Ireland could lose its edge on TB

Ireland could lose its edge on TB

By Angela Long

The outbreak of tuberculosis (TB) in Cork city has focused attention on the former bogeyman of Irish health, as well as medical practice in the county.

The vaccine BCG has not been administered routinely to babies in Cork, as is the case elsewhere in the country. TB laboratories in the county were closed earlier this year.

The TB outbreak happened in two crèches where an infected adult had been working, and caused 16 confirmed cases of the disease at time of writing.

Most of these ­ 14 - are children, and all are receiving medication, with no fears for long term health.

But TB treatment in Ireland has been in limbo since the closing of Peamount Hospital in 2004, says respiratory physician Prof Luke Clancy.

Prof Clancy was medical director of the hospital, which was the headquarters for TB in Ireland for many years. He says treatment of TB in Ireland has been, and continues to be, very good, but that the Irish standard of excellence is being undermined.

"Our mortality rate is down to 2%, which is very good by international standards. In the UK it is about 10%. But we cannot afford to sit back now."

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Professor Luke Clancy

Today there are about 400 cases diagnosed a year, down from 1,000 in the 1980s, and the plague years of the 1940s and 50s, when thousands suffered and died from the disease.

Fictionalised accounts such as in Mary Morrissy’s novel Mother of Pearl paint a poignant picture of the desperation of patients in sanatoriums all over the country.

HSE Southern Region has announced that the universal BCG programme will now be restored in Cork after a break of 35 years.

Dr Clancy says BCG is an important part of an anti-TB strategy, but just one component. "It is only a partial answer," he says. "TB needs a plan, it needs a panoply of things, vaccination, screening, many components in a package."

However not all specialists in the field are convinced of the value of BCG. Dr Charles Bredin, a respiratory consultant, told irishhealth.com he believed BCG should be discontinued as a universal vaccine.

"It is only suitable for targeted populations, such as health care workers, and some deprived populations." He said the vaccine had been discontinued in Northern Ireland some years ago because of doubts as to its benefit. This was why the decision was taken to stop its supply in Cork in 1972, by, he said, an 'enlightened' medical director.

Dr Bredin, who practises at Cork University Hospital, has been warning of the TB threat for some years. In a 2003 article he wrote of 'hidden reservoirs' of TB in deprived inner city areas, including Dublin and Cork.

He wrote of a likely peak in people over 60, who were young children when the mid-century epidemic was in full force. Such people, he said, could fit into a 'classic pattern of reactivation or secondary TB'.

One of the features of the Mantoux skin test, done to check for TB, is that it will give a positive result if the subject has had TB in the past, as well as those currently infected. This is one of the problems with BCG, Dr Bredin says. "A group of children who had the BCG as neo-natals will give a positive reading when they are six, and you don't know if they have TB or this is from the vaccine."

DNA fingerprinting would be a more rigorous and superior way to monitor TB, Dr Bredin says, but it is expensive.

Luke Clancy says the complexity of TB is one of its most worrying aspects. “It is an infection, there can be relapses, it has many forms, such as pulmonary TB and TB meningitis.”

"Young children are very susceptible and the disease can have serious effects, but children don’t spread it. That’s how they knew there must have been an adult with TB in the Cork crèches."

The airborne bacteria can be spread easily, by anyone coughing, spitting, yawning or even singing, he says.

Some fears have been expressed that Ireland is at more risk from TB now that there is significant emigration from eastern Europe and Russia, where some vaccine-resistant forms of the disease have been found.

Prof Clancy says it is not racist to say that new arrivals could be bringing TB. "It is a fact. Countries such Latvia, Lithuania, Estonia all have a high incidence of multi-drug resistance. People have to be screened when they arrive here."

WHAT IS TB?

Tuberculosis, known as TB for short, is an infection caused by a bacterium, Mycobacterium tuberculosis. It is one of the oldest diseases known to man, and was once so common that every adult was thought to have experienced a bout of TB infection during their lives.

TB is contagious, and is caught by inhaling microscopic droplets containing the bacterium, which are produced when an infected person coughs or sneezes. The illness usually affects the lungs, but sometimes can spread to other organs. It gets its name from the tubercles, or hard lumps that form on the lungs to contain the TB bacteria.

TB in the past could be a serious illness. Consumption, as TB used to be called, claimed the lives of up to a quarter of all adults in Britain during the 19th century. TB remains very common in other parts of the world, especially Africa and South-East Asia. Over 80% of India's adult population have had the disease at least once. It is estimated that a third of the world's population could be infected with TB, and over three million may die from it this year.

TB is now much less common in developed countries, such as Ireland. In European countries, the disease is found in deprived city areas, among the homeless, alcoholics, older people, those who are HIV positive and among people who come into close contact with those suffering from TB.

The most common form of TB is pulmonary, but there are also forms which attack the nervous system and the lymphatic system.

BCG is short for Bacille Calmette-Guerin, and was developed in France in the first decades of the 20th century.

The World Health Organisation says:

-   Someone in the world is newly infected with TB bacilli every second.

-   Overall, one-third of the world's population is currently infected with the TB bacillus.

-       5-10% of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life. People with HIV and TB infection are much more likely to develop TB.

-       An estimated 1.6 million people worldwide died from TB in 2005. However the incidence around the world is falling.

Comments

AL - 26/04/2007 16:10

Cannot believe they stopped vaciinating babies in 1972. Just because the problem was slowing down didn't they stop to think it was slowing down because people were being vaccinated and didn't they stop to think that people would be travelling to different countries where TB could be caught as well as people visiting Ireland who may have TB. It is now turning into an epidemic in Cork! I thought this happened in third world countries.

eriam - 26/04/2007 18:45

If the BCG is so ineffective, why is it in Cork the two major outbreaks in the past 10 years have been located ie Mitchelstown and Cork City. These outbreaks have been among a young population - a secondary school and the 2 creches. Also I know where the 2 creches are located, neither, by any stretch of the imagination could be called disadvantaged, inner city. I know of NO person over 35 who is affected by TB.... so the vacinne must be effective, to some extent at least. An article I read said it was 50 - 80% effective.

Anonymous - 26/04/2007 22:17

I think now that we have become so well travelled and our country is open to many more tourists and immigrants that the need to vaccinate is even more important than ever. Such a simple jab at an early stage can prevent what is now happening and will only increase as time goes on if the programme is not implemented immediately.

Gerry - 26/04/2007 23:38

I was vaccinated with BCG in 1975 as a health care worker and went on to develop pulmonary TB in 1983, so I don't believe in it's effectiveness as a preventitive. I don't think the BCG programme should be restored, but that anybody who works in the childcare sector should have a medical before commencement of employment,also immigrants from countries who have multi drug resistant TB . If you are emigrating to New Zealand you have to have a full medical before you are accepted into the country,

Cassie - 27/04/2007 09:25

What any sane person would ask if WHY the vaccine BCG has not been administered routinely to babies in Cork, as is the case elsewhere in the country?? Why were TB laboratories in the county closed? The former certainly seems the height of stupidity and negligence to me. Asking for trouble

Lemmy - 27/04/2007 11:05

We should be screening people entering the country, be they immigrants, tourists returning from exotic locations or aid workers returning from 3rd world countries. Would you stop somebody with a contagious disease entering your house to protect your family from catching said disease? I know I would.

Anonymous - 27/04/2007 14:43

Good in theory Lemmy, but you would need a vast number of infection control specialists at all international airports and all ferry ports on the island.

knipex - 27/04/2007 16:16

Cassie did you even read the article. BCG is not a proven preventative. Haven received the BCG shot as babies 6 year old were failing TB tests due to having the antibodies in their systems. This made it next to impossible to monitor TB levels. Those were the reasons BCG was stopped in Cork. (I received the BCG my wife received it again recently and our kids will get it but I can see the logic of why it was stopped in Cork.)

Charlie - 27/04/2007 20:37

Ireland has the 4th highest rate for sarcoidosis in the world which is a multi organ disease with 90% having lung involvement. My mother was told and treated for TB. I myself and members of my family have sarcoidosis is it possible that my mother was misdiagnosed, or is this happening with other people.

Ann - 27/04/2007 22:55

All children are vaccinated against TB at either birth or in school but the problem is, they need to be screened routinely. The vaccination does not give LIFE coverage. You need to be screened for antibodies at various stages in your life and given the vaccine again as necessary. TB has not been eradicated, so there will always be pockets of it arising. Gerry, unfortunately because you are a health care worker, you are more at risk. You need to be screened routinely. The vaccination certainly does work but only when it is used with adequate screening. The rise in TB cases here, if that IS the case, is a mirror image of what is happening in the UK. I suppose it all boils down to the fact that screening and preventative medicine really does not exist in this country leaving us wide open to problems such as this which in the end just puts more pressure on a very overstretched and inadequate health service.

AL - 30/04/2007 08:13

I am from Australia and I had the TB jab when I was young and I haven't heard of anyone contracting TB after having the jab. I would think the number of people who have had the BCG jab and haven't contracted TB outweights the people who have had the jab and contracted TB. I therefore would think it should be up to the parents of each child born to decide whether they want to vaccinate their child against TB. I believe there is 3 children contracting the disease every week in Cork and it is spreading to outside of Cork city also.

Anonymous - 03/06/2008 00:31

I was diagnosed with TB last year after being misdiagnosed for three months. I am very annoyed that it took so long to diagnose me because the infection spread in those three months. I spent another 3 months in hospital and found the nurses to be very supportive but the facilities are not up to standard. I do not have much confidence in the doctors after the misdiagnosis. I went to a private clinic and told the doctor my symptoms and the doctor told me straight out I could have TB. Yet in the public hospital they failed to diagnose me, I think this was pure negligence on their behalf. Some of the doctors are getting away with "murder". Thanks to the persistence of a certain doctor I am well on my way to recovery. I am only a teenager and thanks to this doctor I hope to get back to my full health. I also believe the saying "your health is your wealth" is a joke because only that I was able to afford to go privately, I would not be here today. "Doctors differ patients die". Always get a second opinion!

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