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

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

0

10

20

30

40

50

60

70

80

90

100

Incarcerated COT >12 monthsNot incarcerated COT >12 months

Year

% e

lig

ible

pa

tie

nts

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

1999 2000 2001 2002 2003 2004 2005 2006 2007 20080

10

20

30

40

50

60

70

80

90

100

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

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

0

10

20

30

40

50

60

70

80

90

100

U.S.-born COT ≤12 monthsForeign-born COT ≤12 months

Year

% e

lig

ible

pa

tie

nts

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

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

0

10

20

30

40

50

60

70

80

90

100

U.S.-born COT >12 monthsForeign-born COT >12 months

Year

% e

lig

ible

pa

tie

nts

No Known Treatment Completion Among Incarcerated, by Origin *

1999 2000 2001 2002 2003 2004 2005 2006 2007 20080

10

20

30

40

50

60

70

80

90

100

Foreign-born no known comple-tion

U.S.-born no known comple-tion

Year

% e

lig

ible

pe

rso

ns

*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

Steve Kammerer and Bob Pratt Technical support