Andhra Pradesh Priorities: Tuberculosis - Arinaminpathy

1. Investments in tuberculosis control in Andhra
Pradesh
Nimalan Arinaminpathy, D.Phil
Department of Infectious Disease Epidemiology,
Imperial College London
Andhra Pradesh Priorities conference, Vijayawada June 18-20

2. Tuberculosis today
10.4M new TB cases,1.7M deaths in
2016
1.1M TB/HIV+ cases, 370k deaths
Global Tuberculosis Report, 2017
As yet no effective TB vaccine
But most TB cases are curable with 6-9
months of drug treatment.

3. Impressive successes in India…
DOTS scale-up under RNTCP (status report 2009)

4. …but challenges remain
Global Tuberculosis Report, 2014

5. Background: major challenges
• Private healthcare sector dominates TB control in India
• Vast, fragmented disorganized
• Substandard TB care:
•Missed opportunities for diagnosis
•Treatment: lack of adherence support leads to inferior outcomes
• Vulnerable populations, such as slum dwellers, have concentrated TB
burden, with implications for broader transmission
•Delays in presentation for care: protracted opportunities for transmission
• Multi-drug-resistant (MDR) TB: ~4% of burden, but >40% of budget
•Harder to recognize at the point of diagnosis

6. Background: ways forward
• Ambitious, far-reaching vision for TB control
• Need to see that “services are established as
per Standards for TB Care in India to privately-
managed patients…Regulatory tools, however,
are limited, and partnership is the preferred
way to move forward.”
• “Active case finding in vulnerable groups is a
focus over the next 5 years” with priority
groups including slums
What is the potential benefit-
cost of these interventions at
scale, in Andhra Pradesh?

7. Background: transmission dynamics
• Infectious diseases: indirect effects can be as important as direct
effects
Start of
symptoms
Spontaneous
cure or death
Detection and cure

8. Background: transmission dynamics
• Infectious diseases: indirect effects can be as important as direct
effects
• Mathematical modelling is a helpful tool for capturing these overall
health gains
Detection and cure

9. The model framework

10. 1st analyzed solution
Private sector engagement

11. Private sector engagement: activities
• Public Private Support Agency (PPSA): recent, successful pilots for engaging
the private sector in Mumbai, Patna and elsewhere in India
• Sensitise and engage with private providers, offering:
•Subsidies for high-quality diagnostic tests
•Free TB treatment for all those treated in the private sector
•Adherence support to patients with linkage to a call centre
•Provider support for notifying TB
• Aim: not to ‘displace’ the private sector, but offer high-quality diagnosis and
treatment wherever patients seek care
• Assume an intervention that reaches 75% of private providers, and
successfully engages with 2/3 of them

12. Intervention 1: Impact on the epidemic

13. Intervention 1: Incremental costs

14. Overall benefits and costs
Interventions Benefit
(INR crores)
Cost
(INR crores)
BCR Quality of
Evidence
Intervention 1 51598 460 112.2 Medium
Programmatic costs only
All figures assume a 5% discount rate

15. 2nd analyzed solution
Private sector engagement
+ Active Case Finding in urban slums

16. Intensified case-finding
• Implemented in combination with private sector engagement
• Urban slums in the state: accounting for ~10% of population, but 25%
of TB burden
• Mobile diagnostic units screening the slum population, with potential
TB cases being diagnosed with rapid molecular tests (e.g. GeneXpert)
• If positive, referred to the public sector for TB treatment
• Assume an intervention that screens the whole slum population each
year, to detect 2/3 of prevalent cases each year in the state

17. Intervention 2: Impact on the epidemic

18. Intervention 2: Incremental costs

19. Overall benefits and costs
Interventions Benefit
(INR crores)
Cost
(INR crores)
BCR Quality of
Evidence
Intervention 2 84187 826 101.9 Limited
Programmatic costs only
All figures assume a 5% discount rate

20. Concluding comments

21. Overall benefits and costs
Interventions Benefit
(INR crores)
Cost
(INR crores)
BCR Quality of
Evidence
Intervention 1 51598 460 112.2 Medium
Intervention 2 84187 826 101.9 Limited
Programmatic costs only
Notes: All figures assume a 5% discount rate

22. Overall benefits and costs
Interventions Benefit
(INR crores)
Cost
(INR crores)
BCR Quality of
Evidence
Intervention 1 51598 440 117.4 Medium
Intervention 2 84187 776 108.5 Limited
Programmatic + patient costs (including patient time and spending)
Notes: All figures assume a 5% discount rate

23. Limitations and caveats
• As with any modelling study, simplifying assumptions:
•Averaging over different forms of TB (e.g. extrapulmonary TB)
•Not including age structure
• Interventions: limited evidence for impact of active case-finding in
South Asian settings
•However, ongoing RNTCP efforts likely to address this gap
• Effective measures for engaging the private sector may vary by state
•E.g. incentivization vs support for notification

24. Conclusions
• Tuberculosis is a major public health challenge, needing significant
investment
• However, this investment could offer major returns
• Critically: TB interventions are a low-cost way of saving lives
•Especially when transmission is taken into account
• While MDR-TB is not a major component of burden, it is a major
contributor to costs
•Reducing MDR burden can make this a cost-saving intervention in the long
term

25. Thank you

26. Spare slides

27. Sensitivity
analysis
Sensitivity analysis

28. Importance of time horizon