Fighting poverty to control TB
Carlton A Evans ([email protected])
IFHAD: Innovation For Health And Development research group:
Peru: Universidad Peruana Cayetano Heredia
Asociacion Benefica PRISMA
UK:
Imperial College London
USA: Johns Hopkins Bloomberg School of Public Health
DOTS
Care
Policies
Prevention
Innovation
Health
systems
People
Pathogens Smear & treat
Saved millions of lives
Revolutionised TB care
Extremely cost-effective
Model for global health
Over-emphasizes smear
Under-emphasizes MDR
Under-emphasizes people
Under-emphasizes prevention
Poverty is bigger than money
Addressing social determinants is bigger than cash transfers
20
%
depressed
Hazard of
Abandoning
Treatment
not
depressed
10
%
0
%
0
1
2
3
4
5
6
Treatment Month
C Acosta, D Boccia, R Montoya , D Onifade, C Ford, J Franco, J Alva, C Evans. TB stigmatization is associated with disease concealment and poor treatment adherence. IJTLD 2010: 14 (11);
S248. Allen, F Fernandez, C Loiselle, C Rocha, R Montoya, K Zevallos, A Curatola, C Evans Depression & suicidal tendencies in TB patients. IJTLD 2010:14;S312. M Maritz, A Bayer, K
Zevallos, CD Acosta, R Montoya, M Rivero, CM Ford, CA Evans. TB treatment adherence &mortality are predicted by low social capital. IJTLD 2011:15;S304-5
Divorcing direct observation
Supervised direct observation
(with menaces) is:
• stigmatising,
• patronising,
• disrespects social justice
• doesn’t help (Pasipanodya 2013)
10
8
6
4
2
0
Failure
Risk difference (x10)
Relapse
DOT incidence
Aquired-DR
Self incidence
Helping with the bus fare
is not social justice;
we should change to informing,
incentivising & enabling adherence
Addressing TB social determinants: why
Social justice: TB pills are an inadequate response to despair
Necessity: social protection necessary for DOTS to work:
labs & pills can only cure if access is affordable
Social protection may allow DOTS-cure to evolve into TB control
EVIDENCE:
1. PAST: wealth & poverty causes great changes in TB rates
2. PRESENT: success of DOTS saving lives & reducing suffering
is not achieving control; social determinants still drive TB rates
3. PRINCIPLE: TB pills respond to poverty effects ~war surgery
4. PREVALANCE: most prevalent TB is not currently detected
National changes
in TB rates
are associated
with
socioeconomic
development
not control TB
programs
Dye, C et al. Trends in TB incidence and their determinants in 134 countries. Bull World Health Organ 2009;87:683–691
Simplifying DOTS evolution
Care
Policies
DOTS
Prevention
Innovation
Health
systems
(DRAFT) - Proposed
Pillars and Principles of the
People
Post-2015 TB Strategy
(DRAFT) Post-2015 TB Strategy
Pathogens Smear & treat
Vision: A world free of TB
WHO
Surveillance, Monitoring and Evaluation
GOAL
Message
Innovative
TB Care
Bold Policies
and
Supportive
Systems
Intensified
Research
and
Innovation
Zero TB deaths (or)
Elimination of TB deaths and suffering (or)
Elimination of TB as a public health problem
Innovative TB Care
Rapid diagnosis of TB including
universal drug-susceptibility testing ;
systematic screening of contacts and
high-risk groups
Treatment of all forms of TB
including drug -resistant TB with
patient support
TARGETS FOR 2025
TB mortality rate reduced by 50% (compared with 2015)
TB prevalence rate reduced by 50% (compared with 2015)
A target on MDR-TB / TB treatment coverage (for discussion)
Bold policies and supportive
systems
Government stewardship , commitment,
and adequate resources for TB care and
control with monitoring and evaluation
Engagement of communities , civil
society organizations, and all public and
private care providers
Collaborative TB/HIV activities and
management of co-morbidities
Regulatory framework for vital
registration, case notification, drug
quality and rational use, and infection
control
Preventive treatment for high-risk
groups and vaccination of children
Universal Health Coverage, social
protection and other measures to
address social determinants of TB
Intensified Research
Discovery, development and rapid
uptake of new diagnostics, drugs
and vaccines
Operational research to optimize
implementation and adopt
innovations
Care
Prevention Innovation
Policies
Health systems
Wealth
Operational research
People
Equitable
access
Health
Trials
Simplifying DOTS evolution
Care
Policies
DOTS
Prevention
Innovation
Health
systems
(DRAFT) - Proposed
Pillars and Principles of the
People
Post-2015 TB Strategy
(DRAFT) Post-2015 TB Strategy
Pathogens Smear & treat
Vision: A world free of TB
WHO
Surveillance, Monitoring and Evaluation
GOAL
Message
Innovative
TB Care
Bold Policies
and
Supportive
Systems
Intensified
Research
and
Innovation
Zero TB deaths (or)
Elimination of TB deaths and suffering (or)
Elimination of TB as a public health problem
Innovative TB Care
Rapid diagnosis of TB including
universal drug-susceptibility testing ;
systematic screening of contacts and
high-risk groups
Treatment of all forms of TB
including drug -resistant TB with
patient support
TARGETS FOR 2025
TB mortality rate reduced by 50% (compared with 2015)
TB prevalence rate reduced by 50% (compared with 2015)
A target on MDR-TB / TB treatment coverage (for discussion)
Bold policies and supportive
systems
Government stewardship , commitment,
and adequate resources for TB care and
control with monitoring and evaluation
Engagement of communities , civil
society organizations, and all public and
private care providers
Collaborative TB/HIV activities and
management of co-morbidities
Regulatory framework for vital
registration, case notification, drug
quality and rational use, and infection
control
Preventive treatment for high-risk
groups and vaccination of children
Universal Health Coverage, social
protection and other measures to
address social determinants of TB
Intensified Research
Discovery, development and rapid
uptake of new diagnostics, drugs
and vaccines
Operational research to optimize
implementation and adopt
innovations
Care
Prevention Innovation
Policies
Health systems
Wealth
Operational research
People
Equitable
access
Health
Trials
Evidence for impact of social protection for TB
“This review
shows a lack of
studies on
microfinance and
cash transfer
interventions that
specifically address TB or other
respiratory
infections. “
D Boccia, J Hargreaves, K Lonnroth, E Jaramillo, J Weiss, M Uplekar, JDH Porter, CA Evans. Cash transfer & microfinance
interventions for TB control: review of evidence & policy implications. IntJ TB & Lung Disease 2011: 15(6); S37-59
‘ISIAT: Innovative Socioeconomic Interventions Against TB’ project
Social support
to facilitate TB care
Economic support
To reduce poverty
Objective:
EVALUATION
to
generate
evidence
whether socio-economic interventions
can strengthen TB control
Population:
Improved TB care
Reduced TB risk
TB-affected
families,
living with impoverishment of TB &
risk of recurrence & transmission
Reduced TB
A Curatola, R Montoya, M Rivero, C Rocha, M Tovar, T Valencia, K Zevallos, C Evans. Fighting
poverty to control TB: preliminary results of a trial in Peru. IJTLD 2009: 13(12);S60
ISIAT: Conceptual Framework
Activities
Social dimension
* Household
* Community
Visits
Workshops
Outputs
Conditional food transfers &
* psychology support
(b)
(a)
Outcomes along the
TB causal pathway
Economic dimension
(c)
* Community mobilization for
health & gender rights
* Health
Seeking
(1)
* Timely
diagnosis
(2)
* Treatment
completion
(3)
* Sustained
Cure through
MDRTB & (4)
HIV testing
* Vocational
Microenterprise
training
(d)
Recruitment &
participation
Community support to increase access to TB care
* Microcredit &
(e)
* Loan repayment, productive
activities & income
Poverty reduction to reduce TB risk
* Infection
prevention
(5)
Improved
environmental
conditions
Reduced TB
susceptibility
D Boccia, J Hargreaves, K Lonnroth, E Jaramillo, J Weiss, M Uplekar, J Porter, C Evans. Cash transfer &microfinance for TB control. IJTLD 2011:15(5);S64-9
ISIAT– Uptake
% of participants (+95% confidence interval)
100
80
60
40
20
0
Excellent uptake
of social
interventions
100 97 96
97 75 56
85 64 62
50 22 14
34 25 23
49 37 16
(a)
Household
visits
(b)
Community
mobilization
(c)
Psychological
support
(d)
Microcredit
(d)
Microenterprize
(e)
Vocational
training
Requested
Initiated
Completed
2,050 people (329 patients) enrolled to the socioeconomic interventions 12/2007-9/2010
and this interim analysis demonstrates greatest uptake of health promotion activities.
C Rocha, R Montoya, K Zevallos, A Curatola, W Ynga, J Franco, F Oliver, M Sabaduche, N Becerra, M Tovar, E Ramos, A Tapley, N Allen, D Onifade, C Acosta,
M Maritz, S Schumacher, C Evans. The Innovative socioeconomic interventions against TB (ISIAT) project–an operational assessment. IJTLD 2011: 15(5); S50-57
ISIAT microcredit & TB - Jason Kahn
Of total 151 loans, 36% (55)
defaulted.
Associations with default:
• the borrower being male
(RR=2.0, p<0.02),
• living in a TB-affected
household (RR=1.4,
p<0.001),
• and the loan being
larger (p<0.001).
Default rates were not
associated with:
• schooling completion,
• income / spending,
crowding or
• loan multiplicity (all
p>0.1).
ISIAT– Uptake
% of participants (+95% confidence interval)
100
9% commenced vocational training
3.2% increased income
80
60
40
20
0
100 97 96
97 75 56
85 64 62
50 22 14
34 25 23
49 37 16
(a)
Household
visits
(b)
Community
mobilization
(c)
Psychological
support
(d)
Microcredit
(d)
Microenterprize
(e)
Vocational
training
Requested
Initiated
Completed
C Rocha, R Montoya, K Zevallos, A Curatola, W Ynga, J Franco, F Oliver, M Sabaduche, N Becerra, M Tovar, E Ramos, A Tapley, N Allen, D Onifade, C Acosta,
M Maritz, S Schumacher, C Evans. The Innovative socioeconomic interventions against TB (ISIAT) project–an operational assessment. IJTLD 2011: 15(5); S50-57
ISIAT– Uptake
% of participants (+95% confidence interval)
100
Food & cash transfers for all households
$160 average value
=42% of median per capita income
=10% of median household income
23% food – optimized for TB immunity
13% indirect diagnosis & treatment
costs
25% treatment travel expenses
39% supporting microenterprise
80
60
40
20
0
100 97 96
97 75 56
85 64 62
50 22 14
34 25 23
49 37 16
(a)
Household
visits
(b)
Community
mobilization
(c)
Psychological
support
(d)
Microcredit
(d)
Microenterprize
(e)
Vocational
training
Requested
Initiated
Completed
2,050 people (329 patients) enrolled to the socioeconomic interventions 12/2007-9/2010
and this interim analysis demonstrates greatest uptake of health promotion activities.
C Rocha, R Montoya, K Zevallos, A Curatola, W Ynga, J Franco, F Oliver, M Sabaduche, N Becerra, M Tovar, E Ramos, A Tapley, N Allen, D Onifade, C Acosta,
M Maritz, S Schumacher, C Evans. The Innovative socioeconomic interventions against TB (ISIAT) project–an operational assessment. IJTLD 2011: 15(5); S50-57
ISIAT increased access to TB care
100
**
**
*
**
**
(1)
Health insurance
registration
(2)
Contact
screening
(≥18y)
(3)
Successful
treatment
completion
(4)
MDRTB
testing
(4)
HIV
testing
**
90
80
70
60
50
40
30
20
10
-
Pre-interventions (baseline)
(5
Preve
therapy i
(<1
After socioeconomic
Socioeconomic interventions were associated with increased uptake of TB control interventions;
follow-up comparing intervention versus no intervention communities is in progress
C Rocha, R Montoya, K Zevallos, A Curatola, W Ynga, J Franco, F Oliver, M Sabaduche, N Becerra, M Tovar, E Ramos, A Tapley, N Allen, D Onifade, C Acosta,
M Maritz, S Schumacher, C Evans. The Innovative socioeconomic interventions against TB (ISIAT) project–an operational assessment. IJTLD 2011: 15(5); S50-57
Innovative Socioeconomic Interventions Against TB – Project Design
5. CS 3 de Febrero
36 cases/y
14. CS Bahía Blanca
16 cases/y
8. CS Cedros
10 cases/y
2. CS Pachacútec
26 cases/y
3. CS Defensores
19 cases/y
1.
CS Hijos de Grau
2. 20 cases/y
4. CS Angamos
37 cases/y
13. CS Ventanilla Baja 11
cases/y
12. CS Luis Felipe
36 cases/y
11. CS Villa los Reyes
54 cases/y
6. CS Sta Rosa Pachac.
24cases/y
16. CS Mi Peru.
80cases/y
15. CS Ventanilla Alta
27 cases/y
10. CB Ventanilla
76 cases/y
7. CS Ventanilla Este
15 cases/y
9. CS Márquez
42 cases/y
Phased implementation in 8 shantytowns over 3 years to facilitate impact evaluation
C Rocha, R Montoya, K Zevallos, W Ynga, J Franco, F Fernandez, M Sabaduche, N Becerra, A
Tapley, N Allen, D Onifade, M Tovar, T Valencia, C Evans. Impact of socio-economic
interventions on access to TB care. CDC late-breaker proceedings IUATLD 2010;2.
ISIAT – Gender Impact
P=0.003
Standard passive programmatic
case finding diagnosed fewer
women (40%) than men.
P<0.0001
P=0.4
Our active screening of
household contacts diagnosed
TB slightly more often (51%) in
women than men.
Passive case finding underdiagnosed women; our
active case-finding
overcame this inequality.
D Onifade, R Montoya, R Gilman, J Alva, N Becerra, A Gavino, M Rivero, C Evans. Active case
finding overcomes gender barriers to TB diagnosis. IJTLD 2009: 13(12); S150.
Children completing chemoprophylaxis
(%+95%CI)
ISIAT – Equity Impact
50
P=0.6
P=0.0002
45
40
35
30
Poorer
25
Less poor
20
15
10
5
17%
28%
(75/437) (121/440)
41%
(63/154)
38%
(45/118)
0
Control TB-affected families
TB-affected families
(without intervention)
receiving socio-economic
intervention
Socioeconomic interventions significantly increased the uptake & equity
of TB preventive therapy. A prevalence survey with universal sputum
culture is in progress to determine impact on prevalent TB rates
C Rocha, R Montoya, K Zevallos, A Curatola, W Ynga, J Franco, F Oliver, M Sabaduche, N Becerra, M Tovar, E Ramos, A Tapley, N Allen, D Onifade, C Acosta,
M Maritz, S Schumacher, C Evans. The Innovative socioeconomic interventions against TB (ISIAT) project–an operational assessment. IJTLD 2011: 15(5); S50-57
Thanks to:
Presented on behalf of a multi-disciplinary research team in Peru:
Contact: [email protected]
Sponsors: World Bank, DFID-CSCF, FIND, Bill & Melinda Gates Foundation,
WHO, The Wellcome Trust, Sir Halley Stewart Trust, NIH, NAMRU-6, IFHAD