Efectos de la protección social en los resultados del tratamiento contra la tuberculosis en países con baja o media renta y gravemente afectados: revisión sistemática y metaanálisis

Andrade, Kaio Vinicius Freitas de; Nery, Joilda Silva; Souza, Ramon Andrade de; Pereira, Susan Martins

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REVIEW • Cad. Saúde Pública 34 (1) • 2018 • https://doi.org/10.1590/0102-311X00153116 copiar

Efectos de la protección social en los resultados del tratamiento contra la tuberculosis en países con baja o media renta y gravemente afectados: revisión sistemática y metaanálisis

Autoría SCIMAGO INSTITUTIONS RANKINGS

La tuberculosis (TB) es una enfermedad infecciosa, característica de la pobreza, que afecta a millones de personas en todo el mundo. Las evidencias sugieren que las estrategias de protección social (EPS) pueden mejorar los resultados del tratamiento de la TB. El objetivo de este estudio ha sido resumir tales evidencias, a través de una revisión sistemática de la literatura y metaanálisis. Buscamos estudios realizados en países de baja renta o ingresos medios y con altas tasas de morbilidad por TB, publicados durante 1995-2016. La revisión la llevamos a cabo realizando búsquedas en PubMed/MEDLINE, Scopus, Web of Science, ScienceDirect y LILACS. Incluimos sólo estudios que investigaron los efectos de las EPS en los resultados de los tratamientos contra la TB. Seleccionamos 25 estudios para realizar su síntesis cualitativa. Realizamos metaanálisis con 9 ensayos controlados aleatorios, incluyendo a un total de 1.687 participantes. Los resultados agrupados mostraron que las EPS estaban asociadas con tratamientos exitosos contra la TB (RR = 1,09; 95%CI: 1,03-1,14), la curación en pacientes de TB (RR = 1,11; 95%CI: 1,01-1,22) y con la reducción en el riesgo de abandono del tratamiento de TB (RR = 0,63; 95%CI: 0,45-0,89). No detectamos efectos de las EPS en los resultados de fracaso del tratamiento y muerte por TB. Estos hallazgos revelaron que las EPS podrían mejorar los resultados de los tratamientos por TB en las economías de países con baja renta o ingresos medios, o países con altas tasas de esta enfermedad. No obstante, la calidad general de las evidencias, en relación con estos resultados, es baja e indica que son necesarios más estudios controlados aleatorios bien realizados.

Tuberculosis; Resultado del Tratamiento; Bienestar Social; Política Pública

Study/Country	Income/TB-burden	n	Study location	Study design (score) *	Population and study period	Intervention	Main outcome
Baral et al. ²²22. Baral SC, Aryal Y, Bhattrai R, King R, Newell JN. The importance of providing counselling and financial support to patients receiving treatment for multi-drug resistant TB: mixed method qualitative and pilot intervention studies. BMC Public Health 2014; 14:46./Nepal	Low-income	I₁: 33 I₂: 42 C: 81	7 DOTS-plus centers	Mixed-method (intervention and qualitative)	MDR-TB patients (Jan-Dec 2008)	I₁: counselling. I₂: counselling and financial support	Cure (I₁: 85%; I₂: 76%; C: 67%)
Cantalice Filho ³⁷37. Cantalice Filho JP. Efeito do incentivo alimentício sobre o desfecho do tratamento de pacientes com tuberculose em uma unidade primária de saúde no município de Duque de Caxias, Rio de Janeiro. J Bras Pneumol 2009; 35:992-7./Brazil	Upper middle-income High TB-burden	142 (I: 74, C: 68)	Primary care clinics in Duque de Caxias, Rio de Janeiro State	Retrospective comparative study (7 points)	≥ 15 years old with confirmed TB diagnosis (Jan 2004-Jul 2006)	Monthly food baskets delivered in the healthcare clinic	Cure (I: 87.1%; C: 69.7%)
Ciobanu et al. ²⁷27. Ciobanu A, Domente L, Soltan V, Bivol S, Severin L, Plesca V, et al. Do incentives improve tuberculosis treatment outcomes in the Republic of Moldova? Public Health Action 2014; 4 Suppl 2:S59-63./Republic of Moldova	Lower middle-income	4,870 (I: 2378, C: 2492)	National data, before (2008) and after (2011) incentives	Retrospective cohort study (14 points)	≥ 18 years old, TB patients treated in 2008 and in 2011	Cash, non-cash or both incentives. (I: groups that received cash)	TSR (I: 88%; C: 79%; p < 0.001)
Clarke et al. ³¹31. Clarke M, Dick J, Zwarenstein M, Lombard CJ, Diwan VK. Lay health worker intervention with choice of DOT superior to standard TB care for farm dwellers in South Africa: a cluster randomised control trial. Int J Tuberc Lung Dis 2005; 9:673-9./South Africa	Upper middle-income High TB-burden	89 (I: 47, C: 42)	211 farms (I: 106; C: 105)	Cluster randomized controlled trial	Permanent farm dwellers ≥ 15 years old treated (from Nov 1, 2000 to Oct 31, 2001)	Adult farm dwellers trained as lay health workers	TSR (I: 83%; C: 64.3%; p = 0.042)
Datiko & Lindtjørn ¹⁹19. Datiko DG, Lindtjørn B. Health extension workers improve tuberculosis case detection and treatment success in Southern Ethiopia: a community randomized trial. PLoS One 2009; 4:e5443./Ethiopia	Low-income High TB-burden	318 (I: 230, C: 88)	51 kebeles in two rural districts of Southern Ethiopia	Community-randomized trial	All new smear-positive pulmonary TB cases	Trained community health workers	TSR (I: 89.3%; C: 81.3%; p = 0.012)
Demissie et al. ²⁰20. Demissie M, Getahun H, Lindtjørn B. Community tuberculosis care through "TB clubs" in rural North Ethiopia. Soc Sci Med 2003: 56:2009-18./Ethiopia	Low-income High TB-burden	128 (I: 64, C: 64)	2 rural districts of Northern Ethiopia	Mixed-method - cohort and qualitative (12 points)	Smear-positive TB patients (from July 1 to Oct 15, 1998)	TB patients in rural kebeles organized in “TB clubs”	TCR (I: 68.7%; C: 46.8%; p = 0.02)
Gärden et al. ²³23. Gärden BB, Samarina AA, Stavchanskaya I, Alsterlund RR, Övregaard AA, Taganova OO, et al. Food incentives improve adherence to tuberculosis drug treatment among homeless patients in Russia. Scand J Caring Sci 2012; 27:117-22./Russia	High-income High TB-burden	518 (I: 142, C: 376)	St. Petersburg’s TB dispensary	Historical controlled intervention study (11 points)	Homeless patients referred to TB dispensary (from Dec 2001 to Jan 2004)	Food packages delivered once a day 5 days a week and support from a social worker	TSR (I: 78.2%; C: 31.0%)
Jakubowiak et al. ²⁴24. Jakubowiak WM, Bogorodskaya EM, Borisov SE, Danilova ID, Lomakina OB, Kourbatova EV. Social support and incentives programme for patients with tuberculosis: experience from the Russian Federation. Int J Tuberc Lung Dis 2007; 11:1210-5./Russia	High-income High TB-burden	1,389 (I: 382, C: 1,007)	4 regions with TB services	Cross-sectional study (5 points)	New pulmonary TB patients ≥ 15 years old treated (from Jan 1, 2004 to Mar 31, 2005)	Social support during TB treatment (food packs, hygiene kits, transportation incentives, etc.)	28.1% of adherents and 18.4% of non-adherents with incentives
Kliner et al. ²⁹29. Kliner M, Canaan M, Ndwandwe SZ, Busulwa F, Welfare W, Richardson M, et al. Effects of financial incentives for treatment supporters on tuberculosis treatment outcomes in Swaziland: a pragmatic interventional study. Infect Dis Poverty 2015; 4:29./Swaziland	Lower middle-income	1,077 (I: 161, C: 916)	Hospital in a rural district	Pragmatic controlled interventional study (12 points)	TB patients (Jan 2010-Sep 2011)	Treatment support from community workers	TSR (I: 73% vs. C: 60%; p = 0.003)
Lönnroth et al. ³⁸38. Lönnroth K, Aung T, Maung W, Kluge H, Uplekar M. Social franchising of TB care through private GPs in Myanmar: an assessment of treatment results, access, equity and financial. Health Policy Plan 2007; 22:156-66./Myanmar	Lower middle-income High TB-burden	253 (non-controlled)	National case notification data and survey in clinics in Yangon	Cross-sectional study (10 points)	All patients treated in Sun Quality Health (SQH) clinics in Yangon (from Sep 1 to Oct 30 2004)	Sun Quality Health (SQH), a social franchise that licensed practitioners with clinics serving low-income people	TSR for new smear-positive cases was 84%
Lutge et al. ⁴³43. Lutge E, Lewin S, Volmink J, Friedman I, Lombard C. Economic support to improve tuberculosis treatment outcomes in South Africa: a pragmatic cluster-randomized controlled trial. Trials 2013; 14:154./South Africa	Upper middle-income High TB-burden	4,091 (I: 2,107, C: 1,984)	20 public sector clinics in Kwazulu-Natal	Cluster-randomized controlled trial	TB patients within (July 1, 2009 to Mar 31, 2010)	Monthly vouchers (US$ 15) redeemable at specific general stores	TSR (I: 76.2% vs. C: 70.7%; p = 0.107)
Martins et al. ³⁰30. Martins N, Morris P, Kelly PM. Food incentives to improve completion of tuberculosis treatment: randomised controlled trial in Dili, Timor-Leste. BMJ 2009; 339:b4248./Timor-Leste	Lower-middle income	265 (I: 136, C: 129)	3 primary clinics in Dili: government, private and church operated)	Randomized controlled trial	TB patients aged ≥ 18 and that agree to treatment at diagnostic clinic for eight months	Daily meal in attendance to the clinic and unprepared food to take home, in continuation phase	TSR (I: 76% vs. C: 78%; p = 0.7)
Ngamvithayapong-Yanai et al. ³⁵35. Ngamvithayapong-Yanai J, Luangjina S, Nedsuwan S, Kantipong P, Wongyai J, Ishikawa N. Engaging women volunteers of high socioeconomic status in supporting socioeconomically disadvantaged tuberculosis patients in Chiang Rai, Thailand. Western Pac Surveill Response J 2013; 4:34-8./Thailand	Upper middle-income High TB-burden	759 (I: 192, C: 567)	Chiang Rai, Thailand’s northern province	Intervention study - before and after (7 points)	Extremely poor TB patients, living alone, with elderly caregivers or isolated from community	Engagement of Chiang Rai women’s organization to support them financially and socially	TSR (I: 69.3% vs. C: 51.6%; p < 0.00)
Ritchie et al. ²¹21. Ritchie LMP, Schull MJ, Martiniuk ALC, Barnsley J, Arenovich T, Lettow MV, et al. A knowledge translation intervention to improve tuberculosis care and outcomes in Malawi: a pragmatic cluster randomized controlled trial. Implement Sci 2015; 10:38./Malawi	Low-income	110 (I: 30, C: 80)	28 health centers in Zomba district	Cluster randomized controlled trial	All lay health workers involved in providing care to TB patients	Two knowledge translation interventions: educational outreach and reminders	TSR (I: 70% vs. C: 58%; p = 0.578)
Rocha et al. ²⁸28. Rocha C, Montoya R, Zevallos K, Curatola A, Ynga W, Franco J, et al. The Innovative Socio-economic Interventions Against Tuberculosis (ISIAT) project: an operational assessment. Int J Tuberc Lung Dis 2011; 15 Suppl 2:S50-7./Peru	Upper middle-income	1,861 (I: 307, C: 1,554)	Eight contiguous slums in Northern Lima	Intervention study (4 points)	Subsequently diagnosed TB patients and their household contacts (Dec 2007-Oct 2010)	Household visits, counselling, food and cash transfers, microenterprise, microcredits and training	TSR (91% before vs. 97% after intervention)
Singh et al. ³²32. Singh AA, Parasher D, Shekhavat GS, Sahu S, Wares DF, Granich R. Effectiveness of urban community volunteers in directly observed treatment of tuberculosis patients: a field report from Haryana, North India. Int J Tuberc Lung Dis 2004; 8:800-2./India	Lower middle-income High TB-burden	617 (I:1 41, C: 476)	One tuberculosis unit covering a population of 600,000 in Haryana State	Intervention study (10 points)	New sputum smear-positive patients registered in the tuberculosis unit for treatment	Directly Observed Treatment (DOT) from community volunteers vs. government health workers	TSR (I: 78% vs. C: 77%)
Soares et al. ³³33. Soares ECC, Vollmer WM, Cavalcante SC, Pacheco AG, Saraceni V, Silva JS, et al. Tuberculosis control in a socially vulnerable area: a community intervention beyond DOT in a Brazilian favela. Int J Tuberc Lung Dis 2013; 17:1581-6./Brazil	Upper middle-income High TB-burden	2,623 (I: 1,771, C: 852)	Rocinha Favela, the largest urban slum in South America	Intervention study (before and after) (13 points)	All patients with pulmonary or extra-pulmonary TB who started treatment between 2001 and 2008	DOT implementation and training 40 lay persons as community health workers	TSR (83.2% vs. 67.6%; p < 0.001) pre- and post-intervention
Sripad et al. ²⁵25. Sripad A, Castedo J, Danford N, Zaha R, Freile C. Effects of Ecuador's national monetary incentive program on adherence to treatment for drug-resistant tuberculosis. Int J Tuberc Lung Dis 2014; 18:44-8./Ecuador	Upper middle-income	191 (I: 105, C: 86)	Ecuador’s NTP	Non-randomized trial with historical controls (8 points)	Drug-resistant (DR-TB) patients (from Aug 2011 to Jan 2012 - intervention and from Jan to Aug 2010 - pre-program)	Ecuador’s NTP enacted a monetary incentive program giving adherent DR-TB patients a USD 240 bonus each month	1-year default rate (9.5% vs. 26.7%; p < 0.05), in program and pre-program
Sudarsanam et al. ³⁶36. Sudarsanam TD, John J, Kang G, Mahendri V, Gerrior J, Franciosa M, et al. Pilot randomized trial of nutritional supplementation in patients with tuberculosis and HIV-tuberculosis coinfection receiving directly observed short-course chemotherapy for tuberculosis. Trop Med Int Health 2011; 16:699-706./India	Lower middle-income High TB-burden	97 (I: 48, C: 49)	One of four clinics in Vellore town, southern Indian state of Tamil Nadu	Randomized controlled trial	Patients aged > 12 years diagnosed with TB (recruited between Jan and Nov 2005)	Macronutrient supplement (cereal and lentil mixture) and micronutrients (one-a-day multivitamin table)	Higher poor outcomes in the non-supplemented HIV-TB co-infected group
Torrens et al. ⁴²42. Torrens AW, Rasella D, Boccia D, Maciel ELN, Nery JS, Olson ZD, et al. Effectiveness of a conditional cash transfer programme on TB cure rate: a retrospective cohort study in Brazil. Trans R Soc Trop Med Hyg 2016; 110:199-206./Brazil	Upper middle-income High TB-burden	7,255 (I: 5,788, C: 1,467)	Brazilian national databases (SINAN and CadÚnico)	Retrospective cohort (14 points)	All new TB cases diagnosed in 2010, recorded in SINAN database and registered in CadÚnico	Brazilian national conditional cash transfer (Brazilian Income Transfer Program)	Cure rates (I: 82.1% vs. C: 76.9%; p < 0.001)
Wei et al. ³⁹39. Wei X, Zou G, Yin J, Walley J, Yang H, Kliner M, et al. Providing financial incentives to rural-to-urban tuberculosis migrants in Shanghai: an intervention study. Infect Dis Poverty 2012; 1:9./China	Upper middle-income High TB-burden	183 (I: 90, C: 93)	2 districts of Shanghai (1 intervention/1 control)	Controlled intervention study - before and after (8 points)	Poor migrants TB patients	Financial incentives to poor migrant TB patients (transportation and living subsidies)	TCR (I: from 78% to 89%; and C: from 73% to 76%; p = 0.03)
Yao et al. ⁴⁰40. Yao H, Wei X, Liu J, Zhao J, Hu D, Walley JD. Evaluating the effects of providing financial incentives to tuberculosis patients and health providers in China. Int J Tuberc Lung Dis 2008; 12:1166-72./China	Upper middle-income High TB-burden	9,194 (I: 5,449, C: 3,745)	Fifty poor counties of Shanxi (Fidelis project) and 51 control counties	Pilot evaluation study (8 points)	New TB cases in baseline (Jan-Sep 2004) and during the intervention (Jan-Sep 2005) using routine TB reporting data	Financial incentives for doctors. Incentives to village leaders for community health education	TSR baseline (I: 95.3 vs. C: 93.9%; p < 0.01); project (I: 96.9 vs. C: 96.9%; p > 0.05)
Zou et al. ⁴¹41. Zou G, Wei X, Witter S, Yin J, Walley J, Liu S, et al. Incremental cost-effectiveness of improving treatment results among migrant tuberculosis patients in Shanghai. Int J Tuberc Lung Dis 2013; 17:1056-64./China	Upper middle-income High TB-burden	356 (I: 263, C: 93)	Three districts located in Shanghai: (i) Communicable Disease Research Consortium (COMDIS), (ii) The Global Fund Project, (iii) control	Intervention study (case study) - before and after (8 points)	Poor migrants TB patients living in Shanghai, China, targeted by two projects involving financial incentives (introduced in Oct 2007)	COMDIS: single living and transportation subsidies Global Fund Project: living and, transportation incentives, plus incentives to clinic staff for each extended working hour	TCR District I (78 vs. 89%); District II (73 vs. 88%); Control (73 vs. 76%).
Zwarenstein et al. ³⁴34. Zwarenstein M, Schoeman JH, Vundule C, Lombard CJ, Tatley M. A randomised controlled trial of lay health workers as direct observers for treatment of tuberculosis. Int J Tuberc Lung Dis 2000; 4:550-4./South Africa	Upper middle-income High TB-burden	98 (I: 54, C: 44)	Four clinics in Elsies River, suburb (20km from Cape Town)	Randomized controlled trial	Adult (aged > 15 years) pulmonary TB patients, who started TB treatment (new and retreatment)	Supervision by volunteers lay health workers in a poor community/Supervision by clinic nurse/Self-supervision	% of success: lay health workers (74%), clinic DOT (57%) and self-supervision (59%)
Álvarez Gordillo et al. ²⁶26. Álvarez Gordillo GC, Álvarez Gordillo JF, Dorantes Jiménez JE. Estrategia educativa para incrementar el cumplimiento del régimen antituberculoso en Chiapas, México. Rev Panam Salud Pública 2003; 14:402-8./Mexico	Upper middle-income	87 (I: 44, C: 43)	Health centers in Chiapas	Controlled intervention study	>15 years old with sputum smear-positive pulmonary TB (Feb 2001-Jan 2002)	Training program for health professionals and self-help groups for TB patients	TSR (I: 97.7%; C: 81.4%)

Outcomes	Number of participants (studies) - follow-up	Quality of the evidence (GRADE)	RR (95%CI)	Anticipated absolute effects
Outcomes	Number of participants (studies) - follow-up	Quality of the evidence (GRADE)	RR (95%CI)	Risk with TB usual care	Risk difference with social protection interventions
Treatment success	1,687 (9 RCTs)	⨁⨁◯◯ LOW ^a,b	1.09 (1.03-1.14)	723 per 1,000	65 more per 1,000 (22 more to 101 more)
Cure	1,590 (8 RCTs)	⨁◯◯◯ VERY LOW ^a,b,c	1.11 (1.01-1.22)	493 per 1,000	54 more per 1,000 (5 more to 109 more)
Treatment default	1,325 (7 RCTs)	⨁⨁◯◯ LOW ^a,b	0.63 (0.45-0.89)	126 per 1,000	46 fewer per 1,000 (69 fewer to 14 fewer)
Treatment failure	1,245 (6 RCTs)	⨁⨁◯◯ LOW ^a,b	0.78 (0.44-1.40)	50 per 1,000	11 fewer per 1,000 (28 fewer to 20 more)
Death	1,238 (6 RCTs)	⨁⨁◯◯ LOW ^a,b	0.98 (0.61-1.57)	68 per 1,000	1 fewer per 1,000 (27 fewer to 39 more)

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[1] *Correspondence K. V. F. Andrade Instituto de Saúde Coletiva, Universidade Federal da Bahia. Rua Basílio da Gama s/n, Salvador, BA 40110-040, Brasil. kaiovinnicius@yahoo.com.br