Impact of active case-finding for tuberculosis on case-notifications in Blantyre, Malawi: A community-based cluster-randomised trial (SCALE).
Active case-finding (ACF) for tuberculosis can help find the "missing millions" with undiagnosed tuberculosis. In a cluster-randomised trial, we investigated impact of ACF on case-notifications in Blantyre, Malawi, where ACF has been intensively implemented following 2014 estimates of ~1,0...
| Main Authors: | , , , , , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
Public Library of Science (PLoS)
2023-01-01
|
| Series: | PLOS Global Public Health |
| Online Access: | https://doi.org/10.1371/journal.pgph.0002683 |
| _version_ | 1797315849365749760 |
|---|---|
| author | Helena R A Feasey McEwen Khundi Rebecca Nzawa Soko Christian Bottomley Lingstone Chiume Helen E D Burchett Marriott Nliwasa Hussein H Twabi James A Mpunga Peter MacPherson Elizabeth L Corbett |
| author_facet | Helena R A Feasey McEwen Khundi Rebecca Nzawa Soko Christian Bottomley Lingstone Chiume Helen E D Burchett Marriott Nliwasa Hussein H Twabi James A Mpunga Peter MacPherson Elizabeth L Corbett |
| author_sort | Helena R A Feasey |
| collection | DOAJ |
| description | Active case-finding (ACF) for tuberculosis can help find the "missing millions" with undiagnosed tuberculosis. In a cluster-randomised trial, we investigated impact of ACF on case-notifications in Blantyre, Malawi, where ACF has been intensively implemented following 2014 estimates of ~1,000 per 100,000 adults with undiagnosed TB. Following a pre-intervention prevalence survey (May 2019 to March 2020), constrained randomisation allocated neighbourhoods to either door-to-door ACF (sputum microscopy for reported cough >2 weeks) or standard-of-care (SOC). Implementation was interrupted by COVID-19. Cluster-level bacteriologically-confirmed case-notification rate (CNR) ratio within 91 days of ACF was our redefined primary outcome; comparison between arms used Poisson regression with random effects. Secondary outcomes were 91-day CNR ratios comparing all tuberculosis registrations and all non-ACF registrations. Interrupted time series (ITS) analysis of CNRs in the SOC arm examined prevalence survey impact. (ISRCTN11400592). 72 clusters served by 10 study-supported tuberculosis registration centres were randomised to ACF (261,244 adults, 58,944 person-years follow-up) or SOC (256,713 adults, 52,805 person-years). Of 1,192 ACF participants, 13 (1.09%) were smear-positive. Within 91 days, 113 (42 bacteriologically-confirmed) and 108 (33 bacteriologically-confirmed) tuberculosis patients were identified as ACF or SOC cluster residents, respectively. There was no difference by arm, with adjusted 91-day CNR ratios 1.12 (95% CI: 0.61-2.07) for bacteriologically-confirmed tuberculosis; 0.93 (95% CI: 0.68-1.28) for all tuberculosis registrations; and 0.86 (95%CI: 0.63-1.16) for non-ACF (routinely) diagnosed. Of 7,905 ACF and 7,992 SOC pre-intervention survey participants, 12 (0.15%) and 17 (0.21%), respectively, had culture/Xpert-confirmed tuberculosis. ITS analysis showed no survey impact on SOC CNRs. Despite residual undiagnosed tuberculosis of 150 per 100,000 population, there was no increase in tuberculosis notifications from this previously successful approach targeting symptomatic disease, likely due to previous TB ACF and rapid declines in TB burden. In such settings, future ACF should focus on targeted outreach and demand creation, alongside optimised facility-based screening. Trial Registration: ISRCTN11400592. |
| first_indexed | 2024-03-08T03:09:48Z |
| format | Article |
| id | doaj.art-6df1cb7eab434d49b45c57bbab6dc330 |
| institution | Directory Open Access Journal |
| issn | 2767-3375 |
| language | English |
| last_indexed | 2024-03-08T03:09:48Z |
| publishDate | 2023-01-01 |
| publisher | Public Library of Science (PLoS) |
| record_format | Article |
| series | PLOS Global Public Health |
| spelling | doaj.art-6df1cb7eab434d49b45c57bbab6dc3302024-02-13T06:00:17ZengPublic Library of Science (PLoS)PLOS Global Public Health2767-33752023-01-01312e000268310.1371/journal.pgph.0002683Impact of active case-finding for tuberculosis on case-notifications in Blantyre, Malawi: A community-based cluster-randomised trial (SCALE).Helena R A FeaseyMcEwen KhundiRebecca Nzawa SokoChristian BottomleyLingstone ChiumeHelen E D BurchettMarriott NliwasaHussein H TwabiJames A MpungaPeter MacPhersonElizabeth L CorbettActive case-finding (ACF) for tuberculosis can help find the "missing millions" with undiagnosed tuberculosis. In a cluster-randomised trial, we investigated impact of ACF on case-notifications in Blantyre, Malawi, where ACF has been intensively implemented following 2014 estimates of ~1,000 per 100,000 adults with undiagnosed TB. Following a pre-intervention prevalence survey (May 2019 to March 2020), constrained randomisation allocated neighbourhoods to either door-to-door ACF (sputum microscopy for reported cough >2 weeks) or standard-of-care (SOC). Implementation was interrupted by COVID-19. Cluster-level bacteriologically-confirmed case-notification rate (CNR) ratio within 91 days of ACF was our redefined primary outcome; comparison between arms used Poisson regression with random effects. Secondary outcomes were 91-day CNR ratios comparing all tuberculosis registrations and all non-ACF registrations. Interrupted time series (ITS) analysis of CNRs in the SOC arm examined prevalence survey impact. (ISRCTN11400592). 72 clusters served by 10 study-supported tuberculosis registration centres were randomised to ACF (261,244 adults, 58,944 person-years follow-up) or SOC (256,713 adults, 52,805 person-years). Of 1,192 ACF participants, 13 (1.09%) were smear-positive. Within 91 days, 113 (42 bacteriologically-confirmed) and 108 (33 bacteriologically-confirmed) tuberculosis patients were identified as ACF or SOC cluster residents, respectively. There was no difference by arm, with adjusted 91-day CNR ratios 1.12 (95% CI: 0.61-2.07) for bacteriologically-confirmed tuberculosis; 0.93 (95% CI: 0.68-1.28) for all tuberculosis registrations; and 0.86 (95%CI: 0.63-1.16) for non-ACF (routinely) diagnosed. Of 7,905 ACF and 7,992 SOC pre-intervention survey participants, 12 (0.15%) and 17 (0.21%), respectively, had culture/Xpert-confirmed tuberculosis. ITS analysis showed no survey impact on SOC CNRs. Despite residual undiagnosed tuberculosis of 150 per 100,000 population, there was no increase in tuberculosis notifications from this previously successful approach targeting symptomatic disease, likely due to previous TB ACF and rapid declines in TB burden. In such settings, future ACF should focus on targeted outreach and demand creation, alongside optimised facility-based screening. Trial Registration: ISRCTN11400592.https://doi.org/10.1371/journal.pgph.0002683 |
| spellingShingle | Helena R A Feasey McEwen Khundi Rebecca Nzawa Soko Christian Bottomley Lingstone Chiume Helen E D Burchett Marriott Nliwasa Hussein H Twabi James A Mpunga Peter MacPherson Elizabeth L Corbett Impact of active case-finding for tuberculosis on case-notifications in Blantyre, Malawi: A community-based cluster-randomised trial (SCALE). PLOS Global Public Health |
| title | Impact of active case-finding for tuberculosis on case-notifications in Blantyre, Malawi: A community-based cluster-randomised trial (SCALE). |
| title_full | Impact of active case-finding for tuberculosis on case-notifications in Blantyre, Malawi: A community-based cluster-randomised trial (SCALE). |
| title_fullStr | Impact of active case-finding for tuberculosis on case-notifications in Blantyre, Malawi: A community-based cluster-randomised trial (SCALE). |
| title_full_unstemmed | Impact of active case-finding for tuberculosis on case-notifications in Blantyre, Malawi: A community-based cluster-randomised trial (SCALE). |
| title_short | Impact of active case-finding for tuberculosis on case-notifications in Blantyre, Malawi: A community-based cluster-randomised trial (SCALE). |
| title_sort | impact of active case finding for tuberculosis on case notifications in blantyre malawi a community based cluster randomised trial scale |
| url | https://doi.org/10.1371/journal.pgph.0002683 |
| work_keys_str_mv | AT helenarafeasey impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT mcewenkhundi impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT rebeccanzawasoko impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT christianbottomley impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT lingstonechiume impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT helenedburchett impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT marriottnliwasa impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT husseinhtwabi impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT jamesampunga impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT petermacpherson impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale AT elizabethlcorbett impactofactivecasefindingfortuberculosisoncasenotificationsinblantyremalawiacommunitybasedclusterrandomisedtrialscale |