The South African Ministry of Health has proposed

screening all clinic attendees for tuberculosis (TB).

Amongst other factors, male sex and bar attendance are

associated with higher TB risk. We show that 45% of

adults surveyed in Western Cape attended a clinic within

6 months, and therefore potentially a relatively high proportion

of the population could be reached through clinic-based

screening. However, fewer than 20% of all men

aged 18–25 years, or men aged 26–45 who attend bars,

attended a clinic. The population-level impact of clinic-based

screening may be reduced by low coverage

among key risk groups

Ayles, H.

Dodd, P.J.

Faghmous, I.

Godfrey-Faussett, P.

Looker, C.

McCreesh, N.

Muyoyeta, M.

Plumb, I.D.

Shanaube, K.

White, R.G.

PubMed

N. McCreesh

I. Faghmous

C. Looker

P. J. Dodd

I. D. Plumb

K. Shanaube

M. Muyoyeta

P. Godfrey-Faussett

H. Ayles

R. G. White

Crossref

Public Health Action

Coverage of clinic-based TB screening in South Africa may be low in key risk groups

White Rose Research Online

Public Health Action International Union Against Tuberculosis and Lung DiseaseHealth solutions for the poorvol 6 no 1 published 21 march 2016PHA 2016; 6(1): 19–21 © 2016 McCreesh et al.AFFILIATIONS1 TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK2 Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK3 ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia4 TB Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia5 Department of Clinical Research, LSHTM, London, UKCORRESPONDENCENicky McCreeshDepartment of Infectious Disease EpidemiologyLSHTM, Keppel StreetLondon, WC1E 7HT, UKe-mail: nicky.mccreesh@lshtm.ac.ukKEY WORDStuberculosis; screening; South Africa; primary health careSHORT COMMUNICATIONCoverage of clinic-based TB screening in South Africa  may be low in key risk groupsN. McCreesh,1 I. Faghmous,1 C. Looker,1 P. J. Dodd,1,2 I. D. Plumb,1 K. Shanaube,3  M. Muyoyeta,3,4 P. Godfrey-Faussett,5 H. Ayles,3,5 R. G. White1South Africa has one of the highest tuberculosis (TB) burdens in the world, with an estimated disease prevalence in 2013 of 715 per 100 000 population.1 Dis-ease incidence has been falling since 2008,2 but the de-cline is slow, and new approaches are needed to accel-erate the rate of decline. As part of its ‘90s’ strategy, on World TB Day 2015, the South African Ministry of Health proposed implementing screening of all health centre attendees for TB disease (unpublished speech given by Minister of Health A. Motsoaledi). This is a po-tentially more cost-effective approach than communi-ty-based screening programmes, as it is plausible that the prevalence of TB will be higher in clinic attendees than in the wider community, and the costs of reach-ing clinic attendees are likely to be lower than more ac-tive community-based screening programmes. Its pop-ulation-level impact will be lower, however, if screening coverage is low among population subgroups that are at higher risk of developing TB disease. We investigated clinic attendance in adults in Western Cape, and in particular among two key risk groups: (young) men and people who visit bars.STUDY POPULATION, DESIGN AND METHODSThe study sampling frame consisted of adults living in eight communities in Western Cape, South Africa, who were enrolled in the final Zambia/South Africa TB and acquired immune-deficiency syndrome Reduction (ZAMSTAR) prevalence survey.3 Four sampling enu-meration areas (SEAs) from each ZAMSTAR commu-nity were selected proportional to size, and 40 people were sampled at random from each SEA, stratified by sex and age. A full description of the sampling method is given elsewhere.4Respondents were interviewed in their own homes using a structured questionnaire.4 The main purpose of the questionnaire was to collect data on contact and activity patterns relevant to Mycobacterium tuber-culosis transmission. Respondents were also asked if they had visited a health care facility for any reason in the last 6 months.Logistic regression was used to examine associa-tions between a number of variables and clinic atten-dance. Estimates were adjusted for age and sex and weighted to account for the stratified sampling design.Ethical approval was obtained from the University of Stellenbosch Health Research Ethics Committee, Stellenbosch, South Africa (N04/10/173), the Univer-sity of Zambia Biomedical Research Ethics Committee, Lusaka, Zambia (007-10-04), and the London School of Hygiene & Tropical Medicine Ethics Committee, London, UK (A211 3008).RESULTSA total of 1272 adults living in Western Cape were in-terviewed. Results are presented for the 1271 adults who provided information on clinic attendance.Overall, 55% (95% confidence interval [CI] 48–61) of women and 29% (95%CI 23–34) of men reported visiting a clinic in the past 6 months (Table 1). Adjust-ing for sex, the odds of having visited a clinic in-creased with age (P = 0.001), with people aged 18–25 years having 0.47 (95%CI 0.31–0.70) times the odds compared to people aged 45 years. People who re-ported attending bars had 0.45 (95%CI 0.33–0.60) times the odds of clinic attendance compared to peo-ple who reported never attending bars.Reported clinic attendance in the past 6 months was 50% for women in all age groups who never at-tended bars and for women aged 45 years who at-tended bars (Table 2). Reported attendance was 20% for all men aged 18–25 and for men aged 26–45 who attended bars.DISCUSSIONWe demonstrate that a clinic-based screening ap-proach in Western Cape could achieve a potentially relatively high overall level of population coverage, Received 13 October 2015Accepted 1 December 2015First published online 25 January 2016http://dx.doi.org/10.5588/pha.15.0064The South African Ministry of Health has proposed screening all clinic attendees for tuberculosis (TB). Amongst other factors, male sex and bar attendance are associated with higher TB risk. We show that 45% of adults surveyed in Western Cape attended a clinic within 6 months, and therefore potentially a relatively high pro-portion of the population could be reached through clin-ic-based screening. However, fewer than 20% of all men aged 18–25 years, or men aged 26–45 who attend bars, attended a clinic. The population-level impact of clin-ic-based screening may be reduced by low coverage among key risk groups.Public Health Action Clinic-based TB screening coverage in SA  20with 45% of adults reporting visiting a clinic in the last 6 months. In line with other studies from South Africa, we show that clinic attendance is lower among men than women,5,6 and is lower in younger than older adults.5 Coverage may be substantially lower than average in some population groups, in particular men aged 18–25 and men aged 26–45 who visit bars. Fewer than 20% of men in these groups may be reached by clinic-based screening programmes in any 6-month period. This is of particular concern, as these demographic groups are at increased risk of contract-ing TB,7,8 and passive case detection may be particu-larly inadequate in people who consume alcohol,9 po-tentially reducing the wider impact of clinic-based TB screening programmes.We present data on clinic visits in the last 6 months. Coverage will be higher over longer time peri-ods, as a higher proportion of the population will visit a clinic in 12 months, for example, than in 6 months. For people who visit clinics less frequently, however, time between screenings will be longer, reducing the average impact of screening on the time between the onset of infectiousness and diagnosis. Coverage will also be lower if not all clinics screen 100% of attendees.The main limitation of our approach is that data on both clinic and bar attendance were collected for similar time periods. This means that some of the ob-served inverse association between bar and clinic at-tendance may have resulted from illness that caused individuals to both attend a clinic and to stop attend-ing bars, rather than a genuine reluctance or inability to attend clinics in people who visit bars. This may have biased the association upwards, but is unlikely to be responsible for more than a small proportion of the large observed difference in clinic attendance.A second limitation of our findings is that only communities with a clinic could be selected for inclu-sion in the original ZAMSTAR study. Clinic usage has been shown to decrease in South Africa as distance to the nearest clinic increases.10 Coverage may therefore be lower in communities with poorer access to health care, reducing overall coverage.Clinic-based TB screening programmes have the po-tential to reach nearly half the adult population over a 6-month period in Western Cape, and may be a cost-effective way to reduce the prevalence of TB. Their effectiveness may be reduced by poor coverage in cer-tain risk groups, however, and we recommend that clinic-based screening should be supplemented by case-finding programmes targeting key risk groups.References1 World Health Organization. Global tuberculosis report 2014. WHO/HTM/TB/2014.08. Geneva, Switzerland: WHO, 2014.2 Nanoo A, Izu A, Ismail N A, et al. Nationwide and regional in-cidence of microbiologically confirmed pulmonary tuberculo-sis in South Africa, 2004–2012: a time series analysis. Lancet Infect Dis 2015; 15: 1066–1076.ACKNOWLEDGEMENTSThe authors would like to acknowledge the ZAMSTAR study team and R Dunbar, K Eames, J Edmunds, A Crampin and I Kleinschmidt, all of whom contributed advice in the design and analysis of the social contact survey. We would like to thank the Ministry of Health, District Health Management teams and the communities where the studies were undertaken for their help and advice.NM was supported by the UK Medical Research Council (MR/J005088/1), London, UK. RGW, PJD, CL and IP were supported by the Consortium to Respond Effectively to the AIDS TB Epidemic funded by the Bill and Melinda Gates Foundation (19790.01), Seattle, WA, USA. RGW was also supported by the Bill and Melinda Gates Foundation (OPP1084276) and the UK Medical Research Council (G0802414, MR/J005088/1).Conflicts of interest: none declared.This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.TABLE 1 Association between sex, age and bar attendance and clinic attendance within the previous 6 monthsn (%)Proportion who visited a clinic% (95%CI)*Odds ratio(95%CI)*† P valueSex Female 638 (50) 55 (48–61) 1 (reference) Male 633 (50) 29 (24–34) 0.33 (0.24–0.45) 0.001Age, years 45 296 (23) 57 (49–64) 1 (reference) 26–45 578 (45) 42 (36–48) 0.53 (0.37–0.77) 0.001 18–25 397 (31) 39 (33–45) 0.47 (0.31–0.70)Ever go to bars? No 830 (65) 53 (48–58) 1 (reference) Yes 441 (35) 26 (22–32) 0.45 (0.33–0.60) 0.001Total 1271 (100) 45 (41–50)* Weighted to account for sampling method.† Adjusted for age and sex.CI = confidence interval.TABLE 2 Proportion of people reporting clinic attendance in past 6 months by sex, age and bar attendanceAgeyearsMennProportion visited clinic % (95%CI)*WomennProportion visited clinic % (95%CI)*Ever go to bars 18–25 250 19 (13–29) 90 35 (21–53)26–45 367 18 (12–26) 131 29 (18–43)45 159 33 (17–53) 22 67 (38–87)Never go to bars 18–25 335 20 (13–30) 502 55 (44–67)26–45 285 34 (25–45) 714 59 (51–66)45 294 49 (38–60) 368 63 (52–74)* Weighted to account for sampling method.CI = confidence interval.Public Health Action Clinic-based TB screening coverage in SA  213 Ayles H M, Sismanidis C, Beyers N, Hayes R J, Godfrey-Faussett P. ZAMSTAR, the Zambia South Africa TB and HIV Reduction Study: design of a 2 x 2 fac-torial community randomized trial. Trials 2008; 9: 63.4 Dodd P J, Looker C, Plumb I, et al. Age- and sex- specific social contact pat-terns and incidence of Mycobacterium tuberculosis infection. Am J Epide-miol 2015; 183:156–166.5 Harris B, Goudge J, Ataguba J E, et al. Inequities in access to health care in South Africa. J Public Health Policy 2011; 32 (Suppl 1): S102–S123.6 Chihota V N, Ginindza S, McCarthy K, Grant A D, Churchyard G, Fielding K. Missed opportunities for TB investigation in primary care clinics in South Africa: experience from the XTEND trial. PLOS ONE 2015; 10: e0138149.7 Lawn S D, Bekker L-G, Middelkoop K, Myer L, Wood R. Impact of HIV infec-tion on the epidemiology of tuberculosis in a peri-urban community in South Africa: the need for age-specific interventions. Clin Infect Dis 2006; 42: 1040–1047.8 Harling G, Ehrlich R, Myer L. The social epidemiology of tuberculosis in South Africa: a multilevel analysis. Soc Sci Med 2008; 66: 492–505.9 van’t Hoog A H, Marston B J, Ayisi J G, et al. Risk factors for inadequate TB case finding in rural Western Kenya: a comparison of actively and passively identified TB patients. PLOS ONE 2013; 8: e61162.10 Tanser F, Gijsbertsen B, Herbst K. Modelling and understanding primary health care accessibility and utilization in rural South Africa: an exploration using a geographical information system. Soc Sci Med 2006; 63: 691–705.Le Ministère de la Santé d’Afrique du Sud a proposé de dépister la tuberculose (TB) chez tous les patients visitant un centre de santé. Parmi d’autres facteurs, le sexe masculin et la fréquentation des bars sont associés à un risque plus élevé de TB. Nous montrons que 45% des adultes dépistés dans la province du Cap Ouest s’étaient rendus dans un centre de santé au cours des 6 derniers mois et c’est pourquoi une proportion relativement élevée de la population pourrait être atteinte à travers un dépistage en centre de santé. Cependant, moins de 20% de tous les hommes âgés de 18–25 ans, ou des hommes âgés de 26–45 ans qui fréquentent les bars, se rendent dans un centre de santé. L’impact sur la population de ce type de dépistage pourrait donc être réduit par une faible couverture parmi les groupes à risque majeur.El Ministerio de Salud de Suráfrica propuso una detección sistemática de la tuberculosis (TB) a todas las personas que acudían a los consultorios. Entre los factores asociados con un mayor riesgo de padecer TB están el sexo masculino y la frecuentación de bares. El presente artículo pone de manifiesto que 45% de los adultos encuestados en la Ciudad del Cabo había acudido a un establecimiento de salud en los últimos 6 meses, por lo cual se pudo llegar a una proporción relativamente alta de la población mediante esta detección sistemática. Sin embargo, menos del 20% de todos los hombres entre los 18 y los 25 años, o entre los 26 y los 45 años de edad que frecuenta los bares, acudió a los establecimientos de salud. La repercusión a escala de la población de una detección sistemática realizada en los consultorios podría verse atenuada por una baja cobertura de los grupos más vulnerables.Public Health Action (PHA) The voice for operational research.Published by The Union (www.theunion.org), PHA provides a platform to fulfil its mission, ‘Health solutions for the poor’. PHA publishes high-quality scientific research that provides new knowledge to improve the accessibility, equity, quality and efficiency of health systems and services. e-ISSN 2220-8372Editor-in-Chief: Dermot Maher, MD, SwitzerlandContact: pha@theunion.orgPHA website: http://www.theunion.org/what-we-do/journals/phaArticle submission: http://mc.manuscriptcentral.com/pha

The South African Ministry of Health has proposed screening all clinic attendees for tuberculosis (TB). Amongst other factors, male sex and bar attendance are associated with higher TB risk. We show that 45% of adults surveyed in Western Cape attended a clinic within 6 months, and therefore potentially a relatively high proportion of the population could be reached through clinic-based screening. However, fewer than 20% of all men aged 18-25 years, or men aged 26-45 who attend bars, attended a clinic. The population-level impact of clinic-based screening may be reduced by low coverage among key risk groups

McCreesh, N

Faghmous, I

Looker, C

Dodd, PJ

Plumb, ID

Shanaube, K

Muyoyeta, M

Godfrey-Faussett, P

Ayles, H

White, RG

LSHTM Research Online

McCreesh, N; Faghmous, I; Looker, C; Dodd, PJ; Plumb, ID; Shanaube,K; Muyoyeta, M; Godfrey-Faussett, P; Ayles, H; White, RG (2016)Coverage of clinic-based TB screening in South Africa may be lowin key risk groups. Public Health Action, 6 (1). pp. 19-21. ISSN2220-8372 DOI: 10.5588/pha.15.0064Downloaded from: http://researchonline.lshtm.ac.uk/2537068/DOI: 10.5588/pha.15.0064Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: http://creativecommons.org/licenses/by/2.5/Public Health Action International Union Against Tuberculosis and Lung DiseaseHealth solutions for the poorvol 6 no 1 published 21 march 2016PHA 2016; 6(1): 19–21 © 2016 McCreesh et al.AFFILIATIONS1 TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK2 Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK3 ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia4 TB Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia5 Department of Clinical Research, LSHTM, London, UKCORRESPONDENCENicky McCreeshDepartment of Infectious Disease EpidemiologyLSHTM, Keppel StreetLondon, WC1E 7HT, UKe-mail: nicky.mccreesh@lshtm.ac.ukKEY WORDStuberculosis; screening; South Africa; primary health careSHORT COMMUNICATIONCoverage of clinic-based TB screening in South Africa  may be low in key risk groupsN. McCreesh,1 I. Faghmous,1 C. Looker,1 P. J. Dodd,1,2 I. D. Plumb,1 K. Shanaube,3  M. Muyoyeta,3,4 P. Godfrey-Faussett,5 H. Ayles,3,5 R. G. White1South Africa has one of the highest tuberculosis (TB) burdens in the world, with an estimated disease prevalence in 2013 of 715 per 100 000 population.1 Dis-ease incidence has been falling since 2008,2 but the de-cline is slow, and new approaches are needed to accel-erate the rate of decline. As part of its ‘90s’ strategy, on World TB Day 2015, the South African Ministry of Health proposed implementing screening of all health centre attendees for TB disease (unpublished speech given by Minister of Health A. Motsoaledi). This is a po-tentially more cost-effective approach than communi-ty-based screening programmes, as it is plausible that the prevalence of TB will be higher in clinic attendees than in the wider community, and the costs of reach-ing clinic attendees are likely to be lower than more ac-tive community-based screening programmes. Its pop-ulation-level impact will be lower, however, if screening coverage is low among population subgroups that are at higher risk of developing TB disease. We investigated clinic attendance in adults in Western Cape, and in particular among two key risk groups: (young) men and people who visit bars.STUDY POPULATION, DESIGN AND METHODSThe study sampling frame consisted of adults living in eight communities in Western Cape, South Africa, who were enrolled in the final Zambia/South Africa TB and acquired immune-deficiency syndrome Reduction (ZAMSTAR) prevalence survey.3 Four sampling enu-meration areas (SEAs) from each ZAMSTAR commu-nity were selected proportional to size, and 40 people were sampled at random from each SEA, stratified by sex and age. A full description of the sampling method is given elsewhere.4Respondents were interviewed in their own homes using a structured questionnaire.4 The main purpose of the questionnaire was to collect data on contact and activity patterns relevant to Mycobacterium tuber-culosis transmission. Respondents were also asked if they had visited a health care facility for any reason in the last 6 months.Logistic regression was used to examine associa-tions between a number of variables and clinic atten-dance. Estimates were adjusted for age and sex and weighted to account for the stratified sampling design.Ethical approval was obtained from the University of Stellenbosch Health Research Ethics Committee, Stellenbosch, South Africa (N04/10/173), the Univer-sity of Zambia Biomedical Research Ethics Committee, Lusaka, Zambia (007-10-04), and the London School of Hygiene & Tropical Medicine Ethics Committee, London, UK (A211 3008).RESULTSA total of 1272 adults living in Western Cape were in-terviewed. Results are presented for the 1271 adults who provided information on clinic attendance.Overall, 55% (95% confidence interval [CI] 48–61) of women and 29% (95%CI 23–34) of men reported visiting a clinic in the past 6 months (Table 1). Adjust-ing for sex, the odds of having visited a clinic in-creased with age (P = 0.001), with people aged 18–25 years having 0.47 (95%CI 0.31–0.70) times the odds compared to people aged 45 years. People who re-ported attending bars had 0.45 (95%CI 0.33–0.60) times the odds of clinic attendance compared to peo-ple who reported never attending bars.Reported clinic attendance in the past 6 months was 50% for women in all age groups who never at-tended bars and for women aged 45 years who at-tended bars (Table 2). Reported attendance was 20% for all men aged 18–25 and for men aged 26–45 who attended bars.DISCUSSIONWe demonstrate that a clinic-based screening ap-proach in Western Cape could achieve a potentially relatively high overall level of population coverage, Received 13 October 2015Accepted 1 December 2015First published online 25 January 2016http://dx.doi.org/10.5588/pha.15.0064The South African Ministry of Health has proposed screening all clinic attendees for tuberculosis (TB). Amongst other factors, male sex and bar attendance are associated with higher TB risk. We show that 45% of adults surveyed in Western Cape attended a clinic within 6 months, and therefore potentially a relatively high pro-portion of the population could be reached through clin-ic-based screening. However, fewer than 20% of all men aged 18–25 years, or men aged 26–45 who attend bars, attended a clinic. The population-level impact of clin-ic-based screening may be reduced by low coverage among key risk groups.Public Health Action Clinic-based TB screening coverage in SA  20with 45% of adults reporting visiting a clinic in the last 6 months. In line with other studies from South Africa, we show that clinic attendance is lower among men than women,5,6 and is lower in younger than older adults.5 Coverage may be substantially lower than average in some population groups, in particular men aged 18–25 and men aged 26–45 who visit bars. Fewer than 20% of men in these groups may be reached by clinic-based screening programmes in any 6-month period. This is of particular concern, as these demographic groups are at increased risk of contract-ing TB,7,8 and passive case detection may be particu-larly inadequate in people who consume alcohol,9 po-tentially reducing the wider impact of clinic-based TB screening programmes.We present data on clinic visits in the last 6 months. Coverage will be higher over longer time peri-ods, as a higher proportion of the population will visit a clinic in 12 months, for example, than in 6 months. For people who visit clinics less frequently, however, time between screenings will be longer, reducing the average impact of screening on the time between the onset of infectiousness and diagnosis. Coverage will also be lower if not all clinics screen 100% of attendees.The main limitation of our approach is that data on both clinic and bar attendance were collected for similar time periods. This means that some of the ob-served inverse association between bar and clinic at-tendance may have resulted from illness that caused individuals to both attend a clinic and to stop attend-ing bars, rather than a genuine reluctance or inability to attend clinics in people who visit bars. This may have biased the association upwards, but is unlikely to be responsible for more than a small proportion of the large observed difference in clinic attendance.A second limitation of our findings is that only communities with a clinic could be selected for inclu-sion in the original ZAMSTAR study. Clinic usage has been shown to decrease in South Africa as distance to the nearest clinic increases.10 Coverage may therefore be lower in communities with poorer access to health care, reducing overall coverage.Clinic-based TB screening programmes have the po-tential to reach nearly half the adult population over a 6-month period in Western Cape, and may be a cost-effective way to reduce the prevalence of TB. Their effectiveness may be reduced by poor coverage in cer-tain risk groups, however, and we recommend that clinic-based screening should be supplemented by case-finding programmes targeting key risk groups.References1 World Health Organization. Global tuberculosis report 2014. WHO/HTM/TB/2014.08. Geneva, Switzerland: WHO, 2014.2 Nanoo A, Izu A, Ismail N A, et al. Nationwide and regional in-cidence of microbiologically confirmed pulmonary tuberculo-sis in South Africa, 2004–2012: a time series analysis. Lancet Infect Dis 2015; 15: 1066–1076.ACKNOWLEDGEMENTSThe authors would like to acknowledge the ZAMSTAR study team and R Dunbar, K Eames, J Edmunds, A Crampin and I Kleinschmidt, all of whom contributed advice in the design and analysis of the social contact survey. We would like to thank the Ministry of Health, District Health Management teams and the communities where the studies were undertaken for their help and advice.NM was supported by the UK Medical Research Council (MR/J005088/1), London, UK. RGW, PJD, CL and IP were supported by the Consortium to Respond Effectively to the AIDS TB Epidemic funded by the Bill and Melinda Gates Foundation (19790.01), Seattle, WA, USA. RGW was also supported by the Bill and Melinda Gates Foundation (OPP1084276) and the UK Medical Research Council (G0802414, MR/J005088/1).Conflicts of interest: none declared.This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.TABLE 1 Association between sex, age and bar attendance and clinic attendance within the previous 6 monthsn (%)Proportion who visited a clinic% (95%CI)*Odds ratio(95%CI)*† P valueSex Female 638 (50) 55 (48–61) 1 (reference) Male 633 (50) 29 (24–34) 0.33 (0.24–0.45) 0.001Age, years 45 296 (23) 57 (49–64) 1 (reference) 26–45 578 (45) 42 (36–48) 0.53 (0.37–0.77) 0.001 18–25 397 (31) 39 (33–45) 0.47 (0.31–0.70)Ever go to bars? No 830 (65) 53 (48–58) 1 (reference) Yes 441 (35) 26 (22–32) 0.45 (0.33–0.60) 0.001Total 1271 (100) 45 (41–50)* Weighted to account for sampling method.† Adjusted for age and sex.CI = confidence interval.TABLE 2 Proportion of people reporting clinic attendance in past 6 months by sex, age and bar attendanceAgeyearsMennProportion visited clinic % (95%CI)*WomennProportion visited clinic % (95%CI)*Ever go to bars 18–25 250 19 (13–29) 90 35 (21–53)26–45 367 18 (12–26) 131 29 (18–43)45 159 33 (17–53) 22 67 (38–87)Never go to bars 18–25 335 20 (13–30) 502 55 (44–67)26–45 285 34 (25–45) 714 59 (51–66)45 294 49 (38–60) 368 63 (52–74)* Weighted to account for sampling method.CI = confidence interval.Public Health Action Clinic-based TB screening coverage in SA  213 Ayles H M, Sismanidis C, Beyers N, Hayes R J, Godfrey-Faussett P. ZAMSTAR, the Zambia South Africa TB and HIV Reduction Study: design of a 2 x 2 fac-torial community randomized trial. Trials 2008; 9: 63.4 Dodd P J, Looker C, Plumb I, et al. Age- and sex- specific social contact pat-terns and incidence of Mycobacterium tuberculosis infection. Am J Epide-miol 2015; 183:156–166.5 Harris B, Goudge J, Ataguba J E, et al. Inequities in access to health care in South Africa. J Public Health Policy 2011; 32 (Suppl 1): S102–S123.6 Chihota V N, Ginindza S, McCarthy K, Grant A D, Churchyard G, Fielding K. Missed opportunities for TB investigation in primary care clinics in South Africa: experience from the XTEND trial. PLOS ONE 2015; 10: e0138149.7 Lawn S D, Bekker L-G, Middelkoop K, Myer L, Wood R. Impact of HIV infec-tion on the epidemiology of tuberculosis in a peri-urban community in South Africa: the need for age-specific interventions. Clin Infect Dis 2006; 42: 1040–1047.8 Harling G, Ehrlich R, Myer L. The social epidemiology of tuberculosis in South Africa: a multilevel analysis. Soc Sci Med 2008; 66: 492–505.9 van’t Hoog A H, Marston B J, Ayisi J G, et al. Risk factors for inadequate TB case finding in rural Western Kenya: a comparison of actively and passively identified TB patients. PLOS ONE 2013; 8: e61162.10 Tanser F, Gijsbertsen B, Herbst K. Modelling and understanding primary health care accessibility and utilization in rural South Africa: an exploration using a geographical information system. Soc Sci Med 2006; 63: 691–705.Le Ministère de la Santé d’Afrique du Sud a proposé de dépister la tuberculose (TB) chez tous les patients visitant un centre de santé. Parmi d’autres facteurs, le sexe masculin et la fréquentation des bars sont associés à un risque plus élevé de TB. Nous montrons que 45% des adultes dépistés dans la province du Cap Ouest s’étaient rendus dans un centre de santé au cours des 6 derniers mois et c’est pourquoi une proportion relativement élevée de la population pourrait être atteinte à travers un dépistage en centre de santé. Cependant, moins de 20% de tous les hommes âgés de 18–25 ans, ou des hommes âgés de 26–45 ans qui fréquentent les bars, se rendent dans un centre de santé. L’impact sur la population de ce type de dépistage pourrait donc être réduit par une faible couverture parmi les groupes à risque majeur.El Ministerio de Salud de Suráfrica propuso una detección sistemática de la tuberculosis (TB) a todas las personas que acudían a los consultorios. Entre los factores asociados con un mayor riesgo de padecer TB están el sexo masculino y la frecuentación de bares. El presente artículo pone de manifiesto que 45% de los adultos encuestados en la Ciudad del Cabo había acudido a un establecimiento de salud en los últimos 6 meses, por lo cual se pudo llegar a una proporción relativamente alta de la población mediante esta detección sistemática. Sin embargo, menos del 20% de todos los hombres entre los 18 y los 25 años, o entre los 26 y los 45 años de edad que frecuenta los bares, acudió a los establecimientos de salud. La repercusión a escala de la población de una detección sistemática realizada en los consultorios podría verse atenuada por una baja cobertura de los grupos más vulnerables.Public Health Action (PHA) The voice for operational research.Published by The Union (www.theunion.org), PHA provides a platform to fulfil its mission, ‘Health solutions for the poor’. PHA publishes high-quality scientific research that provides new knowledge to improve the accessibility, equity, quality and efficiency of health systems and services. e-ISSN 2220-8372Editor-in-Chief: Dermot Maher, MD, SwitzerlandContact: pha@theunion.orgPHA website: http://www.theunion.org/what-we-do/journals/phaArticle submission: http://mc.manuscriptcentral.com/pha

Coverage of clinic-based TB screening in South Africa may be low in key risk groups.

https://eprints.whiterose.ac.uk/101340/1/Coverage%20of%20clinic-based%20TB%20screening%20in%20South%20Africa%20may%20be%20low%20in%20key%20risk%20groups.pdf

Coverage of clinic-based TB screening in South Africa may be low in key risk groups

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