Leaving on a jet plane: My patient is leaving. What do I do?

Transcription

1 Leaving on a jet plane: My patient is leaving. What do I do? Kim Vuong PHN Case Study 1 81 year old Asian male, retired physician Smear positive (4+) pulmonary TB Fully sensitive to IREZ CT showed cavitation Started IREZ on 2/13 DOT daily at home Follow up sputum 3/8 smear negative 1

2 Case Study 1 Left country on 3/11 Can the patient leave the country? What will you do next? Case Study 1 NOTIFICATION/REFERRAL Who do you notify and why? 2

3 Case Study 2 51 year old visitor from Congo Smear negative, culture confirmed pulmonary TB CXR/CT showed abnormal non cavitary Returned to her country before culture confirmed Case Study 2 Should the community provider do anything different? What will you do next? 3

4 Case Study 2 NOTIFICATION/REFERRAL Who do you notify and why? Case Study 2 DOH DGMQ 4

5 Case 1 Assist patient to change/cancel flight Check fee waiver request approval Track TB treatment progress Coordinate travel plan Case 1 Currently on TB treatment Weekly sputum collection overseas Plan to return to US when off isolation 5

6 Case 2 Explain to patient/family the lab result and follow up Release medical record to patient/family Forward updated labs to patient/family Case 2 Currently on TB treatment Weekly follow up at local hospital in Congo 6

7 National Center for Emerging and Zoonotic Infectious Diseases Leaving on a Jet Plane: My patient is leaving. What do I do? Reena K. Gulati, MD, MPH Lead, Epidemiology Field Team Division of Global Migration and Quarantine TB Nursing Workshop June 12, 2018

8 History of Do Not Board and Public Health Lookout Formal process developed in 2007 between the US Departments of Health and Human Services Homeland Security Relied on airlines and US Customs and Border Protection to help prevent travel before 2007

9 Regulatory Authority: Illness in Travelers Quarantinable Communicable Diseases, Presidential Executive Order 13295, April 2003 (Amended April 2005 and July 2014) Cholera Diphtheria Infectious tuberculosis Plague Smallpox Yellow fever Viral hemorrhagic fevers Severe acute respiratory syndromes Novel or reemerging influenza causing or with potential to cause a pandemic

10 Do Not Board (DNB) This travel restriction prevents people who meet specific criteria from obtaining a boarding pass for any flight arriving in, departing from, or flying within the United States Does not prevent passengers from boarding ships, trains, or buses Implemented by Transportation Security Administration (TSA) Public Health Lookout (PHLO) This intervention alerts US Customs and Border Protection officers of a person having an issue of public health concern who attempts to enter the United States Prompts notification to CDC Quarantine Station staff when the person attempts to enter the United States Implemented by US Customs and Border Protection (CBP)

11 Do Not Board (DNB) This travel restriction prevents people who meet specific criteria from obtaining a boarding pass for any flight arriving in, departing from from, or flying within the United States Does not prevent passengers from boarding ships, trains, or buses Implemented by Transportation Security Administration (TSA) Public Health Lookout (PHLO) This intervention alerts US Customs and Border Protection Officers of a person on the DNB who attempts to enter the United States Prompts notification to CDC Quarantine Station staff when the person attempts to enter the United States Implemented by US Customs and Border Protection (CBP)

12 DNB Process: Key Partners CDC Quarantine Stations Local and State Health Departments Department of Homeland Security Foreign Public Health Agencies

13 CDC Quarantine Stations

14 Criteria for DNB Addition 1 Infectious, likely infectious, or at risk of becoming infectious with a serious contagious disease that poses a public health threat to the traveling public AND Nonadherent with public health recommendations, unaware of diagnosis, or unable to be located OR At risk of traveling on a commercial flight or of traveling internationally OR Travel restrictions needed to respond to a public health outbreak or to help enforce a public health order

15 Criterion for DNB Removal 1 Individual is no longer considered to be infectious or at risk of becoming infectious

16 DNB Addition Process State or local health department (SLHD) notifies Quarantine Station (QS); Quarantine Medical Officer (QMO) reviews case; conference call convened to make a preliminary decision QMO drafts case summary; Travel Restriction and Intervention Activity (TRIA) requests leadership approval TRIA submits request to the Department of Homeland Security (DHS), TSA and CBP for processing; person is added to the DNB/PHLO lists QS notifies the SLHD and person of DNB/PHLO action

17 DNB Conference Call Provide overview of public health travel restriction process and DNB criteria Review clinical case summary and current laboratory information Smear microscopy, molecular testing, culture results, drug susceptibility, treatment history, relevant diagnostic tests Discuss adherence with public health recommendations and travel risk Discuss attempts to locate person, initiate treatment, advise against travel, issue state/local public health orders Determine appropriate action

18 DNB Removal Process SLHD determines the person is noninfectious and notifies the QS QMO drafts case summary; TRIA requests leadership approval TRIA submits request to DHS, TSA and CBP for processing; person is removed from the DNB/PHLO lists QS notifies the SLHD and person of DNB/PHLO removal SLHD continues case management or transfers care as needed; provides updates to the QS as needed

19 Overview ADDITION Convene conference call Obtain approval from CDC if addition criteria are met Send request to DHS for processing for addition to DNB and PHLO DURING SLHD monitors and provides regular clinical updates to QS QS and partners respond to any interceptions during travel REMOVAL Determine when individual is no longer infectious or at risk of becoming infectious Remove from DNB/PHLO lists Continue patient followup as appropriate

20 CDC Roles Quarantine Station, Quarantine Medical Officer, and Travel Restriction and Intervention Activity Receives DNB requests from SLHD, and coordinates conference call Obtains CDC leadership approval for DNB actions, and manages administrative processes for DNB actions Maintains communication with SLHD to obtain case updates, and determines when person meets criteria for DNB addition or removal Manages responses to interception of persons on DNB at US ports of entry and inquiries from federal partners regarding DNB cases Reviews all DNB and potential DNB cases routinely

21 Health Department Roles Contacts jurisdictional CDC Quarantine Station for initial consultation, and participates in DNB conference call(s) Provides regular updates on patient status Shares responsibility with QS for case management Notifies QS when patient meets DNB removal criterion Continues case management after DNB removal, and alerts QS if new concerns develop

22 Cure TB CureTB starts in San Diego County TB program as a collaboration with sister city of Tijuana Mexico CureTB expands to routinely include all Latin America Joins CDC s Division of Global Formal Migration and agreement with Quarantine US Immigration (DGMQ) and and Customs expands to all Enforcement countries, (ICE) to link becoming outbound transnational persons to care Maintains MOU/DUA with San Diego TB Control

23 CDC Quarantine Stations at US Ports of Entry Division of Global Migration and Quarantine CureTB staff locations

24 Cure TB Services provided by CureTB for all health departments and correctional partners Referral of patients with active tuberculosis* Any country Source case finding Mexico Contact notification Mexico Clinical history request Mexico and Central America *Verified or possible TB in a person moving outside the United States and needing <30 days of treatment

25 Cure TB elements Receive referral from originating provider/jurisdiction Interview patient by telephone to develop rapport, educate, assist Continuousl y motivate the patient by maintaining contact Send accurate and up-to-date clinical information to downstream provider, state, national level Maintain communication with patient and helath system until linked to care Determine treatment outcome and notify originating jurisdiction

26 2017 TB referrals n=254 Country Referral Country Referral Mexico 115 Eritrea 2 Honduras 31 Afghanistan 1 Guatemala 12 Congo 1 Haiti 10 Cuba 1 Philippines 8 Dominican Republic 1 United States 6 Ghana 1 India 5 Indonesia 1 China 4 Iran 1 Ecuador 4 Japan 1 Guinea 4 Kenya 1 Nepal 4 Laos 1 Bangladesh 3 Liberia 1 Brazil 3 Mali 1 El Salvador 3 Mongolia 1 Peru 3 Myanmar 1 Cameroon 2 Nicaragua 1 Ethiopia 2 Nigeria 1 Pakistan 2 Panama 1 Senegal 2 Republic of Congo 1 Thailand 2 St.Kitts 1 The Gambia 2 Swaziland 1 Venezuela 2 Togo 1 Vietnam 2

27 Patient-centered care Health department Local Primary provider ICE Correction or detention facilities State Patient and family = Treatment completion

28 Challenges and Strategies Mobility Advance planning for movement is helpful Patients often prefer private physicians May be distant from capital/main city Continuity of care how to refer Simple but clear history Smear-negative patients may not be recognized as cases Original lab reports helpful, CXR image if possible Important to clarify why patient on non-standard regimen and any adverse reactions/side effects

29 Challenges and Strategies Ensuring medication adherence Not all countries have equivalent DOT Not all countries have same availability of medications (rifabutin) or formulations (fixed-dose combinations) or ready supply CureTB will provide outcomes and best assessment of DOT/adherence Should your program provide the medication? Resources we use NTPs, IHR contacts, CDC partners CDC partners including TRIA

30 CureTB Resources For Referrals (except from California) For California Referrals CureTB.org FAX (619) PHONE (619) (619)

31 Acknowledgments Travel Restriction Intervention Activity (TRIA) Robynne Jungerman Cure TB Sonia Montiel Kathy Moser Carlos Vera

32 Thank you! SEA QS: For more information, contact CDC CDC-INFO ( ) TTY: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.