Measuring TB burden and access to TB services for people who inject drugs in the WHO European Region, 2010 and 2011 Annabel Baddeley Global TB Programme WHO, Geneva
Outline of presentation Global and European burden and evidence Policy and TB/PWID indicators European data reported for 2010 and 2011 Conclusion
The global burden in 2011 All forms of TB Estimated number of cases 8.7 million (range, 8.3 9.0 million) Estimated number of deaths 0.99 million 1 (range, 0.84 1.1 million) HIV-associated TB 1.1 million (12%) (range, 1.0 1.2 million) 0.43 million (range, 0.4 0.46 million) IDU-related HIV 3 million (19%) 2 (range, 0.76-6.6 million) No data IDU-associated TB No data No data 1. Excluding deaths among HIV+ve people 2. Estimated prevalence in 2007, Mathers et al, The Lancet 2008, 372:1733-1745
HIV in PWID per 100,000, 2011 TB and Multidrug and extensively drug-resistant TB, WHO, Copenhagen, Europe HIV/AIDS surveillance in Europe 2011. ECDC/WHO, Stockholm Estimated HIV in TB cases per 100,000, 2011
PWID with HIV at higher risk of TB HIV/AIDS surveillance in Europe 2010. ECDC/WHO, Stockholm
Drug use, TB, HIV and Prisons Up to 80% of PWID reported history of incarceration 1 Up to 74% prisoners injected and up to 94% shared equipment while in prison 2 PWID & ex-pwid found to be 5 times more at risk of TB/HIV after 23 months in prison than at time of admission 3 The risk of MDR-TB in prisoners found to be around double the rate of the civilian population - RR 1.8 (1.5 2.2) 4 1. Getahun et al, Bull World Health Organ 2013; 91:154 156 doi:10.2471/blt.13.117267 2. Jürgens et al, Lancet Infec Dis 2009;9:57-66 3. Martin et al, INT J TUBERC LUNG DIS 4 (1):41-46 4. Dubrovina et al Int J Tuberculosis Lung Dis 2008; 12:756-762
Policy guidelines for TB and HIV services for drug users UPDATE IN 2014 Joint Planning Service providers National & local coordination body Plans with roles, responsibilities & M&E Human resources and training Support to operational research Package of Care TB infection control plans in care settings Case finding protocols at services drug users present Treatment services for TB and HIV Isoniazid prevention HIV prevention (Harm Reduction Package) Overcoming Barriers Integrated services (Link TB/HIV treatment and harm reduction) Equivalence of care in prisons Adherence support measures Comorbidity not to be used to withhold treatment
TB Indicators for PWID-Targeted Services Number of PWID-targeted services providing TB diagnosis and treatment (key indicator) TB infection control at PWID-targeted services Number of PWID-targeted services providing TB preventive therapy Assessment of PWID TB status by HIV treatment and care services PWID living with HIV starting isoniazid preventive therapy (IPT) Stakeholders are urged to report TB/PWID data nationally
PWID indicators for TB Services in Europe Number of narcology services collaborating with the NTP through referral/diagnosis/ notification of all TB cases Number of all TB cases contributed by narcology services through referral/diagnosis/ notification Among new cases registered in the reporting how many were PWID Stakeholders should work closely with TB Programmes
Analysis and methodology Analysis and comparison of: The proportion of PWID among notified new TB cases versus PWID in the general population in 2010 and 2011 Rates of notification of new TB cases among PWID versus the general population Reported collaboration and contribution by narcology services Data sources: TB data and general population estimates: The Global TB Report 2012, WHO. TB data for PWID were provided by WHO Europe. PWID estimates: Global HIV/AIDS Response Progress Report 2011, WHO, UNAIDS and UNICEF and The Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review, Mathers et al, The Lancet,15 November 2008 Proportions and risk ratios were calculated for European countries where estimates and data were available for general population, PWID and TB cases that were PWID.
Collaboration between TB & Narcology Services Countries Reported collaboration in 2010 Reported collaboration in 2011 Reported TB cases contributed by narcology services Republic of Moldova 1 2 Romania 12 12 Russian Federation 150 Tajikistan 1 9 4 out of 54 European countries reported collaboration
100,000 person years Notification of new TB cases, 2010 and 2011 900 800 700 600 500 400 300 200 100 0 Estonia (40) Kazakhstan (91) General population Latvia (95) PWID Lithuania (18) Republic of Moldova (29) Romania (18) Serbia (1) Tajikistan (2) The Former Yugoslav Republic of Macedonia (18) Ukraine (1182) Uzbekistan (638) In brackets are the total number of new TB patients reported to inject drugs in 2010 and 2011 combined.
100,000 population Proportion of PWID among New TB cases 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 Estonia Kazakhstan Latvia Lithuania Romania Tajikistan The Former Yugoslav PWID per 100,000 gen. population PWID per 100,000 TB cases (2010) PWID per 100,000 TB cases (2011) Republic of Macedonia Ukraine Uzbekistan
Interpretation of the results Higher rates of notification of new TB cases among PWID support evidence that PWID are at higher risk of TB. Lower rates might reflect lower environmental TB infection, limited reporting of drug-use data by TB services and/or inequitable access to TB services. Very low levels of reported collaboration between TB and narcology services. Few countries report TB patients that inject drugs.
Limitations Accuracy of PWID estimates Small numbers of TB/PWID reported in some countries Under-reporting and unlikely to capture the whole story Relies on TB services recognizing/reporting injecting drug use Biases related to PWID access to healthcare (e.g. fear of being reported & criminalization) Unclear if TB data from prisons is included each country
Conclusion Addressing TB among PWID is a public health priority. Harm reduction stakeholders should increase efforts to reach this at-risk group by including TB interventions in their services. Services should be scaled-up in a client friendly manner with due respect to basic human rights Improved monitoring and reliable data on the TB burden and access to TB services for PWID is crucial.
Acknowledgements Andrei Dadu, TB and Multidrug and extensively drug-resistant TB (TBM), WHO Europe Pierpaolo de Colombani, TBM, WHO Europe Smiljka de Lussigny, HIV/AIDS, STI and Viral Hepatitis, WHO Europe Haileyesus Getahun, Global TB Programme, WHO, Geneva Christian Gunneberg, Global TB Programme, WHO, Geneva Linh Nguyen, Global TB Programme, WHO, Geneva Annette Verster, HIV Department, WHO, Geneva