Tuberculosis

Cathriona Kearns and Michael Devine ‘Health Protection Inequalities on the Island of Ireland’ Seminar, 18 February 2016 ,

Belfast

William Hogarth. Gin lane

Tuberculosis – ‘The perfect expression ofan imperfect civilisation’1

1.Dormandy T. The white death. New York: New York University Press, 2000.

Social determinants of TB

Risk factors for TB infection

• Age: young adults/Young children/the elderly

• Contact with a TB case

• Immunocompromised patients

• Ethnic minority groups: A large proportion of TB cases occur in those from ethnic minorities, In addition, those individuals born in, or arrived from, or returned from countries with a high incidence of TB within the last 5 years are at greater risk with a greater than average lifetime risk that extends to their children and close contacts born in the UK.

• Lifestyle factors: alcohol or drug misuse. Less likely to access health services during the early stages of disease.

• Living in crowded or unsanitary accommodation: (homeless, prison, poverty, malnutrition, overcrowding and poor housing encourage the spread of TB).

• Smoking, diet: More than 20% of TB cases worldwide are attributable to smoking

Epidemiology of TB in Northern Ireland

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

10

20

30

40

50

60

70

80

90

100

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Non-UK UK born Rate/100,000 Mean rate

Num

ber o

f cas

es

NI r

ate

per 1

00,0

00

TB case reports and rate (per 100,000) Northern Ireland, 2000-2014

2008 2009 2010 2011 2012 2013 20140.0

0.5

1.0

1.5

2.0

2.5

3.0

UK-born

Rate

per

100

,000

2008 2009 2010 2011 2012 2013 20140.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Non-UK born

Rate

per

100

,000

Rates of TB in Northern Ireland in the UK and Non-UK born population

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

2

4

6

8

10

12

14

0-14 15-44 45-64 65+

Rate

(per

100

,000

)

TB age-specific rates, Northern Ireland, 2000-2014

1; 0% 8; 3%

43; 18%

77; 32%

111; 46%

0-45-1415-4445-6465+

4; 2%

201; 80%

39; 15%

8; 3%

5-1415-4445-6465+

Age profile of UK and Non-UK born TB cases 2008-2015

Non-UK born (n=252)

UK born (n=240)

Distribution of Northern Ireland TB cases 2000-2015 by HSCT

MonaghanCavan

Donegal

Louth

2000-2002

2001-2003

2002-2004

2003-2005

2004-2006

2005-2007

2006-2008

2007-2009

2008-2010

2009-2011

2010-2012

2011-2013

2012-2014

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

BHSCT NHSCT SEHSCT SHSCT WHSCT

Rate

per

100

,000

Three year moving average rates of TB cases by HSCT in Northern Ireland, 2000-2014

1 2 3 4 50.0

2.0

4.0

6.0

8.0

10.0

12.0

Deprivation quintile (1= most deprived, 5= least deprived)

Rate

per

100

,000

The Index of Multiple Deprivation (IMD) 2010, is an overall measure of multiple deprivation experienced by people living in an area and is measured at Super Output (SOA) level. Commissioned output is based on Small Area Population Estimates for 890 Super Output Areas in Northern Ireland. NISRA - Demography and Methodology Branch

Rates of TB by deprivation, Northern Ireland 2014

Q1 Q2 Q3 Q4 Q50.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

UK-born Non-UK born

Prop

ortio

n of

case

sProportion of Northern Ireland TB cases living in deprivation by

country of birth (n=1063)

Distribution of Northern Ireland TB cases 2008-2015 by deprivation quintile and UK/Non-UK born

UK born

c

Distribution of TB cases in Belfast area 2008-2015 by deprivation quintile and UK/Non-UK born

UK born

Distribution of TB cases in Southern area 2008-2015 by deprivation quintile and UK/Non-UK born

UK born

The drivers behind increasing numbers in the SHSCT- an example of a recent Investigation

• In-migration increased rapidly in the period following EU enlargement in 2004- Migration inflows are concentrated in Belfast and the SHSCT, with Dungannon the most popular location in the latter.

• Compared to the UK, NI based EU accession migrants are disproportionately found in manufacturing areas.

• This area experienced a large influx of migrant workers first Portuguese and then A* nationals.

• Migrant workers face poor quality housing largely in the private sector often resultant in overcrowding. Migrant worker households in this area tend to be large, younger, predominantly male with high employment rates but lower incomes than comparable households in the area (Campbell and Frey, 2010).

2054282014 pul smear-ve138843

2011 non-pul

Same house flat10

1526192012 pul smear+ve

201478 2013 pul sputum smear-ve culture+ve

216230 2015 pul smear -ve

2075582014 nonpul

Same house different flat Same house flat11

2029342014 pul smear-ve

Factory 2

Factory1

vntr

Legend

VNTR cluster 1Work colleagues

Same addressVNTR cluster2

Same addressEmployer N/K

141132 2012 Non-pul cervical node LTF209102 pul. Labs all –ve:clinical

2014

Same address

207431 2014 pul sputum -ve

207335 2014 pul sputum -ve

214006 2015 CNS culture +ve smear N/K

All live same area different address

VNTR cluster3

Cluster 3

2131882015 Pulmonary culture & smear+ve

2012 152878Non-pulmonary. Iso & Strp. Resistant

1428942012 Pul. Smear +ve

VNTR cluster4

Same address

2013 Clinical

Cluster 4

• With the exception of one case all cases are from a high incident country (Timor-Leste) • incidence rates of TB are estimated to be in the region of 400/100,000.

• All cases lived in a similar area of Northern Ireland • All cases are male of working age• VNTR cannot infer timing or direction of transmission

Anecdotal evidence of :• Shift work with multiple individuals sharing accommodation (same beds night v day shifts)• Poor accommodation – low rent to allow for sending money back home*• Most individuals in this community smoke – not known if cases did/did not *• Linguistic barriers. English not widely spoken in E.Timor*• Access to healthcare may be limited due to shift work- differential consequences relating

to pay if absent• Cultural perceptions of the illness (stigma) and effectiveness of treatment*

• Factory owners fair employers but concerns directed towards business /productsreputation not just the health of the employees (source PHE).

*Ref: G. Peake,2013

Considerations…….

The social conditions in which people live and work can help create or destroy theirhealth. Lack of income, inappropriate housing, unsafe workplaces and lack of accessto health care systems are some of the social determinants of health leading toinequalities. (World Health Organization [WHO], 2004)

Prior to entry, a migrant’s health reflects the disease profile of his or her country of origin….. In a new country, living and/or working conditions can also affect a migrant’s health (ECDC, 2009)

Crowded, unventilated living conditions facilitate the spread of TB infection. Poor housing conditions have been documented among migrants and ethnic minority groups in the EU (Bates et al., 2004; Wanyeki et al.,2006; ECDC & WHO Regional Office for Europe, 2009)

Health services may be inaccessible by those most in need for several reasons: e.g. gender, geographic distance from health care facilities, the costs associated with receiving care and fear or stigma (WHO, 2010)

Health behaviours influenced by social/ personal/ environmental factors (peer networks, income or other resources, access to facilities and amenities, food production and promotion, work and living conditions, cultural practices, stress and isolation)

• Improvements in the collection of relevant health data, on an all-Ireland basis, would make an important contribution to working for greater health equity.• The collective burden of TB on the Island of Ireland/ most affected

populations/ identifying principal risk factors • The principal TB strain types (Types found in NI not similar to elsewhere in

UK)• Identifying reason for non-compliance/late access to services

• Analysis of patient trajectories, particularly those suffering from multiple morbidities, can complement quantitative analysis of health system functioning.

• Not all associations between social determinants and epidemiological data can easily be accessed via statistical analysis (Blas & Sivasankara Kurup)

Considerations…….

• Chris Nugent , Eamon Nancarrow, Paul Cabrey, Dr Declan Bradley, PHA

• Dr Rory Convery, Nuala McNeice, Audrey Johntson, Respiratory Team SHSCT

• Dr Colin Goldsmith and team, Regional Microbiology Laboratory Northern Ireland

• Public Health England, TB and Microbiology Teams

Lönnroth K et al. (2009a). Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Social Science & Medicine,68(12):2240–2246.

Campbell D. and Frey J. (2010) Migrant workers and the housing market a case study of Dungannon, NIHE

Peake, G. (2013) Beloved Land -Stories, Struggles, and Secrets from Timor-Leste

WHO (2004). Interim policy on collaborative TB/HIV activities. Geneva, World Health Organization (http://www.who.int/hiv/pub/tb/en/Printed_version_interim-policy_2004.pdf, accessed 10 April 2010).

ECDC (2009). Migrant health: background note to the ECDC report on migration and infectious diseases in the EU . Stockholm, EuropeanCentre for Disease Prevention and Control (http://www.ecdc.europa.eu/en/publications/Publications/0907_TER_Migrant_health_Background_note.pdf, accessed 20 February 2010).

Bates I et al. (2004).Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individualand household level. The Lancet Infectious Diseases, 4(5): 267−277.

Wanyeki I et al. (2006). Dwellings, crowding, and tuberculosis in Montreal. Social Science and Medicine, 63(2): 501–511.

WHO Regional Office for Europe. Plan to Stop TB in 18 High-priority Countries in the WHO European Region, 2007–2015 .Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/document/E91049.pdf, accessed 25 January 2010).

Blas E, Sivasankara Kurup A (in press). Synergy for equity. In: Blas E, Sivasankara Kurup A, eds. Priority public health conditions: from learningto action on social determinants of health. Geneva, World Health Organization.

References