Global Epidemiology of Tuberculosis

AbstractTuberculosis (TB) was the underlying cause of 1.3 million deaths among human immunodeficiency virus (HIV)-negative people in 2016, exceeding the global number of HIV/acquired immune deficiency syndrome (AIDS) deaths. In addition, TB was a contributing cause of 374,000 HIV deaths. Despite the success of chemotherapy over the past seven decades, TB is the top infectious killer globally. In 2016, 10.4 million new cases arose, a number that has remained stable since the beginning of the 21th century, frustrating public health experts tasked to design and implement interventions to reduce the burden of TB disease worldwide. Ambitious targets for reductions in the epidemiological burden of TB have been set within the context of the Sustainable Development Goals (SDGs) and the End TB Strategy. Achieving these targets is the focus of national and international efforts, and demonstrating whether or not they are achieved is of major importance to guide future and sustainable investments. This article reviews epidemiological facts about TB, trends in the magnitude of the burden of TB and factors contributing to it, and the effectiveness of the public health response

Economic benefit of tuberculosis control

Tuberculosis is the most important infectious cause of adult deaths after HIV/AIDS in low- and middle-income countries. This paper evaluates the economic benefits of extending the World Health Organization's DOTS Strategy (a multi-component approach that includes directly observed treatment, short course chemotherapy and several other components) as proposed in the Global Plan to Stop TB, 2006-2015. The authors use a model-based approach that combines epidemiological projections of averted mortality and economic benefits measured using value of statistical life for the Sub-Saharan Africa region and the 22 high-burden, tuberculosis-endemic countries in the world. The analysis finds that the economic benefits between 2006 and 2015 of sustaining DOTS at current levels relative to having no DOTS coverage are significantly greater than the costs in the 22 high-burden, tuberculosis-endemic countries and the Africa region. The marginal benefits of implementing the Global Plan to Stop TB relative to a no-DOTS scenario exceed the marginal costs by a factor of 15 in the 22 high-burden endemic countries, a factor of 9 (95% CI, 8-9) in the Africa region, and a factor of 9 (95% CI, 9-10) in the nine high-burden African countries. Uncertainty analysis shows that benefit-cost ratios of the Global Plan strategy relative to sustained DOTS were unambiguously greater than one in all nine high-burden countries in Africa and in Afghanistan, Pakistan, and Russia. Although HIV curtails the effect of the tuberculosis programs by lowering the life expectancy of those receiving treatment, the benefits of the Global Plan are greatest in African countries with high levels of HIV.Health Monitoring&Evaluation,Disease Control&Prevention,Population Policies,Health Systems Development&Reform,Poverty and Health

Costs and cost-effectiveness of alternative tuberculosis management strategies in South Africa - implications for policy

Objective. To conduct an economic analysis of the Hlabisa community-based directly observed therapy management strategy for tuberculosis and to project costs of three alternative strategies.Setting. Hlabisa health district, Kwazulu-Natal, South Africa.Methods. An economic analysis comparing the current tuberculosis management strategy in Hlabisa with three alternative strategies (the Hlabisa strategy prior to 1991 based on hospitalisation, the national strategy and sanatorium care) in terms of costs to both health service and patient and of cost-effectiveness.Results. The current Hlabisa strategy was the most cost-effective (R3 799 per patient cured), compared with R98 307 for the strategy used prior to 1991, R9 940 for the national strategy, and R11 145 for sanatorium care. Between 71 % and 88% of treatment costs lie with the health service, and hospitalisation (R119 per day) is the most expensive item. Prolonged hospitalisation is extremely expensive, but community care is cheaper (community clinic visit, R28; community health worker visit, R7). The total cost of supervising a patient in the community under the current Hlabisa strategy was R503, equivalent to 4.2 days in hospital. Drug costs (R157) are equivalent to just 1.3 days in hospital.Conclusion. Cost to both health service and patient can be substantially reduced by using community-based directly observed therapy for tuberculosis, a strategy that is cheap and cost-effective in Hlabisa. These findings have important national implications, supporting the goals of the new tuberculosis control programme

Domestic and donor fi nancing for tuberculosis care and control in low-income and middle-income countries: an analysis of trends, 2002–11, and requirements to meet 2015 targets

Background Progress in tuberculosis control worldwide, including achievement of 2015 global targets, requires adequate fi nancing sustained for many years. WHO began yearly monitoring of tuberculosis funding in 2002. We used data reported to WHO to analyse tuberculosis funding from governments and international donors (in real terms, constant 2011 US$) and associated progress in tuberculosis control in low-income and middle-income countries between 2002 and 2011. We then assessed funding needed to 2015 and how this funding could be mobilised. Methods We included low-income and middle-income countries that reported data about fi nancing for tuberculosis to WHO and had at least three observations between 2002 and 2011. When data were missing for specifi c country–year combinations, we imputed the missing data. We aggregated country-specifi c results for eight country groups defi ned according to income level, political and economic profi le, geography, and tuberculosis burden. We compared absolute changes in total funding with those in the total number of patients successfully treated and did cross-country comparisons of cost per successfully treated patient relative to gross domestic product. We estimated funding needs for tuberculosis care and control for all low-income and middle-income countries to 2015, and compared these needs with domestic funding that could be mobilised. Findings Total funding grew from$1·7 billion in 2002 to $4·4 billion in 2011. It was mostly spent on diagnosis and treatment of drug-susceptible tuberculosis. 43 million patients were successfully treated, usually for$100–500 per person in countries with high burdens of tuberculosis. Domestic funding rose from $1·5 billion to$3·9 billion per year, mostly in Brazil, Russia, India, China, and South Africa (BRICS), which collectively account for 45% of global cases, where national contributions accounted for more than 95% of yearly funding. Donor funding increased from $0·2 billion in 2002 to$0·5 billion in 2011, and accounted for a mean of 39% of funding in the 17 countries with the highest burdens (excluding BRICS) and a mean of 67% in low-income countries by 2011. BRICS and upper middleincome countries could mobilise almost all of their funding needs to 2015 from domestic sources. A full response to the tuberculosis epidemic to 2015, including investments to tackle multidrug-resistant tuberculosis, will require international donor funding of $1·6–2·3 billion each year. Interpretation Funding for tuberculosis control increased substantially between 2002 and 2011, resulting in impressive and cost-eff ective gains. The increasing self-suffi ciency of many countries, including BRICS, which account for almost half the world’s tuberculosis cases, is a success story for control of tuberculosis. Nonetheless, international donor funding remains crucial in many countries and more is needed to achieve 2015 targets

Xpert MTB/RIF for diagnosis of tuberculosis and drug-resistant tuberculosis: a cost and affordability analysis.

Xpert MTB/RIF is a rapid test to diagnose tuberculosis (TB) and rifampicin-resistant TB. Cost and affordability will influence its uptake. We assessed the cost, globally and in 36 high-burden countries, of two strategies for diagnosing TB and multidrug-resistant (MDR)-TB: Xpert with follow-on diagnostics, and conventional diagnostics. Costs were compared with funding available for TB care and control, and donor investments in HIV prevention and care. Using Xpert to diagnose MDR-TB would cost US$70-90 million per year globally and be lower cost than conventional diagnostics globally and in all high-burden countries. Diagnosing TB in HIV-positive people using Xpert would also cost US$90-101 million per year and be lower cost than conventional diagnostics globally and in 33 out of 36 high-burden countries. Testing everyone with TB signs and symptoms would cost US$434-468 million per year globally, much more than conventional diagnostics. However, in European countries, Brazil and South Africa, the cost would represent <10% of TB funding. Introducing Xpert to diagnose MDR-TB and to diagnose TB in HIV-positive people is warranted in many countries. Using it to test everyone with TB signs and symptoms is affordable in several middle-income countries, but financial viability in low-income countries requires large increases in TB funding and/or further price reductions

Multiresistentse tuberkuloosi ravi kulutulusus ja ravitulemused erinevate ravistrateegiate rakendamisel

Järjest laialdasemalt rakendatakse multiresistentse tuberkuloosi haigete raviks DOTS-Plus strateegiat, kasutades teise rea ravimeid, kuid teadmised nende efektiivsuse ja kulutulususe kohta on vähesed. Uuringus hinnati alates 2001. a augustist Eestis rakendatud DOTS-Plus strateegia tõhusust, maksumust ja kulutulusust võrreldes 3 alternatiivset ravi strateegiat: DOTS-Plus strateegia, pre-DOTS-plus strateegia ja DOTS-strateegia. Kulud arvutati 2002. a kehtinud hindades, tõhususe näitajateks olid tuberkuloosist põhjustatud surmade arv, kaotatud haiguskoormus ja kulutulususe näitajaks säästetud haiguskoormuse maksumus. Saadud andmete alusel võib väita, et kasutades DOTS-Plus strateegiat, on võimalik oluliselt paran dada multiresistentse tuberkuloosi haigete ravitulemusi ning võrreldes teiste võimalustega on see kulutulusaim. Eesti Arst 2006; 85 (3): 148–15