Download - Treatment completion rates for ltbi, arkansas, 2006-2010: What do we do with negative findings ?
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
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
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 Case rate vs. Treatment LTBI 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
Web-EnabledTB Registry
TB Contact
sLTBI Cases
E-forms E-forms
Evaluation Treatment LTBI
• Contact Investigations
• Targeted Testing
Arkansas 75 Counties Within 5 Regions:A Centralized Public Health Infrastructure
Little Rock
Predictive Modelof LTBI Treatment to include Regions is Pending
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 LTBINumber 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 14.6TLTBI =Treatment LTBI * Provisional Data** Cases per 100,000 population
Genotype Clustering, Arkansas, 2005-2010, (n=401)
64%36%
Spoligotype-MIRU method
ElectronicContact Form
2-Page Electronic LTBI Form
The TB Trends in Arkansas and the USare in similar direction
Are we constructing another U-shaped Curve of Concern ?
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
Next Steps
Computerize all LTBI records 2006-2010
Construct predictive models Treatment Completion
Logistic RegressionTreatment 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