1

Leaving on a jet plane:  My patient is leaving. What do I do?

Kim Vuong PHN

81 year‐old Asian male, retired physician

Smear positive (4+) pulmonary TB 

Fully sensitive to IREZ CT showed cavitation 

Started IREZ on 2/13 DOT daily at home

Follow up sputum 3/8 smear negative

Case Study 1

2

Left country on 3/11

Can the patient leave the country?What will you do next?

Case Study 1

NOTIFICATION/REFERRAL

Who do you notify and why?

Case Study 1

3

51 year‐old visitor from Congo  Smear negative, culture confirmed pulmonary TB

CXR/CT showed abnormal non‐cavitaryReturned to her country before culture confirmed

Case Study 2

Should the community provider do anything different?

What will you do next?

Case Study 2 

4

NOTIFICATION/REFERRAL

Who do you notify and why?

Case Study 2

DOH

DGMQ 

Case Study 2 

5

Assist patient to change/cancel flight Check fee waiver request approval

Track TB treatment progress

Coordinate travel plan 

Case 1

Currently on TB treatment

Weekly sputum collection overseas

Plan to return to US when off isolation

Case 1 

6

Explain to patient/family the lab result and follow up

Release medical record to patient/family

Forward updated labs to patient/family

Case 2 

Currently on TB treatment

Weekly follow up at local hospital in Congo 

Case 2 

National Center for Emerging and Zoonotic Infectious Diseases

Leaving on a Jet Plane: My patient is leaving. What do I do?

Reena K. Gulati, MD, MPHLead, Epidemiology Field TeamDivision of Global Migration and Quarantine

TB Nursing Workshop

June 12, 2018

History of Do Not Board and Public Health Lookout

Formal process developed in 2007 between the US Departments of – Health and Human Services– Homeland Security

Relied on airlines and US Customs and Border Protection to help prevent travel before 2007

Regulatory Authority: Illness in Travelers

• Cholera• Diphtheria• Infectious tuberculosis• Plague• Smallpox• Yellow fever

Quarantinable Communicable Diseases, Presidential Executive Order 13295, April 2003 (Amended April 2005 and July 2014)

• Viral hemorrhagic fevers• Severe acute respiratory

syndromes• Novel or reemerging influenza

causing or with potential to cause a pandemic

Do Not Board (DNB)

This travel restriction prevents people who meet specific criteria

from obtaining a boarding pass for any flight arriving in, departing from,

or flying within the United States

Does not prevent passengers from boarding ships, trains, or buses

Implemented by Transportation Security Administration (TSA)

Public Health Lookout (PHLO)

This intervention alerts US Customs and Border Protection officers of a person having an issue of public

health concern who attempts to enter the United States

Prompts notification to CDC Quarantine Station staff when the

person attempts to enter the United States

Implemented by US Customs and Border Protection (CBP)

Do Not Board (DNB)

This travel restriction prevents people who meet specific criteria

from obtaining a boarding pass for any flight arriving in, departing from

from, or flying within the United States

Does not prevent passengers from boarding ships, trains, or buses

Implemented by Transportation Security Administration (TSA)

Public Health Lookout (PHLO)

This intervention alerts US Customs and Border Protection Officers of a

person on the DNB who attempts to enter the United States

Prompts notification to CDC Quarantine Station staff when the

person attempts to enter the United States

Implemented by US Customs and Border Protection (CBP)

DNB Process: Key Partners

CDC Quarantine

Stations

Department of Homeland

Security

Local and State Health Departments

Foreign Public Health

Agencies

CDC Quarantine Stations

https://www.cdc.gov/quarantine/quarantinestations.html

Criteria for DNB Addition1 Infectious, likely infectious, or at risk of becoming infectious

with a serious contagious disease that poses a public health threat to the traveling public

2Nonadherent with

public health recommendations,

unaware of diagnosis, or unable to be

located

3At risk of traveling on a commercial flight

or of traveling internationally

4Travel restrictions

needed to respond to a public health

outbreak or to help enforce a public

health order

AND

OR OR

https://www.federalregister.gov/documents/2015/03/27/2015-07118/criteria-for-requesting-federal-travel-restrictions-for-public-health-purposes-including-for-viral

Criterion for DNB Removal

1 Individual is no longer considered to be infectious or at risk of becoming infectious

DNB Addition ProcessState or local health department (SLHD) notifies Quarantine Station (QS); Quarantine Medical Officer (QMO) reviews case; conference call convened to make a preliminary decision

QMO drafts case summary; Travel Restriction and Intervention Activity (TRIA) requests leadership approval

TRIA submits request to the Department of Homeland Security (DHS), TSA and CBP for processing; person is added to the DNB/PHLO lists

QS notifies the SLHD and person of DNB/PHLO action

DNB Conference Call Provide overview of public health travel restriction process and DNB

criteria Review clinical case summary and current laboratory information

– Smear microscopy, molecular testing, culture results, drug susceptibility, treatment history, relevant diagnostic tests

Discuss adherence with public health recommendations and travel risk Discuss attempts to locate person, initiate treatment, advise against travel,

issue state/local public health orders Determine appropriate action

DNB Removal Process

SLHD determines the person is noninfectious and notifies the QS

QMO drafts case summary; TRIA requests leadership approval

TRIA submits request to DHS, TSA and CBP for processing; person is removed from the DNB/PHLO lists

QS notifies the SLHD and person of DNB/PHLO removal

SLHD continues case management or transfers care as needed; provides updates to the QS as needed

Overview

ADDITION

• Convene conference call

• Obtain approval from CDC if addition criteria are met

• Send request to DHS for processing for addition to DNB and PHLO

DURING

• SLHD monitors and provides regular clinical updates to QS

• QS and partners respond to any interceptions during travel

REMOVAL

• Determine when individual is no longer infectious or at risk of becoming infectious

• Remove from DNB/PHLO lists

• Continue patient followupas appropriate

CDC Roles Quarantine Station, Quarantine Medical Officer, and Travel Restriction and

Intervention Activity– Receives DNB requests from SLHD, and coordinates conference call– Obtains CDC leadership approval for DNB actions, and manages

administrative processes for DNB actions– Maintains communication with SLHD to obtain case updates, and

determines when person meets criteria for DNB addition or removal – Manages responses to interception of persons on DNB at US ports of

entry and inquiries from federal partners regarding DNB cases– Reviews all DNB and potential DNB cases routinely

Health Department Roles Contacts jurisdictional CDC Quarantine Station for initial consultation, and

participates in DNB conference call(s) Provides regular updates on patient status Shares responsibility with QS for case management Notifies QS when patient meets DNB removal criterion Continues case management after DNB removal, and alerts QS if new

concerns develop

Cure TB1997

CureTB starts in San Diego County TB program as a

collaboration with sister city of Tijuana Mexico

2013

CureTB expands to routinely

include all Latin

America

2016

Joins CDC’s Division of Global

Migration and Quarantine (DGMQ) and

expands to all countries, becoming

transnational

Maintains MOU/DUA with San Diego TB

Control

2017

Formal agreement with US Immigration and Customs Enforcement (ICE) to link outbound

persons to care

CDC Quarantine Stations at US Ports of EntryDivision of Global Migration and Quarantine

CureTB staff locations

Cure TB

Referral of patients with active tuberculosis*Any country

Clinical history requestMexico and Central America

Contact notificationMexico

Source case findingMexico

Services provided by CureTB for all health departments and correctional partners

*Verified or possible TB in a person moving outside the United States and needing <30 days of treatment

Cure TB elements

Determine treatment outcome and notify originating jurisdiction

Maintain communication with patient and helath system until

linked to care

Send accurate and up-to-date clinical information to downstream

provider, state, national level

Interview patient by telephone to develop rapport, educate, assist

Receive referral from originating provider/jurisdiction

Continuously motivate the patient

by maintaining

contact

2017 TB referralsn=254

Country Referral Country ReferralMexico 115 Eritrea 2

Honduras 31 Afghanistan 1Guatemala 12 Congo 1

Haiti 10 Cuba 1Philippines 8 Dominican Republic 1

United States 6 Ghana 1India 5 Indonesia 1China 4 Iran 1

Ecuador 4 Japan 1Guinea 4 Kenya 1Nepal 4 Laos 1

Bangladesh 3 Liberia 1Brazil 3 Mali 1

El Salvador 3 Mongolia 1Peru 3 Myanmar 1

Cameroon 2 Nicaragua 1Ethiopia 2 Nigeria 1Pakistan 2 Panama 1Senegal 2 Republic of Congo 1Thailand 2 St.Kitts 1

The Gambia 2 Swaziland 1Venezuela 2 Togo 1Vietnam 2

Patient-centered care

Correction or

detention facilities

ICE

Health department

Primary provider Patient

and family

State

Local

= Treatment completion

Challenges and Strategies Mobility

Advance planning for movement is helpful Patients often prefer private physicians May be distant from capital/main city

Continuity of care – how to refer Simple but clear history Smear-negative patients may not be recognized as “cases” Original lab reports helpful, CXR image if possible Important to clarify why patient on non-standard regimen and any adverse

reactions/side effects

Challenges and Strategies Ensuring medication adherence

Not all countries have equivalent DOT Not all countries have same availability of medications (rifabutin) or formulations

(fixed-dose combinations) or ready supply CureTB will provide outcomes and best assessment of DOT/adherence Should your program provide the medication?

Resources we use NTPs, IHR contacts, CDC partners CDC partners including TRIA

CureTB Resourceswww.cdc.gov/usmexicohealth/curetb.html

For Referrals (except from California)

For California ReferralsCureTB.org

FAX 404-471-8905 (619) 692-8020

E-MAIL curetb@cdc.gov curetb.hhsa@sdcounty.ca.gov

PHONE (619) 542-4013 (619) 542-4013

Travel Restriction Intervention Activity (TRIA)– Robynne Jungerman

Cure TB– Sonia Montiel– Kathy Moser– Carlos Vera

Acknowledgments

For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank you!travelrestrictions@cdc.gov

curetb@cdc.govSEA QS: 206-553-4519