Tuberculosis is still a major problem in Ireland with over 300 cases being recorded annually, according to a leading Consultant Respiratory Physician. “TB was considered a disease of the past but it is still present. It is a complex infectious disease that places great demand on our services. We are currently under great pressure to deal with this demand”, claimed Professor Joseph Keane.
The Consultant Respiratory Physician in St. James’s Hospital, said the epidemic, which is the leading infectious killer globally, has evolved in Ireland to include around five cases of multi drug resistant (or MDR-TB) per year. MDR TB is an urgent public health priority in Europe. Six countries account for 60 per cent of the total global epidemic, however most cases in Ireland come from Europe.
He said: “TB is here and it’s now. It is more complex than before and it overstretches public health, hospital and laboratory manpower resources. The Irish Mycobacteria Reference Laboratory (IMRI) is at the centre of our efforts at dealing with tuberculosis, but the facility is inadequate and needs more staff and better infrastructure. Our pharmacy needs support in ensuring basic things like a reliable supply of pyrazinamine, a drug required in most TB cases.
Professor Keane added: “Public health has also seen their TB dedicated staff diminished at a time when they should be fortified”.
Multidrug-resistant tuberculosis (MDR-TB) is TB disease caused by a Mycobacterium tuberculosis complex strain that is resistant to at least rifampicin and isoniazid. XDR-TB is rare, however 117 countries worldwide had reported at least one case by the end of 2015.
The Irish Thoracic Society, are calling for action in the TB elimination plan for Ireland. The society wrote a letter in response to an article posted in the Irish Times late last year regarding Micheal O’Regan’s recognition of Dr Noël Browne’s work. They respectfully disagreed that TB had been eradicated in Ireland as, “A new case of tuberculosis is diagnosed at a rate of nearly one case per day”.
According to a report published by the European Centre for Disease Prevention and Control (ECDC), in 2015, an estimated one million children became ill with TB and 170 000 children died of TB (excluding children with HIV). The same report, published in December of last year, revealed that seven cases of MDR-TB were diagnosed in Switzerland between February and August 2016 with a strain that was resistant to rifampicin, isoniazid, ethambutol, pyrazinamide and capreomycin, but fully sensitive to amikacin and fluoroquinolones. Germany also reported six cases with the same genetic clone in asylum seekers from Somalia. Over 95 per cent of TB deaths occur in low and middle-income countries.
Professor Keane explained: “TB is a disease of the poor, and people who are on the margins of society such as migrants”.
Migrant groups, including refugees, refused asylum seekers, trafficking victims, and undocumented migrants, may be at risk of MDR-TB due to the collapse of health service infrastructure, exposure to overcrowding, poor social conditions, or HIV co-infection.
Active disease can occur in five to ten percent of those infected within a few months or many years after infection and, in up to ten per cent per year, in HIV-positive people.
Professor Keane described the situation: “Limited drug treatment options for MDR/XDR–TB lead to treatment lasting for 18-24 months. It is awful for an MDR patient to have to remain in isolation for 6 to 9 months. This is particularly the case as the MDR demographic are sometimes the drug-dependent, malnourished, isolated or friendless; they don’t have anyone to visit them.
“When they can’t speak English, they can’t describe the side effects they may be suffering from. In some cases, there are diagnostic delays . This means that they may have been spreading the disease for a significant amount of time before it is treated. Communication is key”.
He said that the ECDC report is a “wake up call” in addressing this sweeping outbreak.
Its conclusion highlighted the importance of epidemiological investigations, the benefit of finding early instances of active TB and establishing drug susceptibility, to ensure the identification and treatment of active cases and to allow preventive treatment or monitoring for those diagnosed with latent tuberculosis infection.
Professor Keane supports the HIQA Health Technology Assessment 2015, which calls for the appointment of a TB controller to focus specifically on tuberculosis in Ireland.
In addition, he claimed: “I would advocate for DOT or ‘directly observed therapy’ which follows up the TB patient each day. I would support the public health doctors who specialise in TB, and I would place significant investment into the IMRL laboratory so that they’re not running out of an inadequate lab”.
He considers Ireland to be in a prime location to curb this issue, should we focus sufficient attention on it: “Here we are on an island at the edge of Europe, we’re in a position of strength to deal with an epidemic”.