1 figure omitted
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. 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
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.
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).
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.
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).
*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.
Post-Detention Completion of Tuberculosis Treatment for Persons Deported or Released from the Custody of the Immigration and Naturalization Service—United States, 2003. JAMA. 2003;289(23):3081-3082. doi:10.1001/jama.289.23.3081