Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial

BackgroundOne of the main strategies to control tuberculosis (TB) is to find and treat people with active disease. Unfortunately, the case detection rates remain low in many countries. Thus, we need interventions to find and treat sufficient number of patients to control TB. We investigated whether involving health extension workers (HEWs: trained community health workers) in TB control improved smear-positive case detection and treatment success rates in southern Ethiopia.
Methodology/Principal FindingWe carried out a community-randomized trial in southern Ethiopia from September 2006 to April 2008. Fifty-one kebeles (with a total population of 296, 811) were randomly allocated to intervention and control groups. We trained HEWs in the intervention kebeles on how to identify suspects, collect sputum, and provide directly observed treatment. The HEWs in the intervention kebeles advised people with productive cough of 2 weeks or more duration to attend the health posts. Two hundred and thirty smear-positive patients were identified from the intervention and 88 patients from the control kebeles. The mean case detection rate was higher in the intervention than in the control kebeles (122.2% vs 69.4%, p<0.001). In addition, more females patients were identified in the intervention kebeles (149.0 vs 91.6, p<0.001). The mean treatment success rate was higher in the intervention than in the control kebeles (89.3% vs 83.1%, p = 0.012) and more for females patients (89.8% vs 81.3%, p = 0.05).
Conclusions/SignificanceThe involvement of HEWs in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This could be applied in settings with low health service coverage and a shortage of health workers.
Trial RegistrationClinicalTrials.gov NCT00803322

研究背景：控制肺结核（Tuberculosis, TB）的核心策略之一，是发现并治疗活动性结核病患者。但当前许多国家的结核病病例检出率仍处于较低水平，因此亟需通过干预措施，发现并治疗足够数量的患者以实现结核病防控目标。本研究旨在评估，让社区健康拓展工作者（health extension workers, HEWs，即经过培训的社区卫生工作者）参与结核病防控工作，是否能够提升埃塞俄比亚南部地区痰涂片阳性病例的检出率与治疗成功率。

研究方法与主要结果：本研究于2006年9月至2008年4月在埃塞俄比亚南部开展社区随机对照试验。共计51个凯贝勒（总人口296811人）被随机分配至干预组与对照组。本研究为干预组凯贝勒的社区健康拓展工作者开展培训，内容包括如何识别结核病可疑患者、采集痰液标本以及实施直接面视下督导治疗。干预组的社区健康拓展工作者会建议持续咳嗽≥2周的湿性咳嗽患者前往基层卫生所就诊。最终，干预组共检出230例痰涂片阳性患者，对照组则检出88例。干预组的平均病例检出率显著高于对照组（122.2% vs 69.4%，p<0.001）。此外，干预组检出的女性患者数量更多（149.0 vs 91.6，p<0.001）。干预组的平均治疗成功率亦高于对照组（89.3% vs 83.1%，p=0.012），其中女性患者的治疗成功率提升更为明显（89.8% vs 81.3%，p=0.05）。

研究结论与意义：社区健康拓展工作者参与痰液标本采集与结核病治疗工作，可有效提升痰涂片阳性病例的检出率与治疗成功率，其潜在机制可能为改善了服务可及性。该干预模式可推广应用于卫生服务覆盖率较低、卫生人力短缺的地区。

试验注册：ClinicalTrials.gov NCT00803322