Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries

A Systematic Review of Methodological Variation in Healthcare Provider Perspective Tuberculosis Costing Papers Conducted in Low- and Middle-Income Settings, Using An Intervention-Standardised Unit Cost Typology

BACKGROUND

There is a need for easily accessible tuberculosis unit cost data, as well as an understanding of the variability of methods used and reporting standards of that data.

OBJECTIVE

The aim of this systematic review was to descriptively review papers reporting tuberculosis unit costs from a healthcare provider perspective looking at methodological variation; to assess quality using a study quality rating system and machine learning to investigate the indicators of reporting quality; and to identify the data gaps to inform standardised tuberculosis unit cost collection and consistent principles for reporting going forward.

METHODS

We searched grey and published literature in five sources and eight databases, respectively, using search terms linked to cost, tuberculosis and tuberculosis health services including tuberculosis treatment and prevention. For inclusion, the papers needed to contain empirical unit cost estimates for tuberculosis interventions from low- and middle-income countries, with reference years between 1990 and 2018. A total of 21,691 papers were found and screened in a phased manner. Data were extracted from the eligible papers into a detailed Microsoft Excel tool, extensively cleaned and analysed with R software (R Project, Vienna, Austria) using the user interface of RStudio. A study quality rating was applied to the reviewed papers based on the inclusion or omission of a selection of variables and their relative importance. Following this, machine learning using a recursive partitioning method was utilised to construct a classification tree to assess the reporting quality.

RESULTS

This systematic review included 103 provider perspective papers with 627 unit costs (costs not presented here) for tuberculosis interventions among a total of 140 variables. The interventions covered were active, passive and intensified case finding; tuberculosis treatment; above-service costs; and tuberculosis prevention. Passive case finding is the detection of tuberculosis cases where individuals self-identify at health facilities; active case finding is detection of cases of those not in health facilities, such as through outreach; and intensified case finding is detection of cases in high-risk populations. There was heterogeneity in some of the reported methods used such cost allocation, amortisation and the use of top-down, bottom-up or mixed approaches to the costing. Uncertainty checking through sensitivity analysis was only reported on by half of the papers (54%), while purposive and convenience sampling was reported by 72% of papers. Machine learning indicated that reporting on 'Intervention' (in particular), 'Urbanicity' and 'Site Sampling', were the most likely indicators of quality of reporting. The largest data gap identified was for tuberculosis vaccination cost data, the Bacillus Calmette-Guérin (BCG) vaccine in particular. There is a gap in available unit costs for 12 of 30 high tuberculosis burden countries, as well as for the interventions of above-service costs, tuberculosis prevention, and active and intensified case finding.

CONCLUSION

Variability in the methods and reporting used makes comparison difficult and makes it hard for decision makers to know which unit costs they can trust. The study quality rating system used in this review as well as the classification tree enable focus on specific reporting aspects that should improve variability and increase confidence in unit costs. Researchers should endeavour to be explicit and transparent in how they cost interventions following the principles as laid out in the Global Health Cost Consortium's Reference Case for Estimating the Costs of Global Health Services and Interventions, which in turn will lead to repeatability, comparability and enhanced learning from others.

Healthcare Resource Uses and Out-of-Pocket Expenses Associated with Pulmonary TB Treatment in Thailand

BACKGROUND

In Thailand, pharmaceutical care has been recently introduced to a tertiary hospital as an approach to improve adherence to tuberculosis (TB) treatment in addition to home visit and modified directly observed therapy (DOT). However, the economic impact of pharmaceutical care is not known.

OBJECTIVE

The aim of this study was to estimate healthcare resource uses and costs associated with pharmaceutical care compared with home visit and modified DOT in pulmonary TB patients in Thailand from a healthcare sector perspective inclusive of out-of-pocket expenditures.

METHODS

We conducted a retrospective study using data abstracted from the hospital billing database associated with pulmonary TB patients who began treatment between 2010 and 2013 in three hospitals in Thailand. We used generalized linear models to compare the costs by accounting for baseline characteristics. All costs were converted to international dollars (Intl$) RESULTS: The mean direct healthcare costs to the public payer were $519.96 (95%confidence interval [CI] 437.31-625.58) associated with pharmaceutical care, $1020.39 (95% CI 911.13-1154.11) for home visit, and $887.79 (95% CI 824.28-955.91) for modified DOT. The mean costs to patients were $175.45 (95% CI 130.26-230.48) for those receiving pharmaceutical care, $53.77 (95% CI 33.25-79.44) for home visit, and $49.33 (95% CI 34.03-69.30) for modified DOT. After adjustment for baseline characteristics, pharmaceutical care was associated with lower total direct costs compared with home visit (-$354.95; 95% CI -285.67 to -424.23) and modified DOT (-$264.61; 95% CI -198.76 to -330.46).

CONCLUSION

After adjustment for baseline characteristics, pharmaceutical care was associated with lower direct costs compared with home visit and modified DOT.

Strengthening tuberculosis control overseas: who benefits?

BACKGROUND

Although tuberculosis is a major cause of morbidity and mortality worldwide, available funding falls far short of that required for effective control. Economic and spillover consequences of investments in the treatment of tuberculosis are unclear, particularly when steep gradients in the disease and response are linked by population movements, such as that between Papua New Guinea (PNG) and the Australian cross-border region.

OBJECTIVE

To undertake an economic evaluation of Australian support for the expansion of basic Directly Observed Treatment, Short Course in the PNG border area of the South Fly from the current level of 14% coverage.

METHODS

Both cost-utility analysis and cost-benefit analysis were applied to models that allow for population movement across regions with different characteristics of tuberculosis burden, transmission, and access to treatment. Cost-benefit data were drawn primarily from estimates published by the World Health Organization, and disease transmission data were drawn from a previously published model.

RESULTS

Investing $16 million to increase basic Directly Observed Treatment, Short Course coverage in the South Fly generates a net present value of roughly $74 million for Australia (discounted 2005 dollars). The cost per disability-adjusted life-year averted and quality-adjusted life-year saved for PNG is $7 and $4.6, respectively.

CONCLUSIONS

Where regions with major disparities in tuberculosis burden and health system resourcing are connected through population movements, investments in tuberculosis control are of mutual benefit, resulting in net health and economic gains on both sides of the border. These findings are likely to inform the case for appropriate investment in tuberculosis control globally.

Global epidemiology of tuberculosis

Despite the availability of effective chemotherapy, tuberculosis (TB) killed 1.3 million people in 2012. Alongside HIV, it remains a top cause of death from an infectious disease. Global targets for reductions in the epidemiological burden of TB have been set for 2015 and 2050 within the context of the Millennium Development Goals (MDGs) and by the Stop TB Partnership. Achieving these targets is the focus of national and international efforts in TB control, and showing whether or not they are achieved is of major importance to guide future and sustainable investments. This article provides a short overview of sources of data to estimate TB disease burden; presents estimates of TB incidence, prevalence, and mortality in 2012 and an assessment of progress toward the 2015 targets for reductions in these indicators based on trends since 1990 and projections up to 2015; analyzes trends in TB notifications and in the implementation of the Stop TB Strategy; and considers prospects for elimination of TB after 2015.

Is there a need to mitigate the social and financial consequences of tuberculosis at the individual and household level?

This paper reviews evidence on social and economic costs of tuberculosis. Key socio-economic consequences include stigma, social isolation, increased out-of-pocket expenditures for medical and non-medical costs and reduced income. Many of the financing methods that households use have long-term negative impacts and the poor are most vulnerable to these costs. Together, these negative consequences adversely affect TB control, in terms of delayed diagnosis, delayed initiation of treatment, suboptimal adherence and failure to complete treatment, as well as the coping and well being of the individual and household. There are two ways to reduce treatment costs for the patient; one can either reduce the direct and indirect costs of seeking a diagnosis and obtaining treatment and/or provide income transfers to offset some of those costs incurred. Social transfers in the form of food, cash or vouchers can mitigate the negative effects by enabling the individual to seek a diagnosis, protecting minimum food expenditures, reducing the need to accumulate debt and reduce productive assets and reducing the negative impacts on other household members, particularly young children and school-age children.

Differential expression of host biomarkers in saliva and serum samples from individuals with suspected pulmonary tuberculosis

The diagnosis of tuberculosis remains challenging in individuals with difficulty in providing good quality sputum samples such as children. Host biosignatures of inflammatory markers may be valuable in such cases, especially if they are based on more easily obtainable samples such as saliva. To explore the potential of saliva as an alternative sample in tuberculosis diagnostic/biomarker investigations, we evaluated the levels of 33 host markers in saliva samples from individuals presenting with pulmonary tuberculosis symptoms and compared them to those obtained in serum. Of the 38 individuals included in the study, tuberculosis disease was confirmed in 11 (28.9%) by sputum culture. In both the tuberculosis cases and noncases, the levels of most markers were above the minimum detectable limit in both sample types, but there was no consistent pattern regarding the ratio of markers in serum/saliva. Fractalkine, IL-17, IL-6, IL-9, MIP-1 β , CRP, VEGF, and IL-5 levels in saliva and IL-6, IL-2, SAP, and SAA levels in serum were significantly higher in tuberculosis patients (P < 0.05). These preliminary data indicate that there are significant differences in the levels of host markers expressed in saliva in comparison to those expressed in serum and that inflammatory markers in both sample types are potential diagnostic candidates for tuberculosis disease.

Identifying dynamic tuberculosis case-finding policies for HIV/TB coepidemics

The global tuberculosis (TB) control plan has historically emphasized passive case finding (PCF) as the most practical approach for identifying TB suspects in high burden settings. The success of this approach in controlling TB depends on infectious individuals recognizing their symptoms and voluntarily seeking diagnosis rapidly enough to reduce onward transmission. It now appears, at least in some settings, that more intensified case-finding (ICF) approaches may be needed to control TB transmission; these more aggressive approaches for detecting as-yet undiagnosed cases obviously require additional resources to implement. Given that TB control programs are resource constrained and that the incremental yield of ICF is expected to wane over time as the pool of undiagnosed cases is depleted, a tool that can help policymakers to identify when to implement or suspend an ICF intervention would be valuable. In this article, we propose dynamic case-finding policies that allow policymakers to use existing observations about the epidemic and resource availability to determine when to switch between PCF and ICF to efficiently use resources to optimize population health. Using mathematical models of TB/HIV coepidemics, we show that dynamic policies strictly dominate static policies that prespecify a frequency and duration of rounds of ICF. We also find that the use of a diagnostic tool with better sensitivity for detecting smear-negative cases (e.g., Xpert MTB/RIF) further improves the incremental benefit of these dynamic case-finding policies.

Patient views on determinants of compliance with tuberculosis treatment in the eastern cape, South Africa: an application of q-methodology

BACKGROUND

: Tuberculosis (TB) constitutes one-quarter of all avoidable deaths in developing countries. In the Eastern Cape, South Africa, TB is a public health problem of epidemic proportion. Poor compliance and frequent interruption to treatment are associated with increased transmission rates, morbidity, and costs to TB control programs. This study explored determinants of (non-)compliance from the patients' perspective.

METHODS

: Semi-structured interviews were conducted with patients (33 treatment compliers and 34 treatment non-compliers) and 14 community health workers from local community clinics and the hospital in the township of Grahamstown, Eastern Cape, South Africa. Q-methodology was used. Patients rank ordered 32 opinion statements describing determinants of treatment compliance from the TB adherence model. By-person factor analysis was used to explore patterns in the rankings of statements by compliers and non-compliers. These patterns were interpreted and described as patient views on determinants of compliance with treatment. Patients and community health workers selected the top five determinants of compliance and non-compliance.

RESULTS

: Compliers believed that completing treatment would cure them of TB. Economic prospects were crucial for compliance. Compliers felt that the support of the government disability grant helped with compliance. Non-compliers believed that stigmatization had the greatest impact on non-compliance, together with the burden of disease, the arrangements involved with receiving treatment, restrictions accompanying treatment, and the association of TB with HIV/AIDS infection.

CONCLUSIONS

: Stigmatization makes TB a 'social disease'. Individual motivation and self-efficacy appear to have a considerable effect on compliance, but, for non-compliers, the general lack of job prospects and being able to provide for themselves or their family also makes TB very much an 'economic disease'.

Pharmacoeconomics and its implication on priority-setting for essential medicines in Tanzania: a systematic review

BACKGROUND

Due to escalating treatment costs, pharmacoeconomic analysis has been assigned a key role in the quest for increased efficiency in resource allocation for drug therapies in high-income countries. The extent to which pharmacoeconomic analysis is employed in the same role in low-income countries is less well established. This systematic review identifies and briefly describes pharmacoeconomic studies which have been conducted in Tanzania and further assesses their influence in the selection of essential medicines.

METHODS

Pubmed, Embase, Cinahl and Cochrane databases were searched using "economic evaluation", "cost-effectiveness analysis", "cost-benefit analysis" AND "Tanzania" as search terms. We also scanned reference lists and searched in Google to identify other relevant articles. Only articles reporting full economic evaluations about drug therapies and vaccines conducted in Tanzania were included. The national essential medicine list and other relevant policy documents related to the identified articles were screened for information regarding the use of economic evaluation as a criterion for medicine selection.

RESULTS

Twelve pharmacoeconomic studies which met our inclusion criteria were identified. Seven studies were on HIV/AIDS, malaria and diarrhoea, the three highest ranked diseases on the disease burden in Tanzania. Six studies were on preventive and treatment interventions targeting pregnant women and children under the age of five years. The national essential medicine list and the other identified policy documents do not state the use of economic evaluation as one of the criteria which has influenced the listing of the drugs.

CONCLUSION

Country specific pharmacoeconomic analyses are too scarce and inconsistently used to have had a significant influence on the selection of essential medicines in Tanzania. More studies are required to fill the existing gap and to explore whether decision-makers have the ability to interpret and utilise pharmacoeconomic evidence. Relevant health authorities in Tanzania should also consider how to apply pharmacoeconomic analyses more consistently in the future priority-setting decisions for selection of essential medicines.

Efficacy of directly observed treatment short-course intermittent regimen in spinal tuberculosis

BACKGROUND

Most important cause of treatment failure and emergence of drug resistance in the treatment of tuberculosis is noncompliance. Compliance can be improved by direct observation of drug intake, intermittent therapy, and short-course treatment. The efficacy of Directly Observed Treatment Short Course (DOTS) strategy advocated by World Health Organization (WHO) in spinal tuberculosis is not yet proven. We conducted a prospective clinical study on a consecutive series of patients with spinal tuberculosis treated by Category I Revised National Tuberculosis Control Programme (RNTCP) regimen based on DOTS strategy of WHO from 2004 to 2007 to evaluate the efficacy.

MATERIALS AND METHODS

Forty-nine consecutive patients of spinal tuberculosis were treated with short-course intermittent chemotherapy under Category I RNTCP/DOTS strategy. Patients were followed up for a minimum period of 2 years. Surgery was done if the patient presented with significant neurologic deficit or when the drug treatment failed. Outcome was assessed by clinical, radiologic, and laboratory criteria, and graded into excellent, good, fair, and poor based on various parameters.

RESULTS

63.4% (n=26) of the patients had excellent results. 14.6% (n=6) of the patients had good and fair results. Three patients (7.3%) had poor results 48.7% (n=20) of the patients had but only one of them was severe enough to warrant change of drug.

CONCLUSIONS

Efficacy of DOTS was comparable with other standard regimens. There was a significant reduction in adverse side effects when compared with daily regimens. Study showed that the outcome was better in those treated early.

Cost-effectiveness of community health worker versus home-based guardians for directly observed treatment of tuberculosis in Vitória, Espírito Santo State, Brazil

The objective of this study was to compare the costs and outcomes associated with guardian-supervised directly observed treatment relative to the standard of care Directly Observed Therapy, Short Course (DOTS) provided by community health workers (CHW). New cases of culture-positive pulmonary tuberculosis (TB) treated in Vitória, Espírito Santo State, Brazil, between January 2005 and December 2006 were interviewed and chose their preferred treatment strategy. Costs incurred by providers and patients (and patients' families) were estimated, and cost-effectiveness was assessed by comparing costs per successfully treated patient. 130 patients were included in the study; 84 chose CHW-supervised DOTS and 46 chose guardian-supervised DOTS. 45 of 46 (98%) patients treated with guardian-supervised DOTS were cured or completed treatment compared to 70/84 (83%) of the CHW-supervised patients (p = 0.01). Logistic regression showed only the strategy of supervision to be a significant association with treatment outcome, with guardian-supervised care strongly protective. Cost per patient treated with guardian-supervised DOTS was US$398, compared to US$548 for CHW-supervised DOTS. The guardian-supervised DOTS is an attractive option to complement CHW-supervised DOTS.

Household costs of illness during different phases of tuberculosis treatment in Central Asia: a patient survey in Tajikistan

BACKGROUND

Illness-related costs incurred by patients constitute a severe economic burden for households especially in low-income countries. High household costs of illness lead to impoverishment; they impair affordability and equitable access to health care and consequently hamper tuberculosis (TB) control. So far, no study has investigated patient costs of TB in the former Soviet Union.

METHODS

All adult new pulmonary TB cases enrolled into the DOTS program in 12 study districts during the study period were enrolled. Medical and non-medical expenditure as well as loss of income were quantified in two interviews covering separate time periods. Costs of different items were summed up to calculate total costs. For missing values, multiple imputation was applied.

RESULTS

A cohort of 204 patients under DOTS, 114 men and 90 women, participated in the questionnaire survey. Total illness costs of a TB episode averaged $1053 (c. $4900 purchasing power parity, PPP), of which $292, $338 and $422 were encountered before the start of treatment, during intensive phase and in continuation phase, respectively. Costs per month were highest before the start of treatment ($145) and during intensive phase ($153) and lower during continuation phase ($95). These differences were highly significant (paired t-test, p < 0.0005 for both comparisons).

CONCLUSIONS

The illness-related costs of an episode of TB exceed the per capita GDP of $1600 PPP about two-and-a-half times. Hence, these costs are catastrophic for concerned households and suggest a high risk for impoverishment. Costs are not equally spread over time, but peak in early stages of treatment, exacerbating the problem of affordability. Mitigation strategies are needed in order to control TB in Tajikistan and may include social support to the patients as well as changes in the management of TB cases. These mitigation strategies should be timed early in treatment when the cost burden is highest.

The Mycobacterium tuberculosis MEP (2C-methyl-d-erythritol 4-phosphate) pathway as a new drug target

Tuberculosis (TB) is still a major public health problem, compounded by the human immunodeficiency virus (HIV)-TB co-infection and recent emergence of multidrug-resistant (MDR) and extensively drug resistant (XDR)-TB. Novel anti-TB drugs are urgently required. In this context, the 2C-methyl-d-erythritol 4-phosphate (MEP) pathway of Mycobacterium tuberculosis has drawn attention; it is one of several pathways vital for M. tuberculosis viability and the human host lacks homologous enzymes. Thus, the MEP pathway promises bacterium-specific drug targets and the potential for identification of lead compounds unencumbered by target-based toxicity. Indeed, fosmidomycin is now known to inhibit the second step in the MEP pathway. This review describes the cardinal features of the main enzymes of the MEP pathway in M. tuberculosis and how these can be manipulated in high throughput screening campaigns in the search for new anti-infectives against TB.

Tuberculosis

Tuberculosis is still a leading cause of death in low-income and middle-income countries, especially those of sub-Saharan Africa where tuberculosis is an epidemic because of the increased susceptibility conferred by HIV infection. The effectiveness of the Bacille Calmette Guérin (BCG) vaccine is partial, and that of treatment of latent tuberculosis is unclear in high-incidence settings. The routine diagnostic methods that are used in many parts of the world are still very similar to those used 100 years ago. Multidrug treatment, within the context of structured, directly observed therapy, is a cost-effective control strategy. Nevertheless, the duration of treatment needed reduces its effectiveness, as does the emergence of multidrug-resistant and extensively drug-resistant disease; the latter has recently become widespread. The rapid expansion of basic, clinical, and operational research, in addition to increasing knowledge of tuberculosis, is providing new diagnostic, treatment, and preventive measures. The challenge is to apply these advances to the populations most at risk. The development of a comprehensive worldwide plan to stop tuberculosis might facilitate this process by coordinating the work of health agencies. However, massive effort, political will, and resources are needed for this plan to succeed.

Tuberculosis and HIV Infection: The Global Setting

Tuberculosis (TB) and human immunodeficiency virus (HIV) infection make each other's control significantly more difficult. Coordination in addressing this "cursed duet" is insufficient at both global and national levels. However, global policy for TB/HIV coordination has been set, and there is consensus around this policy from both the TB and HIV control communities. The policy aims to provide all necessary care for the prevention and management of HIV-associated TB, but its implementation is hindered by real technical difficulties and shortages of resources. All major global-level institutions involved in HIV care and prevention must include TB control as part of their corporate policy. Country-level decision makers need to work together to expand both TB and HIV services, and civil society and community representatives need to hold those responsible accountable for their delivery. The TB and HIV communities should join forces to address the health-sector weaknesses that confront them both.

Cost-effectiveness of treating multidrug-resistant tuberculosis

BACKGROUND

Despite the existence of effective drug treatments, tuberculosis (TB) causes 2 million deaths annually worldwide. Effective treatment is complicated by multidrug-resistant TB (MDR TB) strains that respond only to second-line drugs. We projected the health benefits and cost-effectiveness of using drug susceptibility testing and second-line drugs in a lower-middle-income setting with high levels of MDR TB.

METHODS AND FINDINGS

We developed a dynamic state-transition model of TB. In a base case analysis, the model was calibrated to approximate the TB epidemic in Peru, a setting with a smear-positive TB incidence of 120 per 100,000 and 4.5% MDR TB among prevalent cases. Secondary analyses considered other settings. The following strategies were evaluated: first-line drugs administered under directly observed therapy (DOTS), locally standardized second-line drugs for previously treated cases (STR1), locally standardized second-line drugs for previously treated cases with test-confirmed MDR TB (STR2), comprehensive drug susceptibility testing and individualized treatment for previously treated cases (ITR1), and comprehensive drug susceptibility testing and individualized treatment for all cases (ITR2). Outcomes were costs per TB death averted and costs per quality-adjusted life year (QALY) gained. We found that strategies incorporating the use of second-line drug regimens following first-line treatment failure were highly cost-effective compared to strategies using first-line drugs only. In our base case, standardized second-line treatment for confirmed MDR TB cases (STR2) had an incremental cost-effectiveness ratio of 720 dollars per QALY (8,700 dollars per averted death) compared to DOTS. Individualized second-line drug treatment for MDR TB following first-line failure (ITR1) provided more benefit at an incremental cost of 990 dollars per QALY (12,000 dollars per averted death) compared to STR2. A more aggressive version of the individualized treatment strategy (ITR2), in which both new and previously treated cases are tested for MDR TB, had an incremental cost-effectiveness ratio of 11,000 dollars per QALY (160,000 dollars per averted death) compared to ITR1. The STR2 and ITR1 strategies remained cost-effective under a wide range of alternative assumptions about treatment costs, effectiveness, MDR TB prevalence, and transmission.

CONCLUSIONS

Treatment of MDR TB using second-line drugs is highly cost-effective in Peru. In other settings, the attractiveness of strategies using second-line drugs will depend on TB incidence, MDR burden, and the available budget, but simulation results suggest that individualized regimens would be cost-effective in a wide range of situations.

Effect of BCG vaccination on childhood tuberculous meningitis and miliary tuberculosis worldwide: a meta-analysis and assessment of cost-effectiveness

BACKGROUND

BCG vaccine has shown consistently high efficacy against childhood tuberculous meningitis and miliary tuberculosis, but variable efficacy against adult pulmonary tuberculosis and other mycobacterial diseases. We assess and compare the costs and effects of BCG as an intervention against severe childhood tuberculosis in different regions of the world.

METHODS

We calculated the number of tuberculous meningitis and miliary tuberculosis cases that have been and will be prevented in all children born in 2002, by combining estimates of the annual risk of tuberculosis infection, the proportion of infections that lead to either of these diseases in unvaccinated children, the number of children vaccinated, and BCG efficacy.

FINDINGS

We estimated that the 100.5 million BCG vaccinations given to infants in 2002 will have prevented 29,729 cases of tuberculous meningitis (5th-95th centiles, 24,063-36,192) in children during their first 5 years of life, or one case for every 3435 vaccinations (2771-4177), and 11,486 cases of miliary tuberculosis (7304-16,280), or one case for every 9314 vaccinations (6172-13,729). The numbers of cases prevented would be highest in South East Asia (46%), sub-Saharan Africa (27%), the western Pacific region (15%), and where the risk of tuberculosis infection and vaccine coverage are also highest. At US2-3 dollars per dose, BCG vaccination costs US206 dollars (150-272) per year of healthy life gained.

INTERPRETATION

BCG vaccination is a highly cost-effective intervention against severe childhood tuberculosis; it should be retained in high-incidence countries as a strategy to supplement the chemotherapy of active tuberculosis.

The cost to health services of human immunodeficiency virus (HIV) co-infection among tuberculosis patients in Sudan

OBJECTIVE

To compare the cost of managing HIV-positive and HIV-negative tuberculosis (TB) patients in Sudan.

METHODS

A prospective cohort of 1797 consecutive TB patients referred to the chest clinics within the general health services from March 1998 to March 2000 were included in this study. Patients were tested blindly for HIV; 1724 were HIV-negative and 73 were HIV-positive.

FINDINGS

The total cost associated with management of tuberculosis was significantly higher for HIV-positive, as compared with HIV-negative TB patients (105.08 US dollars versus 73.92, p=0.003). This difference was due mainly to greater costs for hospitalization of those HIV-positive, as compared with those HIV-negative (190.80 versus 141.00, p=0.001). The differences in cost for diagnostic tests, for drugs, for management of adverse reactions and for intercurrent symptoms were not significant (p>0.05) between HIV-positive TB patients and HIV-negative TB patients. Side effects of treatment were slightly more common among persons without HIV infection than among HIV-positive patients (14 and 9.6%, respectively). The total cost of management of HIV-positive patients in this series of patients was 6% of all costs for TB case management and the marginal cost attributable to HIV-positivity was 0.9% of the total cost.

CONCLUSION

The management of the HIV-positive TB case was more costly than that of the HIV-negative case in this stage of the HIV/AIDS epidemic in Sudan.

Cost effectiveness analysis of strategies for tuberculosis control in developing countries

OBJECTIVE

To assess the costs and health effects of tuberculosis control interventions in Africa and South East Asia in the context of the millennium development goals.

DESIGN

Cost effectiveness analysis based on an epidemiological model.

SETTING

Analyses undertaken for two regions classified by WHO according to their epidemiological grouping-Afr-E, countries in sub-Saharan Africa with very high adult and high child mortality, and Sear-D, countries in South East Asia with high adult and high child mortality.

DATA SOURCES

Published studies, costing databases, expert opinion.

MAIN OUTCOME MEASURES

Costs per disability adjusted life year (DALY) averted in 2000 international dollars (dollarsInt).

RESULTS

Treatment of new cases of smear-positive tuberculosis in DOTS programmes cost dollarsInt6-8 per DALY averted in Afr-E and dollarsInt7 per DALY averted in Sear-D at coverage levels of 50-95%. In Afr-E, adding treatment of smear-negative and extra-pulmonary cases at a coverage level of 95% cost dollarsInt95 per DALY averted; the addition of DOTS-Plus treatment for multidrug resistant cases cost dollarsInt123. In Sear-D, these costs were dollarsInt52 and dollarsInt226, respectively. The full combination of interventions could reduce prevalence and mortality by over 50% in Sear-D between 1990 and 2010, and by almost 50% between 2000 and 2010 in Afr-E.

CONCLUSIONS

DOTS treatment of new smear-positive cases is the first priority in tuberculosis control, including in countries with high HIV prevalence. DOTS treatment of smear-negative and extra-pulmonary cases and DOTS-Plus treatment of multidrug resistant cases are also highly cost effective. To achieve the millennium development goal for tuberculosis control, substantial extra investment is needed to increase case finding and implement interventions on a wider scale.

Cost and cost-effectiveness of community based and health facility based directly observed treatment of tuberculosis in Dar es Salaam, Tanzania

BACKGROUND

Identifying new approaches to tuberculosis treatment that are effective and put less demand to meagre health resources is important. One such approach is community based direct observed treatment (DOT). The purpose of the study was to determine the cost and cost effectiveness of health facility and community based directly observed treatment of tuberculosis in an urban setting in Tanzania.

METHODS

Two alternative strategies were compared: health facility based directly observed treatment by health personnel and community based directly observed treatment by treatment supervisors. Costs were analysed from the perspective of health services, patients and community in the year 2002 in USD using standard methods. Treatment outcomes were obtained from a randomised-controlled trial which was conducted alongside the cost study. Smear positive, smear negative and extra-pulmonary TB patients were included. Cost-effectiveness was calculated as the cost per patient successfully treated.

RESULTS

The total cost of treating a patient with conventional health facility based DOT and community based DOT were 145 dollars and 94 dollars respectively. Community based DOT reduced cost by 35%. Cost fell by 27% for health services and 72% for patients. When smear positive and smear negative patients were considered separately, community DOT was associated with 45% and 19% reduction of the costs respectively. Patients used about 43 dollars to follow their medication to health facility which is equivalent to their monthly income. Indirect costs were as important as direct costs, contributing to about 49% of the total patient's cost. The main reason for reduced cost was fewer number of visits to the TB clinic. Community based DOT was more cost-effective at 128 dollars per patient successfully treated compared to 203 dollars for a patient successfully treated with health facility based DOT.

CONCLUSION

Community based DOT presents an economically attractive option to complement health facility based DOT. This is particularly important in settings where TB clinics are working beyond capacity under limited resources.

Cost and cost-effectiveness of community based and health facility based directly observed treatment of tuberculosis in Dar es Salaam, Tanzania

Background

Identifying new approaches to tuberculosis treatment that are effective and put less demand to meagre health resources is important. One such approach is community based direct observed treatment (DOT). The purpose of the study was to determine the cost and cost effectiveness of health facility and community based directly observed treatment of tuberculosis in an urban setting in Tanzania.

Methods

Two alternative strategies were compared: health facility based directly observed treatment by health personnel and community based directly observed treatment by treatment supervisors. Costs were analysed from the perspective of health services, patients and community in the year 2002 in US $ using standard methods. Treatment outcomes were obtained from a randomised-controlled trial which was conducted alongside the cost study. Smear positive, smear negative and extra-pulmonary TB patients were included. Cost-effectiveness was calculated as the cost per patient successfully treated.

Results

The total cost of treating a patient with conventional health facility based DOT and community based DOT were $ 145 and $ 94 respectively. Community based DOT reduced cost by 35%. Cost fell by 27% for health services and 72% for patients. When smear positive and smear negative patients were considered separately, community DOT was associated with 45% and 19% reduction of the costs respectively. Patients used about $ 43 to follow their medication to health facility which is equivalent to their monthly income. Indirect costs were as important as direct costs, contributing to about 49% of the total patient's cost. The main reason for reduced cost was fewer number of visits to the TB clinic. Community based DOT was more cost-effective at $ 128 per patient successfully treated compared to $ 203 for a patient successfully treated with health facility based DOT.

Conclusion

Community based DOT presents an economically attractive option to complement health facility based DOT. This is particularly important in settings where TB clinics are working beyond capacity under limited resources.

The DOTS strategy for controlling the global tuberculosis epidemic

This article reviews the principles, scientific basis, and experience with implementation of the directly observed treatment strategy, short course (DOTS) for tuberculosis. The relevance of DOTS in the context of multidrug-resistant tuberculosis and the HIV epidemic also is discussed.

The role of DOTS in tuberculosis treatment and control

Directly Observed Therapy Shortcourse (DOTS) is composed of five distinct elements: political commitment; microscopy services; drug supplies; surveillance and monitoring systems and use of highly efficacious regimens; and direct observation of treatment. The difference in the way the term 'DOTS' as defined by WHO and interpreted by many observers has led to some misunderstanding. WHO generally uses the term to mean the five components of DOTS. But the word 'DOTS' is an acronym for Directly Observed Therapy Shortcourse. Many workers therefore interpret DOTS purely as direct supervision of therapy. DOTS is not an end in itself but a means to an end. In fact it has two purposes, to ensure that the patient with tuberculosis (TB) completes therapy to cure and to prevent drug resistance from developing in the community. The main criticism of DOTS rightly derives from the fact that some properly conducted randomized, controlled trials of directly observed therapy with or without the other components have shown no benefit from it. The problem is that it is impossible to design a study of modern directly observed therapy against the previous self-administered, poorly-resourced programs. As soon as a study is implemented, the attention to patients in the control (non-directly observed therapy) arm inevitably improves from the previous non-trial service situation. What is of concern is that in some trials less than 70% cure rates were achieved even in the direct observation arm. With no new drugs or adjuvant treatment available to bring the length of treatment down to substantially less than 6 months, DOTS offers the best means we have at our disposal for TB control.

Tuberculosis

Among communicable diseases, tuberculosis is the second leading cause of death worldwide, killing nearly 2 million people each year. Most cases are in less-developed countries; over the past decade, tuberculosis incidence has increased in Africa, mainly as a result of the burden of HIV infection, and in the former Soviet Union, owing to socioeconomic change and decline of the health-care system. Definitive diagnosis of tuberculosis remains based on culture for Mycobacterium tuberculosis, but rapid diagnosis of infectious tuberculosis by simple sputum smear for acid-fast bacilli remains an important tool, and more rapid molecular techniques hold promise. Treatment with several drugs for 6 months or more can cure more than 95% of patients; direct observation of treatment, a component of the recommended five-element DOTS strategy, is judged to be the standard of care by most authorities, but currently only a third of cases worldwide are treated under this approach. Systematic monitoring of case detection and treatment outcomes is essential to effective service delivery. The proportion of patients diagnosed and treated effectively has increased greatly over the past decade but is still far short of global targets. Efforts to develop more effective tuberculosis vaccines are under way, but even if one is identified, more effective treatment systems are likely to be required for decades. Other modes of tuberculosis control, such as treatment of latent infection, have a potentially important role in some contexts. Until tuberculosis is controlled worldwide, it will continue to be a major killer in less-developed countries and a constant threat in most of the more-developed countries.

Costs and effectiveness--the impact of economic studies on TB control

This paper assesses the impact of economic studies on TB control during the period 1982-2002, with a focus on cost and cost-effectiveness studies. It begins by identifying broad categories of economic study relevant to TB control, and how economic studies can, theoretically, have an impact on TB control. The impact that economic studies of TB control have had in practice is then analysed through a systematic review of the literature on cost and cost-effectiveness studies related to TB control, and three case studies (one cost study and two cost-effectiveness studies). The results show that in the past 20 years, 66 cost-effectiveness studies and 31 cost studies have been done on a variety of important TB control topics, with a marked increase occurring after 1994. In terms of numbers, these studies have had most potential for impact in industrialized countries, and within industrialized countries are most likely to have had an impact on policy and practice related to screening and preventive therapy. In developing countries with a high burden of tuberculosis, far fewer studies have been undertaken. Here, the main impact of economic studies has been influencing policy and practice on the use of short-course chemotherapy, justifying the implementation of community-based care in Africa, and helping to mobilize funding for TB control based on the argument that short-course treatment for TB is one of the most cost-effective health interventions available. For the future, cost and cost-effectiveness studies will continue to be relevant, as will other types of economic study.

The TB epidemic from 1992 to 2002

In 1992, less than 20 countries were implementing a sound TB control strategy. At the same time, TB was being resurrected as a major public health problem world-wide after two decades of neglect. Awareness of upward trends in the industrialized countries and MDR-TB outbreaks in large cities were driving forces behind the re-emergence of TB in the international health agenda. New evidence, and consequent estimates, suggested that the situation in developing countries, especially in sub-Saharan Africa, was deteriorating rapidly. Similarly, major increases were observed in the former USSR. It was estimated that some 7-8 million new cases and 2-3 million deaths were occurring annually in the world. The global targets of reaching 85% cure rates and 70% case detection among infectious cases were established by the World Health Assembly in 1991. Both the WHO declaration of TB as a global emergency in 1993 and the launch of the five-element DOTS strategy in 1994-1995 resulted in countries adopting DOTS in encouraging numbers. In fact, in 2000, 148 countries including all 22 highest burden countries (HBC) responsible for 80% of cases world-wide, had adopted the new DOTS strategy. Nevertheless, progress in case detection remained slow due to incomplete geographical coverage or need to widen detection and notification capacity with innovative schemes. The major constraints to TB control became increasingly clear, and a global Stop TB Partnership was eventually established to address such constraints. A Global DOTS Expansion Plan revealed the needs and the gaps to achieve the global targets in 2005. Today, in 2002, the top priority remains that of expanding DOTS, as rapidly as possible, using a number of new approaches to increase case detection and notification while maintaining high cure rates. These must involve collaboration with the private sector and communities, as well as strengthening of primary care services. Similarly, crucial is the rapid identification of solutions to TB/HIV and MDR-TB.

The politics of 'branding' in policy transfer: the case of DOTS for tuberculosis control

How and why policies are transferred between countries has attracted considerable interest from scholars of public policy over the last decade. This paper, based on a larger study, sets out to explore the processes involved in policy transfer between international and national levels. These processes are illustrated by looking at a particular public health policy--DOTS for the control and treatment of tuberculosis. The paper demonstrates how, after a long period of neglect, resources were mobilised to put tuberculosis back on international and national public policy agendas, and then how the policy was 'branded' and marketed as DOTS, and transferred to low and middle income countries. It focuses specifically on international agenda setting and policy formulation, and the role played by international organisations in those processes. It shows that policy communities, and particular individuals within them, may take political rather than technical positions in these processes, which can result in considerable contestation. The paper ends by suggesting that while it is possible to raise the profile of a policy dramatically through branding and marketing, success also depends on external events providing windows of opportunity for action. Second, it warns that simplifying policy approaches to 'one-size-fits-all' carries inherent risks, and can be perceived to harm locally appropriate programmes. Third, top-down internationally driven policy changes may lead to apparent policy transfer, but not necessarily to successfully implemented programmes.

Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence

BACKGROUND

Evidence for cost-effectiveness of interventions for HIV/AIDS in Africa is fragmentary. Cost-effectiveness is, however, highly relevant. African governments face difficult choices in striking the right balance between prevention, treatment, and care, all of which are necessary to deal comprehensively with the epidemic. Reductions in drug prices have raised the priority of treatment, though treatment access is restricted. We assessed the existing cost-effectiveness data and its implications for value-for-money strategies to combat HIV/AIDS in Africa.

METHODS

We undertook a systematic review using databases and consultations with experts. We identified over 60 reports that measured both the cost and effectiveness of HIV/AIDS interventions in Africa. 24 studies met our inclusion criteria and were used to calculate standardised estimates of the cost (US$ for year 2000) per HIV infection prevented and per disability-adjusted life-year (DALY) gained for 31 interventions.

FINDINGS

Cost-effectiveness varied greatly between interventions. A case of HIV/AIDS can be prevented for $11, and a DALY gained for $1, by selective blood safety measures, and by targeted condom distribution with treatment of sexually transmitted diseases. Single-dose nevirapine and short-course zidovudine for prevention of mother-to-child transmission, voluntary counselling and testing, and tuberculosis treatment, cost under $75 per DALY gained. Other interventions, such as formula feeding for infants, home care programmes, and antiretroviral therapy for adults, cost several thousand dollars per infection prevented, or several hundreds of dollars per DALY gained.

INTERPRETATION

A strong economic case exists for prioritisation of preventive interventions and tuberculosis treatment. Where potentially exclusive alternatives exist, cost-effectiveness analysis points to an intervention that offers the best value for money. Cost-effectiveness analysis is an essential component of informed debate about priority setting for HIV/AIDS.

Trends in multidrug-resistant Mycobacterium tuberculosis in relation to sputum smear positivity in Hong Kong, 1989-1999

We studied retrospectively the territory-wide occurrence and trends of multidrug-resistant tuberculosis (MDR-TB) in Hong Kong over an 11-year period during which a short-course directly observed therapy ("DOTS-Plus") strategy has been in operation. The overall MDR rate was 2.1% (primary, 1.4% and acquired, 9.5%) and declined at 0.08% per year: smear-positive primary MDR cases declined at yearly rate of -0.065% (R2=.23), and smear-negative primary MDR cases increased at 0.035% yearly. With declining rates of smear positivity, sputum culture has become the mainstay of detection of MDR-TB. Although the overall notification rates showed the elderly (age >65 years) age group to be most affected, the occurrence of MDR-TB has been consistently highest in the 35-65 year age group (60.4% of MDR caseload). We demonstrated declining rates of sputum smear positivity of MDR-TB in a DOTS-plus environment and that a centralized laboratory database is essential in gathering epidemiological information for identifying particular risk groups and monitoring trends of MDR-TB in a community.

Screening for tuberculosis: the port of arrival scheme compared with screening in general practice and the homeless

BACKGROUND

Tuberculosis is increasing in London, especially in those recently entering the UK from an area of high incidence. Screening through the port of arrival scheme has a poor yield and has been considered discriminatory.

METHODS

A study was undertaken to compare the yield and costs of screening new entrants in a hospital based new entrants' clinic (1262 referrals from the port of arrival), general practice (1311 new registrations), and centres for the homeless (267 individuals) using a symptom questionnaire and tuberculin testing if indicated. Clinical outcome measures were cases of tuberculosis, tuberculin reactors requiring chemoprophylaxis and BCG vaccinations. Cost outcomes were cost per individual screened and cost per individual per case of tuberculosis prevented.

RESULTS

Verbal screening limited tuberculin testing to 16% of those in general practice; most were tested at the other two locations. Intervention (BCG vaccination, chemoprophylaxis or treatment) occurred in 27% of those who received tuberculin testing. Attendance for screening was 17% of the port of arrival notifications (63% had registered with a GP), 54% in primary care, and 67% in the homeless (42% registered with a GP). Costs for screening an individual in general practice, hostels for the homeless, and the new entrants' clinic were 1.26 pounds sterling, 13.17 pounds sterling and 96.36 pounds sterling, respectively, while the cost per person screened per case of tuberculosis prevented was 6.32 pounds sterling, 23.00 pounds sterling, and 10.00 pounds sterling, respectively. The benefit of screening was highly sensitive to the number of cases of tuberculosis identified and case holding during treatment.

CONCLUSION

Screening for tuberculosis in primary care is feasible and could replace hospital screening of new arrivals for those registered with a GP.

Miniature chest radiograph screening for tuberculosis in jails: a cost-effectiveness analysis

Jails are an important reservoir of tuberculosis infection in the United States. Screening for active disease in these high-risk settings is difficult. We used decision analysis to assess the cost effectiveness of routine miniature chest radiography for screening for tuberculosis on admission to jail. Infection rates, probabilities, and costs associated with detecting and treating tuberculosis were derived from published studies. We calculated an average total cost of $6.60 per inmate for routine radiograph screening on admission to jail. The cost of screening for active tuberculosis with miniature chest radiography was estimated to be $9,600 per case identified, compared with $32,100 per case with tuberculin skin testing and $54,100 per case with symptom screening. Chest radiography would also identify substantially more cases than other methods of screening. Screening for tuberculosis with miniature chest radiography is cost effective even under a wide range of assumptions regarding risk factors and prevalence of disease. Miniature chest radiography should be strongly considered as an important tool in the fight to eliminate tuberculosis from the high-risk populations that may be reached through screening in jails.

Adult tuberculosis in the 21st century: pathogenesis, clinical features, and management

This article reviews the significant advances in the past year in the basic and clinical aspects of adult tuberculosis (TB). Further research has deepened our understanding of host susceptibility and resistance mechanisms, including cytotoxicity, apoptosis, and antimicrobial polypeptides such as granulysin. Studies have confirmed the effects of HIV infection on risk of disease and disease manifestations, and have defined the effects of HIV on TB transmission. Recent studies also indicate a possible role for extended treatment of active disease and latent infection in HIV-1 infected individuals. Multidrug-resistant disease has been reported on every continent; rapid molecular approaches to the simultaneous diagnosis of TB and detection of rifampin resistance may facilitate prompt initiation of treatment. TB remains one of the major problems in global health.

Costs of tuberculosis for households and health care providers in Dar es Salaam, Tanzania

OBJECTIVE

To assess the costs of tuberculosis at household level in Dar es Salaam and to compare them with the provider costs of the national tuberculosis control programme.

DESIGN

Tuberculosis patients were found by active case searching within a routine census in three areas of Dar es Salaam, and by examining records for residents already receiving treatment. Costs at household level were evaluated through a cross-sectional household survey.

RESULTS

One hundred and ninety-one tuberculosis cases were included in the survey. With treatment periods of 8 to 12 months, extrapolated average costs of a period of illness to patients and their families were as follows: US 2 dollars for examination and laboratory costs, between US 17 dollars and US 50 dollars for consultation and drugs, less than US 1 dollar for hospitalization and between US 13 dollars and US 20 dollars for transport. The analysis revealed high costs due to inability to work, ranging from US 154 dollars to US 1384 dollars. These data were compared with the operation costs of the tuberculosis programme and proved to comprise 68% to 94% of total costs.

CONCLUSIONS

For patients and their families, tuberculosis implies three main types of cost: drugs, transportation and, most importantly, financial loss due to inability to work. They represent around two thirds of total cost and are a high economic burden for households, in particular those with a low-income. While assessing tuberculosis control strategies such as direct case finding at home, it is therefore important to also include costs incurred at household level.

[Economic and social impact of the National Tuberculosis Control Program (NTCP) on the Cuban population]

Tuberculosis (TB) control strategies provide one of the greatest cost/effectiveness results. To assess the impact of the national TB control program on the Cuban population, the time series of new TB cases and death reports, potential years of life lost, and the numbers of beds for TB case hospitalization in the entire country during 1964-91 and 1992-96 were described by common simple calculation on the basis of estimated expected values. The reduction in new TB cases and deaths, potential years of life saved, and savings in expenditures for treatment, hospitalization, and unemployment compensation were estimated. From 1965 to 1991 new case reports were reduced by 94.6% (4% per year); 86,500 cases were avoided; 166,439 potential years of life were saved; 2,831,625 million pesos were saved on tuberculostatic drugs; 82.7 million pesos were saved on unemployment compensation under the social security system for workers with active TB. Estimated savings totaled 494,919,631.3 pesos. Nationwide intervention for TB control produced an important impact on the basis of the sociopolitical status making it possible to approach complete elimination of the disease in the future.

High mortality rates in tuberculosis patients in Zomba Hospital, Malawi, during 32 months of follow-up

There is little information about long-term follow-up in patients with smear-negative pulmonary tuberculosis (PTB) or extrapulmonary tuberculosis (EPTB) who have been treated under routine programme conditions in sub-Saharan Africa. A prospective study was carried out to determine outcome 32 months from start of treatment in an unselected cohort of 827 adults TB inpatients registered at Zomba Hospital, Malawi, in 1 July-31 December 1995. By 32 months, 351 (42%) patients had died. Death rates were 30% (95% confidence interval [95% CI] 25-35%) in 386 patients with smear-positive PTB, 60% (95% CI 53-67%) in 211 patients with smear-negative PTB and 47% (95% CI 40-54%) in 230 patients with EPTB. Of the 793 patients with concordant HIV test results 612 (77%) were HIV seropositive: 47% HIV-positive patients were dead by 32 months compared with 27% HIV-negative patients (adjusted hazard ratio [HR] 2.3; 95% CI 1.7-3.1, P < 0.001). Smear-negative PTB patients had the highest death rates during the 32-month follow-up (HR 2.7; 95% CI 2.1-3.5, P < 0.001 compared to smear-positive patients), followed by EPTB patients (HR 1.9; 95% CI 1.5-2.5, P < 0.001 compared to smear-positive patients). When analysis was restricted to after the treatment period had finished (i.e., months 12-32), the differences in mortality were maintained for HIV-serostatus and for types of TB. Low-cost, easy to implement strategies for reducing mortality in HIV-positive TB patients in sub-Saharan Africa (such as the use of trimethoprim-sulphamethoxazole prophylaxis) need to be tested urgently in programme settings.

Development of WHO guidelines on generalized cost-effectiveness analysis

The growing use of cost-effectiveness analysis (CEA) to evaluate specific interventions is dominated by studies of prospective new interventions compared with current practice. This type of analysis does not explicitly take a sectoral perspective in which the costs and effectiveness of all possible interventions are compared, in order to select the mix that maximizes health for a given set of resource constraints. WHO guidelines on generalized CEA propose the application of CEA to a wide range of interventions to provide general information on the relative costs and health benefits of different interventions in the absence of various highly local decision constraints. This general approach will contribute to judgements on whether interventions are highly cost-effective, highly cost-ineffective, or something in between. Generalized CEAs require the evaluation of a set of interventions with respect to the counterfactual of the null set of the related interventions, i.e. the natural history of disease. Such general perceptions of relative cost-effectiveness, which do not pertain to any specific decision-maker, can be a useful reference point for evaluating the directions for enhancing allocative efficiency in a variety of settings. The proposed framework allows the identification of current allocative inefficiencies as well as opportunities presented by new interventions.