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Health - April 11, 2025
While TB is primarily a disease that affects the lungs (pulmonary TB) it can also spread to other parts of the body (extrapulmonary TB) and in many instances it actively contributes to a lowering of the effectiveness of the persons immune system.
When this happens conditions like HIV/AIDS, malnutrition, diabetes, or prolonged use of immunosuppressive drugs increase, which in turn generate significant public health concerns.
Indeed, we know from EU health authority reporting that an estimated 18 000 TB deaths occurred among HIV-positive people in the European Region in 2022, equivalent to 1.9 deaths per 100 000 population. This represented a 6% year-on-year increase in the number of deaths against 2021.
The array of these conditions clearly contributes to a society’s overall healthcare cost burden as diagnosis and treatment can involve a 6-9 month usage of antibiotics, and increased levels of hospitalisation.
The knock-on effect in terms of loss of productivity is also significant given that TB disproportionately affects working-age adults (15-54 years), leading to high rates of absenteeism and in many cases even permanent workforce exit.
In fact, the World Health Organisation’s “Tool to Estimate Patients’ Costs” that was developed in collaboration with the KNCV Tuberculosis Foundation and the Japan Anti-Tuberculosis Association has shown TB patients, lose on average work approximately 3-4 months due to illness and treatment demands.
These outcomes should be of particular concern to Ireland given recent confirmation from its Health Protection Surveillance Centre (HPSC) that the rates of tuberculosis have continued to rise in Ireland during the 2024 period when 289 cases of TB were notified.
The Key Points provided by the HPSC are as follows:
• TB incidence increased in 2024 and is now comparable with pre-pandemic levels
• The number of cases reported exceeds the projected number of cases required to achieve End TB target
• An increase in paediatric TB rates was observed
• The number of rifampicin resistant cases has increased
• Treatment outcome completeness remained low
• Number of outbreaks reported has increased sharply in 2024
• 32 cases notified in 2024 were to linked to 25 clusters
According to reporting on this by the Irish Medical Times (IMT) the number of notified cases equates to an incidence rate of 5.6 per 100,000 population, which represents a rise on 2023 figures, when 224 cases were reported.
As noted by several other media outlets in Ireland this level of incidence rate is dramatically out of kilter with the World Health Organisation target of reducing TB cases by 80 per cent before 2030. According to the HPSC, Ireland would have had to have 139 TB cases or fewer in order to remain on track to reach this goal.
Striving to End Tuberculosis – A Strategy for Ireland 2024 – 2030 that was commissioned by Dr Éamonn O’Moore, Ireland’s Health Service Executive Director of National Health Protection and authored by Dr Mary O’Meara, Consultant in Public Health Medicine and Dr James O’Connell, Specialist Registrar in Public Health Medicine, outlines Ireland’s attempt to respond to effectively the numerous interlinked challenges presented by TB.
The Strategy begins by contextualising the global incidence rate of TB. It notes for instance that in 2023, 10.6 million people developed TB and 1.3 million died with it while worldwide in 2023, more than one in every four went undetected. It further notes that during the COVID-19 pandemic, the substantial decline in the number of people treated for drug-resistant TB, the number of people receiving preventive TB treatment and global funding to fight TB have only worsened the global TB burden.
Specifically with respect to Ireland, the Strategy’s authors are at pains to point out that while in 2023 there were 57 countries with a low incidence of TB (less than 10 per 100,000), of which Ireland was one, Ireland cannot afford to develop any kind of complacency in its efforts to further lower the numbers of notifiable cases.
Indeed, the Strategy clearly states that as a low-incidence country, Ireland should not only be aiming to achieve the World Health Organization End TB Strategy target of an 80% reduction in TB incidence before 2030, it should also be aspiring to eliminate TB (an incidence of TB of less than one per million population).
The recent spike in cases demonstrate that achieving this ambition has now become significantly more challenging for Ireland health authorities.
While the HPSC report confirms that a major factor in the increased incidence rate relates to the backlog of undetected cases caused in part by the ongoing impact of the COVID-19 during which TB control was disrupted from 2020 to 2022, it also points to a more politically sensitive cause, namely the re-emergence of the disease because of immigration.
The Report confirms that while TB rates in Irish-born remain stable, rates were higher in people born outside Ireland.
In fact, a dramatic 72% of cases of TB in Ireland in 2024 were from people born outside Ireland.
This is consistent with an article published by The Irish Times on March 21, 2024, titled “Increase in TB cases sends Ireland further away from elimination target.”
The article reports data from the HPSC which noted that there were 224 notified cases of tuberculosis in Ireland in 2023. It states: “Sixty-six per cent of cases last year were in people born outside Ireland,” thereby highlighting a higher incidence rate among foreign-born individuals compared to those born in Ireland.
The impact of immigration on TB incidence rates across the EU is well documented. Data collated by the European Centre for Disease Prevention and Control (ECDC) and in particular the ECDC’s Tuberculosis Surveillance and Monitoring in Europe confirms that while there are country specific variations, the disproportionate burden of TB incidence level is to be found among migrants.
The ECDC also confirms that in 2022, 36 179 cases of TB were reported in all EU/EEA countries. However, the number of cases reported in Romania (9270) accounted for 25.6% of all TB cases reported in 2022, and a rate per 100 000 population of more than six times the EU/EEA rate.
This is particular concern to Ireland as Romanian nationals are now one of the largest immigrant groups in the state. According to Ireland’s Central Statistics Office (CSO) the 2016 Census estimated that there were approximately 29,186 Romanian nationals were living in Ireland. However, by 2022 the number of Romanian-born residents increased to 43,000, reflecting significant growth over six years.
Ireland’s Striving to End Tuberculosis – A Strategy for Ireland 2024 – 2030 also clearly recognises the link between immigration and TB rates.
It outlines its own assessment that in low-incidence countries like Ireland a large proportion of TB cases occur among recent migrants and the majority of cases arising from the reactivation of the disease that is often concentrated in vulnerable population groups.
The Strategy has strongly recommended that because of this these groups should be the focus of heightened prevention activities such as health surveillance, selective Bacillus Calmette-Guérin (BCG) vaccination and contact tracing.
Moreover, recent research highlights another significant concern: latent tuberculosis infection (LTBI), where individuals carry TB bacteria without active symptoms. The World Health Organization estimates that approximately a quarter of the global population harbours latent TB, representing an immense reservoir for potential future cases, particularly when immunity weakens. For Ireland, addressing LTBI could play a pivotal role in meeting national targets, as latent infections often progress to active disease years after initial exposure.
Addressing latent TB proactively through screening programs, especially among high-risk populations, is therefore recommended in the 2024–2030 Strategy as a crucial preventive measure. Additionally, the use of advanced diagnostic technologies, such as Interferon Gamma Release Assays (IGRA), is increasingly advocated by public health professionals to accurately detect latent infections early. Expanding access to these diagnostic tools within primary healthcare settings could significantly enhance Ireland’s ability to identify at-risk individuals before active disease develops, thus aligning more effectively with WHO’s broader objectives for TB eradication.
It also suggests that in order to improve the surveillance of TB and to strengthen the prevention of TB among at-risk groups, Ireland must increase the level of collaboration it currently has with European and other international health organisations.