This week’s Health Information & Quality Authority (HIQA) recommendation to move from universal to selective BCG vaccination against TB for high risk groups raises concerns. A serious concern is that the Government acts to improve Traveller living conditions.
Why are Travellers a High Risk Group?
Firstly, it is important to understand why Travellers have been identified as a high risk group.
The All Ireland Traveller Health Study (AITHS 2010) indicated that Travellers are at higher risk of respiratory disease and have approximately 6 times the rate of deaths from respiratory conditions than the general population .
New data emerging from detailed analysis of the AITHS shows that the higher rate of respiratory disease among Travellers is significantly associated with their living conditions.
The AITHS, which was commissioned by the Departments of Health in the Republic and in Northern Ireland, has extensive evidence on the health status and health needs of Traveller.
We have overwhelming evidence what we now need is an action plan to implement the findings of the AITHS urgently and address the widening gap between the health status of Travellers and the general population.
In his research paper ‘Tuberculosis incidence in the Irish Traveller population in Ireland from 2002 to 2013’ Ronan O’ Toole gave an estimate of the rate of TB in Travellers from data extracted from the national disease surveillance unit.
We have reservations on aspects of these findings as they were based on assumption of Traveller identity rather than self- identification and this could lead to an over or underestimation of rates. Some analysis in this paper also used CSO Traveller Census data, as the denominator population which is an accepted undercount, so this can lead to an overestimation of true rates. The only way to get accurate rates is to include an ethnic and cultural identifier on health data sets.
Selective Vaccination – No clear benefits for Travellers
As it is, high risk groups are already being vaccinated through universal vaccination and it is not clear what additional health outcomes will be achieved for Travellers following a switch to selective vaccination.
HIQA have, in their document, acknowledged the role of improved socioeconomic conditions and nutrition in the reduction of TB. Overcrowding at Traveller accommodation, and in some cases dire living conditions for Traveller, has been an ongoing concern of Pavee Point and is an issue that was recently highlighted by the Carrickmines Fire Tragedy.
The criminalisation of nomadism and the increase in costs of private rented accommodation has also contributed to this situation of overcrowding.
In this context, HIQA do not explain in how vaccination alone will bring down the number of new cases of TB without improvements in the health status and living conditions of Travellers .
How do we know who is a Traveller?
As data collection within the health service does not include a mainstream ethnic identifier it is also a concern to us as how high risk groups are to be identified. Reliable and consistent use of ethnic identifiers across the health service is essential to avoid mistaken classification of infants as low or high TB risk and to record uptake rates of the vaccine in addition to TB incidence and prevalence in Travellers and to monitor access and outcomes to TB treatments.
Preventative and Protective Measures
To roll out selective vaccination HIQA acknowledges the need for appropriate preventative and protective measures. This, we say, echoes our call for improved living conditions for Irish Travellers. This also acknowledges concerns about the quality of treatment received by Travellers and the low levels of trust Travellers have in health service providers. This is detailed in the AITHS 2010.
HIQA also acknowledges the need for resources for public awareness. We would see this as a potentially important role for Traveller Primary Health Care Workers in Traveller Primary Health Care Projects around the country to combat a possible reluctance among Travellers to participate in vaccination programmes – for fear of being stigmatised and blamed for TB in the country.
Similarily, we would see the HIQA acknowledgement of the importance of consultation with Traveller groups as vital in a more successful vaccination programme.