Riga Dr Al Story

Transcription

1 Riga 2013 Dr Al Story

2 Plan TB control - Flawed assumptions 21 st century challenges People not Pathogens Intensified case finding - next steps

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4 Protect the public Treat the patient

5 Infection & Inequality Infectious diseases disproportionately affect vulnerable groups in every EU Member State [1] and internationally TB especially correlates with income equality [2] Vulnerability to infectious diseases is further exacerbated by economic recession [3] 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: 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 Flawed assumptions 1. Sick people seek healthcare Early diagnosis 2. Patients follow medical advice Complete treatment

7 TB: Comparison case numbers UK, US and London Source: Centers for Disease Control and Health Protection Agency 2012

8 TB in London Highest rates of TB in Western Europe [1] More cases annually than Belgium, Denmark, Greece, Netherlands and Norway combined [1] 10.2% 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] Any first line Drug (INH, Rif, E,Z) Tuberculosis in London: Annual report (2011 data). Health Protection Agency London Regional Epidemiology Unit, September 2012.

9 DR 2011

10 Wealth map of London

11 UK born (20%) Foreign born (80%)

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

13 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

14 Hard-to-reach (1:6)

15 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

16 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

17 Risk factors for drug resistance and poor treatment outcomes Not completing TB treatment - homelessness or imprisonment Any drug resistance - drug use, homelessness Multi-drug resistance - previous TB, homelessness TB in London: risk factors for drug resistance, non-adherence and poor treatment outcomes C. Anderson, S. R. Anderson, A. Story PHE National Conference In preparation

18 Drug use Homeless Prison

19 63,000 opiate and/or crack cocaine users aged between 15 and 64.

20 Homelessness - London % increase in rough sleepers (25% E. Europe) 70% increase in new rough sleepers

21 300,000 Arrests 56,000 Detained 73,000 on Bail 30% London sentenced prison releases <28 days served London 2010/11

22 Destitute migrants NRPF No right to remain Many trapped

23 TB rates highest among hardest to reach hardest to treat

24 Case detection strategies Passive Low threshold / one-stop-shop High awareness and clinical suspicion Active Contract tracing Intensified case finding

25 Who have you infected?

26 Where do you think you got TB?

27 Social Network Analysis Structured interviews improve case finding Questionnaires focus on: Drug and alcohol use Residential history Travel history Places of social aggregation Aim: to identify contacts and locations (in the context of high-risk behaviours)

28 Community Networks derived from traditional contact tracing and Social-Network Questionnaires Contact Tracing Social-Network Questionnaire Smear-pos outbreak cases Smear-neg outbreak cases Named contacts Named places of social aggregation Connect active cases to one another Connect active cases to named contacts Connect active cases to places NEJM, Vol 364( 8),pp , feb 2011.

29 TB Risk Poor health service access

30 TB Risk Poor health service access

31 Overcrowding Immunosuppression Delayed diagnosis High contact rate

32 1: Symptom + microscopy low cost & low yield 2: Symptom + microscopy + x-ray 3: X-ray + symptom + microscopy 4: X-ray + symptom + microscopy + culture - high-cost & high-yield 5: X-ray + symptom + Xpert High cost model for Xpert 6: Symptom + x-ray + Xpert Low cost model for Xpert WHO 2011

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34 Detection (1960 s)

35 Detection (21 st C) Dutch style

36 XX/07/2005

37 XX/12/2006

38 XX/07/2008

39 53% lost prior to diagnosis

40 LO S E

41 What did we learn Very high rates of undetected active TB Flawed assumptions Suspected cases don t exist Need a package of health AND social care Leave the hospital Embrace community partners

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43 Pan-London MDT working alongside 30 London TB services plus 223 front-line allied services in every London Borough 84 Hostels 56 Day centres 83 Drug and alcohol projects

44 Active case finding Core business Circa 10K screens per year sessions Support the most complex cases >1,472 referrals so far (34% DR - 68 MDR, 5 XDR) Locate & return to service >250 active TB cases returned so far Raise awareness Peer educators 3 rd Sector non-clinical professionals

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

47 Right tool for the job >75,000 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

48 Sensitivity 82% (95% CI 67.3 to 91.8%) Specificity 99.3% (95% CI 99.1 to 99.3%) CXR 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

49 Impact Early detection = averted transmission Return to service >300 pulmonary cases 75% of LFU s located and returned to service 84% of cases detected complete treatment vs 83% of all cases nationally!

50 Video Observed Therapy

51 Highly cost effective

52 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 Source: NICE PH

53 Going further Diagnosis + +

54 People not Pathogens

55 PTB LTBI HCV HIV HBV

56 Force of infection The steep trajectory in seroprevalence of HCV and HBV within the first year suggests that most new infections occurred very soon after initiation of injection drug use. Garfein RS, Vlahov D, Galai N, Doherty MC, Nelson KE. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. Am J Public Health May;86(5):655-61

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58 Next steps minutes

59 Next steps CAD 4G Teleradiology Multiplo HIV/HCV/HBV (POCT) minutes

60 Conclusions TB cannot be controlled without specific efforts to reach and treat people who are socially excluded and at high risk of disease Service users design and deliver better services

61 Conclusions Intensive cases finding strategies are essential but resource intensive - should be locally tailored and evaluated Need strong case holding service Health AND Social care

62 Conclusions Populations at high risk of TB are co-morbid impact and effectiveness of ICF likely increased by integrating BBV screening and other health / harm minimisation initiatives Integrate care pathways for TB and BBV treatment

63 and lastly What do we mean by cure?

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65 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.

66 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):

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

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