Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC1. Epidemiology and Surveillance of TuberculosisHumanum tuberculosis (TB) is caused by infection with bacteria of the Mycobacterium tuberculosis complex(M. tuberculosis, M. bovis, M. africanum, M. microti, M. canetii, M. caprae or M. pinnipedii). The organismmay infect any part of the body. However, the majority of cases involve the respiratory system.1.1 Global TrendsTB remains a significant cause of morbidity and mortality worldwide. An estimated 9.3 million new caseswere reported in 2007, of which 7.8 million were detected in Asia and Africa. Of the 9.3 million new cases,1.4 million (15%) were co-infected with human immunodeficiency virus (HIV). Approximately 1.8 milliondeaths occurred due to TB, of which 456,000 individuals were co-infected with HIV, accounting for 25% ofthese deaths. Worldwide, the incidence of disease is stable, although case numbers particularly in Africa,South-Eastern Asia and Eastern Mediterranean countries continue to rise. 1 In 1993, the World HealthOrganization (WHO) declared TB a ‘global emergency’ in response to a resurgence in cases, followingnearly a century of decline. 2 To improve control, targets for TB control recommended by WHO’s WorldHealth Assembly 3 were defined within the United Nations Millennium Development Goals (MDG 6, target8), and indicators to measure progress towards these goals were proposed by the Stop TB partnership in2006. 4;5Table 1.1: Indicators of progress towards Millennium Development Goals 5STOP TB PARTNERSHIP TARGETS• By 2005: At least 70% of new sputum smear positive TB cases will be detected and atleast 85% of these cases cured• By 2015: Reduce prevalence of and death due to TB by 50% relative to 1990• By 2050: The global incidence of active TB will be less than 1 case per millionpopulation (i.e. elimination of TB as a global public health problem).The HIV epidemic has had a significant impact on TB rates. Individuals with TB and HIV infection are morelikely to develop active TB disease during their lifetime than those who are HIV negative, making HIV themost potent predictor of progression to active TB. 4;6 Drug resistance, including multidrug-resistant TB(MDR-TB) and extensively drug-resistant TB (XDR-TB) (see table 1.2), together with an increasing numberof TB-HIV co-infected patients is challenging TB control.Table 1.2: Definitions of drug resistanceDRUG RESISTANCE DEFINITIONS• Multidrug-resistant TB (MDR-TB): TB bacilli resistant to at least isoniazid and rifampicinwith or without resistance to ethambutol and streptomycin• Extensively drug-resistant TB (XDR-TB): is resistance to at least isoniazid and rifampicin(i.e. MDR-TB), plus resistance to any fluoroquinolone, and any one of the followingsecond line anti-TB injectable drugs (capreomycin, amikacin or kanamycin).Incomplete and incorrect treatment regimens may result in patients remaining infectious, and bacilli intheir lungs may develop resistance to anti-TB medicines. While drug-resistant TB is generally treatable,it requires extensive chemotherapy (for up to two years) that is often prohibitively expensive (often more-1-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCthan 100 times more expensive than treatment of drug susceptible TB) and is also more toxic to patients.Recent findings from a survey conducted by WHO and the US Centers for Disease Control and Prevention(CDC) on data from 2000-2004 found that XDR-TB has been identified in all regions of the world butwas most frequent in the former Soviet Union and in Asia. 7 A recent outbreak of XDR-TB in HIV-infectedindividuals in South Africa highlighted a worrying situation whereby 52 of 53 XDR-TB patients died within amedian of 16 days. 81.2 Tuberculosis in EuropeIn European countries, the decline of TB in the latter half of the twentieth century was accelerated by acombination of improved socioeconomic conditions such as better housing and reduction of overcrowdingand biological factors e.g. improved nutrition, advent of chemotherapeutic drugs, BCG immunisationprogrammes. 9 However, in the last decade overall rates in the WHO European region began to increasesteadily from 28 notifications per 100,000 population in 1994 to 54 notifications per 100,000 populationin 2007. 10 Disparities in rates between Western and Eastern European countries are apparent and havediverged further in recent years. The incidence of disease in the Eastern European region (comprisingmostly of states of the former Soviet Union) continues to increase annually and in 2007 rates in excess of131 cases per 100,000 population were reported. Former Soviet Union countries have the greatest burdenof disease and the highest rates of multidrug-resistance and mortality rates ranging from 3.0 to 22.3 deathsper 100,000 population. This region remains a priority for TB control. 10The Western European region (European Union and Western European countries) reported a rate of 17cases per 100,000 population in 2007. This region experienced a steady decrease in overall TB incidencefor a number of decades, briefly reversed in certain countries in the early 1990s. 11 This pattern was also firstobserved in the United States of America during the 1980s and early 1990s due in part to the impact ofHIV but also due to the problems of homelessness, drug abuse, immigration from high incidence countriesand deterioration in living conditions and health care delivery to the poor. 12 A concerted effort to controlTB in the US resulted in a 45% reduction in cases and halved the incidence rate to 5 cases per 100,000population between 1992 and 2002.In low-incidence European countries, specific challenges to TB control have emerged as a result of thisshift from high to low incidence. 13 These include a declining incidence in native populations, the increasingimportance of LTBI, disease in immigrant populations, groups at high risk (HIV-infected, homeless andprisoners) and importation of drug resistance (e.g. multidrug-resistance from Eastern Europe and othercountries). In the United Kingdom, national rates have remained low overall but have gradually increased inEngland by 25% (1994-2004). 14 The London region accounted for the highest proportion of cases in 2007at 41% of all UK cases notified and had the highest TB notification rate at 44.8 per 100,000. Most TB casescontinue to occur in young adults (61% were aged 15-44 years) and in the non-UK born population (72%). 15In 2004, an action plan entitled ‘Stopping Tuberculosis in England’ 16 was published by the UK Departmentof Health, to focus efforts on controlling increasing TB levels.In 1996, a European network for surveillance (EuroTB) was introduced, based on the participation ofnational TB surveillance institutions in the 53 countries of the WHO European Region. Its aims were toimprove the contribution of surveillance to TB control in the WHO European region, through the provisionof valid, comparable epidemiological information on TB. Annual reports indicate that Cyprus had thelowest notification rate of disease in 2007 in the 27 EU countries (EU-27) at 5.3 cases per 100,000, whileIreland ranked in sixteenth position (table 1.3).-2-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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