Deportation of Tuberculosis Patients Complicated by a Medication Shortage --- Honduras, May--August 2006

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The Division of Immigration Health Services (DIHS), within the Bureau of Primary Health Care of the Health Resources and Services Administration, provides health-care and public health services to undocumented persons who are detained by Immigration and Customs Enforcement (ICE) of the U.S. Department of Homeland Security. Detainees in ICE custody are screened for active tuberculosis (TB) disease and, if medically indicated, TB treatment is initiated or continued. Approximately 84% of detainees identified with TB while in ICE custody are deported to their countries of origin before their treatment has been completed (1,2). These patients are only allowed to travel after they have been determined to be noninfectious in accordance with CDC guidelines (3). Patients with active TB who are deported before treatment completion are at high risk for interrupting or not completing treatment (which typically lasts at least 6 months), developing drug-resistant TB, and transmitting TB disease to others; in addition, these patients often illegally reenter the United States after deportation (1).

To facilitate treatment completion in this population, DIHS routinely collaborates with ICE, local and state health departments and health authorities in the United States, local public health authorities in foreign countries, U.S.-Mexico border health offices, binational health programs, foreign national TB programs, the Migrant Clinicians Network (MCN), and the CureTB* program to arrange for TB treatment to continue in the patient's home country after deportation. During May--August 2006, Honduras experienced a shortage of TB medication. This report describes the joint U.S.-Honduras public health actions taken to facilitate treatment completion for 30 detainees who had active TB disease and were awaiting deportation to Honduras during this shortage, highlighting a potentially effective approach, the "meet-and-greet" process, for promoting continuity of TB care among deported persons. Successful global TB control must address the challenges of treating highly mobile populations (e.g., persons who are being deported) and requires multiagency collaboration and support, including partners outside the public health field.

Medication Shortage and Plan of Action

On May 23, 2006, an official from the Honduras National TB Program (NTP) notified MCN and DIHS that procurement problems had resulted in a national shortage of first-line TB medications (i.e., isoniazid, rifampin, ethambutol, and pyrazinamide). Because of the shortage, initiation of treatment for newly identified TB patients in Honduras had been suspended to avoid interruptions in TB therapy for patients already receiving treatment. DIHS officials notified ICE leadership of the medication shortage and proposed two possible solutions: 1) hold detainees receiving TB treatment in the United States until the medication shortage was resolved, or 2) deport the detainees with a medication supply that would allow them to complete treatment in Honduras. The first solution would have resulted in prolonged detention of Honduran nationals, for medical reasons, who were otherwise cleared for deportation. Although federal immigration statutes allow ICE to detain persons to facilitate deportation, it generally must occur within 90 days of issuing a final order of removal (4); health status is not usually considered during deportation. The second solution required collaboration among U.S. local and state health departments, TB-referral programs, ICE officials, Honduran public health and customs authorities, and the U.S. Marshals Service Justice Prisoner and Alien Transportation System (JPATS), which transports detainees who are being deported.

Because of the legal and ethical implications of prolonged detention for medical reasons, the second option was chosen. Preparations were made to 1) deport Honduran detainees who were cleared for deportation and receiving TB treatment, sending them with a 2-week supply of medication, and 2) send the remainder of the patients' individual treatment medications (1-month to 5-months' supply) directly to the Honduras NTP at the time of deportation. Each transfer of medication from one health official to another would be documented to ensure that patients continued treatment with appropriate supervision by health-care professionals.

To facilitate tracking of deportees and medications, a medical "meet-and-greet" process was used with the Honduras NTP, in which deportees were met at the international airport in Tegucigalpa, Honduras, by a Honduras NTP official. The purpose of the meet-and-greet process, which was modeled after a procedure developed by the Arizona State Department of Health Services TB Control Program and involved coordination with ICE officials and Sonora (Mexico) state public health authorities (5), was threefold: 1) to explain to deportees how to access health-care services in their home countries; 2) to provide the Honduras NTP with an opportunity to verify the final destination (i.e., residence) of the deportees on arrival, and occasionally to provide ancillary support services (e.g., social services or transportation from arrival destination to residence); and 3) to provide an opportunity for public health authorities in Honduras to educate deportees about the importance of continuing and completing TB treatment without interruption. This was the first instance in which the meet-and-greet process was used specifically to facilitate medication transfers and deportation of persons with TB during a medication shortage.

Continuing TB Treatment During and After Deportation

Under normal circumstances, detainees generally are not deported with a large supply of medications for self-administration. Typically, DIHS and ICE provide a 2-week supply of prescribed medications to prevent treatment interruptions during the transition period from deportation until follow-up at the clinic to which patients are referred in their country of origin. However, TB treatment is complex; patients can experience adverse effects from medications or acquire resistance to TB medications if they are not taken properly. Therefore, treatment must be supervised by a team of health-care professionals during the entire treatment course (6). The preferred supervision method for TB treatment is directly observed therapy (i.e., a health-care professional watches the patient swallow each dose of medication during the entire course of treatment) (6).

Two packages of medications were prepared by DIHS for each patient: 1) a package with a 2-week supply (to be sent with the patient) for the transition between departure from the United States and follow-up in Honduras; and 2) a second package (transferred to the NTP) with the remaining medication needed to complete treatment after arrival. Before leaving the United States, patients were provided information on taking TB medication during the 2-week transition period and on symptoms of adverse medication effects. The second package of medication was transferred to ICE deportation officers, then to JPATS flight nurses, and finally to a Honduras NTP representative at the airport in Tegucigalpa, Honduras. Officials from the Honduras NTP received each deportee's medical summary in advance from TBNet and assumed the responsibility for transferring each deportee's medication package to the deportee's assigned local clinic. Signed medication-transfer summaries were faxed to DIHS. Treatment was monitored by the Honduras NTP directly observed therapy, short-course program.

During the 3-month TB medication shortage, 30 Honduran detainees in ICE custody were receiving or needed treatment initiated for TB. Of these, during May 23--August 8, 2006, 16 (53%) were deported with the remainder of their TB medications. Of the 14 who were not, 10 were still awaiting deportation, one had completed treatment before deportation, one had treatment stopped because TB was ruled out by a DIHS physician, one refused treatment, and one requested political asylum and remained in ICE custody. None of the detainees were known to have drug-resistant TB, as determined through cultures and susceptibility tests performed in the United States on specimens collected during initial examinations.

In collaboration with the Honduras NTP and the local clinics to which the deportees were referred, TBNet continued to monitor deportees who received treatment in Honduras. The Honduras NTP notified TBNet when a TB treatment course was completed, and TBNet sent the information to DIHS and relevant U.S. state and local health departments.

On August 8, 2006, DIHS was informed that all first-line TB medications again had become available in Honduras, and the usual practice of deporting patients with a 2-week supply of medications resumed. Of the 16 patients deported with the remainder of their TB treatment medications, two had nonmycobacterium TB and did not continue treatment. Of the remaining 14 deportees, 13 (93%) completed treatment, and one (7%) was lost to follow-up 1 week before treatment completion in Honduras.

Reported by: K Rodriguez, MD, Honduras National Tuberculosis Program, Tegucigalpa, Honduras. R Arce, J Laswell, E Zuroweste, MD, Migrant Clinicians Network, Austin, Texas. D Katsch, MPH, Justice Prisoner Air Transport System, US Marshals Svc. A Fike, MSN, D Schneider, DrPH, T Shack, MD, E Johnson, MD, E Fleming, DO, L Peredo-Berger, MD, J Cheng, MPH, Div of Immigration Health Svcs, Bur of Primary Health Care, Health Resources and Svcs Admin.

Editorial Note:

Persons born in Honduras, a country with high TB incidence, are at risk for TB disease (7,8). In 2005, the year before the medication shortage, 142 ICE detainees with TB disease were identified; 58 (41%) were from Honduras, 55 of whom were deported to Honduras before their TB treatment was complete. Because TB requires at least 6 months of supervised treatment (2), prolonged detention of patients cleared for deportation solely because they require medical treatment usually is not legally possible or ethically acceptable. Under normal circumstances, ICE detainees who are scheduled to be deported before their TB treatment is complete are placed on short-term medical holds to allow time for health-care arrangements and international referrals by DIHS, CureTB, TBNet, or all of these agencies. The referral process includes verifying deportee addresses and identifying clinics where deportees will be monitored until treatment is complete.

In 2002, the federal Advisory Council for the Elimination of Tuberculosis (ACET) made specific recommendations to address continuity and completion of TB therapy for patients with verified or suspected TB disease who are in the custody of the former Immigration and Naturalization Service (1). In response to the ACET recommendations, with guidance from a governmental working group established in 2002, ICE and DIHS established policies and procedures to collaborate with state and local TB control programs, foreign national TB programs, and governmental and nongovernmental programs that coordinate international TB referrals and continuity of care.

Because of experience gained during the Honduran TB medication shortage, medical meet-and-greets are now used frequently for detainees being deported to Honduras, Guatemala, El Salvador, Nicaragua, and Mexico and are considered an option for detainees being deported to any country in which public health authorities can provide support. DIHS is evaluating the ICE TB continuity-of-care program to assess whether the program, including the meet-and-greet process, promotes TB treatment completion among persons who have been deported.

References

* CureTB and MCN are U.S.-based programs that provide international services for detainees who are receiving TB treatment while awaiting deportation.

TBNet, a multinational TB patient tracking and referral project of MCN, is designed to assist mobile, underserved populations with completing their TB treatment. Additional information is available at http://www.migrantclinician.org/network/tbnet.

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