TREATMENT COMPLETION RATES FOR LTBI ARKANSAS 2006 2010

TREATMENT COMPLETION RATES FOR LTBI, ARKANSAS, 2006 -2010: WHAT DO WE DO WITH NEGATIVE FINDINGS ? Mukasa LN, MBCh. B Ph. D. , Bates JH, MD. , Phillips J. MD. , Abernathy RS, MD. , Karpoff E. BSN RNP. , Diatta N. , Patil N, MD MHSA. Arkansas Department of Health

Background/Statement of Problem Treatment completion for LTBI was original focus area for program evaluation in Arkansas, 2006 LTBI is reportable in Arkansas Over the years, treatment LTBI remained priority Thirty seven percent of the cases, 2004 -2007 were missed opportunities We sought to increase LTBI Tx completion to 65% by 2010

Background… Average 2500 LTBI cases diagnosed per year Reporting LTBI initially incomplete using paper forms In 2005, we predicted that the TB case rate would be 2. 0 per 100, 000 population in 2010 if interventions at time were maintained q We sought to accelerate TB elimination by aggressively treating LTBI

A Missed TB Opportunity was defined as a TB case: Known to have a prior LTBI diagnosis Known to be HIV positive before TB diagnosis From established targeted intervention groups Nursing Homes Prisons Health Care Workers Foreign-born students Age less than 5 years Reported After Death

Prediction of Arkansas TB Case Rates 2006 -2010 Year TB Case Rate Predicted Observed 2006 47 36 2007 32 37 2008 28 29 2009 24 28 2010 20 27 *Rate Per million population

Aims/Objectives 1) Evaluate Completion LTBI Treatment 2004 -2010 2) Illustrate concept second generation surveillance Ø Case rate vs. Treatment LTBI Ø Clustering vs. Treatment of LTBI 3) Discuss next steps

Methods Stakeholders included clinicians, colleges, poultry workers, correction institutions and nursing homes LTBI cases came from targeted testing and contact investigation Cases LTBI were captured using a standard form Analysis was approached in 3 ways: Treatment completion rates for LTBI Construction of a missed opportunity measure Genotype cluster analysis

Data Flow • Contact Investigations • Targeted Testing TB Contacts LTBI Cases E-forms Web-Enabled TB Registry Evaluation Treatment LTBI

Arkansas 75 Counties Within 5 Regions: A Centralized Public Health Infrastructure Predictive Model of LTBI Treatment to include Regions is Pending Little Rock

Results Treatment completion rates for LTBI ranged from 50 to 55% during the 5 -year study period 35 -40% of all TB cases were missed opportunities 13. 5% of all cases were known prior LTBI 64% of case-isolates were in genotype clusters

TB Cases Reported from Prior LTBI, Arkansas, 2004 -2010 Year Total Cases Prior LTBI Number Percent 2010 78 7 9. 0 2009 82 11 13. 4 2008 83 21 25. 3 2004 -2007 454 55 12. 1 Overall 697 94 13. 5

TB Trends by Treatment Completion for LTBI, Arkansas, 2004 -2010 Year TB Cases TB Case Rate** Foreign-born (%) Completion TLTBI (%) 2010 78 2. 7 30. 8 48. 0* 2009 82 2. 8 28. 0 55. 7 2008 83 2. 9 22. 9 54. 6 2007 106 3. 7 29. 2 53. 2 2006 102 3. 6 31. 4 50. 5 2005 114 4. 1 29. 0 52. 8 2004 132 4. 8 36. 4 49. 3 2003 127 4. 7 18. 9 2002 136 5. 0 14. 7 2001 162 6. 1 17. 9 2000 199 7. 8 14. 6 TLTBI =Treatment LTBI ** Cases per 100, 000 population * Provisional Data

Genotype Clustering, Arkansas, 20052010, (n=401) 36% 64% Spoligotype-MIRU method

Electronic Contact Form

2 -Page Electronic LTBI Form

The TB Trends in Arkansas and the US are in similar direction Are we constructing another U-shaped Curve of Concern ?

Conclusions/Recommendations q The goal of increasing LTBI treatment completion rates from 50% to 65% was not achieved. Complete data analysis is pending q We could not link the modest decline in TB incidence, 2006 -2010 to treatment LTBI q The level of clustering by genotype suggests substantial ongoing TB transmission q Deployment of two electronic forms for TB contacts and LTBI will greatly improve surveillance and real-time analysis of LTBI in Arkansas q. The introduction of the long awaited “game changers”, namely IGRA and 3 -month regimen for LTBI is ongoing in Arkansas. q The new tools in deployment, we believe, will reverse the negative findings in our study

Next Steps q Computerize all LTBI records 2006 -2010 q Construct predictive models Treatment Completion Ø Logistic Regression Treatment completion (Y/N)=region + gender+ age + US-born status, etc… Ø Cox’s Proportional Hazards Model Curves Months on Isoniazid by group e. g region, US-born status, etc. . q Study and adopt interventions from other programs