# Presentation: 570661

## TB in the United States, with a focus on the foreign-born population 

**Andrew Vernon, MD, MHS**
**Chief, Clinical & Health Systems Research Branch**
**Division of TB Elimination/NCHSTP**
**April 2005**

## Contents of Presentation

**Overview of TB surveillance data**
**Foreign born population in the U.S.**
**TB in the foreign-born**
**Examples relevant to U.S. efforts to control and eliminate TB in the foreign-born**

## Overview of National TB Surveillance System

**Data reported from 59 reporting areas**
**50 states**
**D.C. and New York City**
**Puerto Rico**
**6 jurisdictions in Pacific and Caribbean**

**Notes:**
Reports of tuberculosis (TB) cases are submitted to the Division of TB Elimination (DTBE), Centers for Disease Control and Prevention (CDC), by 59 reporting areas (the 50 states, the District of Columbia, New York City, Puerto Rico, and six other jurisdictions in the Pacific and Caribbean). 

## Overview of National TB Surveillance System

**Data reported on 3-part RVCT form**
**Patient demographics and lab results**
**Drug susceptibility results**
**Treatment outcome**
**Transferred electronically to CDC via TIMS**

**Notes:**
Currently, data items are reported using the Report of Verified Case of Tuberculosis (RVCT) form. The RVCT contains 41 major data items, designed to collect information on verified cases of tuberculosis. The RVCT form (expanded in 1993 and revised in 2003) consists of three data collection forms printed in triplicate on carbonless paper:
Report of Verified Case of Tuberculosis – Questions 1-22 are printed on page 1, and questions 23-32 and user comments on page 2.  Patient demographics, laboratory and risk behavior data are collected on these pages.
The Initial Drug Susceptibility Report (Follow Up Report -1) – Includes Questions 33, 34, and a space for user comments. Susceptibility results are collected on this page. 
 The Case Completion Report (Follow Up Report – 2) Includes Questions 35-41 and a space for user comments. Treatment outcomes are collected on this page. 
While a case of TB is required to be reported to CDC only if active disease is verified and the case is to be a part of the annual morbidity count, CDC encourages the uses of the RVCT forms and TIMS for the collection of data on suspected cases of TB. Verification of suspected cases can be accomplished through periodic updates of the records in TIMS. TIMS will automatically verify a case as data are entered or updated in the databases and flag the record for transmission to CDC.
In 2005, the planned retirement of TIMS is expected to begin, to be replaced by the TB Patient Management Program (TB PAM), a component of the NEDSS/PHIN surveillance system.

## U.S. TB Case Definition

**Incident cases, active disease**
**Three alternatives:**
**1. Bacteriological confirmation ****	****(~81%)**
**  ****~80% culture confirmed**
**2. Clinical evidence ****	****	****	****(~12%)**
**3. “provider diagnosis” ****	****	****	****(  ~7%)**

**Notes:**
A clinical case must meet the following criteria:
- Positive TST
- Abnormal and unstable CXR 
   or
   clinical signs and symptoms consistent with TB
- treatment with two or more TB drugs
- completed diagnostic evaluation

## TB MorbidityUnited States, 2000-2004

** ****Year****	****	**** Cases****	****	**** Rate***

**2000****	****	****16,377****	****	****  5.8**
**2001****	****	****15,989****	****	****  5.6**
**2002****	****	****15,075****	****	****  5.2**
**2003****	****	****14,874****	****	****  5.1**
**2004****†****	****	****14,511****	****	****  4.9**

- *Cases per 100,000         † provisionall

## Slide 7

## Reported TB Cases United States, 1982-2003

**Year**

**1983**

**1987**

**1991**

**1995**

**1999**

**2003**

**No. of Cases**

**12,000**

**16,000**

**20,000**

**24,000**

**28,000**

## TB Case Rates,* United States, 2003

_**<**_** 3.5 (year 2000 target)**

**3.6 - 5.1**

**> 5.1 (national average)**

**D.C.**

- *Cases per 100,000

## Reported TB Cases by Age Group United States, 2003

**25 - 44 yrs**
**    ****(34%)**

**<15 yrs**
**(6%)**

**15 - 24 yrs**
**(11%)**

**45 - 64 yrs**
**   ****(29%)**

**65+ yrs**
**  ****(20%)**

## TB Case Rates* by Age Group and Sex, United States, 2003

** ****Cases per 100,000**

- *Cases per 100,000.

## Reported TB Cases by Race/Ethnicity* United States, 2003

**Hispanic or Latino**
**(28%)**

**Black or African American**
**(28%)**

**Asian**
**(23%)**

**White**
**(19%)**

**American Indian or**
**  ****Alaska Native (1%)**

**Native Hawaiian or**
**Other Pacific Islander (1%)**

- *All races are non-Hispanic. Persons reporting two or more races comprised less than 1% of all cases.

## TB Case Rates* by Race/Ethnicity** United States, 1993-2003

**TB Case Rates* by Race/Ethnicity** United States, 1993-2003**

** ****Cases per 100,000**

- *Cases per 100,000.**All races are non-Hispanic. In 2003, Asian/Pacific Islander category includes persons who reported race as Asian only and/or Native Hawaiian or Other Pacific Islander only.

## Estimated HIV Coinfection in Persons Reported with TB, United States,1993-2002

**% Coinfection**

- Note: Minimum estimates based on reported HIV-positive status
- among all TB cases in the age group.

## Primary MDR TBUnited States, 1993-2003

## Mode of Treatment Administration in Persons Reported with TB United States, 1993-2001

- Directly observed therapy (DOT); Self-administered therapy (SA)

## Completion of TB Therapy United States, 1993-2001

- *Healthy People 2010 target: 90% completed in 1 yr or less.
- Note: EXCLUDES persons with initial isolate resistant to rifampin, children         	< 15 years old, and meningeal, bone or joint, or miliary TB.

**Percentage**

*****

## Concepts and Terminology

_***Foreign Born***__** and **__***Immigrant***_
***Foreign Born***** – Anyone who is **_**not**_** a U.S. citizen at birth, including immigrants, legal nonimmigrants (temporary migrants), humanitarian migrants, and people illegally present in the United States.**
***Immigrant***** – Aliens admitted to the U.S. for ****lawful permanent residence, as defined in ****the Immigration & Nationality Act.**

## National Quick Facts: 2000

- Source:  1990 Census and Census 2000

|  | 1990 | 2000 |
| --- | --- | --- |
| Total Population | 249 million | 281 million |
| Total Foreign Born | 20 million | 31 million |
| Percent Foreign Born | 8 percent |    11 percent |

## Percent Foreign Bornby World Region of Birth: 2002

- Source:  American Community Survey 2002

|  | Percent |
| --- | --- |
| Total Foreign Born | 100 |
|      Latin America | 52 |
|      Asia | 27 |
|      Europe | 15 |
|      Africa | 3 |
|      Other Regions | 3 |

## Percent Foreign Born Within Each State: 2000

- Source:  Census 2000

- Prepared with American FactFinder

## Top Five States with the Highest Foreign-Born Population and Highest Rate of Change: 2000

| California | 9 million |  | North Carolina | 274% |
| --- | --- | --- | --- | --- |
| New York | 4 million |  | Georgia | 233% |
| Texas | 3 million |  | Nevada | 202% |
| Florida | 3 million |  | Arkansas | 196% |
| Illinois | 2 million |  | Utah | 171% |

**Highest Number of Foreign Born 2000 **
_**Number**_

**Highest Percent Change 1990-2000 **
_**Percent**_

- Source: U.S. Census Bureau, Census 2000

**Notes:**
In 2000, Illinois foreign-born population is 1.5 million – which rounds to 2 million

## Age Distribution by Sex for the Native and Foreign-Born Populations: 2002 

**Age Distribution by Sex for the Native and Foreign-Born Populations: 2002 **

- Source:  Current Population Survey, (2002) Annual Social and Economic Supplement

**Native**

**Foreign Born**

**Age**

**Male**

**Female**

**Male**

**Female**

**Notes:**

Relatively few foreign-born people are under age 20 (11.8 percent of the foreign-born population is 0-19 years of age) compared with 30.7 percent of the native population.
The foreign born are more likely than natives to be 18 to 64 years of age. 
The largest percentage of foreign born are in the 30-34 age group.

## Percent of Foreign Born Naturalized by Year of Entry:  2002 (In Percent)

- Source:  Current Population Survey, (2002) Annual Social and Economic Supplement

## Percent of Population with Less Than 9th Grade Completed by Place of Birth: 2002 (Population 25 years and over)

- Source:  Current Population Survey, (2002) Annual Social and Economic Supplement

**Foreign Born**

## Language Spoken at Home     for the Foreign Born: 2002(Population 5 years and over)

- Source:  American Community Survey 2002

|  | Percent |
| --- | --- |
| Total Foreign Born | 100 |
|   Speak only English | 17 |
|   Speak a language other than English | 83 |
|      Speak Spanish | 45 |
|      Speak Asian or Pacific Island languages | 18 |
|      Speak other Indo-European languages | 17 |
|      Speak other languages | 3 |

**Notes:**
CAUTION:  The category “Speak a language other than English” is not in the original table– I created it by summing the specific-language-group categories (“speak Spanish”, etc).  If this table needs to have only the categories originally published, simply delete the “Speak a language other than English” row.  The other rows were pulled directly from the table (Ns, of course; no percents were given, so I had to calculate those).

SOURCE: 
PCT020. Nativity by Language Spoken at Home by Ability to Speak English for the Population 5 Years and Over

NOTES:
Of the foreign born who do not speak “only English” at home, the majority (53.8%) speak Spanish. 
[14,665,296 is 53.8% of 27,260,662]

## Number of TB Cases inU.S.-born vs. Foreign-born Persons  United States, 1993-2003

**No. of Cases**

## Percentage of TB Cases Among Foreign-born Persons, United States

_**>**_**50%**

**25% - 49%**

**<25%**

**1993**

**2003**

**DC**

**DC**

## Slide 29

## The gap in TB rates between foreign- born and U.S.- born persons is widening

**                          ****Rates           ****	****Rate ratios**
**                          ****1992     2002 *****	******	*****1992     2002**
**Foreign-born      34.5      23.6           **
**U.S.-born              8.2        2.8           ****	**** 4.2         8.4****   **

## Percent Foreign-born TB Cases, United States, 2004*

**D.C.**

- *Percent foreign-born cases over total cases

**57% – 66%**

**≥ ****67%**

**41% - 56%**** ****(%foreign-born for U.S.= 53.7%)**

**26% - 40%**

**≤**** ****25%**

## Percent Foreign-born TB Cases, United States, 2004*

**D.C.**

- *Percent foreign-born cases over total cases

**57% – 66%**

**≥ ****67%**

**41% - 56%**
**(%foreign-born for U.S.= 53.7%)**

**26% - 40%**

**≤**** ****25%**

**Percent Foreign Born ****Within Each State: 2000**

- Source:  Census 2000

- Prepared with American FactFinder

## Countries of Birth for Foreign-born Persons Reported with TB United States, 2003

**Mexico [33]**
**(26%)**

**Philippines [320]**
**(12%)**

**Viet Nam [189]**
**(8%)**

**India [168]**
**(8%)**

**China [113]**
**(5%)**

**Haiti [319]**
**(3%)**

**S. Korea**
**[91]**
**(2%)**

**Other**
**Countries**
**(36%)**

**Incidence **
**per 100,000 **
**shown in **
**brackets**

## Length of U.S. Residence Prior to TB Diagnosis, United States, 2003

## Primary MDR TB inU.S.-born vs. Foreign-born Persons, United States, 1993-2003

**% Resistant**

- Note: Based on initial isolates from persons with no prior history of TB.
- MDR TB defined as resistance to at least isoniazid and rifampin.

## US-Born

**Disproportionately affects minorities**
**Elderly**
**Homeless**
**Substance abuse**
**HIV co-infection**
**Access to care**

## Foreign-Born

**Culture**
**Language**
**Western medical approach**
**Stigma**
**Access to care**
**Fear of deportation**

##  “Ending Neglect” Challenges

**Maintain TB control – focus on Foreign-born **
**Overseas screening and stateside notification**
**Speed TB decline **
**	****–  ****Identify and treat latent infection (LTBI)**
**Develop new tools **
**Tests (LTBI), drugs, vaccine**
**Increase U.S. role in global elimination**
**Mobilize support and measure progress**

## Estimated Migrants “Entering” U.S.

**Source: U.S. Department of Homeland Security, 2003 (2002 data)**

**Status adjusters in U.S.:**
**679,305**

**Immigrants and refugees **
**411,266**

**Undocumented migrants  **
** ****~ 275,000 ????**

**Non-immigrant visas**
** ****27,907,139**

**N= ~ 59,000,00000**

**Visitors without visas**
**~ 30,000,000**

**Estimated Migrants “Entering” U.S.**

## Foreign-born (FB) Persons Screened for TB Before U.S. “Entry”

|  FB Category | Number | TB Screening*
 | Screening Site |
| --- | --- | --- | --- |
| Immigrants |     384,427 | CXR + smear;  >15 yr | Overseas |
| Refugees |        26,839** | CXR + smear; >15 yr | Overseas |
| Status adjusters |     679,305 | TST + CXR;     >2 yr | U.S. |
| TOTAL |   1,090,571 |  |  |

*** CXR, chest radiograph; TST, tuberculin skin testing**
****2001: 68,925**
**Source: U.S. Department of Homeland Security, 2003 (2002 data)**

**Notes:**
However, in certain areas of the world refugees are not so unfortunate and continue their lives outside their homes

Of the 10 top countries creating refugees, 5 of these countries originate in Sub-Sahara Africa

Somalia, Burundi, Liberia, Sudan, and Sierra Leone all have has conflicts for years and have created 
about a 1⁄2 million refugees each living in neighboring countries with no solution in sight

Dr. Manuel Carballo will discuss these conflicts and affects of public health later in the hour

## Foreign-born Persons not Screened for TB before U.S. "Entry”

**Visitors not requiring visas:  ~30, 000,000 **
**Non-Immigrant Visas:               27,907,139**
**Temporary Visitors                       24,344,216**
**Temporary Workers/family                722,424**
**Students/family                                   687,506**
**Transit Aliens                                      614,934**
**Treaty traders                                     171,368**
**Foreign government officials           140,898**
**Other                                                   1,225,793**
**Undocumented visitors:                      ???**

****

## Opportunities for TB Prevention in Foreign-born Persons in U.S.

**Opportunities for TB Prevention in ****Foreign-born Persons in U.S.**

## Bureau of Customs and Border Protection

**BCBP is one of three components in the Border and Transportation Security Directorate....(it is) responsible for enforcing customs and immigration laws at and between the 307 ports of entry.   Approximately 30,000 inspectors from the Customs Service, INS and the Plant Protection and Quarantine (PPQ) Bureau of Agriculture work together under the new bureau.  The Border Patrol, from INS is also part of BCBP. **

##  Objectives of Overseas TB Screening

**Restrict travel/entry of persons with infectious TB**
**Class A TB (AFB-smear positive)**
**Identify persons with suspect TB requiring follow-up stateside evaluation, and notify receiving jurisdictions of US arrival**
**        **

## Process Overview

**Overseas Medical Exam**
**Classification**
**US Admissions Visa**
**Domestic notification **
**Follow-up by Local TB Program**

**Notes:**
There are several components to the overseas TB screening process which I will review in the following slides

## Overseas TB Screening Process

**Chest radiograph**
_**>**_** 15 years old**

**Active TB**

**AFB sputum smears (3)**

**Inactive TB**

**No TB**

**Infectious TB **
**Class A**

**Noninfectious active TB **
**Class B1**

**All (****-****)**

**(at least one +)**

**Class B2**

**Notes:**
This algorithm indicates the diagnostic testing procedure for those 15 years of age and older.  All are given a chest radiograph and if the reading of the chest x-ray suggests active TB, a sputum microscopy is  then performed.  Treatment is required for all infectious TB patients and is provided to many active, non-infectious TB patients as well. 

## TB Notification in the US

**Generated by the CDC Quarantine Stations**
**Mailed to health departments**
**Follow-up evaluation**
**Submit follow-up to CDC **

**Notes:**
Upon arrival, immigration paper work including the report of the overseas medical exam is received by one of the 8 CDC Quarantine Stations.  Notification to the the health departments are generated at these stations and Mailed to health departments
HDs identify these individuals and intiate the Follow-up evaluation and then Submit the outcomes of this follow-up to CDC

## TB Classifications for Refugees and Immigrants, IMP, FY 2003

| TB Class |  | Refugees | Immigrants | Total |
| --- | --- | --- | --- | --- |
|    Class A |        |   1 | 2 | 3 |
|    Class B1* |  | 548 | 3715 | 4262 |
|    Class B2* |  | 746 | 2637 | 3383 |
|  |  |  |  |  |
| TOTAL |  | 1295 | 6354 | 7649 |

*** Class B1 TB:  3 - 14% active TB in US; **
**  ****Class B2 TB: 0.4 - 3.8% active TB in US (Binkin, et al. CID 1996)**

## Overseas TB Class, Notifications, and Outcome, IMP, CY 2003 

| TB  |  | Notified | Follow up (%) | AFB Smear (%) |
| --- | --- | --- | --- | --- |
| B1 |  | 4573 | 3019 (66) | Positive:       62 (2)
Negative: 1575 (52)
Not done:   830 (28)  
Blank:         551 (18) |
| B2 |  | 3603 | 2300 (64) | Positive:        24 (1)
Negative:    823 (36)
Not done:    912 (40)
Blank:          541 (23) |

**B1 rate of smear+ TB = 62/1637 = 3,787/100,000**
**B2 rate of smear+ TB = 24/  847 = 2,834/100,000**

## Median Time Intervals for Migrants with Suspect TB and Subsequent AFB Positive Smears, IMP, CY 2003 

| TB  | AFB smear- positive in US
(number) | Overseas Exam to US Arrival 
(days) | US Arrival to US Exam
(days) | Overseas Exam to US Exam 
(days)
 |
| --- | --- | --- | --- | --- |
| B1 | 62 | 76.5 | 43.5 | 142 |
| B2 | 24 | 87.5 | 24 | 163 |

## Current Challenges and Opportunities 

**Quality assurance of overseas TB screening**
**Limitations of screening algorithm **
**Sensitivity and specificity**
**Diagnostic tools **
**Local resources **
**Timely state-side notification, follow-up, and interventions**
**Expansion of scope and underlying objectives**** **
** **

## Two examples:Foreign-born TB and the national effort to eliminate TB 

## 1. US-Mexico Binational Tuberculosis Referral and Case Management Project

**Notes:**
Today I’m will be providing you with an update on the binational case management and referral system, also known as the binational card project.  This project is the product of a close collaboration between CDC, the Mexico Ministry of Health, and US and Mexican border state and migrant health partners.

## * 2000 Data

**Baja California**
**Norte**

**Chihuahua**

**Sonora**

**Nuevo Leon**

**Tamaulipas**

**Coahuila de**
**Zaragoza**

**California (CA)**

**Arizona (AZ)**

**Texas (TX)**

**New Mexico (NM)**

*** 2000 Data**

## Goals of the US-Mexico Binational TB Referral and Case Management Project

**Goals of the US-Mexico Binational TB Referral and Case Management Project**

**Ensure continuity of care and completion of therapy**** **
**Reduce TB incidence and prevent drug resistance**** **
**Coordinate referral of patients between health systems**** **
**Provide model for other diseases**

**Notes:**
The goals of the Project are to:

 Ensure continuity of care and completion of Rx
 Reduce TB and prevent drug resistance in both countries 
 Coordinate referral of patients between health systems, drawing upon the referral/counter-referral experience of:
CDC sponsored binational TB projects, San Diego County HHS (CureTB), Migrant Clinicians Network (TBNet) , and to
4) Provide model for other diseases

## Binational Health Card – Data Elements

**Location where card was issued**
**Treatment initiation date**
**Date of last dose TB treatment**
**Treatment regimen**** **
**DOT (yes/no)**** **
**Bilingual**
**Toll-free telephone numbers ****in the US and Mexico**

**Binational Health Card – Data Elements**

**Notes:**
The project has as its centerpiece a binational TB Card.  This Card has the following data elements:  unique ID number, location where card was issued, treatment initiation date, date of last dose for TB treatment, treatment regimen, and DOT.  In addition the card is in both Spanish and English, and contains toll free telephone contact numbers.  Given the potential for stigma and issues of confidentiality, the Card does not contain reference to TB nor the patient’s name.  

The two most important elements on this Card are one, the Unique ID number, which links the Card, the patient, and clinical information in the two national databases, and two, the toll-free telephone numbers in the US and Mexico where the provider and/or patient can call for more clinical/ patient management information or to find the appropriate facility to receive care.

## TB Patients - Eligibility 

_**US**_
**Active TB**
**Mexico-born, *****and/or***
**Mexico-bound, such as:**
**Recently arrived to the US from MX**
**Migrant worker**
**Close or immediate family lives in MX**
**Works in the US and lives in MX**
**Lives in the US and receives medical care in MX**
**Suspect TB**
**ICE Detention Centers**
_**Mexico**_
**Active TB **

**Notes:**
Given time constraints, I will not describe in detail the project protocol.  In brief, however, for patients from the US, they are eligible to be in the project if they have active TB, are Mexican-born, and/or are Mexico-bound, regardless of where they were born.  Mexico-bound is defined as having either recently arrived to the US from Mexico, being a Migrant worker, having close or immediate family living in Mexico, working in the US, but living in Mexico, or living in the US, but receiving medical care in Mexico. 

For patients from Mexico, all patients are eligible for the project if they have Active TB-.

The eligible patient is asked to carry the card with them.

## Pilot Sites

_**US-Mexico border sister cities/states**_
**San Diego, CA – Tijuana, BC**
**El Paso, TX/Las Cruces, NM - Ciudad Juarez, CHIH**
**Webb/Cameron Counties, TX – Matamoros, TAMAU**
**Arizona – Sonora**
_**INS / ICE Detention Centers**_
**Texas, California, Arizona**
_**Mexican states **_
**Coahuila, Nuevo Leon**
_**US States**_
**Tennessee, Washington, Illinois**

**Notes:**
Pilot sites include 4 sister border regions: San Diego and Tijuana; El Paso and Las Cruces in the US, and Ciudad Juarez in Mexico; Webb and Cameron counties in TX & Matamoros in MX; and Arizona in the US and Sonora in MX.   In addition, 2 interior US sites will be also added, Tennessee and Chicago.  

INS detention facilities, now part of the bureau of immigration and customs enforcement or ICE in Texas, California, and Arizona have also agreed to participate in the project by referring TB patients being deported to Mexico to the project. One of the important benefits of this project, which is already evident, is the much improved communication and collaboration between INS detention centers and the local TB programs. A very successful binational card training session occurred in Port Isabel INS detention center in Texas with both US and Mexican participants at the end of September.  Representatives from INS and the local TB programs are very pleased with the improved communication made possible by the project.

In addition, six other states in the interior of MX have been selected.  These states are the place of origin of many Mexicans moving to the United States. 

Know Incidence TB, #/% of FB, # Mexican-born (2001) EP, Texas: 67 cases, 49 FB 73.1%, New Mexico 8 mx-born cases, Texas: 388 mx-born cases; SD, California: 332 cases, 227 FB 68.4%;  California: 791 mx-born cases; Arizona 82 mx-born cases  133 FB 46% 
Tennessee 10 mx-born cases 44 FB 14.1%; Chicago, Ill  237 FB 37.9%;  Illinois: 75 mx-born cases; TOTAL MX-born US (rough estimate): 1354; Tamaulipas: 1041, Chihuahua 533, BC 1321, Nuevo Leon 1113, Coahuila 422, Sonora 501 TOTAL: 4931;TOTAL US + MEXICO == (ROUGHLY) 6285 TB patients could be affected

## Data Flow/Management

**ACTION**

** ****Registers patient**
** ****Educates/issues card **
** ****Notifies Referral System when patient MOVES**

** ****Registers patient **
** ****Notifies TB provider in destination location**
** ****Reports final outcome to both US/MX**

** ****Notifies Referral System on other side of border**
** ****Provides information**

**US-MEXICO BORDER**

**Notes:**
To briefly review the flow of events: a provider will initially register an eligible patient in one of two central databases, one located in the US, managed by CureTB in California, the other in MX, managed by the NTP.  The databases will be updated every 2-4 weeks.  The provider will also educate and issue the patient a card.  The initial information entered into the database includes essential data about their treatment. 

When a patient anticipates a move across the border or has moved, the provider will notify the referral system on their side of the border and if possible issue a 2 week supply of TB medication to the patient.  

The referral system contacts the referral system on the other side of the border, forwarding treatment and destination information.  The referral system on the other side of the border will then notify the local TB control program or provider in the destination location, thus promoting continuity of care.  Upon receipt of a patient with a Card, the health departments can access the necessary clinical information to manage the case from the 2 national databases.  All notification is done via toll free telephone numbers.  

## Card Distribution

**As of December 31, 2004: **
**US Pilot Sites (n=488)**
**Mexico Pilot Sites (n=793)**

**Notes:**
With respect to Project Progress, as of Feb 19, 2004....(see above for numbers)

## Project Partners

**National TB Program of Mexico **
**Mexican Ministry of Health**
**Mexican National Center for Epidemiological Surveillance**
**National Institute of Diagnostic and Epidemiological Laboratory**
**Centers for Disease Control and Prevention**
**US-Mexico Border Health Commission **
**California Department of Health Services**
**San Diego County Health and Human Services Agency and its CureTB program**
**Texas Department of Health, TB Elimination Division**
**El Paso City-County Health Department**
**Migrant Clinicians Network**** ****and its TB*****Net *****program**
**The Binational TB Prevention and Control Project, “JUNTOS”**
**La Fe Community Health Center**
**Institute of Health Services of Baja California**

**State of New Mexico Department of Health**
**Secretary of Health of Chihuahua, Tamaulipas, Sonora, Coahuila. Nuevo Leon**
**Secretary of Health of Jalisco, Michoacan, Vera Cruz, Oaxaca**
**Ciudad Juarez Secretary of Health**
**US Agency for International Development (USAID)**
**US Department of Health and Human Services (HHS)**
**US Department of Homeland Security**
**US Department of Health Resources and Services Administration (HRSA)**
**US Department of Immigration and Naturalization Services (INS)/ICE**
**Ten Against TB**
**American Lung Association**
**American Lung Association of Texas (ALAT)**
**Pan American Health Organization (PAHO)**

**Notes:**
Although the CDC and the Mexican NTP are leading this effort, there are numerous US and Mexican governmental organizations at the federal, state, and local levels, as well as NGO’s working on binational and US-Mexico border health issues who have been involved in this project.

## Project Summary

**Responds to identified TB needs in the region**
**Has become an integral part of TB management in ICE detention centers **
**Strong political commitment exists at the national, state, and local levels**
**Represents a model for consensus for binational collaboration**
**Should lead to improved treatment outcomes**
**Should provide model for other similar settings or ****for other diseases in this setting**

**Notes:**
We feel that the considerable efforts over the past two years have been necessary and successful in achieving a consensus on how to move forward on this somewhat complex binational project.  Both countries’ public health systems see the establishment of the binational referral and information system for tuberculosis as a critical step to respond to identified TB needs in the region.  Indeed this project has become an integral part of TB mangement in ICE detention centers in the US-
Strong political commitment exists at the national, state, and local levels for this project.  This project represents a model for consensus for binational collaboration, as a way to improve treatment outcomes, and as providing a model for other similar settings or other diseases in this setting.  
PLUG SATURDAY LUNCH TIME THING

If this project proves successful in the pilot sites, the goal will be to extend it to all of the US and Mexico.  

## Challenges

**Notification/ referral information flow between and within countries not completely functional**
**Database management challenging**
**Remains difficult to obtain treatment outcome status of patients who have moved**
**Budget needs**

**Notes:**
We have now completed almost 1 year of project implementation, and we believe the Card is enjoying many successes.  Nonetheless, we have also experienced a number of challenges in implementation: First, the notification/ referral information flow between and within countries not completely functional—there are gaps in information and delays, which we need to focus on in this second year of implementation,  Second, 
Overall database management challenging—we are managing essentially 4 databases of information—a Project database and a national database in each country.  Merging the critical information in these databases is a fundamental component of this project and is only now underway-we hope to streamline this process in the coming months.
In addition, it remains difficult to obtain treatment outcome status of patients who have moved—we will be focusing on that in the coming months as well.  And Finally, we have a small budget for this project and will likely need more funds to maintain or especially expand this project.

## 2. Drug-sensitive and Multidrug-resistant Tuberculosis Among U.S.-bound Hmong Refugees

## Hmong Refugees, Thailand , 2004-2005

- Historically persecuted
- Fled Laos to Thailand >20 years ago
- First wave of U.S. resettlement  > 10 years ago
- Wat Tham Krabok, 2004
- Urgent U.S. resettlement
-  ~ 15, 000 refugees
- 52% < 15 years old
- Anticipated high TB rates
- Enhanced TB diagnosis and treatment

## Timeline of Overseas Screening and U.S. Resettlement, Hmong Refugees, 2004-2005

**Movement to US,** **CDC Enhanced TB Screening Rec #1**

**Standard overseas TB screening started**

**Overseas & U.S.-based investigations**
**CDC Enhanced TB Screening Rec #2**

_**June 2004-January 2005**_
**4 MDR-TB cases overseas;**
**6 active TB cases in US (2 MDR-TB)**

**Additional overseas data: 17 MDR-TB**
**Movement halted**

## Hmong Refugees Preliminary Data* (1)Overseas TB Screening

- Total Population
- 	15,645 (7,499 _> _15 years [48%])
- Arrived in U.S. : 	9,455
- Still in Thailand:	6,190
- Majority adults underwent initial overseas screening
- Thailand
- ~424 with overseas TB classification
- ~351 with TB cultures performed
- 56 positive TB culture results
- 17 MDR TB (30%)
- 184 negative TB culture results
- 111 culture results pending

***As of February 5, 2005**

## Hmong Refugees Preliminary Data* (2)Overseas TB Screening

**Thailand**
**247 active cases**
**175 on  treatment  **
**Estimated rates among adults**
**Active: 3,294/100,000   (247/7,499)**
**MDR:     227/100,000    (17/7,499)**

***As of February 5, 2005**

## Top Five States of U.S. Arrivals, Hmong Refugees, June-January 2005

|  | Number | % |
| --- | --- | --- |
| Minnesota | 3,060 | 35 |
| California | 3,046 | 34 |
| Wisconsin | 1,951 | 22 |
| Michigan | 169 | 2 |
| North Carolina | 158 | 2 |
| Other states* | 442 | 5 |
|  | 8,826 | 100 |

*** Resettled to 22 other states**

## Overseas Classifications, Hmong Refugees, March 2004 – Feb 2005

|  | Thailand | U.S. |
| --- | --- | --- |
| TB | 424 | 161 |
|    Suspect Active TB   
          Class A  | 
16* | 
0 |
|           Class B1 | 311 | 74 |
|     Suspect Inactive TB          
          Class B2 | 
97 | 
87 |
| HIV-infected | 8 | 0
 |

***One with HIV infection**

## Hmong Refugees Preliminary Data* U.S. Stateside Reporting 

**36 verified TB cases in Hmong refugees  **
**29 from CA, 5 from  WI, 1 from MN, 1 from OH**
**At least 4 MDR-TB**
**21/36 (58%) adults**
**8/21 (38% ) with overseas TB classification **
**15/36 (42%) in children < 15 years**

***As of April 7, 2005**

## Relative Risk of TB Each Year After Initial Infection1

- 1. Sutherland I. KNCV 1968

## National TB Genotyping and Surveillance Network, 1996-2000

| Variable | Clustered | Rel. Risk | P |
| --- | --- | --- | --- |
| Overall | 48.1% | -- | -- |
| Drug use | 78.5% | 1.7 | <.001 |
| Incarcerated | 73.4% | 1.6 | <.001 |
| Homeless | 72.7% | 1.6 | <.001 |
| Alcohol | 71.9% | 1.6 | <.001 |
| Black | 64.6% | 1.6 | <.001 |
| US-born | 62.2% | 1.8 | <.001 |

## Summary Points

**Future burden of TB in the U.S. will be increasingly driven by patterns of immigration**
**Other factors that will effect future TB burden:**
**  ****Hard-to-reach/poor/disenfranchised persons**

## 		With assistance of: 

**	**
**Thomas Navin, MD**
**	****Surv. Epid. Outbreak Inv. Br., DTBE**
**Kayla Laserson, PhD**
**	****Internat. Prog. & Res. Br., DTBE**
**Susan A. Maloney, MD, MHSc**
**	****Div Global Migration and Quarantine**
**Zachary Taylor, MD**
**	****Field Svcs. & Eval. Br., DTBE**

## I was gratified to be able to answer promptly.  I said I didn’t know.

- 				Mark Twain

**-- Questions --**