مراجعة
Management and control of tuberculosis control in socially complex groups: a research programme including three RCTs
| العنوان: | Management and control of tuberculosis control in socially complex groups: a research programme including three RCTs |
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| المؤلفون: | Story A; Institute of Health Informatics, University College London, London, UK; Find&Treat, University College Hospitals NHS Foundation Trust, London, UK, Garber E; Institute of Health Informatics, University College London, London, UK; Royal Free London NHS Foundation Trust, London, UK, Aldridge RW; Institute of Health Informatics, University College London, London, UK, Smith CM; Institute of Health Informatics, University College London, London, UK, Hall J; Institute of Health Informatics, University College London, London, UK; Royal Free London NHS Foundation Trust, London, UK, Ferenando G; Institute of Health Informatics, University College London, London, UK; Royal Free London NHS Foundation Trust, London, UK, Possas L; Institute of Health Informatics, University College London, London, UK; Royal Free London NHS Foundation Trust, London, UK, Hemming S; Institute of Health Informatics, University College London, London, UK; Royal Free London NHS Foundation Trust, London, UK, Wurie F; Institute of Health Informatics, University College London, London, UK, Luchenski S; Institute of Health Informatics, University College London, London, UK, Abubakar I; Institute for Global Health, University College London, London, UK, McHugh TD; Centre for Clinical Microbiology, University College London, London, UK, White PJ; Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK; National Institute for Health Research Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK; Modelling and Economics Unit, National Infection Service, Public Health England, London, UK, Watson JM; Research Department of Infection and Population Health, University College London, London, UK, Lipman M; Royal Free London NHS Foundation Trust, London, UK; Respiratory Medicine, Division of Medicine, University College London, London, UK, Garfein R; Division of Global Public Health, School of Medicine, University of California, San Diego, CA, USA, Hayward AC; Institute of Epidemiology and Health Care, University College London, London, UK |
| المصدر: | 2020 Oct. |
| المصدر: | Programme Grants for Applied Research |
| نوع المنشور: | Review |
| اللغة: | English |
| بيانات الدورية: | Publisher: NIHR Journals Library |
| أسماء مطبوعة: | Southampton (UK) : NIHR Journals Library |
| مستخلص: | Background: Socially complex groups, including people experiencing homelessness, prisoners and drug users, have very high levels of tuberculosis, often complicated by late diagnosis and difficulty in adhering to treatment. Objective: To assess a series of interventions to improve tuberculosis control in socially complex groups. Design: A series of observational surveys, evaluations and trials of interventions. Setting: The pan-London Find&Treat service, which supports tuberculosis screening and case management in socially complex groups across London. Participants: Socially complex groups with tuberculosis or at risk of tuberculosis, including people experiencing homelessness, prisoners, drug users and those at high risk of poor adherence to tuberculosis treatment. Interventions and Main Outcome Measures: We screened 491 people in homeless hostels and 511 people in prison for latent tuberculosis infection, human immunodeficiency virus, hepatitis B and hepatitis C. We evaluated an NHS-led prison radiographic screening programme. We conducted a cluster randomised controlled trial (2348 eligible people experiencing homelessness in 46 hostels) of the effectiveness of peer educators (22 hostels) compared with NHS staff (24 hostels) at encouraging the uptake of mobile radiographic screening. We initiated a trial of the use of point-of-care polymerase chain reaction diagnostics to rapidly confirm tuberculosis alongside mobile radiographic screening. We undertook a randomised controlled trial to improve treatment adherence, comparing face-to-face, directly observed treatment with video-observed treatment using a smartphone application. The primary outcome was completion of ≥ 80% of scheduled treatment observations over the first 2 months following enrolment. We assessed the cost-effectiveness of latent tuberculosis screening alongside radiographic screening of people experiencing homelessness. The costs of video-observed treatment and directly observed treatment were compared. Results: In the homeless hostels, 16.5% of people experiencing homelessness had latent tuberculosis infection, 1.4% had current hepatitis B infection, 10.4% had hepatitis C infection and 1.0% had human immunodeficiency virus infection. When a quality-adjusted life-year is valued at £30,000, the latent tuberculosis screening of people experiencing homelessness was cost-effective provided treatment uptake was ≥ 25% (for a £20,000 quality-adjusted life-year threshold, treatment uptake would need to be > 50%). In prison, 12.6% of prisoners had latent tuberculosis infection, 1.9% had current hepatitis B infection, 4.2% had hepatitis C infection and 0.0% had human immunodeficiency virus infection. In both settings, levels of latent tuberculosis infection and blood-borne viruses were higher among injecting drug users. A total of 1484 prisoners were screened using chest radiography over a total of 112 screening days (new prisoner screening coverage was 43%). Twenty-nine radiographs were reported as potentially indicating tuberculosis. One prisoner began, and completed, antituberculosis treatment in prison. In the cluster randomised controlled trial of peer educators to increase screening uptake, the median uptake was 45% in the control arm and 40% in the intervention arm (adjusted risk ratio 0.98, 95% confidence interval 0.80 to 1.20). A rapid diagnostic service was established on the mobile radiographic unit but the trial of rapid diagnostics was abandoned because of recruitment and follow-up difficulties. We randomly assigned 112 patients to video-observed treatment and 114 patients to directly observed treatment. Fifty-eight per cent of those recruited had a history of homelessness, addiction, imprisonment or severe mental health problems. Seventy-eight (70%) of 112 patients on video-observed treatment achieved the primary outcome, compared with 35 (31%) of 114 patients on directly observed treatment (adjusted odds ratio 5.48, 95% confidence interval 3.10 to 9.68; p < 0.0001). Video-observed treatment was superior to directly observed treatment in all demographic and social risk factor subgroups. The cost for 6 months of treatment observation was £1645 for daily video-observed treatment, £3420 for directly observed treatment three times per week and £5700 for directly observed treatment five times per week. Limitations: Recruitment was lower than anticipated for most of the studies. The peer advocate study may have been contaminated by the fact that the service was already using peer educators to support its work. Conclusions: There are very high levels of latent tuberculosis infection among prisoners, people experiencing homelessness and drug users. Screening for latent infection in people experiencing homelessness alongside mobile radiographic screening would be cost-effective, providing the uptake of treatment was 25–50%. Despite ring-fenced funding, the NHS was unable to establish static radiographic screening programmes. Although we found no evidence that peer educators were more effective than health-care workers in encouraging the uptake of mobile radiographic screening, there may be wider benefits of including peer educators as part of the Find&Treat team. Utilising polymerase chain reaction-based rapid diagnostic testing on a mobile radiographic unit is feasible. Smartphone-enabled video-observed treatment is more effective and cheaper than directly observed treatment for ensuring that treatment is observed. Future Work: Trials of video-observed treatment in high-incidence settings are needed. Trial Registration: Current Controlled Trials ISRCTN17270334 and ISRCTN26184967. Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research ; Vol. 8, No. 9. See the NIHR Journals Library website for further project information. (Copyright © Queen’s Printer and Controller of HMSO 2020. This work was produced by Story et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.) |
| فهرسة مساهمة: | Keywords: TUBERCULOSIS; HEPATITIS B; HEPATITIS C; HIV; HOMELESS; IMPRISONMENT; SUBSTANCE USE DISORDER |
| رمز التحديث: | 20240629 |
| DOI: | 10.3310/pgfar08090 |
| PMID: | 33119243 |
| Book AN: | NBK563462 |
| قاعدة البيانات: | MEDLINE |
| DOI: | 10.3310/pgfar08090 |
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