(MDR) MDR-TB is defined as TB resistant to the two most

1
Stopping TuberculosisRole 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

2
Objectives

• Provide an overview of tuberculosis (TB) disease
• 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

3
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

4
Airborne transmission coughing, singing,
laughing, etc. in confined spaces
5
Why is our role TB Control Important?

• One-third of the worlds population is infected
  with the tuberculosis bacillus
• Someone in the world is newly infected every
  second
• 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

6
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)

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Positive TB skin test
8
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

9
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

10
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)

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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

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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 costly
• Much greater likelihood of dying from XDR-TB
• Often associated with HIV disease

13
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
  medication

14
Screening for TB

• Teleradiology unit
  Airborne Infection Isolation rooms

15
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 treatment

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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 treatment
• 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

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ICE TB Continuity of CareProgram 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

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ICE/DRO Role in TB Continuity of Care
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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 Director
• 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

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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 detainees 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)

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TB Medical Hold Form
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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
  hindered

23
Release TB Medical Hold Form
24
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

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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

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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

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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, OREC, BOND)
• Once treatment is complete DIHS notifies FOD in
  writing that patient has completed treatment
• Alien may then be removed as per usual ICE
  procedure

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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)
• IDENT, ENFORCE
• Helps to minimize exposure to law enforcement
  personnel
• If alien found with alert call DIHS HQ for
  guidance

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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

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Summary

• Domestic and global TB control requires
  collaborations
• Public health authorities (local, state, federal,
  and foreign national)
• ICE, DRO, DIHS
• USM JPATS
• TB referral programs (TBNet and Cure-TB)

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Contacts

• Division of Immigration Health Services,
  Epidemiology Program
• Dr. Diana Schneider
• phone [phone]
• cell [phone]
• e-mail Diana.Schneider_at_dhs.gov
• LCDR Jennifer Jones
• Nurse Epidemiologist
• phone [phone]
• cell [phone]
• e-mail Jennifer.Jones1_at_dhs.gov
• Ms. Ana Burns
• phone [phone]
• e-mail Ana.Burns_at_dhs.gov
• Fax [phone] [phone]