Impact of contact tracing, respect of isolation, and lockdown in reducing the number of cases infected with COVID-19. Case study: Tunisia's response from March 22 to May 4, 2020

Background

Coronavirus disease 2019 (COVID-19) has spread rapidly across the world. Tunisia reacted early to COVID-19, resulting in a low number of infections during the first wave of the pandemic. This study was performed to model the effects of different interventions on the evolution of cases and to compare these with the Tunisian experience.

Methods

A stochastic transmission model was used to quantify the reduction in number of cases of COVID-19 with the interventions of contact tracing, compliance with isolation, and a general lockdown.

Results

In the model, increasing contact tracing from 20% to 80% after the first 100 cases reduced the cumulative number of infections (CNI) by 52% in 1 month. Similarly, increased compliance with isolation from 20% to 80% after the first 100 cases reduced the CNI by 45%. These reductions were smaller if the interventions were implemented after 1000 cases. A general lockdown reduced the CNI by 97% after the first 100 cases. Tunisia implemented its general lockdown after 75 cases were confirmed, which reduced the cumulative number of infected cases by 86% among the general population.

Conclusions

This study shows that the early application of critical interventions contributes significantly to reducing infections and the evolution of COVID-19 in a country. Tunisia’s early success with the control of COVID-19 is explained by its quick response.

Pooling arrangements in health financing systems: a proposed classification

OBJECTIVES

The function of pooling and the ways that countries organize this is critical for countries' progress towards universal health coverage, but its potential as a policy instrument has not received much attention. We provide a simple classification of country pooling arrangements and discuss the specific ways that fragmentation manifests in each and the typical challenges with respect to universal health coverage objectives associated. This can help countries assess their pooling setup and contribute to identifying policy options to address fragmentation or mitigate its consequences.

METHODS

The paper is based on a review of published and grey literature in PubMed, Google and Google Scholar and our information gathered from our professional work in countries on health financing policies. We examined the nature and structure of pooling in more than 100 countries across all income groups to develop the classification.

FINDINGS

We propose eight broad types of pooling arrangements: (1.) a single pool; (2.) territorially distinct pools; (3.) territorially overlapping pools in terms of service and population coverage; (4.) different pools for different socio-economic groups with population segmentation; (5.) different pools for different population groups, with explicit coverage for all; (6.) multiple competing pools with risk adjustment across the pools; and in combination with types (1.)-(6.), (7.) fragmented systems with voluntary health insurance, duplicating publicly financed coverage; and (8.) complementary or supplementary voluntary health insurance. However, we recognize that any classification is a simplification of reality and does not substitute for a country-specific analysis of pooling arrangements.

CONCLUSION

Pooling arrangements set the potential for redistributive health spending. The extent to which the potential redistributive and efficiency gains established by a particular pooling arrangement are realized in practice depends on its interaction and alignment with the other health financing functions of revenue raising and purchasing, including the links between pools and the service benefits and populations they cover.

Strengthening Urban Health for Advancing Universal Health Coverage in India

In 2011, nearly 31 per cent of Indian population lived in urban areas and this proportion was rapidly growing. In parallel, the disease epidemiology in India, as a whole, was changing, with non-communicablediseases (NCDs) contributing to nearly two-thirds of total disease burden stressing the already overburdened health systems in Indian states. Contrary to common perceptions, the health outcomes of the urban poor in India are not any better and at times worse than those of the rural population. The challenges in urban health are well known—poor infrastructure, uncoordinated and fragmented health service delivery, suboptimal financing, insufficient coordination amongst multiple agencies, migrant population, shortage of human resources, high level of inequalities and inequities, etc. In recent years, with the recognition that replication of what is being done in rural areas may not be sufficient to address challenges in urban settings, unique solutions to urban health have been identified.

This article summarizes the key health challenges and proposes a few solutions to address urban health challenges and improved health outcomes in urban agglomerations. The authors argue that progress towards universal health coverage in India would be partial unless sustained and harmonized initiatives are done to improve health situation in urban India.

Effect of probiotics (Lactobacillus plantarum 299 plus Bifidobacterium Cure21) in patients with poor ileal pouch function: a randomised controlled trial

OBJECTIVE

Poor pouch function after restorative proctocolectomy for ulcerative colitis is a considerable problem. Pouchitis and functional disorders are the most common reasons. Probiotics seem to have a beneficial effect in pouchitis but have not been assessed in functional pouch disorders. The aim was to analyse the effects of probiotics in patients with poor pouch function.

METHODS

Thirty-three patients were randomized to probiotics (Lactobacillus plantarum 299 and Bifidobacterium infantis Cure 21) or placebo in a double blinded, 1:1 fashion. The treatment effect was assessed by the pouch functional score (PFS; 0-15, 15 worst), pouchitis disease activity index (PDAI; 0-18, 18 worst), and levels of four faecal biomarkers of inflammation (calprotectin, lactoferrin, myeloperoxidase [MPO] and eosinophilic cationic protein [ECP]).

RESULTS

Thirty-two patients were included (probiotics = 17, placebo = 16). There was no difference in change in the PFS from before to after treatment between the groups (median difference: -1.00, 95% C.I. -3.00 to 0.00, p = 0.119). Furthermore, probiotics had no effect on PDAI (median difference: 0.00, 95% C.I. 0.00-1.00, p = 0.786), or on faecal biomarkers. Significant correlations were observed between PDAI and each of the faecal biomarkers at study start. There were no correlations between PFS or PDAI symptom subscore and the biomarkers. PDAI endoscopic and histologic subscores correlated significantly to each of the biomarkers.

CONCLUSION

The hypothesis that probiotics improves pouch-related dysfunction was not confirmed. Faecal biomarkers could play a future role in the management of pouch patients.

Inputs for universal health coverage: a methodological contribution to finding proxy indicators for financial hardship due to health expenditure

BACKGROUND

Universal health coverage is high on national health agendas of many countries at the moment. Absence of financial hardship is a key component of universal health coverage and should be monitored regularly. However, relevant household survey data, which is traditionally needed for this analysis is not frequently collected in most countries and in some countries, has not been collected at all. As such, proxy indicators for financial hardship would be very useful.

METHODS

We use data from the World Health Survey and use multi-level modeling with national and household level characteristics to see which indicators have a consistent and robust relationship with financial hardship. To strengthen the validity of our findings, we also use different measures of financial hardship.

RESULTS

There are several household level characteristics that seem to have a consistent relationship with financial hardship. However there is only one strong candidate for a proxy indicator at the national level- the share of out-of-pocket payments in total health expenditure. Additionally, the Gini coefficient of total household expenditure was also correlated to financial hardship in most of our models.

CONCLUSION

The national level indicators related only weakly to the risk of financial hardship. Hence, there should not be an over-reliance on them and collecting good quality household survey data is still a superior option for monitoring financial hardship.

Financial risk protection and universal health coverage: evidence and measurement challenges

Financial risk protection is a key component of universal health coverage (UHC), which is defined as access to all needed quality health services without financial hardship. As part of the PLOS Medicine Collection on measurement of UHC, the aim of this paper is to examine and to compare and contrast existing measures of financial risk protection. The paper presents the rationale behind the methodologies for measuring financial risk protection and how this relates to UHC as well as some empirical examples of the types of measures. Additionally, the specific challenges related to monitoring inequalities in financial risk protection are discussed. The paper then goes on to examine and document the practical challenges associated with measurement of financial risk protection. This paper summarizes current thinking on the area of financial risk protection, provides novel insights, and suggests future developments that could be valuable in the context of monitoring progress towards UHC.

General budget support: has it benefited the health sector?

There has been recent controversy about whether aid directed specifically to health has caused recipient governments to reallocate their own funds to non-health areas. At the same time, general budget support (GBS) has been increasing. GBS allows governments to set their own priorities, but little is known about how these additional resources are subsequently used. This paper uses cross-country panel data to assess the impact of GBS programmes on health spending in low-income and middle-income countries, using dynamic panel techniques to estimate unbiased coefficients in the presence of serial correlation. We found no clear evidence that GBS had any impact, positive or negative, on government health spending derived from domestic sources. GBS also had no observed impact on total government health spending from all sources (external as well as domestic). In contrast, health-specific aid was associated with a decline in health expenditures from domestic sources, but there was not a full substitution effect. That is, despite this observed fungibility, health-specific aid still increases total government health spending from all sources. Finally, increases in total government expenditure led to substantial increases in domestic government health expenditures.

The financial burden from non-communicable diseases in low- and middle-income countries: a literature review

Non-communicable diseases (NCDs) were previously considered to only affect high-income countries. However, they now account for a very large burden in terms of both mortality and morbidity in low- and middle-income countries (LMICs), although little is known about the impact these diseases have on households in these countries. In this paper, we present a literature review on the costs imposed by NCDs on households in LMICs. We examine both the costs of obtaining medical care and the costs associated with being unable to work, while discussing the methodological issues of particular studies. The results suggest that NCDs pose a heavy financial burden on many affected households; poor households are the most financially affected when they seek care. Medicines are usually the largest component of costs and the use of originator brand medicines leads to higher than necessary expenses. In particular, in the treatment of diabetes, insulin--when required--represents an important source of spending for patients and their families. These financial costs deter many people suffering from NCDs from seeking the care they need. The limited health insurance coverage for NCDs is reflected in the low proportions of patients claiming reimbursement and the low reimbursement rates in existing insurance schemes. The costs associated with lost income-earning opportunities are also significant for many households. Therefore, NCDs impose a substantial financial burden on many households, including the poor in low-income countries. The financial costs of obtaining care also impose insurmountable barriers to access for some people, which illustrates the urgency of improving financial risk protection in health in LMIC settings and ensuring that NCDs are taken into account in these systems. In this paper, we identify areas where further research is needed to have a better view of the costs incurred by households because of NCDs; namely, the extension of the geographical scope, the inclusion of certain diseases hitherto little studied, the introduction of a time dimension, and more comparisons with acute illnesses.

Patient costs for paediatric hospital admissions in Tanzania: a neglected burden?

OBJECTIVE

Tanzania has a policy of free provision of inpatient care for young children in order to promote timely access and thus reduce the current levels of mortality. However, little is known about out-of-pocket costs that may be incurred by families in seeking care for sick children. We conducted this study to identify the magnitude of these costs in relation to family income.

METHODS

Five hundred and ten caretakers were interviewed on the day of discharge of their child from 11 hospitals in north-east Tanzania. Caretakers were asked to report expenditure related to hospitalization in various categories and family wealth was assessed through reported expenditure in the previous month.

RESULTS

Food (mean US$2.2, median US$1.6), transport (mean US$1.7, median US$0) and medicines (mean US$1.0, median US$0.4) were the leading categories of expenditure, and overall the mean out-of-pocket expenditure was US$5.5 (median US$3.7) per admission. Mean out-of-pocket expenditure was more than 1.5 times higher for households in the highest monthly expenditure quintile compared with those in the lowest. However, this differential was reversed when expenditure was considered as a proportion of family expenditure in the previous month; for the lowest quintile, families spent more than three-quarters of their total monthly expenditure on a single paediatric admission.

CONCLUSION

Out-of-pocket expenditure on child hospitalization places a considerable burden on poor families. Our findings justify a closer scrutiny of how this expenditure could be reduced, particularly through the provision of adequate food for both children and caretakers and through reducing stock-outs of essential medicines.

Expression of cellular retinoid-binding proteins during normal and abnormal epidermal differentiation

Retinoids have important roles in growth and differentiation of epidermal cells. We have analyzed the expression of two intracellular retinoid-binding proteins, the cellular retinol-binding protein type I and the cellular retinoic acid-binding protein type I, during normal and abnormal epidermal differentiation. Both proteins were found to be expressed in normal epidermis with increasing expression from basal layer towards superficial layers. In psoriatic lesions, a hyperproliferative condition of the skin, the epidermal expression of cellular retinol-binding protein I was induced, whereas expression of cellular retinoic acid-binding protein I was sharply down-regulated. This and other features of psoriatic lesions indicate that down-regulation of cellular retinoic acid-binding protein I expression might cause aberrant retinoid-regulated gene expression in skin. In basal and squamous cell carcinomas, cellular retinoic acid-binding protein I expression was down-regulated, whereas cellular retinol-binding protein I was expressed. Apart from epidermal cells, a mesenchymal, dendritic cell-type, strongly expressing cellular retinoic acid-binding protein I, was identified in the dermis. In several hyperproliferative conditions of the skin, including psoriasis, and squamous and basal cell carcinomas, this cell type was abundant. These results have implications for the role of retinoids in normal and abnormal epidermal differentiation and suggest that part of the phenotype of psoriasis is due to inappropriate metabolism of retinoic acid in skin.

Isolation and characterization of a cDNA clone corresponding to bovine cellular retinoic-acid-binding protein and chromosomal localization of the corresponding human gene

A bovine adrenal cDNA library was constructed and a clone corresponding to cellular retinoic-acid-binding protein (CRABP) mRNA was isolated and sequenced. The insert of the clone corresponds to 75 bp of the 5' untranslated portion, the whole translated and the complete 3' untranslated portion of the bovine CRABP mRNA. A genomic Southern blot, probed with CRABP cDNA, indicated that only one copy of the gene is present in the human genome. Hybridizing bands in restricted chicken and fish DNA were also observed. Using the CRABP cDNA as probe we have located the human CRABP gene to chromosome 3 in hybridizations to mouse-human, hamster-human and rat-human cell hybrids. In situ hybridizations on rat testis cells probed with CRABP and cellular retinol-binding protein antisense mRNA indicate that both proteins are expressed in tubuli cells.