Economic evaluation of diagnosis and treatment for latent tuberculosis infection among contacts of pulmonary tuberculosis patients in Thailand

Currently, interferon-gamma release assay (IGRA) is costly and not included as latent tuberculosis infection (LTBI) screening test strategy in Thailand's Universal Coverage Scheme (UCS) benefit package. The objective of this study was to assess the cost-utility of LTBI screening strategies among tuberculosis (TB) contacts in Thailand. A hybrid decision tree and Markov model was developed to compare the lifetime costs and health outcomes of tuberculin skin test (TST) and IGRA, in comparison to no screening, based on a societal perspective. Health outcomes were the total number of TB cases averted and quality-adjusted life years (QALYs), with results presented as an incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were performed to explore uncertainties in all parameters. The ICER of TST compared with no screening was 27,645 baht per QALY gained, while that of IGRA compared to TST was 851,030 baht per QALY gained. In a cohort of 1000 TB contacts, both TST and IGRA strategies could avert 282 and 283 TB cases, respectively. At the Thai societal willingness-to-pay threshold of 160,000 baht per QALY gained, TST was deemed cost-effective, whereas IGRA would not be cost-effective, unless the cost of IGRA was reduced to 1,434 baht per test.

Costs and cost-effectiveness of Gene Xpert compared to smear microscopy for the diagnosis of pulmonary tuberculosis using real-world data from Arsi zone, Ethiopia

Background

Early diagnosis and treatment are one of the key strategies of tuberculosis control globally, and there are strong efforts in detecting and treating tuberculosis cases in Ethiopia. Smear microscopy examination has been a routine diagnostic test for pulmonary tuberculosis diagnosis in resource-constrained settings for decades. Recently, many countries, including Ethiopia, are scaling up the use of Gene Xpert without the evaluation of the cost and cost-effectiveness implications of this strategy. Therefore, this study evaluated the cost and cost-effectiveness of Gene Xpert (MTB/RIF) and smear microscopy tests to diagnosis tuberculosis patients in Ethiopia.

Methods

We compared the costs and cost-effectiveness of tuberculosis diagnosis using smear microscopy and Gene Xpert among 1332 patients per intervention in the Arsi zone. We applied combinations of top-down and bottom-up costing approaches. The costs were estimated from the health providers’ perspective within one year (2017–2018). We employed “cases detected” as an effectiveness measure, and the incremental cost-effectiveness ratio was calculated by dividing the changes in cost and change in effectiveness. All costs and incremental cost-effectiveness ratio were reported in 2018 US$.

Results

The unit cost per test for Gene Xpert was $12.9 whereas it is $3.1 for AFB smear microscopy testing. The cost per TB case detected was $77.9 for Gene Xpert while it was $55.8 for the smear microscopy method. The cartridge kit cost accounted for 42% of the overall Gene Xpert’s costs and the cost of the reagents and consumables accounted for 41.3% ($1.3) of the unit cost for the smear microscopy method. The ICER for the Gene Xpert strategy was $20.0 per tuberculosis case detected.

Conclusion

Using Gene Xpert as a routine test instead of standard care (smear microscopy) can be potentially cost-effective. In the cost scenario analysis, the price of the cartridge, the number of tests performed per day, and the life span of the capital equipment were the drivers of the unit cost of the Gene Xpert method. Therefore, Gene Xpert can be a part of the routine TB diagnostic testing strategy in Ethiopia.

Estimating Cost Functions for Resource Allocation Using Transmission Models: A Case Study of Tuberculosis Case Finding in South Africa

OBJECTIVE

Cost functions linked to transmission dynamic models are commonly used to estimate the resources required for infectious disease policies. We present a conceptual and empirical approach for estimating these functions, allowing for nonconstant marginal costs. We aim to expand on the current approach which commonly assumes linearity of cost over scale.

METHODS

We propose a theoretical framework adapted from the field of transport economics. We specify joint functions of production of services within a disease-specific program. We expand these functions to include qualitative insights of program expansion patterns. We present the difference in incremental total costs between an approach assuming constant unit costs and alternative approaches that assume economies of scale, scope and homogeneous or heterogeneous facility recruitment into the programme during scale-up. We illustrate the framework's application in tuberculosis, using secondary data from the literature and routine reporting systems in South Africa.

RESULTS

Economies of capacity and scope substantially change cost estimates over time. Cost data requirements for the proposed approach included standardized and disaggregated unit costs (for a limited number of outputs) and information on the facilities network available to the program.

CONCLUSIONS

The defined functional form will determine the magnitude and shape of costs when outputs and coverage are increasing. This in turn will impact resource allocation decisions. Infectious diseases modelers and economists should use transparent and empirically based cost models for analyses that inform resource allocation decisions. This framework describes a general approach for developing these models.

Catastrophic costs of tuberculosis care in a population with internal migrants in China

BACKGROUND

The internal rural-to-urban migration is one of the major challenges for tuberculosis (TB) control in China. Patient costs incurred during TB diagnosis and treatment could cause access and adherence barriers, particularly among migrants. Here, we estimated the prevalence of catastrophic costs of TB patients and its associated factors in an urban population with internal migrants in China.

METHODS

A cross-sectional survey was conducted to enroll culture-confirmed pulmonary TB patients in Songjiang district, Shanghai, between December 1, 2014, and December 31, 2015. Consenting participants completed a questionnaire, which collected direct and indirect costs before and after the diagnosis of TB. The catastrophic cost was defined as the annual expenses of TB care that exceeds 20% of total household disposable income. We used logistic regression to identify factors associated with catastrophic costs.

RESULTS

Overall, 248 drug-susceptible TB patients were enrolled, 70% (174/248) of them were from migrants. Migrant patients were significantly younger compared to resident patients. The total costs were 25,824 ($3689) and 13,816 ($1974) Chinese Yuan (RMB) in average for resident and migrant patients, respectively. The direct medical cost comprised about 70% of the total costs among both migrant and resident patients. Overall, 55% (132 of 248) of patients experienced high expenses (>10% of total household income), and 22% (55 of 248) experienced defined catastrophic costs. The reimbursement for TB care only reduced the prevalence of catastrophic costs to 20% (49 of 248). Meanwhile, 52% (90 of 174) of the internal migrants had no available local health insurance. Hospitalizations, no available insurance, and older age (> 45-year-old) contributed significantly to the occurrence of catastrophic costs.

CONCLUSIONS

The catastrophic cost of TB service cannot be overlooked, despite the free policy. Migrants have difficulties benefiting from health insurance in urban cities. Interventions, including expanded medical financial assistance, are needed to secure universal TB care.

Cost-Effectiveness Analysis of Xpert MTB/RIF for Multi-Outcomes of Patients With Presumptive Pulmonary Tuberculosis in Thailand

OBJECTIVES

The cost-effectiveness of screening adult patients for pulmonary tuberculosis is not clear. As such, this study aims to identify the cost-effectiveness between the Xpert MTB/RIF assay and the sputum acid-fast bacilli (AFB) smear. Multi-outcomes were correct diagnosis, time to achieve correct diagnosis, and gain in quality-adjusted life-years (QALYs).

METHODS

A decision tree model was constructed to reveal a possible clinical pathway of tuberculosis diagnosis. The researchers used a clinical study to establish the probability of all clinical pathways for input into this model. The sample size was calculated following the correct diagnosis. Participants were randomly divided into 2 groups. A structural questionnaire and the Thai version of quality of life (EQ-5D-5L) were used for interviewing.

RESULTS

The results showed that the time to achieve the correct diagnosis for the group using Xpert MTB/RIF was shorter than that for the group using the sputum AFB smear. Both the correct diagnosis and QALYs of the base case analysis presented the Xpert MTB/RIF method as dominant. A Monte Carlo model, which analyzed the Xpert MTB/RIF method, revealed that the average number of patients who were correctly diagnosed was 673, the QALYs were 945.85 years, and the total cost was $143 110.64. For the sputum AFB smear method, the average number who received a correct diagnosis was 592, the QALYs were 940.40 years, and the total cost was $196 666.84. Probabilistic and one-way sensitivity analysis confirmed that the Xpert MTB/RIF remained dominant.

CONCLUSIONS

These results provide useful information for the National Strategic Plan to screen all adult patients for pulmonary tuberculosis.

Patient-incurred cost of inpatient treatment for Tuberculosis in rural Malawi

OBJECTIVES

To mitigate the economic burden of tuberculosis (TB), it is important to fully understand the costs of TB treatment from the patient perspective. We therefore sought to quantify the patient-incurred cost of TB treatment in rural Malawi, with specific focus on costs borne by patients requiring inpatient hospitalisation.

METHODS

We conducted a cross-sectional survey of 197 inpatients and 156 outpatients being treated for TB in rural Malawi. We collected data on out-of-pocket costs and lost wages, including costs to guardians. Costs for inpatient TB treatment were estimated and compared to costs for outpatient TB treatment. We then explored the equity distribution of inpatient TB treatment cost using concentration curves.

RESULTS

Despite free government services, inpatients were estimated to incur a mean of $137 (standard deviation: $147) per initial TB episode, corresponding to >50% of annual household spending among patients in the lowest expenditure quintile. Non-medical hospitalisation costs accounted for 88% of this total. Patients treated entirely as outpatients incurred estimated costs of $25 (standard deviation: $15) per episode. The concentration curves showed that, among individuals hospitalised for an initial TB episode, poorer patients shouldered a much greater proportion of inpatient TB treatment costs than wealthier ones (concentration index: -0.279).

CONCLUSION

Patients hospitalised for TB in resource-limited rural Malawi experience devastating costs of TB treatment. Earlier diagnosis and treatment must be prioritised if we are to meet goals of effective TB control, avoidance of catastrophic costs and provision of appropriate patient-centred care in such settings.

Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000-17: a financial modelling study

BACKGROUND

Estimates of government spending and development assistance for tuberculosis exist, but less is known about out-of-pocket and prepaid private spending. We aimed to provide comprehensive estimates of total spending on tuberculosis in low-income and middle-income countries for 2000-17.

METHODS

We extracted data on tuberculosis spending, unit costs, and health-care use from the WHO global tuberculosis database, Global Fund proposals and reports, National Health Accounts, the WHO-Choosing Interventions that are Cost-Effective project database, and the Institute for Health Metrics and Evaluation Development Assistance for Health Database. We extracted data from at least one of these sources for all 135 low-income and middle-income countries using the World Bank 2019 definitions. We estimated tuberculosis spending by source and function for notified (officially reported) and non-notified tuberculosis cases separately and combined, using spatiotemporal Gaussian process regression to fill in for missing data and estimate uncertainty. We aggregated estimates of government, out-of-pocket, prepaid private, and development assistance spending on tuberculosis to estimate total spending in 2019 US$.

FINDINGS

Total spending on tuberculosis in 135 low-income and middle-income countries increased annually by 3·9% (95% CI 3·0 to 4·6), from $5·7 billion (5·2 to 6·5) in 2000 to $10·9 billion (10·3 to 11·8) in 2017. Government spending increased annually by 5·1% (4·4 to 5·7) between 2000 and 2017, and reached $6·9 billion (6·5 to 7·5) or 63·5% (59·2 to 66·8) of all tuberculosis spending in 2017. Of government spending, $5·8 billion (5·6 to 6·1) was spent on notified cases. Out-of-pocket spending decreased annually by 0·8% (-2·9 to 1·3), from $2·4 billion (1·9 to 3·1) in 2000 to $2·1 billion (1·6 to 2·7) in 2017. Development assistance for country-specific spending on tuberculosis increased from $54·6 million in 2000 to $1·1 billion in 2017. Administrative costs and development assistance for global projects related to tuberculosis care increased from $85·3 million in 2000 to $576·2 million in 2017. 30 high tuberculosis burden countries of low and middle income accounted for 73·7% (71·8-75·8) of tuberculosis spending in 2017.

INTERPRETATION

Despite substantial increases since 2000, funding for tuberculosis is still far short of global financing targets and out-of-pocket spending remains high in resource-constrained countries, posing a barrier to patient's access to care and treatment adherence. Of the 30 countries with a high-burden of tuberculosis, just over half were primarily funded by government, while others, especially lower-middle-income and low-income countries, were still primarily dependent on development assistance for tuberculosis or out-of-pocket health spending.

FUNDING

Bill & Melinda Gates Foundation.

The NHS visitor and migrant cost recovery programme - a threat to health?

BACKGROUND

In April 2014 the UK government launched the 'NHS Visitor and Migrant Cost Recovery Programme Implementation Plan' which set out a series of policy changes to recoup costs from 'chargeable' (largely non-UK born) patients. In England, approximately 75% of tuberculosis (TB) cases occur in people born abroad. Delays in TB treatment increase risk of morbidity, mortality and transmission in the community. We investigated whether diagnostic delay has increased since the Cost Recovery Programme (CRP) was introduced.

METHODS

There were 3342 adult TB cases notified on the London TB Register across Barts Health NHS Trust between 1st January 2011 and 31st December 2016. Cases with missing relevant information were excluded. The median time between symptom onset and treatment initiation before and after the CRP was calculated according to birthplace and compared using the Mann Whitney test. Delayed diagnosis was considered greater or equal to median time to treatment for all patients (79 days). Univariable logistic regression was used to manually select exposure variables for inclusion in a multivariable model to test the association between diagnostic delay and the implementation of the CRP.

RESULTS

We included 2237 TB cases. Among non-UK born patients, median time-to-treatment increased from 69 days to 89 days following introduction of CRP (p < 0.001). Median time-to-treatment also increased for the UK-born population from 75.5 days to 89.5 days (p = 0.307). The multivariable logistic regression model showed non-UK born patients were more likely to have a delay in diagnosis after the CRP (adjOR 1.37, 95% CI 1.13-1.66, p value 0.001).

CONCLUSION

Since the introduction of the CRP there has been a significant delay for TB treatment among non-UK born patients. Further research exploring the effect of policies restricting access to healthcare for migrants is urgently needed if we wish to eliminate TB nationally.

The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal

BACKGROUND

The World Health Organization (WHO) End TB Strategy has established a milestone to reduce the number of tuberculosis (TB)- affected households facing catastrophic costs to zero by 2020. The role of active case finding (ACF) in reducing patient costs has not been determined globally. This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding (PCF), and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal.

METHODS

The study was conducted in two districts of Nepal: Bardiya and Pyuthan (Province No. 5) between June and August 2018. One hundred patients were included in this study in a 1:1 ratio (PCF: ACF, 25 consecutive ACF and 25 consecutive PCF patients in each district). The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs. Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20% of their annual household income. The intensity of catastrophic costs was calculated using the positive overshoot method. The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs. Meanwhile, the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis.

RESULTS

Ninety-nine patients were interviewed (50 ACF and 49 PCF). Patients diagnosed through ACF incurred lower costs during the pre-treatment period (direct medical: USD 14 vs USD 32, P = 0.001; direct non-medical: USD 3 vs USD 10, P = 0.004; indirect, time loss: USD 4 vs USD 13, P <  0.001). The cost of the pre-treatment and intensive phases combined was also lower for direct medical (USD 15 vs USD 34, P = 0.002) and non-medical (USD 30 vs USD 54, P = 0.022) costs among ACF patients. The prevalence of catastrophic direct costs was lower for ACF patients for all thresholds. A lower intensity of catastrophic costs was also documented for ACF patients, although the difference was not statistically significant.

CONCLUSIONS

ACF can reduce patient-incurred costs substantially, contributing to the End TB Strategy target. Other synergistic policies, such as social protection, will also need to be implemented to reduce catastrophic costs to zero among TB-affected households.

Delayed diagnosis and treatment of pulmonary tuberculosis in high-burden countries: a systematic review protocol

INTRODUCTION

Countries identified to bear the highest tuberculosis (TB) incidence account for approximately 85% of the global TB burden. TB is curable, yet nearly 40% of TB cases remained undiagnosed hence delaying treatment and perpetuating transmission. This systematic review aimed to review current evidence on factors associated with delayed diagnosis and treatment of TB in the high TB-burden countries.

METHODS AND ANALYSIS

This systematic review will incorporate qualitative and observational study designs published between 2008 and 2018. Articles will be retrieved from major databases including PubMed, EMBASE, CINAHL and PsycINFO. Reference lists of key articles, including relevant systematic reviews and meta-analysis, will be screened for additional studies. Two independent reviewers will screen and select studies, extract data and assess the quality and risk of bias of each study. Study-specific estimates will be pooled by meta-analysis, and effect sizes will be presented as OR and their 95% CI. Levels of heterogeneity will be evaluated using chi-square statistic Q and I2. Publication bias will be assessed using forest plots and Egger's tests. Qualitative findings and sample quotes will be extracted. Textual references to the topics of interest will be retrieved and categorised using qualitative thematic analysis. We will triangulate quantitative and qualitative findings for a complete understanding of the reasons for delayed TB diagnosis and treatment. Results will be presented by geographical region.

ETHICS AND DISSEMINATION

This study will be conducted based on published data. This systematic review may provide insights into the reasons for delayed TB diagnosis in high-burden countries. These findings will also inform future research and key stakeholders in developing interventions to reach these undiagnosed cases effectively. Findings from this review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018107237.

Acceptability of active case finding with a seed-and-recruit model to improve tuberculosis case detection and linkage to treatment in Cambodia: A qualitative study

Background

With support of the national tuberculosis (TB) program, KHANA (a local non-governmental organization in Cambodia) has implemented an innovative approach using a seed-and-recruit model to actively find TB cases in the community. The model engaged community members including TB survivors as seed and newly diagnosed people with TB as recruiters to recruit presumptive TB cases in their social network in a snowball approach for screening and linkage to treatment. This study aimed to explore the acceptability of the active case finding with the seed-and-recruit model in detecting new TB cases and determine the characteristics of successful seeds.

Methods

This qualitative study was conducted in four provinces (Banteay Meanchey, Kampong Chhnang, Siem Reap, and Takeo) in Cambodia in 2017. Fifty-six in-depth interviews and ten focus group discussions (with a total of 64 participants) were conducted with selected beneficiaries and key stakeholders at different levels to gain insights into the acceptability, strengths, and challenges in implementing the model and the characteristics of successful seeds. Transcripts were coded and content analyses were performed.

Results

The seed-and-recruit active case finding model was generally well-received by the study participants. They saw the benefits of engaging TB survivors and utilizing their social network to find new TB cases in the community. The social embeddedness of the model within the local community was one of the major strengths. The success of the model also hinges on the integration with existing health facilities. Having an extensive social network, being motivated, and having good knowledge about TB were important characteristics of successful seeds. Study participants reported challenges in motivating the presumptive TB cases for screening, logistic capacities, and high workload during the implementation. However, there was a general consensus that the model ought to be expanded.

Conclusions

These findings indicate that the seed-and-recruit model is well-accepted by the beneficiaries and key stakeholders. Further studies are needed to more comprehensively evaluate the impacts and cost-effectiveness of the model for future expansion in Cambodia as well as in other resource-limited settings.

Inequity in catastrophic costs among tuberculosis-affected households in China

BACKGROUND

There are limited nationally representative studies globally in the post-2015 END tuberculosis (TB) era regarding wealth related inequity in the distribution of catastrophic costs due to TB care. Under the Chinese national tuberculosis programme setting, we aimed to assess extent of equity in distribution of total TB care costs (pre-treatment, treatment and overall) and costs as a proportion of annual household income (AHI), and describe and compare equity in distribution of catastrophic costs (pre-treatment, treatment and overall) across population sub-groups.

METHODS

Analytical cross-sectional study using data from national TB patient cost survey carried out in 22 counties from six provinces in China in 2017. Drug-susceptible pulmonary TB registered under programme, who had received at least 2 weeks of intensive phase therapy were included. Equity was depicted using concentration curves and concentration indices were compared using dominance test.

RESULTS

Of 1147 patients, the median cost of pre-treatment, treatment and overall care, were USD 283.5, USD 413.1 and USD 965.5, respectively. Richer quintiles incurred significantly higher pre-treatment and treatment costs compared to poorer quintiles. The distribution of costs as a proportion of AHI and catastrophic costs were significantly pro-poor overall as well as during pre-treatment and treatment phase. All the concentration curves for catastrophic costs (due to pre-treatment, treatment and overall care) stratified by region (east, middle and west), area of residence (urban, rural) and type of insurance (new rural co-operative medical system [NCMS], non-NCMS) also exhibited a pro-poor pattern with statistically significant (P <  0.01) concentration indices. The pro-poor distribution of the catastrophic costs due to TB treatment was significantly more inequitable among rural, compared to urban patients, and NCMS compared to non-NCMS beneficiaries.

CONCLUSIONS

There is inequity in the distribution of catastrophic costs due to TB care. Universal health coverage, social protection strategies complemented by quality TB care is vital to reduce inequitable distribution of catastrophic costs due to TB care in China.

Out of pocket expenditure on tuberculosis in India: Do households face hardship financing?

BACKGROUND

In 2017, India accounted for 27 percent of the global burden on tuberculosis, and the highest among the top 30 countries with high TB burden. Despite the expansion of DOTS programme many households in India incur high expenditure towards TB treatment. Most of the studies in India have focused on measuring catastrophic health expenditure on TB. Catastrophic health expenditure and its impoverishment effects are difficult to calculate and may misrepresent economic hardship.

METHODS

This paper uses hardship financing, i.e. when a household sells assets or borrows money on interest to pay for healthcare expenditure, as an indicator of the hardship of the family when it spends on TB treatment using NSSO 71st Round 2014 data.

RESULTS

Using the NSSO national representative sample, the paper estimated that 26.7% of hospitalized cases and 3.5% percent of patients utilising outpatient care experience hardship financing due to TB in the country. 25.9% of the general population had to sell assets or used borrowings for financing TB hospitalization expenses. Education of head of household, income, type of health facility used, and number of hospitalized days were found to be significant factors influencing hardship financing.

CONCLUSION

Our study highlights that even with free care for tuberculosis, 21.3% were exposed to hardship financing, suggesting the need to re-look at the subsidy coverage of tuberculosis treatment in the country. The study also suggests the use of hardship financing as an alternative to catastrophic spending method as a index of effectiveness of tuberculosis control programme in the country.

Tuberculosis in Brazil and cash transfer programs: A longitudinal database study of the effect of cash transfer on cure rates

Introduction

Tuberculosis incidence is disproportionately high among people in poverty. Cash transfer programs have become an important strategy in Brazil fight inequalities as part of comprehensive poverty alleviation policies. This study was aimed at assessing the effect of being a beneficiary of a governmental cash transfer program on tuberculosis (TB) treatment cure rates.

Methods

We conducted a longitudinal database study including people ≥18 years old with confirmed incident TB in Brazil in 2015. We treated missing data with multiple imputation. Poisson regression models with robust variance were carried out to assess the effect of TB determinants on cure rates. The average effect of being beneficiary of cash transfer was estimated by propensity-score matching.

Results

In 2015, 25,084 women and men diagnosed as new tuberculosis case, of whom 1,714 (6.8%) were beneficiaries of a national cash transfer. Among the total population with pulmonary tuberculosis several determinants were associated with cure rates. However, among the cash transfer group, this association was vanished in males, blacks, region of residence, and people not deprived of their freedom and who smoke tobacco. The average treatment effect of cash transfers on TB cure rates, based on propensity score matching, found that being beneficiary of cash transfer improved TB cure rates by 8% [Coefficient 0.08 (95% confidence interval 0.06–0.11) in subjects with pulmonary TB].

Conclusion

Our study suggests that, in Brazil, the effect of cash transfer on the outcome of TB treatment may be achieved by the indirect effect of other determinants. Also, these results suggest the direct effect of being beneficiary of cash transfer on improving TB cure rates.

Cash interventions to improve clinical outcomes for pulmonary tuberculosis: systematic review and meta-analysis

OBJECTIVE

To assess cash transfer interventions for improving treatment outcomes of active pulmonary tuberculosis in low- and middle-income countries.

METHODS

We searched PubMed®, Embase®, Cochrane Library and ClinicalTrials.gov for studies published until 4 August 2017 that reported on cash transfer interventions during the treatment of active pulmonary tuberculosis in low- and middle-income countries. Our primary outcome was a positive clinical outcome, defined as treatment success, treatment completion or microbiologic cure. Using the purchasing power parity conversion factor, we converted the amount of cash received per patient within each study into international dollars (Int$). We calculated odds ratio (OR) for the primary outcome using a random effects meta-analysis.

FINDINGS

Eight studies met eligibility criteria for review inclusion. Seven studies assessed a tuberculosis-specific intervention, with average amount of cash ranging from Int$ 193-858. One study assessed a tuberculosis-sensitive intervention, with average amount of Int$ 101. Four studies included non-cash co-interventions. All studies showed better primary outcome for the intervention group than the control group. After excluding three studies with high risk of bias, patients receiving tuberculosis-specific cash transfer were more likely to have a positive clinical outcome than patients in the control groups (OR: 1.77; 95% confidence interval: 1.57-2.01).

CONCLUSION

The evidence available suggests that patients in low- and middle-income countries receiving cash during treatment for active pulmonary tuberculosis are more likely to have a positive clinical outcome. These findings support the incorporation of cash transfer interventions into social protection schemes within tuberculosis treatment programmes.

Shorter treatment for minimal tuberculosis (TB) in children (SHINE): a study protocol for a randomised controlled trial

BACKGROUND

Tuberculosis (TB) in children is frequently paucibacillary and non-severe forms of pulmonary TB are common. Evidence for tuberculosis treatment in children is largely extrapolated from adult studies. Trials in adults with smear-negative tuberculosis suggest that treatment can be effectively shortened from 6 to 4 months. New paediatric, fixed-dose combination anti-tuberculosis treatments have recently been introduced in many countries, making the implementation of World Health Organisation (WHO)-revised dosing recommendations feasible. The safety and efficacy of these higher drug doses has not been systematically assessed in large studies in children, and the pharmacokinetics across children representing the range of weights and ages should be confirmed.

METHODS/DESIGN

SHINE is a multicentre, open-label, parallel-group, non-inferiority, randomised controlled, two-arm trial comparing a 4-month vs the standard 6-month regimen using revised WHO paediatric anti-tuberculosis drug doses. We aim to recruit 1200 African and Indian children aged below 16 years with non-severe TB, with or without HIV infection. The primary efficacy and safety endpoints are TB disease-free survival 72 weeks post randomisation and grade 3 or 4 adverse events. Nested pharmacokinetic studies will evaluate anti-tuberculosis drug concentrations, providing model-based predictions for optimal dosing, and measure antiretroviral exposures in order to describe the drug-drug interactions in a subset of HIV-infected children. Socioeconomic analyses will evaluate the cost-effectiveness of the intervention and social science studies will further explore the acceptability and palatability of these new paediatric drug formulations.

DISCUSSION

Although recent trials of TB treatment-shortening in adults with sputum-positivity have not been successful, the question has never been addressed in children, who have mainly paucibacillary, non-severe smear-negative disease. SHINE should inform whether treatment-shortening of drug-susceptible TB in children, regardless of HIV status, is efficacious and safe. The trial will also fill existing gaps in knowledge on dosing and acceptability of new anti-tuberculosis formulations and commonly used HIV drugs in settings with a high burden of TB. A positive result from this trial could simplify and shorten treatment, improve adherence and be cost-saving for many children with TB. Recruitment to the SHINE trial begun in July 2016; results are expected in 2020.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number: ISRCTN63579542 , 14 October 2014. Pan African Clinical Trials Registry Number: PACTR201505001141379 , 14 May 2015. Clinical Trial Registry-India, registration number: CTRI/2017/07/009119, 27 July 2017.

Adaptation of the Tool to Estimate Patient Costs Questionnaire into Indonesian Context for Tuberculosis-affected Households

BACKGROUND

Indonesia is the second-highest country for tuberculosis (TB) incidence worldwide. Hence, it urgently requires improvements and innovations beyond the strategies that are currently being implemented throughout the country. One fundamental step in monitoring its progress is by preparing a validated tool to measure total patient costs and catastrophic total costs. The World Health Organization (WHO) recommends using a version of the generic questionnaire that has been adapted to the local cultural context in order to interpret findings correctly. This study is aimed to adapt the Tool to Estimate Patient Costs questionnaire into the Indonesian context, which measures total costs and catastrophic total costs for tuberculosis-affected households.

METHODS

the tool was adapted using best-practice guidelines. On the basis of a pre-test performed in a previous study (referred to as Phase 1 Study), we refined the adaptation process by comparing it with the generic tool introduced by the WHO. We also held an expert committee review and performed pre-testing by interviewing 30 TB patients. After pre-testing, the tool was provided with complete explanation sheets for finalization.

RESULTS

seventy-two major changes were made during the adaptation process including changing the answer choices to match the Indonesian context, refining the flow of questions, deleting questions, changing some words and restoring original questions that had been changed in Phase 1 Study. Participants indicated that most questions were clear and easy to understand. To address recall difficulties by the participants, we made some adaptations to obtain data that might be missing, such as tracking data to medical records, developing a proxy of costs and guiding interviewers to ask for a specific value when participants were uncertain about the estimated market value of property they had sold.

CONCLUSION

the adapted Tool to Estimate Patient Costs in Bahasa Indonesia is comprehensive and ready for use in future studies on TB-related catastrophic costs and is suitable for monitoring progress to achieve the target of the End TB Strategy.

Comparison Of Ziehl-Neelsen Based Light Microscopy With Led Fluorescent Microscopy For Tuberculosis Diagnosis: An Insight From A Limited Resource-High Burden setting

BACKGROUND

Microscopy is the most widely used tool for Tuberculosis screening. Conventionally, Ziehl-Neelsen (ZN) staining has been the widely used for staining Acid-Fast Bacilli (AFB) but with the advent of Fluorescent staining, Auramine O stain is now being adapted as the preferred method for setups with high workload as it has the advantage of being less laborious, since bacteria fluoresce in front of a dark background and are easier to count. This study was performed to compare the efficiency of the two methods in a high-burden, limited resource setting to see the magnitude of diagnostic accuracy between ZN and Fluorescent Microscopy, using culture as the standard..

METHODS

Altogether 987 culturally confirmed cases were considered from the period 36 months during January 2011 to December 2013 and data were compiled from the records maintained at the Provincial Tuberculosis Reference Laboratory at Ojha Institute of Chest Diseases, Dow University of Health Sciences, Karachi. The results from 523 cases examined using ZN and 464 cases using Fluorescent staining method were compared for diagnostic accuracy on the basis of Mycobacterial culture results. Smears are prepared from the clinical samples obtained from presumptive tuberculosis patients.

RESULTS

The results of ZN method showed 94.23% [95% CI 91.32-96.39%] sensitivity and 84.91% [95% CI 78.38-90.08%] specificity. While FM showed a sensitivity of 97.15% [95% CI 94.82-98.63%] and specificity of 83.19% [95% CI 74.99-89.56%]..

CONCLUSIONS

The results showed that Fluorescent microscopy was slightly more sensitive than ZN light Microscopy, while specificity of both the methods were comparable.

How much does tuberculosis cost? An Australian healthcare perspective analysis

Tuberculosis (TB) remains a disease of high morbidity in Australia, with implications for both public health and the individual. Cost analyses is relevant for programmatic evaluation of TB. There is minimal published TB cost data in the Australian setting. Patients with drug sensitive active pulmonary TB (DS-PTB) and latent TB (LTBI) were enrolled in a single tertiary referral centre to evaluate healthcare provider costs. The median cost of treating drug susceptible pulmonary TB in this case series was 11,538 AUD. Approximately 50% of total costs is derived from inpatient hospitalisation bed days. In comparison, the average cost of managing latent TB was 582 AUD per completed course. We find the median provider cost of our DS-PTB treatment group comparable to costs from other regions globally with similar economic profiles. A program designed to detect and treat LTBI to prevent subsequent disease may be cost effective in appropriately selected patients and warrants further study.

The costs of providing antiretroviral therapy services to HIV-infected individuals presenting with advanced HIV disease at public health centres in Dar es Salaam, Tanzania: Findings from a randomised trial evaluating different health care strategies

BACKGROUND

Understanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa.

MATERIAL AND METHODS

The study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices.

RESULTS

Of 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101-112) and US$ 265 (95%CI 254-275) respectively. ART drugs, clinic visits and hospital admission constituted 50%, 19%, and 19% of the total cost per patient year, while diagnostic tests and non-ART drugs (co-trimoxazole) accounted for 10% and 2% of total per patient year costs. The incremental costs of the intervention to the health service over the first three months was US$ 59 (p<0.001; 95%CI 52-67) and over a one year period was US$ 67(p<0.001; 95%CI 50-83). This is equivalent to an increase of 55% (95%CI 51%-59%) in the mean cost of care over the first three months, and 25% (95%CI 20%-30%) increase over one year of follow up.