The combined effects of Covid-19 and the Russian invasion of Ukraine are about to hit the Irish health system. With tuberculosis (TB) numbers at the national TB treatment centre here rising already, refugees from Ukraine are set to pile additional pressure on TB services. It’s a situation that’s causing concern to the head of our national TB treatment centre.
In Ukraine, an estimated 32,000 people develop active TB each year, and about one-third of all new TB cases are drug resistant. Despite reducing TB incidence in recent years, Ukraine still has one of the highest levels of TB in Europe. Of concern is that nearly a third of the people affected have drug resistance to TB, with high and increasing rates of multi-drug resistant TB (MDRTB).
The invasion of Ukraine is a potential disaster for TB control across Europe. Wars lead to conditions that are the perfect breeding ground for TB, including food insecurity and overcrowding in poorly ventilated places. This is the dire situation currently facing many people in bomb shelters across Ukraine.
Wars ravage healthcare infrastructure, decimate immunisation programmes, and limit access to quality care. This means people often have late diagnoses, resulting in worse complications and a greater chance of onward transmission.
Untreated, TB can spread to the kidneys, brain and spinal cord. It has killed more people than any other single infectious agent in history
Many of these refugees will have what’s called latent tuberculosis infection (LTBI). This is an inactive version of the disease, but one that is prone to erupt into active infection, especially in the stressful conditions encountered by those facing forced evacuation in Ukraine at present.
These challenges come on the backdrop of the Covid pandemic, during which TB notification rates dropped sharply. This was not because TB suddenly went away – rather it was due to reduced access to TB diagnosis and treatment.
According to Prof Joe Keane, consultant respiratory physician and TB specialist at St James's hospital in Dublin "Covid-19 has distanced the tuberculosis patient, who ordinarily is marginalised anyway, from accessing face-to-face healthcare. Tuberculosis is therefore exceptionally sensitive to the neglect that comes with pandemic – enforced distancing. Globally this has been reflected by a dramatic increase in TB cases and deaths, a trend that has reversed the improvement of the last decade."
Keane believes two years of Covid has impacted negatively on TB surveillance and TB treatment in Ireland. Cases are presenting later, he says.
Should the Republic offer LTBI screening to the large number of Ukrainian refugees we expect to welcome here? Yes is Keane’s answer. However we do not have a TB screening programme in the country. There are plans to recruit a ‘TB controller’ here this year – one of whose priorities would be to set up a formal LTBI screening programme.
In the absence of a screening programme is Keane concerned at the potential influx of people with TB from Ukraine? He points out that screening for tuberculosis in incoming persons from the Ukraine could be performed using the blood test called Quantiferon. “If this was positive, then a chest X-ray would be performed. Missing cases of TB would be detected. These missing TB cases might be multiple drug resistant tuberculosis. I am concerned that by failure to screen for tuberculosis in this manner, we will received avoidable cases of drug resistant tuberculosis to our national TB treatment centre at Saint James’s.”
TB is an infectious disease caused by the bacterium mycobacterium tuberculosis and is spread through coughing. Untreated, it can spread to the kidneys, brain and spinal cord. It has killed more people than any other single infectious agent in history, including Sars-CoV-2.
The infection is curable, but people need support to get through the many months of treatment required. Keane’s clear message is that “we will detect cases of multiple drug resistant tuberculosis in this group (of incoming Ukrainians). Picking up one of these cases not only affords the patient treatment and a chance of survival, but also stops spread locally.”