Cost to perform door-to-door universal sputum screening for TB in a high-burden community.

BACKGROUND: Population-based active case-finding (ACF) identifies people with TB in communities but can be costly. METHODS: We conducted an empiric costing study within a door-to-door household ACF campaign in an urban community in Uganda, where all adults, regardless of symptoms, were screened by sputum Xpert Ultra testing. We used a combination of direct observation and self-reported logs to estimate staffing requirements. Study budgets were reviewed to collect costs of overheads, equipment, and consumables. Our primary outcome was the cost per person diagnosed with TB. RESULTS: Over a 28-week period, three teams of two people collected sputum from 11,341 adults, of whom 48 (0.4%) tested positive for TB. Screening 1,000 adults required 258 person-hours of effort at a cost of US$35,000, 70% of which was for GeneXpert cartridges. The estimated cost per person screened was $36 (95% uncertainty range [95% UR] 34­38), and the cost per person diagnosed with Xpert-positive TB was $8,400 (95% UR 8,000­8,900). The prevalence of TB in the underlying community was the primary modifiable determinant of the cost per person diagnosed. CONCLUSION: Door-to-door screening can be feasibly performed at scale, but will require effective triage and identification of high-prevalence populations to be affordable and cost-effective.

The impact of time at home on potential yield of home-based TB contact investigation.

BACKGROUND: The yield of TB contact tracing is often limited by challenges in reaching individuals during the screening process. We investigated the times at which index patients and household contacts were typically at home and the potential effects of expanding the timing of home-based contact investigation.METHODS: Index patients and household contacts in Kampala, Uganda, were asked about their likely availability at different day/time combinations. We calculated the "participant identification gap" (defined as the proportion of participants who reported being home <50% of the time) during business hours only. We then estimated the incremental reduction in the participant identification gap if hours were expanded to include weekday evenings, Saturdays, and Sundays. Statistical significance was assessed using McNemar´s tests.RESULTS: Nearly half of eligible individuals (42% of index patients and 52% of contacts) were not likely to be home during contact investigation conducted only during business hours. Expanding to weekday evenings, Saturdays, and Sundays would reduce this participant identification gap to 15% among index patients and 18% among contacts - while also reducing differences by sex and employment.CONCLUSIONS: Expanding hours for conducting contact investigation or other home-based health interventions could substantially reduce the number of individuals missed and address disparities in access to care.

What will it take to eliminate drug-resistant tuberculosis?

Drug-resistant tuberculosis (DR-TB) is challenging to diagnose, treat, and prevent, but this situation is slowly changing. If the world is to drastically reduce the incidence of DR-TB, we must stop creating new DR-TB as an essential first step. The DR-TB epidemic that is ongoing should also be directly addressed. First-line drug resistance must be rapidly detected using universal molecular testing for resistance to at least rifampin and, preferably, other key drugs at initial TB diagnosis. DR-TB treatment outcomes must also improve dramatically. Effective use of currently available, new, and repurposed drugs, combined with patient-centered treatment that aids adherence and reduces catastrophic costs, are essential. Innovations within sight, such as short, highly effective, broadly indicated regimens, paired with point-of-care drug susceptibility testing, could accelerate progress in treatment outcomes. Preventing or containing resistance to second-line and novel drugs is also critical and will require high-quality systems for diagnosis, regimen selection, and treatment monitoring. Finally, earlier detection and/or prevention of DR-TB is necessary, with particular attention to airborne infection control, case finding, and preventive therapy for contacts of patients with DR-TB. Implementing these strategies can overcome the barrier that DR-TB represents for global TB elimination efforts, and could ultimately make global elimination of DR-TB (fewer than one annual case per million population worldwide) attainable. There is a strong cost-effectiveness case to support pursuing DR-TB elimination; however, achieving this goal will require substantial global investment plus political and societal commitment at national and local levels.

Using composite health status measures to assess the nation's health.

Research in progress at the National Center for Health Statistics for evaluating the usefulness of composite measures of health status for assessing the nation's health is described. Three measures suitable for use in the general population, the Health Insurance Experiment-Functional Limitations (HIE-FL), the Health Utility Index (HUI), and the Quality of Well-being (QWB) scale, have been mapped to data collected in the 1980 National Health Interview Survey (NHIS). Analysis using current algorithms for making composite function status measures according to the QWB methods suggests that traditional single indicators of health tend to overestimate the level of health by about 10%. When symptoms and problems are added to the composite function score, the overestimate as measured by the single indicator is at least 50%. The authors are continuing to validate these algorithms, to develop similar ones for the HIE-FL and HUI, and to extend the analysis to data collected in 1977, 1979, and 1984. Current results indicate that to realize fully the benefits of composite measures, well-established, valid, and reliable measures of health-related quality of life should be included as part of the regular NHIS data collection procedures.