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Managing Cases Across Borders: US, Mexico & Central America
CureTB Tuberculosis Referral and Information Program
TB Control Program County of San Diego Dr. Carlos Vera Garcia .
Why does this matter?
• Retrospective chart review of 136 of 222 verified San Diego cases from 2010 showed that 35% had >1 of the following:
1) Case had identified contacts in Mexico
2) Case had identified/suspected source/assoc case in Mexico
3) Case had tx in Mexico for TB sx in the 3 months prior to dx in the US
4) Case crossed border during TB tx or dx
Beyond the numbers
• 1 year old admitted to a San Diego hospital with advanced
CNS TB
• Grandmother had started treatment for smear + TB in a central CA county and returned to a border town
• Child’s HIV+ uncle lived on both sides of the border, developed CNS and pulmonary TB.
Some barriers to continuity
• Have never had TB before, don’t know where to go
• Language and technical barrier between systems, clinical information gap
• Mexico and Central America diagnostics based on smear, generally smear negative when re-enter Mexico
• May not know they have TB prior to leaving
CureTB
• Part of the San Diego County TB Program, Public Health Services since ~1997
• Started locally to assure continuity of TB care between SD and TJ and grew based on need….to include other parts of CA and Baja CA then….grew to include all other states in the US and Mexico. Just recently grew to include Central America.
• ~Funded by the State of CA and by the Centers for Disease Control and Prevention
www.curetb.org
CURE TB Health
Departments
Immigration Health
Services
Medical Panel of
Physicians
Federal level
State Level
Local Level
Primary Provider
Patients and Family
Categories of Patients
1) Suspect Tuberculosis Case - High suspicion of TB
- Low suspicion of TB
• Outcomes: – TB – TB Not Proven – Permanent Suspect
Suspect TB Referrals Received 2012 – 2013
2012 2013 Total
US Mexico/ Latin Amer.
US Mexico/ Latin Amer.
Suspect TB 88 1 95 0 184
Suspect TB Referral Outcomes Received 2012 – 2013
Suspect TB Referral Outcome
2012 2013 Total
US Mexico/ Latin Amer.
US Mexico/ Latin Amer.
Permanent Suspect 16 (24%) 0 (0%) 33 (49%) 0 49 (36%)
TB Not Proven 52 (76%) 1 (100%) 35 (51%) 0 88 (64%)
Denominator* 68 (100%( 1 (100%) 68 (100%) 0 137 (100%)
Pending Classification 0 0 17 0 17
Referral Not Required 20 0 10 0 30
Total 88 1 95 0 184
*Excludes patients who did not move (referral not required) or classification is still pending.
Categories of Patients
2. Verified Tuberculosis Case CureTB provides preliminary outcome in 30 days, regular
updates, and final outcome by 12 months.
• Outcomes:
– Completed Treatment (Cured)
– Lost to f/u (Refused/Abandoned)
– Died
– Stopped by Medical Provider
Active TB Referrals Received 2011 – 2013
2011 2012 2013 Total
US Mexico/ Latin Amer.
US Mexico/ Latin Amer.
US Mexico/ Latin Amer.
Active TB 125 6 125 13 113 19 401
Active TB Referral Outcomes Received 2011 – 2012
Active TB Referral Outcome
2011 2012 Total
US Mexico/ Latin Amer.
US Mexico/ Latin Amer.
Cured/Completed Tx 85 (77%) 6 (100%) 70 (78%) 12 (100%) 173 (79%)
Open – Continues Tx 0 (0%) 0 (0%) 3 (3%) 0 (0%) 3 (1%)
Stopped by Provider 1 (1%) 0 (0%) 0 (0%) 0 (0%) 1 (0.5%)
Refused/Abandoned 6 (5%) 0 (0%) 6 (7%) 0 (0%) 12 (5%)
Open – Refused/Abandoned 0 (0%) 0 (0%) 1 (1%) 0 (0%) 1 (0.5%)
Lost 15 (14%) 0 (0%) 7 (8%) 0 (0%) 22 (10%)
Died 4 (4%) 0 (0%) 3 (3%) 0 (0%) 7 (3%)
Denominator* 111 (100%) 6 (100%) 90 (100%) 12 (100%) 219 (100%)
Referral Not Required 14 0 35 1 50
Total 125 6 125 13 269
*Excludes patients who did not move (referral not required).
Categories of Patients
3) Past History Request
CureTB will retrieve past medical TB history.
• Outcomes:
– Obtain
– Not Obtained
– Referral Not Required
Past History Request Referrals Received 2012 – 2013
2012 2013 Total
US Mexico/ Latin Amer.
US Mexico/ Latin Amer.
Past History Request 37 7 37 10 91
Past History Request Referral Outcomes Received 2012 – 2013
Suspect TB Referral Outcome
2012 2013 Total
US Mexico/ Latin Amer.
US Mexico/ Latin Amer.
Obtained 23 (66%) 6 (86%) 33 (97%) 5 (63%) 67 (80%)
Not Obtained 12 (34%) 1 (14%) 1 (3%) 3 (38%) 17 (20%)
Denominator* 35 (100%) 7 (100%) 34 (100%) 8 (100%) 84 (100%)
Pending 0 0 3 2 5
Referral Not Required 2 0 0 0 2
Total 37 7 37 10 91
*Excludes those for whom a referral was not required or information is still pending.
Categories of Patients
4) Source Case Finding
Active TB in a young child or others likely to have been
recently infected for whom it is suspected that the source case is in Mexico/Central America
• Outcomes:
– SC Identified
– SC Not Identified
Source Case Finding Request Referrals from US Received 2011 – 2012
2011 2012 Total
Source Case Finding 9 13 22
Source Case Finding Request Referral Outcomes Received 2011 – 2012
2011 2012 Total
Source Case Identified 8 (89%) 9 (75%) 17 (81%)
TB Suspect Identified 0 (0%) 1 (8%) 1 (5%)
Source Case Not Identified 1 (11%) 2 (17%) 3 (14%)
Denominator* 9 (100%) 12 (100%) 21 (100%)
Referral Not Required 0 1 1
Total 9 13 22
*Excludes those for whom a referral was not required.
Source Case Finding
• 17 month old US born hispanic child with L lung consolidation, mediastinal adenopathy, 14mm TST
• Lived in San Diego with mother, 2 uncles
• Babysat in Tijuana during the week with maternal grandmother, uncle, aunt and their 4 children
• CureTB worked with Tijuana HD to obtain CXRs of adults
• 37 year old uncle had no sx but LUL infiltrate. He was unable to cross the border. CBP allowed sputum to be collected at the Port of Entry.
Categories of Patients
5) Contact Notification These patients are divided in two categories:
• Contacts who are moving to Mexico or Central America and have been exposed to an infectious pulmonary case in the U.S. and are under 5 years of age or immunocompromised (HIV, diabetes, etc).
• Contact investigation notice for a smear positive pulmonary case
in the U.S. who was living in Mexico or Central America while likely to have been infectious.
Contact Notification Request Referrals Received 2012 – 2013
Contact Notification Referrals
2012 2013 Total
US Mexico/ Latin Amer.
US Mexico/ Latin Amer.
Household Contact 51 35 55 34 175
Moving Contact 2 0 5 1 8
Total 53 35 60 35 183
July 2013 - report from San Diego Children’s Hospital:
5 month old with altered mental status, seizures, pneumonia: c/w TB meningitis
Investigation revealed: - Child was living in Tijuana with his 14 year old mother. - Mother’s half sister’s father had smear positive TB (Case 1) diagnosed in San Diego in late 2012. Case 1 requested to return to home in Tijuana to finish his treatment after becoming smear negative in Feb 2013. Died in Tijuana in March 2013. - Mother’s boyfriend’s sister had been recently diagnosed with TB (case 2) in Tijuana and started on treatment.
Follow-up
• 5 month old never visited Case 1.
• 5 month old was a frequent visitor to Case 2’s residence
• Doubtful that Case 2 had ever visited Case 1.
• Case 2 was brought to San Diego to provide a sputum for DST and genotyping. • Genotype and DST (suscept RIPE) of child matched Case 2 and did not
match Case 1 (resistant to INH)
Categories of Patients
6) Binational Tuberculosis Continuity of Care Program “Meet and Greets”
• Development of a formal Declaration of Cooperation (DOC) between California and Baja California
• Established protocols for both sides of the border – Baja California: protocol approved.
– California: Finalize and seek California clearance for DOC
• CureTB uses the same protocol for patients referred by other states than California.
Referral Source
Referral Destination
Legend
States Sending/Receiving TB Referrals 2010 – 2013
78% (39/50) states in US and 97% (31/32) states in Mexico sent or received a CureTB referral
In 2012, services were expanded to Central America.
Services have also been provided for Canada, Ecuador and Peru.
Take home
We’re all in this together
Continuity of care across borders is possible and an important TB control strategy
Acknowledgements:
-The CureTB staff
-All referring and receiving providers and partners along the way
-The patients
www.CureTB.org
To Submit a CureTB Referral You can submit a CureTB referral in three ways. Use our referral form and attach hard copies of relevant clinical information whenever possible. Fax: (619) 692-8020 E-mail: [email protected] Call: (619) 542-4013 www.curetb.org