B R E A K F A S T
Plan A bit about TB What I do What I should do
575,475 583,350 810,120 667,228 755,605 7,753,555 1,068,532 2,199,500 3,442,675 1,698,957 3,255,944 2,724,347 745,514
121 39 58 113 3,440 320 515 143 269 256 580 487 91
Western European Capital Cities (2009 pop. > 0.5M) Oslo Helsinki Copenhagen Athens Amsterdam Stockholm Brussels Vienna Paris Rome Madrid Berlin London 121 58 113 91 143 39 320 256 515 487 580 269 3,440 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000
Western European Capital Cities (2009 pop. > 0.5M) Oslo 121 Helsinki 58 Copenhagen 113 Athens 91 Amsterdam 143 Stockholm Brussels 39 320 2,992 Vienna 256 Paris 515 Rome 487 Madrid 580 Berlin 269 London 3,440 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000
709,145 558,165 7,753,555 1,711,466 1,711,466 1,233,211 1,249,798 1,944,226
305 178 3,440 128 304 321 457 1,694
Eastern European Capital Cities (2009 pop. > 0.5M) Vilnius Riga Prague Sofia Budapest Warsaw 178 305 128 457 321 304 Bucharest 1,694 London 3,440 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000
Eastern European Capital Cities (2009 pop. > 0.5M) Vilnius Riga Prague Sofia Budapest Warsaw 178 305 128 457 321 304 3,387 Bucharest 1,694 London 3,440 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000
TB: Comparison case numbers UK, US and London Source: Centers for Disease Control and Health Protection Agency 2013
Infection and Inequality Infectious diseases disproportionately affect vulnerable groups in every single EU Member State [1] 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: 787 792. 2. Suk JMD, Buscher G, Semenza JC (2009) Wealth inequality and TB elimination in Europe. Emerging infectious diseases 15: 1812 1814. 3. 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):e20724. Epub 2011 Jun 10.
Janssens JP, Rieder HL. Eur Respir J 2008;32:1415-6
TB in London Highest rates of TB in Western Europe [1] 10.2% of cases are now drug resistant [2] Significant increase in MDRTB [2] Homelessness independently associated with MDRTB [1] European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2012. Stockholm: European Centre for Disease Prevention and Control, 2012. http://ecdc.europa.eu/en/publications/publications/1203-annual-tb-report.pdf [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.
DR 2011
Percentage of Households below 60% of median income http://data.london.gov.uk
Inequality
UK born (20%) Foreign born (80%)
Britain will be 'swamped' by TB Rise of drug-resistant tuberculosis in the UK 'is linked to immigration Health Minister: Immigrants to blame for record rise in TB Time Bomb - Migrants to bring drug-resistant TB superbug to UK
London TB Profile study - TB Prevalence 1200 1000 800 600 400 200 0 Story A et al. Thorax. 2007 Aug;62(8):667-71
17% of all cases 30% of all infectious cases 50% of all infectious drug resistant cases Story A et al. Thorax. 2007 Aug;62(8):667-71
Hard-to-reach (1:6)
Active case finding Core business Circa 10K screens per year - 290 sessions Support the most complex cases >1,500 referrals so far (34% DR - 68 MDR, 6 XDR) Locate & return to service >250 active TB cases returned so far Training / awareness Peer educators 3 rd Sector non-clinical professionals
Detection (1960 s)
Detection (21 st C) Dutch fleet
XX/07/2005
XX/12/2006
XX/07/2008
CXR 1 in 4 referred start TB treatment Two-thirds less likely to be infectious 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. 2012 Nov;16(11):1461-7
Housing - TB hostel
Impact Early detection prevents future cases Overall 84% of active cases detected or referred are treatment engaged or completed
Highly cost effective
Next steps TB HCV HBV HIV Flu PPV HBV
N I I S Mobile Health Units NIIS Infectious diseases TB 1) Active pulmonary TB [CXR and PCR] 2) TB infection [abnormal CXR >35] * Blood Borne Viruses [Hepatitis B & C, HIV] [Saliva swabs] Venous blood for saliva positives * Vaccine preventable diseases Hepatitis B 1) if neg. on saliva 2) no/incomplete history 3) >5 years Influenza all seasonally PPV - pneumococcal pneumoniae and invasive disease [all not vaccinated] Health MOT Rapid Health Survey [standardised] Health MOT from local primary care specialists [agreed and determined locally] Peer led health promotion * Those requiring full venous bloods will also have IGRA
Force of infection 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. 1996 May;86(5):655-61
Why are we here
Phthisie des pauvres - Guerre au bacille The states responsibility to improve the lot of the masses The physicians responsibility to kill the bacilli
Pidoux What a calamity such a result would be! poor consumptives sequestered like lepers; the tenderness of their families at war with fear and selfishness. Hermann Pidoux, in Discussion sur la tuberculose (at Academy of Medicine, December 3 and 10, 1867), Bulletin de l Académie impériale de médecine 32 (1866 67): 1254 1255, 1261.
Pidoux A medicine of the species above and beyond the medicine of the individual Tuberculosis requires more advanced and more social solutions Hermann Pidoux, in Discussion sur la tuberculose (at Academy of Medicine, December 3 and 10, 1867), Bulletin de l Académie impériale de médecine 32 (1866 67): 1254 1255, 1261.
Pidoux 1: Diatheses Constitutional predisposition Hermann Pidoux, in Discussion sur la tuberculose (at Academy of Medicine, December 3 and 10, 1867), Bulletin de l Académie impériale de médecine 32 (1866 67): 1254 1255, 1261.
Pidoux 2: External Poverty (misère) ignorance overwork malnutrition unsanitary housing Hermann Pidoux, in Discussion sur la tuberculose (at Academy of Medicine, December 3 and 10, 1867), Bulletin de l Académie impériale de médecine 32 (1866 67): 1254 1255, 1261.
Pidoux 3: Internal Poverty (misère) various chronic diseases laziness habits of luxury flabbiness - excesses at table the torments of ambition Hermann Pidoux, in Discussion sur la tuberculose (at Academy of Medicine, December 3 and 10, 1867), Bulletin de l Académie impériale de médecine 32 (1866 67): 1254 1255, 1261.
Pidoux Central to Pidoux s proposed solution was an unprecedented government-sponsored network of local associations to investigate and remedy the social causes of tuberculosis at the local level Hermann Pidoux, in Discussion sur la tuberculose (at Academy of Medicine, December 3 and 10, 1867), Bulletin de l Académie impériale de médecine 32 (1866 67): 1254 1255, 1261.
Robert Koch - March 24th 1882
An Address on the MODERN TREATMENT OF PULMONARY PHTHISIS By C. Theodore Williams M.D. F.R.C.P. London CONSULTING PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, BROMPTON Koch s brilliant discovery, while it has largely assisted diagnosis it cannot be said to have contributed much to the progress of treatment. It was the signal for an enthusiastic outburst of antiseptic or bacillicide measures. All efforts short of destroying the patient were directed to slaughter the Tubercle bacillus. The Lancet. Nov 3, 1894 pp 1021-
A Lecture on the NEW METHOD OF TREATMENT OF CONSUMPTION AND OTHER DISEASES OF THE RESPIRATORY ORGANS BY GASEOUS RECTAL INJECTIONS By I. Burney Yeo M.D. F.R.C.P. PROFESSOR OF CLINICAL THERAPEUTICS IN KING S COLLEGE, AND PHYSICIAN TO KING S COLLEGES HOSPITAL The Lancet. April 16, 1887 pp 761-65
Notification rate per 100,000 population Death rate per 100,000 population 350 300 250 200 150 1963 Rifampicin 1962 Ethambutol 1954 Pyrazinamide 1952 Isoniazid 1949 p-aminosalicylic acid 1943 Streptomycin 160.0 140.0 120.0 100.0 80.0 60.0 100 40.0 50 20.0 0 0.0 1913 1916 1919 1922 1925 1928 1931 1934 1937 1940 1943 1946 1949 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 Year
A new approach to controlling a social disease Political commitment Emphasis on prevention & control measures Financial support Health education of the general public Tuberculosis as a Disease of the Masses and How to Combat it. Knopf, 1901.
Without Koch s discovery, the socio-economic character of tuberculosis would have been clearer, and a demand for redistribution of the wealth of the community would have been a much more important issue Waaler 1982
Thanks to you and the outreach team, and our partners, punters and pundits