1. TB:
impa)o
epidemiologico
sociale
Dennis
FALZON
Stop
TB
Department,
OMS,
Svizzera
3°
CONVEGNO
NAZIONALE
TUBERCOLOSI:
UNA
MALATTIA
SOCIALE
ACQUARIO
CIVICO
DI
MILANO
21-­‐22
SETTEMBRE
2012

2. ORWELL
CHOPIN
CAMUS
BRONTE
BOLIVAR
KAFKA
CHEKOV
KEATS
LAENNAC
MOLIERE
MODIGLIANI
GORKIY
STEVENSON
MORAVIA
RAMANUJAN
SILONE

3. The
global
TB
situa?on
(1)
Estimated number of Estimated number of
cases, 2010 deaths, 2010
All
forms
of
TB
8.8
million
1.1
million*
(8.5–9.2
million)
(0.9–1.2
million)
HIV-­‐associated
TB
1.1
million
350,000
(1.0–1.2
million)
(320,000–390,000)
Mul?drug-­‐ ~
650,000
out
of
12
million
(11-­‐14
million)
resistant
TB
prevalent
TB
cases
*
Excluding
deaths
aXributed
to
HIV/TB
Source:
WHO
Global
Tuberculosis
Control
Report
2011
(www.who.int/tb/publicaons/global_report/2011/gtbr11_full.pdf)
TB:
impa)o
epidemiologico
sociale
3
3°convegno
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TB
–
Milano
09/12

4. The
global
TB
situa?on
(2)
Countries
in
capitals
are
high
burden
for
TB
incidence
TB:
impa)o
epidemiologico
sociale
4
3°convegno
nazionale
TB
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09/12

5. The
global
TB
situa?on
(3)
Es?mated
MDR-­‐TB
cases
among
no?fied
TB
pa?ents
in
2010
>60% of cases occur in Brazil, China, India, the Russian Federation and South Africa
No
data
0-­‐300
301-­‐3,000
3,001-­‐30,000
30,001-­‐60,000
>60,000
The
boundaries
and
names
shown
and
the
designa?ons
used
on
this
map
do
not
imply
the
expression
of
any
opinion
whatsoever
on
the
part
of
the
World
Health
Organiza?on
concerning
the
legal
status
of
any
country,
territory,
city
or
area
or
of
its
authori?es,
or
concerning
the
delimita?on
of
its
fron?ers
or
boundaries.
DoXed
lines
on
maps
represent
approximate
border
lines
for
which
there
may
not
yet
be
full
agreement.
©
WHO
2011.
All
rights
reserved

6. Rudolph
Virchow:
diagnosis
of
the
disease
of
which
TB
is
a
symptom
(1860)
"…it
shows
that
disturbances
exist
in
the
development
of
our
popula?ons,
disturbances
which
arise
from
poli4cal
and
social
ins4tu4ons,
and
are
therefore
preventable".
Robert
Koch:
Offered
an
early
intervenon
strategy
to
cure
that
disease
(Nobel
laureate
1905)
"One
of
the
most
powerful
weapons,
if
not
the
most
powerful,
which
we
can
bring
into
use
against
TB
are
social
welfare
centres:
– …the
sick
person
is
visited
in
his
home,
and
is
given
instruc?on
and
advice
concerning
cleanliness.
– …If
living
condi?ons
are
bad,
then
money
is
granted…
– …poor
families
are
supported
by
gran?ng
them
appropriate
food,
fuel,
etc".
– …private
ac?on
is
virtually
powerless
against
this
nuisance,
while
the
State
can
easily
remedy
the
situa?on
with
suitable
laws"
TB:
impa)o
epidemiologico
sociale
6
3°convegno
nazionale
TB
–
Milano
09/12

7. Rise
and
fall
in
18th
and
19th
century
Europe:
economic
and
social
factors
TB:
impa)o
epidemiologico
sociale
7
3°convegno
nazionale
TB
–
Milano
09/12

8. 20th
century:
2000
Declining
TB
deaths
in
England
and
Wales
World War 1
1500
Test tubes with streptomycin 1946
1000
World War 2
500
0
1900 1920 1940 1960 1980
TB:
impa)o
epidemiologico
sociale
8
3°convegno
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TB
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9. TB
case
noficaon
in
Eastern
Europe
Increase
in
cases
aeer
independence
TB cases / 100,000
240
Kazakhstan
200 Rep. of Moldova
Georgia *
160 Kyrgyzstan
Tajikistan
Russian Federation
120
Uzbekistan
Azerbaijan
80 Ukraine
Armenia
Turkmenistan
40
Belarus
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
TB:
impa)o
epidemiologico
sociale
9
3°convegno
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TB
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10. TB
case
noficaon
in
the
European
Union
Reversal
in
TB
rates
in
early
1990s
in
several
countries
TB cases / 100 000 pop
100
90
80
70
60
Baltic States
50
Other EU countries*
40
30
20
10
TB:
impa)o
epidemiologico
sociale
10
3°convegno
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TB
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09/12

11. TB
and
migra?on:
Italy
Odone
A
et
al.
BMC
Public
Health
2011,
11:376

12. Dose–response
rela?onship
in
the
reviewed
cohort
studies
on
the
associa?on
between
BMI
and
TB
incidence.
The
lines
refer
to
values
from
different
studies
(see
Lönnroth
K
et
al.
A
consistent
log-­‐
linear
rela?onship
between
tuberculosis
incidence
and
body
mass
index.
Inter
J
Epidemiol.
2009.
9;39(1):149–55.)
TB:
impa)o
epidemiologico
sociale
12
3°convegno
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TB
–
Milano
09/12

13. Overlapping
risks
for
TB
:
United
Kingdom
Story
A
et
al.
Thorax
2007;62:667–671

14. "The possibility of eradicating TB in a country is essentially a
function of its economic level" (G. Canetti, 1962)
TB incidence rates & socio-economic level, New York, 1973
(SE level estimated on the basis of education, occupation and income)
-more crowding?
-higher prevalence of HIV, smoking,
malnutrition, alcoholism, social
marginalization etc?
-poor access to health services,
diagnostic delays, prolonged
infectiousness in poor
communities?
Hinman AR et al, Am J Epidem 103:490, 1976
TB:
impa)o
epidemiologico
sociale
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3°convegno
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TB
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15. Eur Respir J. 2008. 32 sociale
TB:
impa)o
epidemiologico
(5):1415-1416
15
3°convegno
nazionale
TB
–
Milano
09/12

16. A. Human development
An ecologic analysis:
15
Change TB incidence (%/yr)
2
R = 0.20
10
associations at global
5
0
level
-5
-10
-15
(Bull WHO 2009;87:683-691) 3 4 5 6 7 8 9 10
Human Development Index (arcsin*1000)
B. Child mortality
12
Change TB incidence (%/yr)
Data for 134 countries
8
4
from 1997-2006 0
-4
-8 2
R = 0.25
TB incidence depends -12
0.4 0.9 1.4 1.9 2.4
also on development level
Child deaths under 5 years per 1000 births (log 10)
C. Sanitation
15
Change TB incidence (%/yr)
2
R = 0.26
10
5
HDI is calculated based on life
0
-5
expectancy, literacy rate, and -10
GDP/capita -15
0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6
Population with improved sanitation (arcsin %)
TB:
impa)o
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3°convegno
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TB
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17. The links between M/XDR-TB & poverty
A
vicious
cycle
:
1. Poor
pa?ents
more
likely
to
interrupt
TB
treatment
:
lack
of
health
coverage,
cheaper
and
poor
quality
drugs,
need
for
gainful
employment
2. Once
MDR-­‐TB
develops,
it
is
more
likely
to
go
untreated
owing
to
the
high
cost
of
care
3. Overcrowding
in
residence
and
in
hospitals
may
promote
transmission
of
emergent
drug-­‐resistant
to
others
4. HIV
may
also
be
poverty
related
and
when
combined
with
DR-­‐TB
makes
for
a
fatal
combina?on
TB:
impa)o
epidemiologico
sociale
17
3°convegno
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TB
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18. Can extreme poverty favour M/XDR-TB?
1. If one agrees that poverty and
impoverishment favour TB, then
MDR-TB is exacerbated even
further
2. A study at Wardha District, India,
showed that compliance to
treatment depends upon family
income and housing (Barnhoorn &
Adriaanse, 1992)
3. "Throughout the world, those
least likely to comply are those
least able to comply" (Farmer, 1999)
4. Mono-therapy may be the result
of cash exhaustion by patients
and scarce financing by countries
TB:
impa)o
epidemiologico
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18
3°convegno
nazionale
TB
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09/12

19. Poverty-­‐disease
trap
(1)
Health in all policies,
UHC, public health
Wealth and wealth
as
applied
to
TB
TB diagnosis and
• Undernutri?on
distribution
treatment
• Poor
housing
• Risk
factors
for
infec?ous
diseases
and
NCDs
• Poor
health
care
access
Social and financial
Poverty
TB
support
• Worse
health
and
s?gma
–
loss
of
income
• Catastrophic
health
expenditure:
• 10-­‐50%
of
annual
income
lost!
TB:
impa)o
epidemiologico
sociale
19
3°convegno
nazionale
TB
–
Milano
09/12

20. Poverty-­‐disease
trap
(2)
Doing
something
about
it:
condi?onal
cash
transfers
Reaching
Mexico’s
poorest
The
poorest
people
oeen
use
health
services
less
than
their
more
affluent
counterparts,
even
when
those
services
are
free
of
charge
and
widely
available.
The
Oportunidades
project
in
Mexico
is
redressing
the
balance.
Bulletin of the World Health Organization
August 2006, 84 (8)
TB:
impa)o
epidemiologico
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20
3°convegno
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TB
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09/12

21. The role of social protection in TB control
1. TB care & control:
• Improve acceptability, relevance and attractiveness of services
• Enable access to improve early and free diagnosis
• Support patients, families and communities to improve outcomes
2. Health systems and policies:
• Universal health coverage, including social & financial protection
• Integrated approach to address patients' health and social needs
3. Sustainable development:
• Contribute to poverty reduction for TB patients, families,
communities, and vulnerable groups
4. Research:
• Build evidence base through operational research on delivery
models, feasibility, local adaptation, and cost-effectiveness
TB:
impa)o
epidemiologico
sociale
21
3°convegno
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TB
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22. Enabler
and
social
protec?on
package
1. Free
clinical
package
– TB
diagnosis
and
treatment
– Co-­‐morbidi?es
(HIV,
substance
abuse,
undernutri?on,
diabetes,
etc)
2. Support
package
– Health
informa?on
and
psychosocial
support
– Cash
transfer
– Travel
vouchers
– Food
assistance
– Housing
assistance
– Voca?onal
training,
income
genera?on,
microcredit
3. Regulaon
and
structural
intervenons
– Workers'
protec?on
– Sickness
insurance
&
welfare
benefits
TB:
impa)o
epidemiologico
sociale
22
3°convegno
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TB
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23. Acknowledgements:
Mario
Raviglione
Knut
Lönnroth
Ernesto
Jaramillo
others
at
the
Stop
TB
Dept
TB:
impa)o
epidemiologico
sociale
23
3°convegno
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TB
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09/12