Resource implications of the latent tuberculosis cascade of care: a time and motion study in five countries

Abstract

Background: The End TB Strategy calls for global scale-up of preventive treatment for latent tuberculosis infection (LTBI), but little information is available about the associated human resource requirements. Our study aimed to quantify the healthcare worker (HCW) time needed to perform the tasks associated with each step along the LTBI cascade of care for household contacts of TB patients. Methods: We conducted a time and motion (TAM) study between January 2018 and March 2019, in which consenting HCWs were observed throughout a typical workday. The precise time spent was recorded in prespecified categories of work activities for each step along the cascade. A linear mixed model was fit to estimate the time at each step. Results: A total of 173 HCWs in Benin, Canada, Ghana, Indonesia, and Vietnam participated. The greatest amount of time was spent for the medical evaluation (median: 11 min; IQR: 6-16), while the least time was spent on reading a tuberculin skin test (TST) (median: 4 min; IQR: 2-9). The greatest variability was seen in the time spent for each medical evaluation, while TST placement and reading showed the least variability. The total time required to complete all steps along the LTBI cascade, from identification of household contacts (HHC) through to treatment initiation ranged from 1.8 h per index TB patient in Vietnam to 5.2 h in Ghana. Conclusions: Our findings suggest that the time requirements are very modest to perform each step in the latent TB cascade of care, but to achieve full identification and management of all household contacts will require additional human resources in many settings.

Active screening for tuberculosis in high-incidence Inuit communities in Canada: a cost-effectiveness analysis

“…Cost of medication for active TB 674 RAMQ 28 Cost of medication for latent TB 114 RAMQ 28 Cost of visits to manage active TB treatment 436 FIQ, 29 Alsdurf et al 30 Cost of visits to manage LTBI treatment 42 FIQ, 29 Alsdurf et al, 30 Campbell et al 31 Cost of severe adverse event caused by active TB treatment 16 364 Tan et al 20 Cost of adverse event during LTBI treatment 782 Campbell et al 31 Cost of medical evacuation 6713 Banerji et al 32 Cost of hospital stay per day 2050 NRBHSS 33 Note: FIQ = Fédération Interprofessionelle de la santé du Québec, LTBI = latent tuberculosis infection, NRBHSS = Nunavik Regional Board of Health and Social Services, RAMQ = Régie de l'assurance maladie du Québec, TB = tuberculosis. *These costs are specific to Village 1 (there were 604 people screened in Village 1).…”

Estimating the population at high risk for tuberculosis through household exposure in high-incidence countries: a model-based analysis

“…Swindells et al reported 512 attempts to reach 308 households for contact investigation, requiring a median time of four hours of staff person-time per attempt across sites in eight countries [23] . Alsdurf and colleagues estimated the time required for health care workers to complete all steps of evaluation of household contacts to be 1·8 hours to 5·2 hours per TB positive patient, though this estimate included steps for tuberculin skin test placement and reading, which may not be conducted in all settings [24] . Engaging community health workers may support this effort; Zawedde-Muyanja et al found improvements in screening of household contacts and initiation and completion of TPT among children in Uganda following training of community health workers [25] .…”

GeneXpert or chest-X-ray or tuberculin skin testing for household contact assessment (GXT): protocol for a cluster-randomized trial

“…All healthcare activities associated with diagnosis of TBI and exclusion of TBD is recorded for each of the three strategies. The healthcare personnel time spent for each of these activities will be estimated from a published time and motion study [ 24 ]. Local unit costs will be used to valuate blood tests, images test (such as CXR), and microbiological tests (smear, culture or GX).…”

“…We have adapted a standardized interviewer-administered questionnaire that we used previously to measure patient and family costs associated with TBD [ 24 ]. We have included a small number of items on this questionnaire regarding patient experience and acceptability of study procedures.…”