Home-based tuberculosis contact investigation in Uganda: a household randomised trial

Abstract

IntroductionThe World Health Organization (WHO) recommends household tuberculosis (TB) contact investigation in low-income countries, but most contacts do not complete a full clinical and laboratory evaluation.MethodsWe performed a randomised trial of home-based, SMS-facilitated, household TB contact investigation in Kampala, Uganda. Community health workers (CHWs) visited homes of index patients with pulmonary TB to screen household contacts for TB. Entire households were randomly allocated to clinic (standard-of-care) or home (intervention) evaluation. In the intervention arm, CHWs offered HIV testing to adults; collected sputum from symptomatic contacts and persons living with HIV (PLWHs) if ≥5 years; and transported sputum for microbiologic testing. CHWs referred PLWHs, children <5 years, and anyone unable to complete sputum testing to clinic. Sputum testing results and/or follow-up instructions were returned by automated SMS texts. The primary outcome was completion of a full TB evaluation within 14 days; secondary outcomes were TB and HIV diagnoses and treatments among screened contacts.ResultsThere were 471 contacts of 190 index patients allocated to the intervention and 448 contacts of 182 index patients allocated to the standard-of-care. CHWs identified 190/471 (40%) intervention and 213/448 (48%) standard-of-care contacts requiring TB evaluation. In the intervention arm, CHWs obtained sputum from 35/91 (39%) of sputum-eligible contacts and SMSs were sent to 95/190 (50%). Completion of TB evaluation in the intervention and standard-of-care arms at 14 days (14% versus 15%; difference −1%, 95% CI −9% to 7%, p=0.81) and yields of confirmed TB (1.5% versus 1.1%, p=0.62) and new HIV (2.0% versus 1.8%, p=0.90) diagnoses were similar.ConclusionsHome-based, SMS-facilitated evaluation did not improve completion or yield of household TB contact investigation, likely due to challenges delivering the intervention components.

Implementing mHealth Interventions in a Resource-Constrained Setting: Case Study From Uganda

“…As previously reported [ 30 ], the mHealth trial showed no improvement in the primary outcome of completing TB evaluation. Although household contacts and health workers spoke positively about the mobile app and text messaging, low rates of delivery and uptake of text-messaged instructions were observed [ 26 , 31 ].…”

Costing the implementation of public health interventions in resource-limited settings: a conceptual framework

“…Where these costs are large and must be incurred before scale-up is certain, they may represent a majority of the total cost of the intervention. For example, in a trial of mobile Health-facilitated home-based contact investigation for TB in Uganda, a software package was required to generate short messaging service (SMS) reminders to facilitate home-based screening, incurring large up-front costs for an initial service contract and adaptation to the Ugandan telecommunications infrastructure [ 15 ]. While this intervention was only delivered to 372 households (919 contacts screened), the cost of designing and developing the intervention ($137 per contact screened, of which $90 was for software development) overshadowed the cost of intervention delivery ($54 per contact screened) [ 16 ].…”

Community health worker-based mobile health (mHealth) approaches for improving management and caregiver knowledge of common childhood infections: A systematic review

“…A cluster RCT in Kenya demonstrated that correct artemether-lumefantrine (AL) management improved by 23.7% (95% confidence interval (CI) = 9.0-33.7, P = 0.0007) immediately after the intervention and by 24.5% (95% CI = 11.6-35.7, P = 0.0001) six months after the intervention when text message reminders were sent to the CHWs on following national malaria management guidelines [ 53 ]. Authors of the same study also determined the cost-effectiveness of the use of these text message reminders on adherence to national malarial treatment guidelines and demonstrated the cost per additional child correctly managed was US$0.50 under study conditions, US$0.36 if implemented by the ministry of health in the same study locations under routine, and USD 0.03 if implemented nationally after being scaled-up [ 37 ].…”