sanghyuk shin, phd department of epidemiology ucla fielding school of public health aug 27, 2015...
TRANSCRIPT
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