Improving Tuberculosis Preventive Therapy Uptake: A Cluster-randomized Trial of Symptom-based Versus Tuberculin Skin Test–based Screening of Household Tuberculosis Contacts Less Than 5 Years of Age

Improving Tuberculosis Preventive Therapy Uptake: A Cluster-randomized Trial of Symptom-based Versus Tuberculin Skin Test–based Screening of Household Tuberculosis Contacts Less Than 5 Years of Age

Abstract Background Tuberculosis preventive therapy (TPT) is highly effective at preventing tuberculosis disease in household child contacts (<5 years), but is poorly implemented worldwide. In 2006, the World Health Organization recommended symptom-based screening as a replacement for tuberculin...

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Published in:Clinical infectious diseases Vol. 70; no. 8; pp. 1725 - 1732
Main Authors: Salazar-Austin, Nicole, Cohn, Silvia, Barnes, Grace Link, Tladi, Molefi, Motlhaoleng, Katlego, Swanepoel, Catharina, Motala, Zarina, Variava, Ebrahim, Martinson, Neil, Chaisson, Richard E
Format: Journal Article
Language:English
Published: US Oxford University Press 10-04-2020
Subjects:
and Commentaries
Child
Child, Preschool
Contact Tracing
Family Characteristics
Humans
South Africa
Tuberculin Test
Tuberculosis - diagnosis
Tuberculosis - epidemiology
Tuberculosis - prevention & control
South Africa
symptom-screening
tuberculin skin test
tuberculosis preventive therapy
tuberculosis
pediatric
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Summary:Abstract Background Tuberculosis preventive therapy (TPT) is highly effective at preventing tuberculosis disease in household child contacts (<5 years), but is poorly implemented worldwide. In 2006, the World Health Organization recommended symptom-based screening as a replacement for tuberculin skin testing (TST) to simplify contact evaluation and improve implementation. We aimed to determine the effectiveness of this recommendation. Methods We conducted a pragmatic, cluster-randomized trial to determine whether contact evaluation using symptom screening improved the proportion of identified child contacts who initiated TPT, compared to TST-based screening, in Matlosana, South Africa. We randomized 16 clinics to either symptom-based or TST-based contact evaluations. Outcome data were abstracted from customized child contact management files. Results Contact tracing identified 550 and 467 child contacts in the symptom and TST arms, respectively (0.39 vs 0.32 per case, respectively; P = .27). There was no significant difference by arm in the adjusted proportion of identified child contacts who were screened (52% in symptom arm vs 60% in TST arm; P = .39). The adjusted proportion of identified child contacts who initiated TPT or tuberculosis treatment was 51.5% in the symptom clinics and 57.1% in the TST clinics (difference −5.6%, 95% confidence interval −23.7 to 12.6; P = .52). Based on the district’s historic average of 0.7 child contacts per index case, 14% and 15% of child contacts completed 6 months of TPT in the symptom and TST arms, respectively (P = .89). Conclusions Symptom-based screening did not improve the proportion of identified child contacts evaluated or initiated on TPT, compared to TST-based screening. Further research is needed to identify bottlenecks and evaluate interventions to ensure all child contacts receive TPT. Clinical Trials Registration NCT03074799. This randomized controlled trial evaluated the effectiveness of the World Health Organization’s 2006 recommendation for a symptom-based screening on the uptake of tuberculosis preventive therapy (TPT) among child tuberculosis contacts. Despite this simplified evaluation process, TPT uptake remains poor.
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ISSN:1058-4838
1537-6591
1537-6591
DOI:10.1093/cid/ciz436