TB: Ensuring patient-centred care amid growing incidence

The pressing need for investment in tuberculosis prevention and care was highlighted at a recent conference. Catherine Reilly reports

Video-observed therapy (VOT) is among the measures needed to enhance tuberculosis (TB) care in Ireland, heard the National TB Conference at St James’s Hospital, Dublin.

The rising incidence of TB nationally was highlighted at the meeting on 23 May. TB cases in 2025 are expected to exceed the 289 reported last year.

Ms Lorraine Dolan, candidate-Advanced Nurse Practitioner (ANP) in TB, presented on the work of the National TB Centre at St James’s Hospital. One of the innovations the team has studied is VOT. Ms Dolan said this technology was proven to be a patient-centred approach that is effective and cost-saving for the health service.

The smartphone application allows patients to record their ingestion of TB medications and send this video securely to the clinical team. For patients who can engage with VOT, it empowers them to continue their lives without the constraints of directly-observed therapy (DOT) – which involves daily visits from a public health nurse or the patient’s attendance at a local health centre.

“It is patient-centred care working for the patient,” Ms Dolan stated. “We did a research study on this which proved a higher compliance rate with VOT compared to directly-observed therapy and a massive cost saving. This is the future of TB care in Ireland; this is what we need.”

TB treatment requires several months of combination drug therapy. Non-adherence to medication regimens can lead to treatment failure, drug resistance, and further spread of TB, posing risks for the patient and to public health. The purpose of VOT/DOT is to support the patient to complete their treatment.

Under HSE national TB guidelines (2024), all patients diagnosed with TB should receive DOT or VOT especially in the early stages of treatment. Where “resources are scarce”, priority for DOT/VOT should be given to patients with drug-resistant TB and/or patients whose medical or social circumstances indicate that treatment adherence may be problematic.

A national VOT programme and increased support for DOT are proposed in the HSE’s national TB strategy (see panel). The strategy, published in March 2024, has not yet received dedicated funding.

Increasing case numbers

Globally, TB is the leading cause of death from infectious disease. Ireland is a low-incidence country (<10 cases per 100,000). The World Health Organisation (WHO) End TB Strategy (2015) included a target of an 80 per cent reduction in cases between 2015 and 2030. This would have equated to approximately 139 cases in Ireland last year – less than half of what was diagnosed.

Ms Sarah Jackson, Senior Epidemiologist at the Health Protection Surveillance Centre (HPSC), said case numbers last year were the highest since 2018. Ireland’s crude incidence rate was 5.6/100,000 and it had veered from the WHO end TB goals. Ms Jackson also noted the growing incidence of TB in the UK, which may lose its low incidence status.

Last year in Ireland, over 70 per cent of diagnoses were in people born abroad – mainly from high-incidence TB countries. The main age range in foreign-born cases was 25-44 years. Ms Jackson also reported a rise in paediatric cases, noting that “very worryingly… there were five cases last year in the under one-year-olds”. The number of rifampicin-resistant cases also increased in 2024. Ms Jackson highlighted the need for more complete data on HIV status and treatment outcomes.

Commenting on factors behind the overall increase, Ms Jackson said it was likely some people were undiagnosed during the acute phase of the Covid-19 pandemic, resulting in late diagnoses and increased transmission.

The social factors included high levels of international migration – including people from high-incidence countries and those fleeing conflict through unsafe and precarious migration pathways. The HPSC had noted an increased number of diagnoses in migrants living in unstable housing. Ms Jackson also referenced some evidence that suppression of cell-mediated immunity due to Covid-19 can enhance susceptibility to TB.  The risk factors for TB include immunosuppressive therapies (ie, risk of TB reactivation), which has also been noted in the HPSC data.

Drug-resistance

Prof Anne Marie McLaughlin, joint Clinical Lead, National TB Centre, mainly discussed the management of drug-resistant cases. Most of these patients are managed by the St James’s service, which works closely with the Irish Mycobacteria Reference Laboratory (IMRL).

Prof McLaughlin said the service was seeing an increasing number of patients with TB. She emphasised that “behind every statistic there is a story of a patient who has gone through an awful lot to come to that diagnosis”. 

Most of the patients were born abroad and aged 25 to 44. Less than one-third were Irish-born and these patients were generally an older cohort with many on immunosuppressive therapies.

During her presentation, she noted it was “sobering” that eight countries carried two-thirds of the global TB burden (Nigeria, Congo, Pakistan, India, Indonesia, Philippines, Bangladesh, and China). Many of the patients in Ireland with drug-resistant TB were from these countries of origin.

The centre has seen an increase in the incidence of drug-resistant cases. “Last year we had 14 cases of drug resistance; similarly in 2022 [when] much of this was related to people coming from Ukraine and displaced by war. As the wars across the globe seem to be increasing and not decreasing, we can anticipate an increase in our experience of managing patients with drug-resistant TB in the years to come.”

Prof McLaughlin noted significant diagnostic improvements. “The IMRL, who we are honoured to share the site of St James’s Hospital with, are doing whole genome sequencing on all of our isolates. This means we know very early on if we can suspect drug resistance.”

“We are also fighting drug-resistant TB with innovations such as VOT, which has been led in Ireland by Lorraine Dolan, our TB ANP. It is facilitating compliance, facilitating communication with patients using an app on their phone…. So this is really something that all patients should be offered.”

In recent years, a number of novel drugs and shorter regimens for drug-resistant TB have emerged and are recommended in WHO guidelines. Prof McLaughlin discussed the newer regimens including BPALM/BPAL, which is a six-month oral treatment comprising bedaquiline, pretomanid, linezolid, and moxifloxacin, if the strain is fluoroquinolone-sensitive.

She noted the importance of the drug bedaquiline and expressed concern about the 6 per cent resistance at baseline in the Nix-TB trial. “Bedaquiline resistance is a huge problem [globally] and it is a problem that is coming down the line at us.”

Bedaquiline, an oral diarylquinoline, inhibits mycobacterial ATP [adenosine triphosphate] synthase and its sterilising activity is comparable to rifampicin. “So bedaquiline is a very precious drug and it is very, very useful.” The medication tends to be associated with the least amount of side-effects in treatment of drug-resistant TB.

“Over the years one of the biggest challenges in running a clinic that looks after patients with drug-resistant TB is managing the side-effects and encouraging the patients along through their regimen and substituting drugs when they develop side-effects.”

Globally, financing for TB treatment had improved through initiatives such as Debt2Health, stated Prof McLaughlin. However, she said the Trump administration’s drastic cuts to USAID would have a hugely detrimental impact in developing countries. She said this will also ultimately impact on the patients who are treated in Ireland.

Speaking to the Medical Independent (MI), Prof McLaughlin confirmed that the National TB Centre and IMRL need additional resourcing to manage increasing workloads.

The National TB Centre mainly provides an ambulatory care service. It assesses patients for suspected TB and cares for those with TB disease and TB infection (formerly termed ‘latent TB’). Patients on treatment are monitored for compliance and side-effects, as well as hepatotoxicity. The service is strongly involved in education and advocacy on behalf of patients. It provides a consult service for clinicians around the country and works closely with public health colleagues.

“Our clinics are massive [in numbers]; they are very complex patients because we have all the drug-resistant cases,” Prof McLaughlin told MI. “Three-quarters of our patients are from overseas so there are complexities around language and cultural sensitivities. So the numbers are exponentially increasing and the resources have stayed the same.”

The multi-disciplinary team members are extremely committed, outlined Prof McLaughlin. Currently, there is no dietetics or social work input for outpatients.

Medication compliance is “really good” because the team is highly responsive. Prof McLaughlin reiterated that VOT would be beneficial in this regard. “It is using technology, but also it is really patient-focused.”

In 2025, TB cases could reach approximately 320 and this was a “conservative” estimate. Prof McLaughlin emphasised the importance of education on TB and addressing stigma. She said many people affected by TB felt stigmatised and frightened to discuss the condition.

“The stories you hear are really sad…. It is very difficult to get a patient to talk to you about their TB journey.”

Speakers at the National TB Conference included Dr Mary O’Meara, Consultant in Public Health Medicine; Dr Cilian Ó Maoldomhnaigh, Paediatric Infectious Diseases Consultant, Children’s Health Ireland; Ms Ciara MacKenna, Senior TB Pharmacist, National TB Centre; Dr Margaret Fitzgibbon, Chief Medical Scientist, IMRL; Dr Gunar Günther, Pulmonologist, University of Bern, University of Namibia and TBnet; and Prof Joe Keane, joint Clinical Lead, National TB Centre.

HSE

A HSE spokesperson told MI: “No additional specific funding was associated with the TB strategy, but work is delivered through the current funded teams, services, and programmes.”

“The National Health Protection Office, working closely with the national TB advisory committee, has continued to progress work to improve active case finding, manage cases and outbreaks, support laboratory diagnostic services, retain people in care to completion of treatment, and support professional development and training of staff.

“Some areas of progress include updates to important areas of evidence-informed guidance, a long overdue need which many public health and clinical colleagues had identified as a key enabler for their work.”

Preliminary work is taking place on the implementation of a selective Bacille Calmette-Guérin (BCG) vaccine programme, which is being overseen by a subgroup of the national TB advisory committee.

This work has identified various “issues and interdependencies” required to progress the programme, including trained staff, screening for immunodeficiencies in children, and identified budgets in regional as well as national structures.

There is no routine systematic TB infection/disease screening programme in place for new entrants to Ireland.

The HSE National Social Inclusion Office funds Safetynet to conduct active case finding for TB among people seeking international protection (aged over 16 years) living in accommodation centres. This is facilitated through Safetynet’s mobile health and screening unit.

There is also work ongoing on development of public health TB nursing workforce capability.

The HSE spokesperson noted that Ireland has signed up to the EU Asylum and Migration Pact. The Government has prepared a brief on its national implementation plan, which outlines the transition to the new “international protection system” under the Pact.

“While Ireland cannot opt-in to the Schengen measures in the Pact, such as the Screening Regulation (Regulation (EU) 2024/1356) which provides for health checks, it is proposed to align national measures with the requirements of the Screening Regulation as appropriate, including the initial screening process for all those entering the country seeking protection.

“This screening involves a preliminary health and vulnerability check to identify persons in need of healthcare and/or persons that might need isolation on public health grounds. The specific elements of the preliminary health check are under consideration.”