Review of published cost-effectiveness studies on tuberculosis treatment programmes.

This article aims to summarise key factors in the published literature associated with cost-effective tuberculosis (TB) treatment programmes and to make recommendations on how techniques for future studies could be improved. There is consistent evidence that fully ambulatory, short course chemotherapy programmes are currently the most cost-effective option, although this may depend on the cost of providing an effective community-based service. Direct supervision may be more cost-effective than self-administration because of the reduced need for monitoring and follow-up; more studies are needed, however, that include real outcome figures and household measures of cost. For studies taking a provider perspective, the methods used for measuring costs will be dependent on sources of information, but centralised accounts are the most preferred source. Effects should be measured in terms of actual outcome, and should preferably not be taken from the literature. Most of the studies reviewed did not consider the difficulties of introducing a theoretically cost-effective change into a health service. More studies are required that document actual changes in programme cost and outcome associated with the introduction of different types of treatment delivery. Future work could consider measuring cost in terms of resources (e.g., staff) rather than only finances, and more work is needed on household perspectives.

Tuberculosis control in remote districts of Nepal comparing patient-responsible short-course chemotherapy with long-course treatment.

SETTING: A tuberculosis programme in hill and mountain districts of Nepal supported by an international non-governmental organisation (NGO). OBJECTIVE: To evaluate under programme conditions the effectiveness of unsupervised monthly-monitored treatment using an oral short-course regimen. DESIGN: In this prospective cohort study, outcomes for new cases of smear-positive tuberculosis starting treatment over a two-year period in four districts in which a 6-month rifampicin-containing regimen was introduced as first-line treatment (subjects) were compared to outcomes for similarly defined cases in four districts where a 12-month regimen with daily streptomycin injections in the intensive phase continued to be used (controls). RESULTS: Of 359 subjects started on the 6-month regimen, 85.2% completed an initial course of treatment compared to 62.8% of 304 controls started on the 12-month regimen (P < 0.001); 78.8% of subjects and 51.0% of controls were confirmed smear-negative at the end of treatment (P < 0.001). The case-fatality rate during treatment was 5.0% among subjects and 11.2% among controls (P = 0.003). Among those whose status was known at two years, 76.9% of subjects were smear-negative without retreatment, compared to 60.9% of controls (P < 0.001). CONCLUSION: In an NGO-supported tuberculosis control programme in remote districts of Nepal, patient-responsible short-course therapy supported by rapid tracing of defaulters achieved acceptable outcomes. Where access and health care infrastructure are poor, district-level tuberculosis teams responsible for treatment planning, drug delivery and programme monitoring can be an appropriate service model.

Foreign aid and TB control policy in Nepal.

PIP: Since 1987, Nepal's national tuberculosis (TB) project has received considerable support from the Nepal-Japan technical cooperation project and has introduced short-course chemotherapy (SCC) into almost half of Nepal's districts. Application of SCC has been limited, however, by lack of supervision, inadequate training, and poor drug supply logistics. Problems continue with drug distribution despite a grant from the Japanese pharmaceutical industry of three to four years' supply of rifampicin. These supply difficulties have led to concerns about the increase of multidrug-resistant TB, which is already seen in Nepal where 5-24% of patients have TB which is resistant to at least one drug. This problem is compounded because the Japanese government will not supply the rifampicin in combination with other drugs. This has led to calls for limiting SCC to areas where its use can be directly observed. Meanwhile, as a compromise, the rifampicin will be combined in blister packs with the other drugs (with packaging technology developed in Nepal). Measures should be taken to insure that the rifampicin will not be used alone and, thus, be responsible for a major epidemic of multidrug-resistant TB.^ieng

Community financing of drug supplies in rural Nepal: evaluating a 'fee per item' drug scheme.

A new programme in rural Nepal was evaluated in which users partly fund the supply of additional drugs needed at health posts. Patients are charged a fee per item prescribed (FPI scheme). The scheme is administered by the District Public Health Office (DPHO). This scheme is compared with two established schemes: one charges patients a fee per prescription ('fee-per-script' or FPS scheme) and is administered by independently paid NGO (non-governmental organization) staff; the other uses local shops as a means of supplying drugs. The new scheme was associated with a rise in average daily attendance from nine to thirty-two patients a day (a 240% increase) when compared to a similar period the previous year. Fewer drugs were prescribed in the FPI scheme (average per patient 1.8 vs. 2.4, Chi square P <0.001). The average cost of a drug from the user's perspective was approximately 12% lower in the FPI scheme. These factors combined to make the average cost to the patient of a prescription half that of one in the FPS scheme. The new scheme was 24% cheaper to run on a 'cost per patient' basis when compared with the FPS scheme. However, the overall subsidy needed for the scheme to operate was higher because of the big increase in attendance. One-off stocktakes of ten essential drugs were used to assess the availability of drugs for patient use. The proportion of these drugs that were in low supply or absent was 24% in the FPI scheme. This was similar in the other two schemes. The government DPHO did not perform all the administrative tasks required. These tasks need to be simplified and different methods for involving DPHO staff in drug scheme management need to be explored. The rapid turnover of senior staff, however, will remain a major impediment. This preliminary evaluation shows that an FPI scheme promotes a more rational use of resources, compared to an FPS scheme. Administration of the scheme may, however, prove to be more difficult. A simple field-based comparative assessment of drug supply schemes can give a valuable insight into the strengths and weaknesses of a new programme.

Intestinal helminthiasis in ex-patriates returning to Britain from the tropics. A controlled study.

A retrospective study was performed of clinical features in expatriates attending the Hospital for Tropical Diseases, London, with a sole diagnosis of ascariasis (100), trichuriasis (100), hookworm (75), and strongyloidiasis (36). Results were compared with a control group of 100 ex-patriates attending the same hospital in whom no diagnosis was made and in whom stool microscopy and peripheral blood eosinophil counts were normal. Almost one half of all patients with intestinal helminthiasis were asymptomatic. Of those with symptoms specific clinical features were no different from controls with the exception of a transient itch or rash in patients with strongyloidiasis. The presence of eosinophilia was not a reliable indicator of infection. This study suggests that it may be worth while performing stool microscopy in ex-patriates returning from the tropics even if they are asymptomatic.

Plasma and urine electrolyte concentrations and vasopressin levels in patients admitted to hospital for falciparum malaria.

Vasopressin levels, together with plasma and urinary electrolytes, were measured in the acute and convalescent stages of 17 patients with malaria and 11 patients with other febrile illnesses. There was a significantly lower serum sodium in the acute stages of both groups (p less than 0.01 and p less than 0.02). There was no significant difference between the malaria and control groups. There were no significant changes in the vasopressin levels, although one patient with malaria showed evidence of inappropriate vasopressin secretion which returned to normal after treatment. This study suggests the mild hyponatraemia sometimes seen in the acute stages of malaria is not related to inappropriate secretion of vasopressin, although this condition may be of importance in more severe cases of hyponatraemia.