Post-Detention Completion of Tuberculosis Treatment for Persons Deported or Released from the Custody of the Immigration and Naturalization Service --- United States, 2003

The Advisory Council for the Elimination of Tuberculosis (ACET) recommends the post-detention completion of tuberculosis (TB) treatment for persons deported or released from the custody of the Immigration and Naturalization Service (INS)* (ACET, personal communication, 2002). The completion of TB therapy prevents disease relapse, subsequent transmission, and the emergence of drug resistance (1). Integral to treatment completion are issues of security and law enforcement involving persons who under immigration law are ineligible for legal admission into the United States. The Health Resources and Services Administration's Division of Immigration Health Services (DIHS) estimates that approximately 150 TB cases are identified annually among INS detainees in the INS service processing centers (SPCs) and contract detention facilities (Figure). Before transfer or deportation, INS policies require that detainees with TB disease receive treatment until they become noncontagious, even if treatment is not completed. INS policies are consistent with federal law, which does not bar deportation of persons with TB disease before the completion of treatment. This report describes three cases that illustrate several issues associated with the deportation of patients with incomplete treatment of TB disease after detention. These cases highlight the need for interagency coordination to ensure completion of treatment for persons being evaluated or treated for TB.

Case Reports

Case 1. A man aged 28 years had drug-susceptible pulmonary TB diagnosed in Seattle, Washington, and was deported before completing TB treatment. One year later, he was apprehended in the United States and, after transfer to four correctional facilities, was found while in the San Francisco, California, county jail to have isoniazid (INH)-resistant TB. After 2 months of treatment for TB, he was again scheduled for deportation. Despite concerns raised by local public health officials and personnel from DIHS, the patient was deported without medications or a referral for treatment in his country. The patient told local TB-program staff that if deported, he would return to the United States. The patient's location is unknown.

Case 2. A man aged 36 years was found to have multidrug-resistant TB while in INS custody in a local Texas jail. One month after starting treatment, he was released from a hospital prison ward without a plan for completing treatment. He was transferred through several INS contract detention facilities. The treatment course was complicated by the patient's refusal to take medicine. When the contract facility staff later expressed concern about the length of the 18--24 month treatment course and their inability to continue to provide it, the patient was transferred to a federal prison, and a federal judge ordered charges dropped against the patient. He was then deported after having completed only 4 months of treatment. The patient's location is unknown.

Case 3. A man aged 31 years with human immunodeficiency virus (HIV) infection had sputum smear-positive TB diagnosed in California. He adhered fully to treatment for 2 months in the community before he was apprehended and placed in INS custody. Because of the patient's increased risk for TB relapse and for acquiring drug resistance, the local TB controller asked INS to recommend a "medical hold" to complete the patient's TB treatment. The state TB-control program cited state law to justify continuing treatment. Both efforts failed, and the final order of deportation was upheld. The local TB-control program was given 1 hour's notice in which to provide the detainee with a supply of medication and to refer the patient to CURE-TB, a binational referral agency to facilitate referral of medical information for TB patients who move across the U.S. border (2). He returned to his family in the United States within 2 weeks of deportation and resumed treatment for TB.

DIHS Data

Data collected by DIHS for fiscal years 2001--2002 indicate that the prevalence of culture-confirmed TB reported from eight SPCs was approximately 67 cases per 100,000 INS detainees, and the average length of TB treatment in an SPC was 22 days before release or deportation. This rate was 12 times the overall U.S. incidence of 5.6 cases in 2001 and 2.5 times the rate for the U.S. foreign-born population (3). After deportation, undocumented persons might return to the United States. During January 2000--March 2001, CURE-TB reported that 25% of TB patients deported to Latin America with known follow-up returned to the United States (K. Moser, San Diego Health and Human Services Agency, personal communication, 2001).

Reported by: CL Nolan, MD, Seattle Dept of Health. LM Kawamura, MD, San Francisco Dept of Health; KS Moser, MD, San Diego Health and Human Svcs Agency; R Granich, MD, California Dept of Health Svcs. CE Wallace, PhD, Texas Dept of Health. D Schneider, DrPH, Div of Immigration Health Svcs, Health Resources and Svcs Administration. MN Lobato, MD, AG Miranda, MD, Div of TB Elimination, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note:

The findings in this report demonstrate some of the barriers to post-detention completion of treatment of TB for INS detainees being deported, including the limited coordination among TB-control programs, federal agencies, and facilities that house INS detainees (4). No uniform system exists to inform state and local TB programs when a person under detention by INS who has TB or suspected TB is released or deported. Federal immigration laws sometimes conflict with state health laws for TB control. Medical treatment often is not readily available to the deported person, and some of these persons might return to the United States while still infectious with TB. Effective treatment of persons with drug-susceptible TB requires a minimum duration of 6 months (5). One of the most challenging tasks in managing TB among detainees is the coordination of care during the post-detention period in the United States or in the patients' countries of origin.

As indicated in the three case reports, social and legal issues complicate the post-detention treatment period. No policies allow for completion of TB therapy in the United States after an immigration judge issues a final order of deportation, and INS is not authorized to hold a patient once a legal disposition has been made.

Deportation before treatment completion allows for the export and re-import of TB into the United States, thus placing other detainees, law enforcement officials, and communities in the country of origin and in the United States at increased risk for exposure to persons with infectious TB. To reduce the risk for exporting and re-importing persons with TB diseases identified while in INS custody, in November 2002, ACET recommended that the U.S. Department of Health and Human Services and the U.S. Department of Justice form a working group to resolve issues concerning the post-detention completion of TB treatment of persons released or deported from INS custody. ACET further recommended that the working group explore the feasibility of treating INS detainees in the United States until their TB is cured in the least restrictive setting.

ACET proposed revising or amending current policies or federal laws for detainees who are being evaluated or receiving treatment for TB disease to allow deportation only after the responsible state TB controller or their designate reviews and approves the treatment plan. For cases of multidrug-resistant TB, the availability of drugs needed to complete treatment in the country of origin should be ensured before deportation. Progress on these recommendations will involve working with professional correctional associations to improve adherence to local public health laws and CDC guidelines for TB screening and case notification and to enhance collaboration among INS SPCs, contract facilities, and TB programs.

Protocols should be developed to require the sharing of medical information and safeguarding its confidentiality and to describe mechanisms for the transfer of care when a patient is deported or released to the community. ACET recommended that appropriate agencies require the reporting of TB and suspected TB patients in INS custody before the transfer or deportation of INS detainees with TB to DIHS and state and local TB-control programs of jurisdictions in which sending and receiving facilities are located. In addition, ACET recommends the expansion of the medical hold authority of DIHS to permit notification of receiving health-care providers or a national referral program (e.g., CURE-TB or TBNet)^†, transfer of medical records, and provision of sufficient TB medications to ensure treatment until the patient's care is resumed (ACET, unpublished data, 2002).

References

1. Weis SE, Slocum PC, Blais FX, et al. The effect of directly observed therapy on the rate of drug resistance and relapse in tuberculosis. N Engl J Med 1994;330:1179--84.
2. CURE-TB Program. CURE-TB: Binational Tuberculosis Referral Program. Available at http://www.curetb.org.
3. CDC. Reported tuberculosis in the United States, 2001. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, September 2002.
4. Geiter L. Institute of Medicine, Committee on the Elimination of Tuberculosis in the United States. Ending neglect: the elimination of tuberculosis in the United States. Washington, DC: National Academy Press, 2000.
5. American Thoracic Society, CDC, Infectious Diseases Society of America. Treatment of tuberculosis. Am J Respir Crit Care Med 2003;167:603--62.

* The functions of INS are now subsumed by the Department of Homeland Security, Directorate of Border and Transportation Security, Bureau of Immigration and Customs Enforcement.

^† CURE-TB and TBNet are U.S.-based referral programs that assist mobile patients to access and complete TB treatment. CURE-TB, operated by the San Diego County Health and Human Services Agency's TB-Control Program, focuses on patients crossing the U.S.-Mexico border. TBNet, operated by the nonprofit Migrant Clinicians Network in Austin, Texas, specializes in migrant populations in the United States. The programs are working together and with INS to assist detainees in continuing TB treatment on release from custody.

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