The outbreak of TB in Cork, where children in two creches and two staff members have contracted the disease, has again put the spotlight on what was once a major problem. Michelle McDonaghreports.
In the Ireland of the 1950s, tuberculosis was a major public health problem with nearly 7,000 cases a year in the early part of the decade. Radio programmes were dominated by requests from families and friends to patients in sanatoria around the State and weekends were often spent visiting relatives hospitalised with TB.
While the levels of TB have dropped significantly over the past 50 years, the disease has certainly not gone away and, in fact, levels have started to rise again in the past five years. The greatest concern is that some of the new strains of TB are resistant to drug treatment with one strain, XTR TB, extremely resistant to every one of the drugs available.
The general consensus among those working in the area of TB in Ireland is that the issue is not being taken seriously enough by the Irish health authorities and proper infrastructure, including sanatoria and modern detection methods such as genetic fingerprinting, urgently need to be put in place.
The current outbreak of TB in Cork - where 14 children and two staff members in two creches have been diagnosed with the disease and over 130 children put on antibiotics - has brought TB to the attention of the national media, but Dr Charles Bredin, respiratory consultant at Cork University Hospital, has been warning that this could happen for years.
In an editorial in the Irish Medical Journalin 2003, Bredin warned that "hidden reservoirs of tuberculosis lie within the deprived inner city or 'fourth world' communities of Ireland, for instance in Dublin and Cork".
He believes TB will never be eliminated unless new thinking and practices are introduced into detection and control methods - such as DNA fingerprinting techniques which can pinpoint the exact source of the infection, for example, a particular pub or swimming pool.
Bredin highlights what he says is the need for dedicated TB clinics around the State - similar to those at St Vincent's in Dublin and the Mater - where public health doctors, consultant respiratory physicians and microbiologists all work together, leading to better detection and treatment as well as better medical intelligence about the disease.
The HSE has announced that all babies will be routinely offered the BCG vaccine against TB from October 2007 after a 35-year absence, but Bredin says routine vaccinations are not the answer. He is also calling for the reopening of the TB labs at Cork University Hospital which were closed earlier this year.
Dr Joan O'Donnell, specialist in public health medicine with the Health Protection Surveillance Centre, explains that there has been a slight increase in TB rates in Ireland since 2001, with provisional data for 2005 showing 461 cases that year at a rate of 11.8 per 100,000 population.
"The current rates are nowhere near the rates of the past, but we still need to remain vigilant, particularly with globalisation because we do not want them to rise any further. It's important that cases are recognised and diagnosed early and that treatment commences as early as possible because TB is a curable and treatable disease," she comments.
In the early 1990s, the rates of TB in Ireland were 14-18 per 100,000 falling to a low of 9.7 per 100,000 (381 cases) in 2001. There were 432 cases of TB reported in Ireland, a rate of about 11 per cent compared with the overall European rate of 12.6 per 100,000 that year.
O'Donnell explains that the overall European rate for 2005 is 18 cases of TB per 100,000 but this increase can be accounted for by the fact that Romania and Bulgaria joined the EU in 2005. The TB rates in Russia are as high as 109 per 100,000 population, in eastern Europe they are 44 to 73 per 100,000 population and in sub-Saharan African and India (where there are no current figures available), are probably in excess of 100 per 100,000 population.
Consultant clinical microbiologist at the Mater hospital in Dublin, Dr Margaret Hannon, points out that the rise in TB levels in Ireland over the past five years - which appears as a U-shaped curved on a graph - indicates that TB is being transmitted in the population.
"This curve indicates that we are either at the beginning of a rising problem or is a very important marker of poor or inadequately controlled TB in the population."
As well as genetic fingerprinting and the need for a national sanatorium to replace Peamount Hospital in Dublin which closed in 2004, Hannon highlights the need for a DOTs programme of directly observed therapy for TB patients in Ireland as recommended by the WHO to control spread of the disease.
"The DOTs programme involves directly observing patients taking their medication over six months, making sure they have somewhere to live and that they are eating properly while on treatment. A significant proportion of TB patients are from lower socio-economic groups including immigrants, prisoners, the homeless and those with HIV. They are the ones who may abscond from their treatment and not finish the medication which means they can go on to infect others," she explains.
A member of the national TB advisory clinic, Hannon says the lack of isolation facilities here is a serious deficiency. Patients may need to be isolated for six months to two years if they have a more serious drug-resistant strain and since Peamount was closed, there is nowhere to send patients for such a length of time. St James's Hospital in Dublin was designated as a replacement but that has not transpired, according to Hannon.
"People should remember that this disease killed one in six people at the turn of the century. We have drugs out there to treat it, but a new form of TB called XDR TB is extremely resistant to all the available treatments.
"Potentially, this strain can come into the Republic at any time and be transmitted like other strains and we must be prepared for when this inevitably happens. The reality is if there are no drugs to treat these new strains, it brings us back to the turn of the century when one-third of people with TB died, one-third got better and one-third didn't develop full blown disease."
So far there has been one case of XDR TB in an immigrant in Dublin who is doing very well on treatment. Most of the drug-resistant cases of TB here are among the immigrant population at the moment, according to Hannon.
However, she stresses that you don't have to be an immigrant or HIV positive to get TB, pointing to the current situation in Cork where middle class Irish children in creches have been infected.
A 2004 study she was involved in detected 26 cases of active TB among a group of Irish nationals, mainly men in employment, who all socialised in the same pubs in north Dublin and had none of the classic risk factors associated with the disease.