Hamada, Yohhei; (2025) Research to understand multimorbidity in households affected by tuberculosis. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background: The syndemic of tuberculosis (TB) and non-communicable diseases (NCD) in low- and middle-income countries (LMIC) threatens lives and livelihoods. I aimed to derive evidence to inform multifaceted interventions for TB and associated multimorbidity in TB-affected households. Method and Findings: First, I conducted an individual participant data (IPD) meta-analysis of 16 national TB prevalence surveys, revealing a higher smoking prevalence in TB-affected households than in households without TB (odds ratio 1.23; 95% confidence interval [CI]: 1.11-1.38, adjusted for age and gender). Second, analysis using the same data suggested that current smokers and people with self-reported diabetes were 1.5 times more likely to have prevalent TB, indicating these groups as targets for TB screening. Third, I conducted an IPD meta-analysis of contact tracing studies to address data gaps in prevalence surveys. Data from 14 studies suggested underdiagnosis of diabetes among household contacts, with scarce data on other NCDs, indicating the need for a prospective clinical study. Fourth, in a pilot cross-sectional study in South Africa and Tanzania, I assessed the burden of select NCDs among TB household contacts through systematic screening, using neighbourhood households as controls. Among contacts, 12.2% and 39.7% had diabetes and hypertension, respectively, with more than half being newly identified. Their prevalence was similar to that of the controls. Fifth, a decision tree analysis found that adding NCD screening to contact investigations would additionally cost $24,940 per DALY averted. This cost exceeded the cost-effectiveness threshold in South Africa, potentially influenced by limitations of the analytical approach (e.g., restricting to cardiovascular disease outcomes). The analysis further suggests that targeted screening in high-risk groups could improve cost-effectiveness. Conclusion: The thesis highlights the high prevalence of undiagnosed NCDs among household contacts of TB, notably diabetes, which could be addressed by integrating NCD screening. Future trials should evaluate its impact on clinical outcomes.

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