Tuberculosis: a private and public health and data mix

(1)

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This is the published version of a paper published in Lancet. Infectious diseases (Print).

Citation for the original published paper (version of record):

Byass, P. (2016)

Tuberculosis: a private and public health and data mix.

Lancet. Infectious diseases (Print), 16(11): 1206-1207 http://dx.doi.org/10.1016/S1473-3099(16)30334-6

Access to the published version may require subscription.

N.B. When citing this work, cite the original published paper.

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1206 www.thelancet.com/infection Vol 16 November 2016

incidences were large. These results support birth cohort eﬀ ects and higher rates of sexual infection in women postulated by prevalence studies.

^5,6

They also suggest that HTLV-1 incidence will continue to fall in Japan as the higher risk cohorts age and die.

Only a few other studies have attempted to determine the incidence of HTLV-1 and even fewer have used representative samples of general populations. Two studies in the USA and one in Brazil estimated incidence in repetitive blood donors and found results that are probably lower than, but of similar magnitude as, general population rates. Glynn and colleagues

⁷

and Zou and colleagues

⁸

in the USA reported incidence rates of 1·6 new infections per 100 000 person-years and 0·21 new infections per 100 000 person-years, respectively. The diﬀ erence between them is probably due to diﬀ ering geographic areas served by the sampled blood centres. In Brazil, Carneiro-Proietti and colleagues

⁹

reported a rate of 3·6 per 100 000 person-years, quite similar to Satake’s estimate for Japan and about three times higher than in the USA, consistent with known HTLV-1 epidemiology.

Three other studies found much higher incidence, probably because they studied higher-risk populations, including a hyperendemic island in Okinawa, Japan (1·0 per 1000 person-years),

¹⁰

a sexually transmitted infection clinic in Jamaica (9·0 per 1000 person-years),

¹¹

and a community sample with high HIV prevalence in Guinea-Bissau (1·7 per 1000 person-years).

¹²

Two main conclusions can be drawn. First, incidence data for HTLV-1 are scarce in many countries and therefore insuﬃ cient to responsibly inform and assess prevention eﬀ orts by public health agencies and allow for international comparisons. Second, since large population-based incidence studies are unlikely to be done for HTLV-1, studies that include repeat blood donors

are a practical and reasonable alternative for international comparisons and monitoring secular trends.

Sarah Mollenkopf, Edward L Murphy*

Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA (SM); Blood Systems Research Institute, San Francisco, CA, USA (SM, ELM); and University of California San Francisco, San Francisco, CA, USA (ELM) ed.murphy@ucsf.edu

We declare no competing interests.

1 Poiesz BJ, Ruscetti FW, Gazdar AF, Bunn PA, Minna JD, Gallo RC.

Detection and isolation of type C retrovirus particles from fresh and cultured lymphocytes of a patient with cutaneous T-cell lymphoma.

Proc Natl Acad Sci USA 1980; 77: 7415–19.

2 Satake M, Iwanaga M, Sagara Y, Watanabe T, Okuma K, Hamaguchi I.

Incidence of human T-lymphotropic virus 1 infection in adolescent and adult blood donors in Japan: a nationwide retrospective cohort analysis.

Lancet Infect Dis 2016; published online Aug 22. http://dx.doi.org/10.1016/

S1473-3099(16)30252-3.

3 Gessain A, Cassar O. Epidemiological aspects and world distribution of HTLV-1 infection. Front Microbiol 2012; 3: 388.

4 Hino S, Katamine S, Miyata H, Tsuji Y, Yamabe T, Miyamoto T.

Primary prevention of HTLV-1 in Japan. Leukemia 1997; 11 (suppl 3): 57–59.

5 Murphy EL, Figueroa JP, Gibs WN, et al. Human T-lymphotropic virus type I (HTLV-I) seroprevalence in Jamaica: I. Demographic determinants.

Am J Epidemiol 1991; 133: 1114–24.

6 Murphy EL, Watanabe K, Nass CC, Ownby H, Williams A, Nemo G.

Evidence among blood donors for a 30-year-old epidemic of human T lymphotropic virus type II infection in the United States. J Infect Dis 1999;

180: 1777–83.

7 Glynn SA, Kleinman SH, Schreiber GB, et al. Trends in incidence and prevalence of major transfusion-transmissible viral infections in US blood donors, 1991 to 1996. Retrovirus Epidemiology Donor Study (REDS).

JAMA 2000; 284: 229–35.

8 Zou S, Stramer SL, Dodd RY. Donor testing and risk: current prevalence, incidence, and residual risk of transfusion-transmissible agents in US allogeneic donations. Transfus Med Rev 2012; 26: 119–28.

9 Carneiro-Proietti ABF, Sabino E, Leao S, et al. HTLV-1 and -2 seroprevalence, incidence and residual transfusion risk among blood donors in Brazil during 2007–2009. AIDS Res Hum Retroviruses 2012; 28: 1265–72.

10 Morofuji-Hirata M, Kajiyama W, Nakashima K, Noguchi A, Hayashi J, Kashiwagi S. Prevalence of antibody to human T-cell lymphotropic virus type I in Okinawa, Japan, after an interval of 9 years. Am J Epidemiol 1993; 137: 43–48.

11 Figueroa JP, Ward E, Morris J, et al. Incidence of HIV and HTLV-1 infection among sexually transmitted disease clinic attenders in Jamaica.

J Acquir Immune Deﬁ c Syndr Hum Retrovirol 1997; 15: 232–37.

12 van Tienen C, van der Loeﬀ MF, Peterson I, et al. HTLV-1 in rural Guinea-Bissau: prevalence, incidence and a continued association with HIV between 1990 and 2007. Retrovirology 2010; 7: 50.

Tuberculosis: a private and public health and data mix

The clue in the title lies in the phrase public health. Data for understanding the health status of communities and nations comprise a fundamental public good.

¹

Public health data can only be captured and curated eff ectively if suffi cient resources and determination are deployed for the purpose. But, from private sector perspectives of profi ts and shareholders, it might seem entirely reasonable not to prioritise the collection of public health data.

In The Lancet Infectious Diseases, Nimalan Arinaminpathy and colleagues

²

tackle a speciﬁ c manifestation of this public–private dichotomy in examining the complex mix of tuberculosis treatment uptake in India. India is a country where health services are undergoing a rapid transition from the former domination of the government sector into a public–private plurality. In a country of over 1 billion people, with huge socioeconomic

Published Online August 24, 2016 http://dx.doi.org/10.1016/

S1473-3099(16)30334-6 See Articles page 1255

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Comment

www.thelancet.com/infection Vol 16 November 2016 1207

inequities, this plurality of health services is likely to persist for a long time. Managing infectious diseases associated with poverty, like tuberculosis, would traditionally have been regarded as a governmental responsibility. The new ﬁ ndings suggest that about two-thirds of tuberculosis treatment in India is now being delivered by the private sector. How can that important private sector input best be monitored?

The USA, with arguably the world’s largest private- dominated health-care system, provides an interesting comparison. The Centers for Disease Control and Prevention, as the national health protection agency, carries responsibility for documenting tuberculosis (which has long been a nationally notiﬁ able disease), in the form of an annual report.

³

Nevertheless, as in India, delivery of tuberculosis treatment is a public–private mix, with a quarter of clinical care for tuberculosis delivered through the private sector.

⁴

One has to assume in the USA that the procedures required of the private sector for notifying tuberculosis cases to the public authorities are suﬃ ciently robust and well-enforced.

India only made tuberculosis a notiﬁ able disease in 2012, following reports of multiple drug-resistant disease.

⁵

To what extent mandatory reporting has facilitated the extraction of reliable data from the private sector is uncertain, particularly given that half of private practitioners in a survey cited lack of time as a reason for failing to notify tuberculosis cases in Chennai.

⁶

The compliance of the Indian private health sector in terms of notifying tuberculosis (and possibly other diseases) thus seems to be a major obstacle to gathering public health data. Alternative and less direct approaches are therefore important for reaching any realistic national picture of tuberculosis treatment in India, where a substantial proportion of worldwide cases occur.

⁷

But are such indirect methods appropriate and relevant?

Arinaminpathy and colleagues

²

chose to move their focus upstream from data at the patient-provider level to drug supply statistics. Since there is no single drug uniquely and solely indicated for treating tuberculosis, this approach involved some fairly brave assumptions.

Sales of drugs containing rifampicin were chosen as the key indicator on the basis of having fewer indications than other drugs for non-tuberculosis treatment.

Patient-months of treatment had to be measured, since there were no direct data on individual treatment duration. The contribution of false-positive diagnoses

of tuberculosis had to be considered. Putting everything into the pot, the public health burden of tuberculosis in India appears to be even higher than has often been assumed, thus representing a major challenge to both the public and private health sectors. The approach taken here seems to be useful, but is by no means equivalent to having the individual-level data one would wish for.

In an era of global concern about tuberculosis, including HIV co-infection and multiple drug-resistant organisms, complacency about gathering tuberculosis treatment data and establishing the corresponding magnitude of public health burdens is not acceptable.

An increasing number of countries with high tuberculosis burdens are also encountering growth in their private health sectors. Private sector involvement might not be a bad thing in itself, but mechanisms to extract reliable public health data from private health providers on tuberculosis and other diseases of public health concern are essential. Just as public health systems implicitly capture data as one of their intrinsic functions, public resources must be more eﬀ ectively deployed for capturing and curating data of public interest from the private sector.

Peter Byass

Umeå Centre for Global Health Research, Epidemiology & Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

peter.byass@umu.se

I declare no competing interests.

1 Rolnick J. Aggregate health data in the United States: steps toward a public good. Health Informatics J 2013; 19: 137–51.

2 Arinaminpathy N, Batra D, Khaparde S, et al. The number of privately treated tuberculosis cases in India: an estimation from drug sales data. Lancet Infect Dis 2016; published online Aug 24. http://dx.doi.org/10.1016/S1473- 3099(16)30259-6.

3 Centers for Disease Control. Reported tuberculosis in the United States, 2014. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control, 2015.

4 Balaban V, Marks SM, Etkind SC, et al. Tuberculosis elimination eﬀ orts in the United States in the era of insurance expansion and the Aﬀ ordable Care Act.

Public Health Rep 2015; 130: 349–54.

5 Gawde N. Do we need notiﬁ cation of tuberculosis? A public health perspective. Indian J Med Ethics 2013; 10: 56–58.

6 Thomas BE, Velayutham B, Thiruvengadam K, et al. Perceptions of private medical practitioners on tuberculosis notiﬁ cation: a study from Chennai, South India. PLoS ONE 2016; 11: e0147579.

7 Cowling K, Dandona R, Dandona L. Improving the estimation of the tuberculosis burden in India. Bull World Health Organ 2014; 92: 817–25.

Mark Williamson/Science Photo Library

Tuberculosis: a private and public health and data mix

http://www.diva-portal.org

This is the published version of a paper published in Lancet. Infectious diseases (Print).

Citation for the original published paper (version of record):

Byass, P. (2016)

Tuberculosis: a private and public health and data mix.

Lancet. Infectious diseases (Print), 16(11): 1206-1207 http://dx.doi.org/10.1016/S1473-3099(16)30334-6

Access to the published version may require subscription.

N.B. When citing this work, cite the original published paper.

Permanent link to this version:

http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-127507

Comment

incidences were large. These results support birth cohort eﬀ ects and higher rates of sexual infection in women postulated by prevalence studies.

They also suggest that HTLV-1 incidence will continue to fall in Japan as the higher risk cohorts age and die.

and Zou and colleagues

reported a rate of 3·6 per 100 000 person-years, quite similar to Satake’s estimate for Japan and about three times higher than in the USA, consistent with known HTLV-1 epidemiology.

Three other studies found much higher incidence, probably because they studied higher-risk populations, including a hyperendemic island in Okinawa, Japan (1·0 per 1000 person-years),

a sexually transmitted infection clinic in Jamaica (9·0 per 1000 person-years),

and a community sample with high HIV prevalence in Guinea-Bissau (1·7 per 1000 person-years).

are a practical and reasonable alternative for international comparisons and monitoring secular trends.

Sarah Mollenkopf, *Edward L Murphy

Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA (SM); Blood Systems Research Institute, San Francisco, CA, USA (SM, ELM); and University of California San Francisco, San Francisco, CA, USA (ELM) ed.murphy@ucsf.edu

Tuberculosis: a private and public health and data mix

The clue in the title lies in the phrase public health. Data for understanding the health status of communities and nations comprise a fundamental public good.

Public health data can only be captured and curated eff ectively if suffi cient resources and determination are deployed for the purpose. But, from private sector perspectives of profi ts and shareholders, it might seem entirely reasonable not to prioritise the collection of public health data.

In The Lancet Infectious Diseases, Nimalan Arinaminpathy and colleagues

Comment

Nevertheless, as in India, delivery of tuberculosis treatment is a public–private mix, with a quarter of clinical care for tuberculosis delivered through the private sector.

One has to assume in the USA that the procedures required of the private sector for notifying tuberculosis cases to the public authorities are suﬃ ciently robust and well-enforced.

India only made tuberculosis a notiﬁ able disease in 2012, following reports of multiple drug-resistant disease.

To what extent mandatory reporting has facilitated the extraction of reliable data from the private sector is uncertain, particularly given that half of private practitioners in a survey cited lack of time as a reason for failing to notify tuberculosis cases in Chennai.

But are such indirect methods appropriate and relevant?

Arinaminpathy and colleagues

chose to move their focus upstream from data at the patient-provider level to drug supply statistics. Since there is no single drug uniquely and solely indicated for treating tuberculosis, this approach involved some fairly brave assumptions.

Sales of drugs containing rifampicin were chosen as the key indicator on the basis of having fewer indications than other drugs for non-tuberculosis treatment.

Patient-months of treatment had to be measured, since there were no direct data on individual treatment duration. The contribution of false-positive diagnoses

In an era of global concern about tuberculosis, including HIV co-infection and multiple drug-resistant organisms, complacency about gathering tuberculosis treatment data and establishing the corresponding magnitude of public health burdens is not acceptable.

Peter Byass

peter.byass@umu.se

Sarah Mollenkopf, Edward L Murphy*