People not Pathogens. Al Story

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Elizabeth Cole
5 years ago
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1 People not Pathogens Al Story

2 Plan Changing epidemiology ACF - Case management - Missed opportunities

3 Epi transition Exposure and infection Overcrowding Homelessness Incarceration Health care access Progression to active disease Drug and alcohol use Smoking Poor nutrition Co-morbidities

4 TB mortality England & Wales

5 TB & Inequality 1. Correlates with income equality 2. Disproportionately affects vulnerable groups internationally 3. Exacerbated by economic recession 1. Suk JMD, Buscher G, Semenza JC (2009) Wealth inequality and TB elimination in Europe. Emerging infectious diseases 15: Semenza JC, Giesecke J (2008) Intervening on infections in inequality. American Journal of Public Health 98: Suhrcke M, Stuckler D, Suk JE, et al. The impact of economic crises on communicable disease transmission and control: a systematic review of the evidence. PLoS One. 2011;6(6):e Epub 2011 Jun 10.

6 Public Health England 2013

7 Wealth map of London

8 TB Prevalence Story A et al. Thorax Aug;62(8):667-71

9 17% of all cases 30% of all infectious cases 50% of all infectious drug resistant cases Story A et al. Thorax Aug;62(8):667-71

10 Addiction Homeless Prison

11 Key exemplars Homeless people Insecure/overcrowded - Hostels - Street Substance users In treatment or Not engaged Prisoners Current and ex Vulnerable migrants Street homeless, destitute, NRPF

12 Convergence Clinical and Social risk Homelessness TB patients in London 2 x risk of being AFB+ aor 1.8, 95% CI x risk of MDR TB aor 2.9, 95% CI x risk of non-adherence aor 10.2, 95% CI Anderson C, Anderson S, Story A. Homelessness is an independent risk factor for infectious and MDRTB in London: retrospective cohort analysis. Public Health England Field Epidemiology Conference 2014

13 Passive-case finding Step 4: Get results Step 3: HCW offers right care Step 2: Find diagnostic services and present Step 1: Recognise self at risk or have symptoms

14 Who have you infected?

15 Know your local population Inverse care law invisible populations Social network analysis + GIS

26 Right tool for the job >95,000 CXRs 1% Query Active TB - 2% Old fibrotic lesions Case finding rate - undetected active PTB homeless people and drug users 230 per 100,000 prisoners 215 per 100,000

A, Aldridge RW, Abubakar I, Stagg HR, Lipman

27 CXR Sensitivity 82% (95% CI 67.3 to 91.8%) Specificity 99.3% (95% CI 99.1 to 99.3%) PPV 0.23 Two-thirds less likely to be AFB + Story A, Aldridge RW, Abubakar I, Stagg HR, Lipman M, Watson JM, Hayward AC. Active case finding for pulmonary tuberculosis using mobile digital chest radiography: an observational study. Int J Tuberc Lung Dis Nov;16(11):1461-7

28 Detection to Diagnosis Pre Find&Treat 53% LFU pre-diagnosis

29 Going further Diagnosis + +

30 + +

support Housing Addiction Mental health Destitution

31 Social Determinants Model of Care Treatment engagement (DOT multiple options (VOT) Psychosocial support Housing Addiction Mental health Destitution Criminal justice Olallo House TB Hostel Video Observed Treatment

32 Impact <6% lost pre-dx 75% of LFU s located and returned to service 84% of cases detected complete treatment vs 83% of all cases nationally!

33 Highly cost effective

34 Identifying and managing tuberculosis among hard-to-reach groups In major urban centres and areas of identified need commissioners should: Offer BBV testing alongside radiology

35 Missed opportunities

36 Active TB Latent TB 0.25% (10% HIV+) 17% Hep C (HCV) Hep B (HBV) HIV 13% 1% (64% no immunity) 1% Story A et al NIHR TB Reach PHE Warwick Sep 2013

37 POCT Simultaneous detection of HIV, HCV and HBV (Multiplo, MedMira Inc, NS, Canada) Hand-held PCR platform Rapid genotype, treatment markers and viral load (Genedrive technology, Epistem Ltd. Manchester, UK)

38 Tele-radiology and rapid TB PCR diagnostics POCT for HIV, HCV, HBV and PCR diagnostics On-the-spot Flu, PPV and Hep B vaccination Laboratory Digital X-ray Reporting station Reception Clinical examination

40 Conclusion Co-morbidity one-stop-shop Social determinants Integrate - screening and case management Outreach combined screening platforms in high burden countries

42 Thank you

30-year-old male crack-cocaine user presented to A&E with heamoptysis. Given oral antibiotics for presumed bronchitis and discharged home. 2 weeks later presented with heamoptysis.

43 30-year-old male crack-cocaine user presented to A&E with heamoptysis. Given oral antibiotics for presumed bronchitis and discharged home. 2 weeks later presented with heamoptysis. CXR and CT revealed a cylindrical density in the lumen of the left mainstem bronchus. 1-cm diameter glass tube with jagged edges removed by bronchoscopy. No recollection of aspiration! Kovitz KL, Mayse ML, Araujo CE, David O. Self-stenting with a crack pipe: the ultimate in 'managed care'. Respiration Jan-Feb;71(1):91.

44 TB and Crack Use 86% of crack cocaine users were smear + on diagnosis vs 36% of patients not known to use drugs Story A, Bothamley G, Hayward A. Crack cocaine and infectious tuberculosis. Emerg Infect Dis Sep;14(9):

45 Smoking crack cocaine alters alveolar macrophage function and cytokine production Crack users have thermal airways injury

TB control. Assumptions. Reality. Symptomatic patients seek care. Patients and professionals don t recognise symptoms

TB control. Assumptions. Reality. Symptomatic patients seek care. Patients and professionals don t recognise symptoms Dr Al Story TB control Assumptions Symptomatic patients seek care Patients self administer treatment Active Case Finding (ACF) is too resource intensive Patients are hard-to-reach Reality Patients and