Dr Joseph Keane on the increasing number of TB cases in Ireland and the challenges to existing services caused by the emergence of a multiple drug resistant form of the disease.
The number of cases of tuberculosis (TB) in Ireland has been increasing each year for the last five years. In 2007, we expect there may have been over five hundred cases reported when final figures are released. This is an issue for public health doctors, general practitioners and hospitals alike.
The tuberculosis service based in St. James’s Hospital and the Tuberculosis Advisory Group of the Health Protection Surveillance Centre have specifically sought to improve resources to deal with this issue. All involved in TB care need to advocate for strengthening existing services as well as investing in new services to deal with the new challenge of multiple drug resistant tuberculosis.
Tuberculosis is primarily a public health disease, with most patients being treated in the outpatient setting. The major epidemic control measure of contact tracing occurs in the public health domain.
There are many issues facing public health colleagues, however one in particular has been singled out. This is the availability of directly observed therapy (DOT).
h4. Highly efficacious
DOT has been shown to be a highly efficacious way of improving the success of treating tuberculosis disease. This has positive consequences for the patient, but also for the community as it prevents further spread of the disease.
The WHO has recommended 85 per cent coverage with DOT. However, in Ireland, it is very unusual for a patient to get DOT. Fortifying public health resources and making available public health nurses to deliver DOT can address this issue.
Other options are to undertake the recruitment of health ambassadors who will give DOT to patients. This model has been successfully used in other countries along with the generation of case managers in TB centres that will specifically be responsible and serve as ‘go-to’ people for the management of tuberculosis.
All doctors are obliged by law to report tuberculosis cases to the Medical Officer of Health (MOH) once a patient is diagnosed or started on treatment. The role of the MOH is to prevent and control the spread of infectious diseases.
h4. Contact tracing
In the case of tuberculosis, this is primarily through contact tracing, which, in our region (the east), is carried out in specialist clinics. To be effective, the contact tracing needs to be done within the context of knowledge of the index case. Therefore, all possible contacts, including those who present to general practice, should be referred to the MOH, who will carry out a risk assessment and follow up as appropriate.
Multiple drug resistant TB is a rapidly-emerging issue that generates a requirement for accessible expert service on an emergency basis. The unit in St James’s is also involved in the management of a number of cases and outbreaks of multiple drug resistant tuberculosis. We have even looked after and treated successfully a patient with extreme drug resistant tuberculosis.
Multiple drug resistant tuberculosis is a disease where the bacillus is resistant to rifampicin and isoniazid. Dealing with such a matter is a specialist issue and the unit in St James’s is becoming increasingly expert at using the second, third and fourth line drugs necessary to deal with this disease, which frequently requires treatment for two years.
In some circumstances, special isolation facilities are required; St James’s has got three dedicated tuberculosis isolation rooms. The care of such complex patients requires a multidisciplinary team effort including nurse practitioners, pharmacists and the support of the tuberculosis reference laboratory.
h4. Plans are under way
There is a clear need for a hospital response to these new challenges. In St James’s, there are plans under way for the development of a new building, which will include a 16-bedded inpatient unit with isolation facilities. This is in addition to an outpatient facility and new accommodation for the TB National Reference Laboratory (already located in St James’s Hospital).
An interim proposal is under way to deal with the demands on the service before this final facility is constructed and occupied. St James’s put together this interim proposal in 2005, and some of the interim measures have been functioning since then.
Given the increased activity and complexity of the tuberculosis service, as well as the large number of negative tests that are referred to the tuberculosis laboratory, the resources underwriting the interim status will have to be increased to meet with demand.
h4. 1947 Act
Multiple drug resistant tuberculosis represents a uniquely difficult issue to manage if the patient is wilfully non-compliant and insists on leaving the hospital or isolation room against medical advice. This generates the potential of infecting a patient with a disease that does not respond necessarily to drugs.
To preserve the public in this setting, the Health Act of 1947 stipulates in Section 38 that such a person can be detained and isolated. In St James’s, there has been an increasing demand to use this Act, either as an encouragement to patients to comply, or alternatively to use the Act to secure this dangerous public health issue, in patients who are wilfully non-compliant with medical advice.
Naturally the use of this Act involves a large number of people – in particular, the Director of Public Health. As it stands, it requires for the hospital to have an isolation room in which a patient can be secured in a safe manner. St James’s has responded to this new challenge and it is hoped that the new unit will make it easier to accommodate such patients for the sake of public health and preventing spread of the epidemic.
The spreading tuberculosis epidemic and the emergence of multi-drug resistance specifically have put an obligation on the health service to react. Failure to do so will be penalised with ‘innocent bystanders’ getting a disease that is potentially not responsive to therapy.
* Dr Joseph Keane is a Consultant Respiratory Physician in St James’s Hopsital, Dublin. The opinions expressed are those of the author and not those of any organisation.
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