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PUBLIC HEALTH PHYSICIANS, SOCIAL INEQUALITIES IN HEALTH AND INFECTIOUS DISEASE CONTROLTERRY-NAN TANNENBAUMPUBLIC HEALTH DEPARTMENT AGENCE DE LA SANTÉ ET DES SERVICES SOCIAUX DE MONTRÉALPHPC CPD SESSION, 9 JUNE 2013

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BACKGROUND

• Infectious disease control– Basic public health function– Protection: case investigations, outbreak control– Prevention/promotion: vaccination, disease prevention activities

• Staff not always aware of importance of social inequalities in effectiveness of public health measures

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OBJECTIVE OF PRESENTATION

• How can staff use equity lens when planning and carrying out prevention/promotion activities

• Share Montreal experience and learn what others are doing

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MONTREAL EXPERIENCE

• Knowledge of social inequalities in health (SIH) in infectious disease control (IDC) low

• Little data on importance of social determinants in disease occurrence

• Little knowledge and capacity to design programs to reduce SIH• “Gut feeling”: most important factors are cultural community, literacy

level, recent immigration, presence of factors such as homelessness

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FIRST EFFORTS

• Needed data to understand importance of social factors in disease occurrence

• Chose one area of IDC to develop interventions: vaccination coverage

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INCOME

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EDUCATION

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ECOLOGIC ANALYSIS OF THE DETERMINANTS OF 9 REPORTABLE DISEASES

Source: Allard R, Steet MC, LeGuerrier P, Jochem K. Analyse écologique des déterminants des MADO, DSP, Agence de Montréal, 2013

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INDICATORS OF SOCIAL INEQUALITY ASSOCIATED WITH CERTAIN REPORTABLE DISEASES

• Households of 6 persons or more• Educational level• Occupational status• Income

• Population measures observed at level of RTA, but not necessarily at individual level

Source: Allard R, Steet MC, LeGuerrier P, Jochem K., Analyse écologique des déterminants des MADO, DSP, Agence de Montréal, 2013

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INCIDENCE OF SHIGELLA BY FSA, MONTREAL 2004-2008

Associated with higher proportion of households with 6 persons or more, certain cultural groups

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INCIDENCE OF INFECTIOUS SYPHILIS BY FSA MONTRÉAL, 2004-2008

Associated with income level, larger households certain cultural groups and lower employment activity

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• No vaccine registry, data on coverage by territory incomplete• School vaccination only available indicator

– Vaccination coverage of HPV (4th grade)– Measles vaccination campaign in 2010

VACCINATION RATES

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MEASLES COVERAGE BY CSSS TERRITORY

Source: Kaiser D. Couverture vaccinale contre la rougeole en milieu scolaire, DSP Agence de Montréal, 2013

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MEASLES COVERAGE BY TYPE OF SCHOOL

Source: Kaiser D. Couverture vaccinale contre la rougeole en milieu scolaire, DSP Agence de Montréal, 2013

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HPV COVERAGE RATES BY SCHOOL, MONTREAL, 2010 - 2011

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PROPOSED INDICATORS FOR INFECTIOUS DISEASE MONITORING

• Rates of HIV, Chlamydia, TB, Influenza and pneumococcal vaccination – recommended

• Rates of gonorrhea, syphilis, basic immunisation coverage, invasive pneumoccal disease – possible indicators

Source: Massé R, Raynault MF. Indicateurs de surveillance pour les ISS en maladies infectieuses. Décembre 2011

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WHERE WE ARE: PUBLIC HEALTH DEPARTMENT

• Small central unit to coordinate projects and support teams• Other teams each chose one area to examine:

– Occupational health: do programs reach vulnerable populations (agency workers)

– Preventive practices: do programs account for literacy issues– Maternal and child health: how to address equity in program to reduce time

spent in front of screens

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WHERE WE ARE: HEALTH PROTECTION TEAM

• Use of indicators– Available data inadequate to guide or evaluate interventions– Data that is available doesn’t necessarily coincide with gut feeling– Need to develop indicators that are available and robust to help develop

programs

• Other possible actions– Apply health equity lens to health promotion/health prevention activities– Examples: prevention of enteric diseases, vaccination promotion

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ACKNOWLEDGEMENTS

• Health protection sector, Public Health Department, Agence de la santé et des services sociaux de Montréal

• Marie-France Raynault, Public Health Department, Agence de la santé et des services sociaux de Montréal