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.

Modelling the impact of social protection on tuberculosis: the S-PROTECT project.

BACKGROUND: Tackling the social determinants of Tuberculosis (TB) through social protection is a key element of the post-2015 End TB Strategy. However, evidence informing policies are still scarce. Mathematical modelling has the potential to contribute to fill this knowledge gap, but existing models are inadequate. The S-PROTECT consortium aimed to develop an innovative mathematical modelling approach to better understand the role of social protection to improve TB care, prevention and control. METHODS: S-PROTECT used a three-steps approach: 1) the development of a conceptual framework; 2) the extraction from this framework of three high-priority mechanistic pathways amenable for modelling; 3) the development of a revised version of a standard TB transmission model able to capture the structure of these pathways. As a test case we used the Bolsa Familia Programme (BFP), the Brazilian conditional cash transfer scheme. RESULTS: Assessing one of these pathways, we estimated that BFP can reduce TB prevalence by 4% by improving households income and thus their nutritional status. When looking at the direct impact via malnutrition (not income mediated) the impact was 33%. This variation was due to limited data availability, uncertainties on data transformation and the pathway approach taken. These results are preliminary and only aim to serve as illustrative example of the methodological challenges encountered in this first modelling attempt, nonetheless they suggest the potential added value of integrating TB standard of care with social protection strategies. CONCLUSIONS: Results are to be confirmed with further analysis. However, by developing a generalizable modelling framework, S-PROTECT proved that the modelling of social protection is complex, but doable and allowed to draw the research road map for the future in this field.

Modelling the social and structural determinants of tuberculosis: opportunities and challenges.

INTRODUCTION: Despite the close link between tuberculosis (TB) and poverty, most mathematical models of TB have not addressed underlying social and structural determinants. OBJECTIVE: To review studies employing mathematical modelling to evaluate the epidemiological impact of the structural determinants of TB. METHODS: We systematically searched PubMed and personal libraries to identify eligible articles. We extracted data on the modelling techniques employed, research question, types of structural determinants modelled and setting. RESULTS: From 232 records identified, we included eight articles published between 2008 and 2015; six employed population-based dynamic TB transmission models and two non-dynamic analytic models. Seven studies focused on proximal TB determinants (four on nutritional status, one on wealth, one on indoor air pollution, and one examined overcrowding, socio-economic and nutritional status), and one focused on macro-economic influences. CONCLUSIONS: Few modelling studies have attempted to evaluate structural determinants of TB, resulting in key knowledge gaps. Despite the challenges of modelling such a complex system, models must broaden their scope to remain useful for policy making. Given the intersectoral nature of the interrelations between structural determinants and TB outcomes, this work will require multidisciplinary collaborations. A useful starting point would be to focus on developing relatively simple models that can strengthen our knowledge regarding the potential effect of the structural determinants on TB outcomes.

Food assistance to tuberculosis patients: lessons from Afghanistan.

Poverty, food insecurity and poor nutrition in the population are important contributors to the burden of tuberculosis (TB). For poor and food-insecure individuals, accessing and successfully completing anti-tuberculosis treatment over an extended period of time is challenging. Food and nutritional support as an incentive and enabler is employed by national TB control programmes (NTPs) worldwide as a means to encourage treatment initiation and adherence and to improve the nutritional status of patients with TB. It also offers a safety net for food-insecure households affected by TB to mitigate the financial consequences of the disease. This paper reports on the primary lessons from the review of the World Food Programme's (WFP's) Food Assistance Programme for TB patients in Afghanistan. It aims to inform the design, implementation and scale-up of TB programmes in settings where food insecurity and malnutrition are prevalent. It also documents qualitative findings that suggest that patients, their families and providers viewed food support as an important asset and an essential element of the national TB control strategy. While the impact on treatment success or case detection could not be quantified, it is likely that the WFP intervention had a positive impact on the patients and their households, therefore contributing to the success of the DOTS-based NTP.

La pauvreté, l'absence de sécurité alimentaire et une nutrition médiocre de la population contribuent largement au poids de la tuberculose (TB). Pour les patients pauvres et ayant du mal à assurer leur alimentation, avoir accès au traitement pour la TB et le suivre sur une longue période jusqu'à la guérison est un défi. Un soutien alimentaire et nutritionnel, qui sert à la fois d'incitation et de facilitateur, est utilisé par les programmes nationaux de lutte contre la TB (PNT) dans le monde comme moyen d'encourager la mise en route du traitement et son adhésion ainsi que d'améliorer l'état nutritionnel des patients tuberculeux. C'est également un filet de sécurité pour les foyers souffrant d'insécurité alimentaire et affectés par la TB afin d'atténuer les conséquences financières de la maladie. Cet article rapporte les premières leçons acquises lors de la revue de l'aide alimentaire du Programme Alimentaire Mondial (PAM) aux patients TB d'Afghanistan. Il a pour objectif d'aider la conception, la mise en œuvre et l'extension des PNT dans les zones à prévalence élevée d'insécurité alimentaire et de malnutrition. Il documente également les résultats qualitatifs qui suggèrent que les patients, leurs familles et les prestataires ont vu l'aide alimentaire comme un atout important et un élément essentiel de la stratégie de lutte contre la TB. Même si l'impact sur le succès du traitement et sur la détection des cas n'a pu être quantifié, il est probable que l'intervention du PAM a eu un impact positif sur les patients et leurs foyers, contribuant par là au succès du PNT basé sur la stratégie DOTS.

La pobreza, la inseguridad alimentaria y la nutrición deficiente de la población son factores que contribuyen de manera importante a la carga de morbilidad por tuberculosis (TB). Acceder al tratamiento de la TB y lograr completarlo durante un período prolongado plantean grandes dificultades a las personas pobres, que sufren de inseguridad alimentaria. Los programas nacionales contra la TB (PNT) utilizan el apoyo alimentario y nutricional como un incentivo y un medio facilitador, con el objeto de estimular la iniciación del tratamiento, reforzar el cumplimiento terapéutico y mejorar la situación nutricional de los pacientes con TB. Estas iniciativas constituyen además una red de seguridad para los hogares que sufren de inseguridad alimentaria y están afectados por la TB, pues menguan las repercusiones económicas de la enfermedad. En el presente artículo se analizan las principales experiencias aprendidas al analizar la ayuda alimentaria a los pacientes con TB del Programa Mundial de Alimentos (PMA) en Afganistán. Su meta consistió en fundamentar los objetivos, la aplicación y la ampliación de escala de los PNT en los entornos donde prevalecen la inseguridad alimentaria y la desnutrición. El estudio documentó además los hallazgos cualitativos que sugieren que los pacientes, sus familias y los profesionales de salud consideran el apoyo alimentario como un recurso importante y un elemento primordial de la estrategia nacional de control de la TB. Si bien no fue posible cuantificar la repercusión de la intervención en el éxito terapéutico ni en la detección de casos, es muy probable que la iniciativa del PMA tenga repercusiones positivas en los pacientes y sus hogares y contribuya de esta manera al éxito del PNT que se basa en DOTS.

TIME Impact - a new user-friendly tuberculosis (TB) model to inform TB policy decisions.

Tuberculosis (TB) is the leading cause of death from infectious disease worldwide, predominantly affecting low- and middle-income countries (LMICs), where resources are limited. As such, countries need to be able to choose the most efficient interventions for their respective setting. Mathematical models can be valuable tools to inform rational policy decisions and improve resource allocation, but are often unavailable or inaccessible for LMICs, particularly in TB. We developed TIME Impact, a user-friendly TB model that enables local capacity building and strengthens country-specific policy discussions to inform support funding applications at the (sub-)national level (e.g. Ministry of Finance) or to international donors (e.g. the Global Fund to Fight AIDS, Tuberculosis and Malaria).TIME Impact is an epidemiological transmission model nested in TIME, a set of TB modelling tools available for free download within the widely-used Spectrum software. The TIME Impact model reflects key aspects of the natural history of TB, with additional structure for HIV/ART, drug resistance, treatment history and age. TIME Impact enables national TB programmes (NTPs) and other TB policymakers to better understand their own TB epidemic, plan their response, apply for funding and evaluate the implementation of the response.The explicit aim of TIME Impact's user-friendly interface is to enable training of local and international TB experts towards independent use. During application of TIME Impact, close involvement of the NTPs and other local partners also builds critical understanding of the modelling methods, assumptions and limitations inherent to modelling. This is essential to generate broad country-level ownership of the modelling data inputs and results. In turn, it stimulates discussions and a review of the current evidence and assumptions, strengthening the decision-making process in general.TIME Impact has been effectively applied in a variety of settings. In South Africa, it informed the first South African HIV and TB Investment Cases and successfully leveraged additional resources from the National Treasury at a time of austerity. In Ghana, a long-term TIME model-centred interaction with the NTP provided new insights into the local epidemiology and guided resource allocation decisions to improve impact.

Epidemiology of tuberculosis in children in London, 2009-2011: are opportunities for prevention being missed?

SETTING: London, United Kingdom. OBJECTIVE: To explore missed opportunities (MO) for the prevention of tuberculosis (TB) in children aged 0-15 years. DESIGN: Parents/guardians of children aged <15 years diagnosed with TB and reported through surveillance were interviewed about bacille Calmette-Guérin vaccination (MO-V) or contact tracing and screening for TB (MO-C) via an algorithm reflecting eligibility. RESULTS: Annual TB incidence was 12 per 100,000 (65/100,000 in Black Africans, 20/100,000 in Indian or Pakistani children). The response rate was 36% (145/405). About 20% of UK-born children had not been vaccinated. MO-V was not associated with any particular factor. Contact with a known TB case before illness had occurred in 71 children (49%; 71% in those aged 0-1 years vs. 30% in those aged 11-15 years), of whom 64 (91%) were diagnosed through contact tracing. MO-C had been conducted in six (4% overall). Children with MO-C were all of Black ethnic origin. Their index cases were family members (within their household) or relatives or family friends from abroad (outside their household). MO-C was not associated with any other factor. CONCLUSION: Although overall few missed opportunities for prevention had occurred, we recommend increased rigour when performing contact tracing in any case where a child may have been exposed.

Monitoring the mechanical behaviour of electrically conductive polymer nanocomposites under ramp and creep conditions.

Various amounts of carbon black (CB) and carbon nanofibres (CNF) were dispersed in an epoxy resin to prepare nanocomposites whose mechanical behaviour, under ramp and creep conditions, was monitored by electrical measurements. The electrical resistivity of the epoxy resin was dramatically reduced by both nanofillers after the percolation threshold (1 wt% for CB and 0.5 wt% for CNF), reaching values in the range of 10(3)-10(4) omega . cm for filler loadings higher than 2 wt%. Due to the synergistic effects between the nanofillers, an epoxy system containing a total nanofiller amount of 2 wt%, with a relative CB/CNF ratio of 90/10 was selected for the specific applications. A direct correlation between the tensile strain and the increase of the electrical resistance was observed over the whole experimental range, and also the final failure of the samples was clearly detected. Creep tests confirmed the possibility to monitor the various deformational stages under constant loads, with a strong dependency from the temperature and the applied stress. The obtained results are encouraging for a possible application of nanomodified epoxy resin as a matrix for the preparation of structural composites with sensing (i.e., damage-monitoring) capabilities.