Binational Border Tuberculosis Case Management

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Binational Border Tuberculosis Case Management

• Gary L. Simpson MD, Ph.D, MPH

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TB Case Rates, United States, 2005
D.C.
3.64.8
4.8 (national average)
Cases per 100,000.
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Our Shared Southern Border
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POPULATION US-MX BORDER
1900 - 53,000 1990 -
7,000,000 2000 - 11,500,000 2025 -
23,000,000

• Projected
• Border is approximately 2000 miles

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TB Rates Along the US-Mexico Border

Country Averages US 5.2 MX 15.1
9.0
3.1
4.8
48.1
7.1
21.7
18.2
Border States Averages US 6.0 MX 28.2
17.2
27.9
35.8
Rate Cases per 100,000 Sources Centers for
Disease Control and Prevention, and Sistema Único
de Información para la Vigilancia Epidemiológica
(SUIVE)
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Case Summary

• 26 y/o Mexican National arrested for marijuana
  smuggling.
• Incarcerated in Luna County Detention Center
  (U.S. Marshalls custody).
• Six weeks later, inmate evaluated for cough.
• Diagnosis of MDR-TB, subsequently established
  (19/23 contacts TST ).

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Case Summary (contd)

• Inmate transferred to Dona Ana County Detention
  Center.
• Treatment initiated with amikacin (I.V.), and
  PZA, EMB, ethionamide, cycloserine and ofloxacin.
• Patient responded clinically.

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Case Summary (contd)

• During the 3rd month of therapy, patient began
  acting out separate psych. Evaluations
• adverse reaction to meds, paranoid
  schizophrenia, streetwise punk.
• Patient refused all medications.
• Time Passes.
• Criminal charges dropped.

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Case Summary (contd)

• Inmate transferred to ICE facility (El Paso,
  TX.).
• Despite extraordinary efforts to assure
  continuity of care, inmate was deported late at
  night, and was lost to follow-up.
• Contact with patient re-established during a
  transnational contact investigation.

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Characteristics Common to Binational Tuberculosis
Patients

• Largely non-US-born, frequently without legal
  status.
• Commonly with outstanding criminal charges.
• Maybe marginalized, stigmatized, homeless and
  have poor access to medical care.

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Characteristics Common to Binational Tuberculosis
Patients

• Significant, undiagnosed and/or untreated,
  comorbid, medical/psychiatric conditions.
• Major cultural and language barriers.
• Environments favoring mistrust, fear and secrecy.
  
• High prevalence of drug resistance.

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Collaborators

• NM Dept. of Health (Santa Fe, Las Cruces, Deming)
• El Paso City-County Dept. of Health
• Texas Dept of State Health Services (Austin)
• Dona Ana County Detention Center
• Luna County Detention Center
• NM Border Health Office
• US-Mexico Border Health Commission
• Pan-American Health Organization
• Juntos Project, Juarez

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Collaborators

• ICE Facility, El Paso
• Mexican Consulate, El Paso
• Div. Of Immigration Health Services (Washington,
  D.C.)
• Migrant Clinicians Network
• Juarez General Hospital
• Chihuahua public health clinicians
• TBNet (Austin)
• CureTB (San Diego)
• Quarantine Div., C.D.C.
• TB Elimination Div., C.D.C.

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Challenges of Binational Tuberculosis Case
Management

• Lack of consensus on tuberculosis treatment
  guidelines (esp. MDR-TB)
• Major issues of information management (esp. the
  need for internet-based, secure, confidential
  EMR/EHR)

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Challenges of Binational Tuberculosis Case
Management

• Lack of funding of excess morbidity/case burden
  of binational, tuberculosis case management
• Uncertain statutory authorities in regional,
  complex, interstate and international public
  health jurisdictions

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Challenges of Binational Tuberculosis Case
Management

• Absence of secure, inpatient isolation and
  treatment facilities -
• (e.g. T.C.I.D.)

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Binational Public Health Statutory Questions

• Can state (district court) jurisdiction be
  asserted over patients in federal custody (i.e.
  ICE, US Marshalls, etc.)?
• Is there federal authority (e.g. Quarantine
  Division, CDC) to compel isolation of persons
  with a threatening communicable disease?

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Binational Public Health Statutory Questions

• Can Mexico (and/or Chihuahua state) refuse entry
  of a patient with a threatening communicable
  disease (e.g. MDR-TB patient, etc)?
• Do public health officials in Mexico (by federal
  or state statute) have the authority to isolate,
  by court order, patients with a threatening
  communicable disease ?

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