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Attempted TB Control in South African Gold Miners

Summary and Comment |
January 22, 2014

Attempted TB Control in South African Gold Miners

  1. Larry M. Baddour, MD

Mass screening, together with treatment for the miners with active disease and isoniazid prophylaxis for all others, failed to reduce the incidence of tuberculosis.

  1. Larry M. Baddour, MD

The high risk for tuberculosis (TB) among South African gold miners has been recognized for many decades and has been intensified by the HIV epidemic. Now, in a cluster-randomized trial involving workers at three gold-mining companies, researchers have evaluated a novel intervention: screening the entire workforce for active TB, then providing treatment for individuals with active disease and isoniazid prophylaxis for all others.

Overall, 15 clusters were included, 8 in the intervention group and 7 in the control group (40,981 and 37,763 miners, respectively). Overall TB incidence per 100 person-years was 3.02 and 2.95 in the intervention and control clusters (adjusted rate ratio for the intervention clusters, 0.96; 95% confidence interval, 0.76–1.21). TB prevalence was 2.35% and 2.14% for the two groups (adjusted prevalence ratio, 0.98; 95% CI, 0.65–1.48). In an analysis of the direct effect of the intervention (n=10,909), isoniazid prophylaxis was associated with a reduction in TB incidence during the 9-month treatment period (1.10 vs. 2.91 cases per 100 person-years; adjusted rate ratio, 0.42; 95% CI, 0.20–0.88) but not during the 12-month follow-up period thereafter.

Comment

Many factors could have contributed to the failure of this intervention; those mentioned by the authors include suboptimal study retention, the possibility of posttreatment reinfection or reactivation of inadequately treated latent infection, and high rates of HIV infection and silicosis (both of which are strong risk factors for TB). Although the results of this trial were negative, they could help in the development of similar interventions that might prove more successful. With an estimated prevalence of latent tuberculosis infection among South African miners close to 90%, a program involving multiple strategies will likely be required to achieve TB control. Effective interventions are sorely needed for this high-risk population.

  • Disclosures for Larry M. Baddour, MD at time of publication Editorial boards UpToDate Leadership positions in professional societies American Heart Association (Chairman, Rheumatic Fever, Endocarditis, Kawasaki Disease Committee)

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