TBNet Part of the Health Network Transborder Migration Care of the Mobile TB Patient Deliana Garcia, Director International, Research, and Development Advisory Committee for the Elimination of Tuberculosis March 20, 2007

2 A national, clinical network founded in ,000 clinician members Oldest and largest clinical network dedicated to the mobile underserved Migrant Clinicians Network MCN’s primary constituents are clinicians working in federally funded CHCs and in state and local health departments. Photo © Alan Pogue

3 U.S. Population By comparison to most of the world the United States is a relatively young country that has always relied on immigration for population growth

4 Migration in the America Enormous expanses of open land created a mentality of unencumbered mobility resulting in the voluntary movement of large numbers of persons seeking adventure and opportunity

5 Changes in Migration The principal US experience of internally displaced people is that of the dust bowl era when thousands of people migrated from states like Oklahoma, Arkansas to escape the unrelenting wind and erosion experienced in the middle part of the US in the 1920’s

6 Changes in Migration Because many of those displaced were share croppers or itinerant farmers the movement was generally west to areas where agriculture promised a large number of labor intensive jobs in the harvesting of fruits and vegetables.

7 Changes in Migration Agriculture was the reining industry for migrant workers for more than 50 years providing jobs for returning WWII veterans and welcoming workers from Mexico and the Caribbean.

8 Changes in Migration Until very recently, the United States has had little experience with massive internal displacement of people and the concomitant problems of housing and health care that are so common in other parts of the world

9 Migration Today México is one of the principal countries that sends migrants to the United States In the 90’s 300,000 migrated, in million migrated In the 90’s 4% of those that migrated would not return to México, now it is 10% that do not return

10 Migration Today Jalisco 18.5% Michoacan 15.8% Zacatecas 8.6% Guanajuato 7.9% Distrito Federal 5.9% Puebla 5.8% Oaxaca 4.2% Durango 3.7% Guerrero 3.6%

11 Texas ranks second among the receiving states in the U.S. Migration Today

12 Migration Today States with the Greatest Immigration from Mexico California 46.4% Texas 21.5% Arizona 6.7% Illinois 6.5% New York 5%

13 GUERRERO GUANAJUAT O Texas is the principal destination for migrants from the states of Guanajuato and Guerrero Migration Today

14 Of the 26.2 million Mexican that live in the U.S.: 11.5% Mexican descent 2.3 % Naturalized citizens 2.1% Residents 10.3% Undocumented Migration Today

15 Migration Today Of the 10.3 million undocumented 97% are mestizos 3% are indigenous

16 Zapoteco 28% Mixtecos 25% Nahuatl 17% Mayas 8% Others 22% Of the approximately 1,339,000 indigenous Migration Today

17 Less than 10 years 5.1% 10 to 19 years 12.6% 20 to 44 years 62.5% 45 to 59 years 13.6% 60 or more 6.1% Age Groups Migration Today

18 Migration today Leprosy affects over 12 million people worldwide, and reported cases have increased in the US as a result of immigration. Of 1835 cases of leprosy reported in the US from , only 25% of imported cases were known to have had leprosy at migration. Although most of remaining 75% were detected within 12 months of entry, cases continued to be reported 10 years after entry.

19 International migration that involves the annual movement of tens of millions of people has become a norm, yet the public health implications are just starting to be assessed. Internal migration that involves the annual movements of millions is still treated as an aberration rather than an on-going event of public health significance Migration Today

20 TB Among the Foreign Born Since 2002 for the first time the majority of TB cases were in the foreign born In 2004, 53.7% of 14,511 active TB cases in the US were in the foreign born Of these, 26% were from Mexico A significant number of these are undocumented residents

21 TB Among the Foreign Born

22 Annual Abandonment Rates Guatemala Source: PNCTB, Guatemala %

23 Distribution of TB Cases by Ethnic Group. Izabal 2002

24 Binational TB Projects 1991 – Project JUNTOS- El Paso/Juarez, MEX 1992 – Yuma, AZ/Sonora, MEX 1993 – Los Dos Laredos- TX/Tamaulipas, MEX 1995 – Grupo Sin Fronteras- Harlingen/Mc Allen/Reynosa/Brownsville/Matamoros TB Net- Austin, TX 1997 – Cochise, AZ/Northeastern Sonora, MEX 1997 – Ambos Nogales- AZ/Sonora, MEX 1997 – Cure TB- San Diego, CA U.S.-Mexico Binational TB Relationship

25 TBNet the Binational Bridge Case Management Program TBNet started in 1996 Has managed more than 2,700 patients Completion rate in 2005 of 71.4% for patients moving while under treatment for active TB disease Managed patients to 30 countries

26 Why Bridge Case Management?

27 Why Bridge Case Management? More than medical records transfer More than communication with NTP More than simple verification of patients’ contact information More than referral to a source of care

28 How? Bridge Case Management Transferring medical records between clinics when participants move Providing phone based care- coordination services: Communicate with sending clinic through treatment completion Communicate with receiving clinic for duration of treatment Educating participants about treatment of tuberculosis and importance of completion Photo: Eduardo Moreno

29 How Does it Work? Discuss the need to remain in care with anyone suspected or known to have active TB disease Gain his/her consent to have medical records transferred to ensure continued care Obtain the contact information for the person or for someone who will always be in contact with Him/her

30 What to ask: Where are you from? How long have you been in the area? What are your plans? How often do you move? What type(s) of work do you do? How can I contact you? Is there someone who will always know how to find you? Photo © Alan Pogue

31 How Does it Work? TBNet staff will verify contact information TBNet staff will identify a treatment provider in the new location TBNet will maintain contact with the provider AND the patient for the duration of treatment

32 TBNet will inform the enrolling provider of the treatment outcome Should the patient fail to present or discontinue treatment, TBNet will communicate with all known contacts to bring the patient back into care How Does it Work?

33 Contact Information Ed Zuroweste, MD (MCN Chief Medical Officer): Deliana Garcia (Director, International, Research, and Development): MCN: or