TB Control Program County of San Diego Challenges: Cross border Continuity of TB Care Response:CureTBUS/Mexico Tuberculosis 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: 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: or Marjorie Lee -Data and Monitoring Lead CureTB.org

Make contact with patient, family, friends and providers

Referral Confirmation Form

CureTB # Tool that helps keep in touch with patients and providers

TB Control Program County of San Diego CureTB Webinar Memorial Day 2011 Participated Did 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

Total Referrals Received 2009 – 2011 Referral Category Total USMexUSMexUSMex Class Class Contact Notification Past History Request Source Case Finding LTBI Total

Class 3 Referrals from US to Mexico Received in 2010 with Outcomes to Date* OutcomeOverallHealth Department (70) ICE/Other Correctional Facility (38) Interviewed before moved Interviewed before deported YesNoYesNo Cured/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%)04 (20%)2 (9%)10 (66%) Lost – After Arrival6 (6%)02 (10%)4 (17%)0 Refused/Abandoned13 (12%)6 (12%)3 (15%)3 (13%)1 (7%) Died4 (3%)2 (4%)2 (10%)00 Total108(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 cases 222 Class 3 from US in * 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 /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 Finding 17 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