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Original article
Twelve-monthly versus six-monthly radiological screening for active case-finding of tuberculosis: a randomised controlled trial
  1. Gavin J Churchyard1,2,
  2. Katherine Fielding2,
  3. Surita Roux1,
  4. Elizabeth L Corbett3,
  5. Richard E Chaisson4,
  6. Kevin M De Cock3,
  7. Richard J Hayes2,
  8. Alison D Grant3
  1. 1Aurum Institute for Health Research, Johannesburg, South Africa
  2. 2Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  3. 3Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
  4. 4Center for TB Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
  1. Correspondence to Professor G J Churchyard, Aurum Institute for Health Research, PostNet Suite 300, Private Bag X30500, Houghton 2041, South Africa; gchurchyard{at}auruminstitute.org

Abstract

Background The incidence of tuberculosis has increased among South African gold miners despite comprehensive control programmes, including a radiological screening programme. No data are available as to the optimal frequency of screening. The aim of this study was to compare 6-monthly and 12-monthly radiological screening for active tuberculosis case-finding.

Methods Employees of a gold mining company were randomly assigned to the control arm (screening at baseline, 12 and 24 months) or the intervention arm (additional ‘intervention’ radiographs at 6 and 18 months after baseline). Study outcomes included proportion of tuberculosis cases detected by screening, proportion smear-positive, extent of disease and mortality.

Results 22 634 miners were randomised. Compared with 12-monthly screening, 6-monthly screening detected more tuberculosis suspects but not more cases, partly due to greater attrition between screening and further investigation after ‘intervention’ compared with routine radiographs. Tuberculosis cases detected in the 6-monthly versus the 12-monthly screening arm had less extensive disease (p=0.05) and a lower tuberculosis-specific mortality (death on tuberculosis treatment) (2.1 and 2.8 per 1000 person-years respectively, HR 0.73, 95% CI 0.50 to 1.08, p=0.1), which was most marked in the first 2 months of treatment (HR 0.48, 95% CI 0.23 to 0.98, p=0.04) when death from tuberculosis is most likely.

Discussion In settings with a high prevalence of HIV and tuberculosis despite standard tuberculosis control measures, more frequent case-finding may reduce the extent of disease, tuberculosis mortality and tuberculosis transmission through earlier detection of active tuberculosis cases. To be effective, however, all tuberculosis suspects identified through screening must be investigated for tuberculosis.

  • Tuberculosis
  • radiological screening
  • active case-finding
  • mortality
  • randomised
  • HIV
  • clinical epidemiology
  • tuberculosis
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Footnotes

  • Funding This study was funded by the Safety In Mines Research Advisory Council of South Africa (SIMHEALTH Gen 524). GJC and KF were funded by Aurum Institute for Health Research. ELC was funded by a Wellcome Trust Training Fellowship in Clinical Tropical Medicine. ADG was supported by a UK Department of Health Public Health Career Scientist award. GJC and KF are funded by the Consortium to Respond Effectively to the AIDS TB Epidemic.

  • Competing interests GJC was employed by AngloGold Health Services during the conduct of the study. None of the other authors has competing interests.

  • Ethics approval The study was approved by the research ethics committees of Anglogold Health Services and the London School of Hygiene and Tropical Medicine, and through the Mine Health and Safety Committees of each mine shaft with the involvement of union representatives. Individual informed consent for the intervention chest radiographs was not obtained as radiological screening is a legal requirement in the industry and the optimal frequency of radiological screening is unknown and both were used. Individuals had the option to undergo or to decline the intervention chest radiograph.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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