Zambia
Effect of household and community interventions on the burden of tuberculosis in southern Africa: the ZAMSTAR community-randomised trial.
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-finding (ECF) and household level tuberculosis—HIV care, were implemented between Aug 1, 2006, and July 31, 2009, and assessed in a 2×2 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 notification rate, were randomly allocated to one of four study groups using a randomisation schedule stratified 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-confirmed pulmonary tuberculosis in adults (≥18 years), defined 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 significant 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 effect on either outcome.
Discussion
We assessed prevalence of tuberculosis in 24 communities in Zambia and South Africa, after 3 years of ECF or household interventions for tuberculosis control. Of 64 463 randomly selected individuals, 894 individuals had active tuberculosis. Averaging over 24 communities the geometric mean of tuberculosis prevalence was 832 per 100 000 population. We also measured the incidence of tuberculous infection in a cohort of 8809 children, followed up for a median of 4 years. The adjusted prevalence ratio for prevalence and the adjusted rate ratio for incidence did not differ significantly for the ECF versus non-ECF or for the household versus non household groups. However, for the household versus non-household groups the upper bounds of the CI for both prevalence ratio and incidence rate ratio were close to unity. The concordance of two robust outcome measures, measured in different population groups and with different methods suggests that the household intervention did have some effect on the burden of tuberculosis in these communities.
The convergence of HIV and tuberculosis has led to an urgent need for an evidence-based public health response to reduce the burden of tuberculosis at the community level. Cluster-randomised trials should provide the gold standard for evidence-based policy making.
A systematic review of published work identified five studies that provided evidence for the effect of interventions on the epidemiology of tuberculosis at community level . Apart from preliminary data from the ZAMSTAR trial, two were randomised trials—the DETECTB trial of enhanced case-finding strategies in Zimbabwe and a trial of a household-level intervention in Brazil. The ZAMSTAR trial is the only study to measure the effect of public health interventions on tuberculosis with a randomised design and direct measurements of the burden of disease as the endpoint. The ZAMSTAR trial covered a population of almost 1 million people and was designed to detect reductions in prevalence of tuberculosis, and incidence of tuberculous infection, of 30%. Our study identified no evidence that the ECF intervention had an effect on the burden of tuberculosis at community level. However, despite not reaching statistical significance, there is plausible evidence that the household intervention did reduce the burden of tuberculosis in these communities.
Source: Lancet
Bill & Melinda Gates Foundation.
Novartis collaboration aims to eliminate rheumatic heart disease (RHD) in Zambia, Africa.
RHD has been eliminated in most developed nations, but sub-Saharan Africa studies show at least 2-3% of school-age children suffer from this often fatal disease.
- Collaboration between Novartis physicians, Zambian healthcare providers, cardiologists from Massachusetts General Hospital (MGH) and the Pan-African Cardiology Society will promote RHD prevention by treating children with streptococcal infections and silent RHD
- The collaboration will screen 3,000 Zambian children by echocardiography and provide monthly penicillin injections to children with silent RHD to prevent recurrent strep throat and associated cardiac damage
Novartis today announced that it has launched an effort to eliminate rheumatic heart disease in Zambia in collaboration with the Lusaka University Teaching Hospital (UTH), the Ministry of Health in Zambia, the Pan-African Cardiology Society and Massachusetts General Hospital (MGH).
RHD is a complication of untreated streptococcal infections in which the valves of the heart are scarred and eventually degenerate, leading to heart failure. Eliminated by antibiotic treatment in most developed nations, in the developing world an estimated 15 million children suffer from this debilitating and often fatal disease[1].
“The toll of heart failure in young children with RHD in Zambia is immense, for the patient, their families, and the nation,” said Mark C. Fishman, Cardiologist and President of the Novartis Institutes for BioMedical Research (NIBR). “It is entirely preventable. For the past several years Novartis has been working with colleagues in Lusaka to help understand and treat asthma in young children. We are expanding the collaboration to raise awareness, educate, and provide antibiotic therapy to prevent RHD.”
To measure RHD prevalence and identify those in need of secondary prophylaxis, teams of health care professionals from Lusaka UTH, the MGH, and Novartis will use portable echocardiography machines to evaluate 3,000 children, ages 9-10, in Lusaka-area public schools. Echocardiography screening is estimated to detect more than 10 times as many cases as clinical screening[1].
Images from the echocardiography screens will be analyzed in Zambia and at the MGH using a cloud-based electronic registry developed by Dimagi Inc, a Cambridge, MA-based company that designs open-source electronic healthcare systems for low resource environments.
Children identified as having RHD will be treated with monthly penicillin injections (termed “secondary prophylaxis”) to prevent recurrent streptococcal infections and additional valve damage.
Primary prevention, the treatment of children with streptococcal infection to prevent RHD, is key to elimination of the disease. To this end, all children diagnosed with strep throat will be treated with injectable penicillin in the community-based study sites. Prevalence of RHD and adherence to secondary prophylaxis will be determined via the mobile electronic registry.
“We have assembled an experienced team from MGH who are excited to bring the mobile heart imaging technology to Zambia,” stated Michael H. Picard, MD, Director of Echocardiography at the Massachusetts General Hospital and a Past President of the American Society of Echocardiography. “We are creating a model for country-wide screening through schools that will not only raise awareness of the magnitude of this disease but also offer a simple method to identify those who will benefit from a very simple and safe treatment. The MGH Cardiology Division and its Cardiac Ultrasound Laboratory are delighted to be a partner in this initiative.”
The Pan-African Cardiology Society will assist with the development of the study protocol and ethics approval. Based on the experience of the initial Lusaka-based effort, Novartis plans to support the rollout of the RHD training and treatment effort to Provinces across Zambia, with the ultimate goal of eliminating RHD in Zambia.
“Rheumatic heart disease is the most common acquired heart ailment in Zambian children, but statistics are spotty and the disease is certainly diagnosed late when damage to the heart valves has already reached advanced stage,” said John Musuku, Principal Investigator and UTH pediatrician. “Our hope is that the collaboration with Novartis will lay the foundation to detect the disease early so preventative measures are instituted. This is an effort to eradicate the disease across Zambia in our life time.”
Source: Novartis
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