Effect of household and community interventions on the burden of tuberculosis in southern Africa: the ZAMSTAR community-randomised trial
Effect of household and community interventions on the burden of tuberculosis in southern Africa: the ZAMSTAR community-randomised trial
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DOI：
10.1016/s0140-6736(13)61131-9
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发表时间：
2013-10-05
期刊：
影响因子：
168.9
通讯作者：
Godfrey-Faussett, Peter
中科院分区：
文献类型：
--
作者：
Ayles, Helen;Muyoyeta, Monde;Godfrey-Faussett, Peter
背景在艾滋病毒流行的推动下，南部非洲的结核病负担出现了前所未有的增长。赞比亚，南非减少结核病和艾滋病(ZAMSTAR)试验研究了两种公共卫生干预措施，旨在通过促进快速痰诊断或在社区内整合结核病和艾滋病毒服务来减轻结核病负担。方法ZAMSTAR是在赞比亚和南非西开普省进行的社区随机试验。在2006年8月1日至2009年7月31日期间实施了两项干预措施，即社区水平的增强型结核病病例筛选(ECF)和家庭水平的结核病-艾滋病毒护理，并在2010年1月9日至2010年12月6日期间采用2x2析因设计进行评估。所有社区都在参与的保健中心实施了加强的结核病-艾滋病毒方案。根据人口数量和结核病通知率选择的24个社区被随机分配到四个研究组之一，采用按国家和结核病感染基线流行程度分层的随机时间表：第一组仅在诊所加强结核病-艾滋病毒规划；第二组，诊所+ECF；第三组，诊所+家庭干预；以及第四组，诊所+ECF和家庭干预。主要结果是成人中培养配置的肺结核的患病率(=18岁)，定义为从一个呼吸道样本中分离的结核分枝杆菌，在干预措施开始4年后测量，2010年在每个社区随机选择4000名成年人进行调查。次要结果是结核感染的发生率，用结核菌素皮肤试验在一群学龄儿童中进行测量，这是干预开始前进行的基线调查后的中位数4年。从24个社区中随机抽取463人进行结核病患病率评估，其中活动性肺结核894人。24个社区的平均结核病患病率几何平均值为每10万人832人。ECF干预组与非ECF干预组比较的校正患病率为1.09(95%CI 0.86~1.40)，家庭干预组与非家庭干预组的调整患病率为0.82(0.64~1.04)。对8809名儿童的结核病感染率进行了测量，中位随访时间为4年，调整后的比例为1.36(95%可信区间0.59~3.14)，调整后的比率为0.45(0.20~1.05)。虽然两种干预措施都没有使结核病发病率在统计学上显著降低，但两个独立的负担指标提供了一些证据，表明接受家庭干预的社区结核病有所减少。相比之下，欧洲央行的干预对这两种结果都没有影响。
Background Southern Africa has had an unprecedented increase in the burden of tuberculosis, driven by the HIV epidemic. The Zambia, South Africa Tuberculosis and AIDS Reduction (ZAMSTAR) trial examined two public health interventions that aimed to reduce the burden of tuberculosis by facilitating either rapid sputum diagnosis or integrating tuberculosis and HIV services within the community.Methods ZAMSTAR was a community-randomised trial done in Zambia and the Western Cape province of South Africa. Two interventions, community-level enhanced tuberculosis case-fi nding (ECF) and household level tuberculosis-HIV care, were implemented between Aug 1, 2006, and July 31, 2009, and assessed in a 2x2 factorial design between Jan 9, 2010, and Dec 6, 2010. All communities had a strengthened tuberculosis-HIV programme implemented in participating health-care centres. 24 communities, selected according to population size and tuberculosis notifi cation rate, were randomly allocated to one of four study groups using a randomisation schedule stratifi ed by country and baseline prevalence of tuberculous infection: group 1 strengthened tuberculosis-HIV programme at the clinic alone; group 2, clinic plus ECF; group 3, clinic plus household intervention; and group 4, clinic plus ECF and household interventions. The primary outcome was the prevalence of culture-confi rmed pulmonary tuberculosis in adults (>= 18 years), defi ned as Mycobacterium tuberculosis isolated from one respiratory sample, measured 4 years after the start of interventions in a survey of 4000 randomly selected adults in each community in 2010. The secondary outcome was the incidence of tuberculous infection, measured using tuberculin skin testing in a cohort of schoolchildren, a median of 4 years after a baseline survey done before the start of interventions. This trial is registered, number ISRCTN36729271.Findings Prevalence of tuberculosis was evaluated in 64 463 individuals randomly selected from the 24 communities; 894 individuals had active tuberculosis. Averaging over the 24 communities, the geometric mean of tuberculosis prevalence was 832 per 100 000 population. The adjusted prevalence ratio for the comparison of ECF versus non-ECF intervention groups was 1.09 (95% CI 0.86-1.40) and of household versus non-household intervention groups was 0.82 (0.64-1.04). The incidence of tuberculous infection was measured in a cohort of 8809 children, followed up for a median of 4 years; the adjusted rate ratio for ECF versus non-ECF groups was 1.36 (95% CI 0.59-3.14) and for household versus non-household groups was 0.45 (0.20-1.05).Interpretation Although neither intervention led to a statistically signifi cant reduction in tuberculosis, two independent indicators of burden provide some evidence of a reduction in tuberculosis among communities receiving the household intervention. By contrast the ECF intervention had no eff ect on either outcome.