Tuberculosis Treatment Completion Among Persons Incarcerated at Diagnosis, U.S. TB Surveillance System, 1999– 2008 Kiren Mitruka, MD, MPH (presented on her behalf by Maryam Haddad) Surveillance, Epidemiology, and Outbreak Investigations Branch ACET Meeting — March 7, 2012 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of TB Elimination
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Tuberculosis Treatment Completion Among Persons Incarcerated at Diagnosis, U.S. TB Surveillance System, 1999–2008 Kiren Mitruka, MD, MPH (presented on.
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Tuberculosis Treatment Completion Among Persons Incarcerated at
Diagnosis, U.S. TB Surveillance System, 1999–
2008Kiren Mitruka, MD, MPH(presented on her behalf by Maryam Haddad)
Surveillance, Epidemiology, and Outbreak Investigations Branch
ACET Meeting — March 7, 2012
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of TB Elimination
Background: Treatment Completion
Treatment completion is a top priority for TB control
Interrupted or incomplete treatment increases risk of relapse, transmission, and drug resistance
Most forms of TB are treatable within 6–9 months
2015 national target: 93% completion (COT) within 12 months among persons eligible for COT ≤12 months
Background: National TB Surveillance
National TB Surveillance System (NTSS) began to collect reason therapy stopped (treatment outcome) in 1993
Also in 1993, NTSS began recording whether patientresiding in correctional facility at time of TB diagnosis Federal prison, state prison, local jail, juvenile facility,
other In 2009, additional variable to ascertain whether under
custody of Immigration and Customs Enforcement (ICE)
Overall Treatment Completion
Overall proportion of cases ever completing treatment 87%92% during 1993–2008 Among persons alive at diagnosis, with initial regimens
of at least one TB drug, who did not die during treatment
Treatment completion within 12 months: 63% 85% Improved but falls short of national goal of 93% Excluded from expectation/calculation of COT≤12
months if• Not on at least one TB drug, death at diagnosis or during
treatment, meningeal disease, pediatric miliary disease or TB bacteremia, or rifampin monoresistance or multidrug resistance (MDR) on initial drug susceptibility testing
Source: Mitruka et al. Predictors of failure in timely tuberculosis treatment completion, United States. Accepted by IJTLD, Feb 2012.
Incarcerated Persons as a Proportion of All TB Cases, 1993–2010
0
5,000
10,000
15,000
20,000
25,000
30,000
All TB cases
Incarcerated at diagnosis
Year
Nu
mb
er
of
cases
Trends in TB Cases in Incarcerated Persons,
1993–2010
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
200
400
600
800
1,000
1,200
0
1
2
3
4
5
6
7
8
9
10No. of cases in incarcerated persons
Percentage of total cases
Year
Nu
mb
er
of
cases
Pe
rce
nta
ge
Treatment Completion Among Persons Incarcerated at Diagnosis
For 1999–2008 cohort, examined treatment outcomes among incarcerated vs. not incarcerated Among all persons alive at diagnosis who started
treatment, reason therapy stopped Among persons eligible for completion (COT) in ≤12
months, stratified by origin (i.e., U.S.-born and foreign-born):
– completion in ≤12 months – delayed completion (>12 months) – no known completion
o by facility at diagnosis
Reason TB Treatment Stopped, 1999–2008,
by Incarceration Status (N=143,515)
Incarcerated at diagnosisN=4,986
n (%)
Not incarceratedN=138,390
n (%)
Completed treatment ever
3,641 (73.0) 119,505 (86.4)
Died 173 (3.5) 10,282 (7.4)
Moved 364 (7.3) 3,036 (2.2)
Lost 571 (11.5) 3,078 (2.2)
Refused 44 (0.9) 844 (0.6)
Adverse event 0 (0.0) 5 (0.0)
Unknown, other, or missing
193 (3.9) 1,640 (1.2)Note: Included all cases in persons reported as alive at diagnosis and taking one or more TB drugs; 139 cases (0.1% ) had missing incarceration status
Reason TB Treatment Stopped, 1999–2008,
Among Incarcerated, by Origin (N= 4,986)
U.S.-bornN=3,148
n (%)
Foreign-bornN=1,814
n (%)
Completed treatment
2,569 (81.6) 1,057 (58.3)
Died 142 (4.5) 31 (1.7)
Moved 90 (2.9) 271 (14.9)
Lost 256 (8.1) 312 (17.2)
Refused 25 (1.0) 19 (1.1)
Adverse event 0 (0.0) 0 (0.0)
Unknown, other, or missing
66 (2.1) 124 (6.8)
Note: Of total 4,986 cases among incarcerated persons, 24 had missing data on origin
Treatment Completion in ≤12 Months by Incarceration Status at Diagnosis*
* Cases were among persons eligible to complete treatment within 12 months: persons had to be alive at diagnosis, initiate TB treatment, not die during treatment, and not have meningeal TB, pediatric (aged <15 years) miliary disease or a positive blood culture for Mycobacterium tuberculosis, or rifampin resistance on initial drug susceptibility testing
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
0
10
20
30
40
50
60
70
80
90
100
Not incarcerated COT ≤12 months Incarcerated COT ≤12 months
Year
% e
lig
ible
pa
tie
nts
Treatment Completion in >12 Months by Incarceration Status at Diagnosis*
* Cases were among persons eligible to complete treatment within 12 months: persons had to be alive at diagnosis, initiate TB treatment, not die during treatment, and not have meningeal TB, pediatric (aged <15 years) miliary disease or a positive blood culture for Mycobacterium tuberculosis, or rifampin resistance on initial drug susceptibility testing
No Known Treatment Completionby Incarceration Status at Diagnosis*
*Cases were among persons eligible to complete treatment within 12 months: persons had to be alive at diagnosis, initiate TB treatment, not die during treatment, and not have meningeal TB, pediatric (aged <15 years) miliary disease or a positive blood culture for Mycobacterium tuberculosis, or rifampin resistance on initial drug susceptibility testing
Incarcer-ated no known completionNot incar-cerated no known completion
Year
% e
lig
ible
pers
on
s
Treatment Completion in ≤12 MonthsAmong Incarcerated, by Origin*
*Cases were among persons eligible to complete treatment within 12 months: persons had to be alive at diagnosis, initiate TB treatment, not die during treatment, and not have meningeal TB, pediatric (aged <15 years) miliary disease or a positive blood culture for Mycobacterium tuberculosis, or rifampin resistance on initial drug susceptibility testing
Treatment Completion in >12 MonthsAmong Incarcerated, by Origin *
*Cases were among persons eligible to complete treatment within 12 months: persons had to be alive at diagnosis, initiate TB treatment, not die during treatment, and not have meningeal TB, pediatric (aged <15 years) miliary disease or a positive blood culture for Mycobacterium tuberculosis, or rifampin resistance on initial drug susceptibility testing
*Cases were among persons eligible to complete treatment within 12 months: persons had to be alive at diagnosis, initiate TB treatment, not die during treatment, and not have meningeal TB, pediatric (aged <15 years) miliary disease or a positive blood culture for Mycobacterium tuberculosis, or rifampin resistance on initial drug susceptibility testing
No Known Treatment Completionby Facility Type at Diagnosis
and Origin, 1999–2008 U.S.-born Foreign-born
n (%) No known
completion
n (%) No known
completion
Total incarcerated
2,965 (14.6) 1,753 (40.6)
Federal prison 112 (21.4) 314 (54.5)
State prison 1,003 (10.8) 130 (30.8)
Local jail 1,680 (16.2) 791 (32.1)
Juvenile corrections
26 (3.9) 16 (18.8)
Other* 78 (14.1) 483 (49.3)
Unk/missing 66 (27.4) 19 (0.4)*Other= ICE detention center, Indian reservation facilities, military stockades and jails, federal
park police facilities, police lockups temporary holding facilities), and other facilities not included in other specific choices
Conclusions
Persons incarcerated at diagnosis are at high risk for not having timely treatment completion Trends in timely completion worsening
Failure is largely attributed to no known completion rather than delayed completion
Foreign-born at particularly high risk for havingno documented completion
Acknowledgment
Author of presentation, Kiren Mitruka Data analysis (ongoing), development of presentation Currently on an Epi-Aid for a TB outbreak