ECDC update on activities for vulnerable groups with focus on migrants Marieke J. van der Werf European Centre for Disease Prevention and Control Stockholm, 31 May 2017
ECDC guidance on tuberculosis control in vulnerable and hardtoreach populations Individuals whose populations social circumstances Homeless or lifestyle make it difficult people to recognise the clinical High onset risk of TB drug users People with access problematic diagnostic and treatment services alcohol use selfadminister treatment People in attend regular appointments prison for clinical Vulnerable followup migrant populations Other marginalised/ poor/remote http://ecdc.europa.eu/en/publications/publications/tbguidanceinterventionsvulnerablegroups.pdf 2
3
Interventions Options for TB prevention and control in vulnerable populations 1. Outreach teams and mobile units 2. Incentives 3. Involvement of key partners 4. Directly Observed Treatment (DOT) 5. Reminders 6. Integrating services 7. Promoting awareness and education 4
ECDC policy briefing Target audience: national policy makers entities responsible for planning of health care and social support systems 5
Examples of interventions to manage tuberculosis in vulnerable groups On ECDC webpage: Three examples of interventions to improve the prevention and control of TB among vulnerable groups Health assistants for Roma communities (Slovakia) http://ecdc.europa.eu/en/healthtopics/tuberculosis/worldtbday/pages/interventionsexamples.aspx 6
Examples of interventions to manage tuberculosis in vulnerable groups On ECDC webpage: Three examples of interventions to improve the prevention and control of TB among vulnerable groups Video Observed Treatment (UK) http://ecdc.europa.eu/en/healthtopics/tuberculosis/worldtbday/pages/interventionsexamples.aspx 7
Examples of interventions to manage tuberculosis in vulnerable groups On ECDC webpage: Three examples of interventions to improve the prevention and control of TB among vulnerable groups Outreach TB team (France) http://ecdc.europa.eu/en/healthtopics/tuberculosis/worldtbday/pages/interventionsexamples.aspx 8
ECDC Rapid Risk Assessment: MDR TB in migrants 9
Cluster of MDR TB in migrants: Whole Genome Sequencing minimum spanning tree Austria (2); Germany (14); Finland (1); France (2); Sweden (1); Switzerland (8) 10
Cluster of MDR TB in migrants: Migration routes 11
Cluster of MDR TB in migrants: Assessment and options for response 23 of 28 cases have epidemiological link with Somalia AND Six cases reported onset of symptoms prior to arrival in the EU of which three prior to migration AND All cases used similar migration routes to the EU Transmission is likely to have taken place either in the patients country of origin or in a place along their migration route to the country of destination. Early case identification of active TB and drug susceptibility testing is important in order to identify and treat active cases and provide preventive treatment or monitoring for those diagnosed with latent tuberculosis infection. 12
Notification rate of TB cases per 100,000 population by origin, EU/EEA, 2010 2015, and prediction for 2016 2025 Hollo et al. Eurosurveillance 2017 13
Number of TB cases in EU/EEA by year and origin, and percentage of noneu/eea origin cases among all tuberculosis cases, 2007 2013 Ködmön et al. Eurosurveillance 2016 14
TB and MDR TB in total population and in migrants in EU/EEA countries, 2015 Percentage foreign born MDR TB cases 25.1% 10 countries >80% of MDR TB cases in foreign born MDR TB notification rate: 0.014 per 100 000 in the native population 0.89 per 100 000 in foreign born Van der Werf et al, Clin Microbiol Inf 2017 15
Pilot study: Interventions to increase TB treatment adherence among vulnerable population groups in Riga, Latvia Intervention: Communications training for health care staff; Psychosocial risk screening tool to identify TB patients likely to struggle with adherence to treatment; Enhanced adherence support for individuals identified by the screening tool. Intravenous drug use Alcohol excess History of incarceration Homeless Social isolation Mental health illness No risk factors (n=77) Preintervention Risk factor noted (n=22) 9 (40.9) 16 (72.7) 5 (22.7) No risk factors (n=32) Intervention Risk factor noted (n=35) 3 (8.6) 14 (40) 8 (22.9) 6 (27.3) 14 (63.6) 2 (5.7) Patients missing dose (n, %) 43 (55.8) 17 (77.3) 9 (28.1) 19 (54.3) Total doses missed (n/n, %) 438/17460 (2.5) 334/3540 (9.4) 39/3600 (1.1) 267/3720 (7.2) 16
Other ongoing ECDC projects Evidence based guidance: Prevention of infectious diseases among newly arrived migrants in the EU/EEA Evidence based guidance: Prevention and control of communicable diseases in prison settings Harmonisation of social determinants and risk factors for tuberculosis surveillance in EU/EEA 17
Acknowledgements Academic Medical Centre, University of Amsterdam: Charlotte C. Heuvelings Sophia G. de Vries Patrick F. Greve Benjamin J. Visser Anne L. Cremers Saskia Janssen Sabine Bélard René Spijker Martin P. Grobusch Queen Margaret University: Karina Kielmann Nicole Vidal; Predrag Duric London School of Hygiene & Tropical Medicine: David Moore; Maria Krutikov Centre for Tuberculosis & Lung Disease, Riga East University Hospital: Vija Riekstina; Evita Biraua Ad hoc expert panel members: Chryssoula Botsi Thierry Comolet Monica Dan Raquel Duarte Enrico Girardi Martin Priwitzer Tore Steen Mihaela Stefan Alistair Story Petra Svetina Rob van Hest German National Reference Laboratory for Mycobacteria, Borstel: Matthias Merker ECDC: Csaba Ködmön Vahur Hollo Julien Beauté Phillip Zucs Sergio Brusin Mike Catchpole Denis Coulombier Josep Jansa Daniel Palm Sarah Earnshaw Karen Aimard ECDC nominated contact point for TB surveillance ECDC National Focal Point for Tuberculosis 18