Catastrophic costs of tuberculosis care: a mixed methods study from Puducherry, India

Background: The average expenditure incurred by patients in low- and middle-income countries towards diagnosis and treatment of TB ranges from $55 to $8198. This out-of-pocket expenditure leads to impoverishment of households. One of the three main targets of the End TB Strategy (2016–2035) is that no TB-affected household suffers catastrophic costs due to TB. Study setting was free care under national tuberculosis program (NTP), Puducherry district, India.

Objectives: The objectives of the study were among the newly diagnosed and previously treated tuberculosis (TB) patients, to (a) estimate patient costs during diagnosis and intensive phase of treatment, (b) determine the proportion of households experiencing catastrophic costs, and (c) explore coping strategies.

Methods: An explanatory mixed methods design comprising both quantitative cost description and qualitative descriptive component was used. Catastrophic cost was defined as total TB care costs exceeding 20% of annual household income.

Results: Of 102 TB patients included, two-thirds (69%) were male, 6% were HIV positive, and 45% reported at least one episode of hospitalization for TB care. The median (IQR) total cost of TB care was US$195 (52.1, 492.9) with a direct cost of US$65.3 (22.3, 156.5) and indirect cost of US$50.2 (0.9, 295.1). Overall, 32.4% of households experienced catastrophic costs due to TB care, significantly higher in patients with HIV coinfection (p = 0.009) and hospitalization (p = 0.009). Pledging jewels and borrowing money were major coping strategies. Cash assistance was the expected remedy from the patient perspective.

Conclusion: Despite free TB care under NTP, more than a third incurred catastrophic costs towards TB care.

Intussusception in Children Aged Less than Five years

OBJECTIVE

To enumerate the cases of intussusception in Chennai during 2012-2013, describe the clinical profile, outcomes of case management and highlight the importance of systematically collecting this data in lieu of rotavirus vaccine introduction in India.

METHODS

Medical records of pediatric intussusception cases admitted in eight large hospitals in Chennai from July 2012 through June 2013 were retrospectively reviewed. Demographic and clinical data including diagnostic and treatment practices were obtained. Cases were categorized based on the diagnostic certainty criteria stipulated by the Brighton collaboration on intussusception.

RESULTS

During the one year of study period, 205 cases of intussusception were diagnosed in 8 hospitals in Chennai city of India. The median age at presentation was 9 mo (Inter Quartile Range, IQR 6-14) with a male to female ratio of 1.8:1. The commonest site of intussusception was ileocolic (80.4 %). Most of the cases (59.8 %) were managed non-surgically. Direct surgical intervention was carried out in 26.5 % cases whereas in 11.8% of cases, surgery was required after failure of non-surgical measures. Median duration of hospital stay was 3 d (IQR 1-5).

CONCLUSIONS

This study documents the case burden of intussusception among children in Chennai in a calendar year. Data on receipt of rotavirus vaccine was not available. The authors recommend collection of rotavirus vaccine data among all cases of intussusception in the country, and do retrospective analysis in other parts of the country and prospective surveillance in pediatric / immunization clinics to assess impact of rotavirus vaccine on intussusception rates in the post rotavirus vaccine introduction scenario.

CYP2D6 genotype and phenotype relationship in South Indians

BACKGROUND

Genotypes of the drug-metabolizing enzyme CYP2D6 influence plasma levels of 25% of commonly prescribed drugs. This is the first study in India to investigate the genotype-phenotype relationship of CYP2D6.

AIM

To study the influence of some CYP2D6 genotypes on the metabolism of its substrate dextromethorphan in healthy South Indian volunteers and to assess the contribution of the CYP2D6*10 and CYP2D6*4 alleles.

MATERIALS AND METHODS

Twenty-six subjects from a previous CYP2D6 genotyping study of healthy volunteers were included for phenotyping in this study. Selected volunteers belonged to any one of three genotype groups:Group I - two normal activity alleles, Group II - one reduced activity allele and one normal activity allele and Group III - one loss of function allele along with either a wild type or reduced activity allele. Volunteers were phenotyped for the CYP2D6 enzyme using dextromethorphan as probe drug. Concentrations of the parent drug and metabolite dextrorphan were estimated using high performance liquid chromatography. Metabolic ratios were calculated as the ratio of parent drug to metabolite in 0-8h urine samples.

STATISTICAL ANALYSIS

Metabolic ratios from each genotype group were compared using the Mann-Whitney test at 5% significance, to observe their difference between genotype groups.

RESULTS

The mean metabolic ratios+/-SD in Groups I, II and III were 0.0039+/-0.0031, 0.0032+/-0.0017 and 0.0391+/-0.0331 respectively. The mean metabolic ratio of Group III was significantly higher when compared with Groups I or II. In heterozygous individuals, the *1 or *2 alleles compensated for the reduced enzyme activity due to the *10 allele. However, if a heterozygous individual had a *4 allele, the reduced enzyme activity could not be compensated by the *1 or *2 alleles.

CONCLUSIONS

The CYP2D6 enzyme activity was found to be decreased in individuals carrying *4 or *5 alleles. The *1 or *2 allele could compensate for the reduced function due to *10 allele, but not for the loss of function due to *4 allele.