Tuberculosis and poverty: the contribution of patient costs in sub-Saharan Africa – a systematic review

Background: Tuberculosis (TB) is known to disproportionately affect the most economically disadvantaged strata of society. Many studies have assessed the association between poverty and TB, but only a few have assessed the direct financial burden TB treatment and care can place on households. Patient costs can be particularly burdensome for TB-affected households in sub-Saharan Africa where poverty levels are high; these costs include the direct costs of medical and non-medical expenditures and the indirect costs of time utilizing healthcare or lost wages. In order to comprehensively assess the existing evidence on the costs that TB patients incur, we undertook a systematic review of the literature. Methods: PubMed, EMBASE, Science Citation Index, Social Science Citation Index, EconLit, Dissertation Abstracts, CINAHL, and Sociological Abstracts databases were searched, and 5,114 articles were identified. Articles were included in the final review if they contained a quantitative measure of direct or indirect patient costs for treatment or care for pulmonary TB in sub-Saharan Africa and were published from January 1, 1994 to Dec 31, 2010. Cost data were extracted from each study and converted to 2010 international dollars (I$). Results: Thirty articles met all of the inclusion criteria. Twenty-one studies reported both direct and indirect costs; eight studies reported only direct costs; and one study reported only indirect costs. Depending on type of costs, costs varied from less than I$1 to almost I$600 or from a small fraction of mean monthly income for average annual income earners to over 10 times average annual income for income earners in the income-poorest 20% of the population. Out of the eleven types of TB patient costs identified in this review, the costs for hospitalization, medication, transportation, and care in the private sector were largest. Conclusion: TB patients and households in sub-Saharan Africa often incurred high costs when utilizing TB treatment and care, both within and outside of Directly Observed Therapy Short-course (DOTS) programs. For many households, TB treatment and care-related costs were considered to be catastrophic because the patient costs incurred commonly amounted to 10% or more of per capita incomes in the countries where the primary studies included in this review were conducted. Our results suggest that policies to decrease direct and indirect TB patient costs are urgently needed to prevent poverty due to TB treatment and care for those affected by the disease

The Hepatitis C Cascade of Care: Identifying Priorities to Improve Clinical Outcomes

Background: As highly effective hepatitis C virus (HCV) therapies emerge, data are needed to inform the development of interventions to improve HCV treatment rates. We used simulation modeling to estimate the impact of loss to follow-up on HCV treatment outcomes and to identify intervention strategies likely to provide good value for the resources invested in them. Methods: We used a Monte Carlo state-transition model to simulate a hypothetical cohort of chronically HCV-infected individuals recently screened positive for serum HCV antibody. We simulated four hypothetical intervention strategies (linkage to care; treatment initiation; integrated case management; peer navigator) to improve HCV treatment rates, varying efficacies and costs, and identified strategies that would most likely result in the best value for the resources required for implementation. Main measures Sustained virologic responses (SVRs), life expectancy, quality-adjusted life expectancy (QALE), costs from health system and program implementation perspectives, and incremental cost-effectiveness ratios (ICERs). Results: We estimate that imperfect follow-up reduces the real-world effectiveness of HCV therapies by approximately 75%. In the base case, a modestly effective hypothetical peer navigator program maximized the number of SVRs and QALE, with an ICER compared to the next best intervention of $48,700/quality-adjusted life year. Hypothetical interventions that simultaneously addressed multiple points along the cascade provided better outcomes and more value for money than less costly interventions targeting single steps. The 5-year program cost of the hypothetical peer navigator intervention was$14.5 million per 10,000 newly diagnosed individuals. Conclusions: We estimate that imperfect follow-up during the HCV cascade of care greatly reduces the real-world effectiveness of HCV therapy. Our mathematical model shows that modestly effective interventions to improve follow-up would likely be cost-effective. Priority should be given to developing and evaluating interventions addressing multiple points along the cascade rather than options focusing solely on single points

Effectiveness of a Messenger RNA Vaccine Booster Dose Against Coronavirus Disease 2019 Among US Healthcare Personnel, October 2021-July 2022

BACKGROUND: Protection against symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019 [COVID-19]) can limit transmission and the risk of post-COVID conditions, and is particularly important among healthcare personnel. However, lower vaccine effectiveness (VE) has been reported since predominance of the Omicron SARS-CoV-2 variant. METHODS: We evaluated the VE of a monovalent messenger RNA (mRNA) booster dose against COVID-19 from October 2021 to June 2022 among US healthcare personnel. After matching case-participants with COVID-19 to control-participants by 2-week period and site, we used conditional logistic regression to estimate the VE of a booster dose compared with completing only 2 mRNA doses \u3e150 days previously, adjusted for multiple covariates. RESULTS: Among 3279 case-participants and 3998 control-participants who had completed 2 mRNA doses, we estimated that the VE of a booster dose against COVID-19 declined from 86% (95% confidence interval, 81%-90%) during Delta predominance to 65% (58%-70%) during Omicron predominance. During Omicron predominance, VE declined from 73% (95% confidence interval, 67%-79%) 14-60 days after the booster dose, to 32% (4%-52%) ≥120 days after a booster dose. We found that VE was similar by age group, presence of underlying health conditions, and pregnancy status on the test date, as well as among immunocompromised participants. CONCLUSIONS: A booster dose conferred substantial protection against COVID-19 among healthcare personnel. However, VE was lower during Omicron predominance, and waning effectiveness was observed 4 months after booster dose receipt during this period. Our findings support recommendations to stay up to date on recommended doses of COVID-19 vaccines for all those eligible

Model input parameters for a Monte Carlo simulation of HCV.

<p>S.D. = standard deviation; PY = person-year; PEG = pegylated interferon; RBV = ribavirin; TPV = telaprevir; SVR = sustained virologic response; ICM = integrated case management; IFN = interferon.</p>a<p>The lifetime probability of linking to HCV care upon receipt of a positive antibody result is 66%.</p>b<p>In the interferon-free scenario, we assumed that 54% of those linked to care would initiate therapy.</p>c<p>Costs varied as a function of age and sex.</p>d<p>Includes the cost of a RNA confirmatory test and a nursing visit.</p>e<p>ntervention costs are presented on a per participant basis, assuming that the participant completes the entire intervention. During the simulation, participants accrued costs on a monthly basis. If the participant was lost to follow-up, or otherwise withdrew from care before the end of the intervention, then that patient stopped accruing intervention costs at the time of being lost (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0097317#pone.0097317.s001" target="_blank">Appendix S1</a> for details).</p>f<p>Treatment visit costs are higher in the first month compared to other months.</p>g<p>13% of patients received a reduced weekly dose of 135 mcg in response to non-treatment ending neutropenia <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0097317#pone.0097317-Food1" target="_blank">[45]</a>.</p>h<p>RBV dose was a function of genotype (genotype 1 = 1,200 mg/day; genotype 2 or 3 = 800 mg/day). In addition, 36% of patients on triple therapy and 17% on dual therapy were treated with reduced dose RBV = 600 mg/day in response to non-treatment ending anemia <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0097317#pone.0097317-Food1" target="_blank">[45]</a>.</p>i<p>Only patients with genotype 1 receive TPV for treatment months 1–3.</p>j<p>13% of patients developed non-treatment ending neutropenia (absolute neutrophil count <750/ml) and received filgrastim 300 mcg/two times weekly <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0097317#pone.0097317-Food1" target="_blank">[45]</a>.</p>k<p>Only patients with genotype 1 treated with PEG/RBV/TPV therapy received 150g/month for treating mild rash (28% during the first 3 months of therapy) <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0097317#pone.0097317-Food1" target="_blank">[45]</a>.</p>l<p>The range reflects the fact that some patients were treated for 6 months, while those without rapid virologic response were treated for 12 months.</p>m<p>Reflects lower quality of life for individuals with HCV risk-factors such as substance use.</p>n<p>This utility weight was multiplied by an individual’s health state utility during the months that a patient was receiving HCV therapy without major toxicity. For example, a patient with HCV and mild to moderate fibrosis who underwent HCV treatment had a utility = 0.801 (0.90×0.89) during the months that (s)he was on medications.</p>o<p>This utility “toll” was subtracted from a patient’s health state utility during the month of a major toxicity event.</p

Projected incremental cost effectiveness ratios of potential interventions to improve HCV follow-up.

<p>QALY = Quality-adjusted life year; ICER = incremental cost-effectiveness ratio.</p><p>Costs and QALYs are lifetime and discounted at an annual rate of 3%. Costs are in 2011 U.S.$and rounded to the nearest$100. All QALYs are rounded to the nearest hundredth.</p>a<p>The ICER of linkage compared to standard of care is $26,500/QALY gained; linkage is extended dominated.</p>b<p>The ICER of treatment initiation compared to standard of care is$19,200/QALY gained; treatment initiation is extended dominated.</p>c<p>The ICER of peer navigators compared to standard of care is $20,000/QALY gained.</p

Intervention clinical outcomes.

<p>The bar graph illustrates the percent of the cohort attaining clinical outcomes along the HCV cascade of care. Each bar shading represents a specific intervention scenario.</p