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Cost-Effectiveness of isoniazid preventive therapy among HIV-infected patients clinicaly screened for latent tuberculosis infection in Dar es Salaam, Tanzania: A prospective Cohort study.

ABSTRACT: One of the reasons why Isoniazid preventive therapy (IPT) for Tuberculosis (TB) is not widely used in low income countries is concerns on cost of excluding active TB. We analyzed the cost-effectiveness of IPT provision in Tanzania having ruled out active TB by a symptom-based screening tool.Data on IPT cost-effectiveness was prospectively collected from an observational cohort study of 1283 HIV-infected patients on IPT and 1281 controls; followed up for 24 months. The time horizon for the analysis was 2 years. Number of TB cases prevented and deaths averted were used for effectiveness. A micro costing approach was used from a provider perspective. Cost was estimated on the basis of clinical records, market price or interviews with medical staff. We annualized the cost at a discount of 3%. A univariate sensitivity analysis was done. Results are presented in US$ at an average annual exchange rate for the year 2012 which was Tanzania shillings 1562.4 for 1 US $.The number of TB cases prevented was 420/100,000 persons receiving IPT. The number of deaths averted was 979/100,000 persons receiving IPT. Incremental cost due to IPT provision was US$ 170,490. The incremental cost effective ratio was US $ 405.93 per TB case prevented and US $ 174.15 per death averted. These costs were less than 3 times the 768 US $ Gross Domestic Product (GDP) per capita for Tanzania in the year 2014, making IPT provision after ruling out active TB by the symptom-based screening tool cost-effective. The results were robust to changes in laboratory and radiological tests but not to changes in recurrent, personnel, medication and utility costs.IPT should be given to HIV-infected patients who screen negative to symptom-based TB screening questionnaire. Its cost-effectiveness supports government policy to integrate IPT to HIV/AIDS care and treatment in the country, given the availability of budget and the capacity of health facilities.

SUBMITTER: Shayo GA

PROVIDER: S-EPMC5518094 | biostudies-other | 2017 Jul

REPOSITORIES: biostudies-other

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Project description:BackgroundMalaria is a major cause of paediatric morbidity and mortality. As no clinical features clearly differentiate malaria from other febrile illnesses, and malaria diagnosis is challenged by often lacking laboratory equipment and expertise, overdiagnosis and overtreatment is common.MethodsChildren admitted with fever at the general paediatric wards at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania from January to June 2009 were recruited consecutively and prospectively. Demographic and clinical features were registered. Routine thick blood smear microscopy at MNH was compared to results of subsequent thin blood smear microscopy, and rapid diagnostics tests (RDTs). Genus-specific PCR of Plasmodium mitochondrial DNA was performed on DNA extracted from whole blood and species-specific PCR was done on positive samples.ResultsAmong 304 included children, 62.6% had received anti-malarials during the last four weeks prior to admission and 65.1% during the hospital stay. Routine thick blood smears, research blood smears, PCR and RDT detected malaria in 13.2%, 6.6%, 25.0% and 13.5%, respectively. Positive routine microscopy was confirmed in only 43% (17/40), 45% (18/40) and 53% (21/40), by research microscopy, RDTs and PCR, respectively. Eighteen percent (56/304) had positive PCR but negative research microscopy. Reported low parasitaemia on routine microscopy was associated with negative research blood slide and PCR. RDT-positive cases were associated with signs of severe malaria. Palmar pallor, low haemoglobin and low platelet count were significantly associated with positive PCR, research microscopy and RDT.ConclusionsThe true morbidity attributable to malaria in the study population remains uncertain due to the discrepancies in results among the diagnostic methods. The current routine microscopy appears to result in overdiagnosis of malaria and, consequently, overuse of anti-malarials. Conversely, children with a false positive malaria diagnosis may die because they do not receive treatment for the true cause of their illness. RDTs appear to have the potential to improve routine diagnostics, but the clinical implication of the many RDT-negative, PCR-positive samples needs to be elucidated.

Project description:BackgroundAedes aegypti (Diptera: Culicidae) is the main vector of the dengue virus globally. Dengue vector control is mainly based on reducing the vector population through interventions, which target potential breeding sites. However, in Tanzania, little is known about this vector's habitat productivity and insecticide susceptibility status to support evidence-based implementation of control measures. The present study aimed at assessing the productivity and susceptibility status of A. aegypti mosquitoes to pyrethroid-based insecticides in Dar es Salaam, Tanzania.MethodsAn entomological assessment was conducted between January and July 2015 in six randomly selected wards in Dar es Salaam, Tanzania. Habitat productivity was determined by the number of female adult A. aegypti mosquitoes emerged per square metre. The susceptibility status of adult A. aegypti females after exposure to 0.05% deltamethrin, 0.75% permethrin and 0.05% lambda-cyhalothrin was evaluated using the standard WHO protocols. Mortality rates were recorded after 24 h exposure and the knockdown effect was recorded at the time points of 10, 15, 20, 30, 40, 50 and 60 min to calculate the median knockdown times (KDT50 and KDT95).ResultsThe results suggest that disposed tyres had the highest productivity, while water storage tanks had the lowest productivity among the breeding habitats Of A. aegypti mosquitoes. All sites demonstrated reduced susceptibility to deltamethrin (0.05%) within 24 h post exposure, with mortalities ranging from 86.3?±?1.9 (mean?±?SD) to 96.8?±?0.9 (mean?±?SD). The lowest and highest susceptibilities were recorded in Mikocheni and Sinza wards, respectively. Similarly, all sites demonstrated reduced susceptibility permethrin (0.75%) ranging from 83.1?±?2.1% (mean?±?SD) to 96.2?±?0.9% (mean?±?SD), in Kipawa and Sinza, respectively. Relatively low mortality rates were observed in relation to lambda-cyhalothrin (0.05%) at all sites, ranging from 83.1?±?0.7 (mean?±?SD) to 86.3?±?1.4 (mean?±?SD). The median KDT50 for deltamethrin, permethrin and lambda-cyhalothrin were 24.9-30.3 min, 24.3-34.4 min and 26.7-32.8 min, respectively. The KDT95 were 55.2-90.9 min for deltamethrin, 54.3-94.6 min for permethrin and 64.5-69.2 min for lambda-cyhalothrin.ConclusionsThe productive habitats for A. aegypti mosquitoes found in Dar es Salaam were water storage containers, discarded tins and tyres. There was a reduced susceptibility of A. aegypti to and emergence of resistance against pyrethroid-based insecticides. The documented differences in the resistance profiles of A. aegypti mosquitoes warrants regular monitoring the pattern concerning resistance against pyrethroid-based insecticides and define dengue vector control strategies.

Project description:BackgroundEffective maternal and perinatal audits are associated with improved quality of care and reduction of severe adverse outcome. Although audits at the level of care were formally introduced in Tanzania around 25 years ago, little information is available about their existence, performance, and practical barriers to their implementation. This study assessed the structure, process and impacts of maternal and perinatal death audit systems in clinical practice and presents a detailed account on how they could be improved.MethodsA cross sectional descriptive study was conducted in eight major hospitals in Dar es Salaam in January 2009. An in-depth interview guide was used for 29 health managers and members of the audit committees to investigate the existence, structure, process and outcome of such audits in clinical practice. A semi-structured questionnaire was used to interview 30 health care providers in the maternity wards to assess their awareness, attitude and practice towards audit systems. The 2007 institutional pregnancy outcome records were reviewed.ResultsOverall hospital based maternal mortality ratio was 218/100,000 live births (range: 0 - 385) and perinatal mortality rate was 44/1000 births (range: 17 - 147). Maternal and perinatal audit systems existed only in 4 and 3 hospitals respectively, and key decision makers did not take part in audit committees. Sixty percent of care providers were not aware of even a single action which had ever been implemented in their hospitals because of audit recommendations. There were neither records of the key decision points, action plan, nor regular analysis of the audit reports in any of the facilities where such audit systems existed.ConclusionsMaternal and perinatal audit systems in these institutions are poorly established in structure and process; and are less effective to improve the quality of care. Fundamental changes are urgently needed for successful audit systems in these institutions.

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Cost-Effectiveness of isoniazid preventive therapy among HIV-infected patients clinicaly screened for latent tuberculosis infection in Dar es Salaam, Tanzania: A prospective Cohort study.

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