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Division of Immigration Health Services

Continuity of Tuberculosis (TB) Therapy for

U.S. Immigration and Customs

Enforcement (ICE) Detainees

Seminar on Migration and HealthOctober 18-19, 2004

U.S. Public Health ServiceDivision of Immigration Health Services (DIHS)

Diana L Schneider, DrPH, MASenior Epidemiologist

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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

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Our Mission

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

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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

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

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Queens, NYElizabeth, NJ

Port Isabel, TX

El Paso, TX

El Centro, CASan Diego, CA

Florence, AZ

Miami, FL

Batavia, NY

Aguadilla, PR

San Pedro, CAL.A. Staging

ICE Detention and Staging FacilitiesICE Detention and Staging FacilitiesWith on-site DIHS Medical FacilitiesWith on-site DIHS Medical Facilities

Houston, TX

Tacoma, WA

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Average Daily Total Detainee Population by Year

1993-2003

0

4000

8000

12000

16000

20000

24000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

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ICE TB Screening Program: DIHS Health Facilities

Detainees admitted for24 hours or more

Detainees admitted forless than 24 hours

Screened for TBConventional or teleradiology

PositiveNegative

General population Airborne infection isolationEvaluation & management

Not screened

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Teleradiology

Digitized radiography Image transmitted to University of Maryland

PositiveNegative

Interpreted within 4 hours

General population Airborne infection isolationEvaluation & management

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Teleradiology Screening

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XXXXXXXXXXXXXXXXXXX

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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

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Conventional TB Screening

PPD planted Interpretation after 48-72 hours

Positive Negative

General population

Airborne infection isolationEvaluation & management

Chest x-rayNegative

Positive

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Comparison of TB Case Rates

95.481.5

23.4 5.1

67

0

20

40

60

80

100

120

INS FY 2001, DIHSFacilities*

INS FY 2002, DIHSFacilities*

ICE FY 2003, DIHSFacilities*

U.S. Foreign-bornCY2003**

U.S. Overall CY2003**

Reporting area & period

TB

Ca

se

Ra

te p

er

10

0,0

00

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

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Active TB Case Counts, FY 2001-FY2003U.S. Immigration & Customs Enforcement Detainees

Immigration Health Services Medical Facilities

3953

68

0

10

20

30

40

50

60

70

80

FY2001 FY2002 FY2003

Fiscal Year

Co

un

t

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Active TB Cases, by Country, FY2003 U.S. Immigration & Customs Enforcement Detainees

Immigration Health Services Medical Facilities

2 13 2 3

61 1

30

1 1

17

0

5

10

15

20

25

30

35

Country

Co

un

t

17

Active TB Cases, by Country and Release Status, FY2003 U.S. Immigration & Customs Enforcement Detainees

Immigration Health Services Medical Facilities

2 35

1

24

1 1

14

0

5

10

15

20

25

30

35

Country

Co

un

t

(blank)

VD

PAROLED

OREC

DIED

DEPORTED

BOND

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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

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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

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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

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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

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Continuity of TB Therapy Communication and Coordination

DetentionFacility

Detainee

DIHSICE/ Detention & RemovalOperations (DRO)

DRO Field Offices

TBNetCureTBBinational TB Card

State/LocalHealth Dept.

TB Control Program inCountry of Origin

Provider, Hospital,and/or Lab in Community

US-Mexico Binational Tuberculosis Referral and Case Management

Project

Division of Global Migration and QuarantineDivision of TB Elimination

CDC

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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

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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

Binational Health Card – Data Elements

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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

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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

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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

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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

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ICE Patients Enrolled in TBNet 2000-2004

8

112 101129

111

214256

197

263

158

0

50

100

150

200

250

300

350

400

Year

Number of

Patients

Ice Enrollments Total Enrollments

(4%)

(44%)(51%)

(49%)(70%)

Source: Migrant Clinicians Network

*Data through July 2004

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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

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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

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Arizona’s Meet and Greet Project

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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

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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

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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

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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

The “Meet and Greet”

Source: J Kokko, Arizona Department of Health Services

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

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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

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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

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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)

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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

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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

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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

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ThankYou

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Steps to Set Up a “Meet and Greet”

1. TB case is identified and is enrolled in the Binational Health Card Project (ICE-Medical Hold for Continuity of Care is initiated)

2. Medical staff is notified of a potential deportation date

3. 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

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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

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Steps to Set Up a “Meet and Greet”

5. 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

6. Border Health Office-Arizona contacts Arizona Department of Health Services (ADHS) to confirm arrangements.

7. 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