Improving TPT Uptake: A Cluster-Randomized Trial of Symptom-Based Versus Tuberculin Skin Test-Based Screening of Household Tuberculosis Contacts Less than 5 Years of Age.

Abstract

BACKGROUND\nTuberculosis preventive therapy(TPT) is highly-effective at preventing tuberculosis disease in household child contacts (<5 years), but is poorly implemented worldwide. In 2006, the World Health Organization recommended symptom-based screening as a replacement for tuberculin skin testing(TST) to simplify contact evaluation and improve implementation. We aimed to determine the effectiveness of this recommendation.\n\n\nMETHODS\nWe conducted a pragmatic cluster-randomized trial to determine whether contact evaluation using symptom screening improved the proportion of identified child contacts who initiated TPT compared to TST-based screening in Matlosana, South Africa. Sixteen clinics were randomized to either symptom-based or TST-based contact evaluation. Outcome data were abstracted from customized child contact management files.\n\n\nRESULTS\nContact tracing identified 550 and 467 child contacts in the symptom and TST arms, respectively (0.39 vs 0.32 per case; p=0.27). There was no significant difference by arm in the adjusted proportion of identified child contacts who were screened (52% vs 60%; p=0.39). The adjusted proportion of identified child contacts who initiated TPT or TB treatment was 51.5% in the symptom clinics and 57.1% in the TST clinics (difference -5.6%; 95%CI: -23.7-12.6; p=0.52). Based on the district s historic average of 0.7 child contacts per index case, 14% and 15% of child contacts completed six-months of TPT in the two arms, respectively(p=0.89).\n\n\nCONCLUSIONS\nSymptom-based screening did not improve the proportion of identified child contacts evaluated or initiated on TPT compared to TST-based screening. Further research is needed to identify bottlenecks and evaluate interventions to ensure all child contacts receive TPT.(ClinicalTrials.gov identifier: NCT03074799).