Seminar on Migration and Health October 18-19, 2004 U.S. Public Health Service

1. Continuity of Tuberculosis (TB) Therapy for U.S. Immigration and Customs Enforcement (ICE) Detainees Seminar on Migration and Health October 18-19, 2004 U.S. Public Health Service Division of Immigration Health Services (DIHS) Diana L Schneider, DrPH, MA Senior Epidemiologist

2. Objectives • To describe the medical services provided for U.S. Immigration and Customs Enforcement (ICE) detainees • To describe DIHS TB screening and surveillance efforts for detained, undocumented migrants in the custody of ICE • To describe efforts to facilitate post-detention continuity of TB therapy for ICE detainees

3. Our Mission We protect America by providing health care and public health services in support of immigration law enforcement.

4. Health Care Delivery System • Provide, arrange, and manage care for an ever-increasing population • 24/7 Medical Care • Emergency Services • International Medical Escorts • Third-Party Administration • Provider Network

5. Intake Screening • Physical • Mental Health • Dental • Tuberculosis Screening • Medical Access Orientation

6. ICE Detention and Staging Facilities With on-site DIHS Medical Facilities Tacoma, WA Batavia, NY Queens, NY Elizabeth, NJ San Pedro, CA L.A. Staging Florence, AZ El Centro, CA San Diego, CA El Paso, TX Houston, TX Miami, FL Port Isabel, TX Aguadilla, PR

7. Average Daily Total Detainee Population by Year 1993-2003

8. ICE TB Screening Program: DIHS Health Facilities Detainees admitted for less than 24 hours Detainees admitted for 24 hours or more Not screened Screened for TB Conventional or teleradiology Negative Positive Airborne infection isolation Evaluation & management General population

9. Teleradiology Image transmitted to University of Maryland Digitized radiography Interpreted within 4 hours Negative Positive Airborne infection isolation Evaluation & management General population

10. Teleradiology Screening

11. XXXXX XXXXXXX XXXXXXX

12. Teleradiology • Reduction in time TB remains undetected • Reduction in time TB may be spread • Safer environment for detainees and staff • Currently functioning in 8 facilities • Plans to expand in new facilities

13. Conventional TB Screening PPD planted Interpretation after 48-72 hours Positive Negative Negative Chest x-ray General population Positive Airborne infection isolation Evaluation & management

14. * Source: DIHS ** Source: U.S. Centers for Disease Control and Prevention

18. The ICE Detainee TB Reality • ICE detainees are at high risk for active TB • From countries with high prevalence of TB • From high risk settings • DIHS has an excellent TB screening program • DIHS identifies TB in ICE detainees • U.S. immigration laws have no provisions for health status with regard to removals • ICE detainees with TB may be removed once rendered noncontagious

19. The ICE Detainee TB Reality • People with active TB who do not have suitable arrangements for continuity of care: • Are at high risk of interrupting treatment • Are at high risk of developing multidrug-resistance • Are at high risk of transmitting TB disease to others, possibly of a multidrug-resistant strain • May die if appropriate treatment is not completed without interruption

20. Continuity of TB Therapy • Coordination and communication between governmental & non-governmental agencies • Sharing of case information for the purpose of TB continuity of therapy • U.S. state & local health departments • TB Net, Cure TB, Binational Referral Program • National TB Control Programs (non-U.S.) • Coordinated removal/medical meet & greet when deported

21. Continuity of TB Therapy • Request short-term hold on detainees with active or suspected active TB • Notifies ICE when all appropriate referrals & notifications are complete • Facilitates coordinated removal with ICE, health department, and National TB Control Program • Cleared for removal when referrals are complete and/or coordinated removal plans are established

22. Continuity of TB Therapy Communication and Coordination TBNet CureTB Binational TB Card DIHS ICE/ Detention & Removal Operations (DRO) State/Local Health Dept. Detention Facility Detainee Provider, Hospital, and/or Lab in Community DRO Field Offices TB Control Program in Country of Origin

23. US-Mexico Binational Tuberculosis Referral and Case Management Project Division of Global Migration and Quarantine Division of TB Elimination CDC

24. Goals of the US-Mexico Binational TB Referral and Case Management Project • Ensure continuity of care and completion of therapy • Reduce TB incidence and prevent drug resistance • Coordinate referral of patients between health systems • Provide model for other diseases

25. Binational Health Card – Data Elements • Unique identification number • Location where card was issued • Treatment initiation date • Date of last dose TB treatment • Treatment regimen • DOT (yes/no) • Bilingual • Toll-free telephone numbers in the US and Mexico

26. TB Patients - Eligibility US • Active TB • Mexico-born, and/or • Mexico-bound, such as: • Recently arrived to the US from MX • Migrant worker • Close or immediate family lives in MX • Works in the US and lives in MX • Lives in the US and receives medical care in MX • Suspect TB • ICE Detention Centers Mexico • Active TB

27. Pilot Sites • US-Mexico border sister cities/states • San Diego, CA – Tijuana, BC • El Paso, TX/Las Cruces, NM - Ciudad Juarez, CHIH • Webb/Cameron Counties, TX – Matamoros, TAMAU • Arizona – Sonora • ICE Detention Centers • Texas, California, Arizona • Mexican states • Coahuila, Nuevo Leon • US States • Tennessee, Washington, Illinois

28. Binational TB Card Project • 15% (42/274) Binational TB Cards distributed in ICE detention facilities or local jails • 71% (30/42) of people receiving the Binational TB Card in ICE facilities or jails have gone to Mexico • ICE detainees with Binational TB Card moved within a median of 11 days (0-118) of receiving Card Source: U.S. Centers for Disease Control and Prevention, data through April 30, 2004

29. TBNet • Facilitates TB continuity of care • People who move between Texas or New Mexico in the U.S. and Mexico • People who move between the U.S. and countries other than Mexico

30. (49%) (44%) (51%) (70%) (4%) *Data through July 2004 Source: Migrant Clinicians Network

31. Coordinated Removals • Establish processes to implement transfer of care model • DIHS requests temporary hold on release or removal until continuity of care is arranged • DIHS coordinates “meet and greet” to transfer care to a public health authority • Goal: Coordinate timing of removal with arranged meeting at the border or airport

32. Coordinated RemovalsImplementation • Mexico: • Functioning in Arizona/Sonora • Need to work out mechanism for local implementation • Non-Mexico: Case-by-Case basis • Request that TB control officials meet individual at the airport • Coordinate itinerary information with ICE

33. Arizona’s Meet and Greet Project

34. What is the “Meet and Greet”? • Informal state to state agreement between Arizona and Sonora, Mexico regarding the deportation of detainees with active TB who are being deported to Mexico • Mexican health officials meet patient at the border and assume responsibility for the treatment of the patient Source: J Kokko, Arizona Department of Health Services

35. Goal of the “Meet and Greet” • To provide continuity of care for individuals with TB who are being deported to Mexico Source: J Kokko, Arizona Department of Health Services

36. The “Meet and Greet” Requires collaboration of: • Arizona Department of Health Services • Border Health Office-Arizona • Border Health Office-Sonora, Mexico, • Semeson (Hospital General de Nogales), • U.S. Immigration and Customs Enforcement (ICE) Service Processing Center • ICE field and headquarters offices (Phoenix, Tucson, Washington), • Contract detention facilities housing ICE detainees Source: J Kokko, Arizona Department of Health Services

37. The “Meet and Greet” Bus/van picks up patient from ICE-SPC or the detention facility Transport officers call Border Health and Customs 1 hour from the border Border Health notifies the doctors in Mexico that the patient is an hour from the border Bus arrives at Lane 8 at the border where they meet Mexican Health Officials (usually around 9am) Mexican Health Officials take patient to Semeson (Hospital General de Nogales) Patient is interviewed and either stays in a special room at the hospital (for up to a week) or other arrangements are made for transportation to their destination Source: J Kokko, Arizona Department of Health Services

38. Room Set Aside for Meet and Greet Patients at Semeson in Nogales, Sonora, Mexico

39. Requests to stay or defer the removal • For patients with multidrug-resistant tuberculosis: • Consider request to stay or defer the removal to allow or facilitate treatment in the U.S. • Case-by-case basis • Possibly for other complicated cases

40. Impact on national and global public health • DIHS is a major source of identifying TB among foreign born in the U.S. • Highly mobile population • If treatment is not completed, will infect others • High risk of developing multidrug-resisitant (MDR) TB • Desired outcome: completion of TB therapy

41. Next Steps • Expand coordinated removal/medical meet and greet program throughout Mexico • Expand coordinated removal/medical meet and greet program to other countries to where ICE detainees are deported (arrivals at airports)

42. Acknowledgements • DIHS Infection Control Officers and DIHS Epidemiologists • Conduct surveillance • Continuity of care program enrollment • TB notification forms • Coordination with health departments • Coordination with ICE/Medical holds • Coordination with national TB control programs internationally

43. Acknowledgements • DIHS: Gene Migliaccio, Diana Schneider, Sara Newman, Christine Williams, Steve Wacha, Denise Williams, Diane Aker, Kirsten Warwar, Tim Shack • ICE/DHS: Jay Brooks, Tim Perry, Victor Cerda, Liz Herskovitz, Mark Lenox, John O’Malley, Christina Hamilton, Joan Lieberman, Michael Biggs, Maria Clayton, Mike Caltabiano • CDC: Ron Valdiserri, Ken Castro, Mark Lobato, Kayla Laserson, Sue Maloney, Leslie Page-Taylor, Phyllis Cruise, Stephen Waterman, many others • State/local HDs: Sarah Royce, Charles Wallace, Cheryl McRill, Dave Ashkin, Ellen Murray, Kathy Moser, Anne Cass, Jamie Kokko, Alberto Colorado, Maria Rodriguez, Elena Torres, others • DHHS/OGC: Jocelyn Mendelsohn, Esq. • Migrant Clinicians Network: Ed Zuroweste, Del Garcia, Jeanne Laswell

44. DIHS / TB Control Partnership • DIHS Epidemiology Unit • Tel: (202) 732-0070; Diana.Schneider@dhs.gov • Fax: (202) 514-0095; (866) 573-8531 • http://www.inshealth.org

45. Thank You

46. Steps to Set Up a “Meet and Greet” • TB case is identified and is enrolled in the Binational Health Card Project (ICE-Medical Hold for Continuity of Care is initiated) • Medical staff is notified of a potential deportation date • Medical staff notifies Arizona Department of Health Services of the need to set up a “meet and greet” Source: J Kokko, Arizona Department of Health Services

47. Steps to Set Up a “Meet and Greet” 4. Arizona Department of Health Services (ADHS) calls the Border Health Office-Arizona to let them know of the need to activate the “meet and greet”. If the TB patient is not currently at ICE-Service Processing Center, ADHS also calls the ICE field or headquarters offices in Phoenix, Tucson, and/or Washington to try to arrange a meet and greet. Source: J Kokko, Arizona Department of Health Services

48. Steps to Set Up a “Meet and Greet” • Border Health Office –Arizona calls Border Health Office-Sonora, Mexico to see if the public health doctors from Semeson (Hospital General de Nogales) can meet this patient on that particular date • Border Health Office-Arizona contacts Arizona Department of Health Services (ADHS) to confirm arrangements. • ADHS works with detention facility, and/or the ICE field or headquarters office in Phoenix, Tucson, and/or Washington to work out the details of the “Meet and Greet” Source: J Kokko, Arizona Department of Health Services