The socioeconomic impact of tuberculosis on children and adolescents: a scoping review and conceptual framework.

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

The economic burden of TB faced by patients and affected families in Papua New Guinea.

BACKGROUND The costs associated with TB disease can be catastrophic for patients, affecting health and socioeconomic outcomes. Papua New Guinea (PNG) is a high TB burden country and the costs associated with TB are unknown.METHODS We undertook a national survey of TB patients to determine the magnitude of costs associated with TB in PNG, the proportion of households with catastrophic costs and cost drivers. We used a cluster sampling approach and recruited TB patients from health facilities. Descriptive statistics were used to analyse the costs and cost drivers and multivariate logistic regression to determine factors associated with catastrophic costs.RESULTS We interviewed 1,000 TB patients; 19 (1.9%) of them had multidrug-resistant TB (MDR-TB). Costs due to TB were attributable to income loss (64.4%), non-medical (29.9%) and medical (5.7%) expenses. Catastrophic costs were experienced by 33.9% (95% CI 31.0-36.9) of households and were associated with MDR-TB (aOR 4.47, 95% CI 1.21-16.50), hospitalization (aOR 3.94, 95% CI 2.69-5.77), being in the poorest (aOR 3.52, 95% CI 2.43-5.10) or middle wealth tertiles (aOR 1.51, 95% CI 1.03-2.21) or being employed (aOR 2.02, 95% CI 1.43-2.89).CONCLUSION The costs due to TB disease were catastrophic for one third of TB-affected households in PNG. Current support measures could be continued, while new cost mitigation interventions may be considered where needed.

Risk factors for TB in Australia and their association with delayed treatment completion.

BACKGROUND: Australia has a low incidence of TB and has committed to eliminating the disease. Identification of risk factors associated with TB is critical to achieving this goal.METHODS: We undertook a prospective cohort study involving persons receiving TB treatment in four Australian jurisdictions. Risk factors and their association with delayed treatment completion (treatment delayed by at least 1 month) were analysed using univariate analyses and multivariate logistic regression.RESULTS: Baseline surveys were completed for 402 persons with TB. Most (86.1%) were born overseas. Exposure to a person with TB was reported by 19.4%. Diabetes mellitus (10.2%), homelessness (9.2%), cigarette smoking (8.7%), excess alcohol consumption (6.0%) and mental illness (6.2%) were other common risk factors. At follow-up, 24.8% of patients had delayed treatment completion, which was associated with adverse events (34.1%, aOR 6.67, 95% CI 3.36-13.27), excess alcohol consumption (6.0%, aOR 21.94, 95% CI 6.03-79.85) and HIV co-infection (2.7%, aOR 8.10, 95% CI 1.16-56.60).CONCLUSIONS: We identified risk factors for TB and their association with delayed treatment completion, not all of which are routinely collected for surveillance purposes. Recognition of these risk factors should facilitate patient-centred care and assist Australia in reaching TB elimination.

Depression, stigma and quality of life in people with drug-susceptible TB and drug-resistant TB in Vietnam.

BACKGROUND: Drug resistance poses a major barrier to global control of TB - a leading infectious cause of death. Depression and stigma occur commonly among people with TB. However, the relationship between drug-resistant forms of TB, depression and stigma are not well understood.OBJECTIVE: To compare depression, stigma and health-related quality of life (HRQoL), among people with drug-susceptible TB (DS-TB) and multidrug-resistant TB (MDR-TB).METHODS: A cross-sectional study of people treated for DS-TB and MDR-TB in four provinces of Vietnam. The survey included a stigma scale (Vietnamese Tuberculosis Stigma Scale), depression scale (9-item Patient Health Questionnaire) and HRQoL scale (Functional Assessment of Chronic Illness Therapy - Tuberculosis). Differences between the two populations were compared using linear regression.RESULTS: Eighty-one people with DS-TB and 315 people with MDR-TB participated in the study. People with MDR-TB had a higher prevalence of depression than those with DS-TB (difference 17.8%, χ² 8.64). The mean depression and stigma scores were higher for people with MDR-TB than those with DS-TB (adjusted difference [AD] 8.6 and 7.6 respectively). People with MDR-TB reported lower HRQoL than those with DS-TB (AD -23.8).CONCLUSION: Depression and stigma are common among people with TB in Vietnam. Strategies to prevent and treat depressive symptoms and stigma in people with TB are critical to a holistic, patient-centred approach to care.

Ethics and benefits of systematic screening for active tuberculosis.

Systematic screening for active tuberculosis (TB) provides public health benefits and is part of the End TB Strategy. However, two of WHO's generic principles for screening for disease state that the natural history of the disease in question must be well understood and that there must be benefits to earlier treatment. TB fulfills the first of these only in part, the other has been less well documented. This paper considers the ethical implications of uncertain individual benefits from screening and the current research gaps.

Nutritional Attributes and Nonvolatile Taste Components of Medicinally Important Wild False Earthstar Mushroom, Astraeus hygrometricus (Agaricomycetes), from India.

Fruiting bodies of Astraeus hygrometricus mushroom grown wild in the forests of Jharkhand, India were investigated for their proximate nutritional composition and taste imparting nonvolatile components. Fruiting bodies contained good amount of total carbohydrates (55.76%), reducing sugars (15.98%), protein (16.02%), and dietary fiber (39.78%) but were low in fat (3.5%), ash (3.8%), and energy (159.5 kcal). Fatty acids were represented by monounsaturated C18:1n9c oleic acid (4.59%) and saturated C16:0 palmitic acid (2.63%). In vitro digestibility of protein is an indicator of its availability to human body and A. hygrometricus has 33.2% in vitro digestibility. Among the minerals found (mg/100 g), potassium (K, 1930.0) was major mineral followed by calcium (Ca, 443.0), magnesium (Mg, 434.0), sodium (Na, 155.0), iron (Fe, 127.0), manganese (Mn, 16.0), and selenium (Se, 1.60). Pro-vitamin D2 (ergosterol) was also determined to be 1.09 mg/g. Analysis of soluble sugars indicated that mannitol (11.22 mg/g) was the major sugar alcohol conferring sweetness to the fruiting bodies. Among total free amino acids (8.20 mg/g), seven essential amino acids (3.9) and eight nonessential amino acids (4.3) were detected. Leucine (0.92) and tyrosine (0.98) were the major essential and nonessential amino acids, respectively. Aspartic (0.61) and glutamic acid (0.63) were also present in AH and responsible for its MSG like taste. Thus, A. hygrometricus is a good source of free essential amino acids and selenium, which is not synthesized by humans. Meaty flavor of the fruiting body of A. hygrometricus was mainly due to umami 5'-guanosine monophosphate (2.43 mg/g). Sweet taste and meaty flavor of the mushroom were due to nonvolatile taste components including soluble sugars and polyols, MSG like aspartic and glutamic acid, and umami 5'-nucleotide. Overall A. hygrometricus proved its edibility as a tasty and nutritional food.

Four of five tuberculosis patients experience catastrophic costs related to TB diagnosis and care in Timor-Leste.

SETTING: Seventeen health care facilities that report to the national tuberculosis (TB) programme in Timor-Leste. Participants were TB patients.OBJECTIVE: To determine the proportion of TB patients who experienced catastrophic costs due to their TB diagnosis and care, and the magnitude and composition of these costs.DESIGN: This was a cross-sectional health facility-based survey, conducted in 17 DOTS centres between October 2016 and March 2017. TB patients were interviewed by trained nurses using a standardised questionnaire.RESULTS: Among the 457 TB patients who participated (response rate 96.6%), the median age was 32 years; 39.2% were from the capital, Dili. The patient was the main income earner in 26.3% of households. Annual individual and household incomes before and after TB diagnosis decreased by respectively 30.4% and 31.1%. Using a cut-off of 20% of annual household income, 83.0% of patients experienced catastrophic costs related to their TB diagnosis and care. Income loss and nutritional supplementation accounted for respectively 40.7% and 37.9% of these costs.CONCLUSION: Four of five TB patients in Timor-Leste experienced catastrophic costs related to TB diagnosis and care. Financial and social protection to mitigate against these costs are urgently needed, in addition to universal health coverage.

Tuberculosis and diabetes mellitus: a dose-response relationship between the odds of tuberculosis and HbA1c.

SETTING: The main hospital tuberculosis (TB) clinic in South Tarawa, the capital of the Republic of Kiribati, a Pacific nation located in the central Pacific Ocean.OBJECTIVE: To determine if higher levels of HbA1c were associated with greater odds of TB.DESIGN: A case-control study to assess the association between TB and diabetes (DM). We recruited 275 TB cases and 498 controls (persons without signs and symptoms of TB), aged 18 years and above. A standardised questionnaire was administered and HbA1c was measured in all participants.RESULTS: The median HbA1c among cases was 6.0%; among controls it was 5.6% (P < 0.001). Comparing cases to controls, the odds ratio for TB was 2.8 (95%CI 2.0-4.1). Adjusted odds ratios for TB associated with HbA1c groupings of 5.7-6.4%, 6.5-8.5% and >8.5% were 1.5, 2.7 and 4.3, respectively (P ≦ 0.001 for trend).CONCLUSIONS: The median HbA1c was higher among TB patients than controls. As the HbA1c rose so did the odds of TB. This demonstrates the importance of targeted TB screening of people with DM in TB-endemic settings. Optimal glycaemic control is also crucial as this reduces DM-related end organ damage and may also reduce TB risk.

Pancreatic neuroendocrine microadenomatosis presenting as a functional VIPoma.

Pancreatic microadenomas are benign tumors of neuroendocrine origin less than 5 mm in size. Whereas most microadenomas are non-functional; a few rare functional pancreatic microadenomas have been described in the setting of multiple endocrine neoplasia type one (MEN-1). In this report, we describe a unique case of multiple functional microadenomas of the pancreatic head in a patient who presented with persistent secretory diarrhea, refractory hypokalemia, metabolic acidosis and elevated plasma vasoactive intestinal peptide (VIP) levels. Following extensive serologic, radiographic and endoscopic work up, our patient underwent open pancreaticoduodenectomy with subsequent resolution of diarrheal symptoms and electrolyte abnormalities on postoperative follow up.

Measuring the economic burden for TB patients in the End TB Strategy and Universal Health Coverage frameworks.

Tuberculosis (TB) is a disease of poverty. Ensuring access to health care without the risk of financial hardship due to out-of-pocket health care expenditures (Universal Health Coverage [UHC]) is essential for providing accessible care to underprivileged populations, but this is not enough. The End TB Strategy promotes both patient-centred TB services and social protection measures, which aim to mitigate the economic hardship faced by TB patients and their households due to direct medical and non-medical expenditures, as well as to lost income. The strategy includes a target that no families should face catastrophic total costs due to TB. The indicator linked to this target aims to capture the total economic burden linked to TB care, and thus differs from the 'catastrophic expenditure on health' indicator, a key component of the UHC monitoring framework aligned with the Sustainable Development Goals. Countries, and particularly high TB burden countries, are expected to conduct nationally representative TB patient cost surveys to establish baseline measurements for the catastrophic costs indicator. Findings from these surveys should also help identify entry points for developing policies to ensure better financial and social protection for TB patients. In this paper, we define the key measurable concepts for TB patient cost surveys, notably the types of costs that are captured, and related affordability measures. We discuss methods for measuring these notions in the UHC framework and contrast them with how they are measured in TB patient cost surveys.

Resection of a mature cystic teratoma of the liver harboring a carcinoid tumor.

Cystic teratomas are rare pluripotent embryonic tumors which most commonly originate in gonadal organs. Extra-gonadal cystic teratomas are exceedingly uncommon, accounting for only 1% of all cystic teratomas, and have been reported in unusual locations including the kidney, mediastinum and liver. These extra-ovarian cystic teratomas have also been known to harbor other neoplasms including carcinoid tumors. In this report, we describe a unique case of a hepatic cystic teratoma occurring as a combined tumor with a carcinoid in a young female. The patient underwent elective laparoscopic resection of her tumor after extensive radiographic and endoscopic work-up for chronic, non-localizable abdominal pain. We believe the carcinoid tumor arose de novofrom committed differentiation of a cell line within the teratoma, and not metastatic spread.

Pertussis epidemiology prior to the introduction of a maternal vaccination program, Queensland Australia.

Pertussis morbidity is highest in infants too young to be fully protected by routine vaccination schedules. Alternate vaccine strategies are required to maximise protection in this age-group. To understand baseline pertussis epidemiology prior to the introduction of the maternal pertussis vaccination program in 2014, we conducted a retrospective case series analyses of 53 901 notifications and temporal trends from 1997 to 2014. Notifications were highest in infants younger than 4 months of age and highest annual notification rates in infants younger than 1 month of age (308/100 000 per year). Amongst Aboriginal and Torres Strait Islander infants aged younger than 1 month, this rate was 576/100 000 per year. Notification rates were 40% higher amongst women 15-44 years, 62·4/100 000 population compared with men (44·5/100 000) and 90% higher in Aboriginal and Torres Strait Islander women of the same age (38·2/100 000) compared with men (19·7/100 000). Six infant deaths were identified, all younger than 2 months of age. Monitoring epidemiology in at-risk groups - infants too young to be vaccinated, women of childbearing age and Aboriginal and Torres Strait Islander peoples - following implementation of the maternal pertussis vaccination program will be important to assess its impact and safety.

Research ethics committees in the Pacific Islands: gaps and opportunities for health sector strengthening.

There has been a range of developments in recent years to stimulate increasing public health research activity throughout the Pacific. Development of local capacity for ethics committee review and oversight is, however, frequently underdeveloped. This is reflected in the number of Pacific Island nations where ethics committees have not been established or where only informal processes exist for ethics review and oversight. This is problematic for the optimal development of relevant and culturally appropriate research, and building up local ethics committees should be part of continued research development in the Pacific. Three areas in which local ethics committees may add value are 1) offering better capacity to reflect local priorities, 2) providing broader benefits for research capacity building, and 3) assisting to strengthen systems beyond research ethics. This article considers benefits and challenges for ethics committees in the Pacific, and suggests directions for regional development to further strengthen public health research activity.

Il y a eu toute une gamme de développements au cours des dernières années visant à stimuler un accroissement des activités de recherche en santé publique à travers la région Pacifique. Cependant, le renforcement des capacités locales de révision et de surveillance par les comités d'éthique est fréquemment sous-développé. Ceci est reflété par le nombre de nations insulaires du Pacifique où aucun comité d'éthique n'a été mis en place ou seules des procédures informelles de revue et de surveillance existent. Ceci pose un problème pour le bon développement d'une recherche pertinente et culturellement appropriée ; la mise en place de comités d'éthique locaux devrait faire partie du développement continu de la recherche dans le Pacifique. Trois domaines dans lesquels les comités d'éthique locaux pourraient avoir une valeur ajoutée sont 1) offrir une meilleure capacité de refléter les priorités locales, 2) apporter des bénéfices plus grands pour le renforcement des capacités de recherche, et 3) contribuer à renforcer les systèmes au-delà de l'éthique de la recherche. Cet article envisage les bénéfices et les défis des comités d'éthique dans le Pacifique et suggère des orientations pour le développement régional afin de développer davantage les activités de recherche en santé publique.

En los últimos años se ha observado una diversidad de progresos que estimulan las actividades de investigación en salud pública en toda la región del Pacífico. Sin embargo, la creación de competencias locales en materia de comités de ética y supervisión suele ser deficiente. Esta situación se refleja en el número de estados insulares del Pacífico que aun no cuentan con comités de ética o donde se practica solo un proceso informal de examen de los aspectos éticos y de supervisión de los estudios clínicos. Estas circunstancias representan un obstáculo al desarrollo óptimo de una investigación pertinente y culturalmente apropiada; la creación de comités de ética debe formar parte del desarrollo continuo de la investigación en el Pacífico. Estos comités aportarían ventajas en tres esferas principales, a saber: 1) una mayor capacidad de responder a las prioridades locales; 2) la ampliación de las ventajas que ofrece el fortalecimiento de la capacidad de realizar investigaciones; y 3) el mejoramiento de los sistemas de salud, más allá del terreno de la ética de la investigación. En el presente artículo se examinan las ventajas y las dificultades que presentan los comités de ética en la región del Pacífico y se proponen orientaciones para el desarrollo regional que promuevan la actividad de investigación en salud pública.