Epidemiology of Tuberculosis in a High HIV Prevalence Population Provided with Enhanced Diagnosis of Symptomatic Disease

Background Directly observed treatment short course (DOTS), the global control strategy aimed at controlling tuberculosis (TB) transmission through prompt diagnosis of symptomatic smear-positive disease, has failed to prevent rising tuberculosis incidence rates in Africa brought about by the HIV epidemic. However, rising incidence does not necessarily imply failure to control tuberculosis transmission, which is primarily driven by prevalent infectious disease. We investigated the epidemiology of prevalent and incident TB in a high HIV prevalence population provided with enhanced primary health care. Methods and Findings Twenty-two businesses in Harare, Zimbabwe, were provided with free smear- and culture-based investigation of TB symptoms through occupational clinics. Anonymised HIV tests were requested from all employees. After 2 y of follow-up for incident TB, a culture-based survey for undiagnosed prevalent TB was conducted. A total of 6,440 of 7,478 eligible employees participated. HIV prevalence was 19%. For HIV-positive and -negative participants, the incidence of culture-positive tuberculosis was 25.3 and 1.3 per 1,000 person-years, respectively (adjusted incidence rate ratio = 18.8; 95% confidence interval [CI] = 10.3 to 34.5: population attributable fraction = 78%), and point prevalence after 2 y was 5.7 and 2.6 per 1,000 population (adjusted odds ratio = 1.7; 95% CI = 0.5 to 6.8: population attributable fraction = 14%). Most patients with prevalent culture-positive TB had subclinical disease when first detected. Conclusions Strategies based on prompt investigation of TB symptoms, such as DOTS, may be an effective way of controlling prevalent TB in high HIV prevalence populations. This may translate into effective control of TB transmission despite high TB incidence rates and a period of subclinical infectiousness in some patients.

[1]  H. Kleeberg,et al.  First tuberculosis prevalence survey in KwaZulu. , 1979, South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde.

[2]  Dermot Maher,et al.  How human immunodeficiency virus voluntary testing can contribute to tuberculosis control. , 2002, Bulletin of the World Health Organization.

[3]  J. Porter,et al.  Twice weekly tuberculosis preventive therapy in HIV infection in Zambia , 1998, AIDS.

[4]  Y. Ng,et al.  Selective area tuberculosis surveys in Singapore 1978. , 1981, Annals of the Academy of Medicine, Singapore.

[5]  P. Glaziou,et al.  Prevalence of pulmonary tuberculosis among HIV-infected persons in a home care program in Phnom Penh, Cambodia. , 2002, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[6]  T. Tupasi,et al.  Tuberculosis in the urban poor settlements in the Philippines. , 2000, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[7]  Y. Berhane,et al.  A rapid survey to determine the prevalence of smear-positive tuberculosis in Addis Ababa. , 2002, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[8]  P. B. Fourie,et al.  Follow-up tuberculosis prevalence survey of Transkei. , 1980, Tubercle.

[9]  D. Enarson,et al.  The fate of cases of pulmonary tuberculosis under various treatment programmes. , 1978 .

[10]  D. Ray,et al.  Incidence of smear-positive pulmonary tuberculosis from 1981-83 in a rural area under an active health care programme in south India. , 1995, Tubercle and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[11]  China Tuberculosis Control Collaboration The effect of tuberculosis control in China , 2004, The Lancet.

[12]  C. Dye,et al.  Cost, affordability and cost-effectiveness of strategies to control tuberculosis in countries with high HIV prevalence , 2005, BMC public health.

[13]  Preventive therapy against tuberculosis in people living with HIV. , 1999, Releve epidemiologique hebdomadaire.

[14]  R. Chaisson,et al.  Will DOTS do it? A reappraisal of tuberculosis control in countries with high rates of HIV infection. , 1999, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[15]  B. Marston,et al.  Tuberculosis in sub-Saharan Africa: opportunities, challenges, and change in the era of antiretroviral treatment , 2006, The Lancet.

[16]  R. Peto,et al.  Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43 000 adult male deaths and 35 000 controls , 2003, The Lancet.

[17]  T. Gilpin,et al.  Active case-finding--for the whole community or for tuberculosis contacts only? , 1987, South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde.

[18]  R. Baltussen,et al.  Cost effectiveness analysis of strategies for tuberculosis control in developing countries , 2005, BMJ : British Medical Journal.

[19]  D. McFarland,et al.  Preventive chemotherapy for HIV‐associated tuberculosis in Uganda: an operational assessment at a voluntary counselling and testing centre , 1995, AIDS.

[20]  Brian G. Williams,et al.  Tuberculosis epidemics driven by HIV , 2003 .

[21]  E. Roelsgaard,et al.  TUBERCULOSIS IN TROPICAL AFRICA. AN EPIDEMIOLOGICAL STUDY. , 1964, Bulletin of the World Health Organization.

[22]  T. Frieden,et al.  Trends in the prevalence and incidence of tuberculosis in south India. , 2001, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[23]  R. Hayes,et al.  Uptake of Workplace HIV Counselling and Testing: A Cluster-Randomised Trial in Zimbabwe , 2006, PLoS medicine.

[24]  M. Raviglione The Global Plan to Stop TB, 2006-2015. , 2006, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[25]  Christopher Dye,et al.  Low access to a highly effective therapy: a challenge for international tuberculosis control. , 2002, Bulletin of the World Health Organization.

[26]  M. Borgdorff,et al.  Trends in tuberculosis and the influence of HIV infection in northern Malawi, 1988-2001. , 2004, AIDS.

[27]  Nalin Rastogi,et al.  Integration of tuberculosis screening at an HIV voluntary counselling and testing centre in Haiti , 2001, AIDS.

[28]  Hong Yp,et al.  The seventh nationwide tuberculosis prevalence survey in Korea, 1995. , 1998 .

[29]  T. Tupasi,et al.  The 1997 Nationwide Tuberculosis Prevalence Survey in the Philippines. , 1999, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[30]  D. Guwatudde,et al.  Burden of tuberculosis in Kampala, Uganda. , 2003, Bulletin of the World Health Organization.

[31]  C. Dye,et al.  Global tuberculosis control: surveillance planning financing. WHO report 2003. , 2003 .

[32]  F. Plummer,et al.  Isoniazid preventive therapy for tuberculosis in HIV‐1‐infected adults: results of a randomized controlled trial , 1997, AIDS.

[33]  Christopher Dye,et al.  Tuberculosis epidemics driven by HIV: is prevention better than cure? , 2003, AIDS.

[34]  S Greenland,et al.  Maximum likelihood estimation of the attributable fraction from logistic models. , 1993, Biometrics.

[35]  K. Chokani,et al.  Tuberculosis in a prison population in Malawi , 1997, The Lancet.

[36]  Tuberculosis control in the era of the HIV epidemic: risk of tuberculosis infection in Tanzania, 1983-1998. , 2001, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[37]  Shenglan Tang,et al.  The effect of tuberculosis control in China. Comment , 2004 .

[38]  R. Gie,et al.  The prevalence of symptoms associated with pulmonary tuberculosis in randomly selected children from a high burden community , 2005, Archives of Disease in Childhood.

[39]  W. Lew,et al.  The seventh nationwide tuberculosis prevalence survey in Korea, 1995. , 1998, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[40]  N. Nagelkerke,et al.  Tuberculosis and the HIV epidemic: increasing annual risk of tuberculous infection in Kenya, 1986-1996. , 1999, American journal of public health.

[41]  M. Vjecha,et al.  A trial of three regimens to prevent tuberculosis in Ugandan adults infected with the human immunodeficiency virus. Uganda-Case Western Reserve University Research Collaboration. , 1997, The New England journal of medicine.

[42]  Tuberculosis in a rural population of South India: a five-year epidemiological study. , 1974, Bulletin of the World Health Organization.

[43]  De Cock Km,et al.  Will DOTS do it? A reappraisal of tuberculosis control in countries with high rates of HIV infection. , 1999 .

[44]  S. Lawn,et al.  Tuberculosis among HIV-infected patients receiving HAART: long term incidence and risk factors in a South African cohort , 2005, AIDS.

[45]  R. Hayes,et al.  Human immunodeficiency virus and the prevalence of undiagnosed tuberculosis in African gold miners. , 2004, American journal of respiratory and critical care medicine.

[46]  Rapid assessment of tuberculosis in a large prison system--Botswana, 2002. , 2003, MMWR. Morbidity and mortality weekly report.