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

Impact of an innovative bundled payment to TB health care providers in China: an economic simulation analysis

BACKGROUND

Tuberculosis is the second most deadly infectious disease after COVID-19 and the 13th leading cause of death worldwide. Among the 30 countries with a high burden of TB, China ranks third in the estimated number of TB cases. China is in the top four of 75 countries with a deficit in funding for TB strategic plans. To reduce costs and improve the effectiveness of TB treatment in China, the NHSA developed an innovative BP method. This study aimed to simulate the effects of this payment approach on different stakeholders, reduce the economic burden on TB patients, improve the quality of medical services, facilitate policy optimization, and offer a model for health care payment reforms that can be referenced by other regions throughout the world.

METHODS

We developed a simulation model based on a decision tree analysis to project the expected effects of the payment method on the potential financial impacts on different stakeholders. Our analysis mainly focused on comparing changes in health care costs before and after receiving BPs for TB patients with Medicare in the pilot areas. The data that were used for the analysis included the TB service claim records for 2019-2021 from the health insurance agency, TB prevalence data from the local Centre for Disease Control, and health care facilities' revenue and expenditure data from the Statistic Yearbook. A Monte Carlo randomized simulation model was used to estimate the results.

RESULTS

After adopting the innovative BP method, for each TB patient per year, the total annual expenditure was estimated to decrease from $2,523.28 to $2,088.89, which is a reduction of $434.39 (17.22%). The TB patient out-of-pocket expenditure was expected to decrease from $1,249.02 to $1,034.00, which is a reduction of $215.02 (17.22%). The health care provider's revenue decreased from $2,523.28 to $2,308.26, but the health care provider/institution's revenue-expenditure ratio increased from -6.09% to 9.50%.

CONCLUSIONS

This study highlights the potential of BPs to improve medical outcomes and control the costs associated with TB treatment. It demonstrates its feasibility and advantages in enhancing the coordination and sustainability of medical services, thus offering valuable insights for global health care payment reform.

Economic burden and coping mechanisms by tuberculosis treatment supporters: a mixed method approach from Bono Region, Ghana

BACKGROUND

The Directly Observed Therapy Short Course (DOTS) strategy recommended by World Health Organization for tuberculosis control requires multiple clinic visits which may place economic burden on treatment supporters especially those with low socio-economic status. The End tuberculosis goal targeted eliminating all tuberculosis associated costs. However, the economic burden and coping mechanisms by treatment supporters is unknown in Ghana.

OBJECTIVES

The study determined the economic burden and coping mechanism by treatment supporters in Bono Region of Ghana.

METHODS

Cross-sectional study using mixed method approach for data collection. For the quantitative data, a validated questionnaire was administered to 385 treatment supporters. Sixty in-depth interviews with treatment supporters to elicit information about their coping mechanisms using a semi-structured interview guide for the qualitative data. Descriptive statistics, costs estimation, thematic analysis and bivariate techniques were used for the data analysis.

RESULTS

Averagely, each treatment supporter spent GHS 112.4 (US$21.1) on treatment support activities per month which is about 19% of their monthly income. Borrowing of money, sale of assets, used up saving were the major coping mechanisms used by treatment supporters. Highest level of education, household size, marital status and income level significantly influence both the direct and indirect costs associated with tuberculosis treatment support. The significant levels were set at 95% confidence interval and p < 0.05.

CONCLUSION

We concludes that the estimated cost and coping mechanisms associated with assisting tuberculosis patients with treatment is significant to the tuberculosis treatment supporters. If not mitigated these costs have the tendency to worsen the socio-economic status and future welfare of tuberculosis treatment supporters.

Nutritional supplements for people being treated for active tuberculosis

BACKGROUND

Tuberculosis and malnutrition are linked in a complex relationship. Tuberculosis may cause undernutrition through increased metabolic demands and decreased intake, and nutritional deficiencies may worsen the disease, or delay recovery by depressing important immune functions. At present, there is no evidence-based nutritional guidance for adults and children being treated for tuberculosis.

OBJECTIVES

To assess the effects of oral nutritional supplements in people being treated with antituberculous drug therapy for active tuberculosis.

SEARCH METHODS

We searched the Cochrane Infectious Disease Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2016), MEDLINE (from 1946 to 4 February 2016), EMBASE (from 1980 to 4 February 2016), LILACS (from 1982 to 4 February 2016), the metaRegister of Controlled Trials (mRCT), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and the Indian Journal of Tuberculosis up to 4 February 2016, and checked the reference lists of all included studies.

SELECTION CRITERIA

Randomized controlled trials that compared any oral nutritional supplement given for at least four weeks with no nutritional intervention, placebo, or dietary advice only for people being treated for active tuberculosis. The primary outcomes of interest were all-cause death, and cure at six and 12 months.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, and extracted data and assessed the risk of bias in the included trials. We presented the results as risk ratios (RR) for dichotomous variables, and mean differences (MD) for continuous variables, with 95% confidence intervals (CIs). Where appropriate, we pooled data from trials with similar interventions and outcomes. We assessed the quality of the evidence using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Thirty-five trials, including 8283 participants, met the inclusion criteria of this review. Macronutrient supplementationSix trials assessed the provision of free food, or high-energy supplements. Only two trials measured total dietary intake, and in both trials the intervention increased calorie consumption compared to controls.The available trials were too small to reliably prove or exclude clinically important benefits on mortality (RR 0.34, 95% CI 0.10 to 1.20; four trials, 567 participants, very low quality evidence), cure (RR 0.91, 95% CI 0.59 to 1.41; one trial, 102 participants, very low quality evidence), or treatment completion (data not pooled; two trials, 365 participants, very low quality evidence).Supplementation probably produces a modest increase in weight gain during treatment for active tuberculosis, although this was not seen consistently across all trials (data not pooled; five trials, 883 participants, moderate quality evidence). Two small studies provide some evidence that quality of life may also be improved but the trials were too small to have much confidence in the result (data not pooled; two trials, 134 participants, low quality evidence). Micronutrient supplementationSix trials assessed multi-micronutrient supplementation in doses up to 10 times the dietary reference intake, and 18 trials assessed single or dual micronutrient supplementation.Routine multi-micronutrient supplementation may have little or no effect on mortality in HIV-negative people with tuberculosis (RR 0.86, 95% CI 0.46 to 1.6; four trials, 1219 participants, low quality evidence), or HIV-positive people who are not taking antiretroviral therapy (RR 0.92, 95% CI 0.69 to 1.23; three trials, 1429 participants, moderate quality evidence). There is insufficient evidence to know if supplementation improves cure (no trials), treatment completion (RR 0.99, 95% CI 0.95 to 1.04; one trial, 302 participants, very low quality evidence), or the proportion of people who remain sputum positive during the first eight weeks (RR 0.92, 95% CI 0.63 to 1.35; two trials, 1020 participants, very low quality evidence). However, supplementation may have little or no effect on weight gain during treatment (data not pooled; five trials, 2940 participants, low quality evidence), and no studies have assessed the effect on quality of life.Plasma levels of vitamin A appear to increase following initiation of tuberculosis treatment regardless of supplementation. In contrast, supplementation probably does improve plasma levels of zinc, vitamin D, vitamin E, and selenium, but this has not been shown to have clinically important benefits. Of note, despite multiple studies of vitamin D supplementation in different doses, statistically significant benefits on sputum conversion have not been demonstrated.

AUTHORS' CONCLUSIONS

There is currently insufficient research to know whether routinely providing free food, or energy supplements improves tuberculosis treatment outcomes, but it probably improves weight gain in some settings.Although blood levels of some vitamins may be low in people starting treatment for active tuberculosis, there is currently no reliable evidence that routinely supplementing above recommended daily amounts has clinical benefits.

Factors that determine catastrophic expenditure for tuberculosis care: a patient survey in China

BACKGROUND

Tuberculosis (TB) often causes catastrophic economic effects on both the individual suffering the disease and their households. A number of studies have analyzed patient and household expenditure on TB care, but there does not appear to be any that have assessed the incidence, intensity and determinants of catastrophic health expenditure (CHE) relating to TB care in China. That will be the objective of this paper.

METHODS

The data used for this study were derived from the baseline survey of the China Government - Gates Foundation TB Phase II program. Our analysis included 747 TB cases. Catastrophic health expenditure for TB care was estimated using two approaches, with households defined as experiencing CHE if their annual expenditure on TB care: (a) exceeded 10 % of total household income; and (b) exceeded 40 % of their non-food expenditure (capacity to pay). Chi-square tests were used to identify associated factors and logistic regression analysis to identify the determinants of CHE.

RESULTS

The incidence of CHE was 66.8 % using the household income measure and 54.7 % using non-food expenditure (capacity to pay). An inverse association was observed between CHE rates and household income level. Significant determinants of CHE were: age, household size, employment status, health insurance status, patient income as a percentage of total household income, hospitalization and status as a minimum living security household. Factors including gender, marital status and type of TB case had no significant associations with CHE.

CONCLUSIONS

Catastrophic health expenditure incidence from TB care is high in China. An integrated policy expanding the free treatment package and ensuring universal coverage, especially the height of UHC for TB patients, is needed. Financial and social protection interventions are essential for identified at-risk groups.

Costs to Health Services and the Patient of Treating Tuberculosis: A Systematic Literature Review

BACKGROUND

Novel tuberculosis (TB) drugs and the need to treat drug-resistant tuberculosis (DR-TB) are likely to bring about substantial transformations in TB treatment in coming years. An evidence base for cost and cost-effectiveness analyses of these developments is needed.

OBJECTIVE

Our objective was to perform a review of papers assessing provider-incurred as well as patient-incurred costs of treating both drug-susceptible (DS) and multidrug-resistant (MDR)-TB.

METHODS

Five databases (EMBASE, Medline, the National Health Service Economic Evaluation Database, the Cost-Effectiveness Analysis Registry, and Latin American and Caribbean Health Services Literature) were searched for cost and economic evaluation full-text papers containing primary DS-TB and MDR-TB treatment cost data published in peer-reviewed journals between January 1990 and February 2015. No language restrictions were set. The search terms were a combination of 'tuberculosis', 'multidrug-resistant tuberculosis', 'cost', and 'treatment'. In the selected papers, study methods and characteristics, quality indicators and costs were extracted into summary tables according to pre-defined criteria. Results were analysed according to country income groups and for provider costs, patient costs and productivity losses. All values were converted to $US, year 2014 values, so that studies could be compared.

RESULTS

We selected 71 treatment cost papers on DS-TB only, ten papers on MDR-TB only and nine papers that included both DS-TB and MDR-TB. These papers provided evidence on the costs of treating DS-TB and MDR-TB in 50 and 16 countries, respectively. In 31 % of the papers, only provider costs were included; 26 % included only patient-incurred costs, and the remaining 43 % estimated costs incurred by both. From the provider perspective, mean DS-TB treatment costs per patient were US$14,659 in high-income countries (HICs), US$840 in upper middle-income countries (UMICs), US$273 in lower middle-income (LMICs), and US$258 in low-income countries (LICs), showing a strong positive correlation. The respective costs for treating MDR-TB were US$83,365, US$5284, US$6313 and US$1218. Costs incurred by patients when seeking treatment for DS-TB accounted for an additional 3 % of the provider costs in HICs. A greater burden was seen in the other income groups, increasing the costs of DS-TB treatment by 72 % in UMICs, 60 % in LICs and 31 % in LMICs. When provider costs, patient costs and productivity losses were combined, productivity losses accounted for 16 % in HICs, 29 % in UMICs, 40 % in LMICs and 38 % in LICs.

CONCLUSION

Cost data for MDR-TB treatment are limited, and the variation in delivery mechanisms, as well as the rapidly evolving diagnosis and treatment regimens, means that it is essential to increase the number of studies assessing the cost from both provider and patient perspectives. There is substantial evidence available on the costs of DS-TB treatment from all regions of the world. The patient-incurred costs illustrate that the financial burden of illness is relatively greater for patients in poorer countries without universal healthcare coverage.

Cost of illness of tuberculosis in tehran in the year 2011

AIM

Present study calculates and analyzes Cost of illness of tuberculosis in Tehran.

PATIENTS AND METHODS

This study was a descriptive analytical study conducted among 121 patients in two stages in 2011. In the first stage, questionnaires were collected by reviewing patient records and phone interviews with patients. The second stage deals with the calculation of costs. For cost calculation, we used incidence based and bottom-up approach, and for calculating indirect costs, human capital approach was used. The vision used for this study was community-based in which all costs are included.

RESULT

The average costs per patient were calculated to be as follows: 28,467,737 Rials(2588 dollars) for direct medical costs, 1,011,360 Rials (92 dollars) for indirect medical costs and 5,533,020 (503 dollars) Rials for indirect costs. On the whole, average costs per patient was 35,056,170 Rials most of which were related to hospital costs (62/11%). Also, the average time away from work was 47 days. Cost calculated for all patients with tuberculosis in Tehran in 1390, including indirect costs caused by premature deaths of patients, was 101,900,501,328 Rials (9,263,681 U.S.$).

CONCLUSION

To sum up, in Tehran in 2011 on average every day about 279,179,456 Rials (25,380 dollars) was spent on TB patients. Moreover, heavy costs caused by TB, which are usually imposed to the households in two or three months, have significant effect of decreasing households' quality of life which calls health policy makers' attention.

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.

Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review

In order to inform the development of appropriate strategies to improve financial risk protection, we conducted a systematic literature review of the financial burden of tuberculosis (TB) faced by patients and affected families. The mean total costs ranged from $55 to $8198, with an unweighted average of $847. On average, 20% (range 0-62%) of the total cost was due to direct medical costs, 20% (0-84%) to direct non-medical costs, and 60% (16-94%) to income loss. Half of the total cost was incurred before TB treatment. On average, the total cost was equivalent to 58% (range 5-306%) of reported annual individual and 39% (4-148%) of reported household income. Cost as percentage of income was particularly high among poor people and those with multidrug-resistant TB. Commonly reported coping mechanisms included taking a loan and selling household items. The total cost of TB for patients can be catastrophic. Income loss often constitutes the largest financial risk for patients. Apart from ensuring that healthcare services are fairly financed and delivered in a way that minimises direct and indirect costs, there is a need to ensure that TB patients and affected families receive appropriate income replacement and other social protection interventions.

Management of children exposed to Mycobacterium tuberculosis: a public health evaluation in West Java, Indonesia

OBJECTIVE

To investigate qualitatively and quantitatively the performance of a programme for managing the child contacts of adult tuberculosis patients in Indonesia.

METHODS

A public health evaluation framework was used to assess gaps in a child contact management programme at a lung clinic. Targets for programme performance indicators were derived from established programme indicator targets, the scientific literature and expert opinion. Compliance with tuberculosis screening, the initiation of isoniazid preventive therapy in children younger than 5 years, the accuracy of tuberculosis diagnosis and adherence to preventive therapy were assessed in 755 child contacts in two cohorts. In addition, 22 primary caregivers and 34 clinic staff were interviewed to evaluate knowledge and acceptance of child contact management. The cost to caregivers was recorded. Gaps between observed and target indicator values were quantified.

FINDINGS

THE GAPS BETWEEN OBSERVED AND TARGET PERFORMANCE INDICATORS WERE: 82% for screening compliance; 64 to 100% for diagnostic accuracy, 50% for the initiation of preventive therapy, 54% for adherence to therapy and 50% for costs. Many staff did not have adequate knowledge of, or an appropriate attitude towards, child contact management, especially regarding isoniazid preventive therapy. Caregivers had good knowledge of screening but not of preventive therapy and had difficulty travelling to the clinic and paying costs.

CONCLUSION

The study identified widespread gaps in the performance of a child contact management system in Indonesia, all of which appear amenable to intervention. The public health evaluation framework used could be applied in other settings where child contact management is failing.

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.

Sex, smoking, and socioeconomic status are associated with body composition among tuberculosis patients in a deuterium dilution cross-sectional study in Mwanza, Tanzania

Underweight is common among tuberculosis (TB) patients. However, there is little information on determinants of body composition at TB treatment initiation in high-TB-burdened countries. This study aimed to determine factors associated with body composition at commencement of TB treatment in Mwanza, Tanzania. A cross-sectional study was conducted from 2007 to 2008 among newly diagnosed TB patients. Fat and fat-free mass were determined using a deuterium dilution technique and fat and fat-free mass indices were computed. Correlates were assessed using multiple regression analysis. A total of 201 pulmonary TB patients were recruited; of these, 37.8% (76) were female, 51.7% (104) were HIV infected, 65.3% (126) had sputum-positive TB, and 24.4% (49) were current smokers. In multiple regressions analysis, males had a 2.2-kg/m(2) [(95% CI = 1.6, 2.9); P < 0.0001] lower fat mass index but 1.5 kg/m(2) [(95% CI = 0.9, 2.0); P < 0.0001] higher fat-free mass index compared with females. Sputum-positive TB was associated with a lower fat mass index among HIV-uninfected patients [-1.4 kg (95% CI = -2.5, -0.4); P = 0.006] but not among HIV-infected patients (P-interaction = 0.09). Current smokers had a 0.7-kg/m(2) [(95% CI = 0.02, 1.5); P = 0.045] lower fat mass index, but smoking did not affect fat-free mass. High socioeconomic status (SES) was associated with higher fat as well as fat-free mass. HIV infection, cluster of differentiation 4 count, and antiretroviral therapy were not correlates. Sex, smoking, and SES were associated with body composition of TB patients at treatment commencement. Prospective studies are needed to determine the role of these factors on weight gain, functional recovery, and survival during and after treatment.

Determinants of household direct and indirect costs: an insight for health-seeking behaviour in Burkina Faso

The objective of the study is to identify the determinants of household direct and indirect costs in the Nouna District, Burkina Faso. The data used were from a household survey conducted during 2000-2001. The multinominal logit models were applied to investigate the determinants of direct and indirect costs. The respondents who were sick in the rainy season and severity of illness significantly increased the probability of having high direct and indirect household costs. Acute illness occured in an adult was positively associated with magnitude of household indirect costs. Household economic status and utilization of western medical care played an important role in magnitude of direct cost. The information on determinants of household direct and indirect costs is necessary in order to get a complete picture of household costs for seeking health care and identification of vulnerable social groups and households.

Tuberculosis and poverty: the contribution of patient costs in sub-Saharan Africa--a systematic review

Background

Tuberculosis (TB) is known to disproportionately affect the most economically disadvantaged strata of society. Many studies have assessed the association between poverty and TB, but only a few have assessed the direct financial burden TB treatment and care can place on households. Patient costs can be particularly burdensome for TB-affected households in sub-Saharan Africa where poverty levels are high; these costs include the direct costs of medical and non-medical expenditures and the indirect costs of time utilizing healthcare or lost wages. In order to comprehensively assess the existing evidence on the costs that TB patients incur, we undertook a systematic review of the literature.

Methods

PubMed, EMBASE, Science Citation Index, Social Science Citation Index, EconLit, Dissertation Abstracts, CINAHL, and Sociological Abstracts databases were searched, and 5,114 articles were identified. Articles were included in the final review if they contained a quantitative measure of direct or indirect patient costs for treatment or care for pulmonary TB in sub-Saharan Africa and were published from January 1, 1994 to Dec 31, 2010. Cost data were extracted from each study and converted to 2010 international dollars (I$).

Results

Thirty articles met all of the inclusion criteria. Twenty-one studies reported both direct and indirect costs; eight studies reported only direct costs; and one study reported only indirect costs. Depending on type of costs, costs varied from less than I$1 to almost I$600 or from a small fraction of mean monthly income for average annual income earners to over 10 times average annual income for income earners in the income-poorest 20% of the population. Out of the eleven types of TB patient costs identified in this review, the costs for hospitalization, medication, transportation, and care in the private sector were largest.

Conclusion

TB patients and households in sub-Saharan Africa often incurred high costs when utilizing TB treatment and care, both within and outside of Directly Observed Therapy Short-course (DOTS) programs. For many households, TB treatment and care-related costs were considered to be catastrophic because the patient costs incurred commonly amounted to 10% or more of per capita incomes in the countries where the primary studies included in this review were conducted. Our results suggest that policies to decrease direct and indirect TB patient costs are urgently needed to prevent poverty due to TB treatment and care for those affected by the disease.

The indirect cost due to pulmonary Tuberculosis in patients receiving treatment in Bauchi State-Nigeria

OBJECTIVE

To determine the time spent and income lost by patients and their households for seeking tuberculosis diagnosis and treatment in Bauchi State-Nigeria.

METHOD

A cross sectional study where 242 TB patients were sampled from 27 out of 67 facilities providing TB services in a north-eastern state of Nigeria. Sampling was stratified based on facility type, patients' HIV status and gender.

RESULTS

The income lost among the hospitalized group was estimated at $156/patient and about $114 in the non-hospitalized patients group. Age, gender, facility of diagnosis, level of education and occupation were significant (p-values <0.05) associated with total (both patients and their households) income lost. However, AFB sputum-smear result and HIV status had no significant effects on the income lost. Hospitalised patients spent an average time of 924.98 hours for diagnosis and treatment whereas the non-hospitalised spent an average of 141.29 hours. The estimated US dollar valued of these hours was US517.98 and US$79.13 for hospitalised and non-hospitalised patient groups respectively. Hospitalisation and the facility of diagnosis were statistically significant (p-value <0.05) predictors of the time patients and household spent on TB.

CONCLUSION

Tuberculosis poses causes tremendous burden in terms of time and productivity lost to both patients and their households in Bauchi State Nigeria.

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.

Nutritional supplements for people being treated for active tuberculosis

BACKGROUND

Tuberculosis and malnutrition are linked in a complex relationship. The infection may cause undernutrition through increased metabolic demands and decreased intake, and nutritional deficiencies may worsen the disease, or delay recovery by depressing important immune functions. At present, there are no evidence-based nutritional guidance for adults and children being treated for tuberculosis.

OBJECTIVES

To assess the effects of oral nutritional supplements (food, protein/energy supplements or micronutrients) on tuberculosis treatment outcomes and recovery in people on antituberculous drug therapy for active tuberculosis.

SEARCH METHODS

We searched the Cochrane Infectious Disease Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, mRCT, and the Indian Journal of Tuberculosis to July 2011, and checked the reference lists of all included studies.

SELECTION CRITERIA

Randomized controlled trials comparing any oral nutritional supplement given for at least four weeks with no nutritional intervention, placebo, or dietary advice only for people being treated for active tuberculosis.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted data, and assessed the risk of bias. Results are presented as risk ratios (RR) for dichotomous variables, and mean differences (MD) for continuous variables, with 95% confidence intervals (CI). Where appropriate, data from trials with similar interventions and outcomes have been pooled. The quality of evidence was assessed using the GRADE methods.

MAIN RESULTS

Twenty-three trials, with 6842 participants, were included. Macronutrient supplementation Five trials assessed the provision of free food, or high energy supplements, although none were shown to provide a total daily kilocalorie intake above the current daily recommended intake for the non-infected population.The available trials were too small to reliably prove or exclude clinically important benefits on mortality, cure, or treatment completion. One small trial from India did find a statistically significant benefit on treatment completion, and clearance of the bacteria from the sputum, but these findings have not been confirmed in larger trials elsewhere (VERY LOW quality evidence).The provision of free food or high-energy nutritional products probably does produce a modest increase in weight gain during treatment for active tuberculosis (MODERATE quality evidence). Two small studies provide some evidence that physical function and quality of life may also be improved but the trials were too small to have much confidence in the result (LOW quality evidence). These effects were not seen in the one trial which included only human immunodeficiency virus (HIV)-positive patients.Micronutrient supplementation Five trials assessed multi-micronutrient supplementation in doses up to ten times the dietary reference intake, and 12 trials assessed single or dual micronutrient supplementation.There is insufficient evidence to judge whether multi-micronutrients have a beneficial effect on mortality in HIV- negative patients with tuberculosis (VERY LOW quality evidence), but the available studies show that multi-micronutrients probably have little or no effect on mortality in HIV-positive patients with tuberculosis (MODERATE quality evidence). No studies have assessed the effects of multi-micronutrients on cure, or treatment completion.Multi-micronutrient supplements may have little or no effect on the proportion of tuberculosis patients remaining sputum positive during the first eight weeks (LOW quality evidence), and probably have no effect on weight gain during treatment (MODERATE quality evidence). No studies have assessed quality of life.Plasma levels of vitamin A appear to increase following initiation of tuberculosis treatment regardless of supplementation. In contrast, plasma levels of zinc, vitamin D and E, and selenium may be improved by supplementation during the early stages of tuberculosis treatment, but a consistent benefit on tuberculosis treatment outcomes or nutritional recovery has not been demonstrated.

AUTHORS' CONCLUSIONS

There is insufficient research to know whether routinely providing free food or energy supplements results in better tuberculosis treatment outcomes, or improved quality of life. Further trials, particularly from food insecure settings, should have adequate sample sizes to identify, or exclude, clinically important benefits.Although blood levels of some vitamins may be low in patients starting treatment for active tuberculosis, there is currently no reliable evidence that routinely supplementing at or above recommended daily amounts has clinical benefits.

Factors determining household expenditure for tuberculosis and coping strategies in Tajikistan

OBJECTIVE

To investigate factors influencing expenditure levels and the use of potentially detrimental coping strategies among tuberculosis (TB) patients. For the purpose of the present study, potentially detrimental coping strategies included borrowing money and selling assets.

METHOD

Questionnaire survey with an initial and a follow-up interview of each adult new pulmonary TB case registered over a period of 4 months, conducted in 12 districts with DOTS in Tajikistan, one of the poorest countries in the world.

RESULTS

Patients and their households faced mean expenditures of US$ 396 related to a TB episode. In multivariate mixed-effect regression models, the main determinants of out-of-pocket payments-either over the whole course of the disease or after enrolment in DOTS treatment-were 'complimentary treatment' besides the anti-TB drugs, duration of hospitalization and treatment delay. Complimentary treatment mainly consisted of vitamins and rehydrating infusions. Sex showed no association with expenditure. To cope with the costs of illness, two-thirds of patients employed a potentially detrimental coping strategy. TB patients raised on average US$ 23 through loans with interest, US$ 57 through loans without interest and US$ 102 through selling assets.

CONCLUSION

The catastrophic out-of-pocket payments faced by TB patients are correlated with receiving complimentary treatment, delay to treatment and duration of hospitalisation. The widespread use of potentially detrimental coping strategies illustrates that TB constitutes a substantial risk of impoverishment. More parsimonious use of complimentary treatment and hospitalisation could reduce illness-related costs for patients and should be carefully considered.

Illness costs to households are a key barrier to access diagnostic and treatment services for tuberculosis in Tajikistan

BACKGROUND

Tuberculosis (TB) control is based on early detection and complete treatment of infectious cases. Consequently, it is important that TB suspects and patients can readily access medical care. This qualitative study investigated determinants of access to DOTS services as identified by patients, health providers and community members in four districts in Tajikistan.

FINDINGS

Focus group discussions were conducted in order to investigate access to TB services. A conceptual framework for access to care guided the analysis. Thirteen focus group discussions involving a total of 97 informants were conducted. Content analysis of discussions and a rating to quantify the relative importance of discussed factors were carried out. The conceptual framework identifies five main components of access to which factors can be assigned: availability, adequacy, acceptability, accessibility and affordability.Financial factors were considered the most important determinants of access to diagnosis and treatment of tuberculosis. Expenditure for drugs and consultations, for transport, and for special foods as well as lost income were identified as major barriers to treatment. Stigma, doubts about curability and low perceived quality of care were not seen to be significant determinants of access to care for tuberculosis. Community members were well aware of symptoms of tuberculosis and of medical services. These findings were consistent between different respondent groups (community members, patients and providers). They were also highly consistent between the open discussion and the confidential rating.

CONCLUSIONS

Illness-costs to households were identified as the main barrier to tuberculosis diagnosis and treatment. To improve access and ultimately adherence to tuberculosis treatment, effective mitigation strategies, e.g. changes in case management, food contributions or financial stimuli, need to be explored and implemented.

Health-system strengthening and tuberculosis control

Weak health systems are hindering global efforts for tuberculosis care and control, but little evidence is available on effective interventions to address system bottlenecks. This report examines published evidence, programme reviews, and case studies to identify innovations in system design and tuberculosis control to resolve these bottlenecks. We outline system bottlenecks in relation to governance, financing, supply chain management, human resources, health-information systems, and service delivery; and adverse effects from rapid introduction of suboptimum system designs. This report also documents innovative solutions for disease control and system design. Solutions pursued in individual countries are specific to the nature of the tuberculosis epidemic, the underlying national health system, and the contributors engaged: no one size fits all. Findings from countries, including Bangladesh, Cambodia, India, Tanzania, Thailand, and Vietnam, suggest that advances in disease control and system strengthening are complementary. Tuberculosis care and control are essential elements of health systems, and simultaneous efforts to innovate systems and disease response are mutually reinforcing. Highly varied and context-specific responses to tuberculosis show that solutions need to be documented and compared to develop evidence-based policies and practice.

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.

Direct and indirect costs of tuberculosis among immigrant patients in the Netherlands

BACKGROUND

In low tuberculosis (TB) incidence countries TB affects mostly immigrants in the productive age group. Little empirical information is available about direct and indirect TB-related costs that patients face in these high-income countries. We assessed the direct and indirect costs of immigrants with TB in the Netherlands.

METHODS

A cross-sectional survey at 14 municipal health services and 2 specialized TB hospitals was conducted. Interviews were administered to first or second generation immigrants, 18 years or older, with pulmonary or extrapulmonary TB, who were on treatment for 1-6 months. Out of pocket expenditures and time loss, related to TB, was assessed for different phases of the current TB illness.

RESULTS

In total 60 patients were interviewed. Average direct costs spent by households with a TB patient amounted euro353. Most costs were spent when being hospitalized. Time loss (mean 81 days) was mainly due to hospitalization (19 days) and additional work days lost (60 days), and corresponded with a cost estimation of euro2603.

CONCLUSION

Even in a country with a good health insurance system that covers medication and consultation costs, patients do have substantial extra expenditures. Furthermore, our patients lost on average 2.7 months of productive days. TB patients are economically vulnerable.

How to optimize tuberculosis case finding: explorations for Indonesia with a health system model

Background

A mathematical model was designed to explore the impact of three strategies for better tuberculosis case finding. Strategies included: (1) reducing the number of tuberculosis patients who do not seek care; (2) reducing diagnostic delay; and (3) engaging non-DOTS providers in the referral of tuberculosis suspects to DOTS services in the Indonesian health system context. The impact of these strategies on tuberculosis mortality and treatment outcome was estimated using a mathematical model of the Indonesian health system.

Methods

The model consists of multiple compartments representing logical movement of a respiratory symptomatic (tuberculosis suspect) through the health system, including patient- and health system delays. Main outputs of the model are tuberculosis death rate and treatment outcome (i.e. full or partial cure). We quantified the model parameters for the Jogjakarta province context, using a two round Delphi survey with five Indonesian tuberculosis experts.

Results

The model validation shows that four critical model outputs (average duration of symptom onset to treatment, detection rate, cure rate, and death rate) were reasonably close to existing available data, erring towards more optimistic outcomes than are actually reported. The model predicted that an intervention to reduce the proportion of tuberculosis patients who never seek care would have the biggest impact on tuberculosis death prevention, while an intervention resulting in more referrals of tuberculosis suspects to DOTS facilities would yield higher cure rates. This finding is similar for situations where the alternative sector is a more important health resource, such as in most other parts of Indonesia.

Conclusion

We used mathematical modeling to explore the impact of Indonesian health system interventions on tuberculosis treatment outcome and deaths. Because detailed data were not available regarding the current Indonesian population, we relied on expert opinion to quantify the parameters. The fact that the model output showed similar results to epidemiological data suggests that the experts had an accurate understanding of this subject, thereby reassuring the quality of our predictions. The model highlighted the potential effectiveness of active case finding of tuberculosis patients with limited access to DOTS facilities in the developing country setting.

Can Malawi's poor afford free tuberculosis services? Patient and household costs associated with a tuberculosis diagnosis in Lilongwe

OBJECTIVE

To assess the relative costs of accessing a TB diagnosis for the poor and for women in urban Lilongwe, Malawi, a setting where public health services are accessible within 6 kilometers and provided free of charge.

METHODS

Patient and household direct and opportunity costs were assessed from a survey of 179 TB patients, systematically sampled from all public and mission health facilities in Lilongwe. Poverty status was determined from the 1998 Malawi Integrated Household Survey (MIHS).

FINDINGS

On average, patients spent US$ 13 (MK 996 or 18 days' income) and lost 22 days from work while accessing a TB diagnosis. For non-poor patients, the total costs amounted to 129% of total monthly income, or 184% after food expenditures. For the poor, this cost rose to 248% of monthly income or 574% after food. When a woman or when the poor are sick, the opportunity costs faced by their households are greater.

CONCLUSION

Patient and household costs of TB diagnosis are prohibitively high even where services are provided free of charge. In scaling up TB services to reach the Millennium Development Goals, there is an urgent need to identify strategies for diagnosing TB that are cost-effective for the poor and their households.

Assessment of indirect cost-of-illness in a subsistence farming society by using different valuation methods

Indirect costs or productive labour time lost are the largest share of household economic burden of illness. However, the estimate of household indirect cost can vary depending on the valuation methods used. We therefore estimated household indirect cost in a subsistence farming society in Burkina Faso based on daily production value. These results were validated by using willingness-to-pay method and current wage rate. Among the three methods, the value of a day lost for adults assessed by willingness-to-pay method was considerably higher than other methods. There were no significant differences in indirect costs estimated by daily production value and wage rate. There were significantly higher indirect costs for households which were of higher economic status when daily production value was used. It might raise a question of equity. The willingness-to-pay method can capture the various aspects of indirect cost such as differences among age groups and gender, important individual characteristics and seasons. Thus, it is an appropriate approach for rural subsistence farmer communities. Estimation of indirect cost by wage rate can also be used as a rapid estimation of indirect cost in a rural area in developing countries as an alternative for daily production value.

Human African trypanosomiasis in a rural community, Democratic Republic of Congo

According to the World Health Organization, human African trypanosomiasis (HAT) (sleeping sickness) caused the loss of approximately 1.5 million disability-adjusted life years (DALYs) in 2002. We describe the effect of HAT during 2000-2002 in Buma, a rural community near Kinshasa in the Democratic Republic of Congo. We used retrospective questionnaire surveys to estimate HAT-related household costs and DALYs. The HAT outbreak in Buma involved 57 patients and affected 47 (21%) households. The cost to each household was equivalent to 5 months' income for that household. The total number of HAT-related DALYs was 2,145, and interventions to control HAT averted 1,408 DALYs. The cost per DALY averted was US $17. Because HAT has a serious economic effect on households and control interventions are cost-effective, considering only global burden of disease rankings for resource allocation could lead to misguided priority setting if applied without caution in HAT-affected countries.

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.

Costs attributable to AIDS at household level in Chad

This paper assesses the economic costs of AIDS at the household level in Chad, one of the poorest countries in the world. One hundred and ninety-three AIDS patients living in four different regions were found by case identification at hospital level and through community based organizations providing psycho-social relief. They were matched by age, sex, professional category and zone of residence with controls. Costs were evaluated through a standard questionnaire. Costs at household level attributable to AIDS up to death were US$836 per case. Costs related to productivity losses made up 28% of total costs. More than half of total costs (56%) were health care related expenditures and funeral costs contributed 16%. AIDS cases relied more often on borrowing and the selling of household assets than controls for treatment. Household expenditures of AIDS cases were much higher than control households mainly due to health related expenditure. The response of concerned families to HIV/AIDS implies high costs and for most households, especially in low-income settings, the consequences of AIDS are devastating. Innovative strategies on how best to assist households are thus requested and may include the strengthening of care and treatment services being offered to AIDS cases.

[Tuberculosis in Salvador, Brazil: costs to health system and families]

OBJECTIVE

Tuberculosis is one the greatest causes of mortality worldwide, but its economic effects are not well known. This study had the objective of estimating the costs to the public and private healthcare systems and to families of tuberculosis treatment and prevention.

METHODS

This study was made in the municipality of Salvador, State of Bahia, Brazil, in 1999. Data for estimating the costs to the healthcare system were collected from the Department of Health, healthcare facilities and a philanthropic institution. The public and private costs were analyzed using cost accounting methodology. Cost data relating to families were collected by means of questionnaires, and included data on transportation, food and other expenses, and also income losses associated with this disease.

RESULTS

The average cost of treating one new case of tuberculosis was approximately US$103. The cost of treating one multiresistant patient was 27 higher than this. The cost to the public services consisted of 65% on hospitalization, 32% on treatment, and only 3% on prevention. The families committed around 33% of their income on expenses related to tuberculosis.

CONCLUSIONS

Despite the fact that the families did not have to pay for medications and treatment, given that this service is offered by the State, the costs to families related to loss of income due to the disease were very high. The proportion of public service funds utilized for prevention is small. Greater investment in prevention campaigns not only might diminish the numbers of cases but also might lead to earlier diagnosis, thus reducing the costs associated with hospitalization. The lack of an integrated cost accounting system makes it impossible to visualize costs across the various sectors.

Patient care seeking barriers and tuberculosis programme reform: a qualitative study

The patient's perspective, including his/her socio-economic and cultural environment, is an important consideration for tuberculosis control programmes. Through semi-structured interviews, this qualitative research studies the barriers to successful care seeking faced by 202 adult patients with pulmonary tuberculosis in urban Zambia. Three common, interdependent themes explain patient barriers to successful care seeking: (1) number of health care encounters and duration of illness prior to diagnosis; (2) existing financial constraints and additional unrecognized patient costs; and (3) travel distances. On average, patients have 6.7 health care encounters prior to being diagnosed with tuberculosis. Within a resource-poor setting, patients face financial constraints and unrecognized costs associated with their illness. Specifically, travel distances and related transportation costs create a significant burden on patients. In addition, 'special food' expenditures add to their financial constraints. The implications of these patient barriers from this study are then discussed in the context of three tuberculosis programme reforms occurring in sub-Saharan Africa: (1) decentralization of tuberculosis services; (2) integration of tuberculosis and other services; and (3) evaluation of diagnostic techniques. The patient's perspective and related care seeking barriers should be considered in reviewing existing tuberculosis programmes and policy, evaluating potential programme reform and assessing new tuberculosis interventions.

Strong general health care systems: a prerequisite to reach global tuberculosis control targets

We argue that tuberculosis control cannot reach its proposed global targets without investment in an adequate network of accessible, effective and comprehensive health services. Lessons from the past are reviewed. They underscore that passive case-detection and adequate case management is the central technical strategy for tuberculosis control. There is no compelling evidence to support active case-detection in the general population. We elaborate on why a strong health care system is a prerequisite in the framework of case-detection and treatment. The necessity to improve quality and accessibility of general health services for ensuring early detection and subsequent cure is demonstrated. It is argued why the need for strong public health care system becomes even more eminent in the light of the tuberculosis/HIV dual epidemics and of the rapid growth of unregulated private-for-profit services. We finally examine the financial gaps for tuberculosis control and discuss the need for allocating more resources to the strengthening of general health care systems.

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.

Tuberculosis in the tropics

Tropical countries bear the brunt of the global TB burden. Young children are at high risk and suffer the most severe forms of TB; adults with pulmonary cavities are the main sources of transmission. The incidence in sub-Saharan Africa is increasing as a consequence of the HIV pandemic. Smear-negative TB, which is common in children and patients who have HIV infection, is becoming a major problem in resource-poor settings where access to mycobacterial culture and histopathology is limited. Clinical case definitions are being developed to address this problem. Short courses of rifampin-based therapy are not universally available, but access is increasing. DOTS is the main strategy that the WHO is promoting to improve TB control. This is particularly important for sputum smear-positive patients. Unfortunately, the DOTS targets set by the WHO have not yet been met. Innovative, low-cost ways of supervising therapy have been developed using family members or lay supervisors. Preventive therapy in tropical countries is limited to high-risk cases (young children and HIV-infected patients who are tuberculin skin test-positive). An improved TB vaccine would dramatically improve TB control.

Advances in adult pulmonary tuberculosis

The immune response is able to contain but not eliminate Mycobacterium tuberculosis. Antigens that are specific to M. tuberculosis can identify latent infection accurately even after BCG vaccination. Genes that are required for persistence of the organism have been identified and new drugs are being developed to disrupt their function. This offers the hope of shortened courses of therapy. New drugs are urgently needed for multidrug-resistant tuberculosis, particularly as some areas are reporting a high prevalence of fluoroquinolone resistance. The sputum smear is the standard rapid diagnostic test for pulmonary tuberculosis, but is frequently negative in HIV infection. The yield of smear can be increased by sputum induction and by concentration. Innovative methods of providing directly observed therapy have been devised. Preventive therapy is effective in HIV infection and probably improves survival. However, the duration of benefit of preventive therapy seems to be relatively short-lived. Effective long-term reduction of tuberculosis risk in HIV-infected patients can be achieved with highly active antiretroviral therapy.