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

Transcription

1 Dr Al Story

2 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 professionals don t recognise symptoms 18% of all TB patients in London are non-adherent ACF potentially cost saving right population & right tool Services are hard-to-reach

3 Infection and Inequality Infectious diseases disproportionately affect vulnerable groups in every EU Member State [1] TB especially correlates with income equality [2] 1. Semenza JC, Giesecke J (2008) Intervening on infections in inequality. American Journal of Public Health 98: Suk JMD, Buscher G, Semenza JC (2009) Wealth inequality and TB elimination in Europe. Emerging infectious diseases 15:

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5 TB in London Highest rates of TB in Western Europe [1] More cases annually than Belgium, Denmark, Greece, Netherlands and Norway combined [1] 10% of cases are now drug resistant [2] Significant increase in MDRTB [2] [1] European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe Stockholm: European Centre for Disease Prevention and Control, [2] Tuberculosis in London: Annual report (2011 data). Health Protection Agency London Regional Epidemiology Unit, September 2012.

6 Vulnerability to infectious diseases is further exacerbated by economic recession [1] increasing contact rates greater sub-group susceptibility worse treatment access & care quality [1] 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.

7 Homelessness 36% increase in number of households accepted as homeless 43% increase in rough sleepers (25% E. Europe) 70% increase in new rough sleepers

8 Destitute migrants NRPF No right to remain Many trapped

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10 300,000 Arrests 56,000 Detained 73,000 on Bail 30% London sentenced prison releases <28 days served London 2009/10

11 Who is Hard-to-reach? Anyone whose social circumstances or lifestyle makes it difficult to:- recognise TB symptoms access health services self-administer treatment and attend regular hospital appointments

12 Key exemplars Homeless people Insecure/overcrowded - Hostels - Street Substance users In treatment - Not engaged Prisoners Current and ex Homeless poly-drug using ex-prisoners

13 Enhanced Case Management (ECM) (x%) Standard Care (y%)

14 Overcrowding Immunosuppression Delayed diagnosis High contact rate

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18 In major urban centres and areas of identified need commissioners should: ensure there is a programme of active casefinding using mobile digital radiography in places where homeless people and substance misusers congregate consider offering homeless people and substance misusers other health interventions when they are screened for TB at a mobile X-ray unit e.g. bloodborne virus [BBV] screening

19 Active case finding Core business 10K screens per year sessions Support the most complex cases >1,300 referrals so far Locate & return to service >250 active TB cases returned so far Raise awareness Peer educators 3 rd Sector non-clinical professionals

20 Peer educators A peer is someone who feels it and knows it

21 Mobile X-ray Unit 64,039 CXRs 1% Query Active TB - 2% Old fibrotic lesions 47,788 homeless people and drug users 230 per 100,000 16,242 prisoners 215 per 100,000

22 Radiology (19 th C) Mobile Digital (21 th C)

23 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 + 81% complete Rx in 1 year

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27 Risk factors for LTBI and HCV Risk of LTBI Age Foreign birth (OR, 6.59; CI 95, ) Smoking heroin/crack (not injecting) (OR, 2.19; CI 95, ) Injecting (OR, 2.36; CI 95, ) Risk of HCV Injecting (OR, 19.62; CI 95, ) (95% of injectors also smoked drugs)

28 Co-infection 29% of Hep C positives have LTBI 26% Quantiferon positives have Hep C

29 The potential use of non-invasive specimens (e.g. oral fluid) for testing in other settings should be considered. Health Protection Agency: Hepatitis C in the UK 2011; July 2011.

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31 PH37 - Recommendation 12 Identifying and managing latent TB: substance misusers and prison populations 12 weekly doses INH/Rifapentine More effective than 9 INH Less toxic Better treatment completion And mild enzyme-inducing effect

32 Units of alcohol consumed in 6 months Daily alcohol consumption

33 Video Observed Treatment

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36 Crack-cocaine a biological risk factor for infectious TB? 86% of crack cocaine users were smear positive on diagnosis compared with 59% of drug users not known to use crack cocaine (RR 1.6 (CI ) p<0.001) 36% of patients not known to use drugs (RR 2.4 (CI ) p<0.001) Story A, Bothamley G, Hayward A. Crack cocaine and infectious tuberculosis Emerg Infect Dis Sep;14(9):

37 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.

38 Harm reduction? Male crack smoker in his forties

39 21 st century TB control Increase proportion of cases detected actively Address multi-morbidity Eliminate step up care Embed with 3 rd sector partners in the community

40 Thank you

41 TB Symptoms among prisoners Symptoms from 5,616 otherwise healthy prisoners and 30 prisoners diagnosed with active TB through the MXU (80% culture confirmed) >3 weeks Cough, Night sweat, Fever, Weight loss and Haemoptysis Untargeted - Number Needed to Screen (NNS) 495 >3 weeks Cough - Need to screen 22% (95% CI 21-23%) of prisoners with a NNS of 182 but would miss 40% of all active pulmonary cases (95% CI 22-57%)

42 TB Symptoms among prisoners Symptom TB cases Proportion TB cases missed Prisoners screened Yes No Yes No Proportion need to screen Cough (>3 weeks) % % Night sweat % % Fever % % Cough + 1 symptom % % Weight loss % % Haemoptysis % % Any symptom % %

43 TB Symptoms among prisoners Conclusions: Restricting chest radiography to prisoners with symptoms of active TB is likely to lead to many missed opportunities to diagnose cases and prevent transmission