Global Expert Meeting on Alcohol, Health and Social Development

Speaking at the Global Expert Meeting on Alcohol, Health and Social Development, Zsuzsanna Jakab, Director of the European Centre for Disease Prevention and Control (ECDC), a technical and scientific agency of the EU, addressed the significance of the study on alcohol and infectious disease.

At the start of her speech Mrs Jakab referred to the recent annual report of the UK Chief Medical Officer in which Sir Liam Donaldson pointed out:

“The many people who drink regularly to excess cause damage far beyond their own bodies. Directly and indirectly they affect the well-being and way of life of millions of others.”

Sir Liam used the phrase “passive drinking” to describe the people damaged by the excessive drinking of others. These victims include the drinker’s family members and friends, as well as the innocent victims of drink related violence or accidents. Despite the huge harm alcohol causes it is deeply ingrained in our societies and our cultures. Tackling it will require the same sort of integrated, multifaceted public health strategies that have been used against tobacco.

The relationship between alcohol consumption and infectious diseases is a subject that has only recently started to get the attention it deserves.

There were two findings of the study that I found particularly striking:

Firstly, the finding that the global mortality burden of infectious disease (overall 13.5% of the detrimental impact of alcohol) ranks right behind the three categories where alcohol consumption impacts the most: unintentional injuries (23.2%), cardiovascular disease (19.0%) and cancer (17.0%).

Indeed, the mortality burden from infectious diseases is slightly higher than alcohol’s mortality burden of liver cirrhosis (13.0%).

The second finding that I found striking was the evidence of multiple pathways – both social and biological – from alcohol consumption to tuberculosis infection. These include increased risk of infection due to social mixing in drinking environments, and increased risk of progression of the disease. This is because alcohol has both a direct effect on weakening the immune system, and an indirect effect via alcohol related disorders such as malnutrition, cancer and other chronic diseases. Heavy drinking also acts as a barrier for access to treatment and compliance with treatment.

Studies have come to different conclusions about the magnitude of alcohol as a risk factor for tuberculosis. But a study looking at Russia concluded that alcohol was the biggest risk factor for TB there, ahead of both smoking and HIV infection.

The need for an integrated public health approach

Tuberculosis is an excellent case study to look at when examining the link between alcohol and infectious diseases. If we map poverty, substance abuse and infectious diseases in Europe we find they overlap. The poorest members of our society bear a greater burden of disease both from communicable and noncommunicable diseases.

As with tuberculosis, so too with many other infectious diseases, alcohol consumption has a number of pathways leading to ill-health, such as weakening the immune system and acting as a pathway to poverty and chronic disease.

Communicable disease experts are only now beginning to investigate and quantify the links between, poverty, alcohol, other kinds of substance abuse and infection.

This needs to be a priority for the coming years, because once one starts to investigate one sees numerous connections.

For example, a proportion of the persons injured because of alcohol will develop wound infections. Some of these infections will be with microbes such as MRSA, which are resistant to commonly used antibiotics. It is likely that, when we start investigating, we will find that alcohol consumption is a factor in nearly all the communicable disease challenges we face.

Alcohol consumption is a determinant that cuts across both communicable and non-communicable diseases. Infectious disease epidemiologists need to be trained to think about alcohol consumption as a factor when investigating trends in communicable diseases. And when looking at health inequalities we must take a holistic approach. We need to look at alcohol’s impact on violence, injuries and poverty together with its impact on both communicable and noncommunicable diseases.

Role of the ECDC

Our role is to provide high quality data, evidence and advice to health policy makers in the EU Institutions and Member States. We support the policy making process, but ECDC as such does not make health policy. This is a clear difference with WHO.

Evidence of link between alcohol consumption and STIs

The main areas in which we can help are:

• Providing the evidence base on the link between alcohol consumption and infectious diseases.

• Advising on the types of measures that may be effective in responding to the challenge this presents.

The link between poverty, alcohol and infectious diseases is an area where we need to gather more evidence, and do more investigation.

Another area where we can provide some immediate evidence of alcohol’s harmful effects is Sexually Transmitted Infections.

Literature reviews of existing evidence show a link between alcohol use and poor sexual health. One review of 42 studies found that problem drinking is clearly associated with an increased risk of STDs across a wide variety of populations¹.

ECDC’s most recent Annual Epidemiological Report showed Chlamydia to be the most frequently reported bacterial infection in the EU and EEA/ EFTA countries.

In 2006 nearly a quarter of a million Chlamydia cases were reported in these countries². This is a Sexually Transmitted Infection that mainly affects young people between the ages of 15 and 24 years old.

Willingness to engage in unprotected casual sex is clearly one of the drivers of the relatively high incidence of Chlamydia we are seeing among young people in Europe.

There is evidence from an EU funded³ study that the culture of binge drinking which has taken root among young people in many parts of Europe is a key driving factor in unsafe sexual practices.

Again none of this should surprise us. Alcohol’s role in reducing inhibition and impairing judgement has been recognised and exploited by individuals for thousands of years.

Alcohol consumption, particularly heavy use of alcohol, can have negative effects on people living with HIV. It can act as a barrier both to access to treatment and compliance with treatment, thus hastening the onset of AIDS.

There is also a growing body of evidence that alcohol consumption may hasten the onset of liver disease among people living with the Hepatitis C virus.

So what needs to be done about alcohol and infectious diseases?

The response will need to vary from country to country, taking into account differences in culture, social attitudes and health systems. There is not one simple solution.

We all agree that alcohol consumption is one of the key determinants of ill health that needs to be addressed by public health.

Ultimately, though, what Europe needs is an integrated public health strategy to address all aspects of alcohol related harm. This is something I hope the EU and WHO Europe can work on together.

1. R. L. Cook et al.: Is there an association between alcohol consumption and Sexually Transmitted Diseases? A systematic review”, Sexually Transmitted Diseases, March 2005

2. 225 996 cases of Chlamydia trachomatis infection were confirmed by 22 EU and EEA/ EFTA Member States, giving a rate of 92 per 100 000. Source: ECDC Annual Epidemiological Report 2008

3. Mark Bellis et al Sexual uses of alcohol and drugs and the associated health risks: A cross sectional study of young people in nine European cities, BMC Public Health 2008