Tuberculosis cost in tunisia

BACKGROUND

Tuberculosis (TB) infects one third of the world population. Its economic impact is important, affecting the global economy in the World.

OBJECTIVE

To determine the economic costs related to tuberculosis in Tunisia.

METHODS

Calculations were made for the reference year 2013; we covered all cost components of the disease, which are related to program management, BCG vaccination, health workers training, social mobilization, screening, chemoprophylaxis, and tuberculosis care. With the exception of costs related to care, which were the subject of a specific survey, the costs of other categories were obtained from the National TB Control Program.

RESULTS

The cost of the different components related to the management, prevention, screening and tuberculosis care in 2013 amounted 504688,000DT. The cost of care represented 80.0% of total costs (6807 808,000DT) ; cost related to program  management represented 13.2% (1 121 580,00 DT) and the BCG vaccination  6.0% e (512 300,00DT) The average cost per patient was 1447,360 DTin 2013.

CONCLUSION

Reducing the cost of tuberculosis, would involve reducing diagnostic delay. It is also recommended to reduce hospitalization recourse, and prevent multidrug resistance which lead to additional expenditures.

Tuberculosis cost in tunisia

BACKGROUND

Tuberculosis (TB) infects one third of the world population. Its economic impact is important, affecting the global economy in the World.

OBJECTIVE

To determine the economic costs related to tuberculosis in Tunisia.

METHODS

Calculations were made for the reference year 2013; we covered all cost components of the disease, which are related to program management, BCG vaccination, health workers training, social mobilization, screening, chemoprophylaxis, and tuberculosis care. With the exception of costs related to care, which were the subject of a specific survey, the costs of other categories were obtained from the National TB Control Program.

RESULTS

The cost of the different components related to the management, prevention, screening and tuberculosis care in 2013 amounted 504688,000DT. The cost of care represented 80.0% of total costs (6807 808,000DT) ; cost related to program  management represented 13.2% (1 121 580,00 DT) and the BCG vaccination  6.0% e (512 300,00DT) The average cost per patient was 1447,360 DTin 2013.

CONCLUSION

Reducing the cost of tuberculosis, would involve reducing diagnostic delay. It is also recommended to reduce hospitalization recourse, and prevent multidrug resistance which lead to additional expenditures.

Cost-effectiveness analysis of an alternative tuberculosis management strategy for permanent farm dwellers in South Africa amidst health service contraction

Aim: To establish the cost-effectiveness of lay health workers (LHWs) in conjunction with the current, local tuberculosis (TB) control programme, amidst health service contraction. Method: A cost-effectiveness analysis, comparing direct time costs of the current TB management strategy among permanent farm dwellers, with an intervention, whereby LHWs are involved in TB control activities on farms. Measure of effectiveness was case finding and cure rates of adult new smear-positive (NSP) TB cases, alongside a randomized control trial (RCT): Results: The observed cost reduction to the Boland Health District was 74% per case detected and cured on the intervention farms relative to the control farms. Intervention farms reached 83% successful treatment completion rate, control farms 65%. Although the successful treatment adherence was significantly different (18% letter). The improved case detection and cure rates were not statistically significant (chisquared test). Direct LHW costs are borne by farmers. Farmers were motivated to bear costs by reduced job absenteeism and other positive side-effects. Even without outcome improvements costs per case cured were 59% lower on the intervention farms. Conclusion: TB control has suffered from budget reductions in South Africa. It is critically important to develop cost-effective strategies to reduce the TB burden. Costs to public budgets can be substantially reduced while maintaining or improving case detection and treatment outcomes, by using farm-based LHWs.

The Ethics of Isolation for Patients With Tuberculosis in Australia

This case study examines the ethical dimensions of isolation for patients diagnosed with tuberculosis (TB) in Australia. It seeks to explore the issues of resource allocation, liberty, and public safety for wider consideration and discussion.

Using Top-down and Bottom-up Costing Approaches in LMICs: The Case for Using Both to Assess the Incremental Costs of New Technologies at Scale

PURPOSE

Estimating the incremental costs of scaling-up novel technologies in low-income and middle-income countries is a methodologically challenging and substantial empirical undertaking, in the absence of routine cost data collection. We demonstrate a best practice pragmatic approach to estimate the incremental costs of new technologies in low-income and middle-income countries, using the example of costing the scale-up of Xpert Mycobacterium tuberculosis (MTB)/resistance to riframpicin (RIF) in South Africa.

MATERIALS AND METHODS

We estimate costs, by applying two distinct approaches of bottom-up and top-down costing, together with an assessment of processes and capacity.

RESULTS

The unit costs measured using the different methods of bottom-up and top-down costing, respectively, are $US16.9 and $US33.5 for Xpert MTB/RIF, and $US6.3 and $US8.5 for microscopy. The incremental cost of Xpert MTB/RIF is estimated to be between $US14.7 and $US17.7. While the average cost of Xpert MTB/RIF was higher than previous studies using standard methods, the incremental cost of Xpert MTB/RIF was found to be lower.

CONCLUSION

Costs estimates are highly dependent on the method used, so an approach, which clearly identifies resource-use data collected from a bottom-up or top-down perspective, together with capacity measurement, is recommended as a pragmatic approach to capture true incremental cost where routine cost data are scarce.

Transaction costs of access to health care: Implications of the care-seeking pathways of tuberculosis patients for health system governance in Nigeria

Health care costs incurred prior to the appropriate patient-provider transaction (i.e., transaction costs of access to health care) are potential barriers to accessing health care in low- and middle-income countries. This paper explores these transaction costs and their implications for health system governance through a cross-sectional survey of adult patients who received their first diagnosis of pulmonary tuberculosis (TB) at the three designated secondary health centres for TB care in Ebonyi State, Nigeria. The patients provided information on their care-seeking pathways and the associated costs prior to reaching the appropriate provider. Of the 452 patients, 84% first consulted an inappropriate provider. Only 33% of inappropriate consultations were with qualified providers (QP); the rest were with informal providers such as pharmacy providers (PPs; 57%) and traditional providers (TP; 10%). Notably, 62% of total transaction costs were incurred during the first visit to an inappropriate provider and the mean transaction costs incurred was highest with QPs (US$30.20) compared with PPs (US$14.40) and TPs (US$15.70). These suggest that interventions for reducing transaction costs should include effective decentralisation to integrate TB care with services at the primary health care level, community engagement to address information asymmetry, enforcing regulations to keep informal providers within legal limits and facilitating referral linkages among formal and informal providers to increase early contact with appropriate providers.

The promise of rapid detection of active pulmonary tuberculosis in rural Alaska

BACKGROUND

The process by which active pulmonary tuberculosis (TB) is detected can be tediously slow in rural and often roadless Alaska, where several hundred air or boat miles can separate a patient from a chest x-ray and/or sputum collection. Additionally, the only TB reference lab in the state is many hundreds of air miles away, albeit centrally located in Anchorage. Under such conditions, it may take up to a week to process serial sputum AFB smears. This can result in either delayed onset of treatment or unnecessary empiric treatment, all while safety for the community is being considered. This dilemma often results in precautionary hospital isolation of a patient who might otherwise have been able to travel home by air. This article proposes a roadmap for remote health care settings that might bridge our current TB diagnostic ability to a better way in the future.

METHODS

Current TB diagnostic guidelines in our area (Yukon-Kuskokwim Delta) were reviewed for integration of the Xpert MTB/ RIF assay with the purpose of improving TB health care while emphasizing patient benefits and cost savings.

RESULTS

A clinical guideline that integrates the rapid TB assay into the current TB diagnostic algorithms for adults and adolescents is proposed. Crude cost savings at our hospital resulting from this guideline are estimated to be $316,000 per year.

CONCLUSION

The proven utility of a new rapid TB diagnostic, the Xpert MTB/RIF assay, offers the promise of more efficient TB medical care, improved patient human rights and improved hospital and community environmental safety, all with likely huge reduced health care costs in remote Alaska.

Designing and implementing a socioeconomic intervention to enhance TB control: operational evidence from the CRESIPT project in Peru

BACKGROUND

Cash transfers are key interventions in the World Health Organisation's post-2015 global TB policy. However, evidence guiding TB-specific cash transfer implementation is limited. We designed, implemented and refined a novel TB-specific socioeconomic intervention that included cash transfers, which aimed to support TB prevention and cure in resource-constrained shantytowns in Lima, Peru for: the Community Randomized Evaluation of a Socioeconomic Intervention to Prevent TB (CRESIPT) project.

METHODS

Newly-diagnosed TB patients from study-site healthposts were eligible to receive the intervention consisting of economic and social support. Economic support was provided to patient households through cash transfers on meeting the following conditions: screening for TB in household contacts and MDR TB in patients; adhering to TB treatment and chemoprophylaxis; and engaging with CRESIPT social support (household visits and community meetings). To evaluate project acceptability, quantitative and qualitative feedback was collected using a mixed-methods approach during formative activities. Formative activities included consultations, focus group discussions and questionnaires conducted with the project team, project participants, civil society and stakeholders.

RESULTS

Over 7 months, 135 randomly-selected patients and their 647 household contacts were recruited from 32 impoverished shantytown communities. Of 1299 potential cash transfers, 964 (74 %) were achieved, 259 (19 %) were not achieved, and 76 (7 %) were yet to be achieved. Of those achieved, 885/964 (92 %) were achieved optimally and 79/964 (8 %) sub-optimally. Key project successes were identified during 135 formative activities and included: strong multi-sectorial collaboration; generation of new evidence for TB-specific cash transfer; and the project being perceived as patient-centred and empowering. Challenges included: participant confidence being eroded through cash transfer delays, hidden account-charges and stigma; access to the initial bank-provider being limited; and conditions requiring participation of all TB-affected household members (e.g. community meetings) being hard to achieve. Refinements were made to improve project acceptability and future impact: the initial bank-provider was changed; conditional and unconditional cash transfers were combined; cash transfer sums were increased to a locally-appropriate, evidence-based amount; and cash transfer size varied according to patient household size to maximally reduce mitigation of TB-related costs and be more responsive to household needs.

CONCLUSIONS

A novel TB-specific socioeconomic intervention including conditional cash transfers has been designed, implemented, refined and is ready for impact assessment, including by the CRESIPT project. The lessons learnt during this research will inform policy-makers and decision-makers for future implementation of related interventions.

Economic evaluation of the practical approach to lung health and informal provider interventions for improving the detection of tuberculosis and chronic airways disease at primary care level in Malawi: study protocol for cost-effectiveness analysis

BACKGROUND

Chronic airway diseases pose a big challenge to health systems in most developing countries, particularly in Sub-Saharan Africa. A diagnosis for people with chronic or persistent cough is usually delayed because of individual and health system barriers. However, delayed diagnosis and treatment facilitates further transmission, severity of disease with complications and mortality. The objective of this study is to assess the cost-effectiveness of the practical approach to lung health strategy, a patient-centred approach for diagnosis and treatment of common respiratory illnesses in primary healthcare settings, as a means of strengthening health systems to improve the quality of management of respiratory diseases.

METHODS/DESIGN

Economic evaluation nested in a cluster randomised controlled trial with three arms will be performed. Measures of effectiveness and costs for all arms of the study will be obtained from the cluster randomised controlled clinical trial. The main outcome measures are a combined rate of major respiratory diseases milestones and process indicators extracted from the practical approach to lung health strategy. For analysis, descriptive as well as regression techniques will be used. A cost-effectiveness analysis will be performed according to intention-to-treat principle and from a societal perspective. Cost-effectiveness ratios will be calculated using bootstrapping techniques.

DISCUSSION

We hope to demonstrate the cost-effectiveness of the practical approach to lung health and informal healthcare providers, see an improvement in patients' quality of life, achieve a reduction in the duration and occurrence of episodes and the chronicity of respiratory diseases, and are able to report a decrease in the social cost. If the practical approach to lung health and informal healthcare provider's interventions are cost-effective, they could be scaled up to all primary healthcare centres.

TRIAL REGISTRATION

PACTR: PACTR201411000910192.

Determinants of consultation, diagnosis and treatment delays among new smear-positive pulmonary tuberculosis patients in Morocco: a cross-sectional study

We conducted a cross-sectional survey in 2012 in 12 selected provinces and prefectures in Morocco to determine consultation delay (patient delay), diagnosis delay and treatment delay (health system delays), and factors relating to these delays. The sample included 250 eligible and consenting newly diagnosed smearpositive pulmonary tuberculosis patients who were interviewed at the time of their registration within Diagnosis of Tuberculosis and Respiratory Diseases Reference Centers (CDTMR) or Integrated Health Centers (CSI) using a pretested and structured questionnaire. The median total delay was 46 days [inter-quartile interval (IQI) = 29-84 days]. Patient delay (median = 20; IQI = 8-47 days) was higher than health system delay (median=15; IIQ = 7-35 days). Being illiterate, thinking symptoms will disappear by themselves; having financial constraints and feeling fear of diagnosis or social isolation were associated with patient delay. Consulting first in the private sector or having 3 or more consultations before diagnosis was associated with health system delay.

Effectiveness and cost effectiveness of screening immigrants schemes for tuberculosis (TB) on arrival from high TB endemic countries to low TB prevalent countries

BACKGROUND

Immigrants to developed countries are a major source of TB. Therefore amongst strategies adopted for TB control in developed countries include; 1) Screening immigrants at ports of entry referred to as "Port of Arrival Screening" (PoA) and 2) Passive screening (PS) for TB which means screening immigrants through general practices, hospitals, chest-clinics and emergency departments. Evidence of the effectiveness and cost effectiveness of these strategies is not consistent.

OBJECTIVE

Evaluate efficiency of active PoA TB screening for immigrants from TB endemic-regions compared with Passive Screening of immigrant-populations from TB endemic-regions.

METHODS

Major electronic-databases and reference lists of relevant studies were searched. Experts of immigrants' TB screening were contacted for additional studies published or unpublished. Systematic search of major databases identified only retrospective cohort-studies. Their qualities were assessed using Scottish Intercollegiate Guidelines Network (SIGN) methodological checklist for comparative cohort-studies.

RESULTS

Systematic electronic searches identified 1443 citations. Of these 74 studies were retrieved for evaluation against the review's inclusion/exclusion criteria (see study inclusion/exclusion criteria). Four studies met the inclusion criteria (figure 2) which were low in the evidence hierarchy of primary effectiveness studies and had heterogeneities between them. Thus descriptive data-synthesis was performed. Proportionately PoA screening had the lowest percentage of receipt of tuberculin skin test (TST) and the highest percentage of non-attendance for TST reading (table 2). Active PoA screening reduced infectiousness by 34% compared to 30% by passive screening and new entrants screened at PoA were 80% less likely to be hospitalised Odds ratio (OR) = 0.2 (95% confidence interval (CI) 0.1 - 0.2). [Table: see text].

ECONOMIC ANALYSIS

One cost effectiveness analysis was found that compared the costs of; active PoA screening, general practice screening and homeless screening groups. The cost of detecting a case of TB were; £1.26, £13.17 and £96.36 for PS, homeless screening and active PoA screening respectively. The cost of preventing a case of TB were; £6.32, £23.00 and £10.00 for PS, homeless screening and PoA screening respectively, showing there is little difference between the different strategies.

CONCLUSION

Active PoA screening is worth doing with significant benefits including early identification of risk groups with possible timely treatment/chemoprophylaxis intervention, prevention of transmission by significantly reducing infectiousness with subsequent avoidance of hospitalisation in active PoA screening group.

Defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru

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.

CONCLUSIONS

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.

UTILITY OF ROUTINE CHEST RADIOGRAPHS IN KENYA

BACKGROUND

Many otherwise healthy Kenyans are required to obtain chest radiographs as part of routine medical examination to exclude pulmonary TB, a condition of significant public health concern. Many of these people are required to have these radiographs taken yearly as part of routine check-up. No local data is available to support this practice. Though a quick procedure to perform and readily available throughout the country, chest radiograph exposes the individual to a dose of ionising radiation. Ionising radiation is associated with increased risk of malignancy. The cost is also substantial.

OBJECTIVE

To determine the prevalence of radiological findings consistent with PTB among routine medical examination chest radiographs.

DESIGN

A cross-sectional descriptive study.

SETTINGS

Department of Radiology Kenyatta National Hospital, Department of Imaging and Radiation Medicine, University of Nairobi, Plaza Imaging Solutions, a private radiology practice in Nairobi and Department of Radiology, the Nairobi Hospital.

SUBJECTS

Four hundred and two chest radiographs of patients presenting for routine medical examinations were analysed.

RESULTS

Sixty three radiographs had abnormal but clinically insignificant findings (16%). Only one radiograph (0.25%) had radiological features of PTB. The rest were reported as normal (84%).

CONCLUSION

In this study, the diagnostic yield for the intended purpose (to include/ exclude PTB) was extremely low (0.25%). It is recommended that routine chest radiographs as screening tools for active pulmonary tuberculosis be reconsidered due to poor diagnostic yield. The authors propose a bigger nation wide study before a policy decision can be proposed.

Are we doing enough to stem the tide of acquired MDR-TB in countries with high TB burden? Results of a mixed method study in Chongqing, China

Multi-drug resistant tuberculosis (MDR-TB) represents a threat to health and development in countries with high TB burden. China’s MDR-TB prevalence rate of 6.8% is the highest in the world. Interventions to remove barriers against effective TB control, and prevention of MDR-TB are urgently needed in the country. This paper reports a cross-sectional questionnaire survey of 513 pulmonary TB (PTB) patients, and qualitative interviews of 10 healthcare workers (HCWs), and 15 PTB patients. The objective was to assess barriers against effective control of PTB and prevention of MDR-TB by elucidating the perspectives of patients and healthcare providers. Results showed that more than half of the patients experienced patient delay of over 12.5 days. A similar proportion also experienced detection delay of over 30 days, and delay in initiating treatment of over 31 days. Consulting a non-TB health facility ≥3 times before seeking care at TB dispensary was a risk factor for both detection delay [AOR (95% CI): 1.89(1.07, 3.34) and delay in initiating treatment[AOR (95% CI): 1.88 (1.06, 3.36). Results revealed poor implementation of Directly Observed Therapy (DOT), whereby treatment of 34.3% patients was never monitored by HCWs. Only 31.8% patients had ever accessed TB health education before their TB diagnosis. Qualitative data consistently disclosed long patient delay, and indicated that patient’s poor TB knowledge and socioeconomic barriers were primary reasons for patient delay. Seeking care and being treated at a non-TB hospital was an important reason for detection delay. Patient’s long work hours and low income increased risk for treatment non-adherence. Evidence-based measures to improve TB health seeking behavior, reduce patient and detection delays, improve the quality of DOT, address financial and system barriers, and increase access to TB health promotion are urgently needed to address the burgeoning prevalence of MDR-TB in China.

Effect of smoking and indoor air pollution on the risk of tuberculosis: smoking, indoor air pollution and tuberculosis

INTRODUCTION

Although epidemiological studies have reported an association between smoking and increases in tuberculosis, the relationship between indoor air pollution and risk of tuberculosis is not fully understood. A limited number of studies have suggested that smoking and indoor air pollution may play a role in the pathogenesis of tuberculosis. In this study, we investigated the effect of smoking and indoor air pollution on the risk of active tuberculosis.

MATERIALS AND METHODS

It is prospectively recorded age matched case-control study. Three hundred sixty two active tuberculosis cases and 409 healthy controls were included to the study. All participants were interviewed face to face by using a questionnaire including smoking habit, quantity and duration of smoking, number of room/person in the house, monthly income of the family, indoor heating system, and environmental tobacco smoke.

RESULTS

Patients who smoke had a five fold (95% CI: 3.2-7.5, p< 0.0001) higher odds of having active tuberculosis compared with patients who do not smoke. Similarly, patients using coal or wood for indoor heating had a 1.6 fold (95% CI: 1.179-2.305, p< 0.003) higher odds having tuberculosis. People who have less income (< 200 Euro/month) had 3.2 fold (95% CI: 2.113-5.106, p< 0.0001) higher odds of having tuberculosis compared with people having high income. There was a significant correlation between heavy smoking (≥ 20 packet/year, p< 0.0001) and age onset of smoking (< 16 years of age, p< 0.041). There was no significant association between environmental tobacco smoke and tuberculosis.

CONCLUSION

Smoking and indoor air pollution may increase the risk of tuberculosis. There is a complex interaction between smoking, socioeconomic conditions, indoor air quality and tuberculosis. Our results suggest that effective indoor air quality control could help to prevent tuberculosis risk.

Assessment of cost of tuberculosis to patients and their families: a cross-sectional study at Addet Health Center, Yilmana Densa District, Amhara National Regional State

INTRODUCTION

The rising number of tuberculosis cases is putting a considerable strain on health budgets, and threatens to drain resources essential to health and welfare services.

OBJECTIVES

The objective of this study was to estimate the cost of tuberculosis to outpatients and their families in a rural district health center, Addet Health Center, Yilmana Densa District, Amhara National Regional State in Ethiopia.

METHODS

Cross-sectional study was conducted to estimate the cost of tuberculosis to outpatients and their families. Data were collected on diagnosis, treatment, transportation, food and other expenses, and also income losses due to tuberculosis before and after the diagnosis of tuberculosis. Data were entered to Epi-Info and transferred to SPSS 13 for analysis. Mean, median, range and standard deviation were used to describe the data.

RESULT

The mean direct cost and indirect cost of tuberculosis to outpatients and their families were 1078.00 Birr and 2080.43 Birr, respectively, at the time of study. The mean total cost of tuberculosis to outpatients and their families was 3159.23 Birr.

CONCLUSION

Cost of tuberculosis to patients and their families, especially before the identification of the disease was found to be very high. Therefore, consequences of tuberculosis to patients and their families are particularly serious and potentially devastating.

The high cost of free tuberculosis services: patient and household costs associated with tuberculosis care in Ebonyi State, Nigeria

Objective

Poverty is both a cause and consequence of tuberculosis. The objective of this study is to quantify patient/household costs for an episode of tuberculosis (TB), its relationships with household impoverishment, and the strategies used to cope with the costs by TB patients in a resource-limited high TB/HIV setting.

Methods

A cross-sectional study was conducted in three rural hospitals in southeast Nigeria. Consecutive adults with newly diagnosed pulmonary TB were interviewed to determine the costs each incurred in their care-seeking pathway using a standardised questionnaire. We defined direct costs as out-of-pocket payments, and indirect costs as lost income.

Results

Of 452 patients enrolled, majority were male 55% (249), and rural residents 79% (356), with a mean age of 34 (±11.6) years. Median direct pre-diagnosis/diagnosis cost was $49 per patient. Median direct treatment cost was $36 per patient. Indirect pre-diagnostic and treatment costs were $416, or 79% of total patient costs, $528. The median total cost of TB care per household was $592; corresponding to 37% of median annual household income pre-TB. Most patients reported having to borrow money 212(47%), sell assets 42(9%), or both 144(32%) to cope with the cost of care. Following an episode of TB, household income reduced increasing the proportion of households classified as poor from 54% to 79%. Before TB illness, independent predictors of household poverty were; rural residence (adjusted odds ratio [aOR] 2.8), HIV-positive status (aOR 4.8), and care-seeking at a private facility (aOR 5.1). After TB care, independent determinants of household poverty were; younger age (≤35 years; aOR 2.4), male gender (aOR 2.1), and HIV-positive status (aOR 2.5).

Conclusion

Patient and household costs for TB care are potentially catastrophic even where services are provided free-of-charge. There is an urgent need to implement strategies for TB care that are affordable for the poor.

Implementation of LED fluorescence microscopy for diagnosis of pulmonary and HIV-associated tuberculosis in a hospital setting in Indonesia

Background

Fluorescence microscopy (FM) has not been implemented widely in TB endemic settings and little evaluation has been done in HIV-infected patients. We evaluated diagnostic performance, time and costs of FM with light-emitting diodes technology (LED-FM), compared with conventional (Zieh-Neelsen) microscopy in a hospital in Indonesia which acts as referral centre for HIV-infected patients.

Method

We included pulmonary tuberculosis suspects from the outpatient and HIV clinic. Direct and concentrated sputum smears were examined using LED-FM and ZN microscopy by two technicians who were blinded for the HIV-status and the result of the comparative test. Mean reading time per slide was recorded and cost of each slide was calculated. Mycobacteria culture served as the reference standard.

Results

Among 404 tuberculosis suspects from the outpatient clinic and 256 from the HIV clinic, mycobacteria culture was positive in 12.6% and 27%, respectively. The optimal sensitivity of LED-FM was achieved by using a threshold of ≥2 AFB/length. LED-FM had a higher sensitivity (75.5% vs. 54.9%, P<0.01) but lower specificity (90.0% vs 96.6%, P<0.01) compared to ZN microscopy. HIV was associated with a lower sensitivity but similar specificity. The average reading time using LED-FM was significantly shorter (2.23±0.78 vs 5.82±1.60 minutes, P<0.01), while costs per slide were similar.

Conclusion

High sensitivity of LED-FM combined with shorter reading time of sputum smear slides make this method a potential alternative to ZN microscopy. Additional data on specificity are needed for effective implementation of this technique in high burden TB laboratories.

Removal of user fees no guarantee of universal health coverage: observations from Burkina Faso

In theory, the removal of user fees puts health services within reach of everyone, including the very poor. When Burkina Faso adopted the DOTS strategy for the control of tuberculosis, the intention was to provide free tuberculosis care. In 2007-2008, interviews were used to collect information from 242 smear-positive patients with pulmonary tuberculosis who were enrolled in the national tuberculosis control programme in six rural districts. The median direct costs associated with tuberculosis were estimated at 101 United States dollars (US$) per patient. These costs represented 23% of the mean annual income of a patient's household. During the course of their care, three quarters of the interviewed patients apparently faced "catastrophic" health expenditure. Inadequacies in the health system and policies appeared to be responsible for nearly half of the direct costs (US$ 45 per patient). Although the households of patients developed coping strategies, these had far-reaching, adverse effects on the quality of lives of the households' members and the socioeconomic stability of the households. Each tuberculosis patient lost a median of 45 days of work as a result of the illness. For a population living on or below the poverty line, every failure in health-care delivery increases the risk of "catastrophic" health expenditure, exacerbates socioeconomic inequalities, and reduces the probability of adequate treatment and cure. In Burkina Faso, a policy of "free" care for tuberculosis patients has not met with complete success. These observations should help define post-2015 global strategies for tuberculosis care, prevention and control.

Treatment of tuberculosis in South Kazakhstan: clinical and economical aspects

BACKGROUND AND OBJECTIVE

Since 1990, the tuberculosis incidence rate in Eastern Europe and post-Soviet republics has been increasing in many countries including Kazakhstan. This problem is particularly important in Kazakhstan regions with limited financial resources, among them - in South Kazakhstan province. The aim of this study was to investigate the main clinical and antibiotic-related economic aspects of tuberculosis treatment in South Kazakhstan province.

MATERIAL AND METHODS

In total, 502 patients participated in the study. They were hospitalized to the tuberculosis dispensary of Sayram district (South Kazakhstan province) in 2007-2013. Statistical analysis included logistic regression for better treatment outcomes and analysis of antibiotic treatment costs.

RESULTS

Two-thirds of patients had infiltrative tuberculosis (67%). Positive treatment outcomes were determined in 85% of cases. The patients were mostly treated with cycloserine, protionamide, capreomycin, and ofloxacin. The majority of antibiotic costs were related to the treatment with capreomycin. In case of the positive results of the test for Mycobacterium tuberculosis, antibiotic expenses were almost 3 times greater than in case of negative test results (P<0.001).

CONCLUSIONS

The majority of patients had extensively drug-resistant tuberculosis. The negative results of the test for Mycobacterium tuberculosis at discharge were not related to pretreatment factors. Antibiotic-related costs were significantly higher in case of the positive results of the test of Mycobacterium tuberculosis, but were not associated with gender, residence place, hospitalization recurrence, or main blood test results before treatment.

Recovery rates of Mycobacterium tuberculosis using five decontamination methods

Tuberculosis (TB) caused by Mycobacterium tuberculosis remains one of the leading infectious diseases in resource limited countries of the world, including Nigeria. For optimal care of patients with pulmonary TB, effective decontamination methods are required for isolation and identification of M. tuberculosis from other fast growing organisms found in sputum samples of infected patients. Five methods of sputum decontamination including the Petroff, oxalic, bleach, simplified concentration and Kudoh methods were assessed prior to mycobacterial culture. In all, thirty human sputum samples were processed and results analysed after eight weeks of incubation. Overall, there was a significant difference in the growth yield using the different methods (Friedman test statistic, Q(K) = 36.3; P < 0.05). Again, a significant difference (Friedman test statistic, Q(K) = 48.0; P < 0.05) was observed between the valuable and non-valuable yield of mycobacteria. Furthermore, the simplified concentration method had the best performance in terms of pure culture growth/minimal media contamination coupled with a cost benefit ratio of 0.10; the bleach method being the least. Given these findings, coupled with laboratory challenges in developing countries as well as ease of use on the field/cost effectiveness; we propose the simplified concentration as an optimal decontamination method for use in resource limited settings where TB remains an endemic problem.

Population health impact and cost-effectiveness of tuberculosis diagnosis with Xpert MTB/RIF: a dynamic simulation and economic evaluation

BACKGROUND

The Xpert MTB/RIF test enables rapid detection of tuberculosis (TB) and rifampicin resistance. The World Health Organization recommends Xpert for initial diagnosis in individuals suspected of having multidrug-resistant TB (MDR-TB) or HIV-associated TB, and many countries are moving quickly toward adopting Xpert. As roll-out proceeds, it is essential to understand the potential health impact and cost-effectiveness of diagnostic strategies based on Xpert.

METHODS AND FINDINGS

We evaluated potential health and economic consequences of implementing Xpert in five southern African countries--Botswana, Lesotho, Namibia, South Africa, and Swaziland--where drug resistance and TB-HIV coinfection are prevalent. Using a calibrated, dynamic mathematical model, we compared the status quo diagnostic algorithm, emphasizing sputum smear, against an algorithm incorporating Xpert for initial diagnosis. Results were projected over 10- and 20-y time periods starting from 2012. Compared to status quo, implementation of Xpert would avert 132,000 (95% CI: 55,000-284,000) TB cases and 182,000 (97,000-302,000) TB deaths in southern Africa over the 10 y following introduction, and would reduce prevalence by 28% (14%-40%) by 2022, with more modest reductions in incidence. Health system costs are projected to increase substantially with Xpert, by US$460 million (294-699 million) over 10 y. Antiretroviral therapy for HIV represents a substantial fraction of these additional costs, because of improved survival in TB/HIV-infected populations through better TB case-finding and treatment. Costs for treating MDR-TB are also expected to rise significantly with Xpert scale-up. Relative to status quo, Xpert has an estimated cost-effectiveness of US$959 (633-1,485) per disability-adjusted life-year averted over 10 y. Across countries, cost-effectiveness ratios ranged from US$792 (482-1,785) in Swaziland to US$1,257 (767-2,276) in Botswana. Assessing outcomes over a 10-y period focuses on the near-term consequences of Xpert adoption, but the cost-effectiveness results are conservative, with cost-effectiveness ratios assessed over a 20-y time horizon approximately 20% lower than the 10-y values.

CONCLUSIONS

Introduction of Xpert could substantially change TB morbidity and mortality through improved case-finding and treatment, with more limited impact on long-term transmission dynamics. Despite extant uncertainty about TB natural history and intervention impact in southern Africa, adoption of Xpert evidently offers reasonable value for its cost, based on conventional benchmarks for cost-effectiveness. However, the additional financial burden would be substantial, including significant increases in costs for treating HIV and MDR-TB. Given the fundamental influence of HIV on TB dynamics and intervention costs, care should be taken when interpreting the results of this analysis outside of settings with high HIV prevalence.