collaboration amongst key stakeholders in global tuberculosis control through continuity of care for u.s. immigration an

1: Collaboration Amongst Key Stakeholders in Global Tuberculosis Control Through Continuity of Care for U.S. Immigration and Customs Enforcement (ICE) Detainees USPHS Scientific and Training Symposium June 2009 LCDR Jennifer Jones, RN, BSN, MPH LT Jennifer Cheng, MPH Division of Immigration Health Services

3: Objectives Discuss unique tuberculosis (TB) case management needs for U.S. Immigration and Customs Enforcement (ICE) detainees Discuss collaborations with local and state public health departments to facilitate continuity and completion of TB treatment Discuss collaborations with non-governmental organizations and foreign agencies

4: Background U.S. Immigration and Customs Enforcement (ICE) Detention and Removal Operations (DRO) Division of Immigration Health Services (DIHS) provides healthcare services for detainees Detention of illegal aliens during immigration proceedings Housed in processing centers, contract detention facilities, and local jails (under intergovernmental service agreements- IGSA)

7: TB Facts More common in foreign born persons More common in southern border states of the United States 8-9 million new cases diagnosed each year worldwide Kills 2 million people each year worldwide

Slide 9:Potential for missed cases not detected e.g., if AFB smear negative and not started on treatment, but cultures later come back positive. Potential for drug-resistant or multidrug-resistant (MDR) cases to be deported before culture or drug-resistance pattern is known.Potential for missed cases not detected e.g., if AFB smear negative and not started on treatment, but cultures later come back positive. Potential for drug-resistant or multidrug-resistant (MDR) cases to be deported before culture or drug-resistance pattern is known.

10: TB Continuity of Care International referral program enrollment for continued treatment and case management CureTB MCN/TBNet Coordinated Removal / Medical “meet and greet” Foreign National TB Program Foreign Consulate (Mexico) Notification to DIHS Epidemiology Unit of TB cases and suspects among ICE detainees by DIHS staff (if DIHS facility) by state and local health departments by contract detention facilities (if no DIHS presence) Short-term medical holds until the patient is non-infectious and until TB continuity of care can be arranged in country of origin Medical “meet and greet” with public health authority in receiving country at the place and time of removal Requests for stays of removal to allow treatment completion in the U.S. (patients meeting specific criteria) Multidrug-resistant (MDR) TB and other medically complicated cases History of repeated deportations State or local health department makes official request in writing ICE reviews and approves/denies the request ICE decides if patient will remain in custody or be released to the community while completing treatment Notification to DIHS Epidemiology Unit of TB cases and suspects among ICE detainees by DIHS staff (if DIHS facility) by state and local health departments by contract detention facilities (if no DIHS presence) Short-term medical holds until the patient is non-infectious and until TB continuity of care can be arranged in country of origin Medical “meet and greet” with public health authority in receiving country at the place and time of removal Requests for stays of removal to allow treatment completion in the U.S. (patients meeting specific criteria) Multidrug-resistant (MDR) TB and other medically complicated cases History of repeated deportations State or local health department makes official request in writing ICE reviews and approves/denies the request ICE decides if patient will remain in custody or be released to the community while completing treatment

11: Case Management Challenges Contact investigations Universal chest x-ray screening Chest x-rays for all upon intake Versus TB clinic setting: referrals or contacts of TB cases Identifies many individuals with minor abnormalities Detention facilities are not TB clinics

12: Case Management Challenges (continued) Patients are often removed prior to completion of treatment Lack of/late notification from facilities without ICE medical staffing Patients may be repatriated before culture and sensitivity results are available Medical Alerts in ICE custody databases

Slide 13:Communications and sharing case information for the purpose of facilitating TB continuity of careCommunications and sharing case information for the purpose of facilitating TB continuity of care

16: Coordinated Removals Arrangement for patient to be received by public health officials at the airport or land border at the time of repatriation National TB Program (NTP) notified Patient received by NTP or quarantine medical officer stationed at airport Consulate assistance

17: Coordinated Removals (continued) Provides an opportunity to Educate patient Verify address and contacts Provide support services if available Ascertain if patient intends to move soon

18: Ethical Considerations Drug-resistant and medically complex cases Appropriate treatment may not be available in country of nationality State and local government may have enacted policies that prohibit use of government funds to provide care for undocumented individuals

19: Hypothetical Case Scenario 33 year-old male from country X Initially sputum smear and culture positive for M. TB Referral for continuity of care in country x coordinated through TBNet Program Determined to be known to the local clinic in country x History of non-adherence to anti-TB treatment and LTBI treatment Health authorities in country x had identified 3 family contacts with active TB, including the patient’s 8 year-old son

20: Case Scenario (continued) Case conference held with DIHS, TBNet, and the country x National TB Program (NTP) NTP indicated that child protection laws could be used to retain patient in hospital Patient would then receive supervised therapy at a hospital under court order Patient then would go on to successfully complete treatment

21: Summary Tuberculosis (TB) Basics TB Facts TB Control within the DIHS setting TB Continuity of Care Challenges in Case Management Interagency Collaboration Non-governmental Organizations Coordinated Removals Ethical Considerations Case Scenario

22: Acknowledgements FEDERAL AGENCIES DHS/ICE/DRO DHS/ICE/DRO/DIHS: CDR Diana Schneider, Ana Burns DHHS/CDC: Ken Castro, Mark Lobato, Kayla Laserson, Stephen Waterman, Maureen Wilce, Miguel Escobedo, Dan Stier DHHS/OGC: Jocelyn Mendelsohn, Jim Misrahi, Elizabeth Jordan Gianturco U.S. Marshals Service: Debra Katsch, Justin Blevins, Carol Lincoln STATE & LOCAL AGENCIES Arizona Dept. of Health Services: Angelito Bravo, Ayesha Bashir Arizona Attorney General’s Office: Kevin Ray, Don Schmid CA Dept. of Public Health: Anne Cass Colorado Department of Health: Mary Goggin Denver TB Control Program: Randall Reves Florida Dept. of Health: Jimmy Keller, Debra Spike New Mexico: Gary Simpson New Mexico Department of Health: Kathy Kunkel Texas Dept. of State Health Services: Charles Wallace, Phyllis Cruise, Sandra Morris, Walter Erhesman, Jose Moreira, Maria Rodriguez San Diego County Health Dept/CureTB: Kathy Moser, Alberto Colorado NON-GOVERNMENTAL ORGANIZATIONS Migrant Clinicians Network: Nora Martinez, Del Garcia, Ed Zuroweste, Bertha Armendariz University of New Mexico, Center for Disaster Medicine: Cliff Rees U.S.-Mexico Border Health Commission: Dan Reyna National TB Programs: Mexico, El Salvador, Guatemala, Honduras, Nicaragua

23: Contacts ICE, Division of Immigration Health Services, Epidemiology Program CDR Diana Schneider, Senior Epidemiologist phone: (202) 732-0070 e-mail: Diana.Schneider@dhs.gov LCDR Jennifer Jones, Nurse Epidemiologist phone: (202) 732-0071 e-mail: Jennifer.Jones1@dhs.gov LT Jennifer Cheng, Staff Epidemiologist phone: (202) 732-0121 e-mail: Jennifer.Cheng@dhs.gov Ana Burns, Program Assistant phone: (202) 732-0054 e-mail: Ana.Burns@dhs.gov www.icehealth.org www.ice.gov

24: Thank you