ARPE

Aggregate Reports for Program Evaluation

Contact Investigation

Janice Westenhouse, MPH Tuberculosis Control Branch

Today’s Training

• Purpose of ARPE • How to complete the ARPE • Schedule of ARPE submission • Uses of ARPE data • Reporting Adverse Events of LTBI

treatment

Today’s Training is NOT:

• A contact investigation (CI) training • A substitute for guidelines about TB

diagnosis, treatment, or control

ARPE Overview • CDC report implemented in 2005 • Contact investigation (CI) data summary

for respiratory TB cases • Preliminary Report

– Evaluation of contacts

• Final Report – Updates to preliminary – Treatment outcomes of contacts with latent TB

infection (LTBI)

Purpose of ARPE

• Contact investigations are one of the first priority TB control activities, following case finding and treatment

• Assess the yield, efficiency, and effectiveness of TB program contact investigations

• Identify areas where programs are doing well, and areas for improvement

Contacts Care Cascade: Treatment ARPE Data California, 2010‒2014

12,353 7,498 4,831

39%

61%

Aggregate Reports for Program Evaluation Preliminary Final

ARPE – Getting Started Preliminary and Final Reports

Reporting Area: Your jurisdiction Submitted by: Your name Cohort: Year (2015 Final or Telephone: 2016 Preliminary) E-mail: Total TB Cases Reported: ALL Counted Cases Date Submitted: Email/fax date

ARPE Part I. Cases

ARPE Part I. Cases (cont’d)

Cases for Investigation – Respiratory Cases – pulmonary or laryngeal – Included in case count whether or not a CI

was performed – Include cases for whom no contacts could

be elicited – Does NOT include pediatric source case

investigation

ARPE Part I. Cases (cont’d)

Cases with No Contacts – Cases for whom no contacts were able to be

elicited (e.g., patient left area or died before interview could be conducted; patient could not name any contacts)

ARPE Part I. Cases (cont’d)

Smear positive – Positive AFB smear from sputum, bronchial or tracheal fluids, whether or

not any culture result is positive

Smear negative / culture or NAAT positive – Negative AFB smear results from sputum, bronchial or tracheal fluids – Culture or NAAT positive for Mtb complex, from sputum, bronchial or

tracheal fluids

Other Pulmonary Verified pulmonary/laryngeal case not in other categories e.g., clinically confirmed, gastric aspirates

ARPE Part I. Contacts

Number of contacts by type of case Outcome of the evaluation of contact

• Completed evaluation • Diagnosed with TB disease • Diagnosed with LTBI

- Started treatment for LTBI

ARPE Part I. Contacts (cont’d)

Number of Contacts – HD believes the person was exposed, warranting

an evaluation for TB disease or infection – Exposure was caused by a TB case counted by the

reporting jurisdiction (regardless of residence of contact!)

– Enough information is available to verify a current location or phone number for the contact (regardless of jurisdiction)

ARPE Part I. Contacts (cont’d)

Number of Contacts (cont’d) • Extended CIs

– Count persons who have been exposed, even if number is large

– Persons tested for public relations purposes, or to decrease anxiety should NOT be counted

ARPE Part I. Contacts

Number of Contacts (cont’d)

If a contact is identified in two related CIs • count only ONCE in a calendar year

If a contact is part of two unrelated CIs and a second evaluation is necessary

• count the contact TWICE

Example 1: Number of Contacts

• Maria is the index TB case • During the CI, Maria’s sister Anna is found to

have active TB • Miguel, Maria’s brother, was a contact both

Maria and Anna. Q: Is Miguel counted once or twice as a contact on the ARPE? A: Count Miguel once since the CI’s were

related.

Example 2: Number of Contacts

• Robert is a TB case reported in Alameda in

2016. • 24 contacts were exposed to Robert

– 18 contacts reside in Alameda – 6 contacts reside Contra Costa

• Contra Costa provides Alameda with the information on the status of those 6 contacts

• Alameda includes all 24 contacts and their outcomes on their ARPE

ARPE Part I. Contacts (cont’d) Contacts Evaluated

– Evaluated to the point where a final diagnosis can be made: LTBI, TB disease, or neither

INDICATIONS EVALUATION STEP

All contacts Interview, and Symptom review

Contacts with no documented history of positive Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) or TB disease

TST #1 placed and read, or IGRA #1 performed and results received.

Contacts with TST #1 placed or IGRA #1 performed <8 weeks from last exposure, and with a negative TST or IGRA #1

TST #2 placed and read, or IGRA #2 performed and results received.

Contacts with documented history of positive TST or IGRA Chest imaging study

Contacts with: • TB symptoms present, or • Positive TST or IGRA #1 or positive TST or

IGRA #2, or • History of TB disease, or • HIV infection, risk for HIV infection, or Contacts age <4 years

Medical evaluation, and Chest imaging study

ARPE Part I. Contacts (cont’d)

Contacts with TB Disease – Diagnosed as part of the contact investigation – Do not include persons with

• Active TB that developed after LTBI was diagnosed during CI

• Previously treated TB or “old” TB

– Do not consider genotyping results

ARPE Part I. Contacts (cont’d)

Latent TB Infection – New, positive TST or IGRA – Exclusion of active TB or – Being treated for LTBI despite negative TST

ARPE Part I. Contacts (cont’d)

LTBI, Started Treatment – Count after first dose of a planned full treatment

• Patient self-report • Medicine picked up from clinic or pharmacy

– Window period treatment pending a second TST or IGRA should NOT be counted

Example: Completing the Preliminary ARPE

Final ARPE

Final ARPE Update Part 1 as needed

LTBI Completed Treatment – Provider believes an adequate LTBI regimen has

been received, discontinues treatment – Contact has taken at least 80% of prescribed doses

(if daily regimen). Intermittent regimens may have different thresholds (e.g., 3HP requires 11/12 doses)

– Treatment is finished within 150% of recommended duration of therapy

Reasons LTBI Treatment Not Completed

Reasons Treatment Not Completed (1) Death Patient died prior to completing LTBI treatment Contact Moved Contact relocates prior to completing treatment

and follow-up information is unavailable Active TB Developed Patient meets definition for a TB case while being

treated for LTBI. If regimen stopped before active TB developed, do not report as Active TB Developed

Reasons Treatment Not Completed (2) Adverse Effect of Medicine

– Treatment not completed due to adverse effect of the medicine

– Documented by provider – Do not report if provider has not recommended

discontinuation of treatment

Contact Chose to Stop – Patient discontinues medicine prior to completion of

regimen and provider has not determined that the medicine should be stopped due to medical reason

Reasons Treatment Not Completed (3) Contact Lost to Follow-up

– LTBI treatment outcome cannot be determined because HD cannot locate patient

Provider Decision – Health care provider discontinues treatment for LTBI

due to concerns about the benefits, safety, or practicality of treatment (e.g., a contact has such erratic attendance at the clinic that the adequacy and safety of the treatment cannot be monitored)

Still on Treatment – Patient still on treatment at the time report is due

Example: Completing the Final ARPE

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Final ARPE Part II. Evaluation Indices

• No contacts rate • Contacts per case • Evaluation rate • Disease rate

• Latent infection rate • LTBI treatment rate • LTBI treatment

completion rate

7 indices are calculated for each case category (smear positive, culture positive, other)

ARPE Part II. Evaluation Indices (cont’d)

• Formulas for indices are shown in each cell of the paper and online copies of the ARPE

• Calculation encouraged to assist in the evaluation of CIs in your program

Example: Calculating Indices

Sputum Smear + Evaluation Rate = (d1 ÷ c1), %

d1 = number of contacts evaluated c1 = total number of contacts (75 ÷ 80) x 100 = 94%

End of ARPE form!

~~~~~~~~~~~~~~~~~~ • Reporting schedule • ARPE data • Adverse Event reporting

Reporting Schedule

Cohort Year (Case Counted) Form

Line Lists Distributed to LHJ

Date Due to CDPH

Jan – Dec 2015 Final April 2017 Friday,

July 7, 2017 Jan – Dec 2016 Preliminary

Jan – Dec 2016 Final April 2018 July 2018

Jan – Dec 2017 Preliminary

http://www.cdph.ca.gov/programs/tb/Documents/TBCB-ARPE-Schedule.pdf

ARPE Data

• CI Indicators National Tuberculosis Indicators Project (NTIP) and TIP

• Future funding formula inclusion • Care Cascade for TB Elimination

NTIP Indicators for Contact Investigations of

Sputum Smear Positive Cases

Indicator California

Performance 2013

National Target 2020

Contacts Completing Examination

86.6% 93.0%

LTBI Treatment Initiation 65.0% 91.0%

LTBI Treatment Completion 61.9% 81.0%

Reporting Adverse Events of LTBI Treatment

• CDC surveillance • Criteria for reporting

– Hospitalization or death of a person receiving treatment for LTBI

– Not limited to severe hepatitis but may include other life-threatening events (anaphylaxis, thrombocytopenia, severe dermatitis, etc.)

Adverse Events: How to Report Contact: Janice Westenhouse, Registry Chief

FAX: 510-620-3035 Phone: 510-620-3055 Include at least the following information:

• Patient name • Date of birth • Type of adverse event • Date of onset • Vital status • Reporting jurisdiction

ARPE Questions?

ARPE FAQs: http://www.cdph.ca.gov/programs/tb/Documents/TBCB-

ARPE-Common-Questions-and-Answers.pdf

Janice Westenhouse, MPH Chief, TB Registry

janice.westenhouse@cdph.ca.gov 510-620-3055

Questions?