TBNetPart of the Health Network

Transborder Migration

Care of the Mobile TB PatientDeliana Garcia, Director

International, Research, and DevelopmentAdvisory Committee for the Elimination of Tuberculosis

March 20, 2007

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A national, clinical network founded in 1984 2,000 clinician membersOldest and largest clinical network dedicated to the mobile underserved

Migrant Clinicians Network

MCN’s primary constituents are clinicians working in federally funded CHCs and in state and local health departments.

Photo © Alan Pogue

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U.S. Population

By comparison to most of the world the United

States is a relatively young country that has

always relied on immigration for

population growth

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Migration in the America

Enormous expanses of open land created a

mentality of unencumbered mobility

resulting in the voluntary movement of large numbers of persons

seeking adventure and opportunity

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Changes in MigrationThe principal US

experience of internally displaced people is that of

the dust bowl era when thousands of people

migrated from states like Oklahoma, Arkansas to escape the unrelenting

wind and erosion experienced in the middle

part of the US in the 1920’s

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Changes in Migration

Because many of those displaced were share croppers or itinerant farmers the movement was generally west to areas where agriculture promised a large number of labor intensive jobs in the harvesting of fruits and vegetables.

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Changes in Migration

Agriculture was the reining industry for migrant workers for more than 50 years providing jobs for returning WWII veterans and welcoming workers from Mexico and the Caribbean.

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Changes in Migration

Until very recently, the United States has had little experience with massive internal

displacement of people and the

concomitant problems of housing and health

care that are so common in other parts of the world

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Migration Today

México is one of the principal countries that sends migrants to the United StatesIn the 90’s 300,000 migrated, in 2004 1.4 million migratedIn the 90’s 4% of those that migrated would not return to México, now it is 10% that do not return

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0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

Jalisco

Michoacán

Zacatecas

Guanajuato

Distrito federal

Puebla

Oaxaca

Durango

Guerrero

Migration TodayJalisco 18.5%

Michoacan 15.8%

Zacatecas 8.6%

Guanajuato 7.9%

Distrito Federal 5.9%

Puebla 5.8%

Oaxaca 4.2%

Durango 3.7%

Guerrero 3.6%

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Texas ranks second among the receiving states in the U.S.

Migration Today

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46.40%

21.50%

6.70%

6.50%

5.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

1

California

Texas

Arizona

Illinois

New York

Migration TodayStates with the Greatest Immigration from

Mexico

California 46.4%Texas 21.5%Arizona 6.7%Illinois 6.5%New York 5%

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GUERRERO

GUANAJUATO

Texas is the principal destination for migrants from the states of Guanajuato and Guerrero

Migration Today

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0

2

4

6

8

10

12

Desc. DeMex.

Nat Res. Indoc

Of the 26.2 million Mexican that live in the U.S.:

11.5% Mexican descent

2.3 % Naturalized citizens

2.1% Residents

10.3% Undocumented

Migration Today

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

mestizos indígenas

Migration Today

Of the 10.3 million undocumented

97% are mestizos

3% are indigenous

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0%

5%

10%

15%

20%

25%

30%

Zapotecos: Mixtecos: Náhuatl: Mayas : Otros*:

Zapoteco 28%

Mixtecos 25%

Nahuatl 17%

Mayas 8%

Others 22%

Of the approximately 1,339,000 indigenous

Migration Today

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Menos de 10 años

10 a 19 años

20 a 44 años

45 a 59 años60 o másLess than 10 years

5.1%

10 to 19 years 12.6%

20 to 44 years 62.5%

45 to 59 years 13.6%

60 or more 6.1%

Age Groups

Migration Today

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Migration today

Leprosy affects over 12 million people worldwide, and reported cases have

increased in the US as a result of immigration. Of 1835 cases of leprosy

reported in the US from 1971-1981, only 25% of imported cases were known to have had leprosy at migration. Although most of

remaining 75% were detected within 12 months of entry, cases continued to be

reported 10 years after entry.

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International migration that involves the annual movement of tens of millions of people has become a norm, yet the public health implications are just starting to be assessed.

Internal migration that involves the annual movements of millions is still treated as an aberration rather than an on-going event of public health significance

Migration Today

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TB Among the Foreign Born

Since 2002 for the first time the majority of TB cases were in the foreign bornIn 2004, 53.7% of 14,511 active TB cases in the US were in the foreign bornOf these, 26% were from MexicoA significant number of these are undocumented residents

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TB Among the Foreign Born

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Annual Abandonment Rates Guatemala 1992-2002

0

1

2

3

4

5

6

7

8

9

1992 1993 1994 1995 1996 1997 1998 1999 2000 2002

Source: PNCTB, Guatemala 2002.

%

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Distribution of TB Cases by Ethnic Group. Izabal 2002

16 (52)

15 (48)

Indigena Ladino

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Binational TB Projects

• 1991 – Project JUNTOS- El Paso/Juarez, MEX

• 1992 – Yuma, AZ/Sonora, MEX

• 1993 – Los Dos Laredos- TX/Tamaulipas, MEX

• 1995 – Grupo Sin Fronteras- Harlingen/Mc Allen/Reynosa/Brownsville/Matamoros

• 1996 - TB Net- Austin, TX

• 1997 – Cochise, AZ/Northeastern Sonora, MEX

• 1997 – Ambos Nogales- AZ/Sonora, MEX

• 1997 – Cure TB- San Diego, CA

U.S.-Mexico Binational TB Relationship

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TBNet the Binational Bridge Case Management Program

TBNet started in 1996Has managed more than 2,700 patientsCompletion rate in 2005 of 71.4% for patients moving while under treatment for active TB diseaseManaged patients to 30 countries

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Why Bridge Case Management?

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Why Bridge Case Management?

More than medical records transferMore than communication with NTPMore than simple verification of patients’ contact informationMore than referral to a source of care

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How? Bridge Case ManagementTransferring medical records between clinics when participants move

Providing phone based care-coordination services:

Communicate with sending clinic through treatment completionCommunicate with receiving clinic for duration of treatmentEducating participants about treatment of

tuberculosis and importance of completion

Photo: Eduardo Moreno

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How Does it Work?

Discuss the need to remain in care with anyone suspected or known to have active TB diseaseGain his/her consent to have medical records transferred to ensure continued careObtain the contact information for the person or for someone who will always be in contact with Him/her

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What to ask:Where are you from?How long have you been in the area?What are your plans?How often do you move?What type(s) of work do you do?How can I contact you?Is there someone who will always know how to find you?

Photo © Alan Pogue

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How Does it Work?

TBNet staff will verify contact informationTBNet staff will identify a treatment provider in the new locationTBNet will maintain contact with the provider AND the patient for the duration of treatment

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TBNet will inform the enrolling provider of the treatment outcomeShould the patient fail to present or discontinue treatment, TBNet will communicate with all known contacts to bring the patient back into care

How Does it Work?

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Contact InformationEd Zuroweste, MD (MCN Chief Medical Officer): kugelzur@migrantclinician.org

Deliana Garcia (Director, International, Research, and Development): dgarcia@migrantclinician.orgMCN: 512-327-2017 or

www.migrantclinician.org