I welcome Dr. TimMcDonnell, Dr. Barry O'Connor, Dr. Terry O'Connor and Dr. Joseph Keane to discuss the increase in the incidence of tuberculosis. Before proceeding, I draw attention to the fact that while the members of the committee have absolute privilege, the same privilege does not apply to those appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. I ask Dr. Tim McDonnell to begin his presentation. I will then ask members to direct their questions to the delegates. We normally ask three members to group their questions together to deal with them more expeditiously.
Tuberculosis Incidence: Presentation.
Dr. Tim McDonnell
I thank the Vice Chairman and members of the Oireachtas Joint Committee on Health and Children for their invitation to attend this hearing. I hope the advisory group will clarify the present status of care for patients with tuberculosis. As members are aware, there has been much controversy recently in the media regarding a supposed rise in the incidence of tuberculosis, particularly in the north inner city of Dublin. While I have tried to get some information in that regard, I have been unable to so do. Certainly, the notion that there were 300 cases in a year in the north inner city does not bear scrutiny.
I have submitted a discussion document which contains some figures. I have documented the incidence of tuberculosis from 1952 to 2002. The number of cases has fallen from almost 7,000 in 1952 to approximately 400 per year in the 2000s. This gives an annual rate of approximately ten per 100,000 of population. The rate of decline has slowed down recently, both nationally and in the greater Dublin area, that is, the area covered by the old Eastern Regional Health Authority. Members can see that nationally the number of cases fell from more than 600 in 1991 to approximately 400 in 2003. The number of cases in the Dublin area covered by the Eastern Regional Health Authority fell to less than 200 during that time.
It might be interesting to consider the regional incidence of tuberculosis. I have provided figures for the old health boards. While the health boards have been abolished following the establishment of the Health Service Executive, they still have some relevance. They have varying incidences of tuberculosis, ranging from the North Western Health Board, at 5 per 100,000 of population, to the Southern Health Board which has the highest incidence in the country, at 13 per 100,000 of population. These figures are presented graphically on the third page of the presentation on a map showing the distribution through the various health boards. The figures are then broken down by county. Unfortunately, County Waterford heads the list with a rate of 27 per 100,000 of population. County Wicklow has the lowest incidence, with 0.9 per 100,000 of population. The advisory group believes it is important to note that there is no consultant respiratory physician for the South Eastern Health Board.
I will reiterate the reasons for the decline in the incidence of tuberculosis which, as I mentioned, has declined from 225 per 100,000 of population in 1952. Such a rate is found in many of what are termed developing countries. I do not need to remind the committee that the rate in the early 1950s was extremely high. The rate is now 10 per 100,000 of population. The reasons for the decline include better social conditions, less overcrowding, better nutrition and health among the general population. Clearly, the introduction of sanatoria in the early 1950 was important. Their main role was to remove infected persons from the community. If one had infectious tuberculosis and was removed to a sanatorium, one did not infect one's family and friends. The introduction of anti-tuberculous drugs was obviously also important.
I will now consider our current standing and how we compare internationally. I have provided on the next page of the submission a map showing European incidence rates. Countries' incidence rates are categorised in rates of zero to ten, 11 to 20, 21 to 50 and in excess of 50 cases per 100,000 of population. Members can see that we fare reasonably well, as we fit into the 11 to 20 category, and that many countries have much higher rates. The rate in eastern bloc countries, that is, the countries of the former Soviet Union, as well as some of the European Union accession states, is in excess of 50 per 100,000 of population. This constitutes a fivefold increase on our present rate. On the surface, the figure looks good. However, compared to western European standards, relatively few of our patients are recent arrivals.
The next map in the presentation shows that in countries such as France, Germany and Britain well over half of the cases of tuberculosis occur in immigrants. In the United Kingdom this is true for approximately 60% of cases. The corresponding figure in Ireland varies. In 2002 it stood at 30%, the highest it has been, while in 2001 it was 17%. Most of our problem is indigenous and dates from the time our incidence of tuberculosis was high. It has never been cleared up satisfactorily.
We have reached what might be termed a mediocre state in our management of tuberculosis. How does the future look? There are two potential problems. First, with regard to the current management of tuberculosis, we must consider the possibility that the incidence might rise. Nowadays, one factor that can lead to a rise in the incidence of tuberculosis is travel, as people arrive from countries with a high incidence. Certainly, as many of our new immigrants come from such areas, it is possible they may bring a higher incidence with them. It is important to note, however, that our rate has been declining. We are included in the category of countries in which the rate has been perceived to have dropped for the past four years. However, the United Kingdom, with Italy and Norway, has noticed a significant increase in the incidence of tuberculosis. Hence, the first problem is that the incidence which is not that low to begin with may rise.
The second problem that might arise is the development of resistant forms of tuberculosis. This is sometimes referred to in the media as the so-called tuberculosis superbug. Normally, the treatment of tuberculosis can be completed within six months. Usually this requires the administration of four drugs, although occasionally three are used. If one loses the drugs, the treatment course is prolonged. For instance, the two principal drugs used are isoniazid and rifampicin. If one loses isoniazid, one must increase the duration of treatment from six months to one year. If one loses rifampicin, one must increase the duration of treatment from six to 18 months. If both are lost, treatment continues for a very long time and, potentially, one faces a mortality rate of 50%.
It is extremely difficult and expensive to treat multi-drug resistant tuberculosis. The sixth page of the submission includes a graph demonstrating the incidence of multi-drug resistant tuberculosis, the most difficult form to treat, in a number of European countries. Ireland has a very low incidence in this respect. Less than 1% of tuberculosis cases here are multi-drug resistant. However, several countries in Europe have an extremely high incidence. I draw members' attention to Estonia, Latvia and Lithuania, members of the European Union with an extremely high incidence of multi-drug resistant tuberculosis. If one considers single drug resistant tuberculosis, many of our immigrants come from areas where single drug resistant tuberculosis is common. In the United Kingdom 8% of cases of tuberculosis are resistant to isoniazid on a national basis, with the figure rising to 15% in London.
I hope I have provided members with some background information on the current epidemiology and its status. What does the advisory group perceive to be the deficits in the management of tuberculosis? The principal problem is the lack of provision for a national diagnostic laboratory. While St. James's Hospital has been identified as the site of a national tuberculosis laboratory, this proposal has not been implemented or funded. Specimens, particularly if one is looking for resistance patterns, are sent from several regional centres to various other hospitals, including hospitals in the United Kingdom. In my hospital, St. Vincent's University Hospital, we send them to the national tuberculosis laboratory in Dulwich, London. Clearly, this leads to a delay in our identification of potential resistant germs. Other Irish hospitals send samples to other locations such as Edinburgh and Cardiff. Consequently, one has a difficulty in knowing when a case of resistant tuberculosis occurs and a delay in the treatment of such cases can further complicate matters.
The second issue concerns isolation beds. While tuberculosis is not overly infectious, it is infectious. To put the matter in context, when one performs contact tracing, one considers those who may have been infected with tuberculosis. One looks for people who have for a period been in close contact with a case of infectious tuberculosis. The cut-off point is usually approximately ten hours. If one has a patient with infectious tuberculosis, he or she rapidly ceases to be infectious once treatment begins. We usually operate a rule of thumb to the effect that such patients will cease to be infectious within two weeks of treatment. However, they probably stop being infectious after receiving one or two doses. Nevertheless, this is still an infectious disease. Consequently, particularly in the hospital environment, having a tuberculosis patient in the next bed to an immuno-compromised patient presents a major problem. I know the committee dealt with the MRSA problem and the lack of isolation facilities in hospitals previously.
We envisage three levels of isolation. The first is the basic ward where there is no isolation and other patients are adjacent to patients infected with tuberculosis, while the second level is single rooms. In St. Vincent's University Hospital, single rooms do not have bathroom facilities so patients must leave their rooms to use these facilities. The third level is what is termed a negative pressure room where all the air is effectively sucked into the room and expelled to the outside world. The air does not escape from these rooms, which have en-suite facilities and are mandatory for the management of multi-drug resistant tuberculosis.
There is only one negative pressure room in Dublin. This one bed is not simply for the treatment of tuberculosis; it is also designated for the treatment of SARS, avian influenza and other extremely dangerous infections. This is the one facility the capital city possesses. Mercy Hospital Cork has four negative pressure rooms. Therefore, the situation is somewhat better in Cork. Isolation rooms and facilities would be required to treat tuberculosis. We also believe that some form of hostel accommodation may be required for some patients who clearly cannot manage in the community.
In respect of the lack of public health resources, we are hospital-based physicians rather than experts in public health. As members of the committee may be aware, there have been some changes in public health recently and the sector is being pulled in many directions. Perhaps a lack of organisation has been a problem in the sector. St. Vincent's University Hospital has an excellent relationship with the public health sector and has a joint public health respiratory consultant-led clinic, which is the way to go. However, this type of clinic is not in operation in many areas of the country.
We emphasise the lack of respiratory physicians, who end up treating patients with tuberculosis. There are a number of what we would regard as under-resourced constituencies. We also treat chronic obstructive pulmonary disease, which kills 2,000 people every year, and are responsible for initiating people on treatment for lung cancer, which kills approximately 1,500 people every year. These are major problems and in many parts of the country, there are either no respiratory physicians or an inadequate number. I thank the committee for its attention.
I thank Dr. McDonnell for his very succinct and informative presentation. I am interested in the varying rate of the incidence of tuberculosis in different counties. Dr. McDonnell mentioned the lack of respiratory physicians in the south east. I noted that Cork and Dublin have the third and fourth highest incidence of the disease. Therefore, other factors must presumably pertain because respiratory physicians are found in both cities. Is there any other explanation for the incidence rates in these cities?
Dr. McDonnell
It is interesting to examine the question in an all-island context. The rate in this State is ten per 100,000, while the rate in Northern Ireland has consistently been 3.3. Effectively, there are approximately 60 cases or fewer in Northern Ireland for its population, while there are 400 cases in this State. The incidence rate appears to increase as one moves down from Northern Ireland toward the Health Service Executive southern area.
Does Dr. McDonnell have any explanation for this?
Dr. McDonnell
There are a number of theories. It could be due to the historical disorganisation of the management of tuberculosis.
Members have indicated that they wish to ask questions. In the first tranche, we will hear from Deputies Connolly, O'Connor and McManus.
I thank Dr. McDonnell for his very clear and, to some extent, startling presentation. The rise in the incidence of tuberculosis is of concern to us all. I was greatly concerned when I recently heard about the rise in tuberculosis in England, Wales, Scotland and Northern Ireland. Has a pattern been discerned or is there any kind of plan or mechanism in place to halt the increase in this disease?
It appears that much of the incidence of tuberculosis is found in people of foreign origin. Is there any plan to introduce a detailed screening programme for people who come to this island? Recently, an alarming number of patrons of a pub in north Dublin were found to have contracted tuberculosis. I was astounded that nobody saw fit to close down the pub until an investigation into whether a patron was a tuberculosis carrier was completed. The public should be protected to some extent from this type of situation. If such a scenario took place in a restaurant or any other workplace, we would demand that it be closed down. What are Dr. McDonnell's views on this matter?
It is also alarming that five per 100,000 people contract tuberculosis in the Health Service Executive north-western area, while the figure is 13 in the south east. According to Dr.McDonnell, this scenario is because the area lacks respiratory physicians. Is he saying that hiring one respiratory physician in this area would reduce the number of tuberculosis cases per 100,000 of the population?
What are Dr. McDonnell's views on the new strain of tuberculosis? A total of 8% of tuberculosis cases in Great Britain and 14% of cases in London are resistant to drugs. Are we witnessing an increase in drug-resistant tuberculosis and what is being done about it? How do we propose to deal with drug-resistant tuberculosis?
I also welcome the delegation to the meeting and thank Dr. McDonnell for his very interesting presentation, which reminded me of a bygone era in Dublin. I grew up in a Dublin where people knew aboutPeamount, Newcastle, Rialto and St. James's Hospitals. I am aware that this is a long way back for some of my colleagues but I remember it very clearly because, as a small child, I used to visit an uncle who was diagnosed with tuberculosis. Many people will probably find it surprising that we are now looking at the same kind of challenges 50 years later, although they are possibly not so serious. One wonders how the former Minister for Health, the late Noel Browne, would react 50 years after his great work. I am too young to remember his tenure as Minister but I remember when tuberculosis was a problem and hearing people in Dublin speak about his impact. It is fascinating and perhaps ironic that we are discussing tuberculosis in the 21st century. I am fascinated by the fact that so much progress has been made in medicine over the last 100 years, yet challenges which reflect the past arise. Could Dr. McDonnell explain why there has been a resurgence in tuberculosis and the challenges it presents? Does this problem necessitate a response akin to that of Dr. Browne during his ministerial tenure, which involved the use of isolation hospitals or units? I am aware that we have moved on.
Is the situation sufficiently serious to necessitate a major public awareness campaign? In his presentation, Dr. McDonnell referred to the availability of facilities for diseases like avian influenza, which would appear to be a more serious threat. What are Dr. McDonnell's suggestions in respect of a major screening programme for people coming to Ireland? Screening programmes take place regularly, even in the Houses of the Oireachtas, and suggestions for various screening programmes have been made. One can see offers for various kinds of screening in the streets of Dublin and other cities and towns. Do we need a screening programme for tuberculosis? I thank the delegation for discussing this important issue with the committee.
I welcome the delegation to the committee and compliment it on its presentation, which should be a model for all visiting delegations.
We hope the questions will be of the same standard.
They will, of course, be of the same standard. Dr. McDonnell mentioned that he could not comment on a report of 300 cases of tuberculosis in north Dublin. I am not sure why a definitive view on this report cannot be given because tuberculosis is, presumably, a notifiable disease and records are kept. I understand that the Health Service Executive southern area does not administer the BCG vaccination against tuberculosis. Would this affect the delegation's findings?
Dr. McDonnell mentioned the lack of a respiratory consultant in the Health Service Executive south-eastern area. It would help the committee if Dr. McDonnell could outline the needs nationwide as he only referred to the issue tangentially. I propose that this submission be sent to both the Tánaiste and Professor Drumm, as it clearly pinpoints issues that must be addressed. Many people believe that this problem owes to immigration but the information presented so far reveals that immigration does not appear to the extent expected. We should point out that there is an indigenous problem that is much greater than any imported one.
Dr. McDonnell highlighted a number of issues, including the diagnostic laboratory and isolation facilities. There was a certain amount of controversy about the change concerning Peamount Hospital. While I understand the argument that treatments have changed and developed, a microbiologist at the Mater Hospital made the relevant point in theIrish Medical Times that Peamount Hospital provided a support centre for people who were homeless, at risk of TB, contracted TB or needed to have supports other than the traditional treatment of being placed in acute beds. Is there not a need for such a support centre? The people most at risk are probably homeless and living in poor social circumstances. If we are to meet their needs, we should have the necessary infrastructure. Dr. McDonnell referred to public health nurses but perhaps the loss of Peamount Hospital is slightly different from what we understood it to be. As a support centre, it is an important facility and we should reconsider that aspect.
Perhaps Dr. McDonnell could answer those questions before we take the next tranche.
Dr. McDonnell
I thank Deputy McManus for her interest and questions. I will begin but will ask some of my colleagues to join in later. The issue of the so-called north Dublin epidemic is spurious as there are no data anywhere to support it. In a report in the medical or trade journals, as it were, someone stated that there are 300 cases, but there clearly have not been that many in a single year in north Dublin. There are fewer than 200 cases annually in all of the eastern area. Whether the figure of 300 relates to infections, which are separate to cases of TB, is another matter. I do not know anything about the pub in question as the relevant information has not been published or put into a form whereby it could be accessed by the regular medical journals. Usually, data are submitted to the Health Protection Surveillance Centre, formerly the National Disease Surveillance Centre, but it does not know anything about the matter either.
When a centre is identified as having TB, public health doctors go in, talk to everyone who could have contracted TB in that area and screen them. In my experience, the doctors do a very efficient job. Consequently, I would have thought that the matter would have come to their attention.
Just to be absolutely clear, is Dr. McDonnell saying that, to his knowledge, public health doctors have had no involvement in any specific pub in north Dublin in respect of this issue?
Dr. McDonnell
I am not aware of their involvement in a specific pub. As a matter of course, they would follow up cases of infectious TB and screen where the patients congregated. I have dealt with patients who underwent screening. Many years ago, there was an outbreak in a pub in the south of Dublin and the doctors screened its customers.
I am frequently involved in and advise on outbreaks in places of work, offices and so forth. It would be relatively common in the case of a person who has an infectious disease in a place of occupation for public health doctors to carry out screenings. There were a number of cases in academic institutions, such as school outbreaks. It is quite conceivable that the public health doctors have screened people in a pub but it would not have been remarkable. No data have been published in the medical journals that would allow us, as people involved in the field, to screen the information.
I will get figures on respiratory physicians in the HSE's south-eastern area and ask Dr. O'Connor, who was involved a number of years ago in examining a manpower study on respiratory needs in the community, to comment on the matter. It must be stressed that immigrants are not a problem in terms of TB. The incidence of TB in foreign-born people in this country is very low. We have not focused on TB as a problem since the time of Noel Browne or organised an examination of how to eradicate it. It should be possible on a small island to have a comprehensive and linked policy that works towards the eradication of the problem. For example, in the United States, which has a national rate of five cases per 100,000, many of the cases are concentrated in city areas. Of the counties there, 50% have no cases of TB in any one year. According to my most recent figures, there are no counties in Ireland that do not have cases of TB. It should be feasible to do a better job but it is not just a question of having respiratory physicians. The issue must be linked to public health and there must be a comprehensive and joined-up service.
What plans for the treatment of drug resistant-TB does the advisory group have?
Dr. Joseph Keane
Drug resistance to TB is an issue and there are five cases at present. The management of each case is highly individualised and even a struggle for the expert involved. The best way to deal with the matter is to ensure that the patients receive expert opinion, are treated in the safest way possible and receive continuing treatment for 18 months after they have fully recovered. The way to prevent a resistance developing is to support TB care generally throughout the country in order that the best treatment is delivered at every level at which each patient is susceptible and patients do not progress to developing a resistance to drugs.
There is a source of resistant TB about which we can do little, that is, immigrant workers. We must extend to them the benefits of TB screening and treatment to prevent them getting TB, if possible. If we achieve that, we will improve their health and prevent our communities reactivating TB and infecting us and them. People who come from countries of high prevalence are most likely to develop tuberculosis within two years of coming to Ireland. It is important that we offer them treatment shortly after they arrive in the country to prevent TB reactivating. However, the issue of resistant TB will not go away in a hurry. It requires the application of expert opinion and we must be cautious. The most obvious actions we can take is to treat TB properly at home with combination drugs and set up a system to offer screenings to immigrant workers and care for them appropriately.
Dr. Barry O’Connell
I am a respiratory physician in St. James's Hospital, which has had close links with Peamount Hospital over the years. I sense from some of the committee members' questions that there is a strong desire to know what is being done about TB or what is the plan for the future. One question related to whether we should have a continuation of a paradigm such as that of Peamount Hospital, which worked best in the days before modern drug treatment of TB. A recent TB working group of the HSE's eastern region reported in December 2004 and firmly stated that TB is a disease that can be treated for the most part in the community with modern drug treatment. To achieve this, we need an adequate number of respiratory physicians nationwide to see and manage the cases. There will always be multi-drug resistant TB. The number of cases might be small but if we do not get them right, there will be a crisis.
There are medically difficult cases and, as Deputy McManus said, there are patients — the homeless, people who cannot care for themselves very well, people with alcohol problems and some immigrants — who do not have the resources and need greater supports, which is perhaps what Peamount Hospital provided over the years. That loss will be felt unless the service is replaced in some way. This group recommended that a TB unit be developed in the Dublin region on one of the major hospital sites and St. James's has been designated as that site. In February 2005 a meeting was held between St. James's, the board of Peamount Hospital and the Health Service Executive, which at the time was the south-western area health board, at which St. James's was asked to develop a TB unit and we agreed to do so.
We immediately seconded time from my colleague, Dr. Joe Keane, to develop a plan for a TB unit at St. James's Hospital. Dr. Keane is recognised as having considerable expertise in TB nationally and internationally. He took on the role and by July 2005 had presented a plan for the development of a TB unit at St. James's Hospital to the HSE and the Department. That plan is on the table and awaits funding. It is a very detailed plan on what is required for a 15-bedded unit to replace the inpatient facilities for TB patients at Peamount Hospital.
Funding was allocated to St. James's for a respiratory position with a special interest in TB. Issues raised about that post have been clarified with the HSE and it will be advertised shortly. Dr. Keane seconded a considerable period of his time to deal with the TB issue in St. James's Hospital at a consultant level. The hospital also agreed to establish a temporary facility which only contains three isolation beds and is about to open. Funding is required to develop these steps for the local region.
Professor Drumm will come before the committee next Thursday. We will ask him what the status of the unit is at present.
Dr. O’Connell
The key is to have in the background adequate respiratory positions nationwide to deal with cases. Difficult cases can be forwarded to centres in Cork, Dublin and perhaps Galway, where respiratory positions will take a more focused interest in difficult cases. A small number of inpatient beds in proper facilities are needed to ensure a multi-drug resistant TB case does not become a mini-epidemic.
My question on an audit system was missed.
Will Deputy O'Connor rephrase the question?
I asked about screening, communications, public awareness and whether we need another Noel Browne type initiative.
Dr. McDonnell
There is more panic than information about TB. In the UK this week, the national institute of clinical excellence launched new guidelines because of concern about the increasing incidence there. Some policies have been changed in the UK and a public awareness campaign has been put together. Appropriate information should be available to patients, not to cause a panic but to explain that while the disease is not very infectious, it is infectious and certain measures must be taken.
The medical community must also be made aware that anybody with a prolonged cough needs a chest X-ray. Sometimes people such as smokers complain of coughs and we all tend to dismiss a cough as an unimportant symptom. Early detection of TB might pay dividends. It is important that people have realistic notions and that the belief one can get TB from library books and other fallacies we may remember from our childhoods are buried. It is not that infectious a disease, but it is infectious, can be treated, and the minimum six-month course of treatment must be taken.
The Deputy mentioned TB in what he called the good old days. We were used to a more stable community in those days. We now have people who are socially disadvantaged and outside the system. We all come into contact with them in terms of treating them for TB. It can be difficult to persuade many of these patients about the importance of the arrangements to turn up, take the medication and comply with the directions. In the stable communities in which we grew up, people tended to do what they were told.
One of the issues regarding Peamount Hospital was sending patients there in the first instance. Many people I deal with in inner city areas are recent arrivals to this country and are tied into their own areas. They are not anxious to spend time in Newcastle.
Dr. Terry O’Connor
I will take up the point of the BCG in the former Southern Health Board area. The BCG vaccination has not been shown to prevent adult pulmonary TB. It has only been shown to prevent TB meningitis in infants and neonates.
What is the BCG?
It is a vaccination given to children.
Some of the members of the committee have a medical background and others do not. Perhaps Dr. O'Connor could answer Senator Browne's question.
Dr. O’Connor
I apologise. BCG stands for Bacille Calmette Guerin. Calmette and Guerin are the names of those who invented the vaccine in approximately 1910. It has been used since in countries with a high prevalence of TB in an attempt to reduce the incidence of it. The vaccine has only been shown to reduce the instance of TB meningitis in children, which is quite low anyway. The World Health Organisation recommends a country's TB policy must pass six criteria before the BCG is withdrawn. This is addressed by the national TB committee in Ireland. Ireland has passed five of those criteria but not the sixth which is on TB meningitis in children. The most recent recommendations are that the country continue BCG vaccination. It is controversial because we are on the cusp of withdrawing it. It is not administered in the Cork area but it is in Kerry. The most recent meeting of the national TB committee recommended a universal national policy, which has not yet been implemented due to funding.
It is not given in Cork but it is in Kerry. Who makes that decision? Is it a local county decision?
Dr. O’Connor
It is related to the funding of those who administer it, normally through the public health system. It can be administered in specific cases but it is not administered as routine to new-born children.
Who decides that children born in Kerry will have the BCG and those in Cork will not?
Dr. O’Connor
The national TB committee makes that decision.
Dr. McDonnell
It is symptomatic of the poor overall management of TB that policies vary throughout the country. This acts as a marker for the fact that we have not been organised in addressing the TB problem. West Cork has a different policy from Cork city. In Galway the BCG is given to schoolchildren at age 12. In Dublin it is given neonatally and it is given at different ages in other areas. Not having a unified policy in a relatively small country is symptomatic of the fact that TB has not had the priority it should have had in the past.
I am confused. Is it a national decision that it is not given in one county and given in another or is it a local county decision?
Dr. McDonnell
These are local practices that have been built up over a period. As Dr. O'Connor mentioned, the BCG is controversial internationally anyway. My view is that the BCG is not worth the money. One would be better off examining infectious cases. However, I have no confidence that if the BCG were abolished in this country, the money would be directed into public health case finding resources. In the United States and the Netherlands the neonatal BCG was never used. Canada does not use the BCG. Germany, Czechoslovakia and Sweden abolished the BCG. It is not a great vaccine. At best, it has marginal effect. However, it probably has some protective effect when given neonatally. The recommendation from the national committee, on which three of us sit, is that the policy of national neonatal BCG is probably best. Some of us do so in view of the fact that choosing an alternative would not mean resources would be distributed for it.
That is where I am confused. The committee makes a decision nationally. However, it does not seem to percolate down. Is the variation between counties for historical reasons?
Dr. McDonnell
Dr. O'Connor stated that part of the reason for the policy in Cork is funding.
Dr. O’Connor
The recommendations have been made to provide for the vaccinations but the necessary funding has not been made available.
Have best practice guidelines not been published or agreed for the prevention and treatment of TB?
Dr. McDonnell
I was a member of a Department of Health and Children committee which in 1996 issued guidelines on what it considered to be best practice. The use of BCG was not clearly defined, which reflected the fact that it was a contentious issue and that some believed the resources spent on administering the vaccine could have been better utilised in providing for other forms of TB control. The current guidelines in the United Kingdom recommend the use of BCG in areas where there is a high incidence of TB. Certain inner city areas of London and other big cities have rates of more than 40 cases per 100,000, whereas the rate in Ireland is ten cases per 100,000. The use of neonatal BCG is being recommended in such communities but the national BCG policy has been abolished in the United Kingdom as of this year. My view is that resources could be better spent in discovering cases of infectious TB.
That is strange, given that the national immunisation advisory committee recommended last year that booster haemophilus vaccine should be administered to two year olds, with the result that a programme is now in place to vaccinate all children between the ages of two and four years. The same body is investigating whether we should implement a hepatitis B vaccination programme for children aged two, four and six months.
It is incredible that the TB vaccination programme isad hoc and that the issue was not referred to the committee. I accept Dr.McDonnell’s point that the United Kingdom has more or less dismantled its national programme because there are pockets where the incidence is but surely it is possible in this country which does not face the same problem to reach a consensus between respiratory doctors and the vaccination board on either abolishing the programme or keeping it, subject to strict protocols. It is ridiculous that the vaccination programme depends on what happens within county boundaries.
Dr. McDonnell
I agree it is ridiculous that there are regional variations rather than one national policy. The advisory committee recommends that neonatal BCG vaccine should be administered nationally.
Is that the committee's recommendation? It is obviously not being followed.
Dr. McDonnell
Part of the reason it is not being followed is some do not think it represents the best use of resources.
In such circumstances, whoever implemented the policy will almost be criminally liable if a child gets TB.
Who makes the decision locally? Why can somebody decide to administer the vaccine in County Kerry or west County Cork but not in Cork city?
Dr. McDonnell
That was the way it was done historically. I presume such has been the case for decades.
The matter urgently needs to be addressed because it must be costing a great deal of money.
Dr. McDonnell
It is not a particularly effective vaccine and it does cost money. As the Senator is aware, resources are available for vaccines and many important vaccines are not administered. There should be a national policy. The HPSC committee, of which three of us are members, will consider the matter and issue further recommendations. I am sure its findings will inform the decisions of the national immunisation advisory committee. The recent change in the policy of the United Kingdom will also have to be considered. Current TB management is more a symptom than a cause of bad control. The existence of so many variant policies indicates that TB perhaps has not received the attention it merits as a public health issue.
Dr. O’Connell
As a hospital physician, I cannot answer the specific question on who has responsibility because immunisation is a public health issue. The question should be put to public health experts.
Is there any evidence to suggest a hereditary element?
Dr. Keane
TB is a genetic disease.
Is it like cystic fibrosis, which can skip generations?
Dr. Keane
TB runs in families. A dreadful accident occurred in Lubeck, Germany, where the BCG vaccine was administered to the entire community and TB was introduced as a result. All of the children were injected but the ones who fell ill came from families with a genetic predisposition to the disease. Everyone knows TB is an infectious disease caused by a bug but it is not as widely known that certain people carry genes which make it more likely that they will fall ill as a consequence of infection.
We do not yet have a test to pick out the families in Ireland at risk of becoming sick. It would be great if we did because we could administer a pill while TB was still in a latent or sleeping state so as to prevent it from wakening. In North America health professionals espouse the concept of eliminating TB completely and regard activation of disease as a failure. We do not think about the matter in that way in Ireland but will have to change our attitude. Latent TB is only treated well here where people have HIV or are undergoing immunosuppressive therapy. Perhaps we should also administer such treatments to persons who come from countries where the disease is prevalent.
Are there gender or age aspects to the prevalence of TB?
Dr. Keane
There is a gender aspect, in that men are much more susceptible to infection than women but that should not distract the Deputy from the fact that both males and females can contract TB. There is also an age aspect because the chances of TB activating increase as a person ages. However, while these are our suspicions, they are not supported by a huge amount of evidence.
Have homeless people ever been screened for TB? What are the symptoms and would one be fully aware of infection? A difficulty can arise in telling a smoker's cough from avian flu or TB.
One should go to a GP.
The problem is that one might not have a GP. A new national laboratory was promised at St. James's Hospital but financial support has not yet been provided. Will funding be provided or have conditions been applied which have delayed the project?
Am I correct to assume people can contract TB, irrespective of whether they receive the vaccine but that the vaccine can reduce the severity of infection?
Dr. McDonnell
No.
I presume the rate of infection is higher among those who did not receive the vaccine. What is the position on recovery time? In areas where the vaccine is not being implemented, are parents being informed that they have the option of getting it afterwards?
Do the witnesses think the closure of Peamount Hospital was premature? We have previously heard that if a facility is closed down, the HSE, the Department of Health and Children or the Minister will promise something else in return. Should Peamount not have been kept open until the 15 beds were built? With Peamount closed there is no isolation facility for a highly infectious disease. It makes avian flu look like a joke to think that although TB is more than active we have no isolation facility apart from four beds. It is beyond a question of resources as the 15 bed facility is not even being built. There is nothing. It looks like the witnesses were hoodwinked.
There are consultants in the south east who practice respiratory medicine, for example, Dr. Colm Quigley, who is a respiratory consultant as well as a general physician. In the past five years a large number of respiratory physicians have been taken on and it is the role of Comhairle na nOspidéal to balance out regional responsibilities across the country. Although there are 400,000 people in the south east there is no dedicated respiratory consultant. One Dublin hospital, which is not represented here today, has seven respiratory consultants and that is not the only Dublin hospital. Comhairle na nOspidéal, which has been in existence for some time, is responsible for approving posts and matching them to where services are needed. Why then are we in a situation where the south east and many other parts of the country do not have these services while many of these specialised posts have been concentrated in Dublin and Cork? Government policy, as implemented by Comhairle na nOspidéal, has utterly failed and this point has not been made, although the witnesses pointed out that we need more respiratory consultants. Any respiratory consultants appointed in the past five to six years have mainly been to Dublin and Cork. I would like to hear comments on that.
Dr. O’Connor
It is a good suggestion to screen the homeless population for TB. The symptoms of full-blown, active TB infection can range from profound weight loss and respiratory symptoms to no symptoms. Symptoms are not a reliable identifier of TB. In a population like this the ideal screening tools are a simple chest X-ray and a mantoux test, an injection that is read after 48 hours to see if there is evidence of active or latent TB infection. This policy would be implemented better in North America than here and should be implemented through public health mechanisms because we see a high prevalence of TB in homeless populations. What makes it difficult is the fact that the homeless are difficult to track. They come and go, in and out of shelters, and many have alcohol and drug problems. That feeds back into the isolation and short-stay bed issue in that this is the ideal setting in which to manage such people. The former southern area is not too bad in that sense but the former eastern region suffers from a lack of those facilities.
I will address overall consultant numbers. In 2003 my colleague, Dr. Neil Brennan, who is based at Mercy University Hospital, and I produced a document entitled INHALE which examined overall figures of mortality and morbidity from respiratory disease in Ireland. Ireland is not doing well by comparison with Europe and has the highest mortality in western Europe. In greater Europe, including the eastern European countries, we have the fourth highest mortality after Kazakhstan, Kurdistan and Turkmenistan. That reflects poorly. While a lack of respiratory consultants is just one part of the problem, we fall well short of both European and British recommendations on respiratory consultants per head of population. While I agree with Dr. Twomey's point on the concentration in Dublin, even in Dublin the numbers fall short of what would be recommended for the population.
Dr. O’Connell
I would like to address the funding of a unit in St. James's and the closure of Peamount, which are intricately linked. It was premature to close Peamount before there was something to take its place. That will not cause a crisis on the spot, but if the momentum to look after the difficult end of TB and the difficult patients is not maintained, there will be a crisis. The question why that happened should be put to the board of Peamount Hospital, the HSE and the policy makers. It has nothing to do with St. James's Hospital, which was not party to that decision. The working group has stated that the Peamount paradigm, a hospital in isolation without the supports of a university hospital, is not best for difficult TB patients in the future. The paradigm for the future should be a proper, stand-alone TB unit in a university-based teaching hospital. The HSE approached us in February to develop this and we had the detailed plan for that unit on the table for July. I do not know if we were, as Dr. Twomey said, hoodwinked. I do not know how to twist somebody's arm to demand immediate funding. At the initial meeting we said a temporary unit with three beds would not be sufficient to look after the long-term TB needs. While we agreed to put that in place and progress the appointment of a TB consultant, we said that would never suffice alone, and we sought an assurance from the HSE at our initial meeting in February 2005 that the funding would be progressed in the background. Perhaps that has been progressed by recent issues in the media. We are due to hear whether this will be funded and it is a key issue for us. There is a detailed plan on the table for that unit and it must be progressed.
To return to Deputy McManus's comment on supports, this is not about a consultant running a clinic in St. James's Hospital, but one who would lead a hospital-based service that would reach out into the community. It would largely be an outreach service to treat people in the community with the proper supports such as interpreters for foreign patients, outreach nurses and good linking with public health services so that individual patients can be properly managed. It would be a comprehensive service to replace what Deputy McManus indicated was lost at Peamount Hospital. This vision is on the table but needs funding.
What is the funding figure?
Dr. O’Connell
I do not have the figure and would rather not guess it. Funding for TB services has been provided to Peamount Hospital over the years and we do not know where that funding went. Although we met Peamount Hospital and the HSE the idea that funds should be transferred was never discussed.
Does Dr. O'Connell mean Peamount Hospital is still receiving funding although it is no longer treating patients?
Dr. O’Connell
I do not know if it is getting the same funding. The possibility that funding might be transferred to us was never raised and as I am not a policy maker or a funder it is not my place to say it should have. It is my place to say that St. James's Hospital can deliver this service if it receives the funds. I do not know whether funds were taken from what would have been a TB service or are still going to Peamount. TB services like this have traditionally been funded but we have not got the funds to develop the unit we said we could develop.
Dr. McDonnell
We have rarely spoken on research into the efficacy of the BCG vaccine and the evidence in medical journals. The best studies demonstrate that the BCG vaccine gives at best 80% protection against TB. Therefore, there is 20% failure to protect. Some studies have demonstrated no benefit. Therefore, it is not a great vaccine. That leads to some of the controversy the committee has rightly picked up about whether it should be given. Many of us feel one could do better with other means of TB control if the funding was available. Although I am one of the seven respiratory physicians in the hospital mentioned by Dr. Twomey we all have other duties. The cystic fibrosis unit has a requirement, in accordance with UK standards, for four consultants but is currently managed by one. The hospital also, incidentally, has the largest sleep clinic in these islands. One of the four is a professor of medicine who has academic duties and the others are a lung transplant physician and me. There are not many available for ordinary "cough and spit" medicine.
I know Dr. Quigley well and as he is inundated with accident and emergency and general medicine duties in Wexford, there is no opportunity to develop a subspecialty respiratory service. Some well merited appointments have been made to Waterford Regional Hospital, including two or three rheumatologists and two or three oncologists, but there is no specific respiratory position as yet. The Deputy is well aware that 30% of accident and emergency admissions in winter are respiratory, often involving COPD symptoms which are a hidden burden of respiratory disease.
COPD is an equal factor in the accident and emergency crisis.
Dr. McDonnell
Absolutely. Those are the patients on trolleys receiving poor care. If I may use a pejorative term, they are the bedblockers who are suffering from the present trolley crisis.
Do we know the amount spent on providing the BCG vaccine each year?
Dr. McDonnell
We do not have a figure for that.
Dr. McDonnell said there were fewer than 200 cases of TB in the greater Dublin area. How many of those are treated at home and how many are hospitalised in the isolation unit?
Dr. McDonnell
The standard guidelines state that most people with TB do not need to be hospitalised. My predecessor, Professor Muiris Fitzgerald, combined the TB and public health clinic in St. Vincent's. A patient with infectious TB or a general practitioner who suspects a case of TB can contact the hospital on a special telephone number. We will see the person in question the following week, check their sputums as an outpatient and, if the results are positive, we will start them on treatment as an outpatient. If they are admitted to hospital it is because they are seriously ill. The worst thing to do with someone who has potentially infectious TB is to direct them to an accident and emergency department to sit on a trolley in grossly overcrowded conditions and cough on their neighbours. In the Dublin area there are mechanisms whereby those patients can be seen outside the accident and emergency system, which needs to be rolled out as a national policy.
They definitely would not be kept in hospital while awaiting a test result from the UK.
Dr. McDonnell
Definitely not.
The doctor referred to parental choice. The BCG is not offered in Cork but are parents informed that, in theory, their children are entitled to the vaccine somewhere, even if it is not available locally?
Dr. O’Connor
As far as I understand it, they are not, but I cannot speak for my general practice or public health colleagues. I know from personal experience that the process of getting a BCG vaccination is difficult and a parent often ends up on a long waiting list with many national and non-national people. For children at risk through contact, resources are very limited.
It is amazing that we are always accused of wearing the county jersey but vaccinations are given according to the county jersey.
Is there anywhere we as a committee could find out where the BCG is offered and where it is not?
Dr. McDonnell
The Health Protection Surveillance Centre may have the information.
Dr. Keane said that tuberculosis is genetic. Is that a personal opinion or one based on scientific fact?
Dr. Keane
I should have been more specific. Susceptibility to developing the disease of tuberculosis may well be genetic. Generally speaking humans are resistant to TB. There is a theory that, hundreds of years ago, the whole population of Europe contracted TB. Those susceptible to the disease died out and the genetically strong group that was resistant to it survived. While most people are resistant to TB, perhaps 10% are susceptible and that is enough to sustain it. We carry out a great deal of research to determine which genes make people resistant and which make them susceptible but I am convinced there is a genetic aspect to TB, though that does not make it a genetic disease like cystic fibrosis.
We have still not isolated a particular gene or chromosome that might indicate where one stands.
Dr. Keane
We have discovered nothing that can provide the basis of a test available to patients but we have many ideas.
Dr. O’Connell
I do not want any soundbites to emerge from the meeting suggesting that TB is a genetic disease like cystic fibrosis. It is not like that at all but depends on susceptibility.
I will return to the question of funding. I said we had a plan for a unit which we were keen to fund and get up and running immediately. That ought to include the national TB reference laboratory which was referred to earlier and which has been allocated to St. James's since 2001 but has never been funded. Two funds need to work in tandem to control TB into the future. There will not be a crisis tomorrow morning but there will be in a few years if it is not progressed very quickly.
Would it be better if there was targeted screening involving two TB tests on certain groups, rather than spending time on the BCG vaccine, which is just historic?
Dr. McDonnell
That would be more my bias. The BCG prevents progression from infection to disease. As the Deputy will be aware from his medical background many people can be infected with TB but only one in 20 of them will progress to disease, and that is usually over a lifetime. Most of the risk occurs immediately after getting infected so in an epidemic somebody who has the infectious disease in an enclosed space like an office or pub can infect colleagues. They have latent TB which can progress to real TB but only does so in approximately one in 20 cases. It is necessary to pick up the infectious cases and give them chemoprophylaxis to eradicate the small amount of TB in their system and prevent them developing the infectious disease later in life. The BCG injection helps prevent the progression from infection to disease but does not break the chain of infection.
I thank the delegation for attending and for their comprehensive presentation. I speak for all members in saying it has been very informative and has posed many questions which we, as a committee, will pursue. We may invite the delegates to return at a later stage to review progress.
The next meeting on 30 March 2006 will be attended by the Tánaiste and Minister for Health and Children, Deputy Harney, and by Professor Brendan Drumm.
The joint committee adjourned at 11.10 a.m. until 9.30 a.m. on Thursday, 30 March 2006.