A Cluster-Randomized Trial of Symptom-based versus Tuberculin Skin Test-based Screening of Household Tuberculosis Contacts Under 5 Years of Age
Embargo until
2021-05-01
Date
2019-03-01
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Johns Hopkins University
Abstract
Background: Interventions to prevent tuberculosis (TB) for children are poorly implemented worldwide. TB preventive therapy (TPT) is highly-effective at preventing TB disease in household contacts < 5 years old, but only 23% of child contacts received in 2017. In 2006, to simplify the process and improve implementation, the World Health Organization (WHO) recommended symptom-based screening as a replacement for tuberculin skin test (TST)-based screening of child contacts. We aimed to determine the effectiveness of this recommendation.
Methods: A cluster-randomized trial was conducted to determine whether contact evaluation using symptom screening improved the proportion of identified child contacts <5 years who initiated TPT compared to TST-based screening. From October 2015 through February 2017 in the Matlosana sub-district of North West Province, 16 clinics were randomized to conduct child contact evaluations with either symptom-based or TST-based screening. Training and customized child contact management files were provided to all clinics. Outcome data were abstracted from clinical records. The continuum of care for child household contacts was determined.
Results: Contact tracing identified 549 and 467 children <5 from 1440 and 1597 TB index patients in the symptom and TST clinics, respectively (0.37 vs 0.28 per case; p=0.16). Of these identified contacts, 51% of children in symptom screening clinics and 57% in TST screening clinics initiated TPT (p=0.55) and 48% and 53% of children who started TPT completed therapy (p=0.65). Four children developed TB disease while on TPT, despite a negative screening at TPT initiation. There were no child deaths. Based on an historic average of 0.7 child contacts per index case in this district, we estimate 14% and 15% TPT coverage among child contacts exposed to TB in the symptom and TST clinics respectively (p=0.83).
Conclusions: Symptom- based screening did not improve the proportion of identified child contacts initiated on TPT when compared to TST-based screening. Further research is needed to identify bottlenecks and evaluate interventions to ensure all TB-exposed children <5 receive TB preventive therapy. (ClinicalTrials.gov identifier: NCT03074799)
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Keywords
childhood tuberculosis prevention