TBNet- TB treatment completion on a global scale Edward L. Zuroweste, MD, Chief Medical Officer, Ricardo Garay, Health Network Manager, Deliana Garcia, Director International Project, Migrant Clinicians Network ABSTRACT INTRODUCTION Transnational tracking is critical to treatment completion for TB among migrants. For 18 years, Migrant Clinicians Network has provided global case management to thousands of TB patients traveling across the world through its project, TBNet. MCN’s Chief Medical Officer completed an analysis of TBNet cases enrolled from January 1, 2005 to December 31, 2011. Results from the seven year analysis are summarized in this presentation and show that TBNet has proven to be an innovative approach to tuberculosis management in migrating patients. RESULTS Transnational tracking is critical to treatment completion for TB among migrants. For 18 years, Migrant Clinicians Network has provided global case management to thousands of TB patients traveling across the world through its project, TBNet. This multi-national tuberculosis patient tracking and referral program is designed to keep mobile, underserved populations in care. Treatment for these populations is complicated by the fact that many, are unable to remain in a given location long enough to complete the TB treatment regimen. A total of 1, 145 active cases of TB were referred by detention facilities that house immigration detainees and health departments across the United States. The destination country did not recommend treatment for 34 cases. treatment was recommended for 1, 111 cases. Thirteen patients died, not all from TB. Of the remaining 1, 098 patients, 112 patients were lost to follow up and 64 refused treatment. TBNet documented successful outcomes for 922 patients resulting in a treatment completion rate of 84%. Analysis of 2011 data indicates that 167 cases were referred between January 1 and December 31. Treatment was not recommended for 4 cases by the destination country. Of the remaining 163 cases, 5 patients died, not all from TB, 13 were lost to follow up and 10 refused treatment. TBNet documented a treatment completion rate of 85. 4%. TBNet’s patient base includes migrant workers, the homeless, immigration detainees, and prison parolees Cases are managed by trained bilingual staff with oversight by MCN’s Chief Medical Officer. Enrollment in TBNet is free but must be initiated by a health care provider. Once a patient is enrolled, TBNet will establish regular contact with both the patient and the treating clinician to document treatment adherence. Before a case can be closed, MCN’s Chief Medical Officer reviews every record for accuracy and completion. At the conclusion of treatment, TBNet notifies the enrolling clinic as well as the state or regional TB Control person that the patient has completed treatment. Throughout its 17 years of operation TBNet has enrolled over 5, 000 patients and worked with almost 3, 000 clinics in U. S. and over 70 countries. In 2010 TBNet received the 2010 Border Models of Excellence in Tuberculosis Surveillance and Control award from the U. S. –México Border Health Commission. CASE STUDY Table 2 Top Ten Nationalities of TBNet Class 3 Active TB Patients 2005 -2011. Country Total Class 3 patients Percent of total patients Percent Treatment Completed (1, 145 total patients-62 countries) Analysis of TBNet cases enrolled from January 1, 2005 to December 31, 2011 was conducted by the Chief Medical Officer (CMO). Final case classification was provided by the treating clinician or through clinical review by the CMO. A second analysis of 2011 cases was also conducted. 393 34. 3% 85% Mexico 229 20. 0% Guatemala 179 15. 6% 117 10. 2% 90% 26 2. 3% 88% Peru 24 2. 1% 91% China 20 1. 7% 90% Ecuador 18 1. 6% 83% India 18 1. 6% 66% Haiti 10 0. 9% 100% CONCLUSIONS Table 1 Class 3 Active TB Treatment Results 2005 -2011. CONTACT Ed Zuroweste, MD Migrant Clinicians Network kugelzur@migrantclinician. org 512 -579 -4540 www. migrantclinician. org 1, 145 Class 3 Active TB Cases Referred 34 treatment not recommended by destination country 1, 111 Treatment Recommended 13 deceased 1, 098 Followed by TBNet for Active TB 112 lost to follow up 64 refused treatment 922 Complete Treatment = 84. 0% In June, 2010 the patient called TBNet from an East Coast location to say that he had been released and wanted to initiate treatment. TBNet found a clinic and the patient started a 4 -drug regimen using DOT. In September 2010 he moved for work to a new location where TBNet was able to find him another clinic to assure continuity of care. The patient completed treatment in April, 2011. 77% El Salvador In May, 2010 his wife called TBNet to say that she had just had word that her husband was being held by coyotes in a U. S. border city and they were demanding a ransom to free him. TBNet staff obtained the phone number of the house where he was being held and urged the coyotes to let him go so that he could receive medical treatment. TBNet staff also initiated a human trafficking report with the US Justice Department. 78% Nicaragua METHODS AND MATERIALS Honduras Male patient was screened for TB in an ICE facility in February 2010. Had a negative smear, RUL consolidation, TST of 20 mm, was asymptomatic and medication was not started. He was enrolled in TBNet prior to being deported to Central America. In March 2010 TBNet was notified of positive culture results. His medical records were sent to his home country and his family was notified. However he had already left his home country to reenter the U. S. by the time the results were available. The World Health Organization’s target for tuberculosis treatment completion is 85% of smear-positive cases. In 2009, the last year for which data are available, 88% of patients requiring treatment of less than one year successfully completed their treatment in the United States. Treatment success rates among difficult-to-follow or mobile populations typically range far below that level. Very little data exists regarding patients who migrate internationally. Typically, when patients cross national borders, there is no mechanism to track their treatment outcome. TBNet has worked with more than 5, 000 participants. While many have stayed in the US the majority of cases returned to their country of origin. Whether assisting to transfer a patient across the Texas/México border or from the USA to one of seventy other countries, TBNet has proven to be an innovative approach to tuberculosis management in migrating patients. REFERENCES TBNet provided bridge case management services to patients in 63 countries and 45 U. S. States from 2005 -2011
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