Community-randomized trial of enhanced DOTS for tuberculosis control in Rio de Janeiro, Brazil.

SETTING: Central Rio de Janeiro, Brazil. OBJECTIVE: To compare the impact of routine DOTS vs. enhanced DOTS (DOTS-Ampliado or DOTS-A) on tuberculosis (TB) incidence. DESIGN: Cluster-randomized trial in eight urban neighborhoods pair-matched by TB incidence and randomly assigned to receive either the DOTS-A or DOTS strategy. DOTS-A added intensive screening of household contacts of active TB cases and provision of treatment to secondary cases and preventive therapy to contacts with latent TB infection (LTBI) to the standard DOTS strategy. The primary endpoint was the TB incidence rates in communities after 5 years of intervention. RESULTS: From November 2000 to December 2004, respectively 339 and 311 pulmonary TB cases were enrolled and 1003 and 960 household were identified in DOTS and DOTS-A communities. Among contacts from DOTS-A communities, 26 (4%) had active TB diagnosed and treated, 429 (61.3%) had LTBI detected and 258 (60.1%) started preventive therapy. TB incidence increased by 5% in DOTS communities and decreased by 10% in DOTS-A communities, for a difference of 15% after 5 years (P = 0.04). CONCLUSION: DOTS-A was associated with a modest reduction in TB incidence and may be an important strategy for reducing the burden of TB.

The cost-effectiveness of DOTS in urban Brazil.

SETTING: Rio de Janeiro, Brazil, is a middle-income setting with an estimated 1% adult human immunodeficiency virus (HIV) seroprevalence. OBJECTIVE: To examine the cost-effectiveness of DOTS in Rio de Janeiro. DESIGN: Cost-effectiveness analysis based on cost data and an epidemiological model based on programmatic outcomes from the Health Department in Rio de Janeiro, cost data from the retail market sector and epidemiological data from published studies. RESULTS: The 10-year cost of a tuberculosis program treating a population of 262 000 based on self-administered therapy (SAT) was estimated to be $580 271 compared to $1047 886 for DOTS. The largest portion of the DOTS budget was for staff costs and costs incurred by patients, both at 28%. For SAT, the largest percentage of the budget was allocated to medication costs, at 34%. Upgrading from SAT to DOTS averted 1558 cases of tuberculosis (TB, uncertainty range [UR] 1418-1704) and 143 TB deaths (UR 131-155). The incremental cost effectiveness ratio (ICER) for DOTS was $300 per case averted (UR $289-$312) and $3270 per death averted (UR $3123-$3435). In terms of disability adjusted life years (DALYs), DOTS saved 5426 DALYs (UR 4908-5961). The ICER for DOTS was $86 per DALY saved (UR $74-$100). CONCLUSIONS: DOTS is a highly cost-effective intervention in Brazil.

Active case finding of tuberculosis: historical perspective and future prospects.

Despite a history of remarkable scientific achievements in microbiology and therapeutics, tuberculosis (TB) continues to pose an extraordinary threat to human health. Case finding and treatment of TB disease are the principal means of controlling transmission and reducing incidence. This review presents a historical perspective of active case finding (ACF) of TB, detailing case detection strategies that have been used over the last century. This review is divided into the following sections: mass radiography, house-to-house surveys, out-patient case detection, enhanced case finding, high-risk populations and cost-effectiveness. The report concludes with a discussion and recommendations for future case finding strategies. Understanding the strengths and weaknesses of these methods will help inform and shape ACF as a TB control policy in the twenty-first century.

Changes in utilization of TB health services in Nepal.

SETTING: Nepal. OBJECTIVE: To assess the impact of community mobilization and health worker training on tuberculosis (TB) health services utilization. DESIGN: Questionnaire. METHODS: The Japan International Cooperation Agency and the Nepal Ministry of Health launched a set of interventions to increase awareness and availability of treatment at government facilities. In 2001 and 2003, a questionnaire was administered to TB patients. RESULTS: In 2001-2002, 77.3% of women and 80.0% of men with TB symptoms consulted at government facilities, compared to 30% of men and 32% of women in 1997-1999. CONCLUSION: In the absence of any secular causes, this change can be attributed to the increasing community awareness of availability and quality of DOTS.