Sanghyuk Shin, PhD Department of Epidemiology UCLA Fielding School of Public Health Aug 27, 2015...

Sanghyuk Shin, PhDDepartment of Epidemiology

UCLA Fielding School of Public HealthAug 27, 2015

Tuberculosis and HIV Co-infection: “A Deadly Syndemic”

Photograph: Union Rescue Mission (www.urm.org)

• LA County Homeless• Estimated 60,000 in

LA County• 5000 in downtown

Skid Row• TB outbreak

• 92 cases since 2007• 16 deaths (17%)• 21% HIV infected

TB Outbreak among Homeless Persons in LA County

1. Background on Tuberculosis

2. Impact of HIV on TB epidemic

3. TB and HIV among LA County homeless persons

Outline

TuberculosisBackground

CDC Division of Tuberculosis Elimination website at http://www.cdc.gov/tb

Active Tuberculosis DiseaseSymptoms

TB infection and disease

TB infection and disease

Active TB disease due to new infection

TB infection and disease

Latent TB infection (LTBI)

Active TB disease due to new infection

TB infection and disease

Latent TB infection (LTBI)

Active TB disease due to new infection

Active TB disease due to reactivation of old infection

TB infection and disease

Latent TB infection (LTBI)

Active TB disease due to new infection

Active TB disease due to reactivation of old infection

90% never develop disease

Detection of TB infection

Tuberculin skin test (TST or PPD)

2-3 days

Detection of TB infection

Tuberculin skin test (TST or PPD)

Blood tests

- T.Spot

- QuantiFERON

2-3 days

Detection of TB disease

Symptoms Sputum microscopy Chest X-ray Culture Molecular tests

TuberculosisTreatment

At least 6 months of drug therapy

Coughing and symptoms stop after 2 months

Treatment = prevention

Prompt diagnosis Completion of

appropriate treatment

Trends in incidence of active TB

WHO, Global Tuberculosis Report 2014

Multi-drug resistant TB (MDR-TB) Extensively drug resistant TB (XDR TB)

Drug-resistant TBMajor global health threat

TB/HIV co-infection

“A syndemic is a set of intertwined and mutually enhancing

epidemics involving disease interactions at the biological

level…”

Singer 2003 Medical Anthropology Quarterly

TB HIV

http://www.askdatasystems.com/EPIDEMI/ep/epimod1.htm

Drivers of TB Epidemic

http://www.askdatasystems.com/EPIDEMI/ep/epimod1.htm

Drivers of TB Epidemic

http://www.askdatasystems.com/EPIDEMI/ep/epimod1.htm

HIV!!!

TB infection and disease

Latent TB infection (LTBI)

Active TB disease due to new infection

Active TB disease due to reactivation of old infection

Never develop disease

TB infection and disease

Latent TB infection (LTBI)

Active TB disease due to new infection

Active TB disease due to reactivation of old infection

Never develop disease

HIV!!!

HIV!!!

TB/HIV co-infection

TB leading cause of death in PLHIV

PLHIV infected with TB 20-40 times more likely to develop active TB.

80% of all TB/HIV cases are in Africa

WHO, Global Tuberculosis Report 2014

HIV Prevalence among TB Cases, 2013

Kwan 2011 Clinical Microbiology Reviews

“Excess” TB due to HIV in the US

TuberculosisTreatment outcomes

WHO, Global Tuberculosis Report 2014

TB and HIV among LA County Homeless

Persons

Photograph: Union Rescue Mission (www.urm.org)

• LA County Homeless• Estimated 60,000 in

LA County• 5000 in downtown

Skid Row• TB outbreak

• 92 cases since 2007• 16 deaths (17%)• 21% HIV infected

Outbreak among Homeless Persons in LA County

Drivers of TB Epidemic

http://www.askdatasystems.com/EPIDEMI/ep/epimod1.htm

HIV!!!

TB among Homeless Persons in the U.S.

Bamrah 2013 International Journal of Tuberculosis and Lung Disease

TB Rates 10-fold higher More likely due to recent infection Delayed detection and treatment Poor completion of treatment High mortality Substance use HIV co-infection 2-3x higher

“TB is the classic disease of poverty, and a classic case study of the impact of social conditions on

disease.”

Rasanathan et al. The social determinants of health: key to global tuberculosis control. INT J TUBERC LUNG DIS 15(6):S30–S36; 2011.

Historical trends

TB PrevalenceLowest vs. Highest Socioeconomic Status

Lönnroth K. Risk factors and social determinants of TB. North American Regional Conference of the Union. Feb 24, 2011. Vancouver, BC, Canada.

New TB cases by Race/Ethnicity in the U.S.

Scott et al. 2015 MMWR

TB Rates by Income among Foreign-born Persons in the U.S.

Olson 2012 BMC Public Health

What Can Be Done to Reduce TB Burden in Low-Income Communities?

Healthcare-related Community health

workers/peer health counselors Mobile health clinics Increase clinic hours Travel vouchers Free universal health insurance

Social interventions Housing Financial support Social welfare programs Improved working conditions

Hargreaves JR, Boccia D, Evans CA, Adato M, Petticrew M, Porter JD. The social determinants of tuberculosis: from evidence to action. Am J Public Health. 2011 Apr;101(4):654-62.

Interventions to overcome socio-economic barriers for TB/HIV

TB/HIV Co-infectionConclusions

TB/HIV co-infection is a major public health concern HIV is the strongest known risk factor for TB disease HIV has had enormous impact on TB epidemiology Poor and marginalized communities most affected Interventions must address social conditions

Thank You!

Photos from 1) Airborne: a journey into the challenges and solutions to stopping MDR-TB and XDR-TB / by John Donnelly. World Health Organization 2009, and 2) WHO Commission on Social Determinants of Health. Closing the Gap in a Generation. 2008