Quarantine Stations and the Control of M. tuberculosis

Institute of Medicine January 20, 2005

Sarah Royce, MD, MPH, ChiefTuberculosis Control Branch

California Dept Health Servicessroyce@dhs.ca.gov

(510) 540 2345

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Arriving in America: Family lands in capital, the first of 16,000 Hmong coming to the US after waiting as refugees in Thailand

--Sacramento Bee, June 20, 2004

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End of the Journey for a 41 Year Old Hmong Refugee, 2004THAILAND4/26: Normal CXR in immigration exam 5/12: Hospitalized, cavity on CXR, smear

positive sputum negative on TB RxCALIFORNIA6/16: Bangkok to LA to Sacramento6/17: Hospitalized: smear positive sputum6/25: Died7/27: M. tuberculosis, multidrug-resistant

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Importation of M. tuberculosis, a Test of Public Health Protection at

our Nation’s Borders

• TB is “bread and butter” for quarantine stations

• “Getting it right” for TB will help quarantine stations prepare for emerging pathogens or bioterrorism agents

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Quarantine Stations, with Health Department Partners, as a Public

Health Intervention*• Preventing TB cases and deaths

– Overseas TB screening– Domestic follow up

• Q stations, at our nation’s borders, – Bridge international and domestic

components– Maximize the public health benefits

* IOM Statement of Task

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Overview

• California TB epidemiology• Purpose of overseas TB screening• Process• Outcomes—averting TB cases and deaths• Challenges• Roles of quarantine stations in maximizing

the benefits of this public health intervention

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Impact of the Global TB Epidemic on California, 2003

• California reports the most TB cases of any state (3,227)

• 75% born outside the US• Most MDR-TB cases of any state (33

incident, nearly 70 prevalent cases)• Over 80% of MDR TB cases are in persons

born outside the US

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Purpose of Overseas TB Screening of Immigrants and

Refugees

• Identify persons with suspected TB• Restrict entry of cases of infectious,

active TB disease• Facilitate entry of rest, so US health

departments can evaluate and treat

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Overseas TB Screening AlgorithmChest radiograph

> 15 years old

Active TB

AFB sputum smears (3)

Inactive TB No TB

Infectious TB Class A

Noninfectious TB Class B1

All (-) (at least one +)

Class B2

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Limits--Today’s Overseas Exams•Embassies select panel MDs•QA visits to 5% of panel MDs/y•Algorithm sensitivity,specificity•Rx w/o culture, susceptibility

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Information = OpportunityOverseas

TB screening

Dept. State-VISAPHS Stamp

Port of EntryIn U.S.

Customs Border Protection PHS Stamp20% loss*

Health Dept20-30% loss*

US evaluation40% loss*

Quarantine Stations:Mail notifications

*DGMQ, 1999 - 2000DGMQ

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Domestic TB categorization

+ TB skin or blood test

NoneLatent TB infection

Abnormal chest x-ray,+ culture

CoughingActive TB Disease

N/ANoneNeither

LaboratorySymptoms

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Domestic Follow up of B Notifications

*highest patient participation

Treat to prevent progression to active TB

Eval. Rx CompleteBest* 85% 80 75Worst 65 45 55

Latent TB infection

Prompt treatment to prevent death, TB spread

Active TB disease

Needed interventionTB status

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B notification patients entering California, annually (1, 2)

4000100Total

198049.5Already treated, or no TB

188047Latent TB infection

140*3.5Active TB disease

#%TB status on entry

*20 smear positive, 2-6 MDR TB cases

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B notification as Active Case Finding (1, 3)

• 5x higher yield of confirmed TB cases than contact investigation (3.5% vs. 0.7%)

• B notification patients are detected earlier--Within 3 months after arrival, vs. 5 months for TB cases* without B notification

* TB diagnosis within 1 year of arrival

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Cost Effectiveness of Domestic Treatment of 4000 B notification

Patients Entering California/Year, Followed for 20 years (4)

savings494638Best*

savings280317Worst

Net cost perQALY

QALYsgained

TB deaths averted

TB cases averted

* Health depts with highest patient participation

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Summary of Challenges

• Staffing, authority for quality assurance of overseas exams

• Timely, complete notification to domestic health departments

• Data available to assess/improve system• US health departments maximizing the

prevention of TB cases, deaths

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IOM TB Report (5)

Federal TB Task Force (6,7)

• Improve quality of overseas TB exams

• Optimize follow-up of immigrants and refugees arriving in US with suspected TB

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Q Station Roles: Improve Quality of

Overseas TB Exams

• Perform QA program visits overseas

• Provide ongoing consultation to panel MDs

• When things go wrong …

– Elicit feedback from US health departments

– Investigate, remediate systems failures

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Q Station Roles: Optimize US Follow-up

• Oversee data collection, entry and use

• Assist US health departments to assess performance, set and reach objectives

• Identify, manage highest priority entrants

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Quarantine Station Needs

1. A functional information system2. Sustainable funding3. Legal framework to enable effective

public health interventions

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1. Electronic Data Network

• Improve timeliness, completeness • Close loop to allow assessment and to

direct interventions: individual, policy• Implement in Q stations, US health depts• Eventually: link overseas panel MDs,

expand to include ill arriving passengersFunding?

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2. Start-up, Sustainable Funding: Options

• User fees

– Panel MD, immigrant applicant

– Airline ticket surcharge

• Emergency preparedness or CDC funding

• International organizations

• Medicaid

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3. Legal Framework

• Medicaid coverage for immigrants during first 5 years in the US (made ineligible with 1996 Welfare Reform Act)

• Establish user fees, CDC authority for panel physicians

• Overseas TB screening for students, workers, visitors who plan to stay > 6 months

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Summary: Overseas TB Screening, Domestic Follow up

• Life (and cost) saving• Q stations play a key role in improving

– both overseas, domestic components – bridges with overseas colleagues

• Need information system, funding and legal authority

• Health department partners who can provide feedback to improve overseas exams, and fully realize public health benefits of preventing TB and saving lives

28Estimates from U.S. Department of Homeland Security, 2003

Status adjusters in U.S.:679,305

Immigrants and refugees 411,266

Undocumented migrants ~ 275,000 ????

Non-immigrant visas27,907,139

N= ~ 59,000,000

Visitors without visas~ 30,000,000

Migrants “Entering” U.S., 2002

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Civil Surgeons

Quarantine station staff could:

• Ensure quality of domestic TB exams for persons adjusting their immigration status*

• Select, train, accredit, oversee civil surgeons*

• Foster health department linkages

*Requires transfer of authority to CDC

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References

1. Sciortino et al. Int J Tuberc Lung Dis 3(9):778-7852. deReimer et al. Arch Intern Med 158:753-760.3. Sprinson et al. Int J Tuberc Lung Dis 7(12):S363-S368.4. Porco et al. submitted for publication5. Institute of Medicine. Ending Neglect: The Elimination of

TB in the US. 20006. US Dept of Health and Human Services, CDC, 2003.

Federal TB Task Force Plan in Response to the IOM Report. (pp. 12-14)

7. US Dept of Health and Human Services, CDC, 2002. CDC’s Response to Ending Neglect.. (pp 30-33)