- Email: [email protected]
Public–private mix in tuberculosis
Correspondence
PE (95% CI)
ARR (95% CI)
p value
Severe malaria 1–6 months 1–3 months 4–6 months 0–6 months
28% (–3 to 50) 42% (5 to 64) 8% (–61 to 47) 26% (–3 to 47)
6·9 (–0·7 to 12·2) 16·5 (2·0 to 25·4) 1·2 (–9·0 to 7·0) 5·9 (–0·6 to 10·5)
0·072 0·030 0·771 0·071
All-cause severe malaria 1–6 months 1–3 months 4–6 months 0–6 months
25% (–13 to 50) 35% (–15 to 63) 19% (–38 to 53) 29% (–7 to 53)
5·4 (–2·7 to 10·8) 9·7 (–4·2 to 17·6) 3·4 (–6·7 to 9·3) 5·9 (–1·4 to 10·8)
0·165 0·140 0·433 0·101
–100
0 Favours placebo
100 Favours IPTpd
Figure: Adjusted treatment effect by time period PE=protective efficacy. ARR=absolute rate reduction per 100 children-years. IPTpd=intermittent preventive therapy post-discharge. PE was calculated from adjusted hazard ratios obtained from Cox regression for repeated events. ARR was calculated as the adjusted HR × incidence rate per child-year in the placebo group.
factors of hospital admission for all-cause severe anaemia.2 Because vitamins A and B12 are essential for erythropoiesis and have immunemodulating effects, we anticipate increased efficacy can be achieved when monthly IPTpd is combined with micronutrient supplementation and short-term antimicrobial prophylaxis. This more integrated approach to the management of children with severe anaemia in hospital and after discharge needs to be explored. We declare that we have no conflicts of interest.
Kamija Phiri, Michael Esan, Michael Boele van Hensbroek, Carole Khairallah, Brian Faragher, *Feiko O ter Kuile [email protected] MLW Clinical Research Programme and Community Health Department, College of Medicine, University of Malawi, Blantyre, Malawi (KP, ME); The Amsterdam Institute for Global Health and Development, Emma Children’s Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands (ME, MBvH); and Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK (FOtK, CK, BF) 1
2
Phiri K, Esan M, van Hensbroek MB, Khairallah C, Faragher B, ter Kuile FO. Intermittent preventive therapy for malaria with monthly artemetherlumefantrine for the post-discharge management of severe anaemia in children aged 4–59 months in southern Malawi: a multicentre, randomised, placebo-controlled trial. Lancet infect Dis 2012; 12: 191–200. Calis JC, Phiri KS, Faragher EB, et al. Severe anemia in Malawian children. N Engl J Med 2008; 358: 888–99.
www.thelancet.com/infection Vol 12 December 2012
Public–private mix in tuberculosis We congratulate Aamir Khan and colleagues for their highly relevant study.1 Engaging with the private sector is a major component in the WHO Stop TB Strategy, a delay in which jeopardises the control of tuberculosis.2 The study has many positive points and has infused much needed optimism regarding tuberculosis control in developing countries. Most notably, the community screeners covered about half the population of the intervention area in 2011, which is a commendable feat. Indeed, such an enthusiastic intervention can perhaps only be achieved by community participation, which is a remarkable strength of this study. The use of mobile telephones for data collection and communication linked to central database showed that the use of appropriate technology improved efficiency and provided prompt information to patients and health workers.3 We hope that high-burden countries such as India and Pakistan will adopt screening with mobile telephones at hospital outpatient departments in their tuberculosis programmes. We feel that treatment continuation would have been better had the patients been treated at the national
tuberculosis programme (NTP) centres closer to home rather than at the Indus Hospital, as shown by 9% of patients transferred out to a centre closer to home.1 Moreover, we would like to know whether patients detected at the family clinics came for directly observed treatment, short-course to the family clinics or the NTP centres, or the drugs were distributed at home by community screeners. A high default rate of 16–17% probably implies that active screening also detects those patients who are reluctant to start or continue treatment because of time constraints or other reasons.4 Once the completed treatment outcome of all the patients detected in this study is available, it will tell us whether high tuberculosis case detection comes at a price of incomplete treatment. Any regular implementation of this intervention will first require us to minimise incomplete treatment and thereby prevent drug resistance in the population. An interesting finding is that about half the 520 referred patients diagnosed with tuberculosis were extrapulmonary cases. That 426 (82%) of these cases were from clinics where screeners were active suggests that sensitivity of the screening questions needs to be improved, particularly with regard to extrapulmonary case detection. The authors have aptly driven home the point that private sector involvement in health can be highly productive, especially when the diagnosis and treatment to patients is free. That five of eight NTP reporting centres were private hospitals points to good private sector cooperation already present in Karachi. We in India stand to benefit much more from sustaining such interventions since only 6% of total new smear-positive cases are being detected by the private and corporate sector.5 We declare that we have no conflicts of interest.
*Suman Saurabh, Sonali Sarkar, Premarajan K C, Akkilagunta Sujiv [email protected]
907
Correspondence
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education And Research (JIPMER), Puducherry, Puducherry 605006, India 1
2
3
4
5
Khan AJ, Khowaja S, Khan F, et al. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12: 608–16. Uplekar M, Lonnroth K. MDR and XDR—the price of delaying engagement with all care providers for control of TB and TB/HIV. Trop Med Int Health 2007; 12: 473–74. Zurovac D, Sudoi RK, Akhwale WS, et al. The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: a cluster randomised trial. Lancet 2011; 378: 795–803. Quy HT, Lan NT, Lönnroth K, Buu TN, Dieu TT, Hai LT. Public-private mix for improved TB control in Ho Chi Minh City, Vietnam: an assessment of its impact on case detection. Int J Tuberc Lung Dis 2003; 7: 464–71. Central TB Division. TB India 2011. Revised National Tuberculosis Control Programme; annual status report. New Delhi, India: Directorate General of Health Services, Ministry of Health and Family Welfare, 2011. Chapter 3, page 57. http://tbcindia.nic.in/pdfs/ RNTCP%20TB%20India%202011.pdf (accessed June 27, 2012).
I read with interest the study by Aamir Khan and colleagues,1 which showed that a multifaceted approach to engagement of the private sector increased tuberculosis case detection. However, the study design and subsequent results did not seem to support such a firm conclusion. First, although an independent monitoring and evaluation agency identified Landhi and Shah Faisal as a suitable control area for the study, the region did not seem to be a suitable control. This is because, despite having a higher population of about 300 000 people more than the intervention area, the control area had only five national tuberculosis programme (NTP) reporting centres compared with eight in the intervention area. Thus, even before the intervention, annual case-notification rate was higher in the intervention area than in the control area. Also, a mass communications strategy in the intervention area was done with “television advertisements” and “flyers”1 to encourage people with tuberculosis symptoms to seek care at 908
either a family clinic or Indus Hospital, and we cannot be sure that these did not reach the control area. Second, despite the intervention, case-notification in the intervention area excluding Indus Hospital decreased by 22% (from 928 to 724) between 2010 and 2011. But, in the control area, case-notification decreased by 9·3% (from 547 to 496) during the same period. This finding suggests that the intervention did not improve case-notification in the participating NTP centres in the intervention area other than the Indus Hospital. Third, admittedly, the intervention increased case detection at Indus Hospital. However, most patients who were diagnosed in this hospital came through self-referrals, which suggests that patients in Karachi are more likely to seek care at the Indus Hospital if they develop tuberculosis symptoms, since it is a recognised referral centre for tuberculosis diagnosis and treatment in Pakistan and all health services there were given free-of-charge.2 The proportion of tuberculosis suspects from the control area who sought care at Indus Hospital was not recorded. Reasons why self-referred patients preferred the hospital to other intervention centres probably closer to their homes were also not recorded. In Nigeria, despite the decentralisation of tuberculosis services, some patients prefer travelling long distances to nationally-recognised faith-based centres offering tuberculosis services (unpublished data). This study showed that a multifaceted approach of engaging the private sector improved tuberculosis case detection in a large tuberculosis referral centre, but these findings might be difficult to replicate throughout Pakistan and indeed other settings. I declare that I have no conflicts of interest.
Kingsley Nnanna Ukwaja [email protected]
Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria 1
2
Khan AJ, Khowaja S, Khan F, et al. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12: 608–16. Indus hospital Pakistan: facts and figures. http:// indushospital.org.pk/kriz/index.php/about-us/ facts-and-figures (accessed June 30, 2012).
I read with interest the Comment by Noor Ahmad Baloch and Madhukar Pai.1 The authors highlighted a business model for the private sector that significantly increased the case notification rate of tuberculosis. The authors very correctly mentioned that, in Pakistan and India, 70–80% of first contact care happens in the private sector and that the diagnostic and treatment practices pertaining to tuberculosis control in the private sector are suboptimum in these countries. Private sector health-care services are disorganised, which further adds to the complex problem. Baloch and Pai also mentioned that private practitioners are estimated to contribute to less than 5% of case notifications to the national tuberculosis control programme. However, recently, tuberculosis has been made a notifiable disease in India and we hope that the picture will change for the better in the near future.2 But, rather than mere notification of tuberculosis, provisions should be made to allow for correction of any faulty management of notified tuberculosis cases rather than simply using the numbers for reporting purposes. Thus the present scenario of tuberculosis health-care in the private sector is a matter of grave concern and makes the participation of private sector in the tuberculosis control programme more imperative. The authors have proposed a largescale business model for the private sector to enable public–private mix in tuberculosis control. The essential components of the model are a largescale communication campaign, involvement of lay persons in screening, provision of incentives to
www.thelancet.com/infection Vol 12 December 2012
PE (95% CI)
ARR (95% CI)
p value
Severe malaria 1–6 months 1–3 months 4–6 months 0–6 months
28% (–3 to 50) 42% (5 to 64) 8% (–61 to 47) 26% (–3 to 47)
6·9 (–0·7 to 12·2) 16·5 (2·0 to 25·4) 1·2 (–9·0 to 7·0) 5·9 (–0·6 to 10·5)
0·072 0·030 0·771 0·071
All-cause severe malaria 1–6 months 1–3 months 4–6 months 0–6 months
25% (–13 to 50) 35% (–15 to 63) 19% (–38 to 53) 29% (–7 to 53)
5·4 (–2·7 to 10·8) 9·7 (–4·2 to 17·6) 3·4 (–6·7 to 9·3) 5·9 (–1·4 to 10·8)
0·165 0·140 0·433 0·101
–100
0 Favours placebo
100 Favours IPTpd
Figure: Adjusted treatment effect by time period PE=protective efficacy. ARR=absolute rate reduction per 100 children-years. IPTpd=intermittent preventive therapy post-discharge. PE was calculated from adjusted hazard ratios obtained from Cox regression for repeated events. ARR was calculated as the adjusted HR × incidence rate per child-year in the placebo group.
factors of hospital admission for all-cause severe anaemia.2 Because vitamins A and B12 are essential for erythropoiesis and have immunemodulating effects, we anticipate increased efficacy can be achieved when monthly IPTpd is combined with micronutrient supplementation and short-term antimicrobial prophylaxis. This more integrated approach to the management of children with severe anaemia in hospital and after discharge needs to be explored. We declare that we have no conflicts of interest.
Kamija Phiri, Michael Esan, Michael Boele van Hensbroek, Carole Khairallah, Brian Faragher, *Feiko O ter Kuile [email protected] MLW Clinical Research Programme and Community Health Department, College of Medicine, University of Malawi, Blantyre, Malawi (KP, ME); The Amsterdam Institute for Global Health and Development, Emma Children’s Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands (ME, MBvH); and Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK (FOtK, CK, BF) 1
2
Phiri K, Esan M, van Hensbroek MB, Khairallah C, Faragher B, ter Kuile FO. Intermittent preventive therapy for malaria with monthly artemetherlumefantrine for the post-discharge management of severe anaemia in children aged 4–59 months in southern Malawi: a multicentre, randomised, placebo-controlled trial. Lancet infect Dis 2012; 12: 191–200. Calis JC, Phiri KS, Faragher EB, et al. Severe anemia in Malawian children. N Engl J Med 2008; 358: 888–99.
www.thelancet.com/infection Vol 12 December 2012
Public–private mix in tuberculosis We congratulate Aamir Khan and colleagues for their highly relevant study.1 Engaging with the private sector is a major component in the WHO Stop TB Strategy, a delay in which jeopardises the control of tuberculosis.2 The study has many positive points and has infused much needed optimism regarding tuberculosis control in developing countries. Most notably, the community screeners covered about half the population of the intervention area in 2011, which is a commendable feat. Indeed, such an enthusiastic intervention can perhaps only be achieved by community participation, which is a remarkable strength of this study. The use of mobile telephones for data collection and communication linked to central database showed that the use of appropriate technology improved efficiency and provided prompt information to patients and health workers.3 We hope that high-burden countries such as India and Pakistan will adopt screening with mobile telephones at hospital outpatient departments in their tuberculosis programmes. We feel that treatment continuation would have been better had the patients been treated at the national
tuberculosis programme (NTP) centres closer to home rather than at the Indus Hospital, as shown by 9% of patients transferred out to a centre closer to home.1 Moreover, we would like to know whether patients detected at the family clinics came for directly observed treatment, short-course to the family clinics or the NTP centres, or the drugs were distributed at home by community screeners. A high default rate of 16–17% probably implies that active screening also detects those patients who are reluctant to start or continue treatment because of time constraints or other reasons.4 Once the completed treatment outcome of all the patients detected in this study is available, it will tell us whether high tuberculosis case detection comes at a price of incomplete treatment. Any regular implementation of this intervention will first require us to minimise incomplete treatment and thereby prevent drug resistance in the population. An interesting finding is that about half the 520 referred patients diagnosed with tuberculosis were extrapulmonary cases. That 426 (82%) of these cases were from clinics where screeners were active suggests that sensitivity of the screening questions needs to be improved, particularly with regard to extrapulmonary case detection. The authors have aptly driven home the point that private sector involvement in health can be highly productive, especially when the diagnosis and treatment to patients is free. That five of eight NTP reporting centres were private hospitals points to good private sector cooperation already present in Karachi. We in India stand to benefit much more from sustaining such interventions since only 6% of total new smear-positive cases are being detected by the private and corporate sector.5 We declare that we have no conflicts of interest.
*Suman Saurabh, Sonali Sarkar, Premarajan K C, Akkilagunta Sujiv [email protected]
907
Correspondence
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education And Research (JIPMER), Puducherry, Puducherry 605006, India 1
2
3
4
5
Khan AJ, Khowaja S, Khan F, et al. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12: 608–16. Uplekar M, Lonnroth K. MDR and XDR—the price of delaying engagement with all care providers for control of TB and TB/HIV. Trop Med Int Health 2007; 12: 473–74. Zurovac D, Sudoi RK, Akhwale WS, et al. The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: a cluster randomised trial. Lancet 2011; 378: 795–803. Quy HT, Lan NT, Lönnroth K, Buu TN, Dieu TT, Hai LT. Public-private mix for improved TB control in Ho Chi Minh City, Vietnam: an assessment of its impact on case detection. Int J Tuberc Lung Dis 2003; 7: 464–71. Central TB Division. TB India 2011. Revised National Tuberculosis Control Programme; annual status report. New Delhi, India: Directorate General of Health Services, Ministry of Health and Family Welfare, 2011. Chapter 3, page 57. http://tbcindia.nic.in/pdfs/ RNTCP%20TB%20India%202011.pdf (accessed June 27, 2012).
I read with interest the study by Aamir Khan and colleagues,1 which showed that a multifaceted approach to engagement of the private sector increased tuberculosis case detection. However, the study design and subsequent results did not seem to support such a firm conclusion. First, although an independent monitoring and evaluation agency identified Landhi and Shah Faisal as a suitable control area for the study, the region did not seem to be a suitable control. This is because, despite having a higher population of about 300 000 people more than the intervention area, the control area had only five national tuberculosis programme (NTP) reporting centres compared with eight in the intervention area. Thus, even before the intervention, annual case-notification rate was higher in the intervention area than in the control area. Also, a mass communications strategy in the intervention area was done with “television advertisements” and “flyers”1 to encourage people with tuberculosis symptoms to seek care at 908
either a family clinic or Indus Hospital, and we cannot be sure that these did not reach the control area. Second, despite the intervention, case-notification in the intervention area excluding Indus Hospital decreased by 22% (from 928 to 724) between 2010 and 2011. But, in the control area, case-notification decreased by 9·3% (from 547 to 496) during the same period. This finding suggests that the intervention did not improve case-notification in the participating NTP centres in the intervention area other than the Indus Hospital. Third, admittedly, the intervention increased case detection at Indus Hospital. However, most patients who were diagnosed in this hospital came through self-referrals, which suggests that patients in Karachi are more likely to seek care at the Indus Hospital if they develop tuberculosis symptoms, since it is a recognised referral centre for tuberculosis diagnosis and treatment in Pakistan and all health services there were given free-of-charge.2 The proportion of tuberculosis suspects from the control area who sought care at Indus Hospital was not recorded. Reasons why self-referred patients preferred the hospital to other intervention centres probably closer to their homes were also not recorded. In Nigeria, despite the decentralisation of tuberculosis services, some patients prefer travelling long distances to nationally-recognised faith-based centres offering tuberculosis services (unpublished data). This study showed that a multifaceted approach of engaging the private sector improved tuberculosis case detection in a large tuberculosis referral centre, but these findings might be difficult to replicate throughout Pakistan and indeed other settings. I declare that I have no conflicts of interest.
Kingsley Nnanna Ukwaja [email protected]
Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria 1
2
Khan AJ, Khowaja S, Khan F, et al. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12: 608–16. Indus hospital Pakistan: facts and figures. http:// indushospital.org.pk/kriz/index.php/about-us/ facts-and-figures (accessed June 30, 2012).
I read with interest the Comment by Noor Ahmad Baloch and Madhukar Pai.1 The authors highlighted a business model for the private sector that significantly increased the case notification rate of tuberculosis. The authors very correctly mentioned that, in Pakistan and India, 70–80% of first contact care happens in the private sector and that the diagnostic and treatment practices pertaining to tuberculosis control in the private sector are suboptimum in these countries. Private sector health-care services are disorganised, which further adds to the complex problem. Baloch and Pai also mentioned that private practitioners are estimated to contribute to less than 5% of case notifications to the national tuberculosis control programme. However, recently, tuberculosis has been made a notifiable disease in India and we hope that the picture will change for the better in the near future.2 But, rather than mere notification of tuberculosis, provisions should be made to allow for correction of any faulty management of notified tuberculosis cases rather than simply using the numbers for reporting purposes. Thus the present scenario of tuberculosis health-care in the private sector is a matter of grave concern and makes the participation of private sector in the tuberculosis control programme more imperative. The authors have proposed a largescale business model for the private sector to enable public–private mix in tuberculosis control. The essential components of the model are a largescale communication campaign, involvement of lay persons in screening, provision of incentives to
www.thelancet.com/infection Vol 12 December 2012