A feasibility study using time-driven activity-based costing as a management tool for provider cost estimation: lessons from the national TB control program in Zimbabwe in 2018.

BACKGROUND: Insufficient cost data and limited capacity constrains the understanding of the actual resources required for effective TB control. This study used process maps and time-driven activity-based costing to document TB service delivery processes. The analysis identified the resources required to sustain TB services in Zimbabwe, as well as several opportunities for more effective and efficient use of available resources. METHODS: A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel's practical capacity and capacity cost rates were calculated on five cost domains. An MS Excel model calculated diagnostic and treatment costs. FINDINGS: Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Considerable variations were observed among the facilities in how health care professionals performed client registration, taking of vital signs, treatment follow-up, dispensing medicines and processing samples. The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost components were personnel (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3). CONCLUSION: TDABC is a feasible and effective costing and management tool in low-resource settings. The TDABC process maps and treatment costs revealed several opportunities for innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could produce better and more uniform TB treatments at significantly lower cost in Zimbabwe.

Fate of Mycobacterium tuberculosis within murine dendritic cells.

The interaction of microbes with dendritic cells (DCs) is likely to have an enormous impact on the initiation of the immune response against a pathogen. In this study, we compared the interaction of Mycobacterium tuberculosis with murine bone marrow-derived DCs and macrophages (M phi) in vitro. M. tuberculosis grew equally well within nonactivated DCs and M phi. Activation of DCs and M phi with gamma interferon and lipopolysaccharide inhibited the growth of the intracellular bacteria in a nitric oxide synthase-dependent fashion. However, while this activation enabled M phi to kill the intracellular bacteria, the M. tuberculosis bacilli within activated DCs were not killed. Thus, DCs could restrict the growth of the intracellular mycobacteria but were less efficient than M phi at eliminating the infection. These results may have implications for priming immune responses to M. tuberculosis. In addition, they suggest that DCs may serve as a reservoir for M. tuberculosis in tissues, including the lymph nodes and lungs.

Reproductive toxicity of 2-methoxyethanol applied dermally to occluded and nonoccluded sites in male rats.

12-Methoxyethanol (2-ME), also known as Methyl Cellosolve, was applied on the backs of Sprague-Dawley male rats at dose levels of 0, 625, 1250, or 2500 mg/kg/day on occluded (covered) sites, and 0, 1250, 2500, or 5000 mg/kg/day on nonoccluded (uncovered) sites for 7 consecutive days. Because deaths occurred at a dose level of 2500 mg/kg/day among rats with occluded test sites, dosing of this group was discontinued after 5 days. The number and morphology of caudal epididymal sperm, number of testicular spermatids, and weights of reproductive organs were determined on Weeks 4, 7, 10, and 15; fertility was assessed on Weeks--1, 4, 7, 10, and 14. The effects of treatment were dose-related and included a decline in epididymal sperm count and testicular spermatid count, a reduction in weights of testes and epididymides, an increase in the number of sperm with abnormal morphology, and a reduction in fertility in rats exposed to 2-ME. The above effects were seen with or without occlusion, but they were more severe and recovery proceeded at a slower rate when the skin sites were covered.