Treatment Default Research Articles

Effectiveness of Directly Observed Therapy Short Course (DOTS) in Patients with Tuberculosis Registered at Federal General Hospital, Islamabad

Background: TB is one of the top 10 killer infectious diseases worldwide and Pakistan ranks 6th. For sputum positive TB cases, incidence is 80/100,000 per year in Pakistan and the disease accounts for 5.1% of the total national disease burden. In Pakistan according to the National Drug resistance (DR) survey (2012-13), the DR-TB incidence is estimated to be at 3.7% among notified new pulmonary cases and 18.1% among retreatment patients. Under DOTS programs, free first line anti-TB medication is provided to the patients. This study was conducted to evaluate the effectiveness of the Directly Observed Therapy Short-course (DOTS) in the study population. Methods & Materials: A cross sectional descriptive study was done at medical unit at Federal General Hospital (FGH), Islamabad from Jan-Dec. 2015. Using consecutive sampling technique, 148 confirmed TB patients presenting to medical OPD were enrolled in study and were registered with DOTS program. After taking informed consent, a validated questionnaire was used to gather information including demography, clinical characteristics, details on compliance and outcome status. Data was analyzed using SPSS software. Results: Total 148 TB patients were enrolled. Male to female ratio was 0.94: 1. Mean age was 36 years (±SD 2.8). The most frequent age group was 15-<50 years (106, 72%). Out of total 148 cases, 126 (85%) had pulmonary tuberculosis, 21 (14%) had extra pulmonary TB while one was (1%) was cryptogenic. 130 patients (89%) were newly diagnosed whereas 18 (11%) were relapse cases. Except for 15 cases (9 lost to follow up and 6 deaths), rest 133 completed treatment with 94% cure rate. Patients with pulmonary tuberculosis were 3.4 times more likely to complete the treatment than with extra pulmonary TB (OR: 3.4. CI: 1.2-9.0, P value: 0.01). Among 12-32 years age group, majority of the patients (66, 86%) were of pulmonary TB. Age and gender did not have any statistical association with treatment outcome. Conclusion: DOTS is a very effective strategy to treat tuberculosis patients. Good counseling of the patients by the doctors and TB health care worker can further minimize the risk of treatment default.

Variations in the Clinical Management of Multibacillary Leprosy Patients in Selected Hospitals in Metro Manila

Introduction. This paper documents the variations in the diagnosis and management of multibacillary leprosy patients in three of the biggest case-holding hospitals in Metro Manila. Furthermore, we aimed to discuss the implications of these variations on the country’s leprosy control and elimination program.&#x0D; Methods. Focus group discussions (FGD) were conducted with 23 health professionals composed of doctors and nurses with at least a year of experience in managing leprosy patients. The topics included procedures on patient diagnosis and management such as treatment duration, patient follow-up and definitions of treatment completion and default. The FGD participants provided suggestions to improve treatment compliance of patients. Their responses were compared with World Health Organization (WHO) standards and/or the 2002 DOH Manual of Operating Procedures (MOP) for leprosy. Transcripts of the recordings of the FGDs were prepared and thematic analysis was then performed.&#x0D; Results. There were variations in the hospitals’ procedures to diagnose leprosy, in treatment duration, and in patient follow-up. Definitions for treatment completion and default differed not just between hospitals but also with the WHO guidelines and the 2002 MOP. Hospitals extended treatment up to 24 or even 36 months, despite the 12 months stipulated in the MOP. Two hospitals required slit skin smear and skin biopsy in diagnosis, despite the MOP and WHO provisions that these were not mandatory. One hospital defined default as three consecutive months without treatment, which was different from the MOP and WHO standards and from the other hospitals.&#x0D; Conclusion. Given the variations in patient management, we recommended that effectiveness of the standard treatment relative to other regimens being practiced by specialists be evaluated.

Access to HIV care and treatment for migrants between Lesotho and South Africa: a mixed methods study

BackgroundHIV treatment and care for migrants is affected by their mobility and interaction with HIV treatment programs and health care systems in different countries. To assess healthcare needs, preferences and accessibility barriers of HIV-infected migrant populations in high HIV burden, borderland districts of Lesotho.MethodsWe selected 15 health facilities accessed by high patient volumes in three districts of Maseru, Leribe and Mafeteng. We used a mixed methods approach by administering a survey questionnaire to consenting HIV infected individuals on anti-retroviral therapy (ART) and utilizing a purposive sampling procedure to recruit health care providers for qualitative in-depth interviews across facilities.ResultsOut of 524 HIV-infected migrants enrolled in the study, 315 (60.1%) were from urban and 209 (39.9%) from rural sites. Of these, 344 (65.6%) were women, 375 (71.6%) were aged between 26 and 45 years and 240 (45.8%) were domestic workers. A total of 486 (92.7%) preferred to collect their medications primarily in Lesotho compared to South Africa. From 506 who responded to the question on preferred dispensing intervals, 63.1% (n = 319) preferred 5–6 month ARV refills, 30.2% (n = 153) chose 3–4 month refills and only 6.7% (n = 34) opted for the standard-of-care 1–2 month refills. A total of 126 (24.4%) defaulted on their treatment and the primary reason for defaulting was failure to get to Lesotho to collect medication (59.5%, 75/126). Treatment default rates were higher in urban than rural areas (28.3% versus 18.4%, p = 0.011). Service providers indicated a lack of transfer letters as the major drawback in facilitating care and treatment for migrants, followed by discrimination based on nationality or language. Service providers indicated that most patients preferred all treatment services to be rendered in Lesotho, as they perceive the treatment provided in South Africa to be different often less strong or with more serious side effects.ConclusionExisting healthcare systems in both South Africa and Lesotho experience challenges in providing proper care and treatment for HIV infected migrants. A need for a differentiated model of ART delivery to HIV infected migrants that allows for multi-month scripting and dispensing is warranted.

Long-term bedaquiline-related treatment outcomes in patients with extensively drug-resistant tuberculosis from South Africa

Optimal treatment regimens for patients with extensively drug-resistant tuberculosis (XDR-TB) remain unclear. Long-term prospective outcome data comparing XDR-TB regimens with and without bedaquiline from an endemic setting are lacking.We prospectively followed-up 272 South African patients (49.3% HIV-infected; median CD4 count 169 cells·µL-1) with newly diagnosed XDR-TB between 2008 and 2017. Outcomes were compared between those who had not received bedaquiline (pre-2013; n=204) and those who had (post-2013; n=68; 80.9% received linezolid in addition).The 24-month favourable outcome rate was substantially better in the bedaquiline versus the non-bedaquiline group (66.2% (45 out of 68) versus 13.2% (27 out of 204); p<0.001). In addition, the bedaquiline group exhibited reduced 24-month rates of treatment failure (5.9% versus 26.0%; p<0.001) and default (1.5% versus 15.2%; p<0.001). However, linezolid was withdrawn in 32.7% (18out of 55) of patients in the bedaquiline group because of adverse events. Admission weight >50 kg, an increasing number of anti-TB drugs and bedaquiline were independent predictors of survival (the bedaquiline survival effect remained significant in HIV-infected persons, irrespective of CD4 count).XDR-TB patients receiving a backbone of bedaquiline and linezolid had substantially better favourable outcomes compared to those not using these drugs. These data inform the selection of XDR-TB treatment regimens and roll-out of newer drugs in TB-endemic countries.

Performance of centralized versus decentralized tuberculosis treatment services in Southern Brazil, 2006\u20132015

BackgroundTuberculosis (TB) control programs face the challenges of decreasing incidence, mortality rates, and drug resistance while increasing treatment adherence. The Brazilian TB control program recommended the decentralization of patient care as a strategy for combating the disease. This study evaluated the performance of this policy in an area with high default rates, comparing epidemiological and operational indicators between two similar municipalities.MethodsThis study analyzed epidemiological and operational indicators on new cases of pulmonary tuberculosis reported in the Brazilian Notifiable Diseases Information System between 2006 and 2015. In addition, to characterize differences between the populations of the two studied municipalities, a prospective cohort study was conducted between 2014 and 2015, in which patients with new cases of culture-confirmed pulmonary tuberculosis were interviewed and monitored until the disease outcome. A descriptive analysis, the chi-square test, and a Poisson regression model were employed to compare TB treatment outcomes and health care indicators between the municipalities.ResultsTwo thousand three hundred nine cases were evaluated, of which 207 patients were interviewed. Over the 2006–2015 period, TB incidence per 100,000 population in the municipality with decentralized care was significantly higher (39%, 95% CI 27–49%) in comparison to that of the municipality with centralized care. TB treatment default rate (45%, 95% CI 12–90%) was also higher in the municipality with decentralized care. During the two-year follow-up, significant differences were found between patients in centralized care and those in decentralized care regarding treatment success (84.5 vs. 66.1%), treatment default (10.7 vs. 25.8%), illicit drug use (27.7 vs. 45.9%), and homelessness (3.6 vs. 12.9%). The operational indicators revealed that the proportion of control smear tests, medical imaging, and HIV tests were all significantly higher in the centralized care. However, a significantly higher proportion of patients started treatment in the early stages of the disease in the municipality with decentralized care.ConclusionsThese data showed a low success rate in TB treatment in both municipalities. Decentralization of TB care, alone, did not improve the main epidemiological and operational indicators related to disease control when compared to centralized care. Full implementation of strategies already recommended is needed to improve TB treatment success rates.

A multi-site community randomized trial of community health workers to provide counseling and support for patients newly entering HIV care in rural Ethiopia: study design and baseline implementation

Background: Although HIV therapy is delivered to millions globally, treatment default (especially soon after entering care) remains a challenge. Community health workers (CHWs) can provide many services for people with HIV, including in rural and resource-limited settings.Objectives: We designed and implemented a 32 site community randomized trial throughout southern Ethiopia to assess an intervention using CHWs to improve retention in HIV care.Methods: Sixteen district hospital and 16 local health center HIV clinics were randomized 1:1 to be intervention or control sites. From each site, we enrolled adults newly entering HIV care. Participants at intervention sites were assigned a CHW who provided: HIV and health education; counseling and social support; and facilitated communication with HIV clinics. All participants are followed through three years with annual health surveys, plus HIV clinic record abstraction including clinic visit dates. CHWs record operational data about their client contacts.Results: 1799 HIV patients meeting inclusion criteria were enrolled and randomized: 59% were female, median age = 32 years, median CD4 + count = 263 cells/mm3, and 41% were WHO Stage III or IV. A major enrollment challenge was fewer new HIV patients initiating care at participating sites due to shortage of HIV test kits. At intervention sites, 71 CHWs were hired, trained and assigned to clients. In meeting with clients, CHWs needed to accommodate to various challenges, including HIV stigma, distance, and clients lacking cell phones.Conclusions: This randomized community HIV trial using CHWs in a resource-limited setting was successfully launched, but required flexibility to adapt to unforeseen challenges.

Fatores associados ao desfecho desfavorável do tratamento da tuberculose em um hospital geral do município do Rio de Janeiro, 2007 a 2014

Justificativa e Objetivo: a tuberculose permanece como relevante problema de saúde pública e a cura dos casos diagnosticados é uma estratégia para redução da elevada morbimortalidade. O objetivo deste estudo é identificar fatores associados a um desfecho desfavorável do tratamento da tuberculose em pacientes diagnosticados no HFSE de 2007 a 2014. &#x0D; Métodos: incluídos 670 casos confirmados notificados neste período na base local do SINAN, com encerramento registrado como cura (383), óbito por tuberculose (159) ou abandono do tratamento (128). Considerou-se desfecho desfavorável óbito ou abandono. Variáveis com razões de chances elevadas na análise bivariada e/ou importância clínica foram consideradas para inclusão em modelo de regressão logística. &#x0D; Resultados: foram identificados como fatores estatisticamente associados a um desfecho desfavorável idade ≥60 anos, raça/cor não branca, tratamento prévio para tuberculose ou situação de tratamento prévio desconhecida, resultado de anti-HIV positivo, forma pulmonar e sobretudo forma extrapulmonares grave. &#x0D; Conclusão: os resultados reforçam a necessidade de investir em políticas que garantam o acesso e a adequada assistência aos pacientes, especialmente àqueles com condições que predispõem a não adesão ao tratamento e a formas graves.

Tuberculosis treatment outcomes in Ethiopia from 2003 to 2016, and impact of HIV co-infection and prior drug exposure: A systematic review and meta-analysis.

BackgroundKnowledge of tuberculosis (TB) treatment outcomes is substantially needed to assess the performance of national TB controls programs (NTPs). To date, the overall estimates of treatment outcomes have not been determined in Ethiopia. Therefore, this meta-analysis was undertaken to produce pooled estimates of TB treatment outcomes and to analyze the impact of prior anti-TB drug exposure and HIV co-infection.MethodsPotentially relevant studies were retrieved from PubMed, EMBASE, and MEDLINE online databases. The unpublished studies have been retrieved from the grey literature through Google and Google Scholar. The pooled estimates were calculated using random effect model. The summary estimates were also presented using Forest plots and Tables. The outcome measures were successful and unsuccessful treatment outcomes. Patients who were cured or with completed treatment defined as successful treatment outcome and patients meeting the definition of death, defaulting and failure are considered as unsuccessfully treated cases.ResultsA total of 34 studies are included for meta-analysis. The pooled estimate of successful TB treatment outcomes amounts to 83.7% (95% CI 81.1%–86.3%). Of successfully treated cases, 33.9% were cured and the remaining completed cases. Besides, among patients with unsuccessful treatment outcome, nearly 50% were dead and the rest were treatment failures and defaulters. Sub-group analysis shows that high treatment success rate was estimated in Afar; 88.9% (95% CI 83.8%–94.2%), followed by Oromia; 88.5% (95% CI 82.6%–94.5%) and Gambella; 86.1% (95% CI 84.4%–87.9%), whereas relatively poor treatment outcome was noted in Tigray; 20.0% (95% CI 2.1%–37.9%) and Amhara; 19.0% (95% CI 12.6%–25.5%). The unsuccessful TB treatment outcome was found to be higher among HIV/TB co-infected cases with an odds ratio of 1.98 (95%CI, 1.56–2.52) and re-treated cases with an odds ratio of 2.17 (95%CI, 1.55–3.03). The time trend was assessed from 2003 to 2016, but it shows insignificant variation with treatment outcome (P = 0.108).ConclusionThe rate of successful treatment outcome in Ethiopia appears generally high, only slightly below the threshold suggested by the World Health Organization. History of tuberculosis treatment and HIV/TB co-infection were inversely associated with favorable treatment outcomes.

Isolated unilateral ptosis as a presenting feature of midbrain infarction

A 60-year-old female patient, non-smoker, with known case of coronary artery disease (CAD) but treatment defaulter, presented to us with complaints of sudden-onset vertigo followed by drooping of the left...

Untreated depression and tuberculosis treatment outcomes, quality of life and disability, Ethiopia.

ObjectiveTo investigate the association between comorbid depression and tuberculosis treatment outcomes, quality of life and disability in Ethiopia.MethodsThe study involved 648 consecutive adults treated for tuberculosis at 14 primary health-care facilities. All were assessed at treatment initiation (i.e. baseline) and after 2 and 6 months. We defined probable depression as a score of 10 or above on the nine-item Patient Health Questionnaire. Data on treatment default, failure and success and on death were obtained from tuberculosis registers. Quality of life was assessed using a visual analogue scale and we calculated disability scores using the World Health Organization’s Disability Assessment Scale. Using multivariate Poisson regression analysis, we estimated the association between probable depression at baseline and treatment outcomes and death.ResultsUntreated depression at baseline was independently associated with tuberculosis treatment default (adjusted risk ratio, aRR: 9.09; 95% confidence interval, CI: 6.72 to 12.30), death (aRR: 2.99; 95% CI: 1.54 to 5.78), greater disability (β: 0.83; 95% CI: 0.67 to 0.99) and poorer quality of life (β: −0.07; 95% CI: −0.07 to −0.06) at 6 months. Participants with probable depression had a lower mean quality-of-life score than those without (5.0 versus 6.0, respectively; P < 0.001) and a higher median disability score (22.0 versus 14.0, respectively; P < 0.001) at 6 months.ConclusionUntreated depression in people with tuberculosis was associated with worse treatment outcomes, poorer quality of life and greater disability. Health workers should be given the support needed to provide depression care for people with tuberculosis.

Effects of social protection on tuberculosis treatment outcomes in low or middle-income and in high-burden countries: systematic review and meta-analysis.

Tuberculosis (TB) is a poverty infectious disease that affects millions of people worldwide. Evidences suggest that social protection strategies (SPS) can improve TB treatment outcomes. This study aimed to synthesize such evidences through systematic literature review and meta-analysis. We searched for studies conducted in low- or middle-income and in high TB-burden countries, published during 1995-2016. The review was performed by searching PubMed/MEDLINE, Scopus, Web of Science, ScienceDirect and LILACS. We included only studies that investigated the effects of SPS on TB treatment outcomes. We retained 25 studies for qualitative synthesis. Meta-analyses were performed with 9 randomized controlled trials, including a total of 1,687 participants. Pooled results showed that SPS was associated with TB treatment success (RR = 1.09; 95%CI: 1.03-1.14), cure of TB patients (RR = 1.11; 95%CI: 1.01-1.22) and with reduction in risk of TB treatment default (RR = 0.63; 95%CI: 0.45-0.89). We did not detect effects of SPS on the outcomes treatment failure and death. These findings revealed that SPS might improve TB treatment outcomes in lower-middle-income economies or countries with high burden of this disease. However, the overall quality of evidences regarding these effect estimates is low and further well-conducted randomized studies are needed.

Prevalence and Predictors of Tuberculosis Treatment Default in Abakaliki, Nigeria: An Implication for Patient Centred Education and Treatment Follow-Up

Prevalence and Predictors of Tuberculosis Treatment Default in Abakaliki, Nigeria: An Implication for Patient Centred Education and Treatment Follow-Up

Tuberculosis treatment outcomes using treatment supporters in Ketu South Municipality of Volta Region in Ghana

Introduction : the current global tuberculosis (TB) epidemic places a lot of pressure on health care managers, especially those in the developing countries to seek innovative ways of delivering effective treatment to TB patients. One of the strategies employed was a directly observed therapy for all patients, where community members are used to supervise TB patients during the treatment regimen. Even though treatment supporters are used to improve the situation, proportion cured and completing treatment are still low. This study was conducted in Ketu South municipality of the Volta region in Ghana on tuberculosis treatment outcomes using treatment supporters to determine treatment supporter factors influencing treatment outcomes in the municipality. Methods : the study was a cross sectional study, using quantitative methods to collect data on 137 TB clients and their treatment supporters. Tuberculosis records were reviewed to determine the proportion of TB clients cured, those who completed treatment and those who defaulted. Questionnaire was then used to collect data from their treatment supporters. The data was analyzed using SPSS and Stata. Univariate, chi-squared and logistic regression analyses were done to determine proportions, differences and strengths of associations between the independent variables and the dependent variables. Results : tuberculosis case detection for the municipality was 96.1% with a treatment success of 79.6%. Treatment outcome for cure, completion and treatment default were 66.7%, 81.9% and 20.4% respectively. It was realized that some treatment supporter factors influenced treatment cure of the TB clients. These factors include: age of treatment supporter being older or younger than the TB client, marital status of the supporter, selection of the treatment supporter and treatment supporter’s knowledge on TB. Conclusion : tuberculosis clients are more likely to be cured when they are supervised by older people, married and have good knowledge of TB and are selected by the TB patient. Financial challenge and time spent on supervising drug intake are the main challenges faced by the treatment supporters in Ketu South municipality.

Evaluating the impact of social support services on tuberculosis treatment default in Ukraine.

Evaluating the impact of social support services on tuberculosis treatment default in Ukraine.

Barriers leading to treatment default among tuberculosis patients in Khartoum State, Sudan: a qualitative study

Barriers leading to treatment default among tuberculosis patients in Khartoum State, Sudan: a qualitative study

Sputum Smear and Culture Conversion in Multidrug Resistance Tuberculosis Patients in Seven Districts of Central Gujarat, India: A Longitudinal Study.

Objectives:To know the sputum smear and culture conversion among multidrug resistance tuberculosis (MDR-TB) patients.Materials and Methods:The longitudinal cohort study was conducted for 142 MDR-TB patients registered in 2010 under Revised National Tuberculosis Control Programme of Vadodara region. Three follow-ups were taken for sputum and culture examination, at completion of 6, 12, and 24 months of treatment. Individuals were interviewed to know the reasons for missed dose and default.Results:The sputum smear and culture conversion rate was 43.4%, 47.7%, and 57% at 6 months, 12 months, and 24 months of follow-up, respectively. Treatment default rate was highest (15.2%) within initial 6 months of therapy. The mean time to sputum smear and culture conversion was 120.27 days and 125.02 days, respectively.Conclusions:Most of patients who were culture positive at 6 months remained so even after 12 months. There was not much difference in the time taken for culture and sputum conversion.

Do retreatment tuberculosis patients need special treatment response follow-up beyond the standard regimen? Finding of five-year retrospective study in pastoralist setting

BackgroundTreatment outcomes serve as proxy measures of the quality of tuberculosis treatment provided by the health care system, and it is essential to evaluate the effectiveness of Directly Observed Therapy-Short course program in controlling the disease, and reducing treatment failure, default and death. Hence, we evaluated tuberculosis treatment success rate, its trends and predictors of unsuccessful treatment outcome in Ethiopian Somali region where 85% of its population is pastoralist.MethodsA retrospective review of 5 years data (September 2009 to August 2014) was conducted to evaluate the treatment outcome of 1378 randomly selected tuberculosis patients treated in Kharamara, Dege-habour and Gode hospitals. We extracted data on socio-demographics, HIV Sero-status, tuberculosis type, treatment outcome and year using clinical chart abstraction sheet. Tuberculosis treatment outcomes were categorized into successful (cured and/or completed) and unsuccessful (died/failed/default) according to the national tuberculosis guideline. Data was entered using EpiData 3.1 and analyzed using SPSS 20. Chi-square (χ2) test and logistic regression model were used to reveal the predictors of unsuccessful treatment outcome at P ≤ 0.05 significance level.ResultThe majority of participants was male (59.1%), pulmonary smear negative (49.2%) and new cases (90.6%). The median age was 26 years [IQR: 18–40] and HIV co-infection rate was 4.6%. The overall treatment success rate was 86.8% [95%CI: 84.9% - 88.5%]; however, 4.8%, 7.6% and 0.7% of patients died, defaulted and failed to cure respectively. It fluctuated across the years and ranged from 76.9% to 94% [p < 0.001]. The odds of death/failure [AOR = 2.4; 95%CI = 1.4–3.9] and pulmonary smear positivity [AOR = 2.3; 95%CI = 1.6–3.5] were considerably higher among retreatment patients compared to new counterparts. Unsuccessful treatment outcome was significantly higher in less urbanized hospitals [p < 0.001]. Treatment success rate had insignificant difference between age groups, genders, tuberculosis types and HIV status (P > 0.05).ConclusionThis study revealed that the overall tuberculosis treatment success rate has realized the global target for 2011–2015. However, it does not guarantee its continuity as adverse treatment outcomes might unpredictably occur anytime and anywhere. Therefore, continual effort to effectively execute DOTS should be strengthened and special follow-up mechanism should be in place to monitor treatment response of retreatment cases.

Drug addiction and alcoholism as predictors for tuberculosis treatment default in Brazil: a prospective cohort study.

This study aimed to evaluate the risk factors for tuberculosis (TB) treatment default in a priority city for disease control in Brazil. A cohort of TB cases diagnosed from 2008 to 2009 was followed up from patients' entry into three outpatient sites, in Juiz de Fora, Minas Gerais (Brazil), until the recording of the outcomes. Drug addiction, alcoholism and treatment site appeared to be independently associated with default. Current users of crack as the hardest drug (odds ratio (OR) 12·25, 95% confidence interval (CI) 3·04-49·26) were more likely to default than other hard drug users (OR 5·67, 95% CI 1·34-24·03), former users (OR 4·12, 95% CI 1·11-15·20) and those not known to use drugs (reference group). Consumers at high risk of alcoholism (OR 2·94, 95% CI 1·08-7·99) and those treated in an outpatient hospital unit (OR 8·22, 95% CI 2·79-24·21%) also were more likely to default. Our results establish that substance abuse was independently associated with default. National TB programmes might be more likely to achieve their control targets if they include interventions aimed at improving adherence and cure rates, by diagnosing and treating substance abuse concurrently with standard TB therapy.

Study of socio-demographic factors causing interruption of anti-tuberculosis treatment in DOTS centre in Warangal district of Telangana State

Background: Tuberculosis has existed for millennia and remains a major global health problem. It causes ill-health in millions of people each year and in 2015 it was one of the top 10 causes of death worldwide. Understanding the specific reasons for unsuccessful outcomes is important to improve the treatment system. This present study was carried out to find out the effects of socio-demographic factors on TB defaulters under DOTS centre in Warangal District, Telangana state.Methods: A cross sectional study was carried among 103 defaulters of TB patients in 3 TB units (TU) Warangal (urban), Ragunathapally (rural) and Eturunagaram (tribal) out of 7 TB units in Warangal district, attached to District Tuberculosis Centre (DTC) from January 2016 to June 2016 by interview technique utilising a pretested and structured questionnaire to collect the data. Statistical analysis: Percentages, proportions and chi-square test were applied whenever necessary.Results: In present study, males (35%) were more than females (7.8%) and 42.8% were in the age group of 40-55 years, followed by 28.1% were 26-39 years age group. Majority of defaulters were in nuclear family (77.7%) followed by joint family (21.3%). Cost of travel as a reason for default of treatment was seen more in tribal area (16.5%) than rural (12.6%) and urban (4.8%) TUs. The TB patients residing in tribal areas are more prone to default, an important reason being the distance needed to travel to the closest health facility, availability and the need to travel by public transport.Conclusions: Tuberculosis is an infectious disease which has a devastating impact on the economic wellbeing of individual and their families. Most of the defaulters were illiterates residing in tribal area. Cost of travel as a reason for default of treatment was seen more in tribal TU 17(16.5%) than urban and rural TUs.

Cost effectiveness of decentralised care model for managing MDR-TB in India

BackgroundIn India, multidrug-resistant tuberculosis (MDR-TB) patients are usually treated in hospitals. Decentralised care model, however, has been suggested as a possible alternative by the World Health Organization (WHO). In the “End TB Strategy”, the WHO highlights, as one of the key targets for 2035, that ‘no TB-affected families should face catastrophic hardship due to the tuberculosis’. Removal of financial barriers to health-care access and mitigation of catastrophic expenditures are therefore considered vital to achieve the universal health coverage (UHC) goal. Since forgoing healthcare due to the financial constraints is a known fact in India, decentralised care as an intervention choice (as against hospital-based care) might enhance equity provided it is an affordable choice. Thus, an economic evaluation was conducted, from the perspective of the national health system in India, to assess the cost-effectiveness of decentralised care compared to centralised care for MDR-TB. MethodsThis study uses a decision-analytic model with a follow-up of two years to assess the expected costs of the decentralised versus the centralised approaches for MDR-TB treatment. A published systematic review of observational studies yielded the MDR-TB treatment outcomes, which included treatment success, treatment default, treatment failure, and mortality parameters. It was observed that these parameters did not vary significantly between the two alternatives. Treatment costs included the following costs: hospital admission costs, clinic costs, visits to laboratory and MDR-TB centre, drug therapy, injections and food. Costs data of drugs, diagnosis, hospital stay and travel to public facilities, based on a simple market survey, were taken from a recently published study on MDR-TB expenditures in the Chhattisgarh state of India. Potential cost savings related to the implementation of decentralised MDR-TB care for all patients who initiated MDR-TB treatment in India were additionally estimated. ResultsEstimated average expected total treatment cost was US$ 3390.56 for the hospital-based model and US$ 1724.1 for the decentralised model for a patient treated for MDR-TB in India, generating potential savings of US$1666.50 per case, with ICER US$ 2382.68 per QALY gained. One of the primary drivers of this difference was the significantly more intensive (thus expensive) stay charges in the hospital. If the costs and treatment probabilities are extrapolated to the whole country, with 48114 MDR-TB patients initiated on treatment in 2017, decentralised care would have additional 1058 patients cured, gain additional 3824 QALYs, and avert 2165 deaths, as compared to centralised care, in India. At various scenarios of coverage rates of decentralised and centralised care the cost difference would range between 23% and 94% for the country. ConclusionOur study provides evidence of cost savings for MDR-TB patients if patients choose decentralised treatment in comparison to suggested hospitalisation of these patients for centralised treatment with similar outcomes. The economic evaluation presented in this study expected significant efficiency gains in choice of two treatment options and the cost savings may improve equity. In India, treatment of MDR-TB using decentralised care is expected to result in similar patient outcomes at markedly reduced public health costs compared with centralised care.