Al Story

People not Pathogens

Plan

• TB in Koch’s time

• Modern challenges

• Displaced paradigms

• Conclusion

• ⅓ adult deaths in European capitals

• 12.26% of all deaths in Prussia (1887)

• 41.3% of all deaths age 25–40 yearsKaufmann S. Robert Koch’s highs and lows in the search for a remedy for tuberculosis. Nature Medicine Special Web Focus: Tuberculosis (2000)

Good food - Fresh air - Hope

TB mortality (per 1000)

by income strata

Hamburg 1896–1910

Murphy S, Egger M. Studies of the social causes of tuberculosis in Germany before the First World War: extracts from Mosse and Tugendreich's landmark book. Int J Epidemiol. 2002 Aug;31(4):742-9.

Wealth inequality and

TB elimination

Europe 2006

Suk JE, Manissero D, Büscher G, Semenza JC. Wealth inequality and tuberculosis elimination in Europe. Emerg Infect Dis. 2009 Nov;15(11):1812-4. PWI = GDP per capita / Eurostat income inequality index

Risk of TB infection and disease*

* Courtesy of Dr Katharina Kranzer 2014 (LSHTM)# Incidence rate ratio for active TB calculated using year-adjusted national estimates (derived from the WHO Global TB report 2013)

Risk population Pooled risk ratio (TST)

Incidence Rate ratio #

HIV-positive patients 1.0 (0.30-4.26) 183

Immigrants & refugees 3.2 (1.00-8.31) 91

Drug users 1.9(0.04-3.44) 33

Prisoners 2.8 (2.46-3.57) 15

TB contacts 2.2 (0.15-11.67) 8

Homeless 2.4 (1.15-2.81) 7

London TB Profile study (prevalence)

Story A et al. Thorax. 2007 Aug;62(8):667-71

0

200

400

600

800

1000

1200

Story A et al. Thorax. 2007 Aug;62(8):667-71

• 17% of all cases

• 30% of all infectious cases

• 44% of all infectious DR cases

• 44% of cases lost to follow up

Convergence of risk factors

Homelessness TB patients in London

• 2 x risk of being highly infectious– aOR 1.8, 95% CI 1.4-2.4

• 3 x risk of having MDR TB– aOR 2.9, 95% CI 1.6-5.2

• 10 x risk of non-adherence– aOR 10.2, 95% CI 7.9-13.2

Anderson C, Anderson S, Story A. Homelessness is an independent risk factor for infectious and MDRTB in London: retrospective cohort analysis. Public Health England Field Epidemiology Conference 2014

Active Case Finding

• Aim: Improve early case detection and outcomes

• Multiple options – Accessible – Acceptable - Accurate

Paquette K, Cheng MP, Kadatz MJ, Cook VJ, Chen W, Johnston JC. Chest radiography for active tuberculosis case finding in the homeless: a systematic review and meta-analysis. Int J Tuberc Lung Dis. 2014 Oct;18(10):1231-6.

N I I S

• Pre Find&Treat 53% LFU pre-diagnosis

• Now <6% LFU pre-diagnosis

Detection to Diagnosis

CXR• Sensitivity 82%

– (95% CI 67.3 to 91.8%)

• Specificity 99.3%– (95% CI 99.1 to 99.3%)

• PPV 0.23

• Two-thirds less likely to be AFB + on diagnosis

– Adjusted OR 0.35 (0.15-0.81) p<0.001

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

Outreach Health and Social Care

• DOT – multiple options (VOT)

• Co-morbidities

• Social Determinants

– Housing

– Addiction

– Mental health

– Destitution

– Criminal justiceVideo Observed Treatment

Highly cost-effective

84% complete

Jit M, Stagg HR, Aldridge RW, White PJ, Abubakar I; Find and Treat Evaluation Team. Dedicated outreach service for hard to reach patients with tuberculosis in London: observational study and economic evaluation. BMJ. 2011 Sep 14;343:d5376.

PTB

LTBI

HCV

HBV

HIV

0.25% (10% HIV+)

17% (19% HCV)

13% (14% LTBI)

2% (64% no immunity)

1%

Story A et al NIHR 2014 (in prep)

Identifying and managing tuberculosis among hard-to-reach groups (NICE)

http://guidance.nice.org.uk/PH37

• Offer BBV testing alongside radiology

Tele-radiology and rapid TB PCR diagnostics

POCT for HIV, HCV, HBV and PCR diagnostics

On-the-spot Flu, PPV and Hep B vaccination

Digital X-ray

Reporting station Reception

Laboratory

Clinical examination

Social determinants

• Moving (back) from individual to societal

The states responsibility to

improve the health of the people

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.

The physicians responsibility

to kill the bacilli

Robert KochHermann Pidoux

Thanks to you and…the outreach team, and our partners, punters and pundits

In loving memory

Stuart Ford

1968-2014