title: Effect of new tuberculosis diagnostic technologies on community-based intensified case finding: a multicentre randomised controlled trial.
abstract: Inadequate case detection results in high levels of undiagnosed tuberculosis in sub-Saharan Africa. Data for the effect of new diagnostic tools when used for community-based intensified case finding are not available, so we investigated whether the use of sputum Xpert-MTB/RIF and the Determine TB LAM urine test in two African communities could be effective.
  
  
  
  In a pragmatic, randomised, parallel-group trial with individual randomisation stratified by country, we compared sputum Xpert-MTB/RIF, and if HIV-infected, the Determine TB LAM urine test (novel diagnostic group), with laboratory-based sputum smear microscopy (routine diagnostic group) for intensified case finding in communities with high tuberculosis and HIV prevalence in Cape Town, South Africa, and Harare, Zimbabwe. Participants were randomly assigned (1:1) to these groups with computer-generated allocation lists, using culture as the reference standard. In Cape Town, participants were randomised and tested at an Xpert-equipped mobile van, while in Harare, participants were driven to a local clinic where the same diagnostic tests were done. The primary endpoint was the proportion of culture-positive tuberculosis cases initiating tuberculosis treatment in each study group at 60 days. This trial is registered at ClinicalTrials.gov, number NCT01990274.
  
  
  
  Between Oct 18, 2013, and March 31, 2015, 2261 individuals were screened and 875 (39%) of these met the criteria for diagnostic testing. 439 participants were randomly assigned to the novel group and 436 to the routine group. 74 (9%) of 875 participants had confirmed tuberculosis. If late culture-based treatment initiation was excluded, more patients with culture-positive tuberculosis were initiated on treatment in the novel group at 60 days (36 [86%] of 42 in the novel group vs 18 [56%] of 32 in the routine group). Thus the difference in the proportion initiating treatment between groups was 29% (95% CI 9-50, p=0·0047) and 53% more patients initiated therapy in the novel diagnostic group than in the routine diagnostic group. One culture-positive patient was treated based only on a positive LAM test.
  
  
  
  Compared with traditional tools, Xpert-MTB/RIF for community-based intensified case finding in HIV and tuberculosis-endemic settings increased the proportion of patients initiating treatment. By contrast, urine LAM testing was not found to be useful for intensive case finding in this setting.
  
  
  
  European and Developing Countries Clinical Trials Partnership and South African Medical Research Council.
authors.affiliation: Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe; Lung Infection and Immunity Unit, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Gregory L
authors.initials: GL
authors.lastname: Calligaro
authors.affiliation: Department of Immunology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Lynn S
authors.initials: LS
authors.lastname: Zijenah
authors.affiliation: Institute of Infectious Diseases and Molecular Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe; Division of Clinical Immunology and Allergology, Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: Peter
authors.affiliation: Lung Infection and Immunity Unit, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe; DST/NRF of Excellence for Biomedical Tuberculosis Research, and MRC Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.
authors.forename: Grant
authors.initials: G
authors.lastname: Theron
authors.affiliation: Lung Infection and Immunity Unit, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Virginia
authors.initials: V
authors.lastname: Buser
authors.affiliation: Lung Infection and Immunity Unit, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Ruth
authors.initials: R
authors.lastname: McNerney
authors.affiliation: Mabvuku Polyclinic, Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe.
authors.forename: Wilbert
authors.initials: W
authors.lastname: Bara
authors.affiliation: Biomedical and Research Training Institute, Harare, Zimbabwe.
authors.forename: Tsitsi
authors.initials: T
authors.lastname: Bandason
authors.affiliation: Lung Infection and Immunity Unit, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Ureshnie
authors.initials: U
authors.lastname: Govender
authors.affiliation: Lung Infection and Immunity Unit, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Michele
authors.initials: M
authors.lastname: Tomasicchio
authors.affiliation: Lung Infection and Immunity Unit, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Liezel
authors.initials: L
authors.lastname: Smith
authors.affiliation: Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.
authors.forename: Bongani M
authors.initials: BM
authors.lastname: Mayosi
authors.affiliation: Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe; Institute of Infectious Diseases and Molecular Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe; Lung Infection and Immunity Unit, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe; Division of Clinical Immunology and Allergology, Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe. Electronic address: keertan.dheda@uct.ac.za.
authors.forename: Keertan
authors.initials: K
authors.lastname: Dheda
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D000554:Ambulatory Care Facilities; D003906:Developing Countries; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D015995:Prevalence; D012680:Sensitivity and Specificity; D013183:Sputum; D013997:Time Factors; D014376:Tuberculosis / Q000175:diagnosis* / Q000628:therapy / Q000635:transmission