1. TB Programs and Migrant Clinicians Network Collaborations Ed Zuroweste, MD Chief Medical Officer Migrant Clinicians Network 16 th Annual IUATLD Conference San Antonio, Texas February 23, 2010

2. Migrant Clinicians Network 10,000 constituents Oldest clinical network serving the mobile poor MCN’s primary constituents are clinicians working in federally funded Migrant and Community Health Centers and in state and local health departments. Photo © Alan Pogue A national, clinical network founded in 1984 We believe no one’s health should be compromised because of her/his mobility and because s/he may be seen by multiple providers and clinics.

3. MCN Mission A force for Health Justice for the mobile poor

4. Migrant Farmworkers Longer stays in the US/more “settled out” immigrants. No accessible means to obtain citizenship Further disenfranchised/isolated immigrants More Fear More confusion

5. Access to Health Care Fear + policy + enforcement + reality of being an immigrant: Language Social/cultural difference Poverty Lack of trust Lack of health insurance Lack of “Know How” to access the system Mobility (Continuity of care difficult) = LIMITED ACCESS TO HEALTH CARE

6. What happens when there are numerous barriers to health care? Individuals present with advanced health care problems The ultimate cost of treatment is higher The outcomes of treatment are significantly poorer Morbidity and Mortality rates are higher

7. MCN Health Network Goal: eliminate health disparities due to patient mobility Responds to challenges in providing continuity of care through patient navigation; medical record transfer and bridge case management program Health Issues: Tuberculosis (TBnet) Diabetes (Track II) Cancer (CAN-Track) Prenatal H1N1 flu, HIV, Hansen’s disease General health issues Services free of charge to clinics and participants

8. What is Bridge Case Management? Bridge between mobile patients and their providers Provides care coordination services and health education to mobile patients Expert bilingual, culturally-competent case managers Transfers medical records Central storehouse of patient medical information Offers toll-free access for patients and clinicians

9. TBNet TBNet began in 1996 Funding: Immigration and Customs Enforcement since 2005 HRSA/BPHC since 2010 New Mexico Dept. of Health through US/Mexico Border Health Commission since 2010 Funding from CDC ended 2008

10. Health Network Enrollment Criteria Patient who is: Mobile Likely to be lost to follow-up Patient who has: Active or latent tuberculosis Diagnosis or at risk for diabetes Needs testing or breast, cervical or colon cancer Is pregnant Is HIV +, H1N1, Hansen’s disease Any general health issue that requires follow-up

11. Pre-enrollment Education/ Assurance to the patient MCN Health Network does not discriminate on the basis of immigration status and will not share personal patient information without patient permission

12. Forms Required for Enrollment

13. Consent Form Gives MCN staff legal permission to transfer participants’ medical records and contact participants This form must have the participant’s signature Participants may renew their consent after it expires if they still need assistance

14. Maintaining a Patient in Care… Contacting patients on a scheduled basis. TB patients monthly. Contacting TB clinics on monthly basis Assisting patients in locating services and resources Reporting back to the enrolling clinic and notifying them of patient status and final outcomes Photo: C. Kugel

15. Maintaining a Patient in Care Patient Role: Inform Health Network of address changes or phone number changes When looking for health services in a new area, call the 800 number for help Receive calls from Health Network staff following up on the patient’s health status

16. TBNet Bridge Case Management TBNet, an innovative approach to tuberculosis management in migrating patients, has demonstrated for 17 years how TB control can be successfully accomplished in highly mobile populations, even those traveling internationally. 4,330 total TB enrollments since 1996 2,951 total clinics, in US and over 70 countries, participated since 1996

17. Impact Table 1: TBNet Enrollment 2005-Present 60 countries served Total 1,803 pts 1996-Present 71 countries served Total 4,330pts

18. Impact Table 1: TBNet Enrollment Country2005-Present 60 countries served Total 1,803 pts Mexico691 (38.3%) Honduras368 (20.4%) Guatemala245 (13.6%) El Salvador143 (7.9%) % of TOTAL80.3%

19. TB Control Among Detainees: An Innovative Public/Private Collaboration U.S. immigration laws have no provisions addressing health status with regard to removal Culture-confirmed case rate 2.5 times higher than other foreign-born individuals. ( Am J Prev Med 2007;33(1):9–14) Detainees often return to countries where access to health care is limited, or fail to complete treatment due to mobility. (Am J Prev Med 2007) Contract with TBNet started 2005.

20. TB Control Among Detainees: An Innovative Public/Private Collaboration Works because of dedicated clinical and administrative staff at ICE facilities and in DC Open communication between ICE Health Service Corps (IHSC) and MCN with continuous quality improvement philosophy Mutual goal—Provide culturally competent compassionate high quality services to the individuals dealing with Tuberculosis

21. TB Net’s International Reach Belgium, Belize, Bolivia, Brazil, Cameroon, China, Canada, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Etiopía, Guatemala, Haití, Honduras, India, México, Micronesia, Nepal, Nicaragua, Perú, Philippines, Romania, Russia, Somalia, South Korea, Sri Lanka, Taiwan, Turkey, United States, Vietnam

22. TBNet Statistics 2005-2010 A review of all referrals made for ICE detainees and State Health Departments to TBNet was completed January 1, 2005, through December 31, 2010 A total of 937 active (Class 3) cases reviewed

23. Nationality TBNet 2005-2010 CountryTotal Class 3 patients (937 total patients) Percent of total patients Honduras34536.8% Mexico 161 17.2% Guatemala15416.4% El Salvador10311% Nicaragua222.3% Peru181.9% China171.8% Ecuador161.7% India101.1% Haiti101.1% Honduras; Mexico; Guatemala; El Salvador 76381.4%

24. Class 3 Active TB: TBNet Treatment Success (2005-2010) 937 Class 3 Active TB Cases Referred 29 treatment not recommended by destination country 908 Treatment Recommended 7 deceased 901 Followed by TBNet for Active TB 95 lost to follow up 49 refused treatment 757 Complete Treatment = 84%

25. 25 Treatment Goals / Benchmarks Healthy People 2010 target for TB treatment completion is 90%. [i] WHO’s Stop TB Partnership sets that goal at 85% of smear-positive cases. [ii] In 2007, the latest data available, 84.5% of patients requiring treatment of less than one year successfully completed their drug regimen in the U.S. [iii] [i] Morbidity and Mortality Weekly Report. Trends in tuberculosis—United States, 2008. Center for Disease Control and Prevention. Mar 2009; 58(10): 249-253. [ii] WHO Report 2009. Global tuberculosis control. Mar 2009. Also available at http://www.who.int/tb/publications/global_report/2009/en/index.html. http://www.who.int/tb/publications/global_report/2009/en/index.html [iii] MMWR Weekly. Trends in tuberculosis—United States, 2010. Center for Disease Control. Mar 2011; 60(11): 333-337.

26. Case Study Feb. 2010 screened in ICE facility Negative smear, RUL consolidation, TST 20 mm, asymptomatic, medication not started Feb. 2010 enrolled TBNet and then deported March 2, 2010 TBNet notified positive culture Clinic identified in Central America and medical records sent Contacted family in Central America but patient had left for US May 4, 2010 wife called stating patient in US being held by coyotes

27. Case Study TBNet case manager called coyote West Coast Spoke to patient and explained culture results and need for treatment Immediately after call TBNet contacted ICE, initiated human trafficking investigation June 11, 2010 patient contacted TBNet was released by coyote now on East Coast Appointment made/medical records sent to local health department Patient started on 4 drug regimen DOT

28. Case Study September 28, 2010 patient called TBNet he had moved to another East Coast State Clinic found, appointment made, medical records transferred from both previous clinics Patient resumed therapy per DOT Wife updated on patients treatment Treatment completed April 7, 2011

29. TBNet Successes Treatment equal to that among geographically stable populations Disease surveillance role Consistency between international protocols Policy recommendations – identify difficult to treat populations Model for management of other diseases in mobile populations

30. Commitment Health Network Staff with TB nurse and patient El Salvador

31. Connection Guatemala NTP

32. Communication El Salvador NTP

33. Consistency CMO with Honduras NTP staff

34. Resources Division of Tuberculosis Elimination (DTBE): http://www.cdc.gov/tb/ http://www.cdc.gov/tb/ Stop TB USA: http://stoptbusa.org/ International Union Against Tuberculosis and Lung Disease: http://www.theunion.org Migrant Clinicians Network: http://www.migrantclinician.org/

35. Contact: Ed Zuroweste MD kugelzur@migrantclinician.org www.migrantclinician.org 1-800-825-8205 (U.S.) 01-800-681-9508 (from Mexico)