Presentation at the 2014 ESCAIDE conference

1. Al Story
People not Pathogens

2. Plan
• TB in Koch’s time
• Modern challenges
• Displaced paradigms
• Conclusion

3. • ⅓ adult deaths in European capitals
• 12.26% of all deaths in Prussia (1887)
• 41.3% of all deaths age 25–40 years
Kaufmann S. Robert Koch’s highs and lows in the search for a remedy for tuberculosis.
Nature Medicine Special Web Focus: Tuberculosis (2000)

4. Good food - Fresh air - Hope

5. 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

6. 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

7. London TB Profile study (prevalence)
Story A et al. Thorax. 2007 Aug;62(8):667-71
0
200
400
600
800
1000
1200

8. 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

9. 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

10. 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

12. • Pre Find&Treat 53% LFU pre-diagnosis
• Now <6% LFU pre-diagnosis
Detection to Diagnosis

13. 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

14. Outreach Health and Social Care
• DOT – multiple options (VOT)
• Co-morbidities
• Social Determinants
– Housing
– Addiction
– Mental health
– Destitution
– Criminal justice Video Observed Treatment

15. 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.

16. 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)

17. Identifying and managing tuberculosis
among hard-to-reach groups (NICE)
http://guidance.nice.org.uk/PH37
• Offer BBV testing alongside radiology

18. 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

19. Social determinants
• Moving (back) from individual to societal

20. 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

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

22. In loving memory
Stuart Ford
1968-2014