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ABSTRACTTuberculosis is recognised as a disease of the economically disadvantaged people due to its association with financial vulnerability. Mozambique still faces the challenge of the high burden of TB and associated costs. We aimed to understand the social and economic impacts of TB and the need for social support among people with TB in Mozambique. We conducted a qualitative study using a phenomenological approach focusing on the lived experiences and perceptions of people with TB. A total of 52 semi-structured one-to-one in-depth interviews were conducted and data were analysed using a reflexive thematic analysis. Three themes were drawn from the analysis: (i) TB has a social and economic impact that requires adaptation and resourcefulness amongst those affected; (ii) People with TB have different preferences and needs for social support, and (iii) People with TB have different knowledge of, and experiences with, formal social support. TB affects family and community relationships mainly due to impacts on the household’s finances. People with TB in Mozambique are not entitled to any form of social support, and they need to rely on help from family and the community which is often insufficient. Further investigation is needed on how social support schemes can be developed in Mozambique.

Abstract Background Vietnam’s primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process. Methods A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated. Results We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers. Conclusions Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.

Abstract Background In Viet Nam, tuberculosis (TB) represents a devastating life-event with an exorbitant price tag, partly due to lost income from daily directly observed therapy in public sector care. Thus, persons with TB may seek care in the private sector for its flexibility, convenience, and privacy. Our study aimed to measure income changes, costs and catastrophic cost incurrence among TB-affected households in the public and private sector. Methods Between October 2020 and March 2022, we conducted 110 longitudinal patient cost interviews, among 50 patients privately treated for TB and 60 TB patients treated by the National TB Program (NTP) in Ha Noi, Hai Phong and Ho Chi Minh City, Viet Nam. Using a local adaptation of the WHO TB patient cost survey tool, participants were interviewed during the intensive phase, continuation phase and post-treatment. We compared income levels, direct and indirect treatment costs, catastrophic costs using Wilcoxon rank-sum and chi-squared tests and associated risk factors between the two cohorts using multivariate regression. Results The pre-treatment median monthly household income was significantly higher in the private sector versus NTP cohort (USD 868 vs USD 578; P = 0.010). However, private sector treatment was also significantly costlier (USD 2075 vs USD 1313; P = 0.005), driven by direct medical costs which were 4.6 times higher than costs reported by NTP participants (USD 754 vs USD 164; P

Abstract Background The psychosocial consequences of tuberculosis (TB) are key barriers to ending TB globally. We evaluated and compared stigma, depression, and quality of life (QoL) among people with TB diagnosed through active (ACF) and passive (PCF) case-finding in Nepal. Methods We prospectively recruited adults with TB diagnosed through ACF and PCF in four districts of Nepal between August 2018 and April 2019. Participants were interviewed at 8–12 weeks (baseline) and 22–26 weeks (follow-up) following treatment initiation. TB stigma was measured using an adapted Van Rie Stigma Scale (0 = no stigma to 30 = highest stigma). Depression was measured using a locally-validated Patient Health Questionnaire (PHQ-9). Mild and major depression were indicated by PHQ-9 scores 5–9 and ≥ 10, respectively. QoL was measured using the EuroQoL 5-Dimension 5-level (EQ-5D-5L) from 0 to 1 (optimal QoL); and self-rated health from 0 to 100 (optimal self-rated health). Results We recruited 221 participants (111 ACF; 110 PCF) with a mean age of 48 years (standard deviation [SD] = ± 16), of whom 147/221 (67%) were men. The mean TB stigma score was 12 (SD = 7.3) at baseline and 12 (SD = 6.7) at follow-up. The most commonly perceived elements of TB stigma at baseline were that people with TB experienced guilt (110/221, 50%) and feared disclosure outside their household (114/221, 52%). Self-rated health and EQ-5D-5L scores increased from baseline to follow-up (69.3 to 80.3, p

Abstract Background Globally, most people with multidrug-resistant tuberculosis (MDR-TB) and their households experience catastrophic costs of illness, diagnosis, and care. However, the factors associated with experiencing catastrophic costs are poorly understood. This study aimed to identify risk factors associated with catastrophic costs incurrence among MDR-TB-affected households in Ho Chi Minh City (HCMC), Viet Nam. Methods Between October 2020 and April 2022, data were collected using a locally-adapted, longitudinal WHO TB Patient Cost Survey in ten districts of HCMC. Ninety-four people with MDR-TB being treated with a nine-month TB regimen were surveyed at three time points: after two weeks of treatment initiation, completion of the intensive phase and the end of the treatment (approximately five and 10 months post-treatment initiation respectively). The catastrophic costs threshold was defined as total TB-related costs exceeding 20% of annual pre-TB household income. Logistic regression was used to identify variables associated with experiencing catastrophic costs. A sensitivity analysis examined the prevalence of catastrophic costs using alternative thresholds and cost estimation approaches. Results Most participants (81/93 [87%]) experienced catastrophic costs despite the majority 86/93 (93%) receiving economic support through existing social protection schemes. Among participant households experiencing and not experiencing catastrophic costs, median household income was similar before MDR-TB treatment. However, by the end of MDR-TB treatment, median household income was lower (258 [IQR: 0–516] USD vs. 656 [IQR: 462–989] USD; p = 0.003), and median income loss was higher (2838 [IQR: 1548–5418] USD vs. 301 [IQR: 0–824] USD; p

Abstract Background Tuberculosis (TB) has been repeatedly shown to have socioeconomic impacts in both individual-level and ecological studies; however, much less is known about this effect among children and adolescents and the extent to which being affected by TB during childhood and adolescence can have life-course implications. This paper describes the results of the development of a conceptual framework and scoping review to review the evidence on the short- and long-term socioeconomic impact of tuberculosis on children and adolescents. Objectives To increase knowledge of the socioeconomic impact of TB on children and adolescents. Methods We developed a conceptual framework of the socioeconomic impact of TB on children and adolescents, and used scoping review methods to search for evidence supporting or disproving it. We searched four academic databases from 1 January 1990 to 6 April 2021 and conducted targeted searches of grey literature. We extracted data using a standard form and analysed data thematically. Results Thirty-six studies (29 qualitative, five quantitative and two mixed methods studies) were included in the review. Overall, the evidence supported the conceptual framework, suggesting a severe socioeconomic impact of TB on children and adolescents through all the postulated pathways. Effects ranged from impoverishment, stigma, and family separation, to effects on nutrition and missed education opportunities. TB did not seem to exert a different socioeconomic impact when directly or indirectly affecting children/adolescents, suggesting that TB can affect this group even when they are not affected by the disease. No study provided sufficient follow-up to observe the long-term socioeconomic effect of TB in this age group. Conclusion The evidence gathered in this review reinforces our understanding of the impact of TB on children and adolescents and highlights the importance of considering effects during the entire life course. Both ad-hoc and sustainable social protection measures and strategies are essential to mitigate the socioeconomic consequences of TB among children and adolescents.

To achieve the Sustainable Development Goal's targets of universal health coverage (UHC) and poverty reduction, interventions are required that strengthen and harmonize both UHC and social protection. Vietnam is committed to achieving financial protection and over 90% of the general population has enrolled in its social health insurance (SHI) scheme. However, an estimated 63% of tuberculosis (TB)-affected households in Vietnam still face catastrophic costs and little is known about the optimal strategies to mitigate the costs of TB care for vulnerable families. This study assessed the acceptability of a social protection package containing cash transfers and SHI using individual interviews (n = 19) and focus group discussions (n = 3 groups). Interviews were analyzed through framework analysis. The study's main finding indicated that both conditional and unconditional cash transfers paired with SHI were acceptable, across six dimensions of acceptability. Cash transfers were considered beneficial for mitigating out-of-pocket expenditure, increasing TB treatment adherence, and improving mental health and general well-being, but the value provided was inadequate to fully alleviate the economic burden of the illness. The conditionality of the cash transfers was not viewed by participants as inappropriate, but it increased the workload of the TB program, which brought into question the feasibility of scale-up. SHI was viewed as a necessity by almost all participants, but people with TB questioned the quality of care received when utilizing it for auxiliary TB services. Access to multiple sources of social protection was deemed necessary to fully offset the costs of TB care. Additional research is needed to assess the impact of cash transfer interventions on health and economic outcomes in order to create an enabling policy environment for scale-up.

Abstract Background Access to health care is an essential health policy issue. In several countries, waiting time guarantees mandate set time limits for assessment and treatment. High-quality waiting time data are necessary to evaluate and improve waiting times. This study’s aim was to investigate health care providers and administrative management professionals’ perceptions of validity and usefulness of waiting time reporting in specialist care. Methods Semi-structured interviews (n = 28) were conducted with administrative management and care professionals (line managers and care providers) in specialized clinics in the Stockholm Region, Sweden. Clinic-specific data from the waiting time registry was used in the care provider interviews to assess face validity. Clinics were purposefully sampled for maximum variation in complexity of care, volume of production, geographical location, private or public ownership, and local waiting times. Thematic analysis was used. Results The waiting time registry was perceived to have low validity and usefulness. Perceived validity and usefulness were interconnected, with mechanisms that reinforced the connection. Structural and cognitive barriers to validity included technical and procedural errors, errors caused by role division, misinterpretation of guidelines, diverging interpretations of nonregulated cases and extensive willful manipulation of data. Conclusions We identify four misconceptions underpinning the current waiting time reporting system: passive dissemination of guidelines is sufficient as implemented, cognitive load of care providers to report waiting times is negligible, soft-law regulation and presentation of outcome data is sufficient to drive improvement, and self-reported data linked to incentives poses a low risk of data corruption. To counter low validity and usefulness, we propose the following for policy makers and administrative management when developing and implementing waiting time monitoring: communicate guidelines with instructions for operationalization, address barriers to implementation, ensure quality through monitoring of implementation and adherence to guidelines, develop IT ontology together with professionals, avoid parallel measurement infrastructures, ensure waiting times are presented to suit management needs, provide timely waiting time data, enable the study of single cases, minimize manual data entry, and perform spot-checks or external validity checks. Several of these strategies should be transferable to waiting time monitoring in other contexts.

Abstract Background Despite free diagnosis and treatment for tuberculosis (TB), the costs during treatment impose a significant financial burden on patients and their households. The study sought to identify the determinants for catastrophic costs among patients with drug-sensitive TB (DSTB) and their households in Kenya. Methods The data was collected during the 2017 Kenya national patient cost survey from a nationally representative sample (n = 1071). Treatment related costs and productivity losses were estimated. Total costs exceeding 20% of household income were defined as catastrophic and used as the outcome. Multivariable Poisson regression analysis was performed to measure the association between selected individual, household and disease characteristics and occurrence of catastrophic costs. A deterministic sensitivity analysis was carried using different thresholds and the significant predictors were explored. Results The proportion of catastrophic costs among DSTB patients was 27% (n = 294). Patients with catastrophic costs had higher median productivity losses, 39 h [interquartile range (IQR): 20–104], and total median costs of USD 567 (IQR: 299–1144). The incidence of catastrophic costs had a dose response with household expenditure. The poorest quintile was 6.2 times [95% confidence intervals (CI): 4.0–9.7] more likely to incur catastrophic costs compared to the richest. The prevalence of catastrophic costs decreased with increasing household expenditure quintiles (proportion of catastrophic costs: 59.7%, 32.9%, 23.6%, 15.9%, and 9.5%) from the lowest quintile (Q1) to the highest quintile (Q5). Other determinants included hospitalization: prevalence ratio (PR) = 2.8 (95% CI: 1.8–4.5) and delayed treatment: PR = 1.5 (95% CI: 1.3–1.7). Protective factors included receiving care at a public health facility: PR = 0.8 (95% CI: 0.6–1.0), and a higher body mass index (BMI): PR = 0.97 (95% CI: 0.96–0.98). Pre TB expenditure, hospitalization and BMI were significant predictors in all sensitivity analysis scenarios. Conclusions There are significant inequities in the occurrence of catastrophic costs. Social protection interventions in addition to existing medical and public health interventions are important to implement for patients most at risk of incurring catastrophic costs. Graphic abstract

Abstract Background Nepal has a high burden of undetected tuberculosis (TB). In line with the World Health Organization’s End TB Strategy, the National TB Programme promotes active case-finding (ACF) as one strategy to find people with TB who are unreached by existing health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented in four districts in Nepal, generating a substantial yield of previously undetected TB. We aimed to identify the facilitators and barriers linked to the implementation of ACF within IMPACT TB, as well as how those facilitators and barriers have been or could be addressed. Methods This was an exploratory qualitative study based on 17 semi-structured key-informant interviews with people with TB who were identified through ACF, and community health workers who had implemented ACF. Thematic analysis was applied in NVivo 11, using an implementation science framework developed by Grol and Wensing to classify the data. Results We generated five main themes from the data: (1) ACF addressed the social determinants of TB by providing timely access to free healthcare, (2) knowledge and awareness about TB among people with TB, communities and community health workers were the ‘oil’ in the ACF ‘machine’, (3) trust in community health workers was fundamental for implementing ACF, (4) community engagement and support had a powerful influence on ACF implementation and (5) improved working conditions and enhanced collaboration with key stakeholders could further facilitate ACF. These themes covered a variety of facilitators and barriers, which we divided into 22 categories cutting across five framework levels: innovation, individual professional, patient, social context and organizational context. Conclusions This study provides new insights into facilitators and barriers for the implementation of ACF in Nepal and emphasizes the importance of addressing the social determinants of TB. The main themes reflect key ingredients which are required for successful ACF implementation, while the absence of these factors may convert them from facilitators into barriers for ACF. As this study outlined “how-to” strategies for ACF implementation, the findings can furthermore inform the planning and implementation of ACF in Nepal and similar contexts in low- and middle-income countries.

Abstract Background The World Health Organization (WHO) End TB Strategy has established a milestone to reduce the number of tuberculosis (TB)- affected households facing catastrophic costs to zero by 2020. The role of active case finding (ACF) in reducing patient costs has not been determined globally. This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding (PCF), and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal. Methods The study was conducted in two districts of Nepal: Bardiya and Pyuthan (Province No. 5) between June and August 2018. One hundred patients were included in this study in a 1:1 ratio (PCF: ACF, 25 consecutive ACF and 25 consecutive PCF patients in each district). The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs. Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20% of their annual household income. The intensity of catastrophic costs was calculated using the positive overshoot method. The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs. Meanwhile, the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis. Results Ninety-nine patients were interviewed (50 ACF and 49 PCF). Patients diagnosed through ACF incurred lower costs during the pre-treatment period (direct medical: USD 14 vs USD 32, P = 0.001; direct non-medical: USD 3 vs USD 10, P = 0.004; indirect, time loss: USD 4 vs USD 13, P

Abstract Background Asylum seekers in Sweden are offered tuberculosis (TB) screening at a voluntary post-arrival health examination. The role of this screening in improving the TB diagnostic pathway has not been previously evaluated. The aim of this study was to determine diagnostic pathways for active TB cases and compare diagnostic delays between different pathways. Methods Retrospective review of medical records of patients reported with active TB in Stockholm in 2015, using a structured and pre-coded form. Results Seventy-one percent of patients actively sought health care due to symptoms. As for source of referral to TB specialist clinic, 15% came from screening of eligible migrants, of whom the majority were asymptomatic. Among asylum seekers, 69% were identified through screening at a health examination (HE). The main sources of referral to TB clinics were emergency departments (27%) and primary health care centers (20%). Median health care provider delay was significantly longer in patients identified through migrant screening in health examination. Conclusions Screening at a health examination was the main pathway of active TB detection among mainly asymptomatic and non-contagious asylum seekers but contributed modestly to total overall TB case detection. In these patients TB was diagnosed early in a non-contagious phase of the disease. Further research is required to assess the effectiveness and cost-effectiveness of HE TB screening as well as inclusion of other groups of migrants from high incidence countries in the screening program in terms of impact on delay, transmission and treatment outcomes.

The WHO developed a generic ‘TB patient cost survey’ tool and a standardized approach to assess the direct and indirect costs of TB incurred by patients and their households, estimate the proportion of patients experiencing catastrophic costs, and measure the impact of interventions to reduce patient costs. While the generic tool is a facility-based cross-sectional survey, this standardized approach needs to be adapted for longitudinal studies. A longitudinal approach may overcome some of the limitations of a cross-sectional design and estimate the economic burden of TB more precisely. We describe the process of creating a longitudinal instrument and its application to the TB Sequel study, an ongoing multi-country, multi-center observational cohort study. We adapted the cross-sectional WHO generic TB patient cost survey instrument for the longitudinal study design of TB Sequel and the local context in each study country (South Africa, Mozambique, Tanzania, and The Gambia). The generic instrument was adapted for use at enrollment (start of TB treatment; Day 0) and at 2, 6, 12 and 24 months after enrollment, time points intended to capture costs incurred for diagnosis, during treatment, at the end of treatment, and during long-term follow-up once treatment has been completed. These time points make the adapted version suitable for use in patients with either drug-sensitive or drug-resistant TB. Using the adapted tool provides the opportunity to repeat measures and make comparisons over time, describe changes that extend beyond treatment completion, and link cost survey data to treatment outcomes and post-TB sequelae. Trial registration: ClinicalTrials.gov: NCT032516 August 1196, 2017. Abbreviations: DOTS: Directly observed treatment, short-course; DR-TB: Drug-resistant tuberculosis; MDR-TB: Multi-drug resistant tuberculosis; NTP: National Tuberculosis Programme; TB: Tuberculosis; USD: United States Dollar; WHO: World Health Organization.

Abstract Background In Sweden asylum seekers are offered a voluntary health examination, free-of-charge (HE). The HE coverage is low. The organization and implementation of the HE involves collaboration between different agencies with different roles within the provision of health information and service. This study aimed to assess their perspectives on the barriers and facilitators regarding implementation of the HE, as well as on the purpose, content and value of the HE. Method Thematic analysis of focus groups, individual and group interviews conducted between 2016 and 17 with 41 participants from various authorities and healthcare professionals involved in the delivery of HE in Stockholm. Results Suggestions were taken from interviewees of how to facilitate the uptake and delivery of HE through improved outreach to the target group with better collaboration, coordination and continuity between authorities. Apart from control of specific communicable diseases, the perceived ultimate goal of HE varied and was often vaguely formulated. Respondents desired better monitoring to assess the effects of HE and predict needs among asylum seekers. This included standardized procedures to promote equitable health care access and more explicit inclusion of mental health and other health dimensions in the HE. Conclusion There are several possible avenues for improving HE coverage and uptake. However, ambiguity exists concerning the benefits of such efforts given the uncertainty of the value of HE. Lack of available data on health status, determinants of health and impact of HE among asylum seekers emerged as barriers preventing optimal approaches for the assessment of health needs. Implementation of standardized guidelines, procedures and documentation would aid the understanding. A more holistic approach beyond infectious diseases is necessary. This would only be useful if there is value in screening for such conditions. More research is required to assess the effectiveness and cost-effectiveness of HE and related screening policies in Sweden.

Abstract Background Tackling the social determinants of Tuberculosis (TB) through social protection is a key element of the post-2015 End TB Strategy. However, evidence informing policies are still scarce. Mathematical modelling has the potential to contribute to fill this knowledge gap, but existing models are inadequate. The S-PROTECT consortium aimed to develop an innovative mathematical modelling approach to better understand the role of social protection to improve TB care, prevention and control. Methods S-PROTECT used a three-steps approach: 1) the development of a conceptual framework; 2) the extraction from this framework of three high-priority mechanistic pathways amenable for modelling; 3) the development of a revised version of a standard TB transmission model able to capture the structure of these pathways. As a test case we used the Bolsa Familia Programme (BFP), the Brazilian conditional cash transfer scheme. Results Assessing one of these pathways, we estimated that BFP can reduce TB prevalence by 4% by improving households income and thus their nutritional status. When looking at the direct impact via malnutrition (not income mediated) the impact was 33%. This variation was due to limited data availability, uncertainties on data transformation and the pathway approach taken. These results are preliminary and only aim to serve as illustrative example of the methodological challenges encountered in this first modelling attempt, nonetheless they suggest the potential added value of integrating TB standard of care with social protection strategies. Conclusions Results are to be confirmed with further analysis. However, by developing a generalizable modelling framework, S-PROTECT proved that the modelling of social protection is complex, but doable and allowed to draw the research road map for the future in this field.

Summary: Background: The End TB Strategy and the Sustainable Development Goals (SDGs) are intimately linked by their common targets and approaches. SDG 1 aims to end extreme poverty and expand social protection coverage by 2030. Achievement of SDG 1 is likely to affect the tuberculosis epidemic through a range of pathways. We estimate the reduction in global tuberculosis incidence that could be obtained by reaching SDG 1. Methods: We developed a conceptual framework linking key indicators of SDG 1 progress to tuberculosis incidence via well described risk factor pathways and populated it with data from the SDG data repository and the WHO tuberculosis database for 192 countries. Correlations and mediation analyses informed the strength of the association between the SDG 1 subtargets and tuberculosis incidence, resulting in a simplified framework for modelling. The simplified framework linked key indicators for SDG 1 directly to tuberculosis incidence. We applied an exponential decay model based on linear associations between SDG 1 indicators and tuberculosis incidence to estimate tuberculosis incidence in 2035. Findings: Ending extreme poverty resulted in a reduction in global incidence of tuberculosis of 33·4% (95% credible interval 15·5–44·5) by 2035 and expanding social protection coverage resulted in a reduction in incidence of 76·1% (45·2–89·9) by 2035; both pathways together resulted in a reduction in incidence of 84·3% (54·7–94·9). Interpretation: Full achievement of SDG 1 could have a substantial effect on the global burden of tuberculosis. Cross-sectoral approaches that promote poverty reduction and social protection expansion will be crucial complements to health interventions, accelerating progress towards the End TB targets. Funding: World Health Organization.

Abstract Objective To assess the design, delivery and outcomes of interventions to improve adherence to treatment for paediatric tuberculosis in low- and middle-income countries and develop a contextual framework for such interventions. Methods We searched PubMed and Cochrane databases for reports published between 1 January 2003 and 1 December 2013 on interventions to improve adherence to treatment for tuberculosis that included patients younger than 20 years who lived in a low- or middle-income country. For potentially relevant articles that lacked paediatric outcomes, we contacted the authors of the studies. We assessed heterogeneity and risk of bias. To evaluate treatment success - i.e. the combination of treatment completion and cure - we performed random-effects meta-analysis. We identified areas of need for improved intervention practices. Findings We included 15 studies in 11 countries for the qualitative analysis and of these studies, 11 qualified for the meta-analysis - representing 1279 children. Of the interventions described in the 15 studies, two focused on education, one on psychosocial support, seven on care delivery, four on health systems and one on financial provisions. The children in intervention arms had higher rates of treatment success, compared with those in control groups (odds ratio: 3.02; 95% confidence interval: 2.19-4.15). Using the results of our analyses, we developed a framework around factors that promoted or threatened treatment completion. Conclusion Various interventions to improve adherence to treatment for paediatric tuberculosis appear both feasible and effective in low- and middle-income countries.

Background: The economic burden on households affected by tuberculosis through costs to patients can be catastrophic. WHO's End TB Strategy recognises and aims to eliminate these potentially devastating economic effects. We assessed whether aggressive expansion of tuberculosis services might reduce catastrophic costs. Methods: We estimated the reduction in tuberculosis-related catastrophic costs with an aggressive expansion of tuberculosis services in India and South Africa from 2016 to 2035, in line with the End TB Strategy. Using modelled incidence and mortality for tuberculosis and patient-incurred cost estimates, we investigated three intervention scenarios: improved treatment of drug-sensitive tuberculosis; improved treatment of multidrug-resistant tuberculosis; and expansion of access to tuberculosis care through intensified case finding (South Africa only). We defined tuberculosis-related catastrophic costs as the sum of direct medical, direct non-medical, and indirect costs to patients exceeding 20% of total annual household income. Intervention effects were quantified as changes in the number of households incurring catastrophic costs and were assessed by quintiles of household income. Findings: In India and South Africa, improvements in treatment for drug-sensitive and multidrug-resistant tuberculosis could reduce the number of households incurring tuberculosis-related catastrophic costs by 6–19%. The benefits would be greatest for the poorest households. In South Africa, expanded access to care could decrease household tuberculosis-related catastrophic costs by 5–20%, but gains would be seen largely after 5–10 years. Interpretation: Aggressive expansion of tuberculosis services in India and South Africa could lessen, although not eliminate, the catastrophic financial burden on affected households. Funding: Bill & Melinda Gates Foundation.

OBJECTIVE: To determine whether differences in national trends in tuberculosis incidence are attributable to the variable success of control programmes or to biological, social and economic factors. METHODS: We used trends in case notifications as a measure of trends in incidence in 134 countries, from 1997 to 2006, and used regression analysis to explore the associations between these trends and 32 measures covering various aspects of development (1), the economy (6), the population (3), behavioural and biological risk factors (9), health services (6) and tuberculosis (TB) control (7). FINDINGS: The TB incidence rate changed annually within a range of ±10% over the study period in the 134 countries examined, and its average value declined in 93 countries. The rate was declining more quickly in countries that had a higher human development index, lower child mortality and access to improved sanitation. General development measures were also dominant explanatory variables within regions, though correlation with TB incidence trends varied geographically. The TB incidence rate was falling more quickly in countries with greater health expenditure (situated in central and eastern Europe and the eastern Mediterranean), high-income countries with lower immigration, and countries with lower child mortality and HIV infection rates (located in Latin America and the Caribbean). The intensity of TB control varied widely, and a possible causal link with TB incidence was found only in Latin America and the Caribbean, where the rate of detection of smear-positive cases showed a negative correlation with national incidence trends. CONCLUSION: Although TB control programmes have averted millions of deaths, their effects on transmission and incidence rates are not yet widely detectable.

Over the past decade, there has been a rapid increase in the number of initiatives involving "for-profit" private health care providers in national tuberculosis (TB) control efforts. We reviewed 15 such initiatives with respect to contractual arrangements, quality of care and success achieved in TB control. In seven initiatives, the National TB Programme (NTP) interacted directly with for-profit providers; while in the remaining eight, the NTP collaborated with for-profit providers through intermediary not-for-profit nongovernmental organizations. All but one of the initiatives used relational "drugs-for-performance contracts" to engage for-profit providers, i.e. drugs were provided free of charge by the NTP emphasizing that providers dispense them free of charge to patients and follow national guidelines for diagnosis and treatment. We found that 90% (range 61-96%) of new smear-positive pulmonary TB cases were successfully treated across all initiatives and TB case detection rates increased between 10% and 36%. We conclude that for-profit providers can be effectively involved in TB control through informal, but well defined drugs-for-performance contracts. The contracting party should be able to reach a common understanding concerning goals and role division with for-profit providers and monitor them for content and quality. Relational drugs-for-performance contracts minimize the need for handling the legal and financial aspects of classical contracting. We opine that further analysis is required to assess if such "soft" contracts are sufficient to scale up private for-profit provider involvement in TB control and other priority health interventions.

In 1998, the Damien Foundation Bangladesh invited semi-qualified, private "gram dakter" (Bangla for "village doctors") to participate in tuberculosis (TB) programmes in a population of 26 million people in rural Bangladesh. The organization trained 12 525 village doctors to not only refer suspected TB cases for free diagnosis but also to provide directly observed treatment (DOT) free of charge. Source of referral and place of DOT was recorded as part of the standardized TB recording and reporting system, which enabled us to quantify the contribution of village doctors to case detection rates and also allowed disaggregated cohort analysis of treatment outcome. During 2002 and 2003, 11% of all TB cases with positive sputum smears in the study area had been referred by village doctors; the rate of positive tests in patients referred by village doctors was 14.4%. 18 792 patients received DOT from village doctors, accounting for between 20% and 45% of patients on treatment during the 1998-2003 period. The treatment success rate was about 90% throughout the period. Urine samples taken during random checks of treatment compliance were positive for isoniazid in 98% of patients treated by village doctors. Within the framework of Public-Private Mix DOTS, services provided by semi-qualified private health care providers are a feasible and effective way to improve access to affordable high quality TB treatment in poor rural populations. The large informal health workforce that exists in resource poor countries can be used to achieve public health goals. Involvement of village doctors in TB control has now become national policy in Bangladesh.

Abstract Background A project was implemented in 2010 to improve TB notification and TB screening and diagnostic routines in large general hospitals. The aims of present study was to assess baseline TB screening and diagnostic practices in the three largest general hospitals in Vietnam. Objectives To assess baseline TB screening and diagnostic practices in the three largest general hospitals in Vietnam. Method The study had three elements: 1) Focus group discussions with hospital physicians; 2) review of hospital records and structured interviews of people who had a chest X-ray on any indication; and 3) record reviews and structured interviews of people newly diagnosed with TB. Results The most commonly reported diagnostic pathway for pulmonary TB was chest X-ray followed by sputum-smear microscopy. Among 599 individuals who had a chest X-ray performed, 391 (65.1%) had recorded any abnormality, significantly higher in males (73.8%) than in females (54.7%), (p Of 103 consecutive TB cases enrolled in the study, 92 (90%) had chest X-ray as the initial test. Sixty-three (61.2%) fulfilled the TB suspect criteria based on respiratory symptoms (productive cough >2 weeks). Conclusion Chest X-ray is the preferred first test for TB in the largest hospitals in Vietnam. Chest X-ray is a sensitive screening tool for TB, which should be followed by a confirmatory TB test. While the majority of those with chest X-ray abnormalities are investigated with smear-microscopy, the high sputum-smear positivity ratio among them suggests that sputum-smear microscopy is done mainly for persons with quite clear TB signs or symptoms. TB screening and use of confirmatory diagnostic tests on wider indications seem warranted.

Abstract Background In 2004, tuberculosis (TB) was responsible for 2.5% of global mortality (among men 3.1%; among women 1.8%) and 2.2% of global burden of disease (men 2.7%; women 1.7%). The present work portrays accumulated evidence on the association between alcohol consumption and TB with the aim to clarify the nature of the relationship. Methods A systematic review of existing scientific data on the association between alcohol consumption and TB, and on studies relevant for clarification of causality was undertaken. Results There is a strong association between heavy alcohol use/alcohol use disorders (AUD) and TB. A meta-analysis on the risk of TB for these factors yielded a pooled relative risk of 2.94 (95% CI: 1.89-4.59). Numerous studies show pathogenic impact of alcohol on the immune system causing susceptibility to TB among heavy drinkers. In addition, there are potential social pathways linking AUD and TB. Heavy alcohol use strongly influences both the incidence and the outcome of the disease and was found to be linked to altered pharmacokinetics of medicines used in treatment of TB, social marginalization and drift, higher rate of re-infection, higher rate of treatment defaults and development of drug-resistant forms of TB. Based on the available data, about 10% of the TB cases globally were estimated to be attributable to alcohol. Conclusion The epidemiological and other evidence presented indicates that heavy alcohol use/AUD constitute a risk factor for incidence and re-infection of TB. Consequences for prevention and clinical interventions are discussed.

Abstract Background It has long been evident that there is an association between alcohol use and risk of tuberculosis. It has not been established to what extent this association is confounded by social and other factors related to alcohol use. Nor has the strength of the association been established. The objective of this study was to systematically review the available evidence on the association between alcohol use and the risk of tuberculosis. Methods Based on a systematic literature review, we identified 3 cohort and 18 case control studies. These were further categorized according to definition of exposure, type of tuberculosis used as study outcome, and confounders controlled for. Pooled effect sizes were obtained for each sub-category of studies. Results The pooled relative risk across all studies that used an exposure cut-off level set at 40 g alcohol per day or above, or defined exposure as a clinical diagnosis of an alcohol use disorder, was 3.50 (95% CI: 2.01–5.93). After exclusion of small studies, because of suspected publication bias, the pooled relative risk was 2.94 (95% CI: 1.89–4.59). Subgroup analyses of studies that had controlled for various sets of confounders did not give significantly different results and did not explain the significant heterogeneity that was found across the studies. Conclusion The risk of active tuberculosis is substantially elevated in people who drink more than 40 g alcohol per day, and/or have an alcohol use disorder. This may be due to both increased risk of infection related to specific social mixing patterns associated with alcohol use, as well as influence on the immune system of alcohol itself and of alcohol related conditions.

OBJECTIVE: To compare processes and outcomes of four public-private mix (PPM) projects on DOTS implementation for tuberculosis (TB) control in New Delhi, India; Ho Chi Minh City, Viet Nam; Nairobi, Kenya; and Pune, India. METHODS: Cross-project analysis of secondary data from separate project evaluations was used. Differences among PPM project sites in impact on TB control (change in case detection, treatment outcomes and equity in access) were correlated with differences in chosen intervention strategies and structural conditions. FINDINGS: The analysis suggests that an effective intervention package should include the following provider-side components: (1) orienting private providers (PPs) and the staff of the national TB programme (NTP); (2) improving the referral and information system through simple practical tools; (3) the NTP adequately supervising and monitoring PPs; and (4) the NTP providing free anti-TB drugs to patients treated in the private sector. CONCLUSION: Getting such an intervention package to work requires that the NTP be strongly committed to supporting, supervising and evaluating PPM projects. Further, using a local nongovernmental organization or a medical association as an intermediary may facilitate collaboration. Investing time and effort to ensure that sufficient dialogue takes place among all stakeholders is important to help build trust and achieve a high level of agreement.