better
radiological signs of tuberculosis and faster sputum
sterilization after chemotherapy47,48. But these findings were
misinterpreted as these studies seem to indicate that low
cholesterol levels are the consequence and not the cause of
the disease49.
Table I: Incidence/Relative Risk/Odds Ratio of Major Risk Factors Contributing to The Reactivation of Tuberculosis
Risk Factor
HIV
Diabetes Mellitus
CRF /ESRF
Smoking
Aging
Dyslipidaemia
Risk
26.7 (RR*)
3.1 (RR)
6.9 52.5 (RR in CRF and ESRF on dialysis)
2.0 (RR)
1.61 27.02 (OR as an independent risk factor)
2-3 (RR, in nursing home residents)
No data
Studies
17
14, 20
25, 27
6, 34
21
57, 58
No studies
* Relative risk
Chronic renal failure
Odds ratio
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470
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