Strategic investment in tuberculosis control in the Republic of Bulgaria

Abstract

As Bulgaria transitions away from Global Fund grant, robust estimates of the comparative impact of the various response strategies under consideration are needed to ensure sustained effectiveness of the tuberculosis (TB) programme. We tailored an established mathematical model for TB control to the epidemic in Bulgaria to project the likely outcomes of seven intervention scenarios. Under existing programmatic conditions projected forward, the country's targets for achieving TB elimination in the coming decades will not be achieved. No interventions under consideration were predicted to accelerate the baseline projected reduction in epidemiological indicators significantly. Discontinuation of the ‘Open Doors’ program and activities of non-governmental organisations would result in a marked exacerbation of the epidemic (increasing incidence in 2035 by 6–8% relative to baseline conditions projected forward). Changing to a short course regimen for multidrug-resistant TB (MDR-TB) would substantially decrease MDR-TB mortality (by 21.6% in 2035 relative to baseline conditions projected forward). Changing to ambulatory care for eligible patients would not affect TB burden but would be markedly cost-saving. In conclusion, Bulgaria faces important challenges in transitioning to a primarily domestically-financed TB programme. The country should consider maintaining currently effective programs and shifting towards ambulatory care to ensure program sustainability.

Development of a Conceptual Framework for Tuberculosis Man-agement and Control; an Evidence Synthesis using Text Mining Software: A Review

“…Screening is the systematic identification of people at risk for TB disease, in a predetermined target group, by assessing symptoms and using tests, examinations or other procedures that can be applied rapidly ( 3 ). Screening can help health providers understand the TB burden in a population ( 14 ).…”

Inclusion of non-medical interventions in model-based economic evaluations for tuberculosis: A scoping review

“…In the second study, Doan and colleagues [ 23 ] evaluated the health and economic outcomes of seven intervention scenarios including switching to a short course regimen for multi-drug resistant TB (MDR-TB), transitioning from inpatient to ambulatory care, and providing food vouchers for patients undergoing TB treatment (a non-medical intervention). This study was conducted from the healthcare payer perspective and predicted outcomes over a 20-year time horizon.…”

“…In the two Canadian studies, dynamic transmission modeling was used to establish TB prevalence and smoking habits in the population to inform the decision analysis using a Markov model [ 22 , 24 ]. Doan and colleagues [ 23 ] used a dynamic transmission model that simulated the Bulgarian population’s risk of infection, progression, and transmission of TB over the analytic time horizon.…”

“…All three studies noted that there was a lack of evidence to inform some model input parameter values for the effectiveness of some non-medical interventions, a known challenge of economic evaluations of non-medical interventions (i.e., attribution of intervention effects) [ 13 ]. Each study mitigated the challenge of the uncertainty in efficacy data in different ways: Doan et al transparently provided point estimates used in the model and carefully highlighted the strength of supporting evidence using the Oxford Centre for Evidence Based Medicine Levels of Evidence [ 23 ]; N’Diaye and colleagues presented deterministic and probabilistic sensitivity analyses including changing key parameters around intervention effectiveness [ 22 ]; and Uppal et al focused on identifying thresholds of necessary program effectiveness in areas of marked uncertainty, and presented alternative scenarios including combinations of the four strategies [ 24 ]. Several health outcomes were incorporated into these analyses including quality adjusted life years (QALYs), incident TB cases, TB related deaths and TB prevalence.…”

Public health benefits of shifting from hospital-focused to ambulatory TB care in Eastern Europe: Optimising TB investments in Belarus, the Republic of Moldova, and Romania

“…The recommendations from these three countries are regionally relevant, and provide for more robust evidence to encourage national governments within the region to expedite the examination of barriers delaying the adoption of ambulatory DR-TB care towards more efficient and effective treatment modes. Similarly, another study in Bulgaria showed that while it would not affect TB burden, switching to ambulatory care for eligible TB patients would be markedly cost-saving [ 32 ].…”