1
Leaving on a jet plane: My patient is leaving. What do I do?
Kim Vuong PHN
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
Case Study 1
2
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?
Case Study 1
3
51 year‐old visitor from Congo Smear negative, culture confirmed pulmonary TB
CXR/CT showed abnormal non‐cavitaryReturned to her country before culture confirmed
Case Study 2
Should the community provider do anything different?
What will you do next?
Case Study 2
4
NOTIFICATION/REFERRAL
Who do you notify and why?
Case Study 2
DOH
DGMQ
Case Study 2
5
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
Case 1
6
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
Case 2
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, MPHLead, Epidemiology Field TeamDivision of Global Migration and Quarantine
TB Nursing Workshop
June 12, 2018
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
Regulatory Authority: Illness in Travelers
• Cholera• Diphtheria• Infectious tuberculosis• Plague• Smallpox• Yellow fever
Quarantinable Communicable Diseases, Presidential Executive Order 13295, April 2003 (Amended April 2005 and July 2014)
• Viral hemorrhagic fevers• Severe acute respiratory
syndromes• Novel or reemerging influenza
causing or with potential to cause a pandemic
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)
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)
DNB Process: Key Partners
CDC Quarantine
Stations
Department of Homeland
Security
Local and State Health Departments
Foreign Public Health
Agencies
CDC Quarantine Stations
https://www.cdc.gov/quarantine/quarantinestations.html
Criteria for DNB Addition1 Infectious, likely infectious, or at risk of becoming infectious
with a serious contagious disease that poses a public health threat to the traveling public
2Nonadherent with
public health recommendations,
unaware of diagnosis, or unable to be
located
3At risk of traveling on a commercial flight
or of traveling internationally
4Travel restrictions
needed to respond to a public health
outbreak or to help enforce a public
health order
AND
OR OR
https://www.federalregister.gov/documents/2015/03/27/2015-07118/criteria-for-requesting-federal-travel-restrictions-for-public-health-purposes-including-for-viral
Criterion for DNB Removal
1 Individual is no longer considered to be infectious or at risk of becoming infectious
DNB Addition ProcessState 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
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
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
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 followupas appropriate
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
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
Cure TB1997
CureTB starts in San Diego County TB program as a
collaboration with sister city of Tijuana Mexico
2013
CureTB expands to routinely
include all Latin
America
2016
Joins CDC’s Division of Global
Migration and Quarantine (DGMQ) and
expands to all countries, becoming
transnational
Maintains MOU/DUA with San Diego TB
Control
2017
Formal agreement with US Immigration and Customs Enforcement (ICE) to link outbound
persons to care
CDC Quarantine Stations at US Ports of EntryDivision of Global Migration and Quarantine
CureTB staff locations
Cure TB
Referral of patients with active tuberculosis*Any country
Clinical history requestMexico and Central America
Contact notificationMexico
Source case findingMexico
Services provided by CureTB for all health departments and correctional partners
*Verified or possible TB in a person moving outside the United States and needing <30 days of treatment
Cure TB elements
Determine treatment outcome and notify originating jurisdiction
Maintain communication with patient and helath system until
linked to care
Send accurate and up-to-date clinical information to downstream
provider, state, national level
Interview patient by telephone to develop rapport, educate, assist
Receive referral from originating provider/jurisdiction
Continuously motivate the patient
by maintaining
contact
2017 TB referralsn=254
Country Referral Country ReferralMexico 115 Eritrea 2
Honduras 31 Afghanistan 1Guatemala 12 Congo 1
Haiti 10 Cuba 1Philippines 8 Dominican Republic 1
United States 6 Ghana 1India 5 Indonesia 1China 4 Iran 1
Ecuador 4 Japan 1Guinea 4 Kenya 1Nepal 4 Laos 1
Bangladesh 3 Liberia 1Brazil 3 Mali 1
El Salvador 3 Mongolia 1Peru 3 Myanmar 1
Cameroon 2 Nicaragua 1Ethiopia 2 Nigeria 1Pakistan 2 Panama 1Senegal 2 Republic of Congo 1Thailand 2 St.Kitts 1
The Gambia 2 Swaziland 1Venezuela 2 Togo 1Vietnam 2
Patient-centered care
Correction or
detention facilities
ICE
Health department
Primary provider Patient
and family
State
Local
= Treatment completion
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
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
CureTB Resourceswww.cdc.gov/usmexicohealth/curetb.html
For Referrals (except from California)
For California ReferralsCureTB.org
FAX 404-471-8905 (619) 692-8020
E-MAIL [email protected] [email protected]
PHONE (619) 542-4013 (619) 542-4013
Travel Restriction Intervention Activity (TRIA)– Robynne Jungerman
Cure TB– Sonia Montiel– Kathy Moser– Carlos Vera
Acknowledgments
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
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.
Thank [email protected]
[email protected] QS: 206-553-4519