Targeting at-risk households: intensified case-finding for TB and HIV

in contacts of TB patients in South Africa

Adrienne E Shapiro, Modiehi H Rakgokong, Richard E Chaisson, Precious Modiba, Reginah Msandiwa, Jonathan E Golub,

Ebrahim Variava, Neil A Martinson

Active/Intensified Case-finding• DOTS is passive case-finding• WHO 3 I’s

• Multiple ICF approaches– Population– Screening algorithm

• Meta-analysis of household contact screening 4.5% TB prevalence in HH contacts– Little data on HIV ICF

Intensified Case-Finding (ICF)

Isoniazid Prophylaxis

Infection Control

Morrison J, Pai M, Hopewell PC. Lancet ID, 2008

Background & Setting

• South Africa HIV &TB:– Annual TB incidence: 948/100,000– 5.7 million HIV+– 94,000 TB deaths/yr in HIV+

• North West Province:- 200 TB admissions/month, 25% mortality- 4th highest provincial HIV prevalence

(18% among 15-24y)

10 km

Study Area

Methods • 800 index TB cases screened • 723 index TB + HH enrolled in 7 months• Study team (nurse + 2 lay counselors) home visit to

evaluate household contacts• Single sputum specimen

– AFB smear– TB culture (MGIT)– Drug susceptibility testing

• VCT, CD4• Referrals as indicated for rx or further evaluation

– All rx in public sector, free

Participant DemographicsIndex

TB CaseHousehold Contacts

p value

Sex N=723 (%) N=2812 (%)

Male 311 (43) 1183 (42)

Female 412 (57) 1627 (58) 0.77

Age (Mean, range) 38 (18-91) 23 (0-92) <0.01

Unemployed (18+) 564 (78) 791 (61) <0.01

Mean # contacts 3.9 --

Living in shack (%) 193 (27) 682 (24) 0.40

Results: TB

2,812 household contacts enrolled (723 HH)

2,146 (76%) gave sputum

666 did not (24%) give sputum

164 (8%) TB dx

1,982 (92%) TB neg

606 (91%) TB unk

95 (58%) Confirmed69 (42%) Probable

60 (9%) on TB rx

Results: HIV 2,812 contacts enrolled (723 HH)

1,610 (57%) VCT

997 (35%) Refused VCT

164 (10%) HIV+

1,446 (90%) HIV neg

HIV unk

32 (19%) CD4<250

97 (59%) CD4>350

205 (7%) known HIV+

99 (48%) on ARVs

36 (22%) CD4 250-350

TB: Index vs. Household ContactIndex TB Case

N=723 (%)HH ContactN=164 (%)

p value

TB dx basis Smear+ 163 (23) 10 (6)Smear- / Culture+ 16 (2) 154 (94) <0.01

Clinical/CXR 544 (75) 0 TB Symptoms 682 (94) 18 (11) <0.01

MDR 3 (0.4) 5 (3) <0.01

HIV status HIV+ 607 (84) 22 (13) <0.01

HIV- 88 (12) 90 (55)HIV unknown 28 (4) 52 (32)

CD4<250 237 (68) 4 (18) <0.01

Contact tracing vs. random sampling

# Cases TB found per household

# Contact Households

# Randomly selected households

0 585 (81%) 350 (99%)1 113 (16%) 4 (1%)2 24 (3%) 03 1 (0.1%) 0

Total # households with >1 TB case 138 (19%) 4 (1%)

Findings

• Undetected TB (& HIV) highly prevalent in HH contacts of TB patients

-TB in contacts less likely to be HIV+ -TB in contacts less likely to have TB symptoms

• Sputum culture required to detect TB actively

• Household case-finding for TB & HIV in the community is feasible

- Welcomed by most households - Potential to adapt existing services in health

district

Acknowledgments• Participants• PHRU field teams• Matlosana Health Dept & Clinics,

NWPG • National Health Laboratory Services,

South Africa• Johns Hopkins University

Center for TB Research; Johns Hopkins School of Medicine; Bloomberg School of Public Health

• Funding: NIH/NIGMS; USAID via URC and ANOVA Health Institute

The views expressed do not necessarily reflect those of USAID or the United States Government.

Extra Slides

Index TB dx basis

Found TB in 0 HH contacts

N (%)

Found TB in >1 HH contacts

N (%)

p-value (X2)

Smear+ 128 (22) 35 (25)

Smear-/ Cx+

14 (2) 2 (1)

Clinical 447 (76) 101 (73) 0.50