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

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 patient residing 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

Trends in TB Cases in Incarcerated Persons, 1993–2010

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 diagnosis N=4,986 n (%) Not incarcerated N=138,390 n (%) Completed treatment ever 3,641(73.0)119,505(86.4) Died173(3.5)10,282(7.4) Moved364(7.3)3,036(2.2) Lost571(11.5)3,078(2.2) Refused44(0.9)844(0.6) Adverse event0(0.0)5 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.-born N=3,148 n (%) Foreign-born N=1,814 n (%) Completed treatment 2,569(81.6)1,057(58.3) Died142(4.5)31(1.7) Moved90(2.9)271(14.9) Lost256(8.1)312(17.2) Refused25(1.0)19(1.1) Adverse event0(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

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 Completion 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

Treatment Completion in ≤12 Months Among 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 Months Among 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

No Known Treatment Completion Among 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

No Known Treatment Completion by Facility Type at Diagnosis and Origin, 1999–2008 U.S.-bornForeign-born n(%) No known completion n Total incarcerated2,965(14.6)1,753(40.6) Federal prison112(21.4)314(54.5) State prison1,003(10.8)130(30.8) Local jail1,680(16.2)791(32.1) Juvenile corrections 26(3.9)16(18.8) Other*78(14.1)483(49.3) Unk/missing66(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 having no 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