A trial of mass isoniazid preventive therapy for tuberculosis control.
BACKGROUND
Tuberculosis is epidemic among workers in South African gold mines. We evaluated an intervention to interrupt tuberculosis transmission by means of mass screening that was linked to treatment for active disease or latent infection.


METHODS
In a cluster-randomized study, we designated 15 clusters with 78,744 miners as either intervention clusters (40,981 miners in 8 clusters) or control clusters (37,763 miners in 7 clusters). In the intervention clusters, all miners were offered tuberculosis screening. If active tuberculosis was diagnosed, they were referred for treatment; if not, they were offered 9 months of isoniazid preventive therapy. The primary outcome was the cluster-level incidence of tuberculosis during the 12 months after the intervention ended. Secondary outcomes included tuberculosis prevalence at study completion.


RESULTS
In the intervention clusters, 27,126 miners (66.2%) underwent screening. Of these miners, 23,659 (87.2%) started taking isoniazid, and isoniazid was dispensed for 6 months or more to 35 to 79% of miners, depending on the cluster. The intervention did not reduce the incidence of tuberculosis, with rates of 3.02 per 100 person-years in the intervention clusters and 2.95 per 100 person-years in the control clusters (rate ratio in the intervention clusters, 1.00; 95% confidence interval [CI], 0.75 to 1.34; P=0.98; adjusted rate ratio, 0.96; 95% CI, 0.76 to 1.21; P=0.71), or the prevalence of tuberculosis (2.35% vs. 2.14%; adjusted prevalence ratio, 0.98; 95% CI, 0.65 to 1.48; P=0.90). Analysis of the direct effect of isoniazid in 10,909 miners showed a reduced incidence of tuberculosis during treatment (1.10 cases per 100 person-years among miners receiving isoniazid vs. 2.91 cases per 100 person-years among controls; adjusted rate ratio, 0.42; 95% CI, 0.20 to 0.88; P=0.03), but there was a subsequent rapid loss of protection.


CONCLUSIONS
Mass screening and treatment for latent tuberculosis had no significant effect on tuberculosis control in South African gold mines, despite the successful use of isoniazid in preventing tuberculosis during treatment. (Funded by the Consortium to Respond Effectively to the AIDS TB Epidemic and others; Thibela TB Current Controlled Trials number, ISRCTN63327174.).
From the Aurum Institute (G.J.C., L.C.) and the School of Public Health, University of the Witwatersrand (G.J.C.) - both in Johannesburg; the London School of Hygiene and Tropical Medicine, London (G.J.C., K.L.F., J.J.L., E.L.C., P.G.-F., R.J.H., A.D.G.); and the Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore (R.E.C.).
Gavin J
GJ
Churchyard
Katherine L
KL
Fielding
James J
JJ
Lewis
Leonie
L
Coetzee
Elizabeth L
EL
Corbett
Peter
P
Godfrey-Faussett
Richard J
RJ
Hayes
Richard E
RE
Chaisson
Alison D
AD
Grant
D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use*; D058872:Epidemics; D006046:Gold; D006801:Humans; D015994:Incidence; D007538:Isoniazid / Q000627:therapeutic use*; D008297:Male; D008403:Mass Screening; D055118:Medication Adherence; D008906:Mining; D013019:South Africa / Q000453:epidemiology; D017211:Treatment Failure; D014376:Tuberculosis / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control*
D000995:Antitubercular Agents; D006046:Gold; D007538:Isoniazid