Tuberculosis &

Special populations

Sonya Shin, MD, MPH

Division of Infectious Diseases

Division of Global Health Equity

Brigham and Women’s Hospital

Partners In Health, Boston MA

Overview

TB & HIV

TB & Alcohol

TB & PediatricsTB & Pediatrics

Risk factors: special populations

Susceptible

hostsTB MDR-TB,

XDR-TB

Excess morbidity and

mortality

Risk factors: special populations

Susceptible

hostsTB MDR-TB,

XDR-TB

Excess morbidity and

mortality

Godfrey-Faussett et al, 2002 Excess cases of Tuberculosis in Sub-

Sarahan Africa attributable to HIV

Transmission of TB and HIV in

Russia

Experience in Peru: MDR-TB and

HIV co-infection

99 HIV-positive individuals receiving treatment for MDR-TB in Lima, Peru

July 1996 – December 2005July 1996 – December 2005

MOH offers free HAART in 2004; prior to this, donated on individual basis

Experience in Peru: MDR-TB and

HIV co-infection, N=99

ETOH abuse 11%

Previously treated 94%

Extra-pulmonary TB 41% Extra-pulmonary TB 41%

Cavitary disease 46%

Mean CD4 cell count 181

Experience in Peru: MDR-TB and

HIV co-infection

Treatment outcomes

Cure

Failure

Death

Default

in treatment

Transferred

Paterson 2000

DOT for TB and HIV TreatmentHospitalizations and outpatient visits per person-year

Surv

ival D

istr

ibution F

unctio

n 0.75

1.00

Proportion of patients alive and on HAART by time from enrollment

Surv

ival D

istr

ibution F

unctio

n

0.00

0.25

0.50

Time from enrollment (days)

0 100 200 300 400 500 600 700 800

STRATA: CASA Control Censored

Log-Rank test of equality p=0.01

DOT for TB and HIV TreatmentHospitalizations and outpatient visits per person-year

CASA Control

N=33 N=33 IRR (95% CI) IRR (adj) (95% CI)

Unadjusted Adjusted*

Observation days 21160 16628

per enrollee 641.21 503.88

Hospital admissions 25 41

per person-year 0.43 0.90 0.45 (0.19-1.08) 0.42 (0.16-1.10)

Hospital days 315 675

per admission 12.60 16.46 0.77 (0.43-1.35) 0.83 (0.44-1.55)

per person-year 5.43 14.82 0.35 (0.14-0.91) 0.33 (0.11-0.95)

Outpatient visits 1426 1509

per person-year 24.60 33.12 0.73 (0.62-0.87) 0.75 (0.63-0.89)

*Adjusted for drug or alcohol use and marriage status

Risk factors: special populations

Susceptible

hostsTB MDR-TB,

XDR-TB

Excess morbidity and

mortality

TB-Alcohol activities in Tomsk, Russia

Programmatic: Improve management of AUDs within Tomsk TB services within Global Fund (Eur J Public Health 2009)

Research:Prevalence study of AUDs using valid instrument (Substance Use & Misuse 2010)Ethnographic study (Culture, Medicine Ethnographic study (Culture, Medicine and Psychiatry 2010)Role of alcohol on causes of death (IJTLD 2006)Randomized Controlled Trial to assess effectiveness of alcohol interventions on TB and alcohol outcomes (ACER, 2010)

Стандартная Порция Алкоголя (СПА) Standard Drinks Card

4% 1000 мл

= 3 СПА

4% 500 мл

= 1,5 СПА

4% 330 мл

= 1 СПА

Beer / ПИВО Wine / ВИНО

12% 750 мл

= 7,3 СПА

14% 750 мл

= 8,3 СПА

Vodka / ВОДКА

Samogon

Cognac / КОНЬЯК

Whiskey ,Gin / ВИСКИ, ДЖИН

TINCTURE, EAU-DE-COLOGNE

/Настойки , Одеколоны

40% 500 мл

= 16 СПА

40% 100 мл

= 3,2 СПА

5% 330 мл

= 1,3 СПА

Surrogate Spirits, Technical Spirits

Liqueur, Port/Sherry Wine

/Ликёры, Наливки, Портвейн

TOTBS/PIH

40% 700 мл

= 22 СПА

Samogon /Настойки , Одеколоны

40% 30 мл

= 1 СПА

62% 100 мл

= 5 СПА

Surrogate Spirits, Technical Spirits

/ Технические Жидкости

90% 700 мл

= 50 СПА

90% 500 мл

= 35,6 СПА

90% 200 мл (стакан)

= 14 СПА

/Ликёры, Наливки, Портвейн

20% (25%) 100 мл

= 1,6 (2) СПА

Alcohol and TB management:

Integrating ETOH interventions into TB care… in Russiacare… in Russia

Naltrexone

Brief counseling

Potential impact on TB and ETOH outcomes

NIAAA R01 AA016318

342 TB Patients referred to

study

329 screened (CIDI)

251 eligible

13 refused screening

2 did not complete CIDI screening

4 CIDI results pending

73 not eligible, of which:

-68 negative CIDI (of which 1 severe gen. condition, 1 diabetes, 1 opiate user)

-1 passed away

-1 default

-1 hard to reach

-2 heavily drinking

-1 status unclear

164 randomized

42

TAU

37

BCI/ NTX

43

NTX

42

BCI

83 declined enrollment

4 pending IC

-22 Completed:

-2 ISF MDR

-1 ISF not TB

-2 ISF pt declined

-15 active

-18 Completed:

-5 ISF MDR

-1 ISF not TB

-1 ISF pt declined

-1 ISF NTX contra (liver

cancer)

-15 active

-15 Completed:

-1 ISF MDR

-4 ISF pt declined

-3 ISF NTX contra (HIV

serious, opiates,

cerebrovascular trauma)

-14 active

-21 Completed:

-7 ISF MDR

-1 ISF LTFU

-2 ISF not TB

-11 active

Risk factors: special populations

Susceptible

hostsTB MDR-TB,

XDR-TB

Excess morbidity and

mortality

MDR-TB in children, experience in

Peru

38 children

Median age: 11 (2-14)

Primarily household contactsPrimarily household contacts

Time from first TB diagnosis to MDR-TB treatment: 6.5 months (0-46)

Drobac Pediatrics 2006

MDR-TB in children, experience in

Peru

Thank you very much!