12/5/2012
Binational TB Referral
Systems and Continuity of
Care
CDC-DGMQ Perspective
Miguel Escobedo, MD, MPH
US-MX Unit
Centers for Disease Control and Prevention
Division of Global Migration and Quarantine
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine
Presentation Outline
• Describe CDC tools available to detect and
refer binational TB Patients who need follow
up
• Summarize experience with these tools
• Case example
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12/5/2012
Goals of Binational TB Referral and
Case Management Strategy
• Prevent TB treatment lapses and the
development of drug resistance by:
– Working with Health Departments to educate patients
about the TB treatment process
– Linking patients with the health system on the other side
– Facilitating the exchange of clinical case information
across systems in a confidential manner.
– Use of established PH tools to detect and refer patients in
need of treatment.
Quarantinable Diseases*
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•
•
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Smallpox
Cholera
Plague
Viral hemorrhagic fevers
Infectious tuberculosis
Yellow fever
Diphtheria
SARS
Novel influenza virus (pandemic potential)
* By Executive Order of the President, federal isolation and
quarantine are authorized
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Travel Restrictions
• State PH departments can request travel restrictions on
individuals suspected of being infectious with a
communicable disease
• Requests coordinated with
– CDC Division of Global Migration and Quarantine
– Department of Homeland Security
• 2 types:
– Do Not Board List
– Public Health Lookout List
Public Health Border Lookout
• Active at all international land ports of entry; Air, Sea, Land
• Doesn’t necessarily restrict travel or entry in U.S.
• Prompts a review of the individual’s communicable
disease status before allowed to enter U.S. at Port of Entry
(POE)
– Enforced by Customs and Border Protection (CBP)
– Quarantine station staff notified when individual is
detected at the border
– Cross reference with DHS Law Enforcement systems
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Criteria for PH Border Lookout
• Infectious or at risk of rapid progression to
becoming infectious
• Individual is noncompliant with treatment
OR unaware of their diagnosis, or can not be
located
• History of or intent to travel internationally
Case Study Background
• US Marshalls reports 35 y/o TB case, to be
release to MX, no continuity of care plan
• No legal PH control order by Co. Attorney
• Rapid multi-agency collaboration results in
successful Border Meet and Greet
• Added to CDC PH Border LO List 3/30
• Issued one week of TB medication
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12/5/2012
Case Study Follow up
• Patient shows up to clinic in MX, but storms
out after refusing DOT
• Shows up to former work US site on 4/20 to
seek employment
• No show at PH TB clinic in the US
• Patient gets picked up by local LE for theft
• Possible ICE referral for re-repatriation
Case Study Issues to Consider
• Issuing medication without medial
supervision
• Successful meet and greet does not ensure
continuity of care
• Evaded border crossing detection despite
Border LO
• Legal control order ownership
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12/5/2012
TB does not respect borders
• A missed binational TB case becomes a
foreign born case
• A missed foreign born case creates future
foreign born and native born cases
• Collaboration offers the best opportunity to
detect and treat patients in an accepting
environment, no matter where they come
from
Thank you!
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