TB Aftermath

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The overall goal of our tuberculosis (TB) Aftermath study is to identify, implement and measure feasible case finding strategies and identify key populations to screen among treated TB patients in India. People treated for TB have high incidence of recurrent disease. A recent analysis of the TB treatment cascade in Indian public-sector hospitals estimated that under 40% of cases were TB free one year following treatment completion and as much as 13% of reported TB per year in India is recurrent TB. Furthermore, India is home to one-third of the world’s estimated three million undetected TB cases. Thus, active case finding (ACF) approaches targeting recently treated TB cases may be an effective strategy to reduce the global burden of TB. The Indian National TB Control Programs (RNTCP) new strategic plan for TB elimination strongly recommends developing and implementing a scalable surveillance system for recurrent TB. The World Health Organization’s Systematic Screening for Active TB guidelines suggest that screening for recurrent TB in treated TB patients is a “conditional recommendation”; conditional only because there is a lack of evidence. TB Aftermath will compare effectiveness, cost-effectiveness and feasibility of two ACF strategies that are presently being considered by the RNTCP for detecting recurrent TB and provide evidence needed to implement and scale the preferred intervention. In Aim 1, we will conduct a randomized trial to measure the comparative effectiveness of two potentially implementable strategies that are presently being considered by the RNTCP for detecting recurrent TB in India: Household ACF (HHACF) vs. ACF by periodic telephonic interviews (TACF) followed by HH screen for HHs reporting any symptomatic members among treated TB patients and their HH contacts. In Aim 2, we will use the RE-AIM framework to understand barriers and facilitators to implementation of the two interventions and identify sub-populations that are best reached by the interventions and sub- populations who may benefit the most from the interventions. We will enhance the RE-AIM approach, by exploring the acceptability of the strategies in depth across three key stakeholder groups (TB patients, HH members, and health care personnel) to optimize implementation. In Aim 3, we will model the impact and cost- effectiveness of the ACF interventions evaluated in the trial, and of potential alternative strategies for the targeting and timing of those interventions. We will use data from the trial to model and compare potential strategies for ACF in terms of expected diagnostic yield, cost effectiveness, and impact on TB control in India. TB Aftermath will answer key questions in a population that is often ignored by the TB community once treatment is complete, despite being at considerable risk for recurrent TB disease. We will provide evidence for an effective and scalable strategy targeting HHs of treated TB cases, a high priority of the RNTCP. Our high TB burden setting, strong multidisciplinary team, communication with the RNTCP and state TB program, and proven research infrastructure ensures successful implementation of TB Aftermath.