[Show abstract][Hide abstract] ABSTRACT: Background:
Tuberculosis (TB) is a major global public health problem which affects poorest individuals the worst. A high proportion of patients incur 'catastrophic costs' which have been shown to result in severe financial hardship and adverse health outcomes. Data on catastrophic cost incidence is not routinely collected, and current definitions of this indicator involve several practical and conceptual barriers to doing so. We analysed data from TB programmes in India (Bangalore), Bangladesh and Tanzania to determine whether dissaving (the sale of assets or uptake of loans) is a useful indicator of financial hardship.
Data were obtained from prior studies of TB patient costs in Bangladesh (N = 96), Tanzania (N = 94) and Bangalore (N = 891). These data were analysed using logistic and linear multivariate regression to determine the association between costs (absolute and relative to income) and both the presence of dissaving and the amounts dissaved.
After adjusting for covariates such as age, sex and rural/urban location, we found a significant positive association between the occurrence of dissaving and total costs incurred in Tanzania and Bangalore. We further found that, for patients in Bangalore an increase in dissaving of $10 USD was associated with an increase in the cost-income ratio of 0.10 (p < 0.001). For low-income patients in Bangladesh, an increase in dissaving of $10 USD was associated with an increase in total costs of $7 USD (p <0.001).
Dissaving is potentially a convenient proxy for catastrophic costs that does not require usage of complex patient cost questionnaires. It also offers an informative indicator of financial hardship in its own right, and could therefore play an important role as an indicator to monitor and evaluate the impact of financial protection and service delivery interventions in reducing hardship and facilitating universal health coverage. Further research is required to understand the patterns and types of dissaving that have the strongest relationship with financial hardship and clinical outcomes in order to move toward evidence-based policy making.
BMC Health Services Research 10/2015; 15(1):476. DOI:10.1186/s12913-015-1138-z · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
To assess the design, delivery and outcomes of interventions to improve adherence to treatment for paediatric tuberculosis in low- and middle-income countries and develop a contextual framework for such interventions.
We searched PubMed and Cochrane databases for reports published between 1 January 2003 and 1 December 2013 on interventions to improve adherence to treatment for tuberculosis that included patients younger than 20 years who lived in a low- or middle-income country. For potentially relevant articles that lacked paediatric outcomes, we contacted the authors of the studies. We assessed heterogeneity and risk of bias. To evaluate treatment success - i.e. the combination of treatment completion and cure - we performed random-effects meta-analysis. We identified areas of need for improved intervention practices.
We included 15 studies in 11 countries for the qualitative analysis and of these studies, 11 qualified for the meta-analysis - representing 1279 children. Of the interventions described in the 15 studies, two focused on education, one on psychosocial support, seven on care delivery, four on health systems and one on financial provisions. The children in intervention arms had higher rates of treatment success, compared with those in control groups (odds ratio: 3.02; 95% confidence interval: 2.19-4.15). Using the results of our analyses, we developed a framework around factors that promoted or threatened treatment completion.
Various interventions to improve adherence to treatment for paediatric tuberculosis appear both feasible and effective in low- and middle-income countries.
Bulletin of the World Health Organisation 10/2015; 93(10):700-711B. DOI:10.2471/BLT.14.147231 · 5.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Latent tuberculosis infection (LTBI) is characterised by the presence of immune responses to previously acquired Mycobacterium tuberculosis infection without clinical evidence of active tuberculosis (TB). Here we report evidence-based guidelines from the World Health Organization for a public health approach to the management of LTBI in high risk individuals in countries with high or middle upper income and TB incidence of <100 per 100 000 per year. The guidelines strongly recommend systematic testing and treatment of LTBI in people living with HIV, adult and child contacts of pulmonary TB cases, patients initiating anti-tumour necrosis factor treatment, patients receiving dialysis, patients preparing for organ or haematological transplantation, and patients with silicosis. In prisoners, healthcare workers, immigrants from high TB burden countries, homeless persons and illicit drug users, systematic testing and treatment of LTBI is conditionally recommended, according to TB epidemiology and resource availability. Either commercial interferon-gamma release assays or Mantoux tuberculin skin testing could be used to test for LTBI. Chest radiography should be performed before LTBI treatment to rule out active TB disease. Recommended treatment regimens for LTBI include: 6 or 9 month isoniazid; 12 week rifapentine plus isoniazid; 3-4 month isoniazid plus rifampicin; or 3-4 month rifampicin alone.
European Respiratory Journal 09/2015; DOI:10.1183/13993003.01245-2015 · 7.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In August 2011, the World Health Organization and the International Union Against Tuberculosis and Lung Disease launched the Collaborative Framework for Care and Control of Tuberculosis (TB) and diabetes mellitus (DM) to guide policy makers and implementers in combatting the epidemics
of both diseases. Progress has been made, and includes identifying how best to undertake bidirectional screening for both diseases, how to provide optimal treatment and care for patients with dual disease and the most suitable framework for monitoring and evaluation. Key programmatic challenges
include the following: whether screening should be directed at all patients or targeted at those with high-risk characteristics; the most suitable technologies for diagnosing TB and diabetes in routine settings; the best time to screen TB patients for DM; how to provide an integrated, coordinated
approach to case management; and finally, how to persuade non-communicable disease programmes to adopt a cohort analysis approach, preferably using electronic medical records, for monitoring and evaluation. The link between DM and TB and the implementation of the collaborative framework for
care and control have the potential to stimulate and strengthen the scale-up of non-communicable disease care and prevention programmes, which may help in reducing not only the global burden of DM but also the global burden of TB.
The International Journal of Tuberculosis and Lung Disease 08/2015; 19(8):879-86. DOI:10.5588/ijtld.15.0069 · 2.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards "pre-elimination" (<10 cases per million) and eventually the elimination of TB as a public health problem (less than one case per million). TB epidemiology in most low-incidence countries is characterised by a low rate of transmission in the general population, occasional outbreaks, a majority of TB cases generated from progression of latent TB infection (LTBI) rather than local transmission, concentration to certain vulnerable and hard-to-reach risk groups, and challenges posed by cross-border migration. Common health system challenges are that political commitment, funding, clinical expertise and general awareness of TB diminishes as TB incidence falls. The framework presents a tailored response to these challenges, grouped into eight priority action areas: 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. The overall approach needs to be multisectorial, focusing on equitable access to high-quality diagnosis and care, and on addressing the social determinants of TB. Because of increasing globalisation and population mobility, the response needs to have both national and global dimensions.
European Respiratory Journal 03/2015; 45(4). DOI:10.1183/09031936.00214014 · 7.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Diabetes triples the risk of tuberculosis and is also a risk factor for adverse tuberculosis treatment outcomes, including death. Prevalence of diabetes is increasing globally, but most rapidly in low-income and middle-income countries where tuberculosis is a grave public health problem. Growth in this double disease burden creates additional obstacles for tuberculosis care and prevention. We review how the evolution of evidence on the link between tuberculosis and diabetes has informed global policy on collaborative activities, and how practice is starting to change as a consequence. We conclude that coordinated planning and service delivery across communicable and non-communicable disease programmes is necessary, feasible, and creates synergies that will help to reduce the burden of both tuberculosis and diabetes.
[Show abstract][Hide abstract] ABSTRACT: To achieve the post-2015 global tuberculosis target of 90% reduction in tuberculosis incidence by 2035, the present rate of decline must accelerate. Among factors that hinder tuberculosis control, malnutrition and diabetes are key challenges. We review available data to describe the complex relationship between tuberculosis, diabetes, and nutritional status. Additionally, we review past trends, present burden, and available future global projections for diabetes, overweight and obesity, as well as undernutrition and food insecurity. Using a mathematical model, we estimate the potential effect of these factors on tuberculosis burden up to 2035. Great potential exists for reduction of worldwide tuberculosis burden by combination of improved prevention and care of diabetes with reduction of undernutrition. To achieve this combination will require joint efforts and strong cross-programme links, enabling synergistic effects of public health policies that promote good nutrition and optimum clinical care for tuberculosis and diabetes.
[Show abstract][Hide abstract] ABSTRACT: Tuberculosis (TB) remains a major global public health problem. In all societies, the disease affects the poorest individuals the worst. A new post-2015 global TB strategy has been developed by WHO, which explicitly highlights the key role of universal health coverage (UHC) and social protection. One of the proposed targets is that "No TB affected families experience catastrophic costs due to TB." High direct and indirect costs of care hamper access, increase the risk of poor TB treatment outcomes, exacerbate poverty, and contribute to sustaining TB transmission. UHC, conventionally defined as access to health care without risk of financial hardship due to out-of-pocket health care expenditures, is essential but not sufficient for effective and equitable TB care and prevention. Social protection interventions that prevent or mitigate other financial risks associated with TB, including income losses and non-medical expenditures such as on transport and food, are also important. We propose a framework for monitoring both health and social protection coverage, and their impact on TB epidemiology. We describe key indicators and review methodological considerations. We show that while monitoring of general health care access will be important to track the health system environment within which TB services are delivered, specific indicators on TB access, quality, and financial risk protection can also serve as equity-sensitive tracers for progress towards and achievement of overall access and social protection.
PLoS Medicine 09/2014; 11(9):e1001693. DOI:10.1371/journal.pmed.1001693 · 14.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Even when tuberculosis (TB) treatment is free, hidden costs incurred by patients and their households (TB-affected households) may worsen poverty and health. Extreme TB-associated costs have been termed "catastrophic" but are poorly defined. We studied TB-affected households' hidden costs and their association with adverse TB outcome to create a clinically relevant definition of catastrophic costs.
Methods and findings:
From 26 October 2002 to 30 November 2009, TB patients (n = 876, 11% with multi-drug-resistant [MDR] TB) and healthy controls (n = 487) were recruited to a prospective cohort study in shantytowns in Lima, Peru. Patients were interviewed prior to and every 2-4 wk throughout treatment, recording direct (household expenses) and indirect (lost income) TB-related costs. Costs were expressed as a proportion of the household's annual income. In poorer households, costs were lower but constituted a higher proportion of the household's annual income: 27% (95% CI = 20%-43%) in the least-poor houses versus 48% (95% CI = 36%-50%) in the poorest. Adverse TB outcome was defined as death, treatment abandonment or treatment failure during therapy, or recurrence within 2 y. 23% (166/725) of patients with a defined treatment outcome had an adverse outcome. Total costs ≥20% of household annual income was defined as catastrophic because this threshold was most strongly associated with adverse TB outcome. Catastrophic costs were incurred by 345 households (39%). Having MDR TB was associated with a higher likelihood of incurring catastrophic costs (54% [95% CI = 43%-61%] versus 38% [95% CI = 34%-41%], p<0.003). Adverse outcome was independently associated with MDR TB (odds ratio [OR] = 8.4 [95% CI = 4.7-15], p<0.001), previous TB (OR = 2.1 [95% CI = 1.3-3.5], p = 0.005), days too unwell to work pre-treatment (OR = 1.01 [95% CI = 1.00-1.01], p = 0.02), and catastrophic costs (OR = 1.7 [95% CI = 1.1-2.6], p = 0.01). The adjusted population attributable fraction of adverse outcomes explained by catastrophic costs was 18% (95% CI = 6.9%-28%), similar to that of MDR TB (20% [95% CI = 14%-25%]). Sensitivity analyses demonstrated that existing catastrophic costs thresholds (≥10% or ≥15% of household annual income) were not associated with adverse outcome in our setting. Study limitations included not measuring certain "dis-saving" variables (including selling household items) and gathering only 6 mo of costs-specific follow-up data for MDR TB patients.
Despite free TB care, having TB disease was expensive for impoverished TB patients in Peru. Incurring higher relative costs was associated with adverse TB outcome. The population attributable fraction indicated that catastrophic costs and MDR TB were associated with similar proportions of adverse outcomes. Thus TB is a socioeconomic as well as infectious problem, and TB control interventions should address both the economic and clinical aspects of this disease. Please see later in the article for the Editors' Summary.
PLoS Medicine 07/2014; 11(7):e1001675. DOI:10.1371/journal.pmed.1001675 · 14.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In order to inform the development of appropriate strategies to improve financial risk protection, we conducted a systematic literature review of the financial burden of tuberculosis (TB) faced by patients and affected families.
The mean total costs ranged from $55 to $8198, with an unweighted average of $847. On average, 20% (range 0–62%) of the total cost was due to direct medical costs, 20% (0–84%) to direct non-medical costs, and 60% (16–94%) to income loss. Half of the total cost was incurred before TB treatment. On average, the total cost was equivalent to 58% (range 5–306%) of reported annual individual and 39% (4–148%) of reported household income. Cost as percentage of income was particularly high among poor people and those with multidrug-resistant TB. Commonly reported coping mechanisms included taking a loan and selling household items.
The total cost of TB for patients can be catastrophic. Income loss often constitutes the largest financial risk for patients. Apart from ensuring that healthcare services are fairly financed and delivered in a way that minimises direct and indirect costs, there is a need to ensure that TB patients and affected families receive appropriate income replacement and other social protection interventions.
European Respiratory Journal 02/2014; 43(6). DOI:10.1183/09031936.00193413 · 7.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: People with TB and/or HIV frequently experience severe economic barriers to health care, including out-of-pocket expenses related to diagnosis and treatment, as well as indirect costs due to loss of income. These barriers can both aggravate economic hardship and prevent or delay diagnosis, treatment and successful outcome, leading to increased transmission, morbidity and mortality. WHO, UNAIDS and the ILO argue that economic support of various kinds is essential to enable vulnerable people to protect themselves from infection, avoid delayed diagnosis and treatment, overcome barriers to adherence, and avert destitution. This paper analyses successful country proposals to the Global Fund to Fight AIDS, Tuberculosis and Malaria that include economic support in Rounds 7 and 10; 36 and 20 HIV and TB grants in Round 7 and 32 and 26, respectively, in Round 10. Of these, up to 84 percent included direct or indirect economic support for beneficiaries, although the amount constituted a very small proportion of the total grant. In TB grants, the objectives of economic support were generally clearly stated, and focused on mechanisms to improve treatment uptake and adherence, and the case was most clearly made for MDR-TB patients. In HIV grants, the objectives were much broader in scope, including mitigation of adverse economic and social effects of HIV and its treatment on both patients and families. The analysis shows that economic support is on the radar for countries developing Global Fund proposals, and a wide range of economic support activities are in place. In order to move forward in this area, the wealth of country experience that exists needs to be collated, assessed and disseminated. In addition to trials, operational research and programme evaluations, more precise guidance to countries is needed to inform evidence-based decision about activities that are cost-effective, affordable and feasible.
PLoS ONE 01/2014; 9(1):e86225. DOI:10.1371/journal.pone.0086225 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The global burden of diabetes mellitus (DM) is immense,
with numbers expected to rise to over 550 million by
2030. Countries in Asia, such as India and China, will bear
the brunt of this unfolding epidemic. Persons with DM
have a significantly increased risk of developing active tuberculosis
(TB) that is two to three times higher than in
persons without DM. This article reviews the epidemiology
and interactions of these two diseases, discusses how
the World Health Organization and International Union
Against Tuberculosis and Lung Disease developed and
launched the Collaborative Framework for the care and
control of TB and DM, and examines three important
challenges for care. These relate to 1) bi-directional screening
of the two diseases, 2) treatment of patients with dual
disease, and 3) prevention of TB in persons with DM. For
each area, the gaps in knowledge and the priority research
areas are highlighted. Undiagnosed, inadequately
treated and poorly controlled DM appears to be a much
greater threat to TB prevention and control than previously
realised, and the problem needs to be addressed.
Prevention of DM through attention to unhealthy diets,
sedentary lifestyles and childhood and adult obesity must
be included in broad non-communicable disease prevention
strategies. This collaborative framework provides a
template for action, and the recommendations now need
to be implemented and evaluated in the field to lay down
a firm foundation for the scaling up of interventions that
work and are effective in tackling this dual burden of
[Show abstract][Hide abstract] ABSTRACT: Passive case finding, the detection of tuberculosis (TB) cases among persons presenting to health facilities with symptoms suggestive of TB, has remained the principal public health approach for TB diagnosis. While this approach, in combination with improved treatment, has led to substantial global progress, the overall epidemiological impact has been inadequate. Stagnating case notifications and sluggish decline in incidence prompt the pursuit of a more active approach to TB case detection. Screening among contacts of TB patients and people living with human immunodeficiency virus infection, long recommended, needs scaling up. Screening in other risk groups may also be considered, depending on the epidemiological situation. The World Health Organization (WHO) has recently produced recommendations on systematic screening for active TB, which set out principles and provide guidance on the prioritisation of risk groups for screening and choice of screening and diagnostic algorithms. With a view to help translate WHO recommendations into practice, this concluding article of the State of the Art series discusses programmatic approaches. Published literature is scanty. However, considerable field experience exists to draw important lessons. Cautioning against a hasty pursuit of active case finding, the article stresses that programmatic implementation of TB screening requires a systematic approach. Important considerations should include setting clear goals and objectives based on a thorough assessment of the situation; considering the place of TB screening in the overall approach to enhancing TB detection; identifying and prioritising risk groups; choosing appropriate screening and diagnostic algorithms; and pursuing setting-specific implementation strategies with engagement of relevant partners, due attention to ethical considerations and built-in monitoring and evaluation.
The International Journal of Tuberculosis and Lung Disease 10/2013; 17(10):1248-56. DOI:10.5588/ijtld.13.0199 · 2.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Screening for tuberculosis (TB) disease aims to improve early TB case detection. The ultimate goal is to improve outcomes for people with TB and to reduce Mycobacterium tuberculosis transmission in the community through improved case detection, reduction in diagnostic delays and early treatment. Before screening programmes are recommended, evidence is needed of individual and/or community-level benefits.
We conducted a systematic review of the literature to assess the evidence that screening for TB disease 1) initially increases the number of TB cases initiated on anti-tuberculosis treatment, 2) identifies cases earlier in the course of disease, 3) reduces mortality and morbidity, and 4) impacts on TB epidemiology.
A total of 28 798 publications were identified by the search strategy: 27 087 were excluded on initial screening and 1749 on full text review, leaving 62 publications that addressed at least one of the study questions. Screening increases the number of cases found in the short term. In many settings, more than half of the prevalent TB cases in the community remain undiagnosed. Screening tends to find cases earlier and with less severe disease, but this may be attributed to case-finding studies using more sensitive diagnostic methods than routine programmes. Treatment outcomes among people identified through screening are similar to outcomes among those identified through passive case finding. Current studies provide insufficient evidence to show that active screening for TB disease impacts on TB epidemiology.
Individual and community-level benefits from active screening for TB disease remain uncertain. So far, the benefits of earlier diagnosis on patient outcomes and transmission have not been established.
The International Journal of Tuberculosis and Lung Disease 04/2013; 17(4):432-46. DOI:10.5588/ijtld.12.0743 · 2.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recent data for the global burden of disease reflect major demographic and lifestyle changes, leading to a rise in non-communicable diseases. Most countries with high levels of tuberculosis face a large comorbidity burden from both non-communicable and communicable diseases. Traditional disease-specific approaches typically fail to recognise common features and potential synergies in integration of care, management, and control of non-communicable and communicable diseases. In resource-limited countries, the need to tackle a broader range of overlapping comorbid diseases is growing. Tuberculosis and HIV/AIDS persist as global emergencies. The lethal interaction between tuberculosis and HIV coinfection in adults, children, and pregnant women in sub-Saharan Africa exemplifies the need for well integrated approaches to disease management and control. Furthermore, links between diabetes mellitus, smoking, alcoholism, chronic lung diseases, cancer, immunosuppressive treatment, malnutrition, and tuberculosis are well recognised. Here, we focus on interactions, synergies, and challenges of integration of tuberculosis care with management strategies for non-communicable and communicable diseases without eroding the functionality of existing national programmes for tuberculosis. The need for sustained and increased funding for these initiatives is greater than ever and requires increased political and funder commitment.
[Show abstract][Hide abstract] ABSTRACT: The impact of current interventions to improve early detection of tuberculosis (TB) seems to have been saturated. Case detection trends have stagnated. TB incidence is falling in most settings worldwide, but the rate of decline is far lower than expected. There is growing evidence from national TB prevalence surveys and other research of a large pool of undetected TB in the community. Intensified efforts to further break down access barriers and scale up new and rapid diagnostic tools are likely to improve the situation. However, will these be enough? Or do we also need to reach out more towards people who do not actively seek care with well-recognisable TB symptoms? There have recently been calls to revisit TB screening, particularly in high-risk groups. The World Health Organization (WHO) recommends screening for TB in people with human immunodeficiency virus infection and in close TB contacts. Should other risk groups also be screened systematically? Could mass, community-wide screening, which the WHO has discouraged over the past four decades, be of benefit in some situations? If so, what screening tools and approaches should be used? The WHO is in the process of seeking answers to these questions and developing guidelines on systematic screening for active TB. In this article, we present the rationale, definitions and key considerations underpinning this process.
The International Journal of Tuberculosis and Lung Disease 03/2013; 17(3):289-98. DOI:10.5588/ijtld.12.0797 · 2.32 Impact Factor