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Tuberculosis (TB) disproportionally affects impoverished members of society. The adverse socioeconomic impact of TB on households is mostly measured using money-centric approaches which have been criticised as one-dimensional and risk either overestimating or underestimating the true socioeconomic impacts of TB. We propose to use the sustainable livelihood framework, which includes five household capital assets: human, financial, physical, natural and social, and conceptualises that households employ accumulative strategies in times of plenty and coping (survival) strategies in response to shocks such as TB. The proposed measure ascertains to what extent the five capital assets are available to households affected by TB as well as the coping costs (reversible and non-reversible) that are incurred by households at different time points (intensive, continuation and post-TB treatment phase). We assert that our approach is holistic, multi-dimensional and draws attention to multisectoral responses to mitigate the socioeconomic impact of TB on households.

Tuberculosis (TB) and poverty are inextricably linked. Catastrophic costs of TB illness drive TB-affected households into worsening impoverishment and hamper treatment success. The WHO’s End TB Strategy recommends social protection for TB-affected households to mitigate financial shock and improve TB outcomes. This scoping review maps the landscape of social protection interventions for people with TB and their households in low- and middle-income countries with high TB burden. A systematic search of Medline, Embase, PubMed, and Web of Science for relevant articles was performed, supplemented with a gray literature search of key databases. Articles were included if they described social protection available to people with TB and TB-affected households in a low- or middle-income country. Data were synthesized in tabular form, and descriptive narrative outlined the successes and challenges of the social protection interventions identified. The search identified 33,360 articles. After abstract screening, 74 articles underwent full text screening, and 49 were included in the final analysis. Forty-three types of social protection were identified, of which 24 were TB specific (i.e., only people with TB were eligible). Varying definitions were used to describe similar social protection interventions, which limited cross-study comparison. Intervention successes included acceptability and increased financial autonomy among recipients. Challenges included delays in intervention delivery and unexpected additional bank transfer fees. A wide range of acceptable social protection interventions are available, with cash transfer schemes predominating. Use of standardized definitions of social protection interventions would facilitate consolidation of evidence and enhance design and implementation in future.

Tuberculosis is the leading cause of deaths from an infectious disease worldwide. WHO's End TB Strategy is falling short of several 2020 targets. Undernutrition is the leading population-level risk factor for tuberculosis. Studies have consistently found that undernutrition is associated with increased tuberculosis incidence, increased severity, worse treatment outcomes, and increased mortality. Modelling studies support implementing nutritional interventions for people living with tuberculosis and those at risk of tuberculosis disease to ensure the success of the End TB Strategy. In this Personal View, we highlight nutrition-related immunocompromisation, implications of undernutrition for tuberculosis treatment and prevention, the role of nutritional supplementation, pharmacokinetics and pharmacodynamics of antimycobacterial medications in undernourished people with tuberculosis, and the role of social protection interventions in addressing undernutrition as a tuberculosis risk factor. To catalyse action on this insufficiently addressed accelerant of the global tuberculosis epidemic, research should be prioritised to understand the immunological pathways that are impaired by nutrient deficiencies, develop tools to diagnose clinical and subclinical tuberculosis in people who are undernourished, and understand how nutritional status affects the efficacy of tuberculosis vaccine and therapy. Through primary research, modelling, and implementation research, policy change should also be accelerated, particularly in countries with a high burden of tuberculosis.

This narrative systematic review examined effectiveness of interventions during pregnancy and up to 2 years of age in improving energy balance-related behaviors or prevent overweight/obesity in children from families experiencing socio-economic disadvantage. We identified 24 interventions, from 33 articles, since 1990. Overall, despite their heterogeneity and variability in internal and external validity, there was some evidence of beneficial impact of interventions on obesity risk (4/15), and associated behaviors, e.g.: breastfeeding (9/18), responsive feeding (11/16), diet (7/8), sedentary (1/3) and movement (4/7) behaviors, and sleep (1/2). The most effective interventions aimed at promoting breastfeeding commenced antenatally; this was similar for the prevention of obesity, provided the intervention continued for at least 2 years postnatally and was multi-behavioral. Effective interventions were more likely to target first-time mothers and involve professional delivery agents, multidisciplinary teams and peer groups. Among ethnic/racial minorities, interventions delivered by lay agents had some impact on dietary behavior but not weight outcomes. Co-creation with stakeholders, including parents, and adherence to theoretical frameworks were additional ingredients for more pragmatic, inclusive, non-judgmental, and effective programs. The growing body of evidence on obesity prevention interventions targeting families experiencing socio-economic disadvantage is promising for reducing early inequalities in obesity risk.

Background: Tuberculosis (TB) is a leading cause of death due to infectious disease worldwide. People with TB and their households often suffer social and economic losses due to the cost of tuberculosis care. The World Health Organization 2015 End TB strategy called for socioeconomic support through social protection interventions. Social protection has the potential to enable people with TB and their households to break the cycle of TB and poverty, thereby improving both treatment and socioeconomic outcomes. This study aims to evaluate whether people with TB who are recipients of social protection interventions have better treatment and socioeconomic outcomes than those who are not recipients of social protection interventions. Methods: We will systematically review literature published in English between 2012 and 2021 from PubMed, Embase, and Web of Science, and grey literature from Google Scholar and selected, relevant databases. We will include studies that describe a social protection intervention (as defined by the World Bank) and report on TB treatment outcomes and/or socioeconomic outcomes. We will only include studies pertaining to populations in low-and-middle-income countries and/or countries with high TB burden. We will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study quality will be assessed using the Cochrane Risk of Bias for randomized controlled trials and the Newcastle Ottawa Scale for non-randomised controlled studies. If sufficient quantitative data are available, we will perform a meta-analysis of aggregated outcomes. Lastly, we will use the Grading Recommendations Assessment, Development, and Evaluation to describe the overall quality of evidence. Ethics and dissemination: Ethical approval is not required for this systematic review, as all data extraction and analysis will be conducted on published documents. We will disseminate this protocol through conference presentations. The systematic review has been registered prospectively in the PROSPERO database (registration number CRD42022382181).

ObjectivesTuberculosis (TB) and mental illnesses are highly prevalent globally and often coexist. While poor mental health is known to modulate immune function, whether mental disorders play a causal role in TB incidence is unknown. This systematic review examines the association between mental health and TB disease risk to inform clinical and public health measures.DesignSystematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Search strategy and selection criteriaMEDLINE, PsycINFO and PsycEXTRA databases were searched alongside reference list and citation searching. Inclusion criteria were original research studies published 1 January 1970–11 May 2020 reporting data on the association between mental health and TB risk.Data extraction, appraisal and synthesisData were extracted on study design and setting, sample characteristics, measurement of mental illness and TB, and outcomes including effect size or prevalence. Studies were critically appraised using Critical Appraisal Skills Programme (CASP) and Appraisal Tool for Cross-Sectional Studies (AXIS) checklists.Results1546 records published over 50 years were screened, resulting in 10 studies included reporting data from 607 184 individuals. Studies span across Asia, South America and Africa, and include mood and psychotic disorders. There is robust evidence from cohort studies in Asia demonstrating that depression and schizophrenia can increase risk of active TB, with effect estimates ranging from HR=1.15 (95% CI 1.03 to 1.28) to 2.63 (95% CI 1.74 to 3.96) for depression and HR=1.52 (95% CI 1.29 to 1.79) to RR=3.04 for schizophrenia. These data align with evidence from cross-sectional studies, for example, a large survey across low-income and middle-income countries (n=242 952) reports OR=3.68 (95% CI 3.01 to 4.50) for a depressive episode in those with TB symptoms versus those without.ConclusionsIndividuals with mental illnesses including depression and schizophrenia experience increased TB incidence and represent a high-risk population to target for screening and treatment. Integrated care for mental health and TB is needed, and interventions tackling mental illnesses and underlying drivers may help reduce TB incidence globally.PROSPERO registration numberCRD42019158071.

Background The global mining industry has an opportunity to mobilize resources to advance progress against the Sustainable Development Goals (SDGs). In 2018, the Anglo-American Group outlined aspirations for mining host communities to meet the SDG3 health targets. To progress from aspiration to action we designed and implemented a mixed-methods approach to attain a deeper understanding of the health and wellbeing priorities within the local context of host communities of fifteen mines in South Africa. Methods To identify local needs and priorities relating to SDG3 targets in host communities, stakeholder workshops and key informant interviews were conducted between June and August 2019. A baseline assessment of health data, related to each of the SDG3 targets and indicators and to each host community location, was also conducted. Findings emerging from the qualitative and quantitative baseline assessments were compared to identify the extent to which health issues aligned and health and wellbeing priority areas for action. Results A total of 407 people participated in the workshops, and 85 key informants were interviewed. Quantitative data were available at sub-national level for seven of the nine SDG3 targets and eleven of the 21 indicators. Key priority areas for action identified through alignment of the qualitative and quantitative data were maternal mortality (SDG3.1), HIV (SDG3.3.1), tuberculosis (SDG3.3.2), substance abuse (SDG3.5), and road traffic accidents (SDG3.6) We found consistency in the individual, interpersonal, community, societal, and structural factors underlying these priority areas. At a structural level, poor access to quality healthcare was raised at every workshop as a key factor underlying the achievement of all SDG3 targets. Of the five priority areas identified, HIV, TB and substance abuse were found to overlap in the study communities in terms of risk, burden, and underlying factors. Conclusions We demonstrate a mixed method approach for identifying local health needs and prioritised SDG3 targets in mining host communities. Consistency in reporting suggests the need for effective, efficient and feasible interventions to address five priority areas. Given the prominent economic role of the mining sector in South Africa, it can play a critical role in implementing programmatic activities that further progress towards achieving the SDG3 targets.

Financial barriers are a key limitation to accessing health services, such as tuberculosis (TB) care in resource-poor settings. In Ghana, the National Health Insurance Scheme (NHIS), established in 2003, officially offers free TB care to those enrolled. Using data from the first Ghana's national TB patient cost survey, we address two key questions 1) what are the key determinants of costs and affordability for TB-affected households, and 2) what would be the impact on costs for TB-affected households of expanding NHIS to all TB patients? We reported the level of direct and indirect costs, the proportion of TB-affected households experiencing catastrophic costs (defined as total TB-related costs, i.e., direct and indirect, exceeding 20% of their estimated pre-diagnosis annual household income), and potential determinants of costs, stratified by insurance status. Regression models were used to determine drivers of costs and affordability. The effect of enrolment into NHIS on costs was investigated through Inverse Probability of Treatment Weighting Analysis. Higher levels of education and income, a bigger household size and an multi-drug resistant TB diagnosis were associated with higher direct costs. Being in a low wealth quintile, living in an urban setting, losing one's job and having MDR-TB increased the odds of experiencing catastrophic costs. There was no evidence to suggest that enrolment in NHIS defrayed medical, non-medical, or total costs, nor mitigated income loss. Even if we expanded NHIS to all TB patients, the analyses suggest no evidence for any impact of insurance on medical cost, income loss, or total cost. An expansion of the NHIS programme will not relieve the financial burden for TB-affected households. Social protection schemes require enhancement if they are to protect TB patients from financial catastrophe.

Background The proportion of tuberculosis (TB) cases in the European Union/European Free Trade Association (EU/EFTA) that occur in migrants is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality. To date, there has been no in-depth exploration of extrapulmonary TB in migrants across Europe. Methods We analysed 22 years of data from the European Centre for Disease Prevention and Control's European Surveillance System (TESSy) for 32 EU/EFTA countries between 1995 and 2017. We investigated whether the proportion of TB cases that were extrapulmonary varied between migrants and non-migrants, and whether this varied by a) country/region of origin, b) reporting country/region, and c) site of disease. Results 1,270,896 TB cases were included in the analysis, comprising 326,987 (25.7%) migrants, and 943,909 (74.3%) non-migrants. The proportion of TB that is extrapulmonary is significantly higher in migrants than in non-migrants: 45.2% (n = 147,814) of cases in migrants were extrapulmonary, compared to 21.7% (n = 204,613) in non-migrants (χ2=6.7x104, p Conclusions Among TB cases in the EU/EFTA, extrapulmonary disease is significantly more common in migrants than non-migrants, which has clinical and policy implications for patient detection and management. There is a need to improve clinical awareness of extrapulmonary TB, integrate detection of extrapulmonary TB into latent TB infection screening programmes, and harmonise data collection on migrant status in health systems. Key messages Migrants in the EU/EFTA are disproportionately affected by extrapulmonary TB compared to non-migrants. This has clinical and policy implications for diagnosis, screening, and data collection.

Objectives This is a protocol for a Cochrane Review (qualitative). The objectives are as follows: The main aim of this review is to explore how conditional and unconditional cash transfers aimed at impacting on health behaviours are experienced and perceived by recipients. By health behaviours we mean health service use, health outcomes, or socioeconomic outcomes related to health (e.g. cash grants to address catastrophic healthcare costs). We will focus on the general experience, including acceptability and feasibility of these interventions. The secondary objectives include: understanding how differences in context and recipient backgrounds influence experiences and perceptions of conditional and unconditional cash transfer interventions; describing the unintended consequences of conditional and unconditional cash transfers in different settings from recipients’ perspectives.

Background Tuberculosis (TB) remains an urgent global public health priority, causing 1.5 million deaths worldwide in 2018. There is evidence that psychosocial factors modulate immune function; however, how this may influence TB risk or BCG vaccine response, and whether this pathway can be modified through social protection, has not been investigated. This paper aims to: a) systematically review evidence of how psychosocial factors influence the expression of biomarkers of immunity, and b) apply this general evidence to propose plausible TB-specific pathways for future study. Methods Papers reporting on the impact of psychosocial stressors on immune biomarkers in relation to infectious disease risk were identified through a search of the databases MEDLINE, PsycINFO, Global Health and PsycEXTRA alongside reference list and citation searching of key papers. Data extraction and critical appraisal were carried out using a standardised form. The findings were tabulated and synthesised narratively by infectious disease category, and used to propose plausible mechanisms for how psychosocial exposures might influence immune outcomes relevant to TB and BCG response. Results 27,026 citations were identified, of which 51 met the inclusion criteria. The literature provides evidence of a relationship between psychosocial factors and immune biomarkers. While the direction and strength of associations is heterogenous, some overarching patterns emerged: adverse psychosocial factors (e.g. stress) were generally associated with compromised vaccine response and higher antibody titres to herpesviruses, and vice versa for positive psychosocial factors (e.g. social support). Conclusions The evidence identifies pathways linking psychosocial factors and immune response: co-viral infection and immune suppression, both of which are potentially relevant to TB and BCG response. However, the heterogeneity in the strength and nature of the impact of psychosocial factors on immune function, and lack of research on the implications of this relationship for TB, underscore the need for TB-specific research., Highlights • It is unknown whether and how psychosocial factors could modulate immunity to TB. • We systematically review studies of psychosocial influences on immune function. • There is evidence for an association between psychosocial factors and immunity. • The nature and strength of associations are heterogeneous. • Further research is required to establish TB-specific pathways.

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.

Objectives The proportion of tuberculosis (TB) cases occurring in migrants in Europe is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality, yet its extent in migrant populations is unclear. We assessed patterns of extrapulmonary TB in migrants across the European Union (EU)/European Free Trade Association (EFTA). We investigated the proportion of extrapulmonary TB cases among migrants versus non-migrants, and variations by specific site of disease, reporting European region, and migrant region of origin. Methods We carried out a cross-sectional secondary database analysis, utilizing 23 years of data collected between 1995 and 2017 from the European Surveillance System of the European Centre for Disease Prevention and Control for 32 EU/EFTA countries. Results In total, 1 270 896 TB cases were included, comprising 326 987 migrants (25.7%) and 943 909 non-migrants (74.3%). Of TB cases among migrants, 45.2% (n = 147 814) were extrapulmonary compared to 21.7% (n = 204 613) among non-migrants (p

Summary Background The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa. Methods We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016–35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice. Findings Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective. Interpretation Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary. Funding Bill & Melinda Gates Foundation.

Summary Background The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements. Methods 11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy. Findings Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31–62%) and a 72% reduction in mortality (range 64–82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis. Interpretation Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level. Funding Bill and Melinda Gates Foundation

SETTING: Fifty-six public clinics in Limpopo Province, South Africa. OBJECTIVE: To evaluate the association between tuberculosis (TB) patient costs and poverty as measured by a multidimensional poverty index. DESIGN: We performed cross-sectional interviews of consecutive patients with TB. TB episode costs were estimated from self-reported income, travel costs, and care-seeking time. Poverty was assessed using the South African Multidimensional Poverty Index (SAMPI) deprivation score, a 12-item household-level index, with higher scores indicating greater poverty. We used multivariable linear regression to adjust for age, sex, HIV status and travel time. RESULTS: Among 323 participants, 108 (33%) were ‘deprived’ (deprivation score>0.33). For each 0.1-unit increase in deprivation score, absolute TB episode costs were 1.11 times greater (95% confidence interval, CI 0.97–1.26). TB episode costs were 1.19 times greater with each quintile of higher deprivation score (95%CI 1.00–1.40) but 0.54 times lower with each quintile of lower self-reported income (higher poverty, 95%CI 0.46–0.62). CONCLUSION: Individuals experiencing multidimensional poverty faced equal or higher costs of TB than non-impoverished patients. Individuals with lower self-reported income experienced higher costs as a proportion of household income but lower absolute costs. Targeted interventions are needed to reduce the economic burden of TB on patients with multidimensional poverty.

Background Pillar 3 of the End TB Strategy calls for the promotion of research and innovation at the country level to facilitate improved implementation of existing and novel interventions to end tuberculosis (TB). In an era of increasing cross-border migration, there is a specific need to integrate migration-related issues into national TB research agendas. The objective of the present review is to provide a conceptual framework to guide countries in the development and operationalization of a migrant-inclusive TB research agenda. Methods We conducted a literature review, complemented by expert opinion and the previous articles in this State of the Art series, to identify important themes central to migration-related TB. We categorized these themes into a framework for a migration-inclusive global TB research agenda across a comprehensive spectrum of research. We developed this conceptual framework taking into account: 1) the biomedical, social and structural determinants of TB; 2) the epidemiologic impact of the migration pathway; and 3) the feasibility of various types of research based on a country's capacity. Discussion The conceptual framework presented here is based on the key principle that migrants are not inherently different from other populations in terms of susceptibility to known TB determinants, but that they often have exacerbated or additional risks related to their country of origin and the migration process, which must be accounted for in developing comprehensive TB prevention and care strategies. A migrant-inclusive research agenda should systematically consider this wider context to have the highest impact.

Background Evidence suggests that social protection policies such as Brazil’s Bolsa Família Programme (BFP), a governmental conditional cash transfer, may play a role in tuberculosis (TB) elimination. However, study limitations hamper conclusions. This paper uses a quasi-experimental approach to more rigorously evaluate the effect of BFP on TB treatment success rate. Methods Propensity scores were estimated from a complete-case logistic regression using covariates from a linked data set, including the Brazil’s TB notification system (SINAN), linked to the national registry of those in poverty (CadUnico) and the BFP payroll. Results The average effect of treatment on the treated was estimated as the difference in TB treatment success rate between matched groups (ie, the control and exposed patients, n=2167). Patients with TB receiving BFP showed a treatment success rate of 10.58 percentage points higher (95% CI 4.39 to 16.77) than patients with TB not receiving BFP. This association was robust to sensitivity analyses. Conclusions This study further confirms a positive relationship between the provision of conditional cash transfers and TB treatment success rate. Further research is needed to understand how to enhance access to social protection so to optimise public health impact.

BackgroundSocial vulnerability is strongly associated with tuberculosis (TB) indicators like cure rate. By addressing key social determinants, social protection policies such as Brazil’s Bolsa Família Programme (BFP), a governmental conditional cash transfer, may play a role in TB control. Evidence is consolidating around a positive effect of social protection on TB outcomes, however methodological limitations prevent strong conclusions. This paper uses a quasi-experimental approach to more rigorously evaluate the effect of BFP on TB cure rate.Methods & FindingsThe data source was Brazil’s TB notification system (SINAN), linked to the national registry of those in poverty (CadUnico) and the BFP payroll. Propensity scores (PSs) were estimated from a complete-case logistic regression using covariates from this linked dataset, informed by a directed acyclic graph. Control patients were matched to exposed patients on the PS and the average effect of treatment on the treated (ATT) was estimated as the difference in TB cure rate between matched groups (n = 2167). The ATT was estimated as 10·58 (95% CIs: 4·39, 16·77). This suggests that 10·58% of the TB patients receiving BFP who were cured would not have been cured had they not received BFP. The direction of this effect was robust to sensitivity analyses performed and the PS matching broadly improved balance, although missing data limited the sample size.ConclusionsThis work is the first quasi-experimental evaluation of social protection in wide-scale practice on TB outcomes. It demonstrates a positive effect of conditional cash transfers on TB cure rate consistent with existing work, suggesting changes to policy and future research on increasing access to social protection for TB patients who remain uncovered by the programme.

A high burden of TB mortality persists despite the long-term availability of the bacillus Calmette-Guérin (BCG) vaccine, whose efficacy has been highly variable across populations. Innovative and alternative approaches to TB prevention are urgently needed while optimal biomedical tools continue to be developed. We call for new interdisciplinary collaborations to expand and integrate our understanding of how social determinants influence the biological processes that lead to TB disease, how this translates into differential BCG efficacy and, ultimately, how social protection interventions can play a role in reducing the global burden of TB. After providing an overview of the immune pathways important for the establishment of a response to the BCG vaccine, we outline how social determinants and psychosocial stressors can contribute to the observed variation in BCG efficacy above and beyond these biological factors. We conclude by proposing a new interdisciplinary research model based on the integration of social epidemiology theories with biomedical knowledge.

To describe the associations between socio-economic position and prevalent tuberculosis in the 2010 ZAMSTAR Tuberculosis Prevalence Survey, one of the first large tuberculosis prevalence surveys in Southern Africa in the HIV era.The main analyses used data on 34 446 individuals in Zambia and 30 017 individuals in South Africa with evaluable tuberculosis culture results. Logistic regression was used to estimate adjusted odds ratios for prevalent TB by two measures of socio-economic position: household wealth, derived from data on assets using principal components analysis, and individual educational attainment. Mediation analysis was used to evaluate potential mechanisms for the observed social gradients.The quartile with highest household wealth index in Zambia and South Africa had, respectively, 0.55 (95% CI 0.33-0.92) times and 0.70 (95% CI 0.54-0.93) times the adjusted odds of prevalent TB of the bottom quartile. College or university-educated individuals in Zambia and South Africa had, respectively, 0.25 (95% CI 0.12-0.54) and 0.42 (95% CI 0.25-0.70) times the adjusted odds of prevalent TB of individuals who had received only primary education. We found little evidence that these associations were mediated via several key proximal risk factors for TB, including HIV status.These data suggest that social determinants of TB remain important even in the context of generalised HIV epidemics.

A need for national guidelines relating to interactive water features was highlighted following three outbreaks of cryptosporidiosis in the United Kingdom, all of which were related to public water features. In August 2003 the Health Protection Agency South West of England was notified of an outbreak of cryptosporidiosis associated with an interactive water feature designed for water play within an adventure park. The water feature was implicated following samples with a high coliform count and the presence of faecal coliforms. A case was defined as any child (younger than 16 years of age) who had visited the park during August and who subsequently had gastrointestinal symptoms and a faecal sample positive for cryptosporidium. Seventy one children were identified in the cohort. This outbreak of cryptosporidiosis was characterised by a very high attack rate (89%), relatively severe in duration (median 8 days) and had a relatively high hospital admission (16% of cases). The epidemic curve was consistent with a point source of infection, which corresponded to the date 80% of the cohort visited the park. This outbreak has similarities to two other cryptosporidiosis outbreaks reported in England in 2003 that involved public water features. These outbreaks raise issues about the operation and maintenance of water-based recreational attractions that very often involve children. The paper reflects on the basic control measures that can be taken and highlights the need for guidelines, especially since such attractions are becoming increasingly common. The Pool Water Treatment Advisory Group in United Kingdom has now produced guidelines.

Background Illness-related costs for patients with tuberculosis (TB) ≥20% of pre-illness annual household income predict adverse treatment outcomes and have been termed “catastrophic.” Social protection initiatives, including cash transfers, are endorsed to help prevent catastrophic costs. With this aim, cash transfers may either be provided to defray TB-related costs of households with a confirmed TB diagnosis (termed a “TB-specific” approach); or to increase income of households with high TB risk to strengthen their economic resilience (termed a “TB-sensitive” approach). The impact of cash transfers provided with each of these approaches might vary. We undertook an economic modelling study from the patient perspective to compare the potential of these 2 cash transfer approaches to prevent catastrophic costs. Methods and findings Model inputs for 7 low- and middle-income countries (Brazil, Colombia, Ecuador, Ghana, Mexico, Tanzania, and Yemen) were retrieved by literature review and included countries' mean patient TB-related costs, mean household income, mean cash transfers, and estimated TB-specific and TB-sensitive target populations. Analyses were completed for drug-susceptible (DS) TB-related costs in all 7 out of 7 countries, and additionally for drug-resistant (DR) TB-related costs in 1 of the 7 countries with available data. All cost data were reported in 2013 international dollars ($). The target population for TB-specific cash transfers was poor households with a confirmed TB diagnosis, and for TB-sensitive cash transfers was poor households already targeted by countries’ established poverty-reduction cash transfer programme. Cash transfers offered in countries, unrelated to TB, ranged from $217 to $1,091/year/household. Before cash transfers, DS TB-related costs were catastrophic in 6 out of 7 countries. If cash transfers were provided with a TB-specific approach, alone they would be insufficient to prevent DS TB catastrophic costs in 4 out of 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $3.8 million (95% CI: $3.8 million–$3.8 million) and $75 million (95% CI: $50 million–$100 million) per country. If instead cash transfers were provided with a TB-sensitive approach, alone they would be insufficient to prevent DS TB-related catastrophic costs in any of the 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $298 million (95% CI: $219 million–$378 million) and $165,367 million (95% CI: $134,085 million–$196,425 million) per country. DR TB-related costs were catastrophic before and after TB-specific or TB-sensitive cash transfers in 1 out of 1 countries. Sensitivity analyses showed our findings to be robust to imputation of missing TB-related cost components, and use of 10% or 30% instead of 20% as the threshold for measuring catastrophic costs. Key limitations were using national average data and not considering other health and social benefits of cash transfers. Conclusions A TB-sensitive cash transfer approach to increase all poor households’ income may have broad benefits by reducing poverty, but is unlikely to be as effective or affordable for preventing TB catastrophic costs as a TB-specific cash transfer approach to defray TB-related costs only in poor households with a confirmed TB diagnosis. Preventing DR TB-related catastrophic costs will require considerable additional investment whether a TB-sensitive or a TB-specific cash transfer approach is used., In this modelling study, William Rudgard of the London School of Hygiene and Tropical Medicine and colleagues compare two cash-transfer strategies to avert catastrophic costs for poor tuberculosis-affected households in low- and middle-income countries., Author summary Why was this study done? Household costs related to active drug-susceptible (DS) or drug-resistant (DR) tuberculosis (TB) disease include costs for consultations, transport to and from clinics, increased food needs and lost income. If these costs are greater than or equal to one-fifth (20%) of the household’s annual income, then the patient is at risk of unsuccessful TB treatment and these high costs are termed “catastrophic costs.” The World Health Organization’s End TB Strategy prioritises preventing TB-affected households from facing catastrophic costs and proposes cash transfers as one way to achieve this. However, there are at least 2 approaches by which cash transfers could be provided to TB-affected households. In the first, they are provided to defray/reimburse households’ TB-related costs (termed a “TB-specific” approach). In the second, they are provided to increase households’ pre-illness income to prevent poverty and strengthen their economic resilience (termed a “TB-sensitive” approach). Lack of available individual-level data sources has meant that no studies have compared a TB-specific versus a TB-sensitive cash transfer approach. A literature review combined with a secondary data analysis was an effective way to bring together relevant data from several different sources and model the potential of cash transfers provided by these 2 approaches to prevent catastrophic costs. What did the researchers do and find? We performed a rigorous review of public data sources available on the internet, extracting national average data published between 2005 and 2013 for the 7 low- and middle-income economy countries of Brazil, Colombia, Ecuador, Ghana, Mexico, Tanzania, and Yemen. The data values we extracted included the countries’ mean value of TB patient costs, mean household income, mean cash transfers, and the expected size of the population that would be targeted with either TB-specific or TB-sensitive cash transfers. In all 7 countries these analyses were completed for DS TB, and in 1 of the 7 countries we were also able to complete these analyses for DR TB. Expressing TB patient costs as a percentage of household income, we found that average DS TB costs were catastrophic in 6 out of the 7 countries included in the study. In these 6 countries, TB-specific cash transfers prevented DS TB catastrophic costs in only 2, whilst TB-sensitive cash transfers did not prevent DS TB catastrophic costs in any of them. In the 1 country with available data, average DR TB costs were catastrophic, and neither TB-specific nor TB-sensitive cash transfers were sufficient to prevent this. For both TB-specific and TB-sensitive approaches, we then estimated the total value that cash transfers would need to be increased to in order to prevent the countries’ average DS or DR TB costs from being catastrophic for DS or DR TB-affected household. Based on this, we also estimated the average budget that each country would need to prevent catastrophic costs for all DS or DR TB-affected households. We found that a TB-specific approach was much more affordable than a TB-sensitive approach. What do these findings mean? The potential of cash transfers to prevent TB-related catastrophic costs is greater if they are provided to defray/reimburse poor households’ costs (TB-specific approach) rather than to increase the income and strengthen the economic resilience of poor households with high TB risk (TB-sensitive approach). Where cash transfers are insufficient to prevent catastrophic costs, it will be cheaper to supplement their value to achieve this objective using a TB-specific approach rather than a TB-sensitive approach. Important study limitations were that the study was at the country-level, so we might have underestimated the potential of cash transfers to prevent catastrophic costs. Also, we did not assess other health and social benefits of cash transfers, so the impact of TB-specific versus TB-sensitive cash transfers was only judged from the perspective of preventing catastrophic costs.

OBJECTIVE To evaluate the impact of the Brazilian cash transfer programme (Bolsa Familia Programme, BFP) on tuberculosis (TB) incidence in Brazil from 2004 to 2012. DESIGN We studied tuberculosis surveillance data using a combination of an ecological multiple-group and time-trend design covering 2458 Brazilian municipalities. The main independent variable was BFP coverage and the outcome was the TB incidence rate. All study variables were obtained from national databases. We used fixed-effects negative binomial models for panel data adjusted for selected covariates and a variable representing time. RESULTS After controlling for covariates, TB incidence rates were significantly reduced in municipalities with high BFP coverage compared with those with low and intermediate coverage (in a model with a time variable incidence rate ratio = 0.96, 95%CI 0.93-0.99). CONCLUSION This was the first evidence of a statistically significant association between the increase in cash transfer programme coverage and a reduction in TB incidence rate. Our findings provide support for social protection interventions for tackling TB worldwide.

INTRODUCTION: Vaccination is a key intervention to reduce infectious disease mortality and morbidity amongst older individuals. Identifying social factors for vaccine uptake enables targeted interventions to reduce health inequalities. OBJECTIVE: To systematically appraise and quantify social factors associated with vaccine uptake amongst individuals aged ≥60years from Europe. METHODS: We searched Medline and Embase from inception to 24/02/2016. The association of vaccine uptake was examined for social factors relevant at an individual level, to provide insight into individuals' environment and enable development of targeted interventions by healthcare providers to deliver equitable healthcare. Factors included: living alone, marital status, education, income, vaccination costs, area-level deprivation, social class, urban versus rural residence, immigration status and religion. Between-study heterogeneity for each factor was identified using I2-statistics and Q-statistics, and investigated by stratification and meta-regression analysis. Meta-analysis was conducted, when appropriate, using fixed- or random-effects models. RESULTS: From 11,754 titles, 35 eligible studies were identified (uptake of: seasonal influenza vaccine (SIV) only (n=27) or including pneumococcal vaccine (PV) (n=5); herpes zoster vaccine (n=1); pandemic influenza vaccine (n=1); PV only (n=1)). Higher SIV uptake was reported for individuals not living alone (summary odds ratios (OR)=1.39 (95% confidence interval (CI): 1.16-1.68). Lower SIV uptake was observed in immigrants and in more deprived areas: summary OR=0.57 (95%CI: 0.47-0.68) and risk ratio=0.93 (95%CI: 0.92-0.94) respectively. Higher SIV uptake was associated with higher income (OR=1.26 (95%CI: 1.08-1.47)) and higher education (OR=1.05 (95%CI: 1-1.11)) in adequately adjusted studies. Between-study heterogeneity did not appear to result from variation in categorisation of social factors, but for education was partly explained by varying vaccination costs (meta-regression analysis p=

Background For the first time in the modern era of tuberculosis control, the WHO's End TB strategy specifically integrates socioeconomic support for people affected by tuberculosis with existing biomedical interventions. However, there is little evidence of the impact of this approach on tuberculosis outcomes. We designed and implemented one of the world's first tuberculosis-specific socioeconomic support interventions, assessed its impact on tuberculosis prevention measures and treatment success, and refined the support for use in the Community Randomized Evaluation of a Socioeconomic Intervention to Prevent Tuberculosis (CRESIPT) project. Methods This unmasked household-randomised controlled study was done in 32 peri-urban shanty towns in Callao, Peru. Households with patients treated for tuberculosis by Peru's Tuberculosis Program were randomly assigned (1:1, computer-assisted randomisation) to receive the Peruvian Tuberculosis Program standard of care (control group) or to additionally receive socioeconomic support (intervention group). Socioeconomic support consisted of conditional cash transfers (≤US$230) and social support (household visits and community meetings). Primary outcome was initiation of tuberculosis preventive therapy in contacts younger than 20 years available for follow-up assessment. 400 contacts were needed for 80% power at the 95% (two-sided) confidence level to detect a 50% increase in the primary outcome. Secondary outcome was treatment success in patients with tuberculosis by intention to treat. Ethics approval was given by the ethics committees of DIRESA Callao (Regional Ministry of Health) and Asociacion Benefica PRISMA, Lima, Peru, and Imperial College London, UK. All participants gave written informed consent. This study has been registered with the ISCTRN registry, number pending. Findings From Feb 10 to Aug 14, 2014, 282 patients (410 eligible contacts) were recruited. 135 patients were randomised to the intervention group (206 eligible contacts) and 147 to the control group (204 eligible contacts). Follow-up continued to June 30, 2015. Compared with controls, intervention contacts were more likely to start preventive therapy (91/206 [44%] vs 53/204 [26%], adjusted odds ratio 2·2 [95% CI 1·1–4·2]; p=0·02); and intervention patients were more likely to have treatment success (87 [64%] vs 78 [53%], 1·8 [1·1–2·9]; p=0·02). Interpretation Tuberculosis-specific socioeconomic support improved initiation of tuberculosis preventive therapy and treatment success. The CRESIPT study will now evaluate the impact of this socioeconomic support on tuberculosis control. Funding Joint Global Health Trials consortium of Wellcome Trust, Medical Research Council, and Department For International Development; British Infection Association; Bill and Melinda Gates Foundation; Innovation For Health And Development; Wellcome Trust.

To evaluate the impact of socioeconomic support on tuberculosis preventive therapy initiation in household contacts of tuberculosis patients and on treatment success in patients.A non-blinded, household-randomized, controlled study was performed between February 2014 and June 2015 in 32 shanty towns in Peru. It included patients being treated for tuberculosis and their household contacts. Households were randomly assigned to either the standard of care provided by Peru's national tuberculosis programme (control arm) or the same standard of care plus socioeconomic support (intervention arm). Socioeconomic support comprised conditional cash transfers up to 230 United States dollars per household, community meetings and household visits. Rates of tuberculosis preventive therapy initiation and treatment success (i.e. cure or treatment completion) were compared in intervention and control arms.Overall, 282 of 312 (90%) households agreed to participate: 135 in the intervention arm and 147 in the control arm. There were 410 contacts younger than 20 years: 43% in the intervention arm initiated tuberculosis preventive therapy versus 25% in the control arm (adjusted odds ratio, aOR: 2.2; 95% confidence interval, CI: 1.1-4.1). An intention-to-treat analysis showed that treatment was successful in 64% (87/135) of patients in the intervention arm versus 53% (78/147) in the control arm (unadjusted OR: 1.6; 95% CI: 1.0-2.6). These improvements were equitable, being independent of household poverty.A tuberculosis-specific, socioeconomic support intervention increased uptake of tuberculosis preventive therapy and tuberculosis treatment success and is being evaluated in the Community Randomized Evaluation of a Socioeconomic Intervention to Prevent TB (CRESIPT) project.Évaluer l'impact de l'accompagnement socioéconomique sur le commencement du traitement préventif contre la tuberculose par les contacts familiaux des patients atteints de la maladie et sur la réussite du traitement pour les patients.Une étude contrôlée, non aveugle, à répartition aléatoire des foyers a été réalisée entre février 2014 et juin 2015 dans 32 bidonvilles du Pérou. Elle portait sur des patients traités contre la tuberculose et leurs contacts familiaux. Les foyers ont été choisis de façon aléatoire pour recevoir soit les soins standards prévus par le programme national de lutte contre la tuberculose du Pérou (groupe témoin), soit les mêmes soins standards plus un accompagnement socioéconomique (groupe expérimental). L'accompagnement socioéconomique comprenait des transferts monétaires conditionnels pouvant atteindre 230 dollars des États-Unis par foyer, des visites à domicile et des réunions communautaires. Le taux de commencement du traitement préventif contre la tuberculose et le taux de réussite du traitement (guérison ou achèvement du traitement) ont été comparés entre le groupe expérimental et le groupe témoin.Au total, 282 foyers sur 312 (90%) ont accepté de participer: 135 dans le groupe expérimental et 147 dans le groupe témoin. 410 contacts avaient moins de 20 ans: dans le groupe expérimental, 43% ont commencé un traitement préventif contre la tuberculose, contre 25% dans le groupe témoin (rapport des cotes ajusté (RC): 2,2; intervalle de confiance (IC) de 95%: 1,1-4,1). Une analyse par intention de traiter a montré la réussite du traitement chez 64% (87/135) des patients du groupe expérimental contre 53% (78/147) du groupe témoin (RC non ajusté: 1,6; IC 95%: 1,0-2,6). Ces améliorations étaient équitables et indépendantes de la pauvreté des foyers.Une intervention d'accompagnement socioéconomique spécifiquement axé sur la tuberculose a permis d'augmenter la prise d'un traitement préventif contre la tuberculose ainsi que la réussite du traitement contre cette maladie. Elle est actuellement évaluée dans le cadre du projet CRESIPT (Community Randomized Evaluation of a Socioeconomic Intervention to Prevent TB).Evaluar el impacto del apoyo socioeconómico en la iniciación a la terapia preventiva contra la tuberculosis en contactos domésticos de pacientes con tuberculosis, así como en el éxito del tratamiento para los pacientes.Entre febrero de 2014 y junio de 2015, se realizó un estudio controlado, aleatorizado, doméstico y no cegado en 32 barrios bajos de Perú. En este estudio se incluyeron pacientes que estaban siendo tratados contra la tuberculosis y sus contactos domésticos. Los hogares se asignaron de forma aleatoria a la atención estándar ofrecida por el programa nacional contra la tuberculosis de Perú (grupo de control) o bien a la misma atención estándar pero con un apoyo socioeconómico (grupo de intervención). El apoyo socioeconómico consistía en transferencias de efectivo condicionadas de hasta 230 dólares estadounidenses por hogar, visitas domésticas y reuniones comunitarias. Se compararon los grupos de control y de intervención en cuanto a las tasas de iniciación a la terapia preventiva contra la tuberculosis y al éxito del tratamiento (es decir, la cura o la finalización del tratamiento).En general, 282 de 312 (90%) hogares aceptaron participar: 135 en el grupo de intervención y 147 en el grupo de control. Había 410 contactos menores de 20 años: el 43% del grupo de intervención inició la terapia preventiva contra la tuberculosis, frente al 25% del grupo de control (coeficiente de posibilidades ajustado, CPa: 2,2; intervalo de confianza, IC, del 95%: 1,1–4,1). Un análisis de intención de tratar mostró que el tratamiento tuvo éxito en un 64% (87/135) de los pacientes del grupo de intervención, frente a un 53% (78/147) de los pacientes del grupo de control (CP no ajustado: 1,6; IC del 95%: 1,0–2,6). Estas mejoras fueron equitativas, independientemente de la pobreza del hogar.Una intervención de apoyo socioeconómico específica para la tuberculosis aumentó la aceptación de la terapia preventiva contra la tuberculosis y el éxito del tratamiento, y se está evaluando en el proyectoتقييم مدى تأثير الدعم الاجتماعي الاقتصادي على طرح العلاج الوقائي من السل لدى الأُسر التي تتعامل مع مرضى السل ومدى تأثيره على نجاح علاج المرضى.تم إجراء دراسة غير عمياء، عشوائية قائمة على الأُسر، مضبطة في الفترة ما بين فبراير/شباط 2014 إلى يونيو/حزيران 2015 في 32 حيًا فقيرًا في بيرو. وشملت هذه الدراسة المرضى الذين خضعوا للعلاج من السل وأفراد أسرتهم. وتم إسناد الأُسر بشكلٍ عشوائي إما إلى معيار الرعاية التي يوفرها البرنامج القومي لمواجهة السل في بيرو (الشِق الخاص بالرقابة) أو نفس المعيار الخاص بالرعاية بالإضافة إلى الدعم الاقتصادي الاجتماعي (الشِق الخاص بالتدخل). ويتألف الدعم الاقتصادي الاجتماعي من الحوالات النقدية الشرطية التي تصل إلى 230 دولارًا أمريكيًا لكل أسرة، والزيارات المنزلية، واللقاءات المجتمعية. وتمت مقارنة معدلات مبادرة العلاج الوقائي من السل ونجاح العلاج (أي إكمال العلاج أو تحقيق الشفاء) في الشقين المتعلقين بالرقابة والتدخل.إجمالاً، وافقت 282 من أصل 312 (‏90‏%) أسرة على المشاركة: 135 في الشِق الخاص بالتدخل، و147 في الشق الخاص بالرقابة. وكان هناك حوالي 410 أِشخاص محتكين بالمرضى ممن هم أقل من 20 سنة: وبدأ 43‏% منهم في الشِق الخاص بالتدخل في العلاج الوقائي من السل مقابل 25‏% منهم في الشق الخاص بالتحكم (بنسبة احتمال معدّلة تبلغ: 2.2؛ بنسبة أرجحية مقدارها ‏95‏%: 1.1–4.1). وأوضح تحليل لقصد العلاج أن العلاج سجل نجاحًا لدى 64‏% من المرضى (87/135) في الشِق الخاص بالتدخل مقابل 53‏% (78/147) في الشِق الخاص بالرقابة (نسبة احتمال غير معدّلة تبلغ: 1.6؛ ‏95‏% كمقدار لنسبة الأرجحية: 1.0–2.6). وكانت تلك التحسينات عادلة بالنظر إلى عدم ارتباطها بفقر الأُسر.ساهم الدعم الاجتماعي الاقتصادي المخصص لمواجهة داء السل في زيادة استيعاب العلاج الوقائي لداء السل ونجاح علاج داء السل، ويجري تقييمه في إطار التقييم المجتمعي العشوائي لمشروع الدعم الاجتماعي الاقتصادي لمواجهة داء السل (CRESIPT).旨在评估社会经济支持对在结核病患者家庭接触者中发起的结核病预防性治疗的影响以及对患者治疗成功的影响。.于 2014 年 2 月至 2015 年 6 月期间，在秘鲁的 32 个贫民窟开展了一项非盲法家庭随机型对照研究。 该项研究包括因结核病接受治疗的患者及其家庭接触者。所有家庭随机分为接受秘鲁国家结核病项目提供的标准护理的标准护理组(对照组)，和标准护理加社会经济支持组（干预组）。社会经济支持包括每户高达 230 美元的有条件现金转移支付、家庭探望及社区会议。 对干预组及对照组的结核病预防性治疗的发起率及患者治疗成功率（即，治愈或完成治疗）进行了对比。.312 户家庭中总计有 282 (90%) 户家庭同意参加：135 户家庭为干预组，147 户家庭为对照组。其中有 410 名接触者小于 20 岁： 干预组的结核病预防性治疗发起率为 43%，对照组为 25%（调整后比值比，OR： 2.2；95% 置信区间，CI： 1.1–4.1)。 一项意向治疗分析显示，干预组患者的治疗成功率为 64% (87/135)，对照组为 53% (78/147) （调整后 OR： 1.6; 95% CI: 1.0–2.6)。 这些改进均衡分布，与家庭贫困程度无关。.结核病专项社会经济支持干预提高了结核病预防性治疗的接受率及结核病的治疗成功率，目前正在接受结核病社会经济干预的社区随机化评估 (CRESIPT) 项目的评估。.Оценить, как влияет социально-экономическая поддержка на начало профилактического противотуберкулезного лечения членами семьи, контактирующими с больным, а также оценить вклад такой поддержки в успех лечения.Открытое контролируемое исследование с рандомизацией семей было проведено в период между февралем 2014 года и июнем 2015 года в 32 трущобных поселениях в Перу. В исследование включались пациенты, получающие лечение от туберкулеза, и члены их семей, контактировавшие с ними. Семьям случайным образом назначали либо стандартное лечение, положенное в соответствии с национальной противотуберкулезной программой, осуществляемой в Перу (контрольная группа), либо такое же стандартное лечение в сочетании с социально-экономической поддержкой (экспериментальная группа). Социально-экономическая поддержка включала выдачу денежных пособий при соблюдении определенных условий (в сумме до 230 долларов США на семью), посещение семей и собрания общины. В контрольной группе и в экспериментальной группе сравнивались доли участников, начавших профилактическое противотуберкулезное лечение и успешно его завершивших (под успешным завершением подразумевалось излечение или завершение курса лечения).Принять участие в исследовании согласились 282 семьи из 312 (90%). В экспериментальную группу вошли 135 семей, и 147 семей составили контрольную группу. В исследовании участвовали 410 контактирующих лиц в возрасте моложе 20 лет. В экспериментальной группе профилактическое противотуберкулезное лечение начали осуществлять 43% участников против 25% в контрольной группе (скорректированное отношение шансов, ОШ: 2,2; 95%-й доверительный интервал, ДИ: 1,1–4,2). Согласно результатам анализа по всем рандомизированным участникам, лечение было успешным в 64% случаев (87 из 135 семей) в экспериментальной группе и в 53% случаев (78 из 147 семей) в контрольной группе (нескорректированное ОШ: 1,6; 95%-й ДИ: 1,0–2,6). Улучшения наблюдались в равной мере и не зависели от того, насколько бедной была семья.Социально-экономическая поддержка, специально ориентированная на помощь туберкулезным больным, увеличивает использование профилактического лечения и шанс успешного противотуберкулезного лечения и оценивается в рамках проекта оценки социально-экономических вмешательств для предотвращения туберкулеза с рандомизацией по сообществам (Community Randomized Evaluation of a Socioeconomic Intervention to Prevent TB, CRESIPT).

IntroductionTuberculosis incidence is disproportionately high among people in poverty. Cash transfer programs have become an important strategy in Brazil fight inequalities as part of comprehensive poverty alleviation policies. This study was aimed at assessing the effect of being a beneficiary of a governmental cash transfer program on tuberculosis (TB) treatment cure rates.MethodsWe conducted a longitudinal database study including people ≥18 years old with confirmed incident TB in Brazil in 2015. We treated missing data with multiple imputation. Poisson regression models with robust variance were carried out to assess the effect of TB determinants on cure rates. The average effect of being beneficiary of cash transfer was estimated by propensity-score matching.ResultsIn 2015, 25,084 women and men diagnosed as new tuberculosis case, of whom 1,714 (6.8%) were beneficiaries of a national cash transfer. Among the total population with pulmonary tuberculosis several determinants were associated with cure rates. However, among the cash transfer group, this association was vanished in males, blacks, region of residence, and people not deprived of their freedom and who smoke tobacco. The average treatment effect of cash transfers on TB cure rates, based on propensity score matching, found that being beneficiary of cash transfer improved TB cure rates by 8% [Coefficient 0.08 (95% confidence interval 0.06-0.11) in subjects with pulmonary TB].ConclusionOur study suggests that, in Brazil, the effect of cash transfer on the outcome of TB treatment may be achieved by the indirect effect of other determinants. Also, these results suggest the direct effect of being beneficiary of cash transfer on improving TB cure rates.

BACKGROUND: Social protection can reduce poverty and act on the determinants of tuberculosis (TB). OBJECTIVE: To evaluate the impact of the Family Health Strategy (FHS) and the Bolsa Famılia Programme on TB-related mortality in Brazil. METHODS: This was an ecological study in which the units of analysis were Brazilian municipalities between 2001 and 2012. The principal independent variables were the levels of coverage of the primary health care system and the conditional cash transfer programme. The dependent variable was TB mortality rate (obtained from national databases). Descriptive analysis and negative binomial regression based on panel data using fixed-effects models were performed. Crude and adjusted estimates were calculated for continuous and categorical variables. RESULTS: A high FHS coverage was significantly associated with a reduction in the TB mortality rate (RR 0.80, 95%CI 0.72–0.89). An increase in the coverage of the Brazilian cash transfer programme was significantly associated with a reduction in the TB mortality rate (RR 0.87, 95%CI 0.81–0.96). CONCLUSION: FHS and the Bolsa Famılia conditional cash transfer programme had a positive impact on the TB mortality rate in Brazil. Public policies should include economic support combined with health promotion.

BACKGROUND: Despite the efforts of the National Tuberculosis Programme, TB cure rates in Brazil are sub-optimal. The End TB Strategy for post-2015 identifies conditional cash transfer interventions as powerful tools to improve TB control indicators, including TB cure rate. This study aims to inform the new policy by evaluating the role of the Bolsa Familia Programme (BFP), one of the largest conditional cash transfer programmes in the world, on TB cure rates in Brazil. METHODS: We undertook a retrospective cohort study, based on an unprecedented record linkage of socioeconomic and health data, to compare cases of patients newly diagnosed with TB in 2010 receiving BFP cash benefits (n=5788) with those who did not (n=1467) during TB treatment. We used Poisson regression with robust variance to estimate the relative risks for TB cure adjusted for known confounders. RESULTS: The cure rate among patients exposed to BFP during TB treatment was 82.1% (4752/5788), 5.2% higher than among those not exposed. This was confirmed after controlling for TB type, diabetes mellitus, HIV status and other relevant clinical and socioeconomic covariates (RR=1.07, 95% CI 1.04 to 1.11 for cure rates among BFP beneficiaries). This association seemed higher for patients not under directly observed treatment (RR=1.11; 95% CI 1.05 to 1.16). CONCLUSIONS: Although further research is needed, this study suggests that conditional cash transfer programmes can contribute to improve TB cure rate in Brazil.

THERE IS EVIDENCE that the reduction in tuberculosis (TB) mortality observed in Europe and North America before World War II resulted from the successful combination of economic growth and specific public health policies such as patient isolation and the elimination of bovine TB.1,2 The importance of a combined approach has recently been reinforced by a number of studies suggesting that while DOTS programmes have significantly contributed to the reduction of TB prevalence and TB mortality, socio-economic development still remains the main determinant of TB incidence decline in many regions of the world.3-5 Despite this, literature on interventions addressing structural and social determinants6 of TB is currently virtually non-existent. Through the improvement of material living conditions, psychosocial circumstances and health-seeking behaviours, these interventions have the double potential to improve access to quality TB care and also reduce people’s vulnerability to TB. A broad range of poverty alleviation strategies may achieve the above objectives; among them, cash transfer and microfinance programmes have gathered considerable visibility in the last decade, due to both the large number of individuals enrolled and the increasing number of studies formally documenting their impact. Cash transfers are innovative forms of social protection based on the provision of money to poor or vulnerable households and individuals (such as the elderly and children) with the aim of enabling them to move out of poverty by protecting and building their financial, physical and human capital assets.7 Cash transfers can be unconditional (given without obligation) or conditional on some behavioural requirements, such as school enrolment, health services utilisation and/or the attendance of health education workshops. Microfinance programmes are considered poverty alleviation measures aimed at directly averting deprivation.8 These programmes are based on the provision to the poor of small loans to enable them to engage in productive activities that can ultimately contribute to their long-term economic growth and productivity.8 Despite the impressive scale-up of these interventions and their acknowledged potential public health relevance,9,10 their relevance for TB control largely depends on evidence of their effect on outcomes epidemiologically linked to TB and the critical assessment of the challenges limiting their implementation in the context of TB. This review aimed to address these issues by: 1) systematically quantifying the impact of these interventions and 2) evaluating their main design and implementation features from the perspective of TB control.