[The cost of pulmonary tuberculosis treatment in the Congo]

The author assesses the cost of treating pulmonary tuberculosis. This is extremely high because there is no standard treatment. The 15 months--course used in the Congo is 2.5 times more expensive than the standardized regimen using WHO drug prices. The author recommends the institution of a better system of treatment of tuberculosis in order to economise and to assure a regular supply of medicines.

A cost-effectiveness analysis of the routine use of isoniazid prophylaxis in patients with a positive Mantoux skin test

The role of isoniazid prophylaxis in low-risk patients with positive Mantoux skin tests has recently been questioned. In general, recent research has focused on the risk/benefit ratio. We, therefore, decided to extend these data and apply a cost-effectiveness analysis of the routine use of isoniazid prophylaxis from a societal perspective. Costs per case prevented were calculated for a 20-, 50-, and 70-yr-old low-risk patient who had a positive Mantoux test with base, high, and low costings. Rates were also calculated based on the use of direct costs alone and direct and indirect costs combined. Costs varied from Canadian $8,586.00 in a 20-yr-old patient to $40,102.00 in a 70-yr-old patient per case prevented based on direct costs with costs ranging from $3,236.00 to $11,320.00 with both direct and indirect costs included. These costs could be considered reasonable from a societal perspective but do not address the issue of any increased life expectancy resulting from chemoprophylaxis.

A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen

STUDY OBJECTIVE

To evaluate the efficacy and toxicity of a 62-dose, four-drug, 6-month, and directly observed regimen for treatment of pulmonary and extrapulmonary tuberculosis.

DESIGN

An open, nonblinded clinical trial, with intended follow-up of patients for 36 months after the completion of therapy.

SETTING

A metropolitan tuberculosis clinic in a public health department.

PATIENTS

From March 1981 through April 1989, we enrolled 160 patients with suspected or known tuberculosis; 35 of these patients were excluded from the analysis.

INTERVENTIONS

Isoniazid, rifampin, pyrazinamide, and streptomycin were administered daily for 2 weeks; these drugs were then given in higher doses twice weekly for 6 weeks, followed by isoniazid and rifampin twice weekly for 6 weeks, followed by isoniazid and rifampin twice weekly for 18 weeks. A total of 62 doses were administered, and all therapy was directly observed by a nurse or an outreach worker.

MEASUREMENTS AND MAIN RESULTS

Of the 125 evaluable patients, 101 (81%) had pulmonary tuberculosis, 7 (6%) had both pulmonary and extrapulmonary involvement, and 17 (13%) had extrapulmonary disease only. Seventy-one (57%) patients had a history of recent alcoholism. There were two relapses (1.6% +/- 2.2%), occurring 6 and 56 months after the completion of therapy. The time at which sputum samples became culture negative in pulmonary patients ranged from 1 to 19 weeks (median, 4.6 weeks); 40% +/- 9.6% of patients were culture-negative after 4 weeks of therapy, 75% +/- 8.5% after 8 weeks, 94% +/- 4.7% after 12 weeks, 97% +/- 3.3% after 16 weeks, and 100% after 20 weeks. Adverse drug reactions included hyperuricemia (greater than 178 mumol/L [3 mg/dL] above normal) secondary to pyrazinamide in 80 patients (64%), twofold or greater elevations of aspartate aminotransferase in 21 patients (17%), 1.5-fold or greater elevations of alkaline phosphatase in 33 patients (27%), cutaneous abnormalities in 8 patients (6%), nausea in five patients (4%), and dizziness in 1 patient (1%).

CONCLUSIONS

This 62-dose, largely twice-weekly tuberculosis treatment regimen is efficacious and relatively nontoxic and is especially useful for patients in whom directly observed therapy is indicated.

[The anti-tuberculosis campaign throughout the world: strategies and actions in the field]

Tuberculosis will remain one of the main health concerns in the world for the next ten years. Economic crises in the Third World and AIDS epidemics in Africa have contributed to maintain a high level prevalence of tuberculosis in the poorest countries. Failures of tuberculosis control measures are due more often to mistakes in health planning and in health manpower training than to the lack of technologies. Short-course chemotherapy is an important technological achievement for the treatment of tuberculosis, but case holding and case finding are not efficient in several high-prevalence countries. BCG vaccination and chemoprophylaxis, especially in immunodeficient children or adults, need more evaluation studies.

Comparison of daily and twice-weekly regimens to treat pulmonary tuberculosis

A randomised controlled trial compared the effectiveness and toxicity in pulmonary tuberculosis of two drug regimens containing rifampicin and isoniazid given daily or twice-weekly for 4 months after a 2-month period of intensive treatment with daily isoniazid, rifampicin, and pyrazinamide. 667 patients with newly diagnosed pulmonary tuberculosis were randomly allocated to continue daily treatment with isoniazid (400 mg) and rifampicin (600 mg) or to twice-weekly treatment with isoniazid (900 mg) and rifampicin (600 mg). 544 of the 667 patients (81%) completed the 6-month course (287 of 337 [85%] treated daily and 257 of 330 [79%] treated twice-weekly). Drug toxicity was not a great problem; the treatment was permanently discontinued in only 2% of patients. There was no significant difference at the end of months 5 and/or 6 of chemotherapy between the groups treated daily and twice-weekly in the proportions with bacteriological failure (at least one positive sputum culture with more than 20 colonies) or who had died from tuberculosis (17 [6%] vs 10 [3%]). Nor was there a significant difference in the relapse rate (17 [7%] treated daily vs 10 [4%] treated twice-weekly) during follow-up of 12 months. Thus, the twice-weekly regimen was at least as effective as the daily regimen for treatment of pulmonary tuberculosis.

Epidemiological model and cost-effectiveness analysis of tuberculosis treatment programmes in Indonesia

An epidemiological model of tuberculosis, based on the natural history of tuberculosis and the control programmes in Indonesia, was constructed. This model was used for estimating future tuberculosis-prevented cases and costs for three treatment strategies--the 100% standard course, the 100% short course, and the existing strategy (a combination of 65% standard course and 35% short course)--in accordance with the master plan of the Indonesian Government's tuberculosis control programme. A cost-effectiveness analysis of the three strategies confirmed that the short-course strategy was the most cost-effective. Sensitivity analysis, which applied a broad range of parameters, continued to confirm the short-course strategy as the most cost-effective. If the short-course strategy had been applied in 1980 instead of the existing strategy (using the most likely parameters), the short-course strategy would prevent 1.8 million sputum-positive cases and would save 61.0 million dollars by the year 2000.

[Epidemiologic aspects and financial cost of tuberculosis at the Clinical Hospital of Valencia from 1986 to 1987]

Tuberculosis is an important sanitary and social as well as economical problem. This descriptive and retrospective study analyzes the features of the TBC patients in the Hospital Clínico of Valencia during 1986 and 1987 through data proceeding from clinical records and quantifies the social and economical cost coming to conclusions about the hospital's role regarding this disease. Admissions become more frequent in males and patients with current disease (class 3 of American Thoracic Society) from 50 years of age on, location is pulmonary in 95% of the cases, and 68% of the patients show risk factors. From the analysis of the economical data, we inferred the small importance of income and total cost due to TBC in contrast to the hospital whole although its individualized analysis shows an average cost 1.76 times bigger in a TBC patient as well as the fact that 85% tallies to hospital sustenance expenses which brings us to consider the importance of disease prevention.

[Paracoccidioidomycosis: care at a primary health care level]

Discute-se o tratamento de pacientes com paracoccidioidomicose a nível de assistência primária a saúde. Foram tratados 8 pacientes no Centro de Saúde I, de São Carlos, SP (Brasil), empregando-se o cetoconazol, durante um ano, na dose de 400 mg diários, em uma única tomada. Em todos os pacientes tratados, houve remissão do quadro clínico e melhora dos exames laboratoriais. Não houve relato de efeitos colaterais. Conclui com proposta de tratamento da paracoccidioidomicose, a nível de rede básica de saúde.

Survey of the previous investigation and treatment by private practitioners of patients with pulmonary tuberculosis attending government chest clinics in Hong Kong. Hong Kong Chest Service/British Medical Research Council

A questionnaire was applied to 159 consecutive patients with smear-positive and 187 with smear-negative pulmonary tuberculosis attending the 8 full-time Government chest clinics in Hong Kong for the first time for their current illness, who had already attended a private practitioner at a private general practice, a private clinic, or an independent hospital, outside the Government or Government-subsidised Service. The aim was to obtain details of management by private practitioners, and in particular of the antituberculosis chemotherapy prescribed. The great majority (86%) of the patients had originally attended a private practitioner because of symptoms. Only 18% had had their sputum examined, although 76% had had a chest radiograph; 65% of the smear-positive and 71% of the smear-negative patients had been told that they had, or might have, tuberculosis. For 40% there was an interval of more than a month between their first attendance at a private practitioner and at a Government chest clinic. Only 11% of the patients were referred without delay to a Government chest clinic, and another 21% once tuberculosis had been diagnosed or suspected. The patients were asked to name the drugs they had been prescribed, to produce samples, or to identify them from a perspex board containing samples of all 49 antituberculosis tablets and capsules known to be available in Hong Kong at the time. In the event, only 11% of the patients could name some or all of their medicaments and only 7% could produce samples, although a further 76% were able to describe them with or without the aid of the perspex board. In all, 19% of the patients were definitely or probably prescribed an antituberculosis regimen, although this was not always an adequate regimen. The findings suggest that there is considerable scope for active case-finding aimed at encouraging patients who are likely to have tuberculosis to attend a Government chest clinic.