M L Bastos1, O Oxlade2, A Benedetti3, F Fregonese4, C Valiquette4, S C C Lira5, D Carvalho-Cordeiro6, J R Cavalcante7, E Faerstein7, M F M Albuquerque8, M Cordeiro-Santos9, P C Hill10, D Menzies11, A Trajman12. 1. Social Medicine Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil, Respiratory Epidemiology & Clinical Research Unit. 2. McGill International TB Centre. 3. Respiratory Epidemiology & Clinical Research Unit, Departments of Epidemiology, Biostatistics & Occupational Health, and Medicine, McGill University, Montreal, QC, Canada. 4. Respiratory Epidemiology & Clinical Research Unit. 5. Recife Municipal Health Secretariat, Recife, PE, Programa de Pós-graduação em Saúde Coletiva, Universidade Federal do Pernambuco, Recife, PE. 6. Manaus Municipal Health Secretariat, Manaus, AM, Programa de Pós-gradução em Enfermagem, Universidade Federal do Amazonas, Manaus, AM. 7. Social Medicine Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil. 8. Aggeu Magalhães Research Center, Fiocruz, Recife, PE. 9. Tropical Medicine Post-Graduation Program, Amazonas State University, Manaus, AM, Tropical Medicine Foundation Dr Heitor Vieira Dourado, Manaus, AM, Brazil. 10. Centre for International Health, Otago Medical School, University of Otago, Otago, New Zealand. 11. Respiratory Epidemiology & Clinical Research Unit, McGill International TB Centre, Departments of Epidemiology, Biostatistics & Occupational Health, and Medicine, McGill University, Montreal, QC, Canada. 12. McGill International TB Centre, Internal Medicine Post-Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Primary Health Care Post-Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
Abstract
SETTING: Two consecutive trials were conducted to evaluate the effectiveness of a public health approach to identify and correct problems in the care cascade for household contacts (HHCs) of TB patients in three Brazilian high TB incidence cities. METHODS: In the first trial, 12 clinics underwent standardised evaluation using questionnaires administered to TB patients, HHCs and healthcare workers, and analysis of the cascade of latent TB care among HHCs. Six clinics were then randomised to receive interventions to strengthen management of latent TB infection (LTBI), including in-service training provided by nurses, work process organisation and additional clinic-specific solutions. In the second trial, a similar but streamlined evaluation was conducted in two clinics, who then received initial and subsequent intensive in-service training provided by a physician. RESULTS: In the evaluation phase of both trials, many HHCs were identified, but few started LTBI treatment. After the intervention, the number of HHCs initiating treatment per 100 active TB patients increased by 10 (95%CI - 11 to 30) in the first trial, and by 44 (95%CI 26 to 61) in the second trial.DISCUSSION: A public health approach with standardised evaluation, local decisions for improvements, followed by intensive initial and in-service training appears promising for improved LTBI management.
RCT Entities:
SETTING: Two consecutive trials were conducted to evaluate the effectiveness of a public health approach to identify and correct problems in the care cascade for household contacts (HHCs) of TB patients in three Brazilian high TB incidence cities. METHODS: In the first trial, 12 clinics underwent standardised evaluation using questionnaires administered to TB patients, HHCs and healthcare workers, and analysis of the cascade of latent TB care among HHCs. Six clinics were then randomised to receive interventions to strengthen management of latent TB infection (LTBI), including in-service training provided by nurses, work process organisation and additional clinic-specific solutions. In the second trial, a similar but streamlined evaluation was conducted in two clinics, who then received initial and subsequent intensive in-service training provided by a physician. RESULTS: In the evaluation phase of both trials, many HHCs were identified, but few started LTBI treatment. After the intervention, the number of HHCs initiating treatment per 100 active TB patients increased by 10 (95%CI - 11 to 30) in the first trial, and by 44 (95%CI 26 to 61) in the second trial.DISCUSSION: A public health approach with standardised evaluation, local decisions for improvements, followed by intensive initial and in-service training appears promising for improved LTBI management.