Cathriona Kearns and Michael Devine Public Health Agency NI

1. Tuberculosis
Cathriona Kearns and Michael Devine
‘Health Protection Inequalities on the Island of Ireland’ Seminar, 18 February 2016 ,
Belfast

2. William Hogarth. Gin lane
Tuberculosis – ‘The perfect expression of
an imperfect civilisation’1
1.Dormandy T. The white death. New York: New York University Press, 2000.

3. Social determinants of TB

4. Risk factors for TB infection
• Age: young adults/Young children/the elderly
• Contact with a TB case
• Immunocompromised patients
• Ethnic minority groups: A large proportion of TB cases occur in those from ethnic
minorities, In addition, those individuals born in, or arrived from, or returned from
countries with a high incidence of TB within the last 5 years are at greater risk with a
greater than average lifetime risk that extends to their children and close contacts born
in the UK.
• Lifestyle factors: alcohol or drug misuse. Less likely to access health services during the
early stages of disease.
• Living in crowded or unsanitary accommodation: (homeless, prison, poverty,
malnutrition, overcrowding and poor housing encourage the spread of TB).
• Smoking, diet: More than 20% of TB cases worldwide are attributable to smoking

6. Epidemiology of TB in Northern Ireland

7. 0.0
1.0
2.0
3.0
4.0
5.0
6.0
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
NIrateper100,000
Numberofcases
Non-UK UK born Rate/100,000 Mean rate
TB case reports and rate (per 100,000) Northern Ireland, 2000-2014

8. 0.0
0.5
1.0
1.5
2.0
2.5
3.0
2008 2009 2010 2011 2012 2013 2014
Rateper100,000
UK-born
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
2008 2009 2010 2011 2012 2013 2014
Rateper100,000
Non-UK born
Rates of TB in Northern Ireland in the UK and Non-UK born population

9. 0
2
4
6
8
10
12
14
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rate(per100,000)
0-14 15-44 45-64 65+
TB age-specific rates, Northern Ireland, 2000-2014

10. 1, 1% 8, 3%
43, 18%
77, 32%
111, 46%
0-4
5-14
15-44
45-64
65+
4, 2%
201, 80%
39, 15%
8, 3%
5-14
15-44
45-64
65+
Age profile of UK and Non-UK born TB cases 2008-2015
Non-UK born (n=252)
UK born (n=240)

12. Distribution of Northern Ireland TB cases 2000-2015 by HSCT
Monaghan
Cavan
Donegal
Louth

13. 0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
2000-
2002
2001-
2003
2002-
2004
2003-
2005
2004-
2006
2005-
2007
2006-
2008
2007-
2009
2008-
2010
2009-
2011
2010-
2012
2011-
2013
2012-
2014
Rateper100,000
BHSCT NHSCT SEHSCT SHSCT WHSCT
Three year moving average rates of TB cases by HSCT in Northern Ireland,
2000-2014

14. 0.0
2.0
4.0
6.0
8.0
10.0
12.0
1 2 3 4 5
Rateper100,000
Deprivation quintile (1= most deprived, 5= least deprived)
The Index of Multiple Deprivation (IMD) 2010, is an overall measure of multiple deprivation experienced by people living in an area and is measured at
Super Output (SOA) level. Commissioned output is based on Small Area Population Estimates for 890 Super Output Areas in Northern Ireland. NISRA -
Demography and Methodology Branch
Rates of TB by deprivation, Northern Ireland 2014

15. 0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Q1 Q2 Q3 Q4 Q5
Proportionofcases
UK-born Non-UK born
Proportion of Northern Ireland TB cases living in deprivation by
country of birth
(n=1063)

16. Distribution of Northern Ireland TB cases 2008-2015 by deprivation quintile
and UK/Non-UK born
UK born
c

17. Distribution of TB cases in Belfast area 2008-2015 by deprivation quintile
and UK/Non-UK born
UK born

18. Distribution of TB cases in Southern area 2008-2015 by deprivation quintile
and UK/Non-UK born
UK born

19. The drivers behind increasing numbers in the SHSCT- an example
of a recent Investigation
• In-migration increased rapidly in the period following EU
enlargement in 2004- Migration inflows are concentrated in Belfast
and the SHSCT, with Dungannon the most popular location in the
latter.
• Compared to the UK, NI based EU accession migrants are
disproportionately found in manufacturing areas.
• This area experienced a large influx of migrant workers first
Portuguese and then A* nationals.
• Migrant workers face poor quality housing largely in the private
sector often resultant in overcrowding. Migrant worker households
in this area tend to be large, younger, predominantly male with high
employment rates but lower incomes than comparable households
in the area (Campbell and Frey, 2010).

20. 205428
2014 pul smear-ve138843
2011 non-pul
Same house flat10
152619
2012 pul smear+ve
201478
2013 pul sputum smear-ve
culture+ve
216230
2015
pul smear -ve
207558
2014 nonpul
Same house different flat Same house flat11
202934
2014 pul smear-ve
Factory 2
Factory1
vntr
Legend
VNTR cluster 1
Work colleagues
Same address
VNTR
cluster
2
Same address
Empl
oyer
N/K
141132
2012 Non-pul cervical node LTF
209102 pul. Labs all –ve:clinical
2014
Same address
207431
2014 pul sputum -ve
207335
2014 pul sputum -ve
214006
2015 CNS culture
+ve smear N/K
All live same area different
address
VNTR
cluster
3
Cluster 3
213188
2015 Pulmonary culture &
smear+ve
2012 152878
Non-pulmonary. Iso & Strp. Resistant
142894
2012 Pul. Smear +ve
VNTR
cluster
4
Same address
2013 Clinical
Cluster 4

21. • With the exception of one case all cases are from a high incident country (Timor-Leste)
• incidence rates of TB are estimated to be in the region of 400/100,000.
• All cases lived in a similar area of Northern Ireland
• All cases are male of working age
• VNTR cannot infer timing or direction of transmission
Anecdotal evidence of :
• Shift work with multiple individuals sharing accommodation (same beds night v day
shifts)
• Poor accommodation – low rent to allow for sending money back home*
• Most individuals in this community smoke – not known if cases did/did not *
• Linguistic barriers. English not widely spoken in E.Timor*
• Access to healthcare may be limited due to shift work- differential consequences relating
to pay if absent
• Cultural perceptions of the illness (stigma) and effectiveness of treatment*
• Factory owners fair employers but concerns directed towards business /products
reputation not just the health of the employees (source PHE).
*Ref: G. Peake,2013

22. Considerations…….
The social conditions in which people live and work can help create or destroy their
health. Lack of income, inappropriate housing, unsafe workplaces and lack of access
to health care systems are some of the social determinants of health leading to
inequalities. (World Health Organization [WHO], 2004)
Prior to entry, a migrant’s health reflects the disease profile of his or her country of
origin….. In a new country, living and/or working conditions can also affect a
migrant’s health (ECDC, 2009)
Crowded, unventilated living conditions facilitate the spread of TB infection. Poor
housing conditions have been documented among migrants and ethnic minority
groups in the EU (Bates et al., 2004; Wanyeki et al.,2006; ECDC & WHO Regional Office for Europe,
2009)
Health services may be inaccessible by those most in need for several reasons:
e.g. gender, geographic distance from health care facilities, the costs associated
with receiving care and fear or stigma (WHO, 2010)

23. Health behaviours influenced by social/ personal/ environmental factors (peer networks,
income or other resources, access to facilities and amenities, food production and promotion, work and living
conditions, cultural practices, stress and isolation)
• Improvements in the collection of relevant health data, on an all-Ireland basis,
would make an important contribution to working for greater health equity.
• The collective burden of TB on the Island of Ireland/ most affected
populations/ identifying principal risk factors
• The principal TB strain types (Types found in NI not similar to elsewhere in
UK)
• Identifying reason for non-compliance/late access to services
• Analysis of patient trajectories, particularly those suffering from multiple
morbidities, can complement quantitative analysis of health system
functioning.
• Not all associations between social determinants and epidemiological data can
easily be accessed via statistical analysis (Blas & Sivasankara Kurup)
Considerations…….

24. • Chris Nugent , Eamon Nancarrow, Paul Cabrey, Dr Declan
Bradley, PHA
• Dr Rory Convery, Nuala McNeice, Audrey Johntson, Respiratory
Team SHSCT
• Dr Colin Goldsmith and team, Regional Microbiology Laboratory
Northern Ireland
• Public Health England, TB and Microbiology Teams

25. Lönnroth K et al. (2009a). Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Social Science & Medicine,
68(12):2240–2246.
Campbell D. and Frey J. (2010) Migrant workers and the housing market a case study of Dungannon, NIHE
Peake, G. (2013) Beloved Land -Stories, Struggles, and Secrets from Timor-Leste
WHO (2004). Interim policy on collaborative TB/HIV activities. Geneva, World Health Organization (http://www.who.int/hiv/pub/tb/en/
Printed_version_interim-policy_2004.pdf, accessed 10 April 2010).
ECDC (2009). Migrant health: background note to the ECDC report on migration and infectious diseases in the EU. Stockholm, European
Centre for Disease Prevention and Control (http://www.ecdc.europa.eu/en/publications/Publications/0907_TER_Migrant_health_Background_
note.pdf, accessed 20 February 2010).
Bates I et al. (2004).Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual
and household level. The Lancet Infectious Diseases, 4(5): 267−277.
Wanyeki I et al. (2006). Dwellings, crowding, and tuberculosis in Montreal. Social Science and Medicine, 63(2): 501–511.
WHO Regional Office for Europe. Plan to Stop TB in 18 High-priority Countries in the WHO European Region, 2007–2015.
Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/document/E91049.pdf, accessed 25 January 2010).
Blas E, Sivasankara Kurup A (in press). Synergy for equity. In: Blas E, Sivasankara Kurup A, eds. Priority public health conditions: from learning
to action on social determinants of health. Geneva, World Health Organization.
References