Suchergebnisse

New tuberculosis vaccines have made substantial progress in the development pipeline. Previous modelling suggests that adolescent/adult mass vaccination may cost-effectively contribute towards achieving global tuberculosis control goals. These analyses have not considered the budgetary feasibility of vaccine programmes. We estimate the maximum total cost that the public health sectors in India and China should expect to pay to introduce a M72/AS01E-like vaccine deemed cost-effective at country-specific willingness to pay thresholds for cost-effectiveness. To estimate the total disability adjusted life years (DALYs) averted by the vaccination programme, we simulated a 50% efficacy vaccine providing 10-years of protection in post-infection populations between 2027 and 2050 in India and China using a dynamic transmission model of M. tuberculosis. We investigated two mass vaccination strategies, both delivered every 10-years achieving 70% coverage: Vaccinating adults and adolescents (age ≥10y), or only the most efficient 10-year age subgroup (defined as greatest DALYs averted per vaccine given). We used country-specific thresholds for cost-effectiveness to estimate the maximum total cost (Cmax) a government should be willing to pay for each vaccination strategy. Adult/adolescent vaccination resulted in a Cmax of $21 billion (uncertainty interval [UI]: 16-27) in India, and $15B (UI:12-29) in China at willingness to pay thresholds of $264/DALY averted and $3650/DALY averted, respectively. Vaccinating the highest efficiency age group (India: 50-59y; China: 60-69y) resulted in a Cmax of $5B (UI:4-6) in India and $6B (UI:4-7) in China. Mass vaccination against tuberculosis of all adults and adolescents, deemed cost-effective, will likely impose a substantial budgetary burden. Targeted tuberculosis vaccination, deemed cost-effective, may represent a more affordable approach.

OBJECTIVES: To explore stakeholders' and national organisational perspectives on companionship for women/birthing people using antenatal and intrapartum care in England during COVID-19, as part of the Achieving Safe and Personalised maternity care In Response to Epidemics (ASPIRE) COVID-19 UK study. SETTING: Maternity care provision in England. PARTICIPANTS: Interviews were held with 26 national governmental, professional and service-user organisation leads (July–December 2020). Other data included public-facing outputs logged from 25 maternity Trusts (September/October 2020) and data extracted from 78 documents from eight key governmental, professional and service-user organisations that informed national maternity care guidance and policy (February–December 2020). RESULTS: Six themes emerged: 'Postcode lottery of care' highlights variations in companionship and visiting practices between trusts/locations, 'Confusion and stress around 'rules'' relates to a lack of and variable information concerning companionship/visiting, 'Unintended consequences' concerns the negative impacts of restricted companionship or visiting on women/birthing people and staff, 'Need for flexibility' highlights concerns about applying companionship and visiting policies irrespective of need, ''Acceptable' time for support' highlights variations in when and if companionship was 'allowed' antenatally and intrapartum and 'Loss of human rights for gain in infection control' emphasises how a predominant focus on infection control was at a cost to psychological safety and human rights. CONCLUSIONS: Policies concerning companionship and visiting have been inconsistently applied within English maternity services during the COVID-19 pandemic. In some cases, policies were not justified by the level of risk, and were applied indiscriminately regardless of need. There is an urgent need to determine how to sensitively and flexibly balance risks and benefits and optimise outcomes during the current and future crisis situations.

BACKGROUND: A sizeable fraction of tuberculosis (TB) cases go undiagnosed. By analysing data from enhanced demographic, microbiological and geospatial surveillance of TB registrations, we aimed to identify modifiable predictors of inequitable access to diagnosis and care. METHODS: Governmental community health workers (CHW) enumerated all households in 315 catchment areas during October-December 2015. From January 2015, government TB Officers routinely implemented enhanced TB surveillance at all public and private TB treatment registration centres within Blantyre (18 clinics in total). This included collection from registering TB patients of demographic and clinical characteristics, a single sputum sample for TB microscopy and culture, and geolocation of place of residence using an electronic satellite map application. We estimated catchment area annual TB case notification rates (CNRs), stratified by microbiological status. To identify population and area-level factors predictive of CHW catchment area TB case notification rates, we constructed Bayesian spatially autocorrelated regression models with Poisson response distributions. Worldpop data were used to estimate poverty. RESULTS: In total, the 315 CHW catchment areas comprised 753,489 people (range 162 to 13,066 people/catchment area). Between 2015 and 2017, 6077 TB cases (61% male; 99% HIV tested; 67% HIV positive; 55% culture confirmed) were geolocated, with 3723 (61%) resident within a CHW catchment area. In adjusted models, greater distance to the nearest TB registration clinic was negatively correlated with TB CNRs, which halved for every 3.2-fold (95% CI 2.24-5.21) increase in distance. Poverty, which increased with distance from clinics, was negatively correlated with TB CNRs; a 23% increase (95% CI 17-34%) in the mean percentage of the population living on less than US$2 per day corresponded to a halving of the TB case notification rates. CONCLUSIONS: Using enhanced surveillance of TB cases in Blantyre, we show an ecological relationship consistent with an 'inverse care law' whereby poorer neighbourhoods and those furthest from TB clinics have lower relative CNRs. If confirmed as low case detection, then pro-poor strategies to facilitate equitable access to TB diagnosis and treatment are required.

BACKGROUND A sizeable fraction of tuberculosis (TB) cases go undiagnosed. By analysing data from enhanced demographic, microbiological and geospatial surveillance of TB registrations, we aimed to identify modifiable predictors of inequitable access to diagnosis and care. METHODS Governmental community health workers (CHW) enumerated all households in 315 catchment areas during October-December 2015. From January 2015, government TB Officers routinely implemented enhanced TB surveillance at all public and private TB treatment registration centres within Blantyre (18 clinics in total). This included collection from registering TB patients of demographic and clinical characteristics, a single sputum sample for TB microscopy and culture, and geolocation of place of residence using an electronic satellite map application. We estimated catchment area annual TB case notification rates (CNRs), stratified by microbiological status. To identify population and area-level factors predictive of CHW catchment area TB case notification rates, we constructed Bayesian spatially autocorrelated regression models with Poisson response distributions. Worldpop data were used to estimate poverty. RESULTS In total, the 315 CHW catchment areas comprised 753,489 people (range 162 to 13,066 people/catchment area). Between 2015 and 2017, 6077 TB cases (61% male; 99% HIV tested; 67% HIV positive; 55% culture confirmed) were geolocated, with 3723 (61%) resident within a CHW catchment area. In adjusted models, greater distance to the nearest TB registration clinic was negatively correlated with TB CNRs, which halved for every 3.2-fold (95% CI 2.24-5.21) increase in distance. Poverty, which increased with distance from clinics, was negatively correlated with TB CNRs; a 23% increase (95% CI 17-34%) in the mean percentage of the population living on less than US$2 per day corresponded to a halving of the TB case notification rates. CONCLUSIONS Using enhanced surveillance of TB cases in Blantyre, we show an ecological relationship consistent with an 'inverse care law' whereby poorer neighbourhoods and those furthest from TB clinics have lower relative CNRs. If confirmed as low case detection, then pro-poor strategies to facilitate equitable access to TB diagnosis and treatment are required.