This article has Open Peer Review reports available.
Impact of DOTS expansion on tuberculosis related outcomes and costs in Haiti
- Vary Jacquet†1,
- Willy Morose†1,
- Kevin Schwartzman†2,
- Olivia Oxlade†2,
- Graham Barr†3,
- Franque Grimard†4 and
- Dick Menzies†2Email author
© Jacquet et al; licensee BioMed Central Ltd. 2006
Received: 10 February 2006
Accepted: 15 August 2006
Published: 15 August 2006
Implementation of the World Health Organization's DOTS strategy (Directly Observed Treatment Short-course therapy) can result in significant reduction in tuberculosis incidence. We estimated potential costs and benefits of DOTS expansion in Haiti from the government, and societal perspectives.
Using decision analysis incorporating multiple Markov processes (Markov modelling), we compared expected tuberculosis morbidity, mortality and costs in Haiti with DOTS expansion to reach all of the country, and achieve WHO benchmarks, or if the current situation did not change. Probabilities of tuberculosis related outcomes were derived from the published literature. Government health expenditures, patient and family costs were measured in direct surveys in Haiti and expressed in 2003 US$.
Starting in 2003, DOTS expansion in Haiti is anticipated to cost $4.2 million and result in 63,080 fewer tuberculosis cases, 53,120 fewer tuberculosis deaths, and net societal savings of $131 million, over 20 years. Current government spending for tuberculosis is high, relative to the per capita income, and would be only slightly lower with DOTS. Societal savings would begin within 4 years, and would be substantial in all scenarios considered, including higher HIV seroprevalence or drug resistance, unchanged incidence following DOTS expansion, or doubling of initial and ongoing costs for DOTS expansion.
A modest investment for DOTS expansion in Haiti would provide considerable humanitarian benefit by reducing tuberculosis-related morbidity, mortality and costs for patients and their families. These benefits, together with projected minimal Haitian government savings, argue strongly for donor support for DOTS expansion.
Between 1997 and 2002 the incidence of active TB increased in most low and middle income countries . This occurred despite the availability of adequate tools for diagnosis and treatment, and an effective TB control strategy – which has been labelled DOTS. This strategy, originally developed in sub-Saharan Africa, is being promoted by the World Health Organisation (WHO)  because it is feasible in high-burden settings , cost-effective even in low income countries , and can result in substantial reduction in TB incidence .
However, between $290 – $500 million (US) is required annually for the additional training, equipment and infrastructure needed to implement and maintain DOTS in all low and middle income countries [6, 7]. As a result DOTS expansion has lagged considerably behind WHO targets .
In the America's, Haiti is the poorest country , with the highest incidence of smear positive pulmonary TB (138/100,000 in 2002)  and HIV seroprevalence (4.5% in 2002) . In 2002 the WHO estimated that only 37% of the population had access to DOTS programmes , only 49% of all smear positive cases were diagnosed, and only 71% of those diagnosed were successfully treated . We have compared projected TB related outcomes and costs if the current control programme is maintained (status quo), or if DOTS is expanded to reach WHO benchmarks, for 100% of the population in Haiti.
General description of model and the two strategies compared
Summary of key input data for Haiti in 2002(All costs in US dollars)
Gross National Income annual per capita (US$)
Life expectancy at birth
All cause mortality
Incidence new smear positive TB per 100,000 (2001)
Annual risk of TB infection (ARI)
Calculated from  and 
Prevalence of LTBI at age 20
Calculated from 
Likelihood of diagnosis and treatment of LTBI
Completion of LTBI Treatment
Efficacy of 9 INH – INH Sensitive
Prevalence of HIV infection – 2002
Incidence of HIV infection
Calculated from 
DOTS Coverage – 2002
Case detection rate – 2001
Single drug resistance
Multi drug resistance (HR)
Treatment outcomes New cases – 2001
DOTS areas (NTP)
Outcomes Re-treatment cases – 2001
DOTS areas (NTP)
The strategies compared were to continue the present national TB control programme (status quo), or DOTS expansion. With the status quo strategy there would be no change over the 20 year time frame of the analysis, from January 2003 levels of: DOTS coverage , case finding , treatment outcomes , incidence of smear positive TB , prevalence of initial TB drug resistance [12, 13], and HIV seroprevalence . Since incidence of disease did not change with the status quo, risk of TB infection , and LTBI prevalence also remained unchanged throughout the period of analysis. Current levels of DOTS coverage have been achieved with assistance from foreign donors – hence we implicitly accounted for current foreign assistance. However, we did not explicitly add in these expenditures, since they would have been added to both strategies, making both more expensive, but without changing the differences between them.
With DOTS expansion, we assumed that DOTS would be expanded from the level of coverage in January 2003, (Year 1) , to reach 100% of government health facilities by the end of Year 3. Case detection would increase from current WHO estimated levels  to 70%, and treatment success (cure and treatment completion) to 85% – the WHO targets , although treatment failure and TB mortality would not change . Rates of initial drug resistance [12, 13] and HIV prevalence  would not change with DOTS over the full 20 years. DOTS implementation would halve pre-diagnostic health system visits [15, 16], and health system delays [17–19], although patient delays would not change. Hospitalisation duration would decrease by two-thirds [15, 16]. The number of patients investigated for each new case of TB diagnosed would increase from 4 to 16 . Retreatment failures (multi-drug resistant TB) would be treated with second line drugs obtained from the Green Light Committee  with 48% cure, and 12% mortality . Most importantly DOTS expansion was assumed to result in a 6% annual decline in incidence, as described in Peru following national DOTS implementation . This would produce corresponding reductions in the risk, and prevalence of TB infection .
Health states and transitional probabilities (see Figure 1)
At the start of Year 1 (assumed to be 2003), cohort members were considered to be in one of five TB-related states, and one of three HIV-related states. The TB-related states were: 1) no tuberculosis infection; 2) recent latent tuberculosis infection (LTBI) – acquired within 2 years; and, 3) long-standing LTBI – acquired more than 2 years ago; 4) active tuberculosis; and, 5) treated, or spontaneously resolved active TB. States 2–5 were further sub-classified into 3 groups: drug-sensitive, single-drug resistant, or multi-drug resistant TB – with likelihood based on surveys of drug resistance in Haitian populations [12, 13]. The proportion with recent or long-standing LTBI was calculated based on the age structure of the population , and incidence of smear-positive active disease , using the Styblo formula .
Probabilities of outcomes with different TB and HIV health states
Reactivation from latent TB infection
Present more than 2 years ("long-standing LTBI")*
0.1% – 0.2%/year
HIV infected – asymptomatic
3.4% – 8.7%
HIV infected – AIDS
33% – 67%
Within 2 years of new TB infection ("recent LTBI")
2% – 15%
HIV infected – asymptomatic
33% – 100%
HIV infected – AIDS
50% – 100%
Within 2 years following re-infection
33% or 100%
Outcomes of untreated smear positive TB
Mortality – 1 year, & 2 years
33%, & 50%
Relapse after spontaneous remission
1.3% – 2.5%/year
Outcomes of treated smear positive TB
Relapse after cure (total over next 2 years)
1.5% – 5%
Cure rate if default (SDR or drug sensitive) **
Effect of drug sensitivity or treatment outcomes
Relative risk of failure/if single drug resistant
Relative risk of failure/if multi-drug resistant
Relative risk of death/if single drug resistant
Relative risk of death/if multi-drug resistant
If MDR – Probability of cure with treatment
- Probability of death with treatment
HIV Infected and TB
Average duration of HIV infection – Total
- Time spent in HIV asymptomatic state
Annual risk of progression of asymptomatic HIV to AIDS
Annual risk of death from HIV: HIV asymptomatic state
Annual risk of death from HIV: AIDS
Effect of prior active TB on relative risk of death from HIV
(2.2 – 4.0)
Effect of HIV infection on relative risk of death during TB treatment (drug sensitive or single drug resistance)
Relapse after successful TB treatment (cured)
3.1% – 6.4%
The probability of transfer out and default varied by strategy. We assumed that the treatment outcome of "transferred-out" was equivalent to default . For individuals who defaulted from therapy we assumed an overall cure rate of 62%, calculated from the proportion of defaulters after different lengths of therapy , and cure rates in randomised trials of regimens of 3 or 4 months duration [32–34].
The HIV-related states were: 1) no HIV infection; 2) early HIV, defined as having no clinical manifestations; or, 3) late HIV infection – defined as clinical AIDS. HIV-related survival and annual rates of transition from early to late HIV states were based on a Ugandan cohort . Probability of acquiring HIV infection was the same in both strategies. Annual risk of HIV infection was estimated to be 0.49% – calculated from the general population prevalence  divided by the average years of survival in a low-income setting  (and thus assumed to be uniform for the entire population). We assumed no consequence of HIV re-infection.
The same model was used for HIV infected or uninfected. The proportion of HIV infected persons entering the model was 0.045 – corresponding to the estimated seroprevalence in Haiti in 2002 (10). Every year, 0.5% of the uninfected population could acquire new HIV infection, thus changing from an HIV uninfected to an HIV infected state. The major difference in the model for HIV infected and uninfected was in regard to the probability of development of active TB following TB infection and mortality – without TB, or during and after treatment for active TB. The risk of active TB in persons with LTBI, and HIV infection has been studied in a number of settings. We could find only one study that categorized cohort members into the states of new or old TB infection and early or late HIV . This was used for the base case estimate of 3.4% annual risk of active TB disease in persons with long-standing LTBI and HIV infection.
We could not find published estimates of risk of disease following new TB infection in HIV infected individuals. Therefore we extrapolated from HIV negative persons, in whom the risk of development of active TB following new LTBI infection is 20–50 times higher than with long-standing LTBI [24–26]. Given the 3.4% annual risk of active TB in early HIV infection and long-standing LTBI , we assumed the risk of TB disease would be 10 times higher, or 34% per year during the first two years following new TB infection.
Response to treatment of TB disease was not affected by HIV infection. HIV-infected individuals with smear positive active TB were assumed to have no chance of spontaneous cure – hence 100% mortality without treatment. If treated, TB mortality would be 2.25 times higher during treatment [37–39], and 2.2 times higher after treatment [3, 40, 41]. Mortality from active TB disease with MDR strains would be 100% [42, 43].
Beginning in 2003 (Year 1), the model determined the proportion of the cohort developing smear positive active TB, dying from TB, or dying from other causes in each year for 20 successive years. The risk of death from other causes was derived from the age distribution and HIV sero-prevalence of the cohort, and country-specific life tables published by WHO . The probability of TB related outcomes depended on cohort members' TB and HIV related states (infected or not, and new or old), as detailed above, and summarized in Table 2. Clinical outcomes also varied according to whether each TB related state was diagnosed and treated.
Cohort members who survived to the end of each year in the model, entered the following year of the simulation. Health states at the beginning of each year depended on the events during the preceding year. As a (simplified) example, some members of the cohort entered Year 1 in the health state of no TB infection. If they survived Year 1 without acquiring TB or HIV infection they entered Year 2 in the same state. However if they acquired new TB infection during Year 1, they entered Year 2 in the "new TB infection" state. During Year 2, they could develop active TB (with probability as shown in Table 2), die from other causes, or remain with new TB infection (entering Year 3 with this health state). If they developed active TB they could be diagnosed and treated, or remain undiagnosed. Likelihood of diagnosis, and treatment outcomes varied according to the strategy being analyzed (see Table 1), and underlying drug resistance. The probability of having pan- sensitive, single drug resistant, or multi-drug resistant underlying strains, was determined from two surveys of initial drug resistance in Haitian TB patients [12, 13]. If undiagnosed they could die of TB (probability in Table 2) or other causes (from Life Tables), or survive and enter Year 3 with undiagnosed TB disease.
The model generated a single value for the cumulative proportion of the cohort that developed active TB, died of TB, or died of other causes throughout the 20 years for each strategy. This was then multiplied by the size of the population to generate expected total number of persons developing each outcome over the period of analysis.
Costs were estimated from societal, and governmental perspectives . Costs modelled from the government perspective included TB-related health care costs for governments and health care providers, plus costs for DOTS implementation, maintenance, and drug costs. TB related costs from the societal perspective included government costs, plus patients' and families' out-of-pocket expenditures, lost wages (including time caring for ill family members), plus productivity losses resulting from disability and death . All costs were expressed in 2003 US dollars, and all future expenditures and outcomes were discounted 3% annually .
A questionnaire regarding the household impact of fatal adult illness  was adapted, pre-tested in Montreal, and translated into French and Creole – to measure out-of-pocket costs and lost income for patients and families for pre-diagnostic, hospitalisation, treatment and follow-up visits. This was administered by trained interviewers to 84 consenting adults in their second and third months of therapy for new smear positive pulmonary TB, at the same facilities where health system costs were ascertained. To estimate government TB expenditures, we surveyed administrators of 8 rural, and 8 urban health facilities, including 3 TB sanatoria, 5 general hospitals, 5 general clinics, and 3 TB dispensaries. This study was approved by the Institutional Review Board of McGill University, and the National TB control programme of Haiti.
Costs for DOTS implementation and maintenance were based on a DOTS expansion project in Ecuador , pro-rated to Haiti, based on their respective per capita gross national incomes . Drug costs were calculated from the model estimates of number of new and retreatment cases, and unit costs from the Global Drug Facility . Patients with active TB were assumed to be 50% disabled (productivity loss) from symptom onset until diagnosis, unable to work while hospitalised, and 50% disabled for the remainder of the first two months of treatment [17–19]. Patients who were not diagnosed or who failed treatment were assumed to have 50% disability throughout their illness. Productivity loss from death in HIV uninfected was estimated as per capita annual income  times the number of years remaining in the model, with appropriate discounting . For HIV infected the productivity loss was estimated based on the number of years they would be anticipated to survive after development of active TB based on total survival of 9.8 years (35) and the number of years they had survived with HIV infection before developing active TB.
We conducted extensive one-way sensitivity and threshold analyses, to assess the robustness of our findings to variations in key assumptions. Each parameter was varied individually, except for pathogenetic parameters that were based on well characterized, carefully studied cohorts. We examined the effect of varying rates of decline in tuberculosis incidence following DOTS expansion, increasing HIV seroprevalence and drug resistance, case detection rate, and higher costs of DOTS implementation, maintenance and drugs. Where possible, sensitivity analyses reflected ranges from the published literature. If these were not available, other variations were used such as halving or doubling costs. We also modelled composite "best case" and "worst case" scenarios, based on combinations of favourable and unfavourable assumptions for influential model assumptions – reflecting findings of the initial one-way sensitivity analyses.
Summary of health system and patient costs in Haiti
Total Time (onset of symptoms to diagnosis)
Number of Visits
Cost to health system for visits (total)
Lab costs (per patient – 3AFB smears)
Patients out-of-pocket: for visits (total)
Lost income for patient/family: for visits
N (%) hospitalized
Average length of stay (for all 84)
Health system costs (per patient)
Patient out-of-pocket (per hospitalization)
Lost income for patients and family
Direct Observation of Treatment (DOT)
Number of visits
N (%) on DOT
Health system costs: for DOT (total)
For drug costs (new case)
Patient out-of-pocket expenses (total)
Lost income for patient and family
Follow-up (Medical Check Up)
Number of visits
Health system costs (total)
Patient out-of-pocket expenses
Lost income for patient and family
Total cost per TB patient treated
Patient and Family: out-of-pocket costs
Total patients and families
Projected cumulative TB incidence, related mortality, and costs with two strategies for TB control in Haiti: base case analysis
TOTAL COSTS (SAVINGS) ($US MILLIONS)
TOTAL TB CASES
TOTAL TB DEATHS
AFTER ONLY 5 YEARS
- Status Quo
- DOTS expansion
- Cases or deaths averted and added costs or (net savings) with DOTS
AFTER 10 YEARS
- Status Quo
- DOTS expansion
- Cases or deaths averted and added costs or (net savings) with DOTS
Over Full 20 Years
- Status Quo
- DOTS expansion
- Cases or deaths averted and (net savings) with DOTS
We project a reduction in government expenditures for hospital services from $38 million to $22 million. However these savings would be offset by the need for initial investment for DOTS expansion, plus increased recurrent government expenditures for smear microscopy, directly observed treatment, multi-drug resistant (MDR) TB treatment, supervision, training, and quality control. As a result, net government savings are projected to be only $4 million over the full 20 years.
Sensitivity analysis for projected savings over 20 years with DOTS expansion in Haiti
SAVINGS in $US MILLIONS WITH DOTS EXPANSION *
Base Case (from Table 4)
Initial DOTS investment
$8.4 million total
Annual DOTS maintenance
$722,000 per year
Annual DOTS maintenance + cost of TB drugs
$847,900 per year
Foreign Donor Pays: Initial + annual + TB drugs
Eliminate all three
$8.44 million + $847,000 per year
Change average duration of hospitalization
Decrease with DOTS, increase with Non-DOTS
3 days – DOTS 60 days non-DOTS
Single (SDR) and Multi (MDR) Drug resistance
Double prevalence of drug resistance
SDR : 40% MDR : 0.6%
Impact of DOTS expansion on TB incidence in subsequent years
1/3 of base
2/3 of base
0% annual decline
2% annual decline
4% annual decline
$ 14 *
We project that DOTS expansion in Haiti, to reach WHO targets, would cost an initial $4.2 million and result in 28% reduction in TB cases, 49% reduction in mortality and net societal savings of $131 million over 20 years. However, we project that the Haitian government would have to make significant initial investment and only begin to achieve savings after 15 years. Taken together, these findings should provide a powerful argument for foreign donors to support initial DOTS expansion in Haiti.
Several findings deserve comment. We have projected savings totalling $26 million for patients and their families from DOTS expansion. Among the patients surveyed, direct out-of-pocket expenditures and lost income represented 49% and 27% respectively of the average yearly per capita income in Haiti. And patients surveyed also reported a substantial drop in income at the time of the survey compared to prior to onset of their illness. Savings are anticipated with DOTS expansion, because the decentralisation of diagnostic and treatment services should result in faster diagnosis [17–19], reduced hospitalisation [15, 16], and reduced out-of-pocket expenses for treatment and follow-up. Such projected benefits should make DOTS expansion a top priority for donors supporting the Millennium Development goal of poverty reduction .
The estimated current government expenditures of $432 per TB patient were surprisingly high – very close to the average per capita income of $440 . We project potential savings from reduced hospitalization, but these will only be realized if hospital expenditures are actually reduced (i.e., by closing beds and reducing staffing). As well any such savings will be offset by increased expenditures for directly observed treatment, and staff supervision, quality control and training. These costly activities are essential for maintenance of a proper DOTS programme , but are not necessarily components of TB control programmes prior to DOTS expansion. Therefore new positions must be created, and new workers found with different knowledge and skills – a formidable challenge in many low-income countries. And, immediate government expenditures are required, while savings will only begin after 15 years. As Harold Wilson pointed out "a week is a long time in politics"; most governments will consider 15 years far too long to wait for a payback. Hence, there is little immediate incentive for the Haitian government to implement DOTS.
Another important component of projected government expenditures following DOTS expansion will be lab costs, totalling $9.6 million, or 17% of all TB related government expenditures over 20 years. This reflects the high labour costs for smear microscopy , which can take up to 20 minutes of technician time per specimen . In Peru only 2% of TB suspects investigated are smear positive , meaning that up to 150 negative smears are examined for each new case found. If treatment success exceeds 85%, enhanced case detection is essential for the long-term epidemiologic impact of DOTS, given the high mortality, and contagiousness of undiagnosed cases. However, given our projections of substantial expenditures for smear microscopy, a high priority should be given to replacing this labour intensive cornerstone of the DOTS strategy.
This study is novel in that we conducted direct surveys to ascertain costs of health facilities, the national TB programme, and TB patients themselves. In this impoverished nation, patient and government expenditures for TB are remarkably high. We combined this direct data gathering with estimates of disability, costs for DOTS expansion, and TB drugs from published experience elsewhere. Additional strengths include the complex decision analysis model which incorporated five TB related health states (with one of three underlying TB drug resistance states) and three HIV related health states within the same model. As well published estimates of risk of TB and HIV infection, HIV progression, development and outcomes of active TB, and mortality were used.
However, there were a number of important potential limitations of this decision analysis. These included our assumptions regarding impact of DOTS on incidence, prevalence of HIV and drug resistance, stability of the population, methods of calculation of annual risk of infection, and costs for DOTS expansion. The assumption that incidence would decline 6% annually following DOTS expansion was based on observations in Peru after nationwide DOTS implementation . This rate of decline is midway between two recent estimates – of 4.3% annually observed with DOTS in China , and 7.5% annually predicted for countries achieving WHO targets . And, in sensitivity analyses, societal savings were still substantial even with the extreme assumption of no change in incidence at all. We calculated annual risk of new TB infection from estimated incidence using the Styblo formula  – which has been criticized . However, the same formula was applied to both strategies in all years, so inaccuracies in the estimate of infection rates would have been similar for both strategies. We may have over-estimated societal savings because we did not account for other illnesses causing health care costs or disability among those who survived with active TB. However these potential costs should be relatively low since the average age of the patients with active TB in Haiti was 34 so that even those with the most gains in survival would only be 54 by the end of 20 years. As well we did account for mortality from HIV infection (from published studies), and all other causes (from WHO life tables for the general population of Haiti). Thus the most important future societal costs among the added survivors with DOTS, were accounted for in the analysis.
Costs for DOTS expansion are difficult to estimate as there is little published experience to date. For this analysis, costs for expansion were based on published experience in Ecuador . Given the social, economic, and epidemiologic differences between Ecuador and Haiti, these estimates may not be considered valid for Haiti. However these estimated costs were higher than actual costs incurred for a DOTS expansion project in India  where the economic situation is very similar to Haiti .
A very important limitation of our analysis is the assumption that basic government health services would continue to operate. Therefore we only accounted for the additional costs of DOTS expansion and maintenance. Continued basic government health services in Haiti, depends upon political stability, which is among the worst in the Americas. This problem has contributed to the current problems of the national TB control programme. But, the DOTS strategy has been successfully implemented and maintained amidst major civil conflicts in Mozambique and Nicaragua. Therefore we believe our findings should not be dismissed as overly optimistic by foreign donors considering investment in TB control in Haiti.
We assumed that HIV seroprevalence would remain constant over the next 20 years even though HIV seroprevalence has risen in most developing countries over the past two decades. However if HIV seroprevalence did increase, with a corresponding increased incidence of TB, societal saving would be greater with DOTS (Figure 3), because of improved case detection with corresponding reduction in mortality of undiagnosed active TB in HIV infected. We did not model the potential effect of large scale provision of antiretroviral therapy (ART). This is just being introduced in Haiti and other low income countries, so the costs, efficacy, and population impact of ART are currently unknown. Our assumption of unchanged drug resistance may be incorrect. However, in sensitivity analysis, even when the prevalence of drug resistance was doubled, results were very similar. We also assumed no population growth for Haiti, despite current annual growth of 1.4% . However, a larger population would simply mean more new infections, and new active cases – with either strategy. And, as with higher HIV sero-prevalence, DOTS would be even more cost-saving relative to the status quo strategy.
We have projected that DOTS expansion in Haiti could prevent a large number of TB cases, and TB deaths, with substantial resultant societal savings. But this would require significant Haitian government investment – which may be difficult to ensure, given current political instability and the prospect of little payback after many years. Given this, and the substantial potential humanitarian, economic, and public health benefits, we conclude that foreign donors should strongly consider investing in DOTS expansion in Haiti.
We are grateful to many staff of the National TB Programme in Haiti, Sarah Hoibak for assistance in the health facility and patient costs questionnaire, Jason McKnight for assistance in data analysis, and Catherine Michaud for seemingly endless revisions of this manuscript.
Supported by a grant from the Rockefeller Foundation Drs. Schwartzman and Menzies are recipients of research career awards from the Fonds de Recherche en Santé du Québec. Dr. Barr is the recipient of a Robert Wood Johnson Generalist Physician Faculty Scholar Award.
- Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, Raviglione MC, et al: The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med. 2003, 163 (9): 1009-1021. 10.1001/archinte.163.9.1009.View ArticlePubMedGoogle Scholar
- Kochi A: The global tuberculosis situation and the new control strategy of the World Health Organization. Tuberc. 1991, 72: 1-6. 10.1016/0041-3879(91)90017-M.View ArticleGoogle Scholar
- World Health Organization: Treatment of Tuberculosis: Guidelines for National Programmes. Geneva. 1997, SecondGoogle Scholar
- Murray CJL, Styblo K, Rouillon A: Tuberculosis in developing countries: burden, intervention and cost. Bull Int Union Against Tuberculosis. 1990, 65 (1): 2-20.Google Scholar
- Suarez PG, Watt CJ, Alarcon E, Portocarrero J, Zavala D, Canales R, et al: The dynamics of tuberculosis in response to 10 years of intensive control effort in Peru. J Infect Dis. 2001, 184: 473-478. 10.1086/322777.View ArticlePubMedGoogle Scholar
- Floyd K, Blanc L, Raviglione M, Lee JW: Resources required for global tuberculosis control. Science. 2002, 295 (5562): 2040-2041. 10.1126/science.1069771.View ArticlePubMedGoogle Scholar
- Sachs J: Macroeconomics and Health: Investigating in Health for Economic Development. World Health Organization. 2001Google Scholar
- World Health Organization: Global Tuberculosis Control: Surveillance, Planning, Financing. WHO Report. 2003, Geneva, SwitzerlandGoogle Scholar
- The World Bank Group. Haiti Data Profile. 12-8-2003. [http://devdata.worldbank.org/external/CPProfile.asp?CCODE=HTI&PTYPE=CP]
- UNAIDS: Joint United Nations Programme on HIV/AIDS. 2002, [http://www.unaids.org/EN/default.asp#]Google Scholar
- Lee JW, Espinal M, Jaramillo E: Report of site visit to evaluate DOTS expansion in Latin America. World Health Organization, editor. 2002Google Scholar
- Pitchenik AE, Russell BW, Cleary T, Pejovic I, Cole C, Snider D: The prevalence of tuberculosis and drug resistance among Haitians. N Engl J Med. 1982, 307 (3): 162-165.View ArticlePubMedGoogle Scholar
- Scalcini M, Carré G, Jean-Baptiste M, Hershfield E, Parker S, Wolfe J, et al: Antituberculosis drug resistance in Central Haiti. Am Rev Respir Dis. 1990, 142: 508-511.View ArticlePubMedGoogle Scholar
- Styblo K: The relationship between the risk of tuberculosis infection and the risk of developing infectious tuberculosis. Bull Int Union Tuberc. 1985, 60 (3–4): 117-119.Google Scholar
- Floyd K, Skeva J, Nyirenda T, Gausi F, Salaniponi F: Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe District, Malawi. Int J Tuberc Lung Dis. 2003, 7 (9 Suppl 1): S29-S37.PubMedGoogle Scholar
- Floyd K, Wilkinson D, Gilks C: Comparison of cost effectiveness of directly observed treatment (DOT) and conventionally delivered treatment for tuberculosis: experience from rural South Africa. BMJ. 1997, 315 (7120): 1407-1411.View ArticlePubMedPubMed CentralGoogle Scholar
- Sherman LF, Fujiwara PI, Cook SV, Bazerman LB, Frieden TR: Patient and health care system delays in the diagnosis and treatment of tuberculosis. Int J Tuberc Lung Dis. 1999, 3 (12): 1088-1095.PubMedGoogle Scholar
- Yamasaki-Nakagawa M, Ozasa K, Yamada N, Osuga K, Shimouchi A, Ishikawa N, et al: Gender diference in delays to diagnosis and health care seeking behaviour in a rural area of Nepal. Int J Tuberc Lung Dis. 2001, 5 (1): 24-31.PubMedGoogle Scholar
- Wandwalo ER, Mørkve O: Delay in tuberculosis case-finding and treatment in Mwanza, Tanzania. Int J Tuberc Lung Dis. 2000, 4 (2): 133-138.PubMedGoogle Scholar
- Caminero Luna JA: Guia de la Tuberculosis para Medicos Especialistas. Union Internacional contra la Tuberculosis y Enfermedades Respiratorias (UICTER), editor. 6432. 2003, Imprime en France, Imprimerie Chirat, Depot Legal 2003 No 6432Google Scholar
- Gupta R, Cegielski JP, Espinal MA, Henkens M, Kim JY, Lambregts-van Weezenbeek CSB, et al: Increasing transparency in partnerships for health – introducing the Green Light Committee. Tropical Medicine and International Health. 2002, 7 (2): 970-976. 10.1046/j.1365-3156.2002.00960.x.View ArticlePubMedGoogle Scholar
- Suarez PG, Floyd K, Portocarrero J, Alarcon E, Rapiti E, Ramos G, et al: Feasibility and cost-effectiveness of standardised second-line drug treatment for chronic tuberculosis patients: a national cohort study in Peru. Lancet. 2002, 359 (9322): 1980-1989. 10.1016/S0140-6736(02)08830-X.View ArticlePubMedGoogle Scholar
- CIA – The World Factbook. CIA – The World Factbook. 12-9-2003. Washington, DC, Central Intelligence Agency – USA, [http://www.cia.gov/cia/publications/factbook/geos/ha.html]
- Sutherland I: The evolution of clinical tuberculosis in adolescents. Tuberc. 1966, 47: 308-Google Scholar
- Van Zwanenberg D: The Influence of the number of bacilli on the development of tuberculous disease in children. Am Rev Respir Dis. 1960, 82: 31-44.PubMedGoogle Scholar
- Ferebee SH: Controlled chemoprophylaxis trials in tuberculosis. Adv Tuberc Res. 1969, 17: 28-106.Google Scholar
- Menzies D: Issues in the management of contacts of patients with active pulmonary tuberculosis. Can J Public Health. 1997, 88 (3): 197-201.PubMedGoogle Scholar
- Comstock GW, Edwards LB, Livesay VT: Tuberculosis morbidity in the US Navy: its distribution and decline. Am Rev Respir Dis. 1974, 110: 572-580.PubMedGoogle Scholar
- Nolan CM, Elarth AM: Tuberculosis in a cohort of Southeast Asian refugees: A five-year surveillance study. Am Rev Resp Dis. 1988, 137: 805-809.View ArticlePubMedGoogle Scholar
- Cummings KC, Mohle-Boetani J, Royce SE, Chin DP: Movement of tuberculosis patients and the failure to complete antituberculosis treatment. Am J Respir Crit Care Med. 1998, 157 (4 Pt 1): 1249-1252.View ArticlePubMedGoogle Scholar
- Chee CBE, Boudville IC, Chan SP, Zee YK, Wang YT: Patient and disease characteristics, and outcome of treatment defaulters from the Singapore TB control unit – a one-year retrospective survey. Int J Tuberc Lung Dis. 2000, 4 (6): 496-503.PubMedGoogle Scholar
- Parthasarathy R, Prabhakar R, Somasundaram PR: A controlled clinical trial of 3- and 5-month regimens in the treatment of sputum-positive pulmonary tuberculosis in South India. Am Rev Respir Dis. 1986, 134: 27-33.Google Scholar
- East African/British Medical Research Councils Study: Controlled clinical trial of five short-course (4-month) chemotherapy regimens in pulmonary tuberculosis: Second report of the 4th study. Am Rev Respir Dis. 1981, 123: 165-170.Google Scholar
- Singapore Tuberculosis Service/British Medical Research Council: Long-term Follow-up of a clinical trial of six-month and four-month regimens of chemotherapy in the treatment of pulmonary tuberculosis. Am Rev Respir Dis. 1986, 133: 779-783.Google Scholar
- Morgan D, Mahe C, Mayanja B, Okongo JM, Lubega R, Whitworth JA: HIV-1 infection in rural Africa: is there a difference in median time to AIDS and survival compared with that in industrialized countries?. AIDS. 2002, 16 (4): 597-603. 10.1097/00002030-200203080-00011.View ArticlePubMedGoogle Scholar
- Wood R, Maartens G, Lombard CJ: Risk factors for developing tuberculosis in HIV-1 – Infected adults from communities with low or very high incidence of tuberculosis. J Acquir Immune Defic Syndr. 2000, 23: 75-80.View ArticlePubMedGoogle Scholar
- Murray J, Sonnenberg P, Shearer SC, Godgrey-Faussett P: Human immunodeficiency virus and outcome of treatment for new and recurrent pulmonary tuberculosis in African patients. Am J Respir Crit Care Med. 1999, 159: 733-740.View ArticlePubMedGoogle Scholar
- Chaisson RE, Clermont HC, Hole EA, Cantave M, Johnson MP, Atkinson J, et al: Six-month supervised intermittent tuberculosis therapy in Haitian patients with and without HIV infection. Am J Respir Crit Care Med. 1996, 154: 1034-1038.View ArticlePubMedGoogle Scholar
- Desvarieux M, Hyppolite PR, Johnson WD, Pape JW: A novel approach to directly observed therapy for tuberculosis in an HIV-endemic area. Am J Public Health. 2001, 91 (1): 138-141.View ArticlePubMedPubMed CentralGoogle Scholar
- Whalen C, Horsburgh CR, Hom D, Lahart C, Simberkoff M, Ellner J: Accelerated course of human immunodeficiency virus infection after tuberculosis. Am J Respir Crit Care Med. 1995, 151: 129-135.View ArticlePubMedGoogle Scholar
- Connolly C, Reid , Davies G, Sturm W, McAdam K, Wilkinson D: Relapse and mortality among HIV-infected and uninfected patients with tuberculosis successfully treated with twice weekly directly observed therapy in rural South Africa. AIDS. 1999, 13: 1543-1547. 10.1097/00002030-199908200-00015.View ArticlePubMedGoogle Scholar
- Beck-Sague C, Dooley SW, Hutton MD, Otten J, Breedan A, Crawford JT, et al: Hospital outbreak of multi-drug resistant Mycobacterium tuberculosis infections: Factors in transmission to staff and HIV-infected patients. JAMA. 1992, 268: 1280-1286. 10.1001/jama.268.10.1280.View ArticlePubMedGoogle Scholar
- Edlin BR, Tokars JI, Grieco MH, Crawford JT, Williams J, Sordillo EM, et al: An outbreak of multi-drug resistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome. New Engl J Med. 1992, 326 (23): 1514-1521.View ArticlePubMedGoogle Scholar
- Lopez AD, Salomon J, Ahmad O, Murray CJL, Mafat D: Life Tables for 191 Countries: Data, Methods and Results. 2000, Geneva, World Health Organization (GPE Discussion Paper Series: No.9)Google Scholar
- Drummond MF, O'Brien B, Stoddart GL, Torrance GW: Methods for the economic evaluation of health care programmes. 1997, New York: Oxford University Press, 2Google Scholar
- Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB: Recommendations of the Panel on Cost-Effectiveness in Health and Medicine. JAMA. 1996, 276 (15): 1253-1258. 10.1001/jama.276.15.1253.View ArticlePubMedGoogle Scholar
- Ainsworth M, Koda G, Lwihula G, Mujinja P, Over M, Semali I: Measuring the Impact of Fatal Adult Illness in Sub-Saharan Africa – An Annotated Household Questionnaire. LSMS Living Standards Measurements Study Working Paper No.90. 1992, Washington, DC, The World BankGoogle Scholar
- Vaca J, Peralta H, Gresely L, Cordova R, Kuffo D, Romero E, et al: DOTS implementation in a middle income country – Development and evaluation of a novel approach. Int J Tuberc Lung Dis. 2005, 9 (5): 521-527.PubMedGoogle Scholar
- World Bank Website. 2004, Access date: April 15, 2004, [http://www.worldbank.org/data/countrydata/countrydata.html]
- Global Drug Facility: First-Line tuberculosis drugs& formulations currently supplied/to be supplied by the global TB drug facility. World Health Organization, editor. 2003, Access date: November 15, 2003, [http://stoptb.org/gdf/drugsupply/drugs_available.asp]Google Scholar
- The World Bank Group: Achieving the MDG's and related outcomes: A framework for monitoring policies and actions. 2004, [http://www.developmentgoals.org/]Google Scholar
- Management of Tuberculosis: A guide for low income countries. 2000, International Union Against Tuberculosis and Lung Disease, FifthGoogle Scholar
- Roos BR, van Cleeff MRA, Githui WA, Kivihya-Ndugga L, Odhiambo JA, Kibuga DK, et al: Cost-effectiveness of the polymerase chain reaction versus smear examination for the diagnosis of tuberculosis in Kenya: a theoretical model. Int J Tuber Lung Dis. 1997, 2 (3): 235-241.Google Scholar
- Suarez P: Government of Peru MoH. Tuberculosis en el Perú Informe 2000. 2001, Lima, PeruGoogle Scholar
- The effect of tuberculosis control in China. Lancet. 2004, 364 (9432): 417-422. 10.1016/S0140-6736(04)16764-0.Google Scholar
- Elzinga G, Raviglione MC, Maher D: Scale up: meeting targets in global tuberculosis control. Lancet. 2004, 363 (9411): 814-819. 10.1016/S0140-6736(04)15698-5.View ArticlePubMedGoogle Scholar
- Borgdorff MW: Annual risk of tuberculous infection: time for an update?. Bull World Health Organ. 2002, 80 (6): 501-502.PubMed CentralGoogle Scholar
- Khatri GA, Frieden TR: Controlling Tuberculosis in India. N Engl J Med. 2002, 347 (18): 1420-1425. 10.1056/NEJMsa020098.View ArticlePubMedGoogle Scholar
- Burgess AL, Fitzgerald DW, Severe P, Joseph P, Noel E, Rastogi N, et al: Integration of tuberculosis screening at an HIV voluntary counselling and testing centre in Haiti. AIDS. 2001, 15: 1875-1879. 10.1097/00002030-200109280-00018.View ArticlePubMedGoogle Scholar
- Dasgupta K, Schwartzman K, Marchand R, Tannenbaum TN, Brassard P, Menzies D: Comparison of cost effectiveness of tuberculosis screening of close contacts and foreign-born populations. Am J Respir Crit Care Med. 2000, 162 (6): 2079-2086.View ArticlePubMedGoogle Scholar
- Comstock GM: How much isoniazid is needed for prevention of tuberculosis in immunocompetent adults. Int J Tuberc Lung Dis. 1999, 3 (10): 847-850.PubMedGoogle Scholar
- Nolan CM, Aitken ML, Elarth AM, Anderson KM, Miller WT: Active tuberculosis after isoniazid chemoprophylaxis of Southeast Asian refugees. Am Rev Respir Dis. 1986, 133: 431-436.PubMedGoogle Scholar
- Dye C, Espinal MA, Watt CJ, Mbiaga C, Williams BG: Worldwide incidence of multidrug-resistant tuberculosis. J Infect Dis. 2002, 185 (8): 1197-1202. 10.1086/339818.View ArticlePubMedGoogle Scholar
- Whalen CC, Johnson JL, Okwera A, Hom DL, Huebner R, Mugyenyi P, et al: A trial of three regimens to prevent tuberculosis in Ugandan adults infected with the human immunodeficiency virus. N Engl J Med. 1997, Uganda-Case Western Reserve University Research Collaboration, 337 (12): 801-808. 10.1056/NEJM199709183371201.Google Scholar
- Guelar A, Gatell JM, Verdejo J, Podzamczer D, Lozano L, Aznar E, et al: A prospective study of the risk of tuberculosis among HIV-infected patients. AIDS. 1993, 7: 1345-1349.View ArticlePubMedGoogle Scholar
- Grzybowski S, Barnett GD, Styblo K: Contacts of cases of active pulmonary tuberculosis. Bull IUAT. 1975, 50: 90-106.Google Scholar
- Fischl MA, Uttamchandani RB, Daikos L, Poblete RB, Moreno JN, Reyes RR, et al: An outbreak of tuberculosis caused by multiple-drug resistant tubercle bacilli among patients with HIV infection. Ann Intern Med. 1992, 117: 177-183.View ArticlePubMedGoogle Scholar
- Small P, Shafer R, Hopewell P: Exogenous reinfection with multidrug-resistant Mycobacterium tuberculosis in patients with advanced HIV infection. N Engl J Med. 1993, 328: 1137-1144. 10.1056/NEJM199304223281601.View ArticlePubMedGoogle Scholar
- Daley CL, Small PM, Schecter GF, Schoolnik GK, McAdam RA, Jacobs WR, et al: An outbreak of tuberculosis with accelerated progression among persons infected with the human immunodeficiency virus. New Engl J Med. 1992, 326 (4): 231-235.View ArticlePubMedGoogle Scholar
- Stead WW: Management of health care workers after inadvertent exposure to tuberculosis: A guide for use of preventive therapy. Ann Intern Med. 1995, 122: 906-912.View ArticlePubMedGoogle Scholar
- Rieder HL: Epidemiologic basis of tuberculosis control. 1999, Paris, France, International Union Against Tuberculosis and Lung Disease, 1-162. FirstGoogle Scholar
- Grzybowski S, Enarson DA: The fate of cases of pulmonary tuberculosis under various treatment programmes. Bull Int Union Tuberc. 1978, 53 (2): 70-74.PubMedGoogle Scholar
- Horwitz O: Public health aspects of relapsing tuberculosis. Am Rev Respir Dis. 1969, 99: 183-193.PubMedGoogle Scholar
- Cohn DL, Catlin BJ, Peterson KL, Judson FN, Sbarbaro JA: A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen. Ann Intern Med. 1990, 112 (6): 407-415.View ArticlePubMedGoogle Scholar
- Results at 5 years of a controlled comparison of a 6-month and a standard 18-month regimen of chemotherapy for pulmonary tuberculosis. Am Rev Respir Dis. 1977, 116 (1): 3-8.Google Scholar
- Somner AR: Short-course chemotherapy in pulmonary tuberculosis. A controlled trial by the British Thoracic Association (third report). Lancet. 1980, 1 (8179): 1182-1183.PubMedGoogle Scholar
- Controlled clinical trial comparing a 6-month and a 12-month regimen in the treatment of pulmonary tuberculosis in the Algerian Sahara. Algerian working group/British Medical Research Council cooperative study. Am Rev Respir Dis. 1984, 129 (6): 921-928.Google Scholar
- Benator D, Bhattacharya M, Bozeman L, Burman W, Cantazaro A, Chaisson R, et al: Rifapentine and isoniazid once a week versus rifampicin and isoniazid twice a week for treatment of drug-susceptible pulmonary tuberculosis in HIV-negative patients: a randomised clinical trial. Lancet. 2002, 360 (9332): 528-534. 10.1016/S0140-6736(02)09742-8.View ArticlePubMedGoogle Scholar
- Espinal MA, Kim SJ, Suarez PG, Kam KM, Khomenko AG, Migliori GB, et al: Standard short-course chemotherapy for drug-resistant tuberculosis: treatment outcomes in 6 countries. JAMA. 2000, 283 (19): 2537-2545. 10.1001/jama.283.19.2537.View ArticlePubMedGoogle Scholar
- Mitnick C, Bayona J, Palacios E, Shin S, Furin J, Alcantara F, et al: Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. N Engl J Med. 2003, 348 (2): 119-128. 10.1056/NEJMoa022928.View ArticlePubMedGoogle Scholar
- Deschamps MM, Fitzgerald DW, Pape JW, Johnson WD: HIV Infection in Haiti: Natural History and Disease Progression. AIDS. 2000, 14: 2515-2521. 10.1097/00002030-200011100-00014.View ArticlePubMedGoogle Scholar
- Malkin JE, Prazuck T, Simonnet F, Yameogo M, Rochereau A, Ayerour J, et al: Tuberculosis and human immunodeficiency virus infection in West Burkina Faso: clinical presentation and clinical evolution. Int J Tuberc Lung Dis. 1997, 1 (1): 68-74.PubMedGoogle Scholar
- Johnson JL, Okwera A, Vjecha MJ, Byekwaso F, Nakibali J, Nyole S, et al: Risk factors for relapse in human immunodeficiency virus type 1 infected adults with pulmonary tuberculosis. Int J Tuberc Lung Dis. 1997, 1 (5): 446-453.PubMedGoogle Scholar
- Sonnenberg P, Murray J, Glynn JR, Shearer S, Kambashi B, Godfrey-Faussett P: HIV-1 and recurrence, relapse, and reinfection of tuberculosis after cure: a cohort study in South African mineworkers. Lancet. 2001, 358 (9294): 1687-1693. 10.1016/S0140-6736(01)06712-5.View ArticlePubMedGoogle Scholar
- Pulido F, Peña JM, Rubio R, Moreno S, González J, Guijarro C, et al: Relapse of tuberculosis after treatment in human immunodeficiency virus-infected patients. Arch Intern Med. 1997, 157: 227-231. 10.1001/archinte.157.2.227.View ArticlePubMedGoogle Scholar
- Deas J: Haiti's Response to Tuberculosis and Malaria. Application to the Global Fund to Fight AIDS TaM, editor. 2002Google Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/6/209/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.