TB-D-8 TB Continuity of Care for Agency Officials by tlyaappjdlag


									 Stopping Tuberculosis:
Role of DHS/ICE/DRO in Global
     Tuberculosis Control
         Department of Homeland Security
    U.S. Immigration and Customs Enforcement
      Division of Immigration Health Services
    Epidemiology and Infection Control Program
Provide an overview of tuberculosis (TB)
Provide statistics on TB prevalence in ICE
detainee population
Highlight importance of special
coordination for this population
Provide overview on ICE/DRO policy on
TB Continuity of Care
         Tuberculosis (TB)
Serious disease caused by a bacteria-
Mycobacterium tuberculosis

Usually attacks the lungs
– May affect other organs (extrapulmonary)

Transmitted person to person through air

Infected persons can have latent infection
or active disease
 Airborne transmission: coughing,
singing, laughing, etc. in confined spaces
Why is our role TB Control Important?

One-third of the world’s population is infected with
the tuberculosis bacillus
Someone in the world is newly infected every
Worldwide, there are nearly 9 million new cases of
active TB each year
Each year, there are almost 2 million TB-related
deaths worldwide
TB is more common in foreign born persons in the
TB is more common in the southern border states
         Latent TB Infection
Body has isolated the bacteria
Person has no symptoms, is not infectious, and
does not have clinical disease
TB skin test (TST) is positive
Chest x-ray is normal
Can develop active TB later
Treatment is recommended in most cases
(generally 9 months)
Positive TB skin test
       Active TB Disease
Body cannot isolate the bacteria
Person may or may not have symptoms
TB skin test usually positive
Chest X ray abnormal
Person may be contagious
Disease can be treated and cured but
treatment is long and complicated
              TB Facts
More common in foreign born persons

More common in southern border states

8-9 million new cases diagnosed each
year worldwide

Kills 2 million people each year worldwide
          Drug Resistance
When TB bacteria are not killed by certain anti-
TB drugs
Drug resistance may be created when patients
do not complete their treatment regimen
correctly OR may be directly transmitted
Drug resistant cases are more expensive and
difficult to treat
Treatment failures are more common (death)
Multi-Drug Resistance (MDR)
MDR-TB is defined as TB resistant to the
two most powerful drugs against TB
Many developing countries do not have
medications and/or lab capability to
adequately treat MDR-TB
Treatment is difficult, complicated, and
very costly
Extensively-Drug Resistant (XDR) TB

Resistant to the two most powerful anti-TB
drugs plus at least three of the “second
line” drugs used to treat MDR-TB
Treatment is difficult, complicated, and
Much greater likelihood of dying from
Often associated with HIV disease
DIHS Digital X-Ray TB Screening

Aliens detained by ICE given chest x-rays to screen for
TB during initial processing
Results available within four hours
Detainees suspected to have TB are isolated until no
longer contagious
Contrasted with conventional screening (used at most
detention facilities)
– TB skin test (TST) followed by chest x-ray if TST positive
– Takes at least 48-72 hours to identify TB suspects
Provides for a safer work environment
When medically indicated detainee started on
            Screening for TB

Teleradiology unit   Airborne Infection Isolation rooms
   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
U.S. immigration laws have no provisions for
health status with regard to removals
ICE detainees with TB may be removed once
rendered noncontagious
Most are removed before completion of
The ICE Detainee TB Reality (continued)
Detainees with active TB who are repatriated
before treatment completion:
– Are at high risk of interrupting or not completing
– Are at high risk of acquiring drug resistance
– Are at high risk of transmitting TB disease to
  others, possibly of a drug resistant strain

Many will re-enter the US after removal
     ICE TB Continuity of Care
        Program Objective
Facilitate continuity of tuberculosis (TB) therapy
for ICE detainees following custody

Involves coordination with:
     State and local health departments
     TB referral and tracking organizations
     (TBNet, Cure TB)
     National TB Programs in receiving country
     Foreign consulates
ICE/DRO Role in TB Continuity of Care
ICE Continuity of Care History
November 2002: TB Work Group initiated (DIHS, DRO,
Centers for Disease Control an Prevention (CDC) Division of
TB Elimination)
May 2004: Memo sent to all Deputy Assistant Directors,
Branch Chiefs, Field Office Directors from Victor Cerda, DRO
– Stipulates requirements for short term medical hold process
– Specifies FODs or their designee as POC for medical hold
  notification and review
– Addresses stay of removal requests for completion of treatment
  in the U.S. prior to removal
ICE TB Medical Hold Process
Intended to be short term (2-4 weeks)
Allows for detainee to become noncontagious
and able to travel
Provides time to arrange for detainee’s
treatment to continue in their home country
Provides time to coordinate removal with public
health authorities in the country of nationality
(“medical meet and greet”)
TB Medical Hold Form
     TB Medical Hold Process
FOD or designee approves or denies hold
Once detainee continuity of care arrangements are
in place TB Medical Hold is released
–   Treatment plan is established
–   Transnational/binational TB referral complete
–   Address/contact verification done
–   Meet and greet arranged
FOD or designee informed as soon as medical hold
is released so that removal operations are not
Release TB Medical Hold Form
Medical Meet and Greet Process
Public health authority in country of nationality
meets patient upon arrival when removed
Patient received at border or airport
May be done for TB patients from any country
Priorities: medically complicated, patients with
unreliable contact information, questionable
adherence with treatment, etc.
Requires five working days advance notice to DIHS
for coordination before scheduled date of removal
Goal is to facilitate uninterrupted continuity of care
ICE/DRO Role in Meet and Greet
Facilities with DIHS staffing often coordinate
locally with OIC, DIHS, TBNet and/or Cure-TB

Notify DIHS HQ of removal date 5 days in
advance (202-732-0070 / 202-732-0071)
– After coordination arrangements are in place

ICE needs to facilitate coordination with
Consulate for Mexican nationals
     Stay of Removal Process
May be utilized for detainees with multidrug-resistant
(MDR) TB, medically complex patients, inadequate
treatment capabilities in country of nationality (e.g.,
Haiti), and/or nonadherence with treatment
Request made in writing by local or state public
health authority or by DIHS
Routed by DIHS to FOD for review and decision
Approval or denial communicated to DIHS by FOD
or designee
Stay of Removal Process (continued)

Public Health authority (state/local health
department) should suggest or locate
appropriate placement for detainee if detainee
will not remain in ICE custody (e.g., OSUP,
Once treatment is complete DIHS notifies FOD
in writing that patient has completed treatment
Alien may then be removed as per usual ICE
ICE Database TB Medical Alert
Medical alert placed in ICE databases for TB
patients deported without treatment, known to
have incomplete treatment, and/or lost to follow
up while being treated (upon request from DIHS)
Helps to minimize exposure to law enforcement
If alien found with alert call DIHS HQ for
        Challenges and Current Issues
Release or removal before case is confirmed definitively
No notification before release or removal
Limited notification of TB patients held in local jails and
contract detention facilities without a DIHS presence
Transfers from other local, state, & federal law
enforcement entities
Oversight of cases housed in contract detention facilities
and local jails
Cross-jurisdictional legal issues
Patient noncompliance with treatment
No/inadequate address provided; homeless patients
Domestic and global TB control requires
    Public health authorities (local, state,
    federal, and foreign national)
    TB referral programs (TBNet and Cure-TB)
Division of Immigration Health Services, Epidemiology Program

  Dr. Diana Schneider
  phone:      (202) 732-0070
  cell:       (202) 420-8150
  e-mail:     Diana.Schneider@dhs.gov
  LCDR Jennifer Jones
  Nurse Epidemiologist
  phone: (202) 732-0071
  cell:   (202) 253-2722
  e-mail:       Jennifer.Jones1@dhs.gov
  Ms. Ana Burns
  phone: (202) 732-0054
  e-mail: Ana.Burns@dhs.gov

  Fax: (202) 732-0053; (866) 573-8531

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