Tuberculosis (TB) rarely makes the news in Singapore. That abruptly changed on 10th February with Malaysia Health Minister Datuk Seri Dr Dzulkefly Ahmad’s parliamentary disclosure of new TB cases and clusters in Malaysia since the start of the year. The same day, Malaysia’s Ministry of Health reported a 9.8 per cent increase in TB cases compared with the same period in 2025.

Since then, frequent media updates have sustained public concern, especially ahead of Lunar New Year and Ramadan – periods marked by heavier cross-border travel and large gatherings.

Such concern is understandable. It is natural to think of TB as behaving like influenza or COVID – respiratory infections that spread rapidly and make the news regularly. But TB is a fundamentally different pathogen, and for most travellers, the risk of catching TB during short visits has not changed.

TB is caused by a slow-growing bacterium, Mycobacterium tuberculosis, identified by Robert Koch nearly 144 years ago. Unlike viruses that can spread explosively, TB spreads through tiny airborne droplets from someone with active lung disease – and even then, it typically requires prolonged, repeated exposure for transmission to occur. A brief encounter on the same flight or train carriage is very unlikely to lead to infection. The people at highest risk are household members, or those spending many hours together in poorly ventilated spaces.

Even when infection occurs, the vast majority of healthy people will not fall ill. Instead, their immune system holds the bacterium in check – a condition doctors call TB infection (previously known as “latent TB”). In this state, the person cannot spread the disease, and up to 90 per cent will never develop active TB. Most will live out their lives without ever knowing they carry the bacterium. For the small proportion who do eventually develop disease, the process is typically slow and insidious: roughly half fall ill within three years, the rest many years later. Because symptoms build gradually, TB is seldom diagnosed early. An analysis of Singapore’s TB Registry over 15 years ago showed that three in 10 patients were only diagnosed more than two months after their cough began, while one in 10 faced delays exceeding six months.

The picture is considerably more dangerous for people with weakened immune systems – those with HIV, advanced cancer, uncontrolled diabetes, or kidney failure. For them, the risks of both becoming infected and developing severe disease are markedly higher.

Singapore – and the rest of Asia – remains endemic for TB, meaning the disease circulates continuously in the population. Six of the world’s eight highest-burden countries are in Asia: India, Indonesia, the Philippines, China, Pakistan, and Bangladesh. All countries in the region report data to the World Health Organization (WHO). In 2024, the latest year with complete data, Singapore reported 2,238 TB cases to WHO, or 38 per 100,000 population. This is higher than the Ministry of Health’s figure of 1,156 cases in 2024, which only counts citizens and permanent residents (number fell slightly again to 1,019 cases in 2025). WHO’s own modelled estimate for Singapore is slightly higher still at 43 per 100,000, adjusting for cases that may go undiagnosed.

What about Malaysia and other popular travel destinations? Malaysia reported 74 cases per 100,000 population in 2024 – figures that have been broadly stable over the past decade outside of pandemic-related dips. Indonesia stood at 296 per 100,000, Thailand at 146, and Japan – a favourite destination for Singaporeans – at just 8.1.

Crucially, TB is never uniformly distributed across a country. Cases concentrate where overcrowding, poverty, and limited healthcare access converge. Adverse headlines should therefore be interpreted cautiously. If Malaysia’s case numbers do not change significantly over the rest of the year, its overall TB incidence will not rise substantially. Paradoxically, if their health authorities intensify efforts to find and diagnose cases, reported numbers will go up – but this actually reflects better detection rather than increased transmission. It is, in fact, a necessary step towards eliminating TB.

That goal of elimination, however, has grown harder globally. Recovery of TB services in low- and middle-income countries from COVID-19 disruptions has been further set back by steep cuts to international health aid, most significantly the dismantling of the US Agency for International Development (USAID) – historically the source of almost a quarter of all international TB funding. The human toll is staggering: TB kills over a million people annually and costs an estimated US$2 trillion in economic losses worldwide, with the burden falling overwhelmingly on the world’s poorest communities. In many low-income countries, a TB diagnosis drives roughly half of affected households into financial ruin, even when treatment itself is free, due to lost income, travel costs, and other expenses.

Countries in our region are stepping up. Cambodia, Indonesia, and the Philippines have all increased domestic budget allocations for finding and treating TB cases to cover the deficit from global funding cuts. The Philippines is also combining TB case-finding with other essential services in rural areas – screening for diabetes, delivering vaccinations, and providing maternal and child health services – to stretch limited resources further.

Singapore remains well-positioned. We have never relied on foreign funding for TB services, and our programmes were minimally disrupted during the pandemic. Treatment is heavily subsidised, and employment protections mean that individuals cannot be dismissed simply because they have contracted the disease. We can and should continue working towards TB elimination.

What does that look like in practice? For a quarter of a century, Singapore’s approach has centred on ensuring patients complete treatment through directly observed therapy (DOT), where patients visit polyclinics daily or thrice-weekly to take their medication under supervision. Our treatment completion rates are among the world’s best. But as these gains plateau, more effort should go towards making treatment less burdensome – for instance, by being more selective about who requires in-person DOT, expanding the use of video-observed therapy, and reducing the stigma that still shadows the disease.

The next frontier is proactive detection. Our contact tracing has improved markedly, aided by genomic sequencing that can confirm clusters and guide decisive public health responses, as demonstrated at the Singapore Pools Bedok Betting Centre and Jalan Bukit Merah in recent years. Beyond tracing, we should expand screening of high-risk populations for TB infection – people with weakened immune systems, the elderly with additional risk factors, inmates of correctional facilities (link document behind a paywall), and migrant workers from high-prevalence countries – and treat them before infectious disease can develop.

The headlines about Malaysia are a useful reminder that TB has not gone away, even in relatively prosperous parts of Asia. But the right response is not to avoid crossing the Causeway. It is to recognise that TB elimination requires sustained effort on multiple fronts – better detection, less onerous treatment, targeted screening, and continued support for regional neighbours where our contribution is welcomed. After all, bringing down TB rates in the countries where Singaporeans travel and from where our migrant workers originate is firmly in our own interest. Singapore has the resources, the infrastructure, and the expertise. The question is whether we will match them with the sustained political will and public commitment that a disease killing over a million people a year demands.