35 research outputs found
The global impact of household contact management for children on multidrug-resistant and rifampicin-resistant tuberculosis cases, deaths, and health-system costs in 2019: a modelling study
Background:
Estimates suggest that at least 30â000 children develop multidrug-resistant or rifampicin-resistant tuberculosis each year. Despite household contact management (HCM) being widely recommended, it is rarely done.
Methods:
We used mathematical modelling to evaluate the potential country-level and global effects and cost-effectiveness of multidrug-resistant or rifampicin-resistant tuberculosis HCM for children younger than 15 years who are living with a person with newly diagnosed multidrug-resistant or rifampicin-resistant tuberculosis. We compared a baseline of no HCM with several HCM strategies and tuberculosis preventive therapy regimens, calculating the effect on multidrug-resistant or rifampicin-resistant tuberculosis cases, deaths, and health-system costs. All HCM strategies involved the screening of children for prevalent tuberculosis disease but with tuberculosis preventive therapy either not given or targeted dependent on age, HIV status, and result of tuberculin skin test. We evaluated the use of fluoroquinolones (ie, levofloxacin and moxifloxacin), delamanid, and bedaquiline as tuberculosis preventive therapy.
Findings:
Compared with a baseline without HCM, HCM for all adults diagnosed with multidrug-resistant or rifampicin-resistant tuberculosis in 2019 would have entailed screening 227â000 children (95% uncertainty interval [UI]: 205â000â252â000) younger than 15 years globally, and averted 2350 tuberculosis deaths (1940â2790), costing an additional US$63 million (74â95 million). If all the children within the household who had been in contact with the person with multidrug-resistant or rifampicin-resistant tuberculosis received tuberculosis preventive therapy with levofloxacin, 5620 incident tuberculosis cases (95% UI 4540â6890) and an additional 1240 deaths (970â1540) would have been prevented. Incremental cost-effectiveness ratios were lower than half of per-capita gross domestic product for most interventions in most countries. Targeting only children younger than 5 years and those living with HIV reduced the number of incident cases and deaths averted, but improved cost-effectiveness. Tuberculosis preventive therapy with delamanid increased the effect, in terms of reduced incidence and mortality, compared with levofloxacin.
Interpretation:
HCM for patients with multidrug-resistant or rifampicin-resistant tuberculosis is cost-effective in most settings and could avert a substantial proportion of multidrug-resistant or rifampicin-resistant tuberculosis cases and deaths in children globally.
Funding:
UK Medical Research Council
Progress on the elimination of viral hepatitis in Zimbabwe: A review of the policies, strategies and challenges
Very few lowâincome countries have developed national plans to achieve the viral hepatitis elimination targets set in the World Health Organization (WHO) strategy. We reviewed the policy environment, strategies and challenges on the fight against viral hepatitis in Zimbabwe. The review focussed on the Ministry of Health and Child Care (MoHCC) policy documents, strategic plans and reports. We performed key informant interviews to enhance evidence generated from the document review. Twelve documents were reviewed and interviews with 10 key informants were completed. The MoHCC established a technical working group to work towards elimination of viral hepatitis. The technical working group drafted a strategic plan for elimination of viral hepatitis; however, it is still awaiting implementation. Key strategies that are working well include screening of donated blood for transfusion, safe injection practices and hepatitis B virus (HBV) threeâdose vaccination. Current challenges in the drive towards elimination of viral hepatitis include poor to nonâexistent surveillance systems, lack of epidemiological data, absence of the HBV vaccine birth dose and lack of systematic screening and treatment services for viral hepatitis. In conclusion, despite political will demonstrated towards achieving viral hepatitis elimination, substantial investment and work are required to implement the strategic plan and realize significant success
Cost and costâeffectiveness of a simplified treatment model with directâacting antivirals for chronic hepatitis C in Cambodia
Background & Aims
In 2016, MĂ©decins Sans FrontiĂšres established the first general population Hepatitis C virus (HCV) screening and treatment site in Cambodia, offering free directâacting antiviral (DAA) treatment. This study analysed the costâeffectiveness of this intervention.
Methods
Costs, quality adjusted life years (QALYs) and costâeffectiveness of the intervention were projected with a Markov model over a lifetime horizon, discounted at 3%/year. Patientâlevel resourceâuse and outcome data, treatment costs, costs of HCVârelated healthcare and EQâ5Dâ5L health states were collected from an observational cohort study evaluating the effectiveness of DAA treatment under full and simplified models of care compared to no treatment; other model parameters were derived from literature. Incremental costâeffectiveness ratios (cost/QALY gained) were compared to an opportunity costâbased willingnessâtoâpay threshold for Cambodia (925(IQR 376(IQR 187/QALY), cost an additional $14 485/QALY compared to the simplified model, above the willingnessâtoâpay threshold for Cambodia. This result is robust to variation in parameters.
Conclusions
The simplified model of care was cost saving compared to no treatment, emphasizing the importance of simplifying pathways of care for improving access to HCV treatment in lowâresource settings
A systematic approach for reviewing research capacity within Zimbabweâs national blood service
Background
Blood services need to undertake research to improve their strategic goals, operational effectiveness and promote evidence-based policies. NBSZ has along history of active research and undertook a systematic review of its research capacity to guide its new research strategy. In the absence of a published approach for research capacity assessment for national blood services, a frame-work to assess research capacity in African universities was used.
Methods
Semi-structured interviews were conducted with 85 NBSZ internal and external stakeholders. The interview topics were based on eight areas covered by the framework used to assess universitiesâ research systems. Information was ver-iïŹed through triangulation, and recommended actions emerging from the review were validated at a national stakeholder workshop. The appropriateness of the framework for use in the setting of blood services was also evaluated.
Results
Synthesis of information from the multi perspective interviews high-lighted key areas of NBSZâs research capacity for improvement, in particular better dissemination of NBSZâs research priorities and closer ties with academics and their institutions for preparing research proposals and jointly undertaking research projects. With minor adaptations, the framework was found to be applicable to NBSZ, and no aspects of research capacity were identiïŹed which were not covered by the framework.
Discussion
Our results indicate that it is feasible and useful to apply a structured process to review the research capacity of blood services. However, the frame-work needs to be tested in blood services and other non-university setting to assess its usefulness and transferability
Blood use in subâSaharan Africa: a systematic review of current data
Background: Data on the use of blood products in sub-Saharan Africa (SSA) are scarce. A systematic review of published data on blood utilization according to diagnosis in SSA was
performed.
Study design and methods: Studies published from January 2000 to June 2018 were searched in PubMed, Embase and African Index Medicus. Data were extracted and synthesized. The proportion of blood products used for different diagnostic categories is presented.
Results: 37 studies representing 159,746 transfusions to 96,690 patients from 14 countries in SSA were included. Data from six of 37 studies were pooled to determine blood product use according to diagnosis. The primary diagnostic categories were pediatric malaria (20%), sickle cell anemia [SCA] (18%), obstetric hemorrhage (16%), and other causes of bleeding (16%). About 8%, 6% and 2% of products were used for other infections, cancer treatment, and surgery respectively. Overall, 58.5% of the products transfused were red blood cells, 31.7 % whole blood, 7.2% fresh frozen plasma, and 2.6% as platelets. Estimated blood product use per population in SSA was 5.3 transfusions per 1000 people, compared with 52 and 34 per thousand for Australia and United States respectively.
Conclusion: This study provides a systematic attempt to quantify blood utilization for SSA. Blood products in SSA are used primarily for pediatric malaria, SCA, obstetric hemorrhage and other causes of bleeding. Studies such as this represent an important early step towards improving hemovigilance in SSA
Effects and cost of different strategies to eliminate hepatitis C virus transmission in Pakistan: a modelling analysis
Background
The WHO elimination strategy for hepatitis C virus advocates scaling up screening and treatment to reduce global hepatitis C incidence by 80% by 2030, but little is known about how this reduction could be achieved and the costs of doing so. We aimed to evaluate the effects and cost of different strategies to scale up screening and treatment of hepatitis C in Pakistan and determine what is required to meet WHO elimination targets for incidence.
Methods
We adapted a previous model of hepatitis C virus transmission, treatment, and disease progression for Pakistan, calibrating using available data to incorporate a detailed cascade of care for hepatitis C with cost data on diagnostics and hepatitis C treatment. We modelled the effect on various outcomes and costs of alternative scenarios for scaling up screening and hepatitis C treatment in 2018â30. We calibrated the model to country-level demographic data for 1960â2015 (including population growth) and to hepatitis C seroprevalence data from a national survey in 2007â08, surveys among people who inject drugs (PWID), and hepatitis C seroprevalence trends among blood donors. The cascade of care in our model begins with diagnosis of hepatitis C infection through antibody screening and RNA confirmation. Diagnosed individuals are then referred to care and started on treatment, which can result in a sustained virological response (effective cure). We report the median and 95% uncertainty interval (UI) from 1151 modelled runs.
Findings
One-time screening of 90% of the 2018 population by 2030, with 80% referral to treatment, was projected to lead to 13·8 million (95% UI 13·4â14·1) individuals being screened and 350â000 (315â000â385â000) treatments started annually, decreasing hepatitis C incidence by 26·5% (22·5â30·7) over 2018â30. Prioritised screening of high prevalence groups (PWID and adults aged â„30 years) and rescreening (annually for PWID, otherwise every 10 years) are likely to increase the number screened and treated by 46·8% and decrease incidence by 50·8% (95% UI 46·1â55·0). Decreasing hepatitis C incidence by 80% is estimated to require a doubling of the primary screening rate, increasing referral to 90%, rescreening the general population every 5 years, and re-engaging those lost to follow-up every 5 years. This approach could cost US3·9 billion with lowest costs for diagnostic tests and drugs, including health-care savings, and implementing a simplified treatment algorithm.
Interpretation
Pakistan will need to invest about 9·0% of its yearly health expenditure to enable sufficient scale up in screening and treatment to achieve the WHO hepatitis C elimination target of an 80% reduction in incidence by 2030.
Funding
UNITAID
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Cost and cost-effectiveness of a real-world HCV treatment program among HIV-infected individuals in Myanmar
Introduction Over half of those hepatitis C virus (HCV)/HIV coinfected live in low-income and middle-income countries, and many remain undiagnosed or untreated. In 2016, MĂ©decins Sans FrontiĂšres (MSF) established a direct-acting antiviral (DAA) treatment programme for people HCV/HIV coinfected in Myanmar. The purpose of our study was to evaluate the real-world cost and cost-effectiveness of this programme, and potential cost-effectiveness if implemented by the Ministry of Health (MoH).
Methods Costs (patient-level microcosting) and treatment outcomes were collected from the MSF prospective cohort study in Dawei, Myanmar. A Markov model was used to assess cost-effectiveness of the programme compared with no HCV treatment from a health provider perspective. Estimated lifetime and healthcare costs (in 2017 US1250). We evaluated cost-effectiveness with updated quality-assured generic DAA prices and potential cost-effectiveness of a proposed simplified treatment protocol with updated DAA prices if implemented by the MoH.
Results From November 2016 to October 2017, 122 with HIV/HCV-coinfected patients were treated with DAAs (46% with cirrhosis), 96% (n=117) achieved sustained virological response. Mean treatment costs were 1971 (with cirrhosis), with DAA drugs being the largest contributor to cost. Compared with no treatment, the program was cost-effective (ICER 488/DALY averted). A simplified treatment protocol delivered by the MoH could be cost-effective if associated with similar outcomes (ICER $316/DALY averted).
Conclusions Using MSF programme data, the DAA treatment programme for HCV among HIV-coinfected individuals is cost-effective in Myanmar, and even more so with updated DAA prices. A simplified treatment protocol could enhance cost-effectiveness if further rollout demonstrates it is not associated with worse treatment outcomes
Feasibility of a randomized clinical trial evaluating a community intervention for household tuberculosis child contact management in Cameroon and Uganda
Background
One of the main barriers of the management of household tuberculosis child contacts is the necessity for parents to bring healthy children to the facility. We assessed the feasibility of a community intervention for tuberculosis (TB) household child contact management and the conditions for its evaluation in a cluster randomized controlled trial in Cameroon and Uganda.
Methods
We assessed three dimensions of feasibility using a mixed method approach: (1) recruitment capability using retrospective aggregated data from facility registers; (2) acceptability of the intervention using focus group discussions with TB patients and in-depth interviews with healthcare providers and community leaders; and (3) adaptation, integration, and resources of the intervention in existing TB services using a survey and discussions with stakeholders.
Results
Reaching the sample size is feasible in all clusters in 15 months with the condition of regrouping 2 facilities in the same cluster in Uganda due to decentralization of TB services. Community health worker (CHW) selection and training and simplified tools for contact screening, tolerability, and adherence of preventive therapy were key elements for the implementation of the community intervention. Healthcare providers and patients found the intervention of child contact investigations and TB preventive treatment management in the household acceptable in both countries due to its benefits (competing priorities, transport cost) as compared to facility-based management. TB stigma was present, but not a barrier for the community intervention. Visit schedule and team conduct were identified as key facilitators for the intervention.
Conclusions
This study shows that evaluating a community intervention for TB child contact management in a cluster randomized trial is feasible in Cameroon and Uganda.
Trial registration
Clini calTr ials. gov NCT03832023. Registered on February 6th 2019