Jan C Semenza European Centre for Disease Prevention and Control

1. Health Protection Inequalities:
A European Perspective
Jan C. Semenza
European Centre for Disease Prevention and Control

2. Social inequalities in health
Source: National strategy to reduce social inequalities in health, Norwegian Ministry of Health and Care Services, 2007

3. Susceptible
Population
(S)
Infected
Population
(I)
Deaths
Recovered
Population
(R)
The impact of economic crises on
communicable disease control
Infection Rate
Removal
Rate
Determinants
Suhrcke M, et al., PLoS ONE. 2011; 6(6): e20724

4. Susceptible
Population
(S)
Infected
Population
(I)
Deaths
Recovered
Population
(R)
The impact of economic crises on
communicable disease control
Infection Rate
Direct
•Person to person
•Overcrowding (prisons)
•Mixing environments (shelters)
•High risk pop (homeless)
Indirect
•Common Vehicle
•Infrastructure breakdown
(water treatment)
•Vector
•Contact rates (TBE)
•Vector pop (rodent and
mosquitoes)
Removal
Rate
•Treatment
•Doctors
•Access to
drugs
•Nutrition
•Immunity
system
•Immunization
coverage
Determinants
Suhrcke M, et al., PLoS ONE. 2011; 6(6): e20724

5. Tuberculosis control and economic recession
Reeves A, Bulletin of the World Health Organization. 2015;93(6):369-79

6. Intervening on health inequalities of
infectious diseases
Three intervention approaches:
1) The population-at-risk approach
2) The population-based approach
3) The vulnerable population approach

7. 1) The population-at-risk approach
Public health interventions should focus on that
segment of the population with the highest level of
risk exposure as indicated by health risk behaviors
or biological markers.
For example, the homeless, a group at very high risk
for TB.
Lalonde MA. A new perspective on the health of Canadians, 1974.

8. 1) The population-at-risk approach
Semenza JC. Euro Surveill. 2010;15(27):32-9.
Mean effect
Level of (single) risk
After
intervention
Benefits
after
intervention
Before
intervention

9. Intervening on TB
Inequality gradient of tuberculosis in the EU
20
TBprevalence/100,000population
140
120
100
80
60
40
2,000 6,000 10,0000 14,000
R2 = 0.69
Public wealth index: GDP/income inequality
≤ 10%
25%
50%
75%
100%
Percentage of
national TB
cases that
were foreign-
born is related
to the size of
the circle
Suk JE et al., Emerg Infect Dis. 2009;15(11):1812-4.

10. 2) The population-based approach
Mass environmental control methods and
interventions that attempt to alter some of
society’s norms.
For example, public smoking bans; water treatment
and distribution systems; safe sex education; or
cervical cancer screening.
Rose G. The strategy for preventive medicine. Oxford, 1992

11. 2) The population-based approach
Mean effect
Level of risks
Before
intervention
After
intervention
Semenza JC. Euro Surveill. 2010;15(27):32-9.

12. 2) Socio-economic indicators and cervical
cancer
Human Development Index
SDRcervicalcancer
women<64yrs
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
0.800 0.820 0.840 0.860 0.880 0.900 0.920 0.940 0.960 0.980
Franceschi S, et al., Int J Cancer. 2011;128(12):2765-74

13. 2) Socio-economic indicators, cervical cancer
and HPV vaccination
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
0.800 0.850 0.900 0.950 1.000
Human Development Index
SDRcervicalcancer
women<64yrs
HPV programme not implemented HPV programme implemented
Franceschi S, et al., Int J Cancer. 2011;128(12):2765-74

14. 2) The population-based approach
Mean effect
Level of risks
Before
intervention
After
intervention
Concentration
of risksConcentration of
benefits
Semenza JC. Euro Surveill. 2010;15(27):32-9.

15. 3) The vulnerable population approach
Vulnerable groups share social characteristics that
put them at risk for multiple risks. Because of
their position in the social strata they are
commonly exposed to contextual conditions that
distinguish them from the rest of the population.
Low socio economic status is the risk that generates
the exposure to other risks, such as smoking, drug
use, high risk sexual behavior, etc.
For example, occupational training and educational
opportunities for the unemployed
Frohlich KL, Potvin L, AJPH 2008; 98(2):216-221

16. After
intervention
3) The vulnerable population approach
Mean effect
Level of (multiple) risks
Before
intervention
BenefitsMinimal benefits
Semenza JC. Euro Surveill. 2010;15(27):32-9.

17. 3) The vulnerable population approach
Employment
Wages,
unemployment
Faith or
religion
Guiding, ruling
Economics
Community,
personal
Family
structures
Functional,
dysfunctional
Support
networks
Friends,
family
Culture
Values,
traditions
Social factors
Community
expectations
Social
structures
Laws, politics
Social
relationships
Relating to others,
peer influence
Social
view of
health
Adapted from: Mosel-Williams L. Health, Life and Living: Book Two.
Harcourt Education Australia, 1999.

18. Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

19. Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

20. Social protection spending and TB
Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

21. Social protection spending and TB
Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

22. Social protection spending and TB
Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

23. Summary
• Certain high-risk groups in society, including the
poor, migrants, homeless persons, and prison
populations suffer disproportionally from infectious
diseases in Europe.
• This situation is exacerbated during situations of
economic duress.
• Comprehensive interventions should be devised to
reduce health inequalities and to avoid unintended
consequences.
Jan.Semenza@ecdc.europa.eu