Coping with TB
Last year, Zam Zam Binte Juma’at was diagnosed with TB. With a little incentive, she has kept on course with her treatment.
Zam Zam Binte Juma’at.
Last year in June, 73-year-old Zam Zam Binte Juma’at experienced chest pain on her right side and had trouble breathing. She and her husband quickly sought medical attention with a general practitioner (GP) below where she lived. There, the GP thought she might have pneumonia and called an ambulance to admit her to the hospital for one to two weeks.
At the hospital, they found fluid in her liver from doing tests and she was then diagnosed with tuberculosis (TB). The airborne disease is transmitted through fine respiratory droplets from an infected person. It usually affects the lungs, but other areas including the brain, lymph nodes, kidneys, bones and joints can also be affected.
After her discharge, Zam Zam, who is also a diabetic, was referred to the Tuberculosis Control Unit (TBCU) at Tan Tock Seng Hospital (TTSH) for follow-up and introduced to the Directly Observed Therapy (DOT) programme. DOT is recommended by the World Health Organization and the International Union Against Tuberculosis and Lung Disease.
After she was diagnosed with TB, she began her treatment and was told to stay at home for two weeks as patients are considered non-infectious after the first two weeks of treatment. The grandmother of 25 started DOT in August 2020 with her treatment to end in May this year. Under DOT, she has to go to a polyclinic to take her medication daily. However, on Sundays and public holidays, she can take her medication at home. She also visits TTSH outpatient clinic for monthly follow-ups.
Currently, she takes six tablets (more initially) at one-go in the morning every day and shared she has no side effects from her treatment. According to TTSH, generally treatment for normal TB is for six to nine months. DOT is daily for the first eight weeks and after which, it is thrice weekly.
A little help
To help her to stay on course of her DOT treatment, she is part of the DOT & SHOP programme by SATA CommHealth and TTSH. SATA CommHealth is a charity and community healthcare organisation that aims to promote lifelong health for seniors and those vulnerable in the community, and provides its clients subsidised care at its medical centres, and home- and centre-based services such as homecare, doctors-on-wheels, day rehabilitation centres and Fernvale Community Hub. The DOT & SHOP programme offers grocery vouchers to underprivileged TB patients as an incentive to encourage them to complete their course of DOT treatment. From 2021 onwards, the scheme has included additional benefits:
- Extending the group of beneficiaries to non-citizens holding Long-Term Visit Pass, who are immediate family members of Singaporeans, and residents who hold a stateless status under nationality.
- Increasing the Per Capita Income (PCI) cut off from S$1,100 to $1,200 (similar to the CHAS Blue income criteria).
- One-off transport subsidy given in the form of EZ-Link cards valued at S$30 each to every eligible patient, to defray their transportation cost. Previously, only selected TB patients seeking treatment at TTSH were provided cash assistance from a Transport Assistance Fund on a case-by-case basis after assessment by a medical social worker.
Shared Dr Kelvin Phua, CEO of SATA CommHealth: “Whilst the rate of TB locally is kept at a minimal, it is not uncommon to come across new cases where patients are spouses of locals or on Long-Term Visit Pass. SATA will continue to review the DOT & SHOP programme alongside TTSH, to ensure that it stays relevant and is reflective of the needs of our underprivileged community. With the expanded scope of benefits, we hope to help make healthcare services more accessible and close the gaps in care within the community.”
Dr Tan Tiong Har, a doctor from SATA CommHealth, and a respiratory physician with more than 40 years treating TB patients at TTSH and Gleneagles Medical Centre, said: “The DOT programme was introduced by the Singapore TB Elimination Programme (STEP) and is one of the most significant milestones in therapy for TB patients. DOT is administered at a healthcare facility (a polyclinic nearest to the patient), which aims to supervise the patient in taking his or her daily medication.
“This supervision is of paramount importance as the treatment requires six to nine months of medication that is taken daily, which patients might find challenging as they must adhere to this long duration of treatment. If patients stop taking medication prematurely before completing the entire treatment, it results in poorer results of cure and likely to lead to resistant strains of TB germs. The treatment of resistant or multi resistance strains will take much longer (up to 24 months) and require more toxic drugs. Hence, the DOT & SHOP is put in place to encourage and help the lower income patients successfully complete TB treatment under DOT.”
Since its launch in 2009, the DOT & SHOP programme has successfully helped over 2,600 TB patients in completing their course of treatment and has disbursed more than S$670,000 worth of grocery vouchers. These vouchers are given to beneficiaries who have taken all their prescribed doses of medication in the month, and after completing the entire course of treatment. Asked what Zam Zam buys with her grocery vouchers, she shared that it is usually fruits, salads and wholemeal bread. “I am happy to get something rather than nothing and I really appreciate this support,” she said.
When asked if her children provide additional support to her, she said that she does not want to trouble or ask her children for support as most of them are living in Malaysia. However, she said that one of her children in Singapore does offer support to her.
Understanding TB
According to the Ministry of Health (MOH) in its update on the TB situation in Singapore, “TB is endemic in Singapore and latent TB infection is not uncommon in our population, with rates of up to 30 percent in the older age groups. In 2020, there were 1,370 new cases of active TB among Singapore residents. This is lower than the 1,398 cases in 2019. The incidence rate was 33.9 cases per 100,000 population in 2020, compared to 34.7 cases per 100,000 in 2019. Older age groups and males continue to make up a significant proportion of the new active TB cases.” In January this year, there were two TB clusters of a total of 18 people identified in Bedok.
Added Dr Tan, “The ageing population is more vulnerable to TB, due to their waning immunity. Other key affected groups include older male patients, especially those who live alone. In Singapore, of the approximate 1,500 new cases yearly, those in the 60 years and above category accounted for more than 50 percent of patients.”
TB is curable and the spread of TB is preventable, said MOH. However, why is TB still a problem and why have we yet to eradicate it? Explained Dr Tan: “The Singapore public still treats TB with some degree of stigma. As we have become more developed or well-travelled, TB is perceived as a disease of crowded housing, poor hygiene, and associated with a lower socio-economic environment. When a patient develops the disease in Singapore, the family member’s initial reaction is usually one of disbelief.”
(** PHOTO CREDIT: Tan Tock Seng)
The bacteria for TB is the same as for leprosy. When the said bacteria attacks the lugs, it becomes TB. When the said bacteria attacks the nerves, it becomes leprosy. Under the microscope they are exactly the same. This bacteria was prevalent in the early 1950’s in Singapore because of poor hygiene. It is easily curable with medication.