Research | Social Medicine, Infectious diseases and Migration

Social inequity leads to health inequities. Health is improving in Sweden and globally but widening income gaps, further marginalization of some groups and increased forced migration are contributing to widening health disparities. Closing the health equity gap requires actions both within and outside the health sector.

Broad social protection, including Universal Health Coverage, needs to be coupled with tailored delivery models for the most vulnerable, as well as technological innovations that enables better outreach and access.

The epidemiological transition is rapidly changing the health landscape globally, with a clear need to improve prevention and care for non-communicable diseases (NCD). However, infectious diseases remain major contributors to the burden of disease especially in low- and middle-income countries. The Sustainable Development Goals include ambitious targets to end the global tuberculosis (TB), AIDS and malaria epidemics in coming decades. NCDs and infectious disease are interlinked and share largely the same social determinants. Integrated approaches for prevention and care are required.

Research areas

Our research group uses social epidemiology, qualitative methods, as well as health economy and implementation research methods to:

  • identify social determinants and consequences of disease, with a major focus on poverty-related infectious diseases, including TB, HIV, malaria, and Ebola;
  • evaluate interventions to improve health care access and equity;
  • develop and evaluate innovative mobile and digital technologies that improves equitable access;    
  • assess the effectiveness and cost-effectiveness of tuberculosis screening programmes in high- and low-TB burden countries;
  • determine health needs of migrants and evaluate health examinations of asylum seekers and refugees.

Research projects

E-Detect: A research consortium for the early detection and integrated management of tuberculosis in Europe

Logo that reads E-detect

The E-Detect consortium aims to contribute to the ultimate elimination of tuberculosis (TB) in the EU by implementing and evaluating interventions to ensure early diagnosis and improve integrated care, with a main focus on vulnerable groups. The consortium, which was established in 2016 with EU funding, includes several EU member states and is implemented in collaboration with ECDC and WHO. PHS/KI leads Work Package 6 of this project, which aims to develop a multi-country migrant TB screening database, initially including data from Italy, The Netherlands, Sweden and The UK.

This database will be used to perform pooled and comparative analyses of TB epidemiology in migrants from TB endemic countries and to determine coverage and completion of the TB screening and treatment cascade in different subgroups. Ultimately, WP6 results will contribute to evidenced-based and harmonized migrant TB screening policies in Europe and globally. 

The project partners are: University College London, UK; KNCV Tuberculosis Foundation, The Netherlands; Ospedale San Raffaele, Italy; Institutul De Pneumoftiziologie, Romania; University of Brescia, Italy; Public Health England, UK; Delft Imaging systems, The Netherlands; Folkhälsomyndigheten (the Swedish Public Health Agency), Sweden; Instituto Nazionale Malattie Infettive, Italy; and Health Strategies and Programs Center, Bulgaria.   

For more information about the E-Detect research consortium

This project has received funding from the European Union’s Health Programme (2014-2020) under grant agreement No709624.

IMPACT-TB

Logo that reads Impact-TBIMPACT TB will implement, evaluate and scale up proven active tuberculosis (TB) case finding and social support interventions in Nepal and Vietnam. The project will determine the effectiveness and cost-effectiveness of different implementation models and examine barriers and enablers for knowledge translation and scale up. In order for effective translation of research findings to policies on active TB case finding and social protection for people with TB, the project actively engages with Ministry of Health in each country, WHO, and the SPARKS network. The project started 2017, with EU funding (Horizon 2020).

The other project partners are Liverpool School of Tropical Medicine in the UK, Birat Nepal Medical Trust in Nepal, Friends for International TB relief in Germany/Vietnam, and the KNCV Tuberculosis Foundation, in the Netherlands. More information about the IMPACT-TB project

The IMPACT TB project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No 733174.

TB-Sequel

Logo that reads: TB-Sequel

TB-Sequel is a multi-country cohort study designed to determine the short- and long-term medical, social and economic consequences of tuberculosis (TB). The study started in 2017 and is implemented in four African countries: The Gambia, Mozambique, South Africa, and Tanzania. Cohorts of TB patients will be followed from diagnosis to at least one year after treatment completion. KI/PHS is co-leading the socioeconomic work package of this study, which is collecting data on patients‘ socioeconomic situation, health expenditures, income loss, social consequences of disease and health-related quality of life.

The other project partners are: the Aurum Institute, South Africa; Department for Infectious Diseases and Tropical Medicine, University of Munich, Germany; Division of Wits Health Consortium, University Of The Witswatersrand, South Africa; National Institute For Medical Research – Mbeya Medical Research Centre, Tanzania, Instituto Nacional De Saúde, Mozambique; Medical Research Council, United Kingdom; and Research Center Borstel, Germany. 

The project is funded through a grant from Bundesministerium für Bildung und Forschung (BMBF), Germany.

For more information about TB-Sequel study

ISTE – Interdisciplinary Strategies for TB Elimination in Sweden

This project is assessing current strategies for early TB case finding and screening for latent TB infection (LTBI) among migrants from TB endemic countries, with a main initial focus on Stockholm County. This mixed-method project includes: qualitative studies (interviews with users, health providers and other stakeholders) to explore barriers and enablers for optimal implementation of migrant TB screening; epidemiological analyses of diagnostic pathways and TB screening coverage, uptake and results; and an economic evaluation of LTBI screening for asylum seekers based on mathematical modelling. Interventions to optimize implementation of appropriate strategies will be developed. 

The project is implemented in collaboration with Karolinska University Hospital, the infection disease unit of Stockholm County, and Folkhälsomyndigheten (the Swedish Public Health Agency). The project is funded with grants from Swedish Research Council for Health, Working Life and Welfare (FORTE, grant 2015-00304) and the Swedish Heart and Lung Foundation.

CTEST: Improving young Swedish men health services utilization for Chlamydia Trachomatis infection detection and treatment

The aim of this project is to identify individual, social and health service factors facilitating or hindering young men´s health service utilization for Chlamydia Trachomatis detection (CT) in Sweden. We are conducting a mixed-method study combing a population-based survey with qualitative studies with healthcare staff and young men.  

CT is the most common sexually transmitted infection in Sweden. In 2015 357 cases for 100,000 inhabitants were reported. Young people represent 89% of all cases and 3 out 100 young people have been diagnosed with CT during the last year. Young men´s health service utilization for CT detection is very low in Sweden. In 2014 the Public Health Agency of Sweden reported that only 30% of all CT tests were conducted among men. Data from 33 Youth Health Clinics (YHC) in Stockholm revealed that 28% of all young people testing for CT during 2010-2012 were men. CT infection among young men tested at YHC clinics is higher than women´s (11% vs. 5. 7%). Thus it is likely that large pools of infected young men are undetected. No previous studies in Sweden have focused on identifying factors facilitating/constraining young men´s health service utilization for CT detection.

The project is funded with grants from Swedish Research Council for Health, Working Life and Welfare.

Epidemiology, risk factors and transmission mechanisms of the emergence of multidrug and extensively drug resistant TB

This multidisciplinary research project addresses microbiological/molecular, clinical and public health aspects of a multi and extensively drug resistant tuberculosis (M/XDR). In China M/XDR-TB has reached epidemic proportions and in Sweden, it is seen mainly in certain immigrant populations.

Even more resistant M tuberculosis strains, sometime called totally drug resistant (TDR) threatens to make TB an untreatable disease. Suboptimal therapy increases the risk for development of even more resistant M tuberculosis bacteria in the individual patient as well as the transmission of increasingly drug resistant strains in the community. Scientific multidisciplinary research investigations of the dynamics of increasing drug resistance are important to identify and recommend the needed actions to be taken to control it and to develop the tools necessary to make these actions effective.

Our project focuses on these aspects and will include the following three parts: 

  1. Disease burden and social determinants; 
  2. Treatment monitoring and optimization; 
  3. Bacteriological and molecular investigations of drug resistance mechanisms. 

Find more information about the programme

MoMic

Point-of-care diagnostics of infectious diseases and using mobile digital microscopy and artificial intelligence. We have developed a mobile technology based microscope (MoMic) which is used in point of care diagnosis of multiplex of diseases including parasitic, bacterial, helminthic and cancer. Computer vision based on artificial intelligence (AI) can be applied to the analysis of biological samples and support human experts in diagnostics. Substantial improvement of image-based diagnostics can be achieved largely due to recent advances within a specific domain of AI entitled deep learning.

In proof-of-concept studies have shown that it is feasible to digitally scan microscopy samples using low-cost mobile microscopy scanners and apply AI augmented computer vision to support the diagnostic process. 

Chlamydia among youth in Stockholm County; testing habits and evaluation of mobile phone intervention to promote safe sexual practices

The first part of this project aims to describe the testing habits of youth who visits the Youth Health Clinics in Stockholm County, ascertain the frequency of re-testing for Chlamydia trachomatis, and understand the reasons behind re-testing. The second part of the study aims to design, test, and evaluate in a pragmatic randomized controlled trial, a smart phone application to improve sexual health among youth.

CHEST: Coordination of Health and Social care for TB patients in Mozambique

The aim of this project is to develop, implement and evaluate a bi-directional referral system for tuberculosis patients in Mozambique. Mozambique is among the countries with the highest TB burden in the world.

While TB is closely associated with poverty, it can also push TB-affected households into worsening impoverishment through costs associated with having TB disease and accessing treatment, including costs of medicines, food, and travel or indirect costs. Such costs can even become catastrophic, resulting in patients being lost to follow up, failing treatment, or in some cases dying.

Social protection, which can include poverty-reduction, insurance, and cash transfer schemes, could mitigate the costs incurred by patients and their households. Because of this, social protection is a critical element in the WHO’s End TB strategy. Though TB patients and their households need, and may be eligible for, social grants, referral systems between health and social services are often under-developed.

Improving the referral between social and health services for TB patients could have benefits for both TB patients and national TB programmes. When TB patients could be referred to potentially lifesaving grants that can support their treatment adherence, TB control can also be enhanced by using the social protection schemes as platform for TB case finding among the most vulnerable groups. CHEST will evaluate a multisectoral approach with a bi-direction referral system and coordinated patient support.

The project is funded with a grant from the Swedish Research Council.

Supporting Tuberculosis treatment with mobile phones in India

TB care and treatment is prolonged and complex. It requires patients to take medications under daily supervision over at least six months as prescribed to prevent poor health outcomes, including recurrence of infection or drug resistance. Issues such as stigma, difficulties with accessing healthcare and finances along with limited awareness of the seriousness of the poor adherence affects treatment success.

This project determines the effectiveness and cost-effectiveness of a mobile phone application for video-based direct observed treatment (vDOT) in India and assesses barriers to using it in order to ensure that it is contextualized to the Indian scenario.

Networks and centres

SPARKS – The health and social protection action research and knowledge sharing network

The Health and Social Protection Action Research & Knowledge Sharing network (SPARKS) is a global network created to facilitate action-oriented research on the public health impact of social protection, with a main focus on low- and middle-income countries. SPARKS will facilitate networking between prominent research institutions, public health practitioners, international organizations and civil society in order to catalyze and coordinate interdisciplinary action, research and knowledge sharing, develop a common priority research agenda, generate evidence and mobilize financial resources.

Initially, the network will have two hubs operating in close collaboration with the Global TB Programme at World Health Organization (WHO): one at the Department of Public Health Sciences, Karolinska Institutet and one at the London School of Hygiene and Tropical Medicine (LSHTM). Additional hubs will be added, with priority for institutions in low- and middle-income countries. SPARKS will initially focus on tuberculosis (TB), an archetypal disease of poverty and a leading cause of morbidity and mortality in low- and middle-income countries. 

WHO’s End TB Strategy has identified social protection as a critical element of the global response to TB, but acknowledges the lack of and operational and impact evidence to inform recommendation and guide countries through this policy development. Building on TB as tracer condition for poverty-related disorders with medium to long-term financial and social consequences, the work will then expand to look at other health conditions. 

More information about the network SPARKS

Centre for Global health

KI’s Centre for Global Health (CGH) is an initiative to support sustainable, innovative and excellent research, education and advocacy on Global Health. The Centre was established by KI in 2007 and since then it has worked for increasing collaborations between disciplines and departments and research groups through providing virtual and physical platform for meeting.

Several academic, policy related and information activities has been performed. The Centre has taken initiatives to create academic basis for collaboration with foreign universities and encourages multi and interdisciplinary research, education and information collaboration. Recently, the Centre has taken a pivotal role in advocating for Global Health at the Karolinska Institutet and abroad, investing in the young students on campus.

Research support

  • European Union, H2020
  • European Commission, CHAFEA
  • FORTE
  • Swedish Research Council
  • Hjärtlungfonden
  • Bundesministerium für Bildung und Forschung (BMBF), Germany.

Contact

Research group leader

Professor/senior physician

Knut Lönnroth

Organizational unit: Social Medicin
E-mail: knut.lonnroth@ki.se

Global Health