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

The Economic Burden of Severe Acute Malnutrition with Complications: A Cost Analysis for Inpatient Children Aged 6 to 59 Months in Northern Senegal

Severe acute malnutrition (SAM) is a high-fatality condition that affected 13.7 million children under five years of age worldwide in 2022, with complicated cases requiring extensive inpatient stay with an accompanying caregiver. Our objective was to assess the costs of inpatient treatment for complicated SAM in children aged 6 to 59 months in Northern Senegal and identify cost predictors. We performed a retrospective cost analysis, including 140 children hospitalized from January to December 2020 in five SAM inpatient treatment facilities. We adopted a societal perspective, including direct medical and non-medical costs and indirect costs. We extracted patients' sociodemographic and clinical data from medical records and conducted semi-structured interviews with healthcare staff to capture information on time allocation and care management. A multivariable generalized linear model with gamma family and a log link was used to investigate the factors associated with direct costs. Costs are expressed in 2020 international USD using purchasing power parity. Mean length of stay was 5.3 (SD = 3.2) days and diarrhoea was the cause of the admission in 55.7% of cases. Mean total cost was USD 431.9 (SD = 203.9), with personnel being the largest cost item (33% of the total). Households' out-of-pocket expenses represented 45.3% of total costs and amounted to USD 195.6 (SD = 103.6). Costs were significantly associated with gender (20.3% lower in boys), diarrhoea (27% increase), anaemia (49.4% increase), inpatient death (44.9% decrease), and type of facility (26% higher in hospitals vs. health centre). Our study highlights the financial burden of complicated SAM in Senegal in particular for families. This underscores the need for tailored prevention and social policies to protect families from the disease's financial burden and improve treatment adherence, both in Senegal and similar contexts.

Digital Adherence Technologies Linked to Mobile Money Incentives for Medication Adherence Among People Living With Tuberculosis: Mixed Methods Feasibility and Acceptability Study

BACKGROUND

Complementing digital adherence technologies (DATs) with mobile money incentives may improve their utility in supporting tuberculosis medication adherence, yet the feasibility and acceptability of this integrated approach remain unclear.

OBJECTIVE

This study aims to describe the feasibility and acceptability of a novel DAT intervention called My Mobile Wallet composed of real-time adherence monitoring, SMS text message reminders, and mobile money incentives for tuberculosis medication adherence in a low-income setting.

METHODS

We purposively recruited people living with tuberculosis from the Mbarara Regional Referral Hospital in Mbarara, Uganda, who (1) were starting tuberculosis treatment at enrollment or within the past 4 weeks, (2) owned a mobile phone, (3) were able to use SMS test messaging, (4) were aged ≥18 years, and (5) were living in Mbarara district. At study exit (month 6), we used interviews and questionnaires informed by the unified theory of acceptance and use of technology (UTAUT) to collect feasibility and acceptability data, reflecting patients' experiences of using each component of My Mobile Wallet. Feasibility also included tracking the functionality of the adherence monitor (ie, an electronic pillbox) as well as SMS text message and mobile money delivery. We used a content analytical approach to inductively analyze qualitative data and Stata (version 13; StataCorp LLC) to analyze quantitative data.

RESULTS

All 39 participants reported that the intervention was feasible because it was easy for them to use (eg, access and read SMS text messages) and worked as expected. Almost all SMS text messages (6880/7064, 97.4%) were sent as planned. The transmission of adherence data from the monitor worked well, with 98.37% (5682/5776) of the data transmitted as planned. All participants additionally reported that the intervention was acceptable because it helped them take their tuberculosis medication as prescribed; the mobile money incentives relieved them of tuberculosis-related financial burdens; SMS text message reminders and electronic pillbox-based alarms reminded them to take their medication on time; and participants perceived real-time adherence monitoring as "being watched" while taking their medication, which encouraged them to take their medication on time to demonstrate their commitment. The intervention was perceived as a sign of care, which eventually created emotional support and a sense of connectedness to health care. Participants preferred daily SMS text message reminders (32/39, 82%) to reminders linked to missed doses (7/39, 18%), citing the fact that tuberculosis medication is taken daily.

CONCLUSIONS

The use of real-time adherence monitoring linked to SMS text message reminders and mobile money incentives for tuberculosis medication adherence was feasible and acceptable in a low-resource setting where poverty-based structural barriers heavily constrain tuberculosis treatment and care.

Opinion review of drug resistant tuberculosis in West Africa: tackling the challenges for effective control

Drug-resistant (DR) tuberculosis (TB) is a major public health concern globally, complicating TB control and management efforts. West Africa has historically faced difficulty in combating DR-TB due to limited diagnostic skills, insufficient access to excellent healthcare, and ineffective healthcare systems. This has aided in the emergence and dissemination of DR Mycobacterium tuberculosis complex (MTBC) strains in the region. In the past, DR-TB patients faced insufficient resources, fragmented efforts, and suboptimal treatment outcomes. However, current efforts to combat DR-TB in the region are promising. These efforts include strengthening diagnostic capacities, improving access to quality healthcare services, and implementing evidence-based treatment regimens for DR-TB. Additionally, many West African National TB control programs are collaborating with international partners to scale up laboratory infrastructure, enhance surveillance systems, and promote infection control measures. Moreso, novel TB drugs and regimens, such as bedaquiline and delamanid, are being introduced to improve treatment outcomes for DR-TB cases. Despite these obstacles, there is optimism for the future of DR-TB control in West Africa. Investments are being made to improve healthcare systems, expand laboratory capacity, and support TB research and innovation. West African institutions are now supporting knowledge sharing, capacity building, and resource mobilization through collaborative initiatives such as the West African Network for TB, AIDS, and Malaria (WANETAM), the West African Health Organization (WAHO), and other regional or global partners. These efforts hold promise for improved diagnostics, optimized treatment regimens, and provide better patient outcomes in the future where drug-resistant TB in WA can be effectively controlled, reducing the burden of the disease, and improving the health outcomes of affected individuals.

Mycobacterial FtsEX-RipC interaction is required for normal growth and cell morphology in rifampicin and low ionic strength conditions

Tuberculosis, a lung disease caused by Mycobacterium tuberculosis (Mtb), remains a major global health problem ranking as the second leading cause of death from a single infectious agent. One of the major factors contributing toward Mtb's success as a pathogen is its unique cell wall and its ability to counteract various arms of the host's immune response. A recent genome-scale study profiled a list of candidate genes that are predicted to be essential for Mtb survival of host-mediated responses. One candidate was FtsEX, a protein complex composed of an ATP-binding domain, FtsE, and a transmembrane domain, FtsX. FtsEX functions through interaction with a periplasmic hydrolase, RipC. Homologs of FtsEX exist in other bacteria and have been linked with playing a key role in regulating peptidoglycan hydrolysis during cell elongation and division. Here, we report on Mycobacterium smegmatis, FtsE, FtsX, and RipC and their protective roles in stressful conditions. We demonstrate that the individual genes of FtsEX complex and RipC are not essential for survival in normal growth conditions but conditionally essential in low-salt media and antibiotic-treated media. Growth defects in these conditions were characterized by short and bulgy cells as well as elongated filamentous cells. Our results suggest that FtsE, FtsX, and RipC are required for both normal cell elongation and division and ultimately for survival in stressful conditions.

IMPORTANCE

Mycobacterial cell growth and division are coordinated with regulated peptidoglycan hydrolysis. Understanding cell wall gene complexes that govern normal cell division and elongation will aid in the development of tools to disarm the ability of mycobacteria to survive immune-like and antibiotic stresses. We combined genetic analyses and scanning electron microscopy to analyze morphological changes of mycobacterial FtsEX and RipC mutants in stressful conditions. We demonstrate that FtsE, FtsX, FtsEX, and RipC are conditionally required for the survival of Mycobacterium smegmatis during rifampicin treatment and in low-salt conditions. Growth defects in these conditions were characterized by short and bulgy cells as well as elongated filamentous cells. We also show that the FtsEX-RipC interaction is essential for the survival of M. smegmatis in rifampicin. Our results suggest that FtsE, FtsX, and RipC are required for normal cell wall regulation and ultimately for survival in stressful conditions.

Comparing disease specific catastrophic cost estimates using longitudinal and cross-sectional designs: The example of tuberculosis

BACKGROUND

There has been an increasing interest in assessing disease-specific catastrophic costs incurred by affected households as part of economic evaluations and to inform joint social/health policies for vulnerable groups. Although the longitudinal study design is the gold standard for estimating disease-specific household costs, many assessments are implemented with a cross-sectional design for pragmatic reasons. We aimed at identifying the potential biases of a cross-sectional design for estimating household cost, using the example of tuberculosis (TB), and exploring optimal approaches for sampling and interpolating cross-sectional cost data to estimate household costs.

METHODS

Data on patient incurred costs, household income and coping strategies were collected from TB patients in Negros Occidental and Cebu in the Philippines between November 2018 and October 2020. The data collection tools were developed by adapting WHO Tuberculosis Patient Cost Surveys: A Handbook into a longitudinal study design. TB-specific catastrophic cost estimates were compared between longitudinal and simulated cross-sectional designs using different random samples from different times points in treatment (intensive and continuation phases).

RESULTS

A total of 530 adult TB patients were enrolled upon TB diagnosis in this study. Using the longitudinal design, the catastrophic cost estimate for TB-affected households was 69 % using the output approach. The catastrophic cost estimates with the simulated cross-sectional design were affected by the reduction and recovery in household income during the episode of TB care and ranged from 40 to 55 %.

CONCLUSION

Using longitudinally collected costs incurred by TB-affected households, we illustrated the potential limitations and implications of estimating household costs using a cross-sectional design. Not capturing changes in household income at multiple time points during the episode of the disease and estimating from inappropriate samples may result in biases that underestimates catastrophic cost.

Exploring the ethics of tuberculosis human challenge models

We extend recent conversation about the ethics of human challenge trials to tuberculosis (TB). TB challenge studies could accelerate vaccine development, but ethical concerns regarding risks to trial participants and third parties have been a limiting factor. We analyse the expected social value and risks of different challenge models, concluding that if a TB challenge trial has between a 10% and a 50% chance of leading to the authorisation and near-universal delivery of a more effective vaccine 3-5 years earlier, then the trial would save between 26 400 and 1 100 000 lives over the next 10 years. We also identify five important ethical considerations that differentiate TB from recent human challenge trials: an exceptionally high disease burden with no highly effective vaccine; heightened third party risk following the trial, and, partly for that reason, uniquely stringent biosafety requirements for the trial; risks associated with best available TB treatments; and difficulties with TB disease detection. We argue that there is good reason to consider conducting challenge trials with attenuated strains like Bacillus Calmette-Guérin or attenuated Mycobacterium tuberculosis.

Perspectives of healthcare and social support sector policymakers on potential solutions to mitigate financial impact among people with TB in Mozambique: a qualitative study

OBJECTIVE

People with tuberculosis (TB) and their households face severe socioeconomic consequences, which will only be mitigated by intersectoral collaboration, especially between the health and social sectors. Evidence suggests that key factors for successful collaboration include shared goals, trust, commitment, resource allocation, efficient processes and effective communication and motivation among collaborating parties. This study aimed to understand healthcare and social support sector policymakers' perspectives on potential solutions to mitigate financial impact among people with TB and their households in Mozambique.

DESIGN

Qualitative study with primary data collection through one-to-one in-depth interviews.

SETTING

Gaza and Inhambane provinces, Mozambique.

PARTICIPANTS

Policymakers in the health and social support sector.

RESULTS

A total of 27 participants were purposefully sampled. Participants were asked about their perspectives on TB-related financial impact and potential solutions to mitigate such impact. Participants reported that people with TB are not explicitly included in existing social support policies because TB per se is not part of the eligibility criteria. People with TB and underweight or HIV were enrolled in social support schemes providing food or cash. Two themes were generated from the analysis: (1) Policymakers suggested several mitigation solutions, including food and monetary support, but perceived that their implementation would be limited by lack of resources; and (2) lack of shared views or processes related to intersectoral collaboration between health and social support sector hinders design and implementation of social support for people with TB.

CONCLUSION

Despite health and social sector policymakers reporting a willingness for intersectoral collaboration to mitigate TB-related financial impact, current approaches were perceived to be unilateral. Collaboration between health and social support sectors should focus on improving existing social support programmes.

Follow-up of patients diagnosed with and treated for tuberculosis in Brazil: financial burden on the household

OBJECTIVE

To evaluate the implications of the proportion of annual family income spent in the pre- and post-diagnosis periods in tuberculosis patients followed for after at least one year after completing tuberculosis treatment in Brazil.

METHODS

This was a cross-sectional study of tuberculosis patients followed for at least one year after completing tuberculosis treatment in five Brazilian capitals (one in each region of the country).

RESULTS

A total of 62 patients were included in the analysis. The overall average cost of tuberculosis was 283.84 Brazilian reals (R$) in the pre-diagnosis period and R$4,161.86 in the post-diagnosis period. After the costs of tuberculosis disease, 71% of the patients became unemployed, with an overall increase in unemployment; in addition, the number of patients living in nonpoverty decreased by 5%, the number of patients living in poverty increased by 6%, and the number of patients living in extreme poverty increased by 5%. The largest proportion of annual household income to cover the total costs of tuberculosis was for the extremely poor (i.e., 40.37% vs. 11.43% for the less poor).

CONCLUSIONS

Policies to mitigate catastrophic costs should include interventions planned by the health care system and social protection measures for tuberculosis patients with lower incomes in order to eliminate the global tuberculosis epidemic by 2035-a WHO goal in line with the United Nations Sustainable Development Goals.

Journey of the tuberculosis patients in India from onset of symptom till one-year post-treatment

Historically, economic studies on tuberculosis estimated out-of-pocket expenses related to tuberculosis treatment and catastrophic cost, however, no study has yet been conducted to understand the post-treatment economic conditions of the tuberculosis patients in India. In this paper, we add to this body of knowledge by examining the experiences of the tuberculosis patients from the onset of symptoms till one-year post-treatment. 829 adult drug-susceptible tuberculosis patients from general population and from two high risk groups: urban slum dwellers and tea garden families were interviewed during February 2019 to February 2021 at their intensive and continuation phases of treatment and about one-year post-treatment using adapted World Health Organization tuberculosis patient cost survey instrument. Interviews covered socio-economic conditions, employment status, income, out-of-pocket expenses and time spent for outpatient visits, hospitalization, drug-pick up, medical follow-ups, additional food, coping strategies, treatment outcome, identification of post-treatment symptoms and treatment for post-treatment sequalae/recurrent cases. All costs were calculated in 2020 Indian rupee (INR) and converted into US dollar (US$) (1 US$ = INR 74.132). Total cost of tuberculosis treatment since the onset of symptom till one-year post-treatment ranged from US$359 (Standard Deviation (SD) 744) to US$413 (SD 500) of which 32%-44% of costs incurred in pre-treatment phase and 7% in post-treatment phase. 29%-43% study participants reported having outstanding loan with average amount ranged from US $103 to US$261 during the post-treatment period. 20%-28% participants borrowed during post-treatment period and 7%-16% sold/mortgaged personal belongings. Therefore, economic impact of tuberculosis persists way beyond treatment completion. Major reasons of continued hardship were costs associated with initial tuberculosis treatment, unemployment, and reduced income. Therefore, policy priorities to reduce treatment cost and to protect patients from the economic consequences of the disease by ensuring job security, additional food support, better management of direct benefit transfer and improving coverage through medical insurances need consideration.

A sequential explanatory mixed-methods study on costs incurred by patients with tuberculosis comorbid with diabetes in Bhavnagar, western India

Diabetes is one of the commonest morbidity among patients with tuberculosis (TB). We conducted this study to estimate the costs incurred by patients with TB comorbid with diabetes and to explore the perspectives of program managers as well as patients on the reasons and solutions for the costs incurred due to TB-diabetes. We conducted a descriptive cross-sectional study to estimate costs among 304 patients with TB-diabetes comorbidity registered in the public health system during 2017-2020 in the Bhavnagar region of western India, which was followed by in-depth interviews among program functionaries and patients to explore solutions for reducing the costs. Costs, when exceeded 20% of annual household income, were defined as catastrophic as this cut-off was most significantly related to adverse TB outcomes. Among the 304 patients with TB-diabetes comorbidity, 72% were male and the median (interquartile IQR) monthly family income was Indian rupees (INR) 9000 (8000-11,000) [~ US$ 132 (118-162)]. The median (IQR) total costs due to combined TB-diabetes were INR 1314 (788-3170) [~ US$ 19 (12-47)], while that due to TB were INR 618 (378-1933) [~ US$ 9 (6-28)]. Catastrophic costs due to TB were 4%, which increased to 5% on adding the costs due to diabetes. Health system strengthening, an increase in cash assistance, and other benefits such as a nutritious food kit were suggested for reducing the costs incurred. We conclude that, in addition to a marginal increase in the percentage of catastrophic costs, co-existent diabetes nearly doubled the median total costs incurred among patients with TB. Strengthening the TB-diabetes bi-directional activities, tailoring the cash transfer scheme for comorbid patients, and making the common two-drug combination diabetes tablets available at government drug stores would help TB-diabetes comorbid patients cope with the costs of care.

Roadblocks and resilience: A qualitative study of the impact of pediatric tuberculosis on Tanzanian households and solutions from caregivers

Distinct from quantifying the economic sequelae of tuberculosis (TB) in adults, data are scarce regarding lived experiences of youth and their caregivers seeking and sustaining TB treatment in low income communities. Children ages 4-17 diagnosed with TB and their caregivers were recruited from rural and semi-urban northern Tanzania. Using a grounded theory approach, a qualitative interview guide was developed, informed by exploratory research. Twenty-four interviews were conducted in Kiswahili, audio-recorded and analyzed for emerging and consistent themes. Dominant themes found were socioemotional impacts of TB on households, including adverse effects on work productivity, and facilitators and obstacles to TB care, including general financial hardship and transportation challenges. The median percentage of household monthly income spent to attend a TB clinic visit was 34% (minimum: 1%, maximum: 220%). The most common solutions identified by caregivers to mitigate adverse impacts were transportation assistance and nutrition supplementation. To end TB, healthcare systems must acknowledge the total financial burden shouldered by low wealth families seeking pediatric TB care, provide consultations and medications locally, and increase access to TB-specific communal funds to mitigate burdens such as inadequate nutrition.Trial registration: planned sub-study of the registered prospective study, NCT05283967.Trial registration: ClinicalTrials.gov identifier: NCT05283967.

Financial burden and health-seeking behaviors related to chronic diseases under the National Health Insurance Scheme in Bolikhamxay Province, Lao PDR: a cross-sectional study

BACKGROUND

Chronic diseases pose a serious threat to health and longevity worldwide. As chronic diseases require long periods of treatment and may become serious conditions, the ensuing financial burden is often worse than that for non-chronic diseases. In 2016, the Lao PDR implemented the National Health Insurance (NHI) system, which covers select provinces. However, data on health service accessibility and the financial burden on households, especially those with chronically ill members covered by the NHI, are scarce.

METHODS

This study used a cross-sectional design. Data collection was conducted in Bolikhamxay province (population = 273,691), from January 15 to February 13, 2019. In total, 487 households, selected through stratified random sampling, were surveyed via questionnaire-based interviews. Healthcare service usage and financial burden were examined.

RESULTS

A total of 370 households had at least one member with self-reported health issues within the last 3 months prior to the interview, while 170 had at least one member with a chronic condition. More than 75% of the households accessed a health facility when a member experienced health problems. The majority of households (43.2%) spent the maximum value covered by the NHI, but households in the second largest group (21.4%) spent 10 times the maximum value covered by the NHI. The prevalence of catastrophic health expenditure (i.e., health-related expenditure equivalent to > 20% of total income) was 25.9% (20% threshold) and 16.2% (40% threshold). Through logistic regression, we found that the major factors determining financial catastrophes owing to health problems were household members with chronic illness, hospitalization, household poverty status, household size (for both the 20 and 40% thresholds), visiting a private facility (20% threshold), and distance from the province to the referral hospital (40% threshold).

CONCLUSIONS

The NHI system has had a positive effect on households' access to health facilities. However, catastrophic health expenditure remains high, especially among chronically ill patients. Facilities under the NHI system should be improved to provide more services, including care for chronic conditions.

Progress towards the 2020 milestones of the end TB strategy in Cambodia: estimates of age and sex specific TB incidence and mortality from the Global Burden of Disease Study 2019

BACKGROUND

Cambodia was recently removed from the World Health Organization's (WHO's) top 30 high tuberculosis (TB) burden countries. However, Cambodia's TB burden remains substantial, and the country is on the WHO's new global TB watchlist. We aimed to examine the levels and trends in the fatal and non-fatal TB burden in Cambodia from 1990 to 2019, assessing progress towards the WHO End TB interim milestones, which aim to reduce TB incidence rate by 20% and TB deaths by 35% from 2015 to 2020.

METHODS

We leveraged the Global Burden of Disease 2019 (GBD 2019) analytical framework to compute age- and sex-specific TB mortality and incidence by HIV status in Cambodia. We enumerated TB mortality utilizing a Bayesian hierarchical Cause of Death Ensemble modeling platform. We analyzed all available data sources, including prevalence surveys, population-based tuberculin surveys, and TB cause-specific mortality, to produce internally consistent estimates of incidence and mortality using a compartmental meta-regression tool (DisMod-MR 2.1). We further estimated the fraction of tuberculosis mortality among individuals without HIV coinfection attributable to the independent effects of alcohol use, smoking, and diabetes.

RESULTS

In 2019, there were 6500 (95% uncertainty interval 4830-8680) deaths due to all-form TB and 50.0 (43.8-57.8) thousand all-form TB incident cases in Cambodia. The corresponding age-standardized rates were 53.3 (39.9-69.4) per 100,000 population for mortality and 330.5 (289.0-378.6) per 100,000 population for incidence. From 2015 to 2019, the number of all-form TB deaths decreased by 11.8% (2.3-21.1), while the age-standardized all-form TB incidence rate decreased by 11.1% (6.3-15.6). Among individuals without HIV coinfection in 2019, alcohol use accounted for 28.1% (18.2-37.9) of TB deaths, smoking accounted for 27.0% (20.2-33.3), and diabetes accounted for 12.5% (7.1-19.0). Removing the combined effects of these risk factors would reduce all-form TB deaths by 54.2% (44.2-62.2).

DISCUSSION

Despite significant progress in reducing TB morbidity and mortality since 1990, Cambodia is not on track to achieve the 2020 WHO End TB interim milestones. Existing programs in Cambodia can benefit from liaising with risk factor control initiatives to accelerate progress toward eliminating TB in Cambodia.

The household economic burden of drug-susceptible TB diagnosis and treatment in The Gambia

OBJECTIVE: To determine the costs and catastrophic costs incurred by drug-susceptible (DS) pulmonary TB patients in The Gambia.METHODS: This observational study collected cost and socio-economic data using a micro-costing approach from the household perspective from 244 adult DS-TB patients with pulmonary TB receiving treatment through the national treatment programme in The Gambia. We used data collected between 2017 and 2020 using an adapted version of the WHO generic patient cost survey instrument to estimate costs and the proportion of patients experiencing catastrophic costs (≥20% of household income).RESULTS: The mean total cost of the TB episode was $104.11 (2018 USD). Direct costs were highest before treatment ($22.93). Indirect costs accounted for over 50% of the entire episode costs. Using different income estimation approaches and catastrophic cost thresholds, 0.4-75% of participants encountered catastrophic costs, showing the variability of results given the different assumptions we utilised.CONCLUSIONS: We show that despite the benefits of free TB care and treatment, DS-TB patients still incur substantial direct and indirect costs, and cases of impoverishing expenditure varied vastly depending on the income estimation approaches used.

The economic burden of TB faced by patients and affected families in Papua New Guinea

BACKGROUND The costs associated with TB disease can be catastrophic for patients, affecting health and socioeconomic outcomes. Papua New Guinea (PNG) is a high TB burden country and the costs associated with TB are unknown.METHODS We undertook a national survey of TB patients to determine the magnitude of costs associated with TB in PNG, the proportion of households with catastrophic costs and cost drivers. We used a cluster sampling approach and recruited TB patients from health facilities. Descriptive statistics were used to analyse the costs and cost drivers and multivariate logistic regression to determine factors associated with catastrophic costs.RESULTS We interviewed 1,000 TB patients; 19 (1.9%) of them had multidrug-resistant TB (MDR-TB). Costs due to TB were attributable to income loss (64.4%), non-medical (29.9%) and medical (5.7%) expenses. Catastrophic costs were experienced by 33.9% (95% CI 31.0-36.9) of households and were associated with MDR-TB (aOR 4.47, 95% CI 1.21-16.50), hospitalization (aOR 3.94, 95% CI 2.69-5.77), being in the poorest (aOR 3.52, 95% CI 2.43-5.10) or middle wealth tertiles (aOR 1.51, 95% CI 1.03-2.21) or being employed (aOR 2.02, 95% CI 1.43-2.89).CONCLUSION The costs due to TB disease were catastrophic for one third of TB-affected households in PNG. Current support measures could be continued, while new cost mitigation interventions may be considered where needed.

Health-Related Quality of Life of Tuberculosis Patients during the COVID-19 Pandemic in Conakry, Guinea: A Mixed Methods Study

The COVID-19 pandemic has had a significant impact on all facets of life and has exacerbated many challenges faced by people living with tuberculosis (TB). This study aimed to assess the health-related quality of life (HRQoL) of TB patients in Guinea during the first wave of the COVID-19 pandemic. A mixed methods study was conducted using two validated tools to assess HRQoL and qualitative interviews among TB patients enrolled in treatment at 11 health centers in Conakry, Guinea. Logistic regression was used to identify factors associated with the deterioration of HRQoL. We included 439 participants in the study, among whom 44% and 31% experienced pain and anxiety, respectively. We found that an increase in the number of household size and the distance from participants' residence to the health centers were significantly associated with lower HRQoL. Qualitative interviews highlighted nutritional and financial issues, which were exacerbated during the COVID-19 pandemic and beliefs that the Guinean Government's assistance plan was insufficient. This study supports the implementation of specific relief plans for TB patients, which includes nutritional and psychological support, especially those whose movements are limited by travel restrictions, preventing access to TB care, reducing work opportunities and exacerbating financial needs and stress.

Burden, clinical features and outcomes of post-tuberculosis lung disease in sub-Saharan Africa: a protocol for a systematic review and meta-analysis

INTRODUCTION

Tuberculosis (TB) is significantly associated with multiple postinfectious, non-communicable diseases after microbiological cure. For example, those with a history of TB disease have a higher risk of developing chronic lung diseases at a younger age. However, the extent and nature of post-TB complications are not well described. Here, we present a protocol for a systematic review and meta-analysis, which aims to synthesise literature on the burden of post-TB lung disease (PTLD) in sub-Saharan Africa, describe phenotypes, long-term outcomes and the health-related quality of life of people with PTLD.

METHODS AND ANALYSIS

A systematic search will be conducted using PubMed, EMBASE, Web of Science, African Journals Online and the Cochrane Library of Systematic Reviews. Papers published in English and French languages that report the prevalence, clinical features, quality of life and long-term outcomes of people with PTLD in sub-Saharan Africa will be considered. We will assess and critically appraise the methodological quality of all studies using the modified covidence. Qualitative and quantitative (network and meta-analysis) synthesis will be performed and STATA V.16 will be used to estimate the burden of PTLD.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review and meta-analysis. Our results will be published in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021274018.

Evaluation of Web-Based Information on Spine Tuberculosis

Objective: To evaluate and assess the information about spine tuberculosis available on the internet to the general public for its quality, adequacy, and authenticity.

Introduction: Tuberculosis is a bacteriological disease that has been associated with humankind since early human civilization. Spinal tuberculosis is an affection of the spine by the tubercle bacilli and can cause major complications, such as neurological dysfunction and spine deformities. Since the revolution in information technology, information about the disease is widely available on the internet.

Material and methods: A total of 68 websites were selected on Google, Yahoo, and MSN search engines for the information available about the disease. Scientific journals, books, and any other research materials were excluded from this study. The information was documented and evaluated for its validity, sufficiency, and authorship.

Results: The public education websites (PEdWebs: Those websites which did not have direct involvement in patient care) were the major source of the information with 58.82% (40) of it coming from them. In all, there were 69% (47) physicians and 30.9% (21) non-physicians. Among the physicians, 89.4% reviewed the information through commercial websites. “Inadequate” information about spine tuberculosis was provided by 11.8% (8), “Moderate information” by 51.5% (35), and “Sufficient information” by 36.8 % (25) of the websites. Among the websites, 13.2% (9) did not mention any specific presentation of the disease. Sufficient information on that aspect was provided by only 45.58% (31) of the websites. Only 39% emphasized the importance of early diagnosis and subsequent disease management. The majority, i.e., 79.4% (54), did not mention the preventive measures.

Conclusion: The internet has a lot of information regarding spine tuberculosis. The majority of this information comes from physicians. However, not every website has complete and essential information regarding the disease.

Falling through the cracks: Increased vulnerability and limited social assistance for TB patients and their households during COVID-19 in Cape Town, South Africa

Amid the COVID-19 crisis, Tuberculosis (TB) patients in South Africa, as elsewhere, faced increased vulnerability due to the consequences of the COVID-19 response such as loss of income, challenges to access diagnostic testing, healthcare services and TB medication. To mitigate the socio-economic impact of the pandemic, especially among the most vulnerable, the South African government expanded social assistance programmes by creating the Social Relief of Distress grant (SRDG), the first grant for unemployed adults in South Africa. Our study investigated how TB patients experienced the COVID-19 pandemic and the ensuing socio-economic fallout, how this affected their health and that of their household, income and coping mechanisms, and access to social assistance. We interviewed 15 TB patients at a health facility in Cape Town and analysed data thematically. To situate our findings, we adapted the United Nations' conceptual framework on determinants of vulnerability and resilience during or following a shock such as climate shocks or pandemics. We found increased vulnerability among TB patients due to a high exposure and sensitivity to the COVID-19 shock but diminished coping capacity. The loss of income in many households resulted not only in increased food insecurity but also a decreased ability to support others. For the most vulnerable, the loss of social support meant resorting to begging and going hungry, severely affecting their ability to continue treatment. In addition, most participants in the study and especially the most vulnerable, fell through the cracks of the most extensive social assistance programme in Africa as few participants were accessing the special COVID-19 SRDG. Targeted social protection for TB patients with a heightened vulnerability and low coping capacity is urgently needed. TB patients with a heightened vulnerability and low coping capacity should be prioritized for urgent assistance.

“I’m suffering for food”: Food insecurity and access to social protection for TB patients and their households in Cape Town, South Africa

Background

Tuberculosis (TB) is a major health concern and the number one cause of death in South Africa. Social protection programmes can strengthen the resilience of TB patients, their families and households. This study aimed to get a better understanding of the role of social protection and other forms of support in relation to the burden of TB on patients and their households in South Africa.

Methods

This is a cross-sectional exploratory qualitative study using a phenomenological approach to focus on the lived experiences and perceptions of TB patients and healthcare workers. We interviewed 16 patients and six healthcare workers and analysed data thematically.

Results

The challenges faced by participants were closely related to household challenges. Participants reported a heavy physical burden, aggravated by a lack of nutritious food and that households could not provide the food they needed. Some needed to resort to charity. At the same time, households were significantly affected by the burden of caring for the patient—and remained the main source of financial, emotional and physical support. Participants reported challenges and costs associated with the application process and high levels of discretion by the assessing doctor allowing doctors’ opinions and beliefs to influence their assessment.

Conclusion

Access to adequate nutritious food was a key issue for many patients and this need strained already stretched households and budgets. Few participants reported obtaining state social protection support during their illness, but many reported challenges and high costs of trying to access it. Further research should be conducted on support mechanisms and interventions for TB patients, but also their households, including food support, social protection and contact tracing. In deciding eligibility for grants, the situation of the household should be considered in addition to the individual patient.

Expansion of social protection is necessary towards zero catastrophic costs due to TB: The first national TB patient cost survey in the Philippines

BACKGROUND

Tuberculosis (TB) is a disease associated with poverty. Moreover, a significant proportion of TB patients face a substantial financial burden before and during TB care. One of the top targets in the End TB strategy was to achieve zero catastrophic costs due to TB by 2020. To assess patient costs related to TB care and the proportion of TB-affected households that faced catastrophic costs, the Philippines National TB Programme (NTP) conducted a national TB patient cost survey in 2016-2017.

METHODS

A cross-sectional survey of 1,912 TB patients taking treatment in health facilities engaged with the NTP. The sample consists of 786 drug-sensitive TB (DS-TB) patients in urban facilities, 806 DS-TB patients in rural facilities, and 320 drug-resistant TB (DR-TB) patients. Catastrophic cost due to TB is defined as total costs, consisting of direct medical and non-medical costs and indirect costs net of social assistance, exceeding 20% of annual household income.

RESULTS

The overall mean total cost including pre- and post-diagnostic costs was US$601. The mean total cost was five times higher among DR-TB patients than DS-TB patients. Direct non-medical costs and income loss accounted for 42.7% and 40.4% of the total cost of TB, respectively. More than 40% of households had to rely on dissaving, taking loans, or selling their assets to cope with the costs. Overall, 42.4% (95% confidence interval (95% CI): 40.2-44.6) of TB-affected households faced catastrophic costs due to TB, and it was significantly higher among DR-TB patients (89.7%, 95%CI: 86.3-93.0). A TB enabler package, which 70% of DR-TB patients received, reduced catastrophic costs by 13.1 percentage points (89.7% to 76.6%) among DR-TB patients, but only by 0.4 percentage points (42.4% to 42.0%), overall.

CONCLUSIONS

TB patients in the Philippines face a substantial financial burden due to TB despite free TB services provided by the National TB Programme. The TB enabler package mitigated catastrophic costs to some extent, but only for DR-TB patients. Enhancing the current social and welfare support through multisectoral collaboration is urgently required to achieve zero catastrophic costs due to TB.

Association of multidimensional poverty and tuberculosis in India

Background

Reduction of multidimensional poverty and tuberculosis are priority development agenda worldwide. The SDGs aims to eradicate poverty in all forms (SDG 1.2) and to end tuberculosis (SDG 3.3.2) by 2030. While poverty is increasingly being measured across multiple domains, reduction of tuberculosis has been an integral part of public health programmes. Though literature suggests a higher prevalence of tuberculosis among the economically poor, no attempt has been made to understand the association between multidimensional poverty and tuberculosis in India. The objective of this paper is to examine the association of multidimensional poverty and tuberculosis in India.

Methods

The unit data from the National Family Health Survey-4, conducted in 2015–16 covering 628,900 households and 2,869,043 individuals across 36 states and union territories of India was used in the analysis. The survey collected information on the self-reported tuberculosis infection of each member of a sample household at the time of the survey. Multidimensional poverty was measured in the domains of education, health, and standard of living, with a set of 10 indicators. The prevalence of tuberculosis was estimated among the multidimensional poor and non-poor populations across the states of India. A binary logistic regression model was used to understand the association of tuberculosis and multidimensional poverty.

Results

Results suggest that about 29.3% population of India was multidimensional poor and that the multidimensional poverty index was 0.128. The prevalence of tuberculosis among the multidimensional poor was 480 (95% CI: 464–496) per 100,000 population compared to 250 (95% CI: 238–262) among the multidimensional non-poor. The prevalence of tuberculosis among the multidimensional poor was the highest in the state of Kerala (1590) and the lowest in the state of Himachal Pradesh (220). Our findings suggest a significantly higher prevalence of tuberculosis among the multidimensional poor compared to the multidimensional non-poor in most of the states in India. The odds of having tuberculosis among the multidimensional poor were 1.82 times higher (95% CI, 1.73–1.90) compared to the non-poor. Age, sex, smoking, crowded living conditions, caste, religion, and place of residence are significant socio-demographic risk factors of tuberculosis.

Conclusion

The prevalence of tuberculosis is significantly higher among the multidimensional poor compared to the multidimensional non-poor in India.

"Their place is beyond the town's border": A qualitative exploration of stigma associated with tuberculosis in rural and urban areas of Lagos, Nigeria

Tuberculosis (TB) remains a major public health challenge in Nigeria with a minimum yield of various TB control efforts due to sociocultural determinants of health including TB-associated stigma. Therefore, to achieve the Sustainable Development Goal targets for TB control, an understanding and reduction in TB-associated stigma is necessary. The study aims to explore the perspective of community members and investigate the possible ways of mitigating TB-associated stigma in rural and urban areas in Lagos State, Nigeria. Eight focus group discussions (FGD) were conducted among eight homogenous groups of participants living in the community in rural and urban areas of Lagos state who were stratified by gender, between July and November 2017. Analysis of data was done using the modified grounded theory. A total of 86 participants took part in the FGDs. There were various stigmatising behaviours towards people infected with TB in rural and urban communities studied. This includes: Not willing to eat with people suffering from TB, withdrawal from TB patients in social gatherings, verbal abuse of TB patients and refusing to visit their houses because of their illness. There were also misconceptions about the cause of TB in our study which includes spiritual attack, ingestion of cat hair and inhalation of dust. However, participants in the study believed that mitigating the effect of TB-associated stigma will require adequate community education on TB, provision of financial and emotional support to the patients, as well as the involvement of community leaders in TB control activities and stigma reduction interventions. TB-associated stigma exists in rural and urban communities, with a lack of appropriate knowledge of TB and fear of infection as a major determinant in rural and urban areas respectively. Health education and sensitisation about TB, with community leaders as champions could help to mitigate the effect of TB-associated stigma.

Economic evaluation of patient costs associated with tuberculosis diagnosis and care in Solomon Islands

BACKGROUND

Tuberculosis (TB) care can be costly for patients and their families. The End TB Strategy includes a target that zero TB affected households should experience catastrophic costs associated with TB care. Costs are catastrophic when a patient spends 20% or more of their annual household income on their TB diagnosis and care. In Solomon Islands the costs of TB care are unknown. The aim of this study was to determine the costs of TB diagnosis and care, the types of costs and the proportion of patients with catastrophic costs.

METHODS

This was a nationally representative cross-sectional survey of TB patients carried out between 2017 and 2019. Patients were recruited from health care facilities, from all ten provinces in Solomon Islands. During an interview they were asked about the costs of TB diagnosis and care. These data were analysed using descriptive statistics to describe the costs overall and the proportions of different types of costs. The proportion of patients with catastrophic costs was calculated and a multivariate logistic regression was undertaken to determine factors associated with catastrophic costs.

RESULTS

One hundred and eighty-three TB patients participated in the survey. They spent a mean of 716 USD (inter quartile range: 348-1217 USD) on their TB diagnosis and care. Overall, 62.1% of costs were attributable to non-medical costs, while income loss and medical costs comprised 28.5 and 9.4%, respectively. Overall, 19.7% (n = 36) of patients used savings, borrowed money, or sold assets as a financial coping mechanism. Three patients (1.6%) had health insurance. A total of 92.3% (95% CI: 88.5-96.2) experienced catastrophic costs, using the output approach. Being in the first, second or third poorest wealth quintile was significantly associated with catastrophic costs (adjusted odds ratio: 67.3, 95% CI: 15.86-489.74%, p <  0.001).

CONCLUSION

The costs of TB care are catastrophic for almost all patients in Solomon Islands. The provision of TB specific social and financial protection measures from the National TB and Leprosy Programme may be needed in the short term to ameliorate these costs. In the longer term, advancement of universal health coverage and other social and financial protection measures should be pursued.

Socio-protective effects of active case finding on catastrophic costs from tuberculosis in Ho Chi Minh City, Viet Nam: a longitudinal patient cost survey

BACKGROUND

Many tuberculosis (TB) patients incur catastrophic costs. Active case finding (ACF) may have socio-protective properties that could contribute to the WHO End TB Strategy target of zero TB-affected families suffering catastrophic costs, but available evidence remains limited. This study measured catastrophic cost incurrence and socioeconomic impact of an episode of TB and compared those socioeconomic burdens in patients detected by ACF versus passive case finding (PCF).

METHODS

This cross-sectional study fielded a longitudinal adaptation of the WHO TB patient cost survey alongside an ACF intervention from March 2018 to March 2019. The study was conducted in six intervention (ACF) districts and six comparison (PCF) districts of Ho Chi Minh City, Viet Nam. Fifty-two TB patients detected through ACF and 46 TB patients in the PCF cohort were surveyed within two weeks of treatment initiation, at the end of the intensive phase of treatment, and after treatment concluded. The survey measured income, direct and indirect costs, and socioeconomic impact based on which we calculated catastrophic cost as the primary outcome. Local currency was converted into US$ using the average exchange rates reported by OANDA for the study period (VNĐ1 = US$0.0000436, 2018-2019). We fitted logistic regressions for comparisons between the ACF and PCF cohorts as the primary exposures and used generalized estimating equations to adjust for autocorrelation.

RESULTS

ACF patients were poorer than PCF patients (multidimensional poverty ratio: 16 % vs. 7 %; p = 0.033), but incurred lower median pre-treatment costs (US$18 vs. US$80; p < 0.001) and lower median total costs (US$279 vs. US$894; p < 0.001). Fewer ACF patients incurred catastrophic costs (15 % vs. 30 %) and had lower odds of catastrophic cost (aOR = 0.17; 95 % CI: [0.05, 0.67]; p = 0.011), especially during the intensive phase (OR = 0.32; 95 % CI: [0.12, 0.90]; p = 0.030). ACF patient experienced less social exclusion (OR = 0.41; 95 % CI: [0.18, 0.91]; p = 0.030), but more often resorted to financial coping mechanisms (OR = 5.12; 95 % CI: [1.73, 15.14]; p = 0.003).

CONCLUSIONS

ACF can be effective in reaching vulnerable populations and mitigating the socioeconomic burden of TB, and can contribute to achieving the WHO End TB Strategy goals. Nevertheless, as TB remains a catastrophic life event, social protection efforts must extend beyond ACF.

HIV treatment and worker absenteeism: Quasi-experimental evidence from a large-scale health program in South Africa

Over the past decade, large-scale HIV antiretroviral therapy (ART) programs have proven hugely successful in improving the life expectancy of people living with HIV. However, the extent to which treatment allows patients to maintain a productive work life remains an open question. We applied an instrumental variable method based on individual CD4 counts and exogenously changing treatment guidelines to identify the causal effect of ART on health-related absenteeism rates among workers living with HIV. We used monthly data from the occupational health program of one of the world's largest mining companies in South Africa (128,052 observations among 1,924 workers, from 2009 to 2017). Eighteen months after ART initiation, the treatment significantly reduced absenteeism by 1.033 days per worker and month. Using publicly available wage and treatment cost data, we find that the cost savings due to the absenteeism effect of ART alone outweigh treatment costs in the mining sector in several sub-Saharan African countries.

A Framework for Assessing Import Costs of Medical Supplies and Results for a Tuberculosis Program in Karakalpakstan, Uzbekistan

Background. Import of medical supplies is common, but limited knowledge about import costs and their structure introduces uncertainty to budget planning, cost management, and cost-effectiveness analysis of health programs. We aimed to estimate the import costs of a tuberculosis (TB) program in Uzbekistan, including the import costs of specific imported items.Methods. We developed a framework that applies costing and cost accounting to import costs. First, transport costs, customs-related costs, cargo weight, unit weights, and quantities ordered were gathered for a major shipment of medical supplies from the Médecins Sans Frontières (MSF) Procurement Unit in Amsterdam, the Netherlands, to a TB program in Karakalpakstan, Uzbekistan, in 2016. Second, air freight, land freight, and customs clearance cost totals were estimated. Third, total import costs were allocated to different cargos (standard, cool, and frozen), items (e.g., TB drugs), and units (e.g., one tablet) based on imported weight and quantity. Data sources were order invoices, waybills, the local MSF logistics department, and an MSF standard product list.Results. The shipment contained 1.8 million units of 85 medical items of standard, cool, and frozen cargo. The average import cost for the TB program was 9.0% of the shipment value. Import cost varied substantially between cargos (8.9-28% of the cargo value) and items (interquartile range 4.5-35% of the item value). The largest portion of the total import cost was caused by transport (82-99% of the cargo import cost) and allocated based on imported weight. Ten (14%) of the 69 items imported as standard cargo were associated with 85% of the standard cargo import cost. Standard cargo items could be grouped based on contributing to import costs predominantly through unit weight (e.g., fluids), imported quantity (e.g., tablets), or the combination of unit weight and imported quantity (e.g., items in powder form).Conclusion. The cost of importing medical supplies to a TB program in Karakalpakstan, Uzbekistan, was sizable, variable, and driven by a subset of imported items. The framework used to measure and account import costs can be adapted to other health programs.

Health care seeking patterns of rifampicin-resistant tuberculosis patients in Harare, Zimbabwe: A prospective cohort study

Background

Delays in seeking and accessing treatment for rifampicin-resistant tuberculosis (RR-TB) and multi-drug resistant (MDR-TB) are major impediments to TB control in high-burden, resource-limited settings.

Method

We prospectively determined health-seeking behavioural patterns and associations with treatment outcomes and costs among 68 RR-TB patients attending conveniently selected facilities in a decentralised system in Harare, Zimbabwe.

Results

From initial symptoms to initiation of effective treatment, patients made a median number of three health care visits (IQR 2–4 visits) at a median cost of 13% (IQR 6–31%) of their total annual household income (mean cost, US$410). Cumulatively, RR-TB patients most frequently first visited private facilities, i.e., private pharmacies (30%) and other private health care providers (24%) combined. Median patient delay was 26 days (IQR 14–42 days); median health system delay was 97 days (IQR 30–215 days) and median total delay from symptom onset to initiation of effective treatment was 132 days (IQR 51–287 days). The majority of patients (88%) attributed initial delay in seeking care to “not feeling sick enough.” Total delay, total cost and number of health care visits were not associated with treatment or clinical outcomes, though our study was not adequately powered for these determinations.

Conclusions

Despite the public availability of rapid molecular TB tests, patients experienced significant delays and high costs in accessing RR-TB treatment. Active case finding, integration of private health care providers and enhanced service delivery may reduce treatment delay and TB associated costs.

Determinants of household catastrophic costs for drug sensitive tuberculosis patients in Kenya

Background

Despite free diagnosis and treatment for tuberculosis (TB), the costs during treatment impose a significant financial burden on patients and their households. The study sought to identify the determinants for catastrophic costs among patients with drug-sensitive TB (DSTB) and their households in Kenya.

Methods

The data was collected during the 2017 Kenya national patient cost survey from a nationally representative sample (n = 1071). Treatment related costs and productivity losses were estimated. Total costs exceeding 20% of household income were defined as catastrophic and used as the outcome. Multivariable Poisson regression analysis was performed to measure the association between selected individual, household and disease characteristics and occurrence of catastrophic costs. A deterministic sensitivity analysis was carried using different thresholds and the significant predictors were explored.

Results

The proportion of catastrophic costs among DSTB patients was 27% (n = 294). Patients with catastrophic costs had higher median productivity losses, 39 h [interquartile range (IQR): 20–104], and total median costs of USD 567 (IQR: 299–1144). The incidence of catastrophic costs had a dose response with household expenditure. The poorest quintile was 6.2 times [95% confidence intervals (CI): 4.0–9.7] more likely to incur catastrophic costs compared to the richest. The prevalence of catastrophic costs decreased with increasing household expenditure quintiles (proportion of catastrophic costs: 59.7%, 32.9%, 23.6%, 15.9%, and 9.5%) from the lowest quintile (Q1) to the highest quintile (Q5). Other determinants included hospitalization: prevalence ratio (PR) = 2.8 (95% CI: 1.8–4.5) and delayed treatment: PR = 1.5 (95% CI: 1.3–1.7). Protective factors included receiving care at a public health facility: PR = 0.8 (95% CI: 0.6–1.0), and a higher body mass index (BMI): PR = 0.97 (95% CI: 0.96–0.98). Pre TB expenditure, hospitalization and BMI were significant predictors in all sensitivity analysis scenarios.

Conclusions

There are significant inequities in the occurrence of catastrophic costs. Social protection interventions in addition to existing medical and public health interventions are important to implement for patients most at risk of incurring catastrophic costs.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00879-4.

Trend analysis and longitudinal clustering of tuberculosis mortality in Asian and North African countries: Results from the global burden of disease 2017 study

Background: Tuberculosis (TB) is still a serious health problem with a remarkable global burden. In this study, we aimed to assess the trend of TB mortality in Asian and North African countries in the period 1990-2017 and provide a new classification according to TB mortality trend.

Methods: TB mortality rates from 1990 to 2017 were extracted from the Global Burden of Disease website for 55 Asian and North African countries. Trend analysis of TB mortality rates for males, females, and the total population was performed using the marginal modeling approach. Moreover, the latent growth mixture modeling (LGMM) framework was applied to classify these 55 countries based on their trend of TB mortality rate.

Results: In the period between 1990 and 2017, South Asia and High Income Asia-Pacific regions had the highest and lowest death rates due to TB, respectively. The marginal modeling results showed that the Asian and North African countries had experienced a downward trend with an intercept of 28.79 (95%CI: 19.64, 37.94) and a slope (mean annual reduction) of -0.67 (95%CI: -0.91, -0.43) per 100,000 the study period. Finally, the LGMM analysis classified these 55 countries into four distinct classes.

Conclusion: In general, our findings revealed that although the countries in Asia and North Africa super region experienced a descending TB mortality trend in the past decades, the slope of this reduction is quite small. Also, our new classification may be better suited for combating TB through future healthcare planning in lieu of the commonly used geographic classifications.

Determining the value of TB active case-finding: current evidence and methodological considerations

Active case-finding (ACF) is an important component of the End TB Strategy. However, ACF is resource-intensive, and the economics of ACF are not well-understood. Data on the costs of ACF are limited, with little consistency in the units and methods used to estimate and report costs. Mathematical models to forecast the long-term effects of ACF require empirical measurements of the yield, timing and costs of case detection. Pragmatic trials offer an opportunity to assess the cost-effectiveness of ACF interventions within a 'real-world´ context. However, such analyses generally require early introduction of economic evaluations to enable prospective data collection on resource requirements. Closing the global case-detection gap will require substantial additional resources, including continued investment in innovative technologies. Research is essential to the optimal implementation, cost-effectiveness, and affordability of ACF in high-burden settings. To assess the value of ACF, we must prioritize the collection of high-quality data regarding costs and effectiveness, and link those data to analytical models that are adapted to local settings.

Rising Catastrophic Expenditure on Households Due to Tuberculosis: Is India Moving Away From the END-TB Goal?

Introduction: One of the targets of the END-TB strategy is to ensure zero catastrophic expenditure on households due to TB. The information about household catastrophic expenditure is limited in India and, therefore difficult to monitor. The objective is to estimate household and catastrophic expenditure for Tuberculosis using national sample survey data. Methods: For arriving at out-of-pocket expenditure due to tuberculosis and its impact on households the study analyzed four rounds of National Sample Survey data (52nd round-1995-1996, 60th round-2004-2005, 71st round-2014-15, and 75th round 2017-2018). The household interview survey data had a recall period of 365 days for inpatient/ hospitalization and 15 days for out-patient care expenditure. Expenditure amounting to >20% of annual household consumption expenditure was termed as catastrophic. Results: A 5-fold increase in median outpatient care cost in 75th round is observed compared to previous rounds and increase has been maximum while accessing public sector. The overall expense ratio of public v/s private is 1:3, 1:4, 1:5, and 1:5, respectively across four rounds for hospitalization. The prevalence of catastrophic expenditure due to hospitalization increased from 16.5% (52nd round) to 43% (71st round), followed by a decline to 18% in the recent 75th round. Conclusion: Despite free diagnostic and treatment services offered under the national program, households are exposed to catastrophic financial expenditure due to tuberculosis. We strongly advocate for risk protection mechanisms such as cash transfer or health insurance schemes targeting the patients of tuberculosis, especially among the poor.

A Comparative Study of Knowledge, Attitude, and Determinants of Tuberculosis-Associated Stigma in Rural and Urban Communities of Lagos State, Nigeria

Background

Tuberculosis (TB) is an important public health concern in Nigeria. TB-associated stigma could lead to delayed diagnosis and care, treatment default, and multidrug resistance. Understanding of TB-associated stigma is therefore important for TB control. The study is aimed at determining and comparing the knowledge, attitude, and determinants of TB-associated stigma. Methodology. This was a comparative cross-sectional study among adults in urban and rural areas of Lagos State, Nigeria. Respondents were selected through a multistage sampling technique and interviewed using a semistructured questionnaire, which contained the Explanatory Model Interviewed Catalogue (EMIC) stigma scale. IBM SPSS Statistics Software package version 20 was used for analysis.

Results

A total of 790 respondents were interviewed. High proportions of respondents in rural and urban areas were aware of TB (97.5% and 99.2%, respectively). Respondents in the urban areas had overall better knowledge of TB compared to the rural areas (59.4% vs. 23%; p < 0.001), while respondents in the rural areas had a better attitude to TB (60.5% vs. 49.9%; p = 0.002). The majority of respondents in rural and urban areas had TB-associated stigma (93% and 95.7%, respectively). The mean stigma score was higher in the urban compared to rural areas (17.43 ± 6.012 and 16.54 ± 6.324, respectively, p = 0.046). Marital status and ethnicity were the predictors of TB-associated stigma in the rural communities (AOR-0.257; CI-0.086-0.761; p = 0.014 and AOR–3.09; CI-1.087-8.812; p = 0.034, respectively), while average monthly income and age of respondents were the predictors of TB-associated stigma in urban areas (AOR–0.274; CI–0.009-0.807; p = 0.019 and AOR-0.212; CI–0.057-0.788; p = 0.021, respectively).

Conclusion

TB-associated stigma is prevalent in both rural and urban areas in this study. There is therefore a need to disseminate health appropriate information through the involvement of the community. Also, innovative stigma reduction activities are urgently needed.

Households experiencing catastrophic costs due to tuberculosis in Uganda: magnitude and cost drivers

BACKGROUND

Tuberculosis (TB) patients in Uganda incur large costs related to the illness, and while seeking and receiving health care. Such costs create access and adherence barriers which affect health outcomes and increase transmission of disease. The study ascertained the proportion of Ugandan TB affected households incurring catastrophic costs and the main cost drivers.

METHODS

A cross-sectional survey with retrospective data collection and projections was conducted in 2017. A total of 1178 drug resistant (DR) TB (44) and drug sensitive (DS) TB patients (1134), 2 weeks into intensive or continuation phase of treatment were consecutively enrolled across 67 randomly selected TB treatment facilities.

RESULTS

Of the 1178 respondents, 62.7% were male, 44.7% were aged 15-34 years and 55.5% were HIV positive. For each TB episode, patients on average incurred costs of USD 396 for a DS-TB episode and USD 3722 for a Multi drug resistant tuberculosis (MDR TB) episode. Up to 48.5% of households borrowed, used savings or sold assets to defray these costs. More than half (53.1%) of TB affected households experienced TB-related costs above 20% of their annual household expenditure, with the main cost drivers being non-medical expenditure such as travel, nutritional supplements and food.

CONCLUSION

Despite free health care in public health facilities, over half of Ugandan TB affected households experience catastrophic costs. Roll out of social protection interventions like TB assistance programs, insurance schemes, and enforcement of legislation related to social protection through multi-sectoral action plans with central NTP involvement would palliate these costs.

Epidemiological profile among pulmonary and extrapulmonary tuberculosis patients in Laayoune, Morocco

Introduction

despite major strides in the prevention, diagnosis and management of tuberculosis, the disease continues to be one of the most pressing global health problems, particularly in developing countries. The purpose of the present study was to describe the epidemiological profile among tuberculosis patients in Laayoune, Morocco.

Methods

a retrospective study was conducted among tuberculosis patients (having extrapulmonary tuberculosis and pulmonary tuberculosis), registered in the diagnosis of tuberculosis and respiratory diseases reference center of Laayoune, between January 2017 and May 2018. Demographic characteristics, clinical presentation of TB and apparent risk factors of the disease were obtained from the medical case records of all patients.

Results

during the study period, a total of 211 patients (125 males and 86 females) with tuberculosis were enrolled. The majority of cases (93.40%) were newly diagnosed and the segment with the pulmonary tuberculosis was 63.50%. The highest disease burden was found in the ≥15 year age group (92.40%; p=0.022). Men were more frequently affected by pulmonary tuberculosis (70.90%), while extrapulmonary tuberculosis was more commonly detected in women (61%) (p<0.0001). The most common sites of extrapulmonary disease were lymphatic (32.47%), pleural (16.88%) and spinal tuberculosis (15.58%). HIV infection and smoking seem to be the most important risk factors that affect host defense against TB infection.

Conclusion

the results obtained in tuberculosis patients in Laayoune, Morocco, showed that active tuberculosis was associated with risk factors such as sex, age and smoking.

What causes high costs for rural tuberculosis inpatients? Evidence from five counties in China

BACKGROUND

Tuberculosis (TB) still causes high economic burden on patients in China, especially for rural patients. Our study aims to explore the risk factors associated with the high costs for TB inpatients in rural China from the aspects of inpatients' socio-demographic and institutional attributes.

METHODS

Generalized linear models were utilized to investigate the factors associated with TB inpatients' total costs and out-of-pocket (OOP) expenditures. Quantile regression (QR) models were applied to explore the effect of each factor across the different costs range and identify the risk factors of high costs.

RESULTS

TB inpatients with long length of stay and who receive hospitalization services cross provincially, in tertiary and specialized hospitals were likely to face high total costs and OOP expenditures. QR models showed that high total costs occurred in Dingyuan and Funan Counties, but they were not accompanied by high OOP expenditures.

CONCLUSIONS

Early diagnosis, standard treatment and control of drug-resistant TB are still awaiting for more efforts from the government. TB inpatients should obtain medical services from appropriate hospitals. The diagnosis and treatment process of TB should be standardized across all designated medical institutions. Furthermore, the reimbursement policy for migrant workers who suffered from TB should be ameliorated.

Research protocol for a mixed-methods study to characterise and address the socioeconomic impact of accessing TB diagnosis and care in Nepal

Background: WHO's 2015 End TB Strategy advocates social and economic (socioeconomic) support for TB-affected households to improve TB control. However, evidence concerning socioeconomic support for TB-affected households remains limited, especially in low-income countries. Protocol: This mixed-methods study in Nepal will: evaluate the socioeconomic impact of accessing TB diagnosis and care (Project 1); and create a shortlist of feasible, locally-appropriate interventions to mitigate this impact (Project 2). The study will be conducted in the Chitwan, Mahottari, Makawanpur, and Dhanusha districts of Nepal, which have frequent TB and poverty. The study population will include: approximately 200 people with TB (Cases) starting TB treatment with Nepal's National TB Program and 100 randomly-selected people without TB (Controls) in the same sites (Project 1); and approximately 40 key in-country stakeholders from Nepal including people with TB, community leaders, and TB healthcare professionals (Project 2). During Project 1, visits will be made to people with TB's households during months 3 and 6 of TB treatment, and a single visit made to Control households. During visits, participants will be asked about: TB-related costs (if receiving treatment), food insecurity, stigma; TB-related knowledge; household poverty level; social capital; and quality of life. During Project 2, stakeholders will be invited to participate in: a survey and focus group discussion (FGD) to characterise socioeconomic impact, barriers and facilitators to accessing and engaging with TB care in Nepal; and a one-day workshop to review FGD findings and suggest interventions to mitigate the barriers identified. Ethics and dissemination: The study has received ethical approval. Results will be disseminated through scientific meetings, open access publications, and a national workshop in Nepal.  Conclusions: This research will strengthen understanding of the socioeconomic impact of TB in Nepal and generate a shortlist of feasible and locally-appropriate socioeconomic interventions for TB-affected households for trial evaluation.

Pre-diagnostic drop out of presumptive TB patients and its associated factors at Bugembe Health Centre IV in Jinja, Uganda

BACKGROUND

Drop out of presumptive TB individuals before making a final diagnosis poses a danger to the individual and their community. We aimed to determine the proportion of these presumptive TB drop outs and their associated factors in Bugembe Health Centre, Jinja, Uganda.

METHODS

We used data from the DHIS2, presumptive and laboratory registers of Bugembe Health Centre IV for 2017. Descriptive statistics were used to summarize the population characteristics. A modified Poisson regression model via the generalized linear model (GLM) with log link and robust standard errors was used for bivariate and multivariate analysis.We used data from the DHIS2, presumptive and laboratory registers of Bugembe Health Centre IV for 2017. Descriptive statistics were used to summarize the population characteristics. A modified Poisson regression model via the generalized linear model (GLM) with log link and robust standard errors was used for bivariate and multivariate analysis.

RESULT

Among the 216 registered presumptive TB patients who were less than 1% of patients visiting the outpatients' department, 40.7% dropped out before final diagnosis was made. Age and HIV status were significantly associated with pre-diagnostic drop out while gender and distance from the health center were not.

CONCLUSION

A high risk to individuals and the community is posed by the significant proportion of presumptive TB patients dropping out before final diagnosis. Health systems managers need to consider interventions targeting young persons, male patients, HIV positive persons.

Direct and indirect patient costs of tuberculosis care in India

OBJECTIVE

To synthesise the evidence for estimating the direct and indirect patient costs of drug-sensitive and drug-resistant tuberculosis care in India.

METHOD

PubMed, Embase, Web of Science, IndMED and Google Scholar were searched for studies conducted in India between 2000 and 2018 and published in English. The search terms were "tuberculosis" AND "costs" (cost Analysis, economics, cost of illness, health care costs, health expenditures, direct service costs, catastrophic cost) AND "India". The cost of TB care was from the patient's perspective. Data regarding costs were extracted, indexed to the year 2018 using cumulative inflation rate and converted to US dollars at the exchange rate of 2018.

RESULTS

Thirteen studies were included in this review. The mean (unweighted) total cost incurred by patients being treated for drug-sensitive TB in a public health facility was $ 235.00 (SD- 222.10), and the median of means was $ 170.60 (range - 43.70-718.40). The mean direct cost was 45.5% of the total cost. Only one study, which was conducted in a private facility, reported the mean total cost for drug-resistant TB as $ 7778.04. Catastrophic cost (total cost ≥ 20% of the total annual household income) was experienced by 7% to 32.4% of drug-sensitive TB patients and by 68% of drug-resistant TB patients.

CONCLUSION

Despite free diagnostic and treatment services provided under the Revised National Tuberculosis Control Programme, the patient cost of tuberculosis care is high. Relevant studies vary widely in methodology and cost reporting.

Out-of-pocket payments and economic consequences from tuberculosis care in eastern China: income inequality

BACKGROUND

Despite the availability of free tuberculosis (TB) diagnosis and treatment, TB care still generates substantial costs that push people into poverty. We investigated out-of-pocket (OOP) payments for TB care and assessed the resulting economic burden and economic consequences for those with varying levels of household income in eastern China.

METHODS

A cross-sectional study was conducted among TB patients in the national TB programme networks in eastern China. TB-related direct OOP costs, time loss, and coping strategies were investigated across households in different economic strata. Analysis of Variance was used to examine the differences in various costs, and Kruskal-Wallis tests were used to compare the difference in total costs as a percentage of annual household income.

RESULTS

Among 435 patients, the mean OOP total costs of TB care were USD 2389.5. In the lower-income quartile, OOP payments were lower, but costs as a percentage of reported annual household income were higher. Medical costs and costs prior to treatment accounted for 66.4 and 48.9% of the total costs, respectively. The lower the household income was, the higher the proportion of medical costs to total costs before TB treatment, but the lower the proportion of medical costs patients spent in the intensive phase. TB care caused 25.8% of TB-affected households to fall below the poverty line and caused the poverty gap (PG) to increase by United States Dollar (USD) 145.6. Patients in the poorest households had the highest poverty headcount ratio (70.2%) and PG (USD 236.1), but those in moderately poor households had the largest increase in the poverty headcount ratio (36.2%) and PG (USD 177.8) due to TB care. Patients from poor households were more likely to borrow money to cope with the costs of TB care; however, there were fewer social consequences, except for food insecurity, in poor households.

CONCLUSIONS

Medical and pretreatment costs lead to high costs of TB care, especially among patients from the poorest households. It is necessary to train health system staff in general hospitals to promptly identify and refer TB patients. Pro-poor programmes are also needed to protect TB patients from the medical poverty trap.

Research protocol for a mixed-methods study to characterise and address the socioeconomic impact of accessing TB diagnosis and care in Nepal

Background: WHO's 2015 End TB Strategy advocates social and economic (socioeconomic) support for TB-affected households to improve TB control. However, evidence concerning socioeconomic support for TB-affected households remains limited, especially in low-income countries. Protocol: This mixed-methods study in Nepal will: evaluate the socioeconomic impact of accessing TB diagnosis and care (Project 1); and create a shortlist of feasible, locally-appropriate interventions to mitigate this impact (Project 2). The study will be conducted in the Chitwan, Mahottari, Makawanpur, and Dhanusha districts of Nepal, which have frequent TB and poverty. The study population will include: approximately 200 people with TB (Cases) starting TB treatment with Nepal's National TB Program and 100 randomly-selected people without TB (Controls) in the same sites (Project 1); and approximately 40 key in-country stakeholders from Nepal including people with TB, community leaders, and TB healthcare professionals (Project 2). During Project 1, visits will be made to people with TB's households during months 3 and 6 of TB treatment, and a single visit made to Control households. During visits, participants will be asked about: TB-related costs (if receiving treatment), food insecurity, stigma; TB-related knowledge; household poverty level; social capital; and quality of life. During Project 2, stakeholders will be invited to participate in: a survey and focus group discussion (FGD) to characterise socioeconomic impact, barriers and facilitators to accessing and engaging with TB care in Nepal; and a one-day workshop to review FGD findings and suggest interventions to mitigate the barriers identified. Ethics and dissemination: The study has received ethical approval. Results will be disseminated through scientific meetings, open access publications, and a national workshop in Nepal.  Conclusions: This research will strengthen understanding of the socioeconomic impact of TB in Nepal and generate a shortlist of feasible and locally-appropriate socioeconomic interventions for TB-affected households for trial evaluation.

Barriers for tuberculosis case finding in Southwest Ethiopia: A qualitative study

BACKGROUND

Ethiopia is one of the countries with a high burden of tuberculosis (TB). Jimma Zone has the lowest TB case notification rate compared to the national and World Health Organization's (WHO) targets. The aim of the present study was to identify barriers, and explore the origin of these barriers in relation to TB case finding.

METHODS

A qualitative study was conducted by using different data collection methods and sources. Sixty in-depth interviews with TB treatment providers, program managers and TB patients were included. In addition, 42 governmental health facilities were observed for availability of resources. Data obtained from the in-depth interviews were transcribed, coded, categorized and thematized. Atlas.ti version 7.1 software was used for the data coding and categorizing.

RESULTS

Inadequate resources for TB case finding, such as a shortage of health-care providers, inadequate basic infrastructure, and inadequate diagnostic equipment and supplies, as well as limited access to TB diagnostic services such as an absence of nearby health facilities providing TB diagnostic services and health system delays in the diagnostic process, were identified as barriers for TB case finding. We identified the absence of trained laboratory professionals in 11, the absence of clean water supply in 13 and the electricity in seven health facilities. Furthermore, we found that difficult topography, the absence of proper roads, an inadequate collaboration with other sectors (such as education), a turnover of laboratory professionals, and a low community mobilization, as the origin of some of these barriers.

CONCLUSION

Inadequate resources for TB case finding, and a limited access to diagnostic services, were major challenges affecting TB case finding. The optimal application of the directly observed treatment short course (Stop TB) strategy is crucial to increase the current low TB case notification rate. Practical strategies need to be designed to attract and retain health professionals in the health system.

Direct costs of illness of patients with chronic cough in rural Malawi-Experiences from Dowa and Ntchisi districts

INTRODUCTION

Chronic cough is a distressing symptom and a common reason for people to seek health care services. It is a symptom that can indicate underlying tuberculosis (TB) and/or chronic airways diseases (CAD) including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis. In developing countries including Malawi, provision of diagnostic services and clinical management of CAD is rudimentary, so it is thought that patients make costly and unyielding repeated care-seeking visits. There is, however, a lack of information on cost of illness, both direct and indirect, to patients with chronic cough symptom. Such data are needed to inform policy-makers in making decisions on allocating resources for designing and developing the relevant health care services to address universal coverage programmes for CAD. This paper therefore explores health seeking costs associated with chronic cough and explores information on usage of the coping mechanisms which indicate financial hardship, such as borrowing and selling household assets.

METHODS

This economic study was nested within a community-based, population-proportional cross-sectional survey of 15,795 individuals aged 15 years and above, in Dowa and Ntchisi districts. The study sought to identify individuals with symptoms of chronic airways disease whose health records documented at least one of the following diagnoses within the previous year: TB, Asthma, COPD, Bronchitis and Lower Respiratory Tract Infection (LRTI). We interviewed these chronic coughers to collect information on socioeconomic and socio-demographic characteristics, health care utilization, and associated costs of care in 2015. We also collected information on how they funded their health seeking costs.

RESULTS

We identified 608 chronic coughers who reported costs in relation to their latest confirmed diagnosis in their hand-held health record. The mean care-seeking cost per patient was US$ 3.9 (95% CI: 3.00-5.03); 2.3 times the average per capita expenditure on health of US$ 1.69. The largest costs were due to transport (US$ 1.4), followed by drugs (US$ 1.3). The costs of non-medical inputs (US$ 2.09) was considerable (52.3%). Nearly a quarter (24.4%) of all the patients reportedly borrowed or/and sold assets/property to finance their healthcare. CCs with COPD and LRTI had 85.6% and 62.0% lower chance of incurring any costs compared with the TB patients and any patients with comorbidity had 2.9 times higher chance to incur any costs than the patients with single disease. COPD, Bronchitis and LRTI patients had 123.9%, 211.4% and 87.9% lower costs than the patients with TB. The patients with comorbidity incurred 53.9% higher costs than those with single disease.

CONCLUSIONS

The costs of healthcare per chronic cougher was mainly influenced by the transport and drugs costs. Types of diseases and comorbidity led to significantly different chances of incurring costs as well as difference in magnitude of costs. The costs appeared to be unaffordable for many patients.

Time Interval for Diagnosis of Tuberculosis and Related Expenditure in Selected Health Centers in Addis Ababa, Ethiopia

Background. Tuberculosis (TB) has continued to be a major health problem globally, in spite of the efforts to improve the diagnosis, treatment, and prevention. It affects millions of people each year and stands as the second cause of death due to infectious disease in the world. Early case finding and timely initiation of treatment is essential to ensure effective control of the disease as late diagnosis and treatment can aggravate the disease and result in poor outcomes and increase chances of transmission. Although TB services are supposed to be provided free of charge, TB affected families incur different types of costs in the process of seeking care, which might include health and nonhealth related costs. TB programs need to identify the underlying factors for delay and related expenditure for TB related services, in order to devise an effective strategy to reduce them. Therefore, the study aimed to assess the time interval between developing TB symptom until patients start anti-TB treatment and associated cost incurred by patients and families. Methods. This cross-sectional study was conducted among pulmonary TB patients who are bacteriologically confirmed, whose age is above 15 years and diagnosed at health centres in Addis Ababa. Results. The median time interval between onset of symptom and commencement of treatment was 4 weeks (IQR: 3, 6). Most patients with TB symptoms visited several health facilities before the final diagnosis was confirmed, the median number of visits being two, and only 48.8% were diagnosed on their first visit. Hence, they spent a lot of their limited resource in search of getting the right diagnosis. The total combined expenditure for all the visits was estimated to be median (IQR) 172.65 birrs (12, 671). Two variables were found to show statistically significant association with higher expenditure. Respondents who have good level of knowledge about TB are less likely to spend more than the median expenditure almost by a fifth compared to those with limited knowledge on TB, (adjusted odds ratio (AOR) = 0.2, with 95% confidence interval (CI): 0.06, 0.84). Patients who visited public hospitals were almost three times and those who visited private health facilities almost four times more likely to pay more than the median total expenditure, compared to those who visited health centre, AOR (95% CI) = 2.8 (1.53, 5.19) and AOR (CI) of 3.86 (1.06, 14.03), respectively. Conclusion. Patients with TB symptoms visit several health facilities till they are diagnosed, the median duration from onset of symptom till commencement of TB treatment being 4 weeks. It was noted that they face major expenses in the process of navigation to the right care. Two variables had statistically significant association with high pre-diagnosis expenditure, where patients with good level of knowledge about TB are less likely to spend more than the median, while patients who visited public hospitals or private health facilities had very high expenses. Improved public awareness about TB, minimizing service charges and other related fees, and further improvement in increasing access to services could reduce the length of time and expense for TB patients and their families. It is recommended to build capacity of health service providers to update them on programmatic approaches and latest diagnostic algorithm. It is important to strengthen public private partnership for TB services.

User-experience and patient satisfaction with quality of tuberculosis care in India: A mixed-methods literature review

BACKGROUND

Tuberculosis affected 2.7 million people in India in 2017. The Revised National TB Control Programme has achieved milestones in coverage, however quality of TB care remains highly variable and often poor, with significant gaps in provider knowledge, practices, and patients consistently lost to follow-up. These quality gaps are largely informed by studies on provider practices or objective chart abstractions and case data. Per the knowledge of the author, no review has been conducted on first-hand patient perspectives on the quality of TB care they receive. This mixed-methods literature review aims to synthesize evidence on user-experience and patient satisfaction with TB care in India and inform areas for service quality improvement.

METHODS

Five medical databases, including PubMed, EMBASE, Global Health (Ovid), Web of Science, and CINAHL were searched for empirical studies on patient perspectives on TB health services published between January 1st, 2000 to December 31st, 2017. Studies in English with adult patients with any form of TB in the public or private health system were included. Studies prior to entering the health system, on distance to health facilities and cost were excluded. Seven Indian journals were hand searched and a grey literature search was conducted in GoogleScholar. Studies were assessed for methodological quality and thematic analysis was conducted by categorizing data using NVivo 12.

RESULTS

A total of 498 studies were screened, of which 23 met the inclusion criteria. 16 supplementary studies were identified from Indian journals and grey literature. Of the 39 total studies included most were quantitative (29; 74%), based in South India (17; 44%) and focused on drug-sensitive TB patients (19; 49%) within the public health system (25; 64%). Data collection methods were highly heterogenous which limited synthesis and comparisons across population demographics, health sectors, or regions. Overall quantitative patient satisfaction measured in seven studies was high. Two major themes identified were provider-related factors (n = 26 studies) and convenience (n = 25), and six minor themes were supplies and equipment availability (n = 12), confidence (n = 10), information and communication (n = 10), waiting time (n = 8), stigma (n = 4), and confidentiality (n = 4). Each reported positive and negative user-experiences. Most significantly, DOTS did not fit the daily needs and obligations of many patients, particularly due to conflicts with employment and frequency of visits; while positive provider support, information, and flexibility helped patients adhere to treatment.

CONCLUSION

Although quantitative patient satisfaction was found to be high, data were not collected using robust, validated tools. Qualitative and quantitative user-experiences in each theme were variable, making them both barriers and facilitators of good quality TB care. Poor user-experiences were often responsible for patients interrupting treatment or dropping out of TB care. Patient-centeredness, or user-friendliness of TB care can be improved by introducing individualized or flexible DOTS that is responsive to user circumstances and needs. User-experience data should be systematically collected using a standardized, national tool for identification of specific bottlenecks and successes in quality of TB care from the patients' perspective.

Tuberculosis patients with higher levels of poverty face equal or greater costs of illness

SETTING: Fifty-six public clinics in Limpopo Province, South Africa.OBJECTIVE: To evaluate the association between tuberculosis (TB) patient costs and poverty as measured by a multidimensional poverty index.DESIGN: We performed cross-sectional interviews of consecutive patients with TB. TB episode costs were estimated from self-reported income, travel costs, and care-seeking time. Poverty was assessed using the South African Multidimensional Poverty Index (SAMPI) deprivation score (a 12-item household-level index), with higher scores indicating greater poverty. We used multivariable linear regression to adjust for age, sex, human immunodeficiency virus status and travel time.RESULTS: Among 323 participants, 108 (33%) were 'deprived' (deprivation score >0.33). For each 0.1-unit increase in deprivation score, absolute TB episode costs were 1.11 times greater (95%CI 0.97-1.26). TB episode costs were 1.19 times greater with each quintile of higher deprivation score (95%CI 1.00-1.40), but lower by a factor of 0.54 with each quintile of lower self-reported income (higher poverty, 95%CI 0.46-0.62).CONCLUSION: Individuals experiencing multidimensional poverty and the cost of tuberculosis illness in Limpopo, South Africa faced equal or higher costs of TB than non-impoverished patients. Individuals with lower self-reported income experienced higher costs as a proportion of household income but lower absolute costs. Targeted interventions are needed to reduce the economic burden of TB on patients with multidimensional poverty.

Knowledge, attitudes, and practices related to TB among the general population of Ethiopia: Findings from a national cross-sectional survey

INTRODUCTION

Ethiopia is among the high-burden countries for tuberculosis (TB), TB/HIV, and drug-resistant TB. The aim of this nationwide study was to better understand TB-related knowledge, attitudes, and practices (KAPs) and generate evidence for policy and decision-making.

MATERIALS AND METHODS

We conducted a cross-sectional TB KAP survey in seven regions and two city administrations of Ethiopia. Eighty kebeles (wards) and 40 health centers were randomly selected for the study. Using systematic sampling, 22 households and 11 TB patients were enrolled from each selected village and health center, respectively. Variables with a value of p = < 0.25 were included in the model for logistic regression analysis.

RESULTS

Of 3,503 participants, 884 (24.4%), 836 (24.1%), and 1,783 (51.5%) were TB patients, families of TB patients, and the general population, respectively. The mean age was 34.3 years, and 50% were women. Forty-six percent were heads of households, 32.1% were illiterate, 20.3% were farmers, and 19.8% were from the lowest quintile. The majority (95.5%) had heard about TB, but only 25.8% knew that TB is caused by bacteria. Cough or sneezing was reported as the commonest means of TB transmission. The majority (85.3%) knew that TB could be cured. Men, better-educated people, and TB patients and their families have higher knowledge scores. Of 2,483 participants, 96% reported that they would go to public health facilities if they developed TB symptoms.

DISCUSSION

Most Ethiopians have a high level of awareness about TB and seek care in public health facilities, and communities are generally supportive. Inadequate knowledge about TB transmission, limited engagement of community health workers, and low preference for using community health workers were the key challenges.

CONCLUSIONS

Given misconceptions about TB's causes, low preference for use of community health workers, and inadequate engagement, targeted health education interventions are required to improve TB services.

The Presence of Cough and Tuberculosis: Active Case Finding Outcomes in the Philippines

The results of a tuberculosis (TB) active case finding (ACF) program, implemented by International Care Ministries (ICM) in the Philippines, were examined to understand how the presence of physical symptoms might influence ACF outcomes among extreme low-income Filipinos. ICM health staff implemented symptom screening in villages and suspected cases were referred to the closest rural health unit (RHU) for TB testing. ACF was carried out in Mindanao and the Visayas, across 16 different provinces. All participants were interviewed pre/postprogram, and screening outcomes were collected. A multilevel regression model was constructed to explore the effect of factors on the likelihood of getting tested. A total of 4635 individuals were screened; 1290 (27.8%) were symptom positive and referred. From those referred, 336 (7.2%) were tested for TB and 53 (1.1%) were TB positive. “Cough for more than two weeks” was associated with a 1.09 (95% CI 1.01, 1.15) times increase in likelihood of getting tested. The finding that the presence of cough is associated with higher rate of testing suggests that individuals in these settings might not know or believe that the lack of cough does not equate to lack of TB infection. While technologies and screening algorithms give us the ability to refine the ‘supply' side of the TB screening, addressing the knowledge gap should improve ‘demand'.

The impact of increased reimbursement rates under the new cooperative medical scheme on the financial burden of tuberculosis patients

Background

Tuberculosis (TB) is still a major public health problem in China. To scale up TB control, an innovative programme entitled the ‘China-Gates Foundation Collaboration on TB Control in China was initiated in 2009. During the second phase of the project, a policy of increased reimbursement rates under the New Cooperative Medical Scheme (NCMS) was implemented. In this paper, we aim to explore how this reform affects the financial burden on TB patients through comparison with baseline data.

Methods

In two cross-sectional surveys, quantitative data were collected before (January 2010 to December 2012) and after (April 2014 to June 2015) the intervention in the existing NCMS routine data system. Information on all 313 TB inpatients, among which 117 inpatients in the project was collected. Qualitative data collection included 11 focus group discussions. Three main indicators, non-reimbursable expenses rate (NER), effective reimbursement rate (ERR), and out-of-pocket payment (OOP) as a percentage of per capita household income, were used to measure the impact of intervention by comprising post-intervention data with baseline data. The quantitative data were analysed by descriptive analysis and non-parametric tests (Mann-Whitney U test) using SPSS 22.0, and qualitative data were subjected to thematic framework analysis using Nvivo10.

Results

The nominal reimbursement rates for inpatient care were no less than 80% for services within the package. Total inpatient expenses greatly increased, with an average growth rate of 11.3%. For all TB inpatients, the ERR for inpatient care increased from 52 to 66%. Compared with inpatients outside the project, for inpatients covered by the new policy, the ERR was higher (78%), and OOP showed a sharper decline. In addition, their financial burden decreased significantly.

Conclusions

Although the nominal reimbursement rates for inpatient care of TB patients greatly increased under the new reimbursement policy, inpatient OOP expenditure was still a major financial problem for patients. Limited diagnosis and treatment options in county general hospitals and inadequate implementation of the new policy resulted in higher inpatient expenditures and limited reimbursement. Comprehensive control models are needed to effectively decrease the financial burden on all TB patients.

Electronic supplementary material

The online version of this article (10.1186/s40249-019-0575-z) contains supplementary material, which is available to authorized users.

The Financial Burden of Tuberculosis for Patients in the Western-Pacific Region

The End Tuberculosis (TB) Strategy has the ambitious goal of ending the global TB epidemic by the year 2030, which is aligned to the Sustainable Development Goals. One of three high level indicators of the Strategy is the “catastrophic costs” indicator, which aims to determine the proportion of TB-affected households that incur TB-care related costs equivalent to 20% or more of their annual household income. The target is that zero percentage of TB-affected households will incur catastrophic costs related to TB care by the year 2020. In the Western Pacific Region of the World Health Organization, it is a priority to determine the financial burden of TB and then act to mitigate it. To date, eight countries in the Region have conducted nationally representative TB patient cost surveys to determine the costs of TB care. The results from four countries that have completed these surveys (i.e., Fiji, Mongolia, the Philippines, and Vietnam) indicate that between 35% and 70% of TB patients face catastrophic costs related to their TB care. With these results in mind, significant additional efforts are needed to ensure financial risk protection for TB patients, expand Universal Health Coverage, and improve access to social protection interventions. A multi-sectoral approach is necessary to achieve this ambitious goal by the year 2020.