Vulnerable populations include immigrants from countries with high TB incidence, prisoners, HIV-seropositive persons, alcoholics, injecting drug users and the socially and economically disadvantaged especially in congregated urban settings. The most vulnerable and excluded groups are the ones that carry the most significant burden of disease and which have the poorest access to services. Children also belong to a key vulnerable population that has suffered from a long time of neglect.
The evidence around interventions tailored to vulnerable populations require further assessment in order to develop and implement effective strategies for TB control among these groups. Communication around these strategies needs to be developed on the basis of solid evidence in order to avoid stigmatisation of the affected populations. Enhanced surveillance needs to be improved and should pay particular attention to identifying and describing TB vulnerable populations.
Activities
- Childhood TB control and care.
- Good practices for urban TB control.
- Social and wealth inequalities for TB in EU.
- Guidance on infectious disease control (incl. TB and HIV) among injecting drug users.
- Scientific support on cross-border TB control and care
- TB control among migrants and foreign-born.
- TB in alcohol abusing populations
Childhood TB control and care
Children with TB are usually not given high priority in national TB control programmes despite increasing recognition that they are a vulnerable and important group. Children still suffer from TB in the EU and the diagnosis, treatment and control of TB in children pose the same challenges as in TB endemic countries. It is therefore essential to prevent all transmission to children and thus achieve an EU-generation free of TB infection. With optimal TB control strategies which establish rapid case-finding, contact-tracing and treatment within the entire population, this should be feasible. Further, as children have a high rate of primary progression to TB upon infection, childhood TB is a marker of ongoing transmission in the community and this is one of the core epidemiological indicators of the Follow-up to the Framework Action Plan.
In 2011, the activities in ECDC have a strong focus on childhood TB and this is reflected both in the International Childhood TB Meeting 2011, this year’s Surveillance Report, and the TB Spotlight.
Previous work in the TB programme focussed on BCG vaccination and its role in TB control programmes. As countries reach low-TB-incidence, national BCG-vaccination policies are often revised and the value of general vaccination, versus selective vaccination, assessed. In response to this, ECDC developed a model in 2008, with which to estimate the impact of different national BCG vaccination-policies (universal versus selective vaccination) on severe childhood TB, in low-to-intermediate TB countries. By considering the TB prevalence of a setting, and the risks of BCG adverse events, the model provides an estimate of the number of children needed to be vaccinated to prevent disease in different TB-incidence settings (Manissero et al. 2008, Assessing the impact of different BCG vaccination strategies on severe childhood TB in low-intermediate prevalence settings. Vaccine, 26 (18): 2253-2259 ).
Good practices for urban TB control
The changing epidemiology of TB within EU is characterised by a disproportionate accumulation of disease in certain vulnerable populations often concentrated in metropolitan settings, resulting in an urban TB incidence 3-5 times higher than in rural areas. The prevention and control of TB among these risk groups is complicated by delayed diagnosis, onward transmission and poor treatment adherence. TB services that are not tailored towards the needs of urban risk groups carry a continuing risk of higher rates of TB and drug resistant strains.
ECDC is therefore, together with a group emerging from the Wolfheze movement, facilitating the exchange of experiences of different urban TB control programmes. The aim is to increase the awareness around urban TB epidemiology and promote the exchange of experiences on good practices, innovative tools and interventions for enhanced TB control efforts in big cities of the EU.
Social and wealth inequalities for TB in EU
Tuberculosis disease and mortality is accumulated among the socially and economically disadvantaged. The 27 EU Member States display both a wide heterogeneity in TB incidence as well as diverse level of wealth distribution among different settings. ECDC is working towards assessing the impact of socio-economical determinants for TB in the EU. The aim is to better understand the underlying mechanisms for these drivers and how reduced inequalities may have a positive effect on TB rates in the EU.
Related resources
Suk, J. E., D. Manissero, et al. (2009). "Wealth inequality and tuberculosis elimination in Europe." Emerg Infect Dis 15(11): 1812-4. Pubmed, Open access link
Guidance on infectious disease control (incl. TB and HIV) among injecting drug users
Injecting drug use is associated with increased incidence of TB and is a leading cause of death among injecting drug users living with HIV. Drug users belong to an especially hard-to-reach group for which there are substantial challenges with timely diagnosis, appropriate prevention interventions and treatment adherence. We should work for ensuring that drug users have access to the same standards of TB prevention, treatment and care, based on the principles reinforced by the International Standards for Tuberculosis Care and the Patients’ Charter for Tuberculosis Care.
The ECDC Programme on Tuberculosis and the Programme on HIV, STI and other blood-borne diseases are jointly and together with the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), currently developing guidance on infectious disease control among injecting drug users. The goal is to support policymakers in the EU to develop, improve and/or evaluate programmes of services to prevent infectious diseases, particularly blood borne viruses and TB, in drug users.
Scientific support on cross-border TB control and care
Cross-border movements are increasing with the open borders within EU and we face an array of challenges in cross-border TB control. ECDC is working jointly with WHO Regional Office for Europe and a group from the Wolfheze movement to formulate the minimum package for cross-border TB control and care in Europe. The goal is to address all the issues relevant for TB patients who are moving across borders within the EU, and for asylum seekers in the EU risking deportation after TB diagnosis. it is essential to ensure the continuity of TB treatment for these individuals.
TB control among migrants and foreign-born
Migrants bear a disproportionate burden of infectious disease and poor living and working conditions are known to increase the risk of TB. The downward TB trend in some EU countries have been interrupted by the re-emergence of TB among vulnerable populations, including the foreign born. About 20-25% of all reported TB cases in EU are of foreign origin. ECDC is working towards building an evidence base on migrant health-related issues and to investigate the impact of immigration on TB in the EU.
Related resources
Klinkenberg E, Manissero D, Semenza JC, Verver S. (2009) Migrant tuberculosis screening in the EU/EEA: yield, coverage and limitations. Eur Respir J. Nov;34(5):1180-9.PubMed
Mulder C, Klinkenberg E, Manissero D. Effectiveness of tuberculosis contact tracing among migrants and the foreign-born population. Euro Surveill. 2009 Mar 19;14(11). pii: 19153. PubMed
TB in alcohol abusing populations
Alcohol abuse is a major public health problem and it is a particularly visible challenge among TB patients in several countries of the EU. Alcohol abuse is often a major obstacle to improve treatment outcome and alcoholism is strongly associated with high treatment default rates. ECDC is working jointly with WHO Geneva and with EU Member States on issues around TB in alcohol-abusing populations. The goal is to develop new interventions to better reach this vulnerable population. Improving the treatment outcome among alcohol abusers is an important control strategy with the potential to have an impact on the overall TB epidemic.