Comparative Effectiveness/Implementation of TB Case Finding in Rural South Africa

 描述（由申请人提供）：结核病（TB）仍然是全球卫生紧急情况，2012年造成860万新发病例和130万死亡病例。控制结核伙伴关系制定了非常雄心勃勃的目标，其中包括从2015年到2025年将结核病发病率降低50%。因此，如果要实现2025年结核病控制目标，就必须迅速扩大在病程早期发现活动性结核病患者的战略。然而，结核病的主动病例发现（ACF）是昂贵的，难以在实践中实施，并且ACF的理想方法将因流行病学环境而异。农村地区在这方面存在严重的知识差距：尽管农村地区的结核病发病率与大部分地区相当， 在城市，由于基础设施和资源的限制，ACF在农村地区通常被认为是不可行的。在撒哈拉以南非洲地区，60%的人口仍然生活在农村环境中;因此，非洲的结核病不能仅仅通过关注城市来控制。这项研究是一项新的研究，比较有效性，成本效益，并在南非农村活动性结核病病例发现的三种策略的实施。这项研究是一项随机分组的比较有效性研究，涉及南非Vhembe农村地区的56家诊所，该地区的结核病发病率为350/100，000/年。将进行两项比较：（1）平行比较（每个诊所28个）扩大基于设施的结核病筛查（对因任何原因就诊的所有咳嗽患者进行痰液采集和Xpert MTB/RIF检测）与活动性TB病例的接触调查;和（2）接触调查组内的聚类交叉评价，将传统的家庭接触者追踪与基于奖励的追踪（提供通话时间代金券，以换取在诊所就诊的接触者转诊）进行比较。 本研究的具体目的是：（1）评价南非农村活动性结核病例发现策略的可接受性和采用情况;（2）描述以机构为基础的筛查和接触者调查的比较实施情况;（3）测量活动性结核病例发现在农村高负担环境中的比较有效性;（4）评估每种病例发现策略的比较成本和成本效益。这项多学科研究代表了在关键流行病学环境中实现中期结核病控制目标的创新途径（即，农村非洲），但这项研究也可以作为一种方法， 这是如何在紧迫和雄心勃勃的人口健康优先事项的背景下，在广泛的其他领域改善现实世界决策的一个例子。

 DESCRIPTION (provided by applicant): Tuberculosis (TB) remains a global health emergency, responsible for 8.6 million new cases and 1.3 million deaths in 2012. The Stop TB Partnership has set very ambitious targets that include a 50% reduction in TB incidence from 2015 to 2025. Strategies to find people with active TB earlier in their disease course must therefore be rapidly scaled up if TB control targets for 2025 are to be approached. However, active case finding (ACF) for TB is expensive and difficult to implement in practice and the ideal approach to ACF will differ from one epidemiological setting to the next. Rural settings represent a critical knowledge gap in this regard: despite TB incidence in rural areas rivaling that in large cities, ACF is generally seen as infeasible in rural areas due to infrastructure and resource constraints. In sub-Saharan Africa, 60% of the population still lives in rural settings; thus, TB i Africa cannot be controlled by focusing on cities alone. This proposed research is a novel study of the comparative effectiveness, cost-effectiveness, and implementation of three strategies for active TB case finding in rural South Africa. The proposed study is a cluster-randomized comparative effectiveness study involving 56 clinics in the rural district of Vhembe, South Africa - a district with a TB incidence of 350 per 100,000/year. Two comparisons will be made: (1) A parallel comparison (28 clinics each) of augmented facility-based TB screening (sputum collection and Xpert MTB/RIF testing of all coughing patients presenting to clinic for any reason) versus contact investigation of active TB cases; and (2) A cluster- crossover evaluation within the contact investigation arm, comparing traditional household contact tracing versus incentive-based tracing (giving airtime vouchers in exchange for contact referrals presenting at the clinic). The specific aims of this research are: (1) To evaluate acceptability and adoption of active TB case finding strategies in rural South Africa; (2) To describe the comparative implementation of facility-based screening and contact investigation; (3) To measure the comparative effectiveness of active TB case-finding in a rural, high-burden setting; (4) Evaluate the comparative costs and cost-effectiveness of each case-finding strategy. This multidisciplinary research represent an innovative path toward achieving medium-term TB control targets in a key epidemiological setting (i.e., rural Africa), but this study can also serve as a methodological example of how to improve real-world decision-making across a broad array of other fields in the context of urgent and ambitious population health priorities.