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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
per
10
0,0
00
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
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