toman's tuberculosis case detection, treatment and monitoring

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MONITORING Table 55 Estimated household costs of tuberculosis Cost to patient Bangladesh India South Africa Uganda (11) (12) (13) (14) Direct costs (US$) 130 41 99 68 Lost work 57% NA NA 91% Time loss 14 months 3 months 4 months 10 months Lost income (US$) 115 89 272 161 Indirect cost as percentage of 15 14 NA NA annual household income Total cost as percentage of 31 20 NA NA annual household income account for more than 80% of all cases of tuberculosis. Household costs of tuberculosis are substantial (Table 55). Although the “direct” costs of diagnosis and treatment are significant for poor families, the greatest economic loss occurs as a result of “indirect” costs, such as loss of employment, travel to health facilities, sale of assets to pay for treatment-related costs, funeral expenses, and particularly lost productivity from illness and premature death. A study from Uganda found that 95% of subsistence farmers with tuberculosis reported a loss in production, and 80% of wage-earners had stopped work (14). A review of studies investigating the economic impact of tuberculosis showed that, on average, 3–4 months of work time are lost if an adult has tuberculosis, resulting in the loss of 20–30% of annual household income, and an average of 15 years of income is lost if the patient dies from the disease (15). The relation between tuberculosis and poverty is complex, as the disease impoverishes those who suffer from it, and the epidemic is exacerbated by socioeconomic decline. Poverty results in crowded housing with increased risk of transmission and in poor nutrition with increased risk of breakdown from infection to tuberculosis disease. The break-up of the Soviet Union in the early 1990s and the subsequent economic decline and collapse of health and social support structures have led to a rapid rise in tuberculosis, with rates increasing by 7% per year in the Russian Federation, Ukraine and other countries of the former Soviet Union (5). In Cuba over a 3-year period, economic and nutritional hardship resulted in a striking increase (24% per annum) in the tuberculosis notification rate (16). A strengthened programme allowed a renewed trend in transmission reduction, resulting in a renewed reduction in incidence. Negative social consequences, such as stigma, are a particular problem for women in some societies, restricting options for marriage and employment and even leading to divorce. A study in India indicated that 15% of women with tuberculosis (equivalent to 100 000 women per year nationally) faced rejection by their families (12). 235
TOMAN’S TUBERCULOSIS The negative impact carries over to the next generation, as the coping mechanisms of poor families adversely affect their children. The same study from India found that 8% of rural and 13% of urban children (equivalent to 300 000 nationally) were taken out of school when a parent (usually the father) developed tuberculosis. Other longterm consequences include indebtedness; the Indian study showed that more than two-thirds of households went into debt to cover the costs of tuberculosis; the average family debt was US$ 59, equivalent to 12% of the annual household income. Continued spread of tuberculosis infection condemns the next generation to the avoidable risk of tuberculous illness and death. References 1. Dye C et al. Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. Journal of the American Medical Association, 1999, 282:677–686. 2. World Health Report 2000. Health systems: improving performance. Geneva, World Health Organization, 2000. 3. Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996 (Global Burden of Disease and Injury Series, Vol. I). 4. Raviglione MC et al. Tuberculosis and HIV: current status in Africa. AIDS, 1997, 11:S115–S123. 5. Global tuberculosis control. WHO Report 2000. Geneva, World Health Organization, 2000 (document WHO/CDS/TB/2000.275). 6. Anti-tuberculosis drug resistance in the world. Geneva, World Health Organization, 1997 (document WHO/TB/97.229 WHO). 7. Pablos-Mendez A et al. Global surveillance for antituberculosis drug resistance, 1994–1997. New England Journal of Medicine, 1998, 338:1641–1649. 8. Anti-tuberculosis drug resistance in the world. The WHO/IUATLD global project on antituberculosis drug resistance surveillance. Report No.2: prevalence and trends. Geneva, World Health Organization, 2000 (document WHO/CDS/TB/2000.278). 9. Espinal MA et al. Standard short-course chemotherapy for drug-resistant tuberculosis: treatment outcomes in 6 countries. Journal of the American Medical Association, 2000, 283:2537–2545. 10. Knight L. Tuberculosis and sustainable development. Geneva, World Health Organization, 2000 (document WHO/CDS/STB/2000.4; Stop TB Initiative series). 11. Croft RA, Croft RP. Expenditure and loss of income incurred by tuberculosis patients before reaching effective treatment in Bangladesh. International Journal of Tuberculosis and Lung Disease, 1998, 2:252–254. 12. Rajeswari R et al. Socio-economic impact of tuberculosis on patients and family in India. International Journal of Tuberculosis and Lung Disease, 1999, 3:869–877. 13. Floyd K, Wilkinson D, Gilks C. Comparison of cost effectiveness of directly observed treatment (DOT) and conventionally delivered treatment for tuberculosis: experience from rural South Africa. British Medical Journal, 1997, 315:1407–1411. 236
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The second edition of this practica
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WHO Library Cataloguing-in-Publicat
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11. What is the additional yield fr
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46. What are the causes of drug-res
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Preface to the First Edition One of
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plementation of effective control s
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TOMAN’S TUBERCULOSIS This second
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Acknowledgements for the Second Edi
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Contributors Rani Balasubramanian M
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TOMAN’S TUBERCULOSIS Margarita El
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1. What is the role of case detecti
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2. What is a case of tuberculosis?
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3. What is the role of sputum micro
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CASE DETECTION Case detection in ou
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4. How many bacilli are present in
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CASE DETECTION 4. David HL. Bacteri
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CASE DETECTION Table 2 Number of ac
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CASE DETECTION Table 4 Frequency of
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CASE DETECTION (spot sample). The s
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CASE DETECTION the peripheral healt
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6. What are the main causes of fals
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CASE DETECTION with a swab may prov
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CASE DETECTION 2. Smithwick RW. Lab
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CASE DETECTION actually have tuberc
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8. What are the advantages and disa
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Culture Fluorescence Total microsco
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9. What is the role of mycobacteria
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CASE DETECTION Figure 1 Percentage
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CASE DETECTION In a carefully condu
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CASE DETECTION diagnosis. If availa
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CASE DETECTION 8. Rao KP et al. Som
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CASE DETECTION Table 12 Results of
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CASE DETECTION Table 13 Results of
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CASE DETECTION Among patients in wh
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12. How reliable is chest radiograp
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CASE DETECTION Table 16 Observer er
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CASE DETECTION patients with previo
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CASE DETECTION Figure 4 Examples of
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chest radiograph as the diagnostic
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13. What are the relative merits of
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CASE DETECTION Table 21 Correlation
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CASE DETECTION tries, this delay le
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CASE DETECTION Table 22 Interval be
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CASE DETECTION However, even in the
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CASE DETECTION 7. Douglas BH, Pinne
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CASE DETECTION Figure 5 Risk of inf
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CASE DETECTION Table 23 Mode of det
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CASE DETECTION Figure 8 Cumulative
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CASE DETECTION Czechoslovakia. Seco
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CASE DETECTION Figure 9 Radiographi
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CASE DETECTION 4. Harries AD. Tuber
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CASE DETECTION BCG is given in infa
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18. What is the current and potenti
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CASE DETECTION currently performed
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CASE DETECTION 13. Holden M, Dubin
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Exclusion CASE DETECTION Another ap
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CASE DETECTION 6. Khatri GR, Friede
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20. What were the main landmarks in
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TREATMENT 2. WHO Expert Committee o
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TREATMENT present even before treat
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TREATMENT 2. Furesz S et al. Rifamp
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TREATMENT Table 25 Incidence of tub
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TREATMENT 3. Holmes CB, Hausler H,
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TREATMENT The time during which an
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TREATMENT The “flu” syndrome, w
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Streptomycin TREATMENT Isolated by
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Capreomycin TREATMENT Capreomycin i
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valuable in preventing resistance t
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TREATMENT 13. Skolnick JL et al. Ri
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TREATMENT Thus the emergence of new
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TREATMENT Table 27 Recommended trea
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TREATMENT toxicity, particularly in
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TREATMENT drug-resistant organisms
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TREATMENT Table 28 Lag in growth of
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TREATMENT Table 30 Comparison of re
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TREATMENT Table 32 Studies using pa
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TREATMENT tuberculosis in the forme
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28. What is the dosage of drugs in
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29. What is the evidence for tuberc
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TREATMENT 4. Acocella G. Clinical p
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TREATMENT Table 35 Duration of trea
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TREATMENT concluded that smear-nega
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TREATMENT Table 41 Response to trea
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TREATMENT National Tuberculosis Ins
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Rare adverse effects ● Osteomalac
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Management ● For minor adverse ef
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TREATMENT Management of jaundice an
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32. What are the merits of thioacet
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always receive at least two drugs (
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TREATMENT culosis, and brain tuberc
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References TREATMENT 1. Ramanathan
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TREATMENT If a tuberculin skin test
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35. How does treatment of tuberculo
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TREATMENT being part of the immune
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36. What were the main findings of
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TREATMENT decoded by the Centre’s
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TREATMENT Table 45 Quiescence of di
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TREATMENT Summary In a controlled c
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37. How frequently do patients stop
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38. What are the advantages of dire
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Page 272 and 273: 58. How effective is tuberculosis t
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67. What are the principles and req
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MONITORING is not supported by quan
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MONITORING treatment (see “What w
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MONITORING A satisfactory randomiza
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MONITORING pendent readers, if poss
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MONITORING a new treatment. The dra
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MONITORING importantly, molecular a
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MONITORING 4. García-García M et
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69. Can tuberculosis be controlled?
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Prevalence of disease Prevalence of
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MONITORING difficult and are furthe
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MONITORING blunt the impact of this
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MONITORING ation with an emphasis o
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MONITORING tively) and have achieve
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MONITORING and shelters for the hom
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71. What are the indicators of an e
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MONITORING only after several years
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MONITORING More importantly, there
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MONITORING 10. Results of directly
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MONITORING ● Expansion of the lab
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Monitoring (including research) ●
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MONITORING personnel; there is an i
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MONITORING 5. Global tuberculosis c
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MONITORING who fund and support the
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