Quantifying gaps in the tuberculosis care cascade in Brazil: A mathematical model study using national program data.

Autor: Emani S; Harvard Medical School, Boston, Massachusetts, United States of America., Alves K; National Tuberculosis Programme, Ministry of Health, Brasilia, Brazil., Alves LC; National Tuberculosis Programme, Ministry of Health, Brasilia, Brazil., da Silva DA; National Tuberculosis Programme, Ministry of Health, Brasilia, Brazil., Oliveira PB; Health and Environment Surveillance Secretariat, Ministry of Health, Brasilia, Brazil., Castro MC; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston Massachusetts, United States of America., Cohen T; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America., Couto RM; National Tuberculosis Programme, Ministry of Health, Brasilia, Brazil., Sanchez M; Health and Environment Surveillance Secretariat, Ministry of Health, Brasilia, Brazil.; Department of Public Health, University of Brasilia, Brasilia, Brazil., Menzies NA; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston Massachusetts, United States of America.; Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America.
Jazyk: angličtina
Zdroj: PLoS medicine [PLoS Med] 2024 Mar 21; Vol. 21 (3), pp. e1004361. Date of Electronic Publication: 2024 Mar 21 (Print Publication: 2024).
DOI: 10.1371/journal.pmed.1004361
Abstrakt: Background: In Brazil, many individuals with tuberculosis (TB) do not receive appropriate care due to delayed or missed diagnosis, ineffective treatment regimens, or loss-to-follow-up. This study aimed to estimate the health losses and TB program costs attributable to each gap in the care cascade for TB disease in Brazil.
Methods and Findings: We constructed a Markov model simulating the TB care cascade and lifetime health outcomes (e.g., death, cure, postinfectious sequelae) for individuals developing TB disease in Brazil. We stratified the model by age, human immunodeficiency virus (HIV) status, drug resistance, state of residence, and disease severity, and developed a parallel model for individuals without TB that receive a false-positive TB diagnosis. Models were fit to data (adult and pediatric) from Brazil's Notifiable Diseases Information System (SINAN) and Mortality Information System (SIM) for 2018. Using these models, we assessed current program performance and simulated hypothetical scenarios that eliminated specific gaps in the care cascade, in order to quantify incremental health losses and TB diagnosis and treatment costs along the care cascade. TB-attributable disability-adjusted life years (DALYs) were calculated by comparing changes in survival and nonfatal disability to a no-TB counterfactual scenario. We estimated that 90.0% (95% uncertainty interval [UI]: 85.2 to 93.4) of individuals with TB disease initiated treatment and 10.0% (95% UI: 7.6 to 12.5) died with TB. The average number of TB-attributable DALYs per incident TB case varied across Brazil, ranging from 2.9 (95% UI: 2.3 to 3.6) DALYs in Acre to 4.0 (95% UI: 3.3 to 4.7) DALYs in Rio Grande do Sul (national average 3.5 [95% UI: 2.8 to 4.1]). Delayed diagnosis contributed the largest health losses along the care cascade, followed by post-TB sequelae and loss to follow up from TB treatment, with TB DALYs reduced by 71% (95% UI: 65 to 76), 41% (95% UI: 36 to 49), and 10% (95% UI: 7 to 16), respectively, when these factors were eliminated. Total health system costs were largely unaffected by improvements in the care cascade, with elimination of treatment failure reducing attributable costs by 3.1% (95% UI: 1.5 to 5.4). TB diagnosis and treatment of false-positive individuals accounted for 10.2% (95% UI: 3.9 to 21.7) of total programmatic costs but contributed minimally to health losses. Several assumptions were required to interpret programmatic data for the analysis, and we were unable to estimate the contribution of social factors to care cascade outcomes.
Conclusions: In this study, we observed that delays to diagnosis, post-disease sequelae and treatment loss to follow-up were primary contributors to the TB burden of disease in Brazil. Reducing delays to diagnosis, improving healthcare after TB cure, and reducing treatment loss to follow-up should be prioritized to improve the burden of TB disease in Brazil.
Competing Interests: The authors have declared that no competing interests exist.
(Copyright: © 2024 Emani et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)
Databáze: MEDLINE
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