The burden of tuberculosis in crisis-affected populations: a systematic review.

Crises caused by armed conflict, forced population displacement, or natural disasters result in high rates of excess morbidity and mortality from infectious diseases. Many of these crises occur in areas with a substantial tuberculosis burden. We did a systematic review to summarise what is known about the burden of tuberculosis in crisis settings. We also analysed surveillance data from camps included in UN High Commissioner for Refugees (UNHCR) surveillance, and investigated the association between conflict intensity and tuberculosis notification rates at the national level with WHO data. We identified 51 reports of tuberculosis burden in populations experiencing displacement, armed conflict, or natural disaster. Notification rates and prevalence were mostly elevated; where incidence or prevalence ratios could be compared with reference populations, these ratios were 2 or higher for 11 of 15 reports. Case-fatality ratios were mostly below 10% and, with exceptions, drug-resistance levels were comparable to those of reference populations. A pattern of excess risk was noted in UNHCR-managed camp data where the rate of smear testing seemed to be consistent with functional tuberculosis programmes. National-level data suggested that conflict was associated with decreases in the notification rate of tuberculosis. More studies with strict case definitions are needed in crisis settings, especially in the acute phase, in internally displaced populations and in urban settings. Findings suggest the need for early establishment of tuberculosis services, especially in displaced populations from high-burden areas and for continued innovation and prioritisation of tuberculosis control in crisis settings.

Lower copay and oral administration: predictors of first-fill adherence to new asthma prescriptions.

BACKGROUND: Nonadherence to asthma medications is associated with increased emergency department visits and hospitalizations. If adherence is to be improved, first-fill adherence is the first goal to meet after the physician and patient have decided to begin treatment. Little is known about first-fill adherence with asthma medications and the factors for no-fill. OBJECTIVE: The goal of the study was to examine the proportion of patients who fill a new prescription for an asthma medication and analyze characteristics associated with this first-fill. METHODS: This retrospective cohort study linked electronic health records with pharmacy claims. The cohort was comprised of 2023 patients aged 18 years or older who sought care from the Geisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthma medication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescription filled by the patient within 30 days of the prescription order date. Covariates examined included factors related to the patient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office visits, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy copay amount. A logistic-regression model was used to determine covariates associated with first-fill. RESULTS: The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with a copay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients prescribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11). CONCLUSIONS: SEVERAL FACTORS ASSOCIATED WITH FAILING TO FILL AN INITIAL PRESCRIPTION FOR ASTHMA CAN BE ADDRESSED THROUGH SIMPLE INTERVENTIONS: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary medications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreasing copay may improve adherence and, therefore, asthma control.