This document discusses tuberculosis (TB) and strategies for identifying and managing TB among hard-to-reach groups. It provides historical context on TB in Europe in the late 19th/early 20th century and modern challenges. It also describes a study that found homelessness is an independent risk factor for infectious and drug-resistant TB in London. The document advocates active case finding using mobile X-rays and outlines an outreach program that provides on-site testing, treatment, and social services and has achieved high treatment completion rates. It acknowledges the need to address social determinants of health and move from individual to societal approaches in TB elimination efforts.

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