Immigrant, Refugee, and Migrant Health Branch Update

Transcription

1 Immigrant, Refugee, and Migrant Health Branch Update Drew L. Posey, MD, MPH Medical Assessment and Policy Team Immigrant, Refugee, and Migrant Health Branch 2017 National TB Conference April 19, 2017 National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine DGMQ Public Health Mission To reduce morbidity and mortality among immigrants, refugees, travelers, expatriates, and other globally mobile populations, and to prevent the introduction, transmission, and spread of communicable diseases through regulation, science, research, preparedness, and response DGMQ s Regulatory Authority Immigration & Nationality Act 1968 Required medical exam Inadmissible conditions (TB, Hansen s disease, STIs, harmful behavior, drug abuse) Vaccines required International & interstate movement of people, animals, & cargo Prevent importation & spread of cholera, yellow fever, plague, viral hemorrhagic fevers, smallpox, diphtheria, pandemic influenza, infectious TB, SARS Federal Quarantine Regulations 1798 Refugee Act 1980 Prevent & control infectious diseases at origin Diseases of PH significance Meet at ports of entry Notification of state/local HD 1

2 Estimated Annual International Arrivals, U.S.A Refugees 69,920 Immigrants >1,000,000 Non immigrant admissions Temporary Workers and Families 3.7 M Students Visa 1.9 M Others 175 M Source: U.S. Department of Homeland Security Tuberculosis Cases, United States, No. of Cases 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2, TB rates: Total 3.0 per 100,000 US born 1.2 per 100,000 Foreign born 15.1 per 100,000 MDR TB: 86.3% Foreign born % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Proportion Foreign Born U.S. born Foreign born % Foreign born 2

3 Immigration and Refugee Health Working Group * Analysis New Zealand Birth Country of Arrivals, India Philippines Mexico Birth Country for TB Cases, India China Mexico Somalia Pakistan Ethiopia United States Australia US proportion AUS proportion NZ proportion Indonesia Zimbabwe US proportion AUS proportion NZ proportion Canada CAN proportion Sri Lanka CAN proportion France UK proportion Afghanistan UK proportion Turkey Sudan Thailand Myanmar Fiji Thailand Vietnam Nigeria 0.00% 5.00% 10.00% 15.00% 0.00% 5.00% 10.00% 15.00% 20.00% *Australia, Canada, New Zealand, United Kingdom, United States White Z, et al. Tuberculosis Research and Treatment. 2017: Prevalence of smear negative & inactive TB in U.S. bound Immigrants / Refugees, Immigrants 2.7 M screen overseas 26K Active TB smear (-) B1 rate = 961/100K 23K Inactive Old TB B2 rate = 837/100K Refugees 279K screen overseas 3.9K Active smear (-) B1 rate = 1,036/100K 10.7K Inactive Old TB B2 rate = 2,838/100K U.S TB Dz diagnosis B1 f/u = 7% Pulm TB B2 f/u = 2% Pulm TB Susan Maloney et. al. Arch Intern Med. 2006;166:

4 Culture and Directly Observed Therapy TB Technical Instructions If TB rate 20/100,000 or 2 14 years of age: TST 10 mm or positive IGRA HIV or TB signs or symptoms Valid for travel within 3 months Sputum smears and cultures (3) All ( ) One or more (+) Noninfectious Class B1 Infectious Class A DOT until cured Class A Waiver Implementation Strategy Globally Initially target large volume, high burden source countries Ultimately implement in all countries In country Develop culture and DOT infrastructure Link panel physician programs with broader control efforts 4

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8 Laboratory Capacity Building New laboratories China (5), India (5), Kenya, Mexico, Nepal, Thailand (2), Vietnam Greatly expanded laboratories Dominican Republic, Ethiopia, Ghana, India (2) Laboratories performing 2 nd line DST China (Guangzhou), Kenya, Nepal, Thailand, Vietnam Tuberculosis and MDR TB Rates, WHO and U.S. Screening Country Worldwide, panel physicians diagnose >1,500 cases yearly 72% smear-negative, culture-positive FY Arrivals WHO Country of screening 2 US Screening 3 TB Rate per 100,000 MDR TB Rate TB Rate per 100,000 MDR TB Rate Mexico 81, % % Dominican Republic 43, % 66 0% Philippines 35, % % China 38, % % India 27, % % Vietnam 24, % % 1 Department of Homeland Security, October 1, 2014 through September 30, WHO Country Profiles, MDR TB rate is rate among new cases. 3 TB Indicator data, all Class A TB cases, January 1, 2015 December 31, 2015 Liu et al. Annals of Internal Medicine

9 Recent Upgrades to the TB Screening Infrastructure Confirm It Can Be Successfully Modernized and Improve Prevention Number of total cases decreased by 17% : New CDC TB Technical Instructions published and implemented Americas Dominican Republic (2) El Salvador Honduras Mexico Peru Bolivia* Africa Rwanda (2) Zambia Morocco (2) South Africa Kenya Tanzania Sierra Leone* Morocco (lab) Egypt (lab) MAP Trips During FY 2016 Asia Burma India (2) Nepal (2) Malaysia (2) Indonesia (lab) Taiwan (lab) South Korea (lab) Vietnam (lab) Thailand (lab) Middle East Egypt (lab only) Pakistan (lab only) Europe Italy Czech Republic Ukraine Greece* 28 Countries Visited What s Next for Tuberculosis? 9

10 TB Technical Instructions Update to Tuberculosis Technical Instructions Update both panel physician and civil surgeon TB TI Improve readability and clarity Address important issues: Role of tuberculin skin test and interferon gamma release assay LTBI testing of applicants 15 years of age Role of molecular tests Referrals to health departments Implementation of Updated TB TI Receive input from TB TI Working Group Develop new Technical Instructions over next several months If changes require additional panel physician resources Implement October 1,

11 Panel physicians use IGRA Panel physicians use TST Immigrant and Refugee Children with LTBI, 2010 Children diagnosed overseas 8,231 Post arrival evaluation 5,749 (70%) LTBI diagnosed or confirmed stateside 3,299 (57%) LTBI therapy initiated 2,258 (68%) LTBI therapy completed 680 (30%) Taylor EM, et al. J Immigrant Minority Health 2015 DOI /s Preventing TB Overseas (PTOPS) Pilot Study Latent Tuberculosis Infection Testing and Voluntary Treatment for U.S Bound Immigrants from Vietnam Purpose: assess the acceptability and feasibility of offering LTBI treatment to U.S. bound immigrants prior to U.S. arrival Partners CDC Division of Global HIV/AIDs and Tuberculosis CDC Division of Tuberculosis Elimination CDC Division of Global Migration and Quarantine Cho Ray Hospital Visa Medical Department Vietnam NTP UCSF Research Collaboration 11

12 Long Term Visitor Screening Long Term Visitors Persons who will be staying in the United States for 6 months Two main categories: International students Workers Countries that Screen Long Term Visitors Norway Canada United Kingdom France Jordan New Zealand Australia 12

13 The United States is Behind United States 2015: Included in the National Action Plan to Combat Antibiotic Resistant Bacteria TB Among Long Term Visitors US foreign born cases diagnosed within 6 months after arrival 22% are temporary visa holders One third reported having symptoms at or before arrival US international students 48.1 per 100,000 case rate CDC estimated rate among long term visitors from high incidence countries: 60.9 per 100,000 Australia screening program Students: 69 per 100,000 Skilled labor: 44 per 100,000 United Kingdom screening program Students: 76 per 100,000 Workers: 68 per 100,000 Davidow AL, et al. Am J Public Health 2015 Sep;105(9):e81 8. Collins JM, et al. Annals ATS /AnnalsATS OC Liu Y, et al. PLoS ONE 2012;7(2): e doi: /journal.pone Aldridge RW, et al. Lanced Infect Dis 2016;16: Cost effectiveness of Screening Foreign Students for Tuberculosis India China Germany Hypothetical cohort 29,981 58,015 2,795 Cases diagnosed overseas (based on TB Indicators) Cases in Class B1 after arrival (based on EDN) Difference in US costs with overseas screening costs Savings of $458,695 Savings of $2,234,411 Additional cost of $5,201 Wingate, et al. PLOS One (4): e doi: /journal.pone

14 Implementation Requirements Policy Coordination with other Federal departments Department of State (DOS) Regulatory change may be needed Overseas Build panel physician capacity Train panel physicians Evaluate and monitor Cross Border Solutions Identify US bound source communities with high burden of tuberculosis Work directly with TB institutions to provide TB control support in these communities Posey DL, Marano N, Cetron MS. Int J Tuberc Lung Dis 2017;21(5):485. EDN and emedical 14

15 EDN Overseas U.S. EDN IOM Interface EDN DATA ENTRY EDN WEB Overseas Screening Overseas Forms Quarantine Stations Data Entry Center CDC HQ Atlanta Local/State Health Departments emedical Overseas U.S. EDN IOM Interface EDN DATA ENTRY EDN WEB emedical Overseas Screening Data Entry Center CDC HQ Atlanta Local/State Health Departments About emedical System developed by the Australian Department of Immigration and Citizenship Used by panel physicians that screen for Australia, Canada, and New Zealand Used by over 600 panel physicians in 140+ countries Already used by 42% of U.S. panels sites! Aligns with modernized immigrant visa (MIV) initiative at Department of State Consular officers to have access (no paper forms) 15

16 Phased rollout emedical Implementation Implementation for panel physicians and US Consular Sections Begin at key posts as early as November 2017 Rollout complete by end of 2018 Acknowledgments Division of Global Migration Division of Tuberculosis United States Customs and and Quarantine Elimination Immigration Services Monica Adderley Phil LoBue Bruce Larson Rovonda Bradford Ann Cronin Heather Burke Tom Navin Marty Cetron Phil Talboy International Panel Physicians Courtney Chappelle Association Department of State, Bureau of Terry Comans Ahmed Jan Consular Affairs Annelise Doney Alexandra Todd Kaitlin Keating Silia Herrera Joel Nantais Emily Jentes National Tuberculosis Controllers Katrin Kohl Department of State, Bureau of Associat5ion Deborah Lee Populations, Refugees, and Donna Wegener Luis Ortega Migration Nina Marano Margaret Burkhardt Pam McSpadden Mary Naughton International Organization for Migration Joanna Regan Poonam Dhavan Lisa Rotz Warren Jones Michelle Russell Davide Mosca Eric Shropshire Diane Simpson Sean Toney Michelle Weinberg Zack White Thank you For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone, CDC INFO ( )/TTY: E mail: cdcinfo@cdc.gov Web: 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. National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine 16