This document discusses the need for an all-Ireland approach to tackling health protection inequalities. It notes that infectious diseases disproportionately affect socioeconomically deprived communities and vulnerable populations like the homeless, intravenous drug users, prisoners, migrants, and travelers. Examples are given showing higher rates of tuberculosis, HIV, and other diseases in these groups. The document calls for strengthening surveillance, prevention efforts, and collaboration between Northern Ireland and Ireland to address health inequalities in infectious diseases and promote a more equitable approach to health protection.

1. Health Protection Inequalities -
Time for an All Ireland Approach
Dr Lorraine Doherty
Assistant Director Public Health
Public Health Agency, NI
18 February 2016

2. Health Protection Practice
Communicable Disease – Surveillance,
Prevention and Control
Chemicals, Radiation and Poisons
Environmental Health, Emergency Planning
and Response

3. Tackling HP Inequalities
All Ireland Approach
 NI and ROI - both wider policies, strategies on
tackling health inequalities.
 To date - no in-depth consideration of the
issues around inequalities in respect of
infectious diseases or in other health
protection areas.
 Working group (PHA and HSE/HPSC) -scoping
paper, sponsored by Institute of Public Health

4. Infectious Diseases & Inequality
 Infectious diseases disproportionally affect the
most socioeconomically deprived communities.
 Not restricted to a few ‘signature infections,
such as TB or HIV, but also a wide array of
other infectious diseases.
 Elevated infectious disease rates in vulnerable
populations pose a health threat, not only to
them, but to society at large.

5. Ireland - Tuberculosis notification rate by county of residence; 2011
Vulnerable Populations – Infectious
Diseases
 Homeless, people who inject drugs, people in
prison, those who are unemployed, young
children.
 Migrant populations, e.g. the Roma population.
 Migrant populations from countries with a high
prevalence of infectious diseases are
disproportionately affected by HIV, STIs, TB,
Hepatitis B and C, and a range of other
infections.

6. New HIV diagnoses in Northern Ireland, by year of
diagnosis,
by country where infection was acquired, 2000–2013
By heterosexual route of infection

7. MSM HIV
New HIV diagnoses in Northern Ireland, by year of
diagnosis, by country where infection was acquired,
2000–2013, MSM Route of Transmission

8. Number of tuberculosis notifications In Ireland
and rate by country of birth and year of
notification

9. MRSA – link to Socioeconomic
Deprivation
 Study in London.
 All MRSA cases in 4 month period in a three
borough catchment area mapped to area SE and
demographic data. Cases classified as Healthcare
Associated (HA) or Community Associated (CA)
based on WGS.
 Conclusions – HA-MRSA originate from hospital
reservoir. CA- MRSA – higher risk in areas with
overcrowding, homelessness, low income, and
recent immigration to UK.

10. Children/Young People at Risk
of not being fully Immunised
 Missed previous vaccinations (whether as a result of parental
choice or otherwise)
 Looked after children
 Physical or learning disabilities
 Children of teenage or lone parents
 Not registered with a GP
 Younger children from large families
 Children who are hospitalised or have a chronic illness
 Those from some minority ethnic groups
 Those from non-English speaking families
 Vulnerable children, such as those whose families are travellers,
asylum seekers or are homeless.

11. Irish Travellers
 Higher risk of vaccine
preventable diseases.
 Risk factors – living
conditions, health risk
behaviours, low
immunisation uptake,
poor access to services,
misinformation.

12. Roma Migrants
 Largest ethnic minority in
Europe
 Over 25% of Roma children
are not fully vaccinated
 May live in poverty, have low
socioeconomic status, thus are
more vulnerable to diseases
such as TB, measles, and
Hepatitis.
 Discrimination,
marginalisation may affect
access to healthcare
Homeless: A Romanian
family after being
forced from their
Belfast home
Read more:
Homeless: A Romanian family
after being driven out of their
Belfast Home

13. Refugees
 Arriving in Ireland from
war torn countries,
prolonged deprivation as a
consequence of conflict.
 High rates of tuberculosis,
malaria, hepatitis,
intestinal parasites, and
nutritional deficiencies.
Mental Health issues.
 Social isolation,
unemployment, difficulties
accessing services.


14. Climate Change

15. Health Impacts Climate Change
Extremes of weather –
 Heat-waves → Heat related mortality, affects
elderly and other vulnerables
 Flooding → already problem in UK & Ireland.
Effect on health and welfare; disruption of
services, lack of clean water, infectious diseases,
mental health issues.

16. Global warming and Vector Borne Disease
 Direct impact on vector distributions which may carry
disease.
 Direct impact on human behaviour leading to
changing patterns of exposure.
Examples
 Altered incidence of arthropod borne diseases
transmitted by ticks (e.g. Lyme disease), by
mosquitoes (e.g. chikungunya, Zika, Dengue).
 Increased risk of mosquito populations establishing in
UK and Europe.

17. Zika Virus Disease and Inequality
‘Zika’s spread in Brazil is a
crisis of inequality as much as
health’
‘it’s no coincidence that most
Zika-related microcephaly
cases were found in the north-
east of the country: of course,
the weather there is hot, which
is prime breeding ground for
the Aedis aegypti, but it is also
where most of Brazil’s poverty
is concentrated’. Nicole Froio

18. Politics, Economy and Ecology
 Biological environment is
shaped by and shapes society
and economy.
 Africa – long history of strife,
deals done with multinationals,
industry; impact on
environment, e.g. deforestation -
animals closer to humans –
zoonoses.
 Similarly – pandemic 2009,
influenza strains, SARS, Mers-
CoV.
Ebola 2014-15
Deforestation at
border between
Guinea & Liberia.
Bats in closer
contact with
humans.

19. Impact of Financial Crisis
 The economic crisis will adversely impact employment and
increase migration.
 Economic hardship - associated with higher risk of infectious
diseases by virtue of increases in poverty, migration,
homelessness, unemployment, and malnutrition.
 Restricted access to health care.
 Health services cuts and restructuring leading to reduced
capacity to respond to infectious diseases.
 Preventive services are most vulnerable to disinvestment (e.g.
immunisation services in vulnerable populations), as well as
surveillance programmes, hospital infection control activities
and capacity of systems to respond to outbreaks.

20. ECDC – AID Framework
Action: Building the information base, and ensuring the
dissemination of key findings through collaboration with
key stakeholders, specifically action: enhance member
states capacity to act on health inequalities among
vulnerable groups.
Information: Advanced evidence through studies and
investigations, and by leveraging the existing data
sources such as the European surveillance systems.
Dissemination: Communicate best practices and expand
networks to key actors and stakeholders in the field.

21. North-South – Areas for Action
 Strengthen surveillance and monitoring of health inequalities in
infectious diseases/health protection issues.
 Developing data linkages, e.g. between infectious disease
datasets and indices of deprivation, postcode etc. – e.g. TB
and ‘One Health Approach’.
 Strengthening prevention in specific areas - while considering
population-at-risk, entire population and vulnerable
populations.
 Linking tackling health protection inequalities to the wider work
on tackling health inequalities, e.g. migrant health, homeless.
 Strengthening collaboration with existing organisations who
work to address health needs of diverse and disadvantaged
communities.

22. Forward Action
 North- South Forum on Health Protection
Inequalities – Leadership, joint work
programme – advocacy composite logic
model.
 Raising awareness of health protection
inequalities amongst politicians, policy makers,
health services, public and across other
government sectors.
 Actively disseminating and sharing information
on health protection inequalities.

23. Acknowledgements
Health Protection, PHANI - Cathriona Kearns,
Michael Devine, Neil Irvine
IPH - Elizabeth Mitchell, Owen Metcalfe
HPSC - Darina O’Flanagan, Derval Igoe,
Suzanne Cotter, Joan O’Donnell, Paul Mc
Keown, Lelia Thornton
HSE - Kevin Kelleher