Do catastrophic costs impact treatment outcomes in people with rifampicin-resistant tuberculosis in the Republic of Moldova?

Abstract

The Republic of Moldova is among the 30 Rifampicin-Resistant and/or Multidrug-Resistant (RR/MDR) Tuberculosis (TB) high burden countries in the world. Despite free TB diagnostics and treatment, TB patients face substantial economic losses and this may impact overall treatment outcomes. We assessed if there is an association between TB-related catastrophic costs and TB treatment outcomes. We conducted a cohort study using data from patient records and a survey that quantified catastrophic costs among RR/MDR-TB affected households in the Republic of Moldova in 2016. We included adult patients (age ≥18 years) with RR/MDR-TB who had been in inpatient (intensive phase) or outpatient (continuous phase) treatment for at least 2 months. Unfavourable treatment outcome, such as failure, death or lost to follow-up, was the primary outcome variable. The definition of catastrophic TB-related costs followed the World Health Organisation (WHO) guidelines: costs due to TB ≥20% of annual household income. Log-binomial regression was used to assess association between the outcome and catastrophic TB-related costs adjusting for other socio-demographic, behavioural and clinical covariates.  In total 287 RR/MDR-TB patients (78% males, mean age 42 years) were included. Of them, 30% experienced catastrophic TB-related costs. Overall, one in five patients (21%) had unfavourable treatment outcome, such as treatment failure (5%), death (8%) or lost to follow-up (8%). The experience of catastrophic TB-related costs was not associated with unfavourable treatment outcome [adjusted relative risk (aRR)=0.88, 95% CI: 0.50–1.50]. Major factors independently associated with unfavourable TB treatment outcomes were poverty (aRR=2.07; 95% CI: 1.06-4.07), urban residence (aRR=1.99; 95% CI: 1.12-3.52) and positive HIV (Human Immunodeficiency Virus) status (aRR=2.61; 95% CI: 1.31-4.89). As a result, we failed to find an association between catastrophic costs and treatment outcomes of RR/MDR-TB patients in the Republic of Moldova. However, we found that patients from poor households and urban areas were twice more likely to achieve unfavourable TB treatment outcomes disregarding whether they experienced catastrophic costs or not. Also, TB/HIV patients and urban residents were identified as the most vulnerable groups with higher risk of unfavourable treatment outcome and TB-related costs.

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Author Biography

Ana Ciobanu, Health Primary Care Department, University of Medicine and Pharmacy N. Testemitanu, Chisinau

World Health Organization Regional Office for Europe, Copenhagen, Denmark

References

WHO Regional Office for Europe. Defining the tuberculosis research agenda for the WHO European Region: a study report of the European TB Research Initiative. Geneva: World Health Organisation; 2019. Accessed on: 2020 Jul 7. Available from: https://www.euro.who.int/en/publications/abstracts/defining-the-tuberculosis-research-agenda-for-the-who-european-region-a-study-report-of-the-european-tb-research-initiative-2019

WHO, The World Bank. Tracking universal health coverage: first global monitoring report. Geneva: World Health Organization; 2015. Accessed on: 2020 Jul 7. Available from: https://apps.who.int/iris/bitstream/handle/10665/174536/9789241564977_eng.pdf?sequence=1

WHO. Health in 2015: From MDGs, Millennium Development Goals To SDGs, Sustainable Development Goals. Geneva: World Health Organization; 2015. Accessed on: 2020 Jul 7. Available from: https://apps.who.int/iris/bitstream/handle/10665/200009/9789241565110_eng.pdf?sequence=1

Xu K, Evans DB, Carrin G, et al. Protecting households from catastrophic health spending. Health Affairs 2007;26: 972-83.

WHO. End TB strategy. Global strategy and targets for tuberculosis prevention, care and control after 2015. Geneva: World Health Organisation; 2015. Accessed on: 2020 Jul 2. Available from: http://www.who.int/tb/strategy/en/

WHO. Tuberculosis patient cost surveys: a handbook. Geneva: World Health Organization; 2017. Available from: https://www.who.int/tb/publications/patient_cost_surveys/en/

The Word Bank. World Bank Open Data. Accessed on: 2020 Jun 30. Available from: https://data.worldbank.org/indicator/sh.xpd.oopc.ch.zs?locations=md

The World Bank. Republic of Moldova - Country context. 2019 Accessed on: 2019 Nov 11. Available from: https://www.worldbank.org/en/country/moldova/overview

Tanimura T, Jaramillo E, Weil D, et al. Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review. Eur Res J 2014;43:1763-75.

WHO. Use of high burden country lists for TB by WHO in the post-2015 era. Geneva: World Health Organization; 2015 Accessed on: 2020 Jul 7. Available from: https://www.who.int/tb/publications/global_report/high_tb_burdencountrylists2016-2020.pdf

Dadu A, Hovhannesyan A, Ahmedo S, et al. Drug-resistant tuberculosis In Eastern Europe and Central Asia: a time-series analysis of routine surveillance data. Lancet Infect Dis 2019;20:250-8.

WHO Regional Office for Europe. Roadmap to implement the tuberculosis action plan for the WHO European Region 2016–2020. Towards ending tuberculosis and multidrug-resistant tuberculosis (2016). Geneva: World Health Organization; 2016. Accessed on: 2020 Jul 1. Available from: https://www.euro.who.int/en/publications/abstracts/roadmap-to-implement-the-tuberculosis-action-plan-for-the-who-european-region-20162020.-towards-ending-tuberculosis-and-multidrug-resistant-tuberculosis-2016

Republic of Moldova. Government Decision No. 1160 dated 20 October 2016, on the approval of the National Tuberculosis Control Program (NTP) for the years 2016-2020. Available from: http://lex.justice.md/viewdoc.php?action=view&view=doc&id=367268&lang=1

WHO Regional Office for Europe. Analysis of the epidemiological impact of tuberculosis in the Republic of Moldova. Geneva: World Health Organization; 2017. Accessed on: 2020 Jul 7. Available from: http://www.euro.who.int/__data/assets/pdf_file/0011/337853/moldova_epi_review_final.pdf?ua=1

Ministry of Health of the Republic of Moldova. Sime TB - Moldova National Database for Notification and Follow-Up on Tuberculosis Cases. Accessed on: 2020 Jul 7. Available from: http://simetb.ifp.md/

Ciobanu A, Plesca V, Barba O, et al. Assessment of multidrug-resistant tuberculosis associated catastrophic costs incurred by families/households in the Republic of Moldova. 2017. Accessed on: 2020 Jul 1. Available from: https://www.researchgate.net/publication/321051278_assessment_of_multidrug-resistant_tuberculosis_associated_catastrophic_costs_incurred_by_familieshouseholds_in_the_republic_of_moldova

Barter DM, Agboola SO, Murray MB, Bärnighausen T. Tuberculosis and poverty: the contribution of patient costs in Sub-Saharan Africa – a systematic review. BMC Public Health 2012;12:980.

Ananthakrishnan R, Muniyandi M, Jeyaraj A, et al. Expenditure pattern for TB treatment among patients registered in an urban government DOTS program in Chennai City, South India. Tub Res Treat 2012;2012:747924.

Ukwaja KN, Alobu I, Abimbola S, Hopewel PC. Household catastrophic payments for tuberculosis care in Nigeria: incidence, determinants, and policy implications for universal health coverage. Infect Dis Poverty 2013;2:21.

Ukwaja KN, Alobu I, Hopewell PC, et al. The high cost of free tuberculosis services: patient and household costs associated with tuberculosis care in Ebonyi State, Nigeria. Plos One 2013;8:e73134.

Mauch V, Bonsu F, Gyapong M, et al. Free tuberculosis diagnosis and treatment are not enough: patient cost evidence from three continents. Int J Tuberc Lung Dis 2013;17:381-7.

Hanson CL, Weil DE, Floyd K. Tuberculosis in the poverty alleviation agenda. In: L.B. Reichman, E.S. Hershfield, editors. Reichman and Hershfield's Tuberculosis. CRC Press; 2006. p. 1147-64.

Rajeswari R, Balasubramanian R, Muniyandi M, et al. Socio-economic impact of tuberculosis on patients and family in India. Int J Tuberc Lung Dis 1999;3:869-77.

WHO Regional Office for Europe. Definitions and reporting framework for tuberculosis – 2013 revision (updated December 2014). Geneva: World Health Organization; 2014. Accessed on: 2020 Jul 7. Available from: https://apps.who.int/iris/bitstream/handle/10665/79199/9789241505345_eng.pdf

Ciobanu A, Domente L, Soltan V, et al. Do incentives improve tuberculosis treatment outcomes in the Republic of Moldova? Public Health Action 2014;4:S59-63.

World Bank. FAQs: Global poverty line update. Accessed on: 2020 Jul 7. Available from: https://www.worldbank.org/en/topic/poverty/brief/global-poverty-line-faq

Pirani E. Wealth Index. In: A.C. Michalos, editor. Encyclopedia of Quality of Life and Well-Being Research. Dordrecht: Springer; 2014. p. 7017-8.

Wingfield T, Boccia D, Tovar M, et al. Defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru. Plos Med 2014;11:e1001675.

Djibuti M, Mirvelashvili E, Makharashvili N, Magee MJ. household income and poor treatment outcome among patients with tuberculosis in Georgia: a cohort study. BMC Public Health 2014;14:88.

WHO. Barriers and factors facilitating access to health services in the Republic of Moldova. Geneva: World Health Organisation; 2012. Accessed on: 2020 Jul 8. Available from: https://www.euro.who.int/__data/assets/pdf_file/0018/183510/e96775-final.pdf

Peltzer K, Naidoo P, Matseke G, et al. Prevalence of psychological distress and associated factors in tuberculosis patients in public primary care clinics in South Africa. BMC Psychiatry 2012;12:89.

Kristenson M Eriksen HR, Sluiter J K, et al. Psychobiological mechanisms of socioeconomic differences in health. Soc Sci Med 2004;58:1511-22.

WHO, Gulpe T, Ciobanu A, et al. Risk factors associated with loss to follow-up among multidrugresistant tuberculosis patients in the Republic of Moldova in 2014–2016. Public Health Panorama 2019;5‎:493-502.

Ministry of Economy of the Republic of Moldova. Poverty report, Republic of Moldova. 2011. Accessed on: 2020 Jul 8. Available from: https://mei.gov.md/sites/default/files/poverty-report-republic-of-moldova-2010-2011.pdf?attempt=1&status=4

United Nations Development Programme (UNDP) in the Republic of Moldova. Inequalities and sustainable human development in Moldova. UNDP 2017. Accessed on: 2020 Jul 8. Available from: https://www.md.undp.org/content/moldova/en/home/library/human_development/nhdr-2016.html

Van Hest NA, Aldridge RW, De Vries G, et al. Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement. Euro Surveill 2014;19:20728.

Assebe LF, Negussie EK, Jbaily A, et al. Financial burden of HIV and TB among patients in Ethiopia: a cross-sectional survey. BMJ Open 2019;10:e036892.

WHO. Tuberculosis care with TB-HIV co-management. Geneva: World Health Organization; 2007. Accessed on: 2020 Jul 8. Available from: https://www.who.int/hiv/pub/imai/TB_HIVModule23.05.07.pdf

Food and Nutrition Technical Assistance. HIV/AIDS: a guide for nutrition, care and support. 2001. Accessed on: 2020 Jul 8. Available from: https://www.who.int/hac/techguidance/pht/8518.pdf

WHO. Guideline: nutritional care and support for patients with tuberculosis. Geneva: World Health Organization; 2013. Accessed on: 2020 Jul 8. Available from: https://www.who.int/nutrition/publications/guidelines/nutcare_support_patients_with_tb/en/

Babameto G, Kotler DP. Malnutrition in HIV infection. Gastroenterol Clin North Am 1997;26:393-415.

Odone A, Amadasi S, White RG, et al. The impact of antiretroviral therapy on mortality in HIV positive people during tuberculosis treatment: a systematic review and meta-analysis. Plos One 2014;9:E112017.

Published
2021-01-14
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Section
Thematic Articles
Keywords:
Multidrug-resistant tuberculosis, catastrophic cost, treatment outcome, Republic of Moldova, SORT-TB
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How to Cite
Plesca, V., Ciobanu, A., Sereda, Y., & Dadu, A. (2021). Do catastrophic costs impact treatment outcomes in people with rifampicin-resistant tuberculosis in the Republic of Moldova?. Monaldi Archives for Chest Disease, 91(1). https://doi.org/10.4081/monaldi.2021.1650

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