Achieving a step change in the tuberculosis epidemic through comprehensive community-wide intervention: A model-based analysis

Background: Global progress towards reducing tuberculosis (TB) incidence and mortality has consistently lagged behind World Health Organization targets leading to a perception that large reductions in TB burden cannot be achieved. However, several recent and historical trials suggest that intervention efforts that are comprehensive and focused can have substantial epidemiological impact. We aimed to quantify the potential epidemiological impact of an intensive but realistic, community-wide campaign utilizing existing tools, and designed to achieve a “step change” in TB burden.

Methods: We developed a compartmental model of tuberculosis transmission in a mid-sized city in India, the country with the greatest absolute burden of TB worldwide. We modeled the impact of a campaign comprising one-time community-wide screening with treatment for TB disease and preventive therapy for latent TB infection (LTBI). This one-time intervention was followed by strengthening of tuberculosis-related health system achieved by leveraging the one-time campaign. We estimated the tuberculosis cases and deaths that could be averted over 10 years using this comprehensive approach and assessed the contributions of individual components of the intervention.

Results: A campaign that successfully screened 70% of the adult population for active and latent tuberculosis and subsequently reduced diagnostic and treatment delays and unsuccessful treatment outcomes by 50% was projected to avert 7,800 (95% range: 5,450 – 10,200) cases and 1,710 (1,290 – 2,180) tuberculosis-related deaths per 1 million population over 10 years. Of the total averted deaths, 33.5% (28.2 – 38.3) were attributable to inclusion of preventive therapy and 52.9% (48.4 - 56.9) to health system strengthening. 

Conclusions: A one-time, community-wide mass campaign, comprehensively designed to detect, treat, and prevent tuberculosis with currently existing tools can have meaningful and long-lasting epidemiological impact. Successful treatment of LTBI is critical to achieving this result. Health system strengthening is essential to any effort to transform the TB response.