Tuberculosis – Page 3 – International Health Research

Active case-finding to improve tuberculosis control.

Posted on 16/04/2010 by Bernt Lindtjørn — No Comments ↓

Is active case finding necessary to control tuberculosis in developing countries?

Tuberculosis is one of the world’s leading causes of death and disease. Despite effective treatment, tuberculosis still results in several million deaths each year. Reducing the burden of global TB disease is a part the Millennium Development Goals. Earlier, health authorities thought that DOTS (Direct Observed Treatment, Short course) would control tuberculosis. However, we now recognize that DOTS alone is unable of reducing TB incidence in high endemic countries.

Active case finding is to find, diagnose, and treat and follow up tuberculosis patients in the local communities.

To find out the efficacy of community-based case finding, we did a community randomized trial and cost-effectiveness analysis in south Ethiopia. The trial Ethiopia aimed to evaluate if community health workers could improved smear-positive case detection and treatment success rates (Datiko and Lindtjørn, 2009 and Datiko and Lindtjørn, 2010).

The study showed that involving of health extension workers (HEWs) in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This finding has policy implications and could be applied in settings with low health service coverage and a shortage of health workers.

Recently, National TB Control Programme in Ethiopia started to decentralize case finding and treatment to local communities (in Ethiopia called kebeles) using community based-treatment by health extension workers.

We plan to follow up our earlier studies and develop a model for community DOTS in rural Ethiopia. We aim to improve the community-based implementation of case finding and treatment of TB in rural settings of southern Ethiopia. This will try to develop community-based tuberculosis registries, and registries of patients with symptoms suggestive of tuberculosis. Through this work we aim to see if case finding and treatment outcomes can be improved on a larger scale and involving larger populations

Datiko, D., & Lindtjørn, B. (2009). Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial PLoS ONE, 4 (5) DOI: 10.1371/journal.pone.0005443

Datiko, D., & Lindtjørn, B. (2010). Cost and Cost-Effectiveness of Treating Smear-Positive Tuberculosis by Health Extension Workers in Ethiopia: An Ancillary Cost-Effectiveness Analysis of Community Randomized Trial PLoS ONE, 5 (2) DOI: 10.1371/journal.pone.0009158

Operational research

Posted on 10/04/2010 by Bernt Lindtjørn — No Comments ↓

In global health, operational research is an idea increasingly used by donors and policy makers. It involves analytical methods to help improve public health interventions and treatment of diseases in real-life situations. It is thus different from randomized clinical trials that determines efficacy of an intervention in a strictly controlled environment with inclusion and exclusion criteria, whereas operational research assess effectiveness within routine, and real-life settings.

Recently Zachariah and colleagues (2009) defined operational research as: “The search for knowledge on interventions, strategies, or tools that can improve the quality, effectiveness, or coverage of programmes in which the research is being done”.

Operational research involves descriptive, case–control, and cohort analysis. Some say that basic science research and randomised controlled trials is not operational research. However, effectiveness trials refer to whether an intervention works in people to whom it has been offered, and should in my view form an integral part of operational research. Results from such randomized trials can be are translated to benefit in the diverse setting of routine care.

For a health programme, the relevance of such research is whether it contributes to an improved performance or influences policy change at district, national, or even international levels.

Some examples of operational research from south Ethiopia include:

Antiretroviral treatment in resource limited settings (Jerene et al 2006): This cohort study assessed feasibility and effectiveness of antiretroviral therapy by use of historical controls.
An effectiveness trial in south Ethiopia aimed to evaluate if community health workers could improved smear-positive case detection and treatment success rates (Datiko and Lindtjørn, 2009). The study showed that involving of health extension workers (HEWs) in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This finding has policy implications and could be applied in settings with low health service coverage and a shortage of health workers.

References:

Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K, Laserson K, Massaquoi M, Van Herp M, & Reid T (2009). Operational research in low-income countries: what, why, and how? The Lancet infectious diseases, 9 (11), 711-7 PMID: 19850229

Jerene D, Naess A, & Lindtjørn B (2006). Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients. AIDS research and therapy, 3 PMID: 16600050

Treating tuberculosis

Posted on 23/02/2010 by Bernt Lindtjørn — No Comments ↓

We recently published the following article:

Datiko DG, Lindtjørn B (2010) Cost and Cost-Effectiveness of Treating Smear-Positive Tuberculosis by Health Extension Workers in Ethiopia: An Ancillary Cost-Effectiveness Analysis of Community Randomized Trial. PLoS ONE 5(2): e9158. doi:10.1371/journal.pone.0009158

ABSTRACT:

Background

Evidence for policy- and decision-making related to the cost of delivering tuberculosis (TB) control is lacking in Ethiopia. We aimed to determine the cost and cost-effectiveness of involving health extension workers (HEWs) in TB treatment under a community-based initiative in Ethiopia. This paper presents an ancillary cost-effectiveness analysis of data from a RCT, from which the main outcomes have already been published.

Methodology/Principal Findings

Options of treating TB patients in the community by HEWs in the health posts and general health workers at health facility were compared in a community-randomized trial. Costs were analysed from a societal perspective in 2007 in US dollars using standard methods. We prospectively enrolled smear-positive patients, and calculated the cost-effectiveness in terms of the cost per patient successfully treated. The total cost for each successfully treated smear-positive patient was higher in health facilities (US$161.9) compared with the community-based approach (US$60.7). The total, patient and care giver costs of community-based treatment were lower than health facility DOT by 62.6%, 63.9% and 88.2%, respectively. Involving HEWs added a total cost of US$8.80 to the health service per patient treated in the health posts in the community.

Conclusions/Significance

Community-based treatment by HEWs costs only 37% of what treatment by general health workers costs for similar outcomes. Involving HEWs in TB treatment is a cost-effective treatment alternative to the health service and to the patients and their caregivers. Therefore, there is both an economic and public health reason to consider involving HEWs in TB treatment in Ethiopia. However, community-based treatment would require initial investment for implementation, training and supervision.

Trial Registration

ClinicalTrials.gov NCT00913172

Improving tuberculosis control in Ethiopia

Posted on 19/05/2009 by Bernt Lindtjørn — No Comments ↓

By using community health workers in stead of health professionals such as nurses and doctors at institutions, Daniel Datiko at Centre for International Health has shown:

The community based approach (Community DOTS) identifies about 70% of expected tuberculosis cases, compared with only 30 % when patients have to travel to health centres and hospitals

About 90% of the tuberculosis patients were cured when they received treatment in their local communities, compared with 80% at institutions

The community based approach reduced the costs of treatment by 60%.

Most of patients treated by Community DOTS are women. This is a significant improvement from the institutional based tuberculosis control.

The community based DOTS is an approach that improves access to treatment.

These ideas are now being implemented in Ethiopia. As a start it will be carried out in the Southern Nations, Nationalities and Peoples’ Regional State in Ethiopia.

Better tuberculosis control

Posted on 08/05/2009 by Bernt Lindtjørn — No Comments ↓

One of the main strategies to control tuberculosis is to find and treat people with active disease. Unfortunately, the case detection rates remain low in many countries. Thus, we need interventions to find and treat sufficient number of patients to control tuberculosis.

We investigated whether involving health extension workers (HEWs: trained community health workers) in tuberculosis control improved smear-positive case detection and treatment success rates in southern Ethiopia.

We carried out a community-randomized trial in southern Ethiopia. Involving community health workers in tuberculosis control improved the case detection and treatment success rates for smear-positive patients and for women in particular.

We think our approach improved service access, and recommend this could be applied in settings with low health service coverage and a shortage of health workers.
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Datiko DG, Lindtjørn B (2009) Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial. PLoS ONE 4(5): e5443. doi:10.1371/journal.pone.0005443

Intervention studies

Posted on 04/04/2009 by Bernt Lindtjørn — No Comments ↓

During the past years there has been many papers on patient and treatment delay of tuberculosis. The reasons for delay seem to be with the patient: Delay is often associated with illiteracy, distance from the health institution, gender, poverty, and knowledge about tuberculosis.

Over the years, we have also published on this topic. However, I now doubt if we a need for any more cross-sectional studies. I often receive questions from editors to review such papers, and they do not contain anything new.

So, this raises the question on how many descriptive studies do we need before doing anything for the patients? Does a study showing any association between lack of knowledge on tuberculosis prove that educating the population would reduce delay? I doubt that we can make such a conclusion.

More emphasis should be on how to reduce delay. We need more intervention studies. And these intervention studies should focus on the providers’, and not on the patients’ side. One example of an intervention study is by Estifanos Birru. He showed that active case finding reduces patient delay.