TB Control Program County of San Diego

Challenges:Cross border Continuity of TB Care

Response:CureTB

US/MexicoTuberculosis Referral

and Information Program

.

Some barriers to continuity

-Have never had TB before, don’t know where to go

-Language and technical barrier between systems, clinical information gap

-Mexico diagnostics based on smear, generally smear negative when re-enter Mexico

-May not know they have TB prior to leaving

- Deportation does not enhance adherence

But….

These problems can usually be overcome with support and information and follow-up

Few people are seeking to die of TB and infect their family

CureTB

Part of the San Diego County TB Program, Public Health Services

Started locally to assure continuity of TB care between SD and TJ…and grew, in 1997, to include other parts of CA and Baja CA, then grew to include all other states in the US and Mexico

Funded by the State of CA and by the Centers for Disease Control and Prevention

Categories of Patients

1. Suspect and Verified Tuberculosis Case CureTB provides preliminary outcome in 30 days,

regular updates, and final outcome by 12 months.

2. Past History Request CureTB will retrieve past medical TB history.

3. Source case finding

Active TB in a young child or others likely to have been recently infected for whom it is suspected that the source case is in Mexico.

Categories of Referrals

3. Contact notification These patients are divided in two categories:

Contacts who are moving to Mexico and have been exposed to an infectious pulmonary case in the U.S. and are under 5 years of age or immunocompromised.

Contact investigation notice for a smear positive pulmonary case in the U.S. who was living in Mexico while likely to have been infectious.

Binational Referral Form

Fax: 619-692-8020 orEmail:curetb.hhsa@sdcounty.ca.gov

619-692-5794Carlos.vera-garcia@sdcounty.ca.gov

619-692-8831Leticia.browning@sdcounty.ca.gov

619-542-4011Margarita.brooks@sdcounty.ca.gov

Marjorie Lee-Data and Monitoring Lead619-692-8298Marjorie.Lee@sdcounty.ca.gov

CureTB.org

Make contact with patient, family, friends and providers

Referral Confirmation

Form

CureTB 1-800 #

Tool that helps keep in touch with patients and providers 1-800-789-1751

TB Control Program County of San Diego

CureTB Webinar Memorial Day 2011

ParticipatedDid not participate

Legend

Customer Satisfaction Online Survey

Follow-up with patient and providers

Referral Outcome

Notification

Identify common barriers and how to resolve

Deportation x 4

Deported and lost in 2006

Deported in 2007

Deported in 2010

Back in ICE custody 2011 → Long discussion→ Deported → Meet and Greet set up at one port → Sent to another port → Needs money to get home → Family was suspicious → Conference call → Consulate had another govt agency→ provide travel voucher→ Bus station refused voucher→ Consulate brokered ticket→In Nayarit

Case Review with Mexican National TB Program

Action Items examples

MDR referrals

Treatment regimen for PZA or INH resistance

Cross check outcome information

Deportations/Voluntary returns

Data, data, data

States Sending/Receiving Class 3 and Class 5 patients 2009-2011

Total Referrals Received 2009 – 2011

Referral Category

2009 2010 2011 Total

US Mex US Mex US Mex

Class 3 111 4 119 6 125 6 371

Class 5 79 0 78 4 73 1 235

Contact Notification

31 1 33 19 46 20 150

Past History Request

27 7 18 2 34 12 100

Source Case Finding

3 0 6 0 9 0 18

LTBI 11 0 9 0 7 0 27

Total 262 12 263 31 294 39 901

Class 3 Referrals from US to Mexico Received in 2010 with Outcomes to Date*

Outcome Overall Health Department(70)

ICE/Other Correctional Facility (38)

Interviewed before moved Interviewed before deported

Yes No Yes NoCured/Completed Tx. 51 (47%) 33 (66%) 5 (25%) 10 (44%) 3 (20%)

Moved Back – Connected to F/U

18 (17%) 9 (18%) 4 (20%) 4 (17%) 1 (7%)

Lost – Insuff. Info. 16 (15%) 0 4 (20%) 2 (9%) 10 (66%)

Lost – After Arrival 6 (6%) 0 2 (10%) 4 (17%) 0

Refused/Abandoned 13 (12%) 6 (12%) 3 (15%) 3 (13%) 1 (7%)

Died 4 (3%) 2 (4%) 2 (10%) 0 0

Total 108(100%) 50(100%) 20 (100%) 23(100%) 15 (100%)

Excluding referrals with an outcome of Died, 79% Completed or Cured or Reconnected if interviewed and 39% if no interview

*Excludes 3 referrals without a final outcome and 8 referrals for pts that did not move

DSTs for verified cases222

• Class 3 from US in 2010-2011*

192

• Culture proven (86%)

187

• DST results obtained (97%)

22

• Resistant (12%) 12 mono PZA, 4 INH resistant, 1 Rif, 2 strep

3• MDR(1.6%)

*Excludes 22 Class 3 for which a referral was not required as the patient did not move to Mexico as originally intended or referral is open and patient has not yet moved

Resistant TB from Mexico to US

5• Class 3 from Mexico in 2011*

4• Culture proven

4• Susceptibility results obtained

2 • Resistant

2• MDR

*Excludes 1 Class 3 for which a referral was not required

Source case finding 2011

3/3 children <5 yrs

1/1 child with LTBI

1/1 teen:15 yo

3/4 adults

Uncle (cx+), grandmother who abandoned and sick again, HIV+ uncle (sm+)

Grandmother (sm+)

Uncle (sm+) treated the previous year

Drug-using HIV+ friend (sm+), 76 yo mom sm+, 37 yo daughter sm+

Source Case Finding17 month old US born hispanic child with L lung consolidation, mediastinal adenopathy, 14mm TST

Lived in San Diego with mother, 2 uncles

Babysat in Tijuana during the week with maternal grandmother, uncle, aunt and their 4 children

CureTB worked with Tijuana HD to obtain CXRs of adults

37 year old uncle had no sx but LUL infiltrate. He was unable to cross the border. CBP allowed sputum to be collected at the Port of Entry.

2011 Case Counting

*Excludes Class 3 closed as referral was not required as the patient did not move to Mexico as originally intended or referral is open and patient has not yet moved; numbers regarding reporting are preliminary

111 Class 3 Referrals for patients moving from the US to Mexico in 2011*– 52 (47%) have been counted in US only– 4 (4%) have been counted in Mexico only– 44 (40%) have been counted in both countries– 11 (10%) not reported in either country

Take home

We’re all in this together

Continuity of care across borders is possible and an important TB control strategy

Acknowledgements:

-The CureTB staff-All referring and receiving providers and partners along the way-The patients

www.CureTB.org