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Chatterjee S, Das P, Stallworthy G, Bhambure G, Munje R, Vassall A. Catastrophic costs for tuberculosis patients in India: Impact of methodological choices. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003078. [PMID: 38669225 PMCID: PMC11051603 DOI: 10.1371/journal.pgph.0003078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/16/2024] [Indexed: 04/28/2024]
Abstract
As financial risk protection is one of the goals towards universal health coverage, detailed information on costs, catastrophic costs and other economic consequences related to any disease are required for designing social protection measures. End Tuberculosis (TB) Strategy set a milestone of achieving zero catastrophic cost by 2020. However, a recent literature review noted that 7%-32% TB affected households in India faced catastrophic cost. Studies included in the review were small scale cross-sectional. We followed a cohort of 1482 notified drug-susceptible TB patients from four states in India: Assam, Maharashtra, Tamil Nadu, and West Bengal to provide a comprehensive picture of economic burden associated with TB treatment. Treatment cost was calculated using World Health Organization guidelines on TB patient cost survey and both human capital and output approaches of indirect cost (time, productivity, and income loss related to an episode) calculation were used to provide the range of households currently facing catastrophic cost. Depending on choice of indirect cost calculation method, 30%-61% study participants faced catastrophic cost. For over half of them, costs became catastrophic even before starting TB treatment as there was average 7-9 weeks delay from symptom onset to treatment initiation which was double the generally accepted delay of 4 weeks. During that period, they made average 8-11 visits to different providers and spent money on consultations, drugs, tests, and travel. Following the largest cohort of drug-susceptible TB patients till date, the study concluded that a significant proportion of study participants faced catastrophic cost and the proportion was much higher when income loss was considered as indirect cost calculation method. Therefore, ensuring uninterrupted livelihood during TB treatment is an absolute necessity. Another reason of high cost was the delay in diagnosis and costs incurred during pre-diagnosis period. This delay and consequently, economic burden, can be reduced by both supply side (intense private sector engagement, rapid diagnosis) and demand side (community engagement) initiatives. Reimbursement of expenses incurred before treatment initiation could be used as short-term measure for mitigating financial hardship.
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Affiliation(s)
- Susmita Chatterjee
- Research Department, George Institute for Global Health, New Delhi, India
- Department of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Palash Das
- Research Department, George Institute for Global Health, New Delhi, India
| | - Guy Stallworthy
- Bill & Melinda Gates Foundation, Global Health Division, Seattle, Washington State, United States of America
| | - Gayatri Bhambure
- Research Department, George Institute for Global Health, New Delhi, India
| | - Radha Munje
- Department of Respiratory Medicine, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Sharma P, Zadey S, Mor N. Integrating schemes could be beneficial but requires supportive evidence. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 23:100386. [PMID: 38500711 PMCID: PMC10945162 DOI: 10.1016/j.lansea.2024.100386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/27/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Parth Sharma
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Department of Community Medicine, Maulana Azad Medical College, New Delhi, 110060, India
| | - Siddhesh Zadey
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University School of Medicine, Durham, NC, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York City, NY, USA
- Dr. D.Y. Patil Medical College, Hospital, and Research Centre, Pune, Maharashtra, India
| | - Nachiket Mor
- Banyan Academy of Leadership in Mental Health, Thiruvidanthai, Kanchipuram, Tamil Nadu, 603112, India
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3
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Hashim Z, Tyagi R, Singh GV, Nath A, Kant S. Preventive treatment for latent tuberculosis from Indian perspective. Lung India 2024; 41:47-54. [PMID: 38160459 PMCID: PMC10883444 DOI: 10.4103/lungindia.lungindia_336_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/30/2023] [Indexed: 01/03/2024] Open
Abstract
The persistent morbidity and mortality associated with tuberculosis (TB), despite our continued efforts, has been long recognized, and the rise in the incidence of drug-resistant TB adds to the preexisting concern. The bulk of the TB burden is confined to low-income countries, and rigorous efforts are made to detect, notify, and systematically treat TB. Efforts have been infused with renewed vigor and determination by the World Health Organization (WHO) to eliminate tuberculosis in the near future. Different health agencies worldwide are harvesting all possible strategies apart from consolidating ongoing practices, including prevention of the development of active disease by treating latent TB infection (LTBI). The guidelines for the same were already provided by the WHO and were then adapted in the Indian guidelines for the treatment of LTBI in 2021. While the long-term impact of TBI treatment is awaited, in this article, we aim to discuss the implications in the Indian context.
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Affiliation(s)
- Zia Hashim
- Department of Pulmonary Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Richa Tyagi
- Department of Pulmonary Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Gajendra Vikram Singh
- Department of Respiratory Medicine, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
| | - Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Surya Kant
- Department of Respiratory Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
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Reid M, Agbassi YJP, Arinaminpathy N, Bercasio A, Bhargava A, Bhargava M, Bloom A, Cattamanchi A, Chaisson R, Chin D, Churchyard G, Cox H, Denkinger CM, Ditiu L, Dowdy D, Dybul M, Fauci A, Fedaku E, Gidado M, Harrington M, Hauser J, Heitkamp P, Herbert N, Herna Sari A, Hopewell P, Kendall E, Khan A, Kim A, Koek I, Kondratyuk S, Krishnan N, Ku CC, Lessem E, McConnell EV, Nahid P, Oliver M, Pai M, Raviglione M, Ryckman T, Schäferhoff M, Silva S, Small P, Stallworthy G, Temesgen Z, van Weezenbeek K, Vassall A, Velásquez GE, Venkatesan N, Yamey G, Zimmerman A, Jamison D, Swaminathan S, Goosby E. Scientific advances and the end of tuberculosis: a report from the Lancet Commission on Tuberculosis. Lancet 2023; 402:1473-1498. [PMID: 37716363 DOI: 10.1016/s0140-6736(23)01379-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/14/2023] [Accepted: 06/29/2023] [Indexed: 09/18/2023]
Affiliation(s)
- Michael Reid
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Yvan Jean Patrick Agbassi
- Global TB Community Advisory Board, Abidjan, Côte d'Ivoire, Yenepoya Medical College, Mangalore, India
| | | | - Alyssa Bercasio
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Anurag Bhargava
- Department of General Medicine, Yenepoya Medical College, Mangalore, India
| | - Madhavi Bhargava
- Department of Community Medicine, Yenepoya Medical College, Mangalore, India
| | - Amy Bloom
- Division of Tuberculosis, Bureau of Global Health, USAID, Washington, DC, USA
| | | | - Richard Chaisson
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Chin
- Bill and Melinda Gates Foundation, Seattle, WA, USA
| | | | - Helen Cox
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Claudia M Denkinger
- Heidelberg University Hospital, German Center of Infection Research, Heidelberg, Germany
| | | | - David Dowdy
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Dybul
- Department of Medicine, Center for Global Health Practice and Impact, Georgetown University, Washington, DC, USA
| | - Anthony Fauci
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | | | | | | | - Petra Heitkamp
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Nick Herbert
- Global TB Caucus, Houses of Parliament, London, UK
| | | | - Philip Hopewell
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Emily Kendall
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Aamir Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Andrew Kim
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Nalini Krishnan
- Resource Group for Education and Advocacy for Community Health (REACH), Chennai, India
| | - Chu-Chang Ku
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Erica Lessem
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Payam Nahid
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Mario Raviglione
- Centre for Multidisciplinary Research in Health Science, University of Milan, Milan, Italy
| | - Theresa Ryckman
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Sachin Silva
- Harvard TH Chan School of Public Health, Harvard University, Cambridge, MA, USA
| | | | | | | | | | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Gustavo E Velásquez
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Dean Jamison
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Eric Goosby
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
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Sinha R, Rana RK, Kujur A, Jahnavi G, Kumar M, Venugopal V, Priya N, Kujur M, Jha RR, Barnwal R, Nishant N, Murmu N, Pathak R, T A, Prasad R, Dayal R, Modi B, Purty AJ, Bn S, Nair D, Kumar D. Trends of Private Drugs' Sales and Costs Incurred by Patients on Anti-tuberculosis Drugs in Selected Districts of Jharkhand (2022): Results From Sub-national TB-Free Certification. Cureus 2023; 15:e47296. [PMID: 38021489 PMCID: PMC10656432 DOI: 10.7759/cureus.47296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND The government of India is committed to eliminating tuberculosis (TB) by 2025 under the National Tuberculosis Elimination Programme which provides free investigations and treatment as well as incentives for nutritional support during their treatment course. Many TB patients prefer to seek treatment from the private sector which sometimes leads to financial constraints for the patients. Our study aims to find the burden of TB patients in the private sector and the expenses borne by them for their treatment. METHODOLOGY Sales data of rifampicin-containing formulation drug consumption in the private sector of six districts of Jharkhand was collected from Clearing and Forwarding agencies. Based on the drug sales data, the total incurring costs of the drugs, total number of patients, and cost per patient seeking treatment from the private sector were calculated for the year 2015-2021. ANOVA and the post hoc test (Tukey honestly significant difference (HSD)) were applied for analysis. RESULTS There was a marked difference amongst all the districts in relation to all the variables namely total costs, cost per patient, and total private patients seeking treatment from the private sector which was statistically significant (p < 0.001). East Singhbhum had the highest out-of-pocket expense and private patients as compared to all six districts. Lohardaga showed the sharpest decline in total private patients from 2015 to 2021. The average cost borne by private patients in 2015 was INR 1821 (95% CI 1086 - 2556) which decreased to INR 1033 (95% CI 507 - 1559) in 2021. CONCLUSION From the study, it was concluded that the purchase of medicines for TB treatment from the private sector is one of the essential elements in out-of-pocket expenditure (OOPE) borne by TB patients. Hence, newer initiatives should be explored to foresee the future OOPE borne by the patients and decrease OOPE-induced poverty.
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Affiliation(s)
- Ratnesh Sinha
- Department of Community Medicine, Manipal Tata Medical College, Manipal Academy of Higher Education, Jamshedpur, IND
| | - Rishabh K Rana
- Department of Preventive and Social Medicine/Community Medicine, Shaheed Nirmal Mahto Medical College and Hospital (Erstwhile Patliputra Medical College), Dhanbad, IND
| | - Anit Kujur
- Department of Community Medicine, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - G Jahnavi
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Deoghar, Deoghar, IND
| | - Mithilesh Kumar
- Department of Community Medicine, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Vinayagamoorthy Venugopal
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Deoghar, Deoghar, IND
| | - Neha Priya
- Department of Community Medicine, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Manisha Kujur
- Department of Preventive Medicine, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Ravi Ranjan Jha
- Department of Community Medicine, Shaheed Nirmal Mahto Medical College and Hospital (Erstwhile Patliputra Medical College), Dhanbad, IND
| | - Rajan Barnwal
- Department of Community Medicine, Mahatma Gandhi Memorial Medical College and Hospital, Jamshedpur, IND
| | - Nikhil Nishant
- Department of Community Medicine, Medinirai Medical College, Palamu, IND
| | - Nisha Murmu
- Department of Preventive Medicine, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, IND
| | - Rajeev Pathak
- NTEP Technical Support Network, World Health Organization, Ranchi, IND
| | - Anupama T
- NTEP Technical Support Network, World Health Organization, Ranchi, IND
| | - Ranjit Prasad
- State TB Cell, Health Services, Government of Jharkhand, Ranchi, IND
| | - Rakesh Dayal
- State TB Cell, Health Services, Government of Jharkhand, Ranchi, IND
| | - Bhavesh Modi
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Rajkot, Rajkot, IND
| | - Anil J Purty
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, IND
| | - Sharath Bn
- Department of Community Medicine, Employees' State Insurance Corporation (ESIC) Medical College and Post Graduate Institute of Medical Science & Research (PGIMSR), Bengaluru, IND
| | - Dina Nair
- Department of Clinical Research, Indian Council of Medical Research-National Institute for Research in Tuberculosis (ICMR-NIRT), Chennai, IND
| | - Dewesh Kumar
- Department of Community Medicine/Preventive and Social Medicine, Rajendra Institute of Medical Sciences, Ranchi, IND
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6
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Clark RA, Weerasuriya CK, Portnoy A, Mukandavire C, Quaife M, Bakker R, Scarponi D, Harris RC, Rade K, Mattoo SK, Tumu D, Menzies NA, White RG. New tuberculosis vaccines in India: modelling the potential health and economic impacts of adolescent/adult vaccination with M72/AS01 E and BCG-revaccination. BMC Med 2023; 21:288. [PMID: 37542319 PMCID: PMC10403932 DOI: 10.1186/s12916-023-02992-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/20/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND India had an estimated 2.9 million tuberculosis cases and 506 thousand deaths in 2021. Novel vaccines effective in adolescents and adults could reduce this burden. M72/AS01E and BCG-revaccination have recently completed phase IIb trials and estimates of their population-level impact are needed. We estimated the potential health and economic impact of M72/AS01E and BCG-revaccination in India and investigated the impact of variation in vaccine characteristics and delivery strategies. METHODS We developed an age-stratified compartmental tuberculosis transmission model for India calibrated to country-specific epidemiology. We projected baseline epidemiology to 2050 assuming no-new-vaccine introduction, and M72/AS01E and BCG-revaccination scenarios over 2025-2050 exploring uncertainty in product characteristics (vaccine efficacy, mechanism of effect, infection status required for vaccine efficacy, duration of protection) and implementation (achieved vaccine coverage and ages targeted). We estimated reductions in tuberculosis cases and deaths by each scenario compared to the no-new-vaccine baseline, as well as costs and cost-effectiveness from health-system and societal perspectives. RESULTS M72/AS01E scenarios were predicted to avert 40% more tuberculosis cases and deaths by 2050 compared to BCG-revaccination scenarios. Cost-effectiveness ratios for M72/AS01E vaccines were around seven times higher than BCG-revaccination, but nearly all scenarios were cost-effective. The estimated average incremental cost was US$190 million for M72/AS01E and US$23 million for BCG-revaccination per year. Sources of uncertainty included whether M72/AS01E was efficacious in uninfected individuals at vaccination, and if BCG-revaccination could prevent disease. CONCLUSIONS M72/AS01E and BCG-revaccination could be impactful and cost-effective in India. However, there is great uncertainty in impact, especially given the unknowns surrounding the mechanism of effect and infection status required for vaccine efficacy. Greater investment in vaccine development and delivery is needed to resolve these unknowns in vaccine product characteristics.
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Affiliation(s)
- Rebecca A Clark
- TB Modelling Group and TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
- Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
- Vaccine Centre, London School of Hygiene and Tropical Medicine, London, UK.
| | - Chathika K Weerasuriya
- TB Modelling Group and TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Allison Portnoy
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Global Health, Boston University School of Public Health, Boston, USA
| | - Christinah Mukandavire
- TB Modelling Group and TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Quaife
- TB Modelling Group and TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Roel Bakker
- TB Modelling Group and TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Danny Scarponi
- TB Modelling Group and TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Rebecca C Harris
- TB Modelling Group and TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Sanofi Pasteur, Singapore, Singapore
| | | | | | - Dheeraj Tumu
- World Health Organization, New Delhi, India
- Central TB Division, NTEP, MoHFW Govt of India, New Delhi, India
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Richard G White
- TB Modelling Group and TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Vaccine Centre, London School of Hygiene and Tropical Medicine, London, UK
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7
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Bengey D, Thapa A, Dixit K, Dhital R, Rai B, Paudel P, Paudel R, Majhi G, Aryal TP, Sah MK, Pandit RN, Mishra G, Khanal MN, Kibuchi E, Caws M, de Siqueira-Filha NT. Comparing cross-sectional and longitudinal approaches to tuberculosis patient cost surveys using Nepalese data. Health Policy Plan 2023; 38:830-839. [PMID: 37300553 PMCID: PMC10394499 DOI: 10.1093/heapol/czad037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023] Open
Abstract
The World Health Organization has supported the development of national tuberculosis (TB) patient cost surveys to quantify the socio-economic impact of TB in high-burden countries. However, methodological differences in the study design (e.g. cross-sectional vs longitudinal) can generate different estimates making the design and impact evaluation of socio-economic protection strategies difficult. The objective of the study was to compare the socio-economic impacts of TB estimated by applying cross-sectional or longitudinal data collections in Nepal. We analysed the data from a longitudinal costing survey (patients interviewed at three time points) conducted between April 2018 and October 2019. We calculated both mean and median costs from patients interviewed during the intensive (cross-sectional 1) and continuation (cross-sectional 2) phases of treatment. We then compared costs, the prevalence of catastrophic costs and the socio-economic impact of TB generated by each approach. There were significant differences in the costs and social impacts calculated by each approach. The median total cost (intensive plus continuation phases) was significantly higher for the longitudinal compared with cross-sectional 2 (US$119.42 vs 91.63, P < 0.001). The prevalence of food insecurity, social exclusion and patients feeling poorer or much poorer were all significantly higher by applying a longitudinal approach. In conclusion, the longitudinal design captured important aspects of costs and socio-economic impacts, which were missed by applying a cross-sectional approach. If a cross-sectional approach is applied due to resource constraints, our data suggest that the start of the continuation phase is the optimal timing for a single interview. Further research to optimize methodologies to report patient-incurred expenditure during TB diagnosis and treatment is needed.
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Affiliation(s)
- Daisy Bengey
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
| | - Anchal Thapa
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Kritika Dixit
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
- Department of Global Public Health, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Raghu Dhital
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Bhola Rai
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Puskar Paudel
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Rajan Paudel
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Govind Majhi
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | | | - Manoj Kumar Sah
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | | | - Gokul Mishra
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Mukti Nath Khanal
- Planning Monitoring Evaluation & Research Section, National Tuberculosis Control Center, Thimi, Bhaktapur, Nepal
| | - Eliud Kibuchi
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, 90 Byres Road, Glasgow G12 8TB, United Kingdom
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
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8
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Xia L, Gao L, Zhong Y, Wu Y, He J, Zou F, Jian R, Xia S, Chen C, Zhu S. Assessing the influencing factors of out-of-pocket costs on tuberculosis in Sichuan Province: a cross-sectional study. BMC Public Health 2023; 23:1391. [PMID: 37468877 DOI: 10.1186/s12889-023-16180-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 06/22/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Although diagnosis and treatment services for tuberculosis (TB) are provided free of charge in most countries, direct non-medical and indirect costs due to absenteeism, also place a significant burden on patients and their families. Sichuan Province has the second highest incidence of TB in China, with an incidence of approximately 100 cases per 100 000 people. However, there are limited research on out-of-pocket expenditure (OOPE) and its influencing factors in TB patients in Sichuan Province. METHODS A retrospective cross-sectional study was conducted on TB patients in designated medical institutions for TB in Sichuan Province from 2017-2021. A face-to-face questionnaire was conducted to obtain the information related to hospitalization of patients, and the multi-level regression model was used to analyse the factors that influence OOPE and total out-of-pocket expenditure (TOOPE) of TB patients. RESULTS A total of 2644 patients were investigated, and 74.24% of TB patients and their families experienced catastrophic total costs due to TB. The median total cost was 9223.37 CNY (1429.98 USD), in which the median direct and indirect costs of TB patients were 10185.00 CNY (1579.07 USD) and 2400.00 CNY (372.09 USD), respectively, and indirect costs contributed to 43% of total costs. The median OOPE and TOOPE costs were 6024.00 CNY (933.95 USD) and 11890.50 CNY (1843.49 USD), respectively. OOPE and TOOPE had common influencing factors including whether the patient's family had four or more members, a history of hospitalization, combination with other types of TB, the number of visits before diagnosis, and co-occurrence with chronic disease. CONCLUSIONS The OOPE and TOOPE for TB patients and their families in Sichuan Province are still heavy. In the long run, it is necessary to strengthen education and awareness campaigns on TB related knowledge, disseminate basic medical knowledge to the public, improve healthcare-seeking behavior, and enhance the healthcare infrastructure to improve the accuracy of TB diagnosis and reduce the significant OOPE and TOOPE faced by TB patients and their families in Sichuan Province.
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Affiliation(s)
- Lan Xia
- Department of Tuberculosis, Sichuan Provincial Center for Disease Control and Prevention, No.6 Middle School Road, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Lijie Gao
- Department of Epidemiology and Statistics, School of Medicine, Jinan University, Guangzhou, 510632, China
| | - Yin Zhong
- Department of Tuberculosis, Sichuan Provincial Center for Disease Control and Prevention, No.6 Middle School Road, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Ya Wu
- Department of Epidemiology and Statistics, School of Medicine, Jinan University, Guangzhou, 510632, China
| | - Jinge He
- Department of Tuberculosis, Sichuan Provincial Center for Disease Control and Prevention, No.6 Middle School Road, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Fengjuan Zou
- Department of Epidemiology and Statistics, School of Medicine, Jinan University, Guangzhou, 510632, China
| | - Ronghua Jian
- Department of Epidemiology and Statistics, School of Medicine, Jinan University, Guangzhou, 510632, China
| | - Sujian Xia
- Department of Epidemiology and Statistics, School of Medicine, Jinan University, Guangzhou, 510632, China
| | - Chuang Chen
- Department of Tuberculosis, Sichuan Provincial Center for Disease Control and Prevention, No.6 Middle School Road, Wuhou District, Chengdu, 610041, Sichuan Province, China.
| | - Sui Zhu
- Department of Epidemiology and Statistics, School of Medicine, Jinan University, Guangzhou, 510632, China.
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Sodhi R, Penkunas MJ, Pal A. Free drug provision for tuberculosis increases patient follow-ups and successful treatment outcomes in the Indian private sector: a quasi experimental study using propensity score matching. BMC Infect Dis 2023; 23:421. [PMID: 37344775 DOI: 10.1186/s12879-023-08396-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND The private sector is an important yet underregulated component of the TB treatment infrastructure in India. The Joint Effort for Elimination of Tuberculosis (Project JEET) aims to link private sector TB care with the constellation of social support mechanisms available through the Indian National TB Elimination Programme (NTEP), including the provision of free fixed-dose combination (FDCs) drugs to patients. This quasi-experimental study analysed routinely collected data to determine the impact of free drugs on patient follow-ups and treatment outcomes. METHODS We used data for private sector patients enrolled with Project JEET who were diagnosed with pulmonary and extrapulmonary TB between 1 and 2019 and 31 March 2020, and completed treatment by 31 December 2021. Propensity score matching was used to create a dataset to compare the number of follow-ups and proportion of successful treatment outcomes for patients on free drugs to a control group who paid out-of-pocket. 11,621 matched pairs were included in the analysis. Logistic regression and ordinary least squares regression models were used to estimate the impact of free drugs on number of follow-ups and treatment success, where latter is defined as treatment completion or cure. RESULTS After controlling for potential confounders, patients on free drugs received on average 2.522 (95% C.I.: 2.325 to 2.719) additional follow-ups compared to patients who paid out of pocket. This equates to a 25% mean and 32% median increase in follow-ups for patients availing free drugs. For treatment success, patients receiving free drugs had 45% higher odds of a successful treatment (Odds Ratio: 1.452, 95% C.I.: 1.288 to 1.637). CONCLUSIONS Patients receiving free drugs were found to follow up with their treatment coordinator more frequently, in part likely to enable drug refilling, compared to patients who were paying out of pocket. These additional contacts would have offered opportunities to address concerns regarding side effects, provide additional treatment information, and connect with social support services, all of which subsequently contributed to patients' continual engagement with their treatment. This potentially represents the unmeasured effect of free drugs on continual social support, which translates into a higher odds of treatment success for patients.
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Affiliation(s)
- Ridhima Sodhi
- Clinton Health Access Initiative, Inc., New Delhi, India.
| | | | - Arnab Pal
- Clinton Health Access Initiative, Inc., New Delhi, India
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10
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Suseela RP, Shannawaz M. Engaging the Private Health Service Delivery Sector for TB Care in India-Miles to Go! Trop Med Infect Dis 2023; 8:tropicalmed8050265. [PMID: 37235313 DOI: 10.3390/tropicalmed8050265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
More than half of the people with TB in India seek care from the private sector, where suboptimal quality of care is a concern. Significant progress has been made over the last five years to expand the coverage and to involve more private sector providers in TB care under the National TB Elimination Program (NTEP) in India. The objective of this review is to describe the major efforts and the progress made with regard to the engagement of the 'for-profit' private health service delivery sector for TB care in India, to critically discuss this, and to suggest the way forward. We described the recent efforts by the NTEP for private sector engagement based on the literature, including strategy documents, guidelines, annual reports, evaluation studies, and critically looked at the strategies against the vision of partnership. The NTEP has taken a variety of approaches, including education, regulation, provision of cost-free TB services, incentives, and partnership schemes to engage the private sector. As a result of all these interventions, private sector contribution has increased substantially, including TB notification, follow-up, and treatment success. However, these still fall short of achieving the set targets. Strategies were focused more towards the purchase of services rather than creating sustainable partnerships. There are no major strategies to engage the diverse set of providers, including informal health care providers and chemists, who are the first point of contact for a significant number of people with TB. India needs an integrated private sector engagement policy focusing on ensuring standards of TB care for every citizen. The NTEP should adopt an approach specifically tailored to the various categories of providers. For meaningful inclusion of the private sector, it is also essential to build understanding and generate data intelligence for better decision making, strengthen the platforms for engagement, and expand the social insurance coverage.
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Affiliation(s)
- Rakesh P Suseela
- Amity Institute of Public Health, Amity University, Noida 201303, India
- The Union South East Asia Office, New Delhi 110016, India
| | - Mohd Shannawaz
- Amity Institute of Public Health, Amity University, Noida 201303, India
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11
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Kumar D, Prinja S. Costing of services under National Tuberculosis Elimination Program at public health facilities of northern India. Indian J Tuberc 2023; 70:232-238. [PMID: 37100581 DOI: 10.1016/j.ijtb.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 04/28/2023]
Abstract
BACKGROUND Costing of resources helps to measure financial implications and effective utilization of resources of national programs. As there is limited evidence about cost per service, current study was done to assess the cost of services under National Tuberculosis Elimination Program (NTEP) at Community Health Centres (CHCs) and Primary Health Centres (PHCs) of northern state of India. MATERIAL AND METHODS Cross-sectional study carried out in two districts and from each district eight CHCs and PHCs were randomly selected. RESULTS Mean annual cost of providing NTEP services at CHCs and PHCs were US$5243.1 (95%CI: 3008.0-7225.4) and US$1031.9 (95%CI: 669.1-1447.1) respectively. Across both centres human resource contributes to the most (CHC: 72.9%; PHC: 85.9%). One way sensitivity analysis was carried out for all health facilities and observed that human resource cost influences most cost per treated case by providing services under NTEP. Although relatively very less but cost of drugs also influences cost per treatment. CONCLUSION Cost of delivering services was high for CHCs as compared to PHCs. At both types of health facilities, human resource contributes the most to cost of delivering services under the program.
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Affiliation(s)
- Dinesh Kumar
- Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh, 176001, India.
| | - Shankar Prinja
- School of Public Health and Community Medicine, Post Graduate Institute of Medical Education and Research. Chandigarh, 160012, India.
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12
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Chatterjee S, Das P, Shikhule A, Munje R, Vassall A. Journey of the tuberculosis patients in India from onset of symptom till one-year post-treatment. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001564. [PMID: 36811090 PMCID: PMC7614204 DOI: 10.1371/journal.pgph.0001564] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 01/14/2023] [Indexed: 02/12/2023]
Abstract
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.
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Affiliation(s)
- Susmita Chatterjee
- Research Department, George Institute for Global Health, New Delhi, India
- Department of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Palash Das
- Research Department, George Institute for Global Health, New Delhi, India
| | - Aaron Shikhule
- Department of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Radha Munje
- Department of Respiratory Medicine, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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13
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Ghazy RM, Sallam M, Ashmawy R, Elzorkany AM, Reyad OA, Hamdy NA, Khedr H, Mosallam RA. Catastrophic Costs among Tuberculosis-Affected Households in Egypt: Magnitude, Cost Drivers, and Coping Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20032640. [PMID: 36768005 PMCID: PMC9915462 DOI: 10.3390/ijerph20032640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 05/31/2023]
Abstract
Despite national programs covering the cost of treatment for tuberculosis (TB) in many countries, TB patients still face substantial costs. The end TB strategy, set by the World Health Organization (WHO), calls for "zero" TB households to be affected by catastrophic payments by 2025. This study aimed to measure the catastrophic healthcare payments among TB patients in Egypt, to determine its cost drivers and determinants and to describe the coping strategies. The study utilized an Arabic-validated version of the TB cost tool developed by the WHO for estimating catastrophic healthcare expenditure using the cluster-based sample survey with stratification in seven administrative regions in Alexandria. TB payments were considered catastrophic if the total cost exceeded 20% of the household's annual income. A total of 276 patients were interviewed: 76.4% were males, 50.0% were in the age group 18-35, and 8.3% had multidrug-resistant TB. Using the human capital approach, 17.0% of households encountered catastrophic costs compared to 59.1% when using the output approach. The cost calculation was carried out using the Egyptian pound converted to the United States dollars based on 2021 currency values. Total TB cost was United States dollars (USD) 280.28 ± 29.9 with a total direct cost of USD 103 ± 10.9 and a total indirect cost of USD 194.15 ± 25.5. The direct medical cost was the main cost driver in the pre-diagnosis period (USD 150.23 ± 26.89 pre diagnosis compared to USD 77.25 ± 9.91 post diagnosis, p = 0.013). The indirect costs (costs due to lost productivity) were the main cost driver in the post-diagnosis period (USD 4.68 ± 1.18 pre diagnosis compared to USD 192.84 ± 25.32 post diagnosis, p < 0.001). The households drew on multiple financial strategies to cope with TB costs where 66.7% borrowed and 25.4% sold household property. About two-thirds lost their jobs and another two-thirds lowered their food intake. Being female, delay in diagnosis and being in the intensive phase were significant predictors of catastrophic payment. Catastrophic costs were high among TB households in Alexandria and showed wide variation according to the method used for indirect cost estimation. The main cost driver before diagnosis was the direct medical costs, while it was the indirect costs, post diagnosis.
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Affiliation(s)
- Ramy Mohamed Ghazy
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria 21561, Egypt
| | - Malik Sallam
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman 11942, Jordan
| | - Rasha Ashmawy
- Department of Clinical Research, Maamora Chest Hospital, Alexandria 21923, Egypt
| | | | - Omar Ahmed Reyad
- Internal Medicine and Cardiology Clinical Pharmacy Department, Alexandria University Main Hospital, Alexandria 21526, Egypt
| | - Noha Alaa Hamdy
- Department of Clinical Pharmacy & Pharmacy Practice, Faculty of Pharmacy, Alexandria University, Alexandria 21521, Egypt
| | - Heba Khedr
- MDR-TB Center, Maamora Chest Hospital, Alexandria 21912, Egypt
| | - Rasha Ali Mosallam
- Department of Health Administration and Behavioral Science, High Institute of Public Health, Alexandria University, Alexandria 21561, Egypt
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Sharma K, Sharma M, Sharma V, Sharma M, Parmar UPS, Samanta J, Sharma A, Kochhar R, Sinha SK. MTBDRplus and MTBDRsl for simultaneous diagnosis of gastrointestinal tuberculosis and detection of first-line and second-line drug resistance. J Gastroenterol Hepatol 2023; 38:619-624. [PMID: 36652396 DOI: 10.1111/jgh.16124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/24/2022] [Accepted: 01/17/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIM Emergence of drug resistance, especially to second-line drugs, hampers tuberculosis elimination efforts. The present study aimed to evaluate MTBDRplus and MTBDRsl assays for detecting first-line and second-line drug resistance, respectively, in gastrointestinal tuberculosis (GITB). METHODS Thirty ileocecal biopsy specimens, processed in the Department of Microbiology between 2012 and 2022, that showed growth of Mycobacterium tuberculosis on culture were included in the study. DNA, extracted from culture, was subjected to MTBDRplus and MTBDRsl (Hain Lifescience GmbH, Nehren, Germany), following manufacturer's instructions. Their performance was compared against phenotypic drug susceptibility testing (pDST) and gene sequencing. RESULTS Out of the 30 specimens, 4 (13.33%) were mono-isoniazid resistant, 4 (13.33%) were multidrug resistant (MDR), 2 (6.67%) were pre-extensively drug resistant (pre-XDR), and 2 (6.67%) were mono-fluoroquinolone resistant. The results were 100% concordant with pDST and gene sequencing. CONCLUSIONS In the wake of growing drug resistance in all forms of extrapulmonary tuberculosis, including GITB, MTBDRplus and MTBDRsl are reliable tools for screening of resistance to both first-line and second-line drugs.
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Affiliation(s)
- Kusum Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Megha Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.,Department of Microbiology, All India Institute of Medical Sciences, Bilaspur, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Megha Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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15
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Rupani MP, Vyas S. A sequential explanatory mixed-methods study on costs incurred by patients with tuberculosis comorbid with diabetes in Bhavnagar, western India. Sci Rep 2023; 13:150. [PMID: 36600031 PMCID: PMC9811877 DOI: 10.1038/s41598-023-27494-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 01/03/2023] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Mihir P. Rupani
- grid.413227.10000 0004 1801 0602Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat 364001 India ,grid.411877.c0000 0001 2152 424XGujarat University, Ahmedabad, Gujarat 380009 India ,grid.415578.a0000 0004 0500 0771Present Address: Clinical Epidemiology, Division of Health Sciences, ICMR - National Institute of Occupational Health (NIOH), Indian Council of Medical Research, Meghaninagar, near Raksha Shakti University, Ahmedabad, Gujarat 380016 India
| | - Sheetal Vyas
- grid.411877.c0000 0001 2152 424XGujarat University, Ahmedabad, Gujarat 380009 India ,grid.411494.d0000 0001 2154 7601Department of Community Medicine, AMC-MET Medical College, Maninagar, Ahmedabad, Gujarat 380008 India
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Tuberculosis burden in India and its control from 1990 to 2019: Evidence from global burden of disease study 2019. Indian J Tuberc 2023; 70:87-98. [PMID: 36740324 DOI: 10.1016/j.ijtb.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/04/2021] [Accepted: 03/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tuberculosis is still a major public health problem in India. This study aims to assess trends in the burden of tuberculosis from 1990 to 2019 for tracking success of tuberculosis control programme in India. METHODS In this study, the 2019 global burden of disease study data were used to measure the incidence, prevalence, mortality, and disability-adjusted life years lost (DALY)rates of Tuberculosis during 1990-2019 for India and its states. Age and gender-specific rates were also analyzed for India. All rates were age-standardized and 95% uncertainty intervals (UIs) were computed. RESULT Overall incidence, prevalence, death and DALY of TB decreased in India from 1990 to 2019. Tuberculosis morbidity and mortality was higher in males as compared to females. Incidence of TB was low in children up to 14 years of age. Prevalence of TB was higher in females as compared to males till 29 years of age, whereas higher prevalence was reported in males as compared to females in adults aged 30 years and more. Death rate of TB was low in children and young adults up to 29 years of age. CONCLUSION This study shows that overall incidence, prevalence, death and DALY of tuberculosis decreased from 1990 to 2019 in India. The burden of TB was higher among males as compared to females during study period. TB affects all the age groups but deaths were higher in older age groups.
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Out-of-pocket expenditure on childhood infections and its financial burden on Indian households: Evidence from nationally representative household survey (2017-18). PLoS One 2022; 17:e0278025. [PMID: 36574437 PMCID: PMC9794050 DOI: 10.1371/journal.pone.0278025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/08/2022] [Indexed: 12/28/2022] Open
Abstract
The key objective of this research was to estimate out of pocket expenditure (OOPE) incurred by the Indian households for the treatment of childhood infections. We estimated OOPE estimates on outpatient care and hospitalization by disease conditions and type of health facilities. In addition, we also estimated OOPE as a share of households' total consumption expenditure (TCE) by MPCE quintile groups to assess the quantum of the financial burden on the households. We analyzed the Social Consumption: Health (SCH) data from National Sample Survey Organization (NSSO) 75th round (2017-18). Outcome indicators were prevalence of selected infectious diseases in children aged less than 5 years, per episode of OOPE on outpatient care in the preceding 15 days, hospitalization in the preceding year and OOPE as a share of households' total consumption expenditure. Our analysis suggests that the most common childhood infection was 'fever with rash' followed by 'acute upper respiratory infection' and 'acute meningitis'. However, the highest OOPE for outpatient care and hospitalization was reported for 'viral hepatitis' and 'tuberculosis' episodes. Among the households reporting childhood infections, OOPE was 4.8% and 6.7% of households' total consumption expenditure (TCE) for outpatient care and hospitalization, respectively. Furthermore, OOPE as a share of TCE was disproportionately higher for the poorest MPCE quintiles (outpatient, 7.9%; hospitalization, 8.2%) in comparison to the richest MPCE quintiles (outpatient, 4.8%; hospitalization, 6.7%). This treatment and care-related OOPE has equity implications for Indian households as the poorest households bear a disproportionately higher burden of OOPE as a share of TCE. Ensuring financial risk protection and universal access to care for childhood illnesses is critical to addressing inequity in care.
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Costs incurred by patients with tuberculosis co-infected with human immunodeficiency virus in Bhavnagar, western India: a sequential explanatory mixed-methods research. BMC Health Serv Res 2022; 22:1268. [PMID: 36261837 PMCID: PMC9581761 DOI: 10.1186/s12913-022-08647-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND India reports the highest number of tuberculosis (TB) and second-highest number of the human immunodeficiency virus (HIV) globally. We hypothesize that HIV might increase the existing financial burden of care among patients with TB. We conducted this study to estimate the costs incurred by patients with TB co-infected with HIV and to explore the perspectives of patients as well as program functionaries for reducing the costs. METHODS We conducted a descriptive cross-sectional study among 234 co-infected TB-HIV patients notified in the Bhavnagar region of western India from 2017 to 2020 to estimate the costs incurred, followed by in-depth interviews among program functionaries and patients to explore the solutions for reducing the costs. Costs were estimated in Indian rupees (INR) and expressed as median (interquartile range IQR). The World Health Organization defines catastrophic costs as when the total costs incurred by patients exceed 20% of annual household income. The in-depth interviews were audio-recorded, transcribed, and analyzed as codes grouped into categories. RESULTS Among the 234 TB-HIV co-infected patients, 78% were male, 18% were sole earners in the family, and their median (IQR) monthly family income was INR 9000 (7500-11,000) [~US$ 132 (110-162)]. The total median (IQR) costs incurred for TB were INR 4613 (2541-7429) [~US$ 69 (37-109)], which increased to INR 7355 (4337-11,657) [~US$ 108 (64-171)] on adding the costs due to HIV. The catastrophic costs at a 20% cut-off of annual household income for TB were 4% (95% CI 2-8%), which increased to 12% (95% CI 8-16%) on adding the costs due to HIV. Strengthening health systems, cash benefits, reducing costs through timely referral, awareness generation, and improvements in caregiving were some of the solutions provided by program functionaries and the patients. CONCLUSION We conclude that catastrophic costs due to TB-HIV co-infection were higher than that due to TB alone in our study setting. Bringing care closer to the patients would reduce their costs. Strengthening town-level healthcare facilities for diagnostics as well as treatment might shift the healthcare-seeking of patients from the private sector towards the government and thereby reduce the costs incurred.
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Muniyandi M, Karikalan N, Velayutham B, Rajsekar K, Padmapriyadarsini C. Cost Effectiveness of a Shorter Moxifloxacin Based Regimen for Treating Drug Sensitive Tuberculosis in India. Trop Med Infect Dis 2022; 7:tropicalmed7100288. [PMID: 36288029 PMCID: PMC9607110 DOI: 10.3390/tropicalmed7100288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 09/29/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
Abstract
Globally efforts are underway to shorten the existing 6-month tuberculosis (TB) treatment regimen for drug-sensitive patients, which would be equally effective and safe. At present, there is a lack of evidence on the cost implications of a shorter 4-month TB regimen in India. This economic modeling study was conducted in the Indian context with a high TB burden. We used a hybrid economic model comprising of a decision tree and Markov analysis. The study estimated the incremental costs, life years (LYs), and quality-adjusted life years (QALYs) gained by the introduction of a Moxifloxacin-based shorter 4-month treatment regimen for pulmonary TB patients. The outcomes are expressed in incremental cost-effectiveness ratios (ICERs) per QALYs gained. The cost per case to be treated under the 4-month regimen was USD 145.94 whereas for the 6-month regimen it was USD 150.39. A shorter 4-month TB regimen was cost-saving with USD 4.62 per LY and USD 5.29 per QALY. One-way sensitivity analysis revealed that the cost of the drugs for the 4-month regimen, hospitalization cost for adverse drug reactions, and human resources incurred for the 6-month regimen had a higher influence on the ICER. The probability sensitivity analysis highlighted that the joint incremental cost and effectiveness using QALY were less costly and more effective for 67% of the iteration values. The cost-effectiveness acceptability curve highlights that the 4-month regimen was dominant to both patients and the National TB Elimination Programme in India as compared to the 6-month regimen at different cost-effectiveness threshold values.
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Affiliation(s)
- Malaisamy Muniyandi
- ICMR—National Institute for Research in Tuberculosis, Chennai 600031, India
- Correspondence:
| | | | | | - Kavitha Rajsekar
- Department of Health Research, Ministry of Health and Family Welfare, New Delhi 110001, India
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20
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Kanmani S, Logaraj M, John R, Arumai MM. Is economic burden still a problem among the patients with tuberculosis - A cost analysis: A descriptive cross-sectional study in Tamil Nadu. Indian J Tuberc 2022; 69:602-607. [PMID: 36460396 DOI: 10.1016/j.ijtb.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/17/2021] [Indexed: 06/17/2023]
Abstract
BACKGROUND There were more than 10 million people infected with TB across the globe. India has the world's largest tuberculosis load, with 2.4 million recorded cases in 2019. Poverty has an inseparable relationship with Tuberculosis. It is an inevitable risk factor, often resulting in delays in seeking treatment, imposing a financial burden on families, and poor compliance with treatment, etc., thereby leading to a very low rate of success in TB treatment. In this context, a study was undertaken among TB patients in Kanchipuram district with the objective of assessing the different costs associated with treatment and other associated issues they face from society as a consequence of the disease. MATERIALS METHODS A descriptive cross sectional descriptive study design was espoused to study among the 312 TB patients registered in the government's RNTCP program. A multi-stage random sampling technique was adopted to recruit and obtain data from them. A Univariate and bivariate analysis were employed to get the mean costs incurred during the pre & post diagnosis TB treatment. A linear regression test was performed to identify the relationship between the variables that influence the economic burden during the treatment process. CONCLUSION The study demonstrates that the total costs sustained by patients during the post-diagnosis phase are astronomical in contrast to the costs spent during the pre-diagnosis phase. The indirect cost in terms of time lost due to hospital visits and medication pickup, as well as inability to work, imposes a significant economic burden on patients and their families.
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Affiliation(s)
- Sellamuthu Kanmani
- Department of Community Medicine, SRM Medical College Hospital & Research Centre, SRM Institute of Science and Technology Campus, SRM Nagar, Kattankulathur, Chengalpattu District, Tamil Nadu, 603203, India
| | - Muthunarayanan Logaraj
- Department of Community Medicine, SRM Medical College Hospital & Research Centre, SRM Institute of Science and Technology Campus, SRM Nagar, Kattankulathur, Chengalpattu District, Tamil Nadu, 603203, India.
| | - Russelselvan John
- Department of Community Medicine, Apollo Institute of Medical Science & Research, Murakambattu, Chittoor, Andhra Pradesh, India
| | - Mariaselvam Mathew Arumai
- Department of Community Medicine, SRM Medical College Hospital & Research Centre, SRM Institute of Science and Technology Campus, SRM Nagar, Kattankulathur, Chengalpattu District, Tamil Nadu, 603203, India
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21
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Gupta A, Juneja S, Sahu S, Yassin M, Brigden G, Wandwalo E, Rane S, Mirzayev F, Zignol M. Lifesaving, cost-saving: Innovative simplified regimens for drug-resistant tuberculosis. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001287. [PMID: 36962626 PMCID: PMC10021682 DOI: 10.1371/journal.pgph.0001287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Aastha Gupta
- TB Alliance, New York, NY, United States of America
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22
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Garg T, Panibatla V, Carel JP, Shanta A, Bhardwaj M, Brouwer M. Can Patient Navigators Help Potential TB Patients Navigate the Diagnostic and Treatment Pathways? An Implementation Research from India. Trop Med Infect Dis 2021; 6:tropicalmed6040200. [PMID: 34842840 PMCID: PMC8628981 DOI: 10.3390/tropicalmed6040200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/22/2022] Open
Abstract
Navigating the Indian health system is a challenge for people with tuberculosis (TB) symptoms. The onus of organizing care is on the patient and their families alone. Factors like gender discrimination and opportunity costs further aggravate this. As a result, people may not complete the diagnostic and treatment pathway even though they experience poor health. Navigators can aid in the pathway’s completion. We implemented two projects in India—a public sector intervention in Bihar, with a population of 1.02 million, and a private sector intervention in Andhra Pradesh (AP), with a population of 8.45 million. Accredited Social Health Activists (ASHAs) of the public health system in Bihar and local field officers in AP facilitated the patients’ navigation through the health system. In Bihar, ASHAs accompanied community-identified presumptive TB patients to the nearest primary health center, assisted them through the diagnostic process, and supported the patients throughout the TB treatment. In AP, the field officers liaised with the private physicians, accompanied presumptive patients through the diagnosis, counseled and started treatment, and followed-up with the patients during the treatment. Both projects recorded case-based data for all of the patients, and used the yield and historical TB notifications to evaluate the intervention’s effect. Between July 2017 and December 2018, Bihar confirmed 1650 patients, which represented an increase of 94% in public notifications compared to the baseline. About 97% of them started treatment. During the same period in AP, private notifications increased by 147% compared to the baseline, and all 5765 patients started treatment. Patient navigators support the patients in the diagnostic and treatment pathways, and improve their health system experience. This novel approach of involving navigators in TB projects can improve the completion of the care cascade and reduce the loss to follow-up at various stages.
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Affiliation(s)
- Tushar Garg
- Innovators In Health, Patna 800001, India;
- Correspondence:
| | | | - Joseph P. Carel
- Independent Consultant, New Delhi 110001, India; (J.P.C.); (A.S.)
| | - Achanta Shanta
- Independent Consultant, New Delhi 110001, India; (J.P.C.); (A.S.)
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23
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Yuen CM, Majidulla A, Jaswal M, Safdar N, Malik AA, Khan AJ, Becerra MC, Keshavjee S, Lu C, Hussain H. Cost of Delivering 12-Dose Isoniazid and Rifapentine Versus 6 Months of Isoniazid for Tuberculosis Infection in a High-Burden Setting. Clin Infect Dis 2021; 73:e1135-e1141. [PMID: 33289039 PMCID: PMC8423476 DOI: 10.1093/cid/ciaa1835] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Successful delivery and completion of tuberculosis preventive treatment are necessary for tuberculosis elimination. Shorter preventive treatment regimens currently have higher medication costs, but patients spend less time in care and are more likely to complete treatment. It is unknown how economic costs of successful delivery differ between longer and shorter regimens in high-tuberculosis-burden settings. METHODS We developed survey instruments to collect costs from program and patient sources, considering costs incurred from when household contacts first entered the health system. We compared the cost per completed course of preventive treatment with either 6 months of daily isoniazid (6H) or 3 months of weekly isoniazid and rifapentine (3HP), delivered by the Indus Health Network tuberculosis program in Karachi, Pakistan, between October 2016 and February 2018. RESULTS During this period, 459 individuals initiated 6H and 643 initiated 3HP; 39% and 61% completed treatment, respectively. Considering costs to both the program and care recipients, the cost per completed course was 394 US dollars (USD) for 6H and 333 USD for 3HP. Using a new 2020 price for rifapentine reduced the cost per completed course of 3HP to 290 USD. Under varying assumptions about drug prices and costs incurred by care recipients, the cost per completed course was lower for 3HP in all scenarios, and the largest cost drivers were the salaries of clinical staff. CONCLUSIONS In a high-burden setting, the cost of successful delivery of 3HP was lower than that of 6H, driven by higher completion.
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Affiliation(s)
- Courtney M Yuen
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School Center for Global Health Delivery, Boston, Massachusetts, USA
| | | | - Maria Jaswal
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Nauman Safdar
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Amyn A Malik
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
- Interactive Research and Development (IRD) Global, Singapore
| | - Aamir J Khan
- Harvard Medical School Center for Global Health Delivery, Boston, Massachusetts, USA
- Interactive Research and Development (IRD) Global, Singapore
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School Center for Global Health Delivery, Boston, Massachusetts, USA
| | - Salmaan Keshavjee
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School Center for Global Health Delivery, Boston, Massachusetts, USA
| | - Chunling Lu
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Hamidah Hussain
- Interactive Research and Development (IRD) Global, Singapore
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24
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Chandra A, Kumar R, Kant S, Krishnan A. Costs of TB care incurred by adult patients with newly diagnosed drug-sensitive TB in Ballabgarh block in northern India. Trans R Soc Trop Med Hyg 2021; 116:63-69. [PMID: 33836537 DOI: 10.1093/trstmh/trab060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/02/2021] [Accepted: 03/17/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND India's National Tuberculosis Elimination Programme (NTEP) provides free diagnosis and treatment services but does not monitor TB-related costs. This study aimed to estimate the direct and indirect costs borne by adult patients with newly diagnosed TB. METHODS A longitudinal study in Ballabgarh block, Haryana (North India) was conducted. A total of 110 patients were interviewed and data regarding costs were collected at three points of time (after diagnosis, at the end of intensive phase and at the end of the treatment) using a semistructured questionnaire. The total direct (out-of-pocket expenses) and indirect (income lost) costs before and during treatment were calculated for patients who completed the treatment. RESULTS We enrolled 110 patients with drug-sensitive TB; 6 patients could not complete the treatment. The TB-related median total cost was US$150 (IQR 65-335). The median prediagnosis and postdiagnosis costs were US$42 (IQR 19-313) and US$63 (IQR 10.2-190), respectively. The median direct and indirect costs were US$75 (IQR 36-148) and US$16 (IQR 0-197), respectively. A catastrophic cost was experienced by 18% (95% CI 12 to 27%) of households. CONCLUSION Despite free diagnosis and treatment services, there is a substantial TB-related cost for TB care under the NTEP. Accelerated efforts are needed to achieve the target of zero catastrophic cost.
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Affiliation(s)
- Ankit Chandra
- Centre for Community Medicine (CCM), Old OT Block, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Rakesh Kumar
- Centre for Community Medicine (CCM), Old OT Block, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Shashi Kant
- Centre for Community Medicine (CCM), Old OT Block, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Anand Krishnan
- Centre for Community Medicine (CCM), Old OT Block, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
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25
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Setoodehzadeh F, Barfar E, Ansari H, Sari AA, Azizi N. The economic burden of tuberculosis in Sistan: a high-risk region in Iran. Trop Med Int Health 2021; 26:649-655. [PMID: 33668078 DOI: 10.1111/tmi.13570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION To estimate the economic burden of tuberculosis treatment in Sistan, the region with the highest number of tuberculosis cases in Iran. METHODS All patients with smear-positive pulmonary tuberculosis who had contracted tuberculosis in 2018 and successfully completed their treatment were interviewed. RESULTS Ninety patients with a mean age of 57 ± 18 years were interviewed. Most of them were women (58%), housewives (57%) and resided in rural areas (84%). The mean cost of treatment for tuberculosis was estimated as 6800 USD per patient. Direct costs were 87% of the total cost. Twenty-two patients lost an average income of 530 USD (8514590 rials) during treatment. The results showed the significant correlation of direct and indirect costs with sex, age, place of residence and education (P < 0.05). CONCLUSION It appears essential to improve social protection and implement interventions to promote knowledge in rural areas.
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Affiliation(s)
- Fatemeh Setoodehzadeh
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Eshagh Barfar
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Hossein Ansari
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Ali Akbari Sari
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Najmeh Azizi
- Master of Health Care Management, Zahedan University of Medical Sciences, Zahedan, Iran
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26
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Muniyandi M, Lavanya J, Karikalan N, Saravanan B, Senthil S, Selvaraju S, Mondal R. Estimating TB diagnostic costs incurred under the National Tuberculosis Elimination Programme: a costing study from Tamil Nadu, South India. Int Health 2021; 13:536-544. [PMID: 33570132 PMCID: PMC8643484 DOI: 10.1093/inthealth/ihaa105] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/12/2020] [Accepted: 02/05/2021] [Indexed: 11/15/2022] Open
Abstract
Background The National Tuberculosis Elimination Programme (NTEP) of India is aiming to eliminate TB by 2025. The programme has increased its services and resources to strengthen the accurate and early detection of TB. It is important to estimate the cost of TB diagnosis in India considering the advancement and implementation of new diagnostic tools under the NTEP. The objective of this study was to estimate the unit costs of providing TB diagnostic services at different levels of public health facilities with different algorithms implemented under the NTEP in Chennai, Tamil Nadu, South India. Methods This costing study was conducted from the perspective of the health system. This study used only secondary data and information that were available in the public domain. Data were collected with the approval of health authorities. The patient's diagnostic path from the point of registration until the final diagnosis was considered in the costing exercise. The unit costs of different diagnostic tools used in the NTEP implemented by Chennai Corporation were calculated. Results We estimated the unit cost of the eight laboratory tests (Ziehl–Neelsen [ZN], fluorescence microscopy [FM], x-ray, digital x-ray, gene Xpert MTB/RIF (cartridge-based nucleic acid amplification test [NAAT] that identifies rifampicin resistant Mycobacterium Tuberculosis) Mycobacterium Tuberculosis/Rifampicin [MTB/RIF], mycobacteria growth indicator tube [MGIT], line probe assay [LPA] and Lowenstein Jensen [LJ] culture) for diagnosis of drug-sensitive and drug-resistant TB. The unit costs included fixed and variable costs for smear examination by ZN microscopy (₹ [Indian Rupee] 326 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}4.72], FM (₹104 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}1.5]), x-ray (₹218 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}3.15]), digital X-ray (₹281 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}4.07]), gene Xpert MTB/RIF (₹1137 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}16.47]), MGIT (₹7038 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}102]), LPA (₹6448 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}93.44]) and LJ culture (₹4850 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}70.28]). Out of 10 diagnostic algorithms used for TB diagnosis, algorithms using only smear microscopy had the lowest cost, followed by smear microscopy with x-ray for drug-sensitive TB (₹104 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}1.5] to ₹544 [US\documentclass[12pt]{minimal}
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}{}${\$}$\end{document}7.88]). Diagnostic algorithms for drug-resistant TB involving LPA and gene Xpert MTB/RIF were the most expensive. Conclusions Understanding the various costs contributing to TB diagnosis in India provides crucial evidence for policymakers, programme managers and researchers to optimise programme spending and efficiently use resources.
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Affiliation(s)
| | - Jayabal Lavanya
- District TB Office, National TB Elimination Programme, Chennai
| | - Nagarajan Karikalan
- Department ofHealthEconomics, ICMR-National Institute for Research in Tuberculosis, Chennai-600031, India
| | - Balakrishnan Saravanan
- Department ofHealthEconomics, ICMR-National Institute for Research in Tuberculosis, Chennai-600031, India
| | - Sellappan Senthil
- Department ofHealthEconomics, ICMR-National Institute for Research in Tuberculosis, Chennai-600031, India
| | - Sriram Selvaraju
- Department of Epidemiology, ICMR-National Institute for Research in Tuberculosis, Chennai
| | - Rajesh Mondal
- Department of Bacteriology, ICMR-National Institute for Research in Tuberculosis, Chennai
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Rupani MP, Cattamanchi A, Shete PB, Vollmer WM, Basu S, Dave JD. Costs incurred by patients with drug-susceptible pulmonary tuberculosis in semi-urban and rural settings of Western India. Infect Dis Poverty 2020; 9:144. [PMID: 33076969 PMCID: PMC7574230 DOI: 10.1186/s40249-020-00760-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/30/2020] [Indexed: 11/19/2022] Open
Abstract
Background India reports the highest number of tuberculosis (TB) cases worldwide. Poverty has a dual impact as it increases the risk of TB and exposes the poor to economic hardship when they develop TB. Our objective was to estimate the costs incurred by patients with drug-susceptible TB in Bhavnagar (western India) using an adapted World Health Organization costing tool. Methods We conducted a descriptive cross-sectional study of adults, notified in the public sector and being treated for drug-susceptible pulmonary TB during January–June 2019, in six urban and three rural blocks of Bhavnagar region, Gujarat state, India. The direct and indirect TB-related costs, as well as patients’ coping strategies, were assessed for the overall care of TB till treatment completion. Catastrophic costs were defined as total costs > 20% of annual household income (excluding any amount received from cash transfer programs or borrowed). Median and interquartile range (IQR) was used to summarize patient costs. The median costs between any two groups were compared using the median test. The association between any two categorical variables was tested by the Pearson chi-squared test. All costs were described in US dollars (USD). During the study period, on average, one USD equalled 70 Indian Rupees. Results Of 458 patients included, 70% were male, 62% had no formal education, 71% lived in urban areas, and 96% completed TB treatment. The median (IQR) total costs were USD 8 (5–28), direct medical costs were USD 0 (0–0), direct non-medical costs were USD 3 (2–4) and indirect costs were USD 6 (3–13). Among direct non-medical costs, travel cost (median = USD 3, IQR: 2–4) to attend health facilities were the most prominent, whereas the indirect costs were mainly contributed by the patient’s loss of wages (median = USD 3, IQR: 0–6). Four percent of patients faced catastrophic costs, 11% borrowed money to cover costs and 7% lost their employment; the median working days lost to TB was 30 (IQR: 15–45). A majority (88%) of patients received a median USD 43 (IQR: 41–43) as part of a cash transfer program for TB patients. Conclusions Treatment completion was high and the costs incurred by TB patients were low in this setting. However, negative financial consequences occur even in low-cost settings. The role of universal cash transfer programs in such settings requires further study.
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Affiliation(s)
- Mihir P Rupani
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat 364001, India.
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco (UCSF), California, USA
| | - Priya B Shete
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco (UCSF), California, USA
| | - William M Vollmer
- Division of Biostatistics, Kaiser Permanente Center for Health Research, Portland, USA
| | - Sanjib Basu
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, USA
| | - Jigna D Dave
- Department of Respiratory Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Bhavnagar, Gujarat, India
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