Treatment completion rates for ltbi, arkansas, 2006-2010: What do we do with negative findings ?

1. Treatment completion rates for ltbi, arkansas, 2006-2010: What do we do with negative findings ? Mukasa LN, MBChB PhD., Bates JH, MD., Phillips J. MD., Abernathy RS, MD., Karpoff E. BSN RNP., Diatta N., Patil N, MD MHSA. Arkansas Department of Health

2. 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

3. 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 • We sought to accelerate TB elimination by aggressively treating LTBI

4. 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

5. Prediction of Arkansas TB Case Rates 2006-2010 *Rate Per million population

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

7. 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

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

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

10. 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

11. TB Cases Reported from Prior LTBI, Arkansas, 2004-2010

12. TB Trends by Treatment Completion for LTBI, Arkansas, 2004-2010 TLTBI =Treatment LTBI ** Cases per 100,000 population * Provisional Data

13. Genotype Clustering, Arkansas, 2005-2010, (n=401) 36% 64% Spoligotype-MIRU method

14. Electronic Contact Form

15. 2-Page Electronic LTBI Form

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

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

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