Tuberculosis in vulnerable populations

Professor Michel Kazatchkine UN Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central

Asia

Individual and social risk factors for developing active TB

• Being poor • Being Homeless • Being incarcerated • Living with HIV • Using drugs • Misusing alcohol • Smoking • Diabetes • Elderly • Ethnic minority/ indigenous population • Migrant • Health care worker • Immuno-compromizing disease and treatment

TB and economic recession, 1990s Excess morbidity driven by a process common to 15

Central & Eastern European countries

Ukraine

Russia

Moldova

Latvia Kyrgyz

Republic

Georgia

Estonia

Bulgaria

R2 = 0.94

0

10

20

30

40

0 5 10 15 20 25

Lost economic productivity (stnd GDP/head)

Ex

ce

ss

TB

ca

se

s (

stn

d/h

ea

d)

X Cuba

Source: Arinaminpathy N, & Dye C. Health in financial crises: economic recession and tuberculosis in Central and Eastern Europe. J. R. Soc. Interface 2010 doi:10.1098/rsif.2010.0072

VULNERABILITY TRANSLATES INTO HIGHER RISK OF

• Becoming exposed to TB

• Progressing from latent infection to active disease

• Not being diagnosed or of being diagnosed late

• Not accessing treatment and/or of not completing treatment successfully

• Being discriminated and marginalized socially, including by the health care system

• Confronting “catastrophic” costs due to TB

• Acquiring MDR TB

6

Policemen flank prison health care clinic in Ukraine

Photo: Gladyelov

TB and prisons; WHO Europe, 2012 6.4% of total new TB cases are reported from prisons (1.6% in EU/EEA and 7.4% in non-EU/EEA)

0

10

20

30

40

50

60

0

500

1000

1500

2000

2500

Rel

ativ

e ri

sk

TB n

oti

fica

tio

n r

ate

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0,0

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inm

ates

Relationship between average TB incidence and

incarceration rates, 1991–2002.

David Stuckler et al. PNAS 2008;105:13280-13285

©2008 by National Academy of Sciences

Same national TB guidelines than civilian system (equivalence); need of more (equity of health status in-out prisons)

Airborne infection control

Early case detection through a combination of screening methods (entry, periodic, contact, passive)

Early diagnostics (rapid methods) and effective treatment under direct observation

Comprehensive care (HIV, hepatitis, etc.)

Recording and reporting

Continuity of care after prison release

Awareness, health education

Social support

WHO. Prison and health. Copenhagen: WHO, 2014

Prisons: key actions for TB control

• Igor, 44, Kirovograd, Ukraine

Association between HIV and MDR-TB in Europe

TB surveillance and monitoring in Europe 2014. ECDC/WHO, Stockholm

Post et al, Journal of Infection (2014) 68, 259-263, (Belarus, Latvia, Romania, Russia & Ukraine)

WHO UNAIDS UNODC recommended health sector interventions for HIV prevention, treatment and care

for people who inject drugs

• Comprehensive condom programming

• Harm reduction interventions (needle exchange, opioid substitutive therapy)

• Behavioral interventions

• HIV testing and counselling

• HIV treatment and care

• Prevention and management of viral hepatitis and tuberculosis

• Sexual and reproductive health interventions

13

Фото: Hans Jürgen Burkard

Photo; Hans Jurgen Burkhart

Drug user awaits interrogation, Tajikistan

WHO UNAIDS UNODC recommended strategies for an enabling environment

• Supportive legislation, policy and financial commitment, including decriminalization of certain behaviors of key populations

• Addressing stigma and discrimination, including making services available, accessible and acceptable

• Community empowerment

• Addressing violence against key populations

• Olga, 48, Odessa

ECDC/WHO-Europe. Tuberculosis surveillance and monitoring in Europe 2014 Stockholm, ECDC, 2014

Notified TB cases by origin; EU/EEA, 2012

0%

25%

50%

75%

100%

Unknown Native origin Foreign origin (birthplace) Foreign origin (citizenship)

Source: Project Hope, IOM, IFRC, WHO. Situation analysis for Global Fund, 2011.

TB and migration in Eastern Europe

699 (21%)

394 (12%)

2,267 (67%)

0 500 1000 1500 2000 2500

Hospitalized

Deported

Unknown

TB in labour migrants; Russian Fed, 2007

National TB burden (estimated) due to labour migrants; CAR, 2011

Source: N. Frolova, Unit for Surveillance of Inf. and Parasitic Diseases, Moscow. Presentation in Wolfheze 2008. (600,000 persons examined during Mar-Dec

2007 3,058 TB cases detected [>500 per 100,000])

Vulnerability of labour migrants

Huffman SA, et al. Exploitation, vulnerability to tuberculosis and access to treatment among Uzbek labour migrants in Kazakhstan. Social Science & Medicine (2011), doi:10.1016/j.socscimed.2011.07.019

The Wolfheze trans-border migration task force consensus, 2012

• Defining a consensus minimum package of cross-border TB control and care

• Recommending to address current shortcomings in political commitment (including a legal framework for trans-border collaboration), financial mechanisms and adequate health services delivery (prevention, infection control, contact management, diagnosis and treastment and psychosocial support)

Actions: from prime minister to clinic

Know your epidemic, document determinants and risk factors Link TB control to development agenda and poverty alleviation

Contribute to public health interventions to address risk factors

Identify health care barriers, improve access : – Free TB diagnosis and treatment, decentralisation, integration – Outreach, health information, enablers, screening, mobile teams targeting

vulnerable, etc

Provide comprehensive treatment, care and support a. Provide social and financial protection for TB affected families – Cash transfer, food assistance, social support, microcredit, housing assistance – Regulation on workers' protection and sickness insurance b. Screen for and manage TB co-morbid conditions – HIV, smoking, diabetes, under-nutrition, alcohol/substance use disorder

Synthesis report of the UN SG on the post-2015 sustainable development agenda

• If the global community does not exercise national and international leadership in the service of the people, we risk further fragmentation, impunity and strife, endangering both the planet itself as well as the future of peace, sustainable development and respect for human rights. Simply put, this generation is charged with the duty of transforming our societies.

Acknowledgements

• Masoud Dara, Pierpaolo de Colombania and the TB team, WHO Euro, Copenhagen

• Knut Lonnroth, Global TB program, WHO, Geneva

• Misha Friedman, Raminta Stuikyte, Vilnius; the HIV/AIDS Alliance, Ukraine