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Drug resistance, recidivism probes under way
By the time the year is over, the Immigration and Naturalization Service (INS) probably will have deported about 250,000 people. One of those already deported is a multidrug-resistant tuberculosis (MDR-TB) patient from Mexico. Deported last month, he’d been convicted of a crime and had done time in a federal prison in Springfield, MO. After an appearance in immigration court, the deportation wheels began to turn.
By the time Jeannie Laswell, RN, heard about the man with MDR-TB, he was back home in Mexico, the central-line catheter through which he’d been getting drugs still dangling from his neck.
Laswell, who works for a cross-border TB referral program called TB NET, frantically began working the phone lines and soon managed to locate both the patient and a free supply of the expensive medications he needs to finish treatment. But there was a problem: Though the drugs and the treatment would be free, they weren’t available in the man’s hometown. He and his family would have to pack up and move far away.
Across the miles and the language barrier, Laswell fought to convey the importance of finishing treatment. (She also found a clinic nurse in Mexico who took out the dangling catheter.) But as of late last month, the man had simply disappeared; not even his family knew where he was.
"I haven’t given up," says Laswell, explaining that she’s just gotten off the phone from talking with the man’s sister. "I’ve got lots of my fingers crossed. He may turn up yet."
Physicians who work for the Division of Immigration Health Services (DIHS), the medical arm of the INS, say the scenario is not rare. What’s more, they say, some as-yet-unknown proportion of INS deportees with active TB are slipping back across the border into the United States again, continuing to expose others to disease in this country.
Like Laswell’s MDR-TB patient, many deportees — again, there are only preliminary estimates of how many — have some degree of drug-resistant disease.
The deportation issue has prompted a working group of the federal Advisory Committee to Eliminate Tuberculosis (ACET) to begin a search for information and solutions. At a recent ACET meeting in Atlanta, the group reported preliminary findings and conclusions. They include:
• Some deportees with TB return, still untreated, to the United States.
• Because many countries lack the resources, many other deportees with TB fail to get proper treatment in countries to which they return.
• INS detainees with TB who are deported before completing treatment are, therefore, an "international public-health hazard."
Working-group members are trying to arrange a meeting with U.S. Health and Human Services (HHS) chief Tommy Thompson to air the issue. Finding a solution that addresses all the various issues, they concede, will be tough.
From a public-health perspective, the ideal answer would probably be a policy change that lets the DIHS hold detainees with TB instead of deporting them so they can complete treatment of their TB. (Current policy allows DIHS to hold and treat patients only until they are noninfectious.)
Such a policy change would need to be brokered, at the very least, between the Department of Justice (which oversees the INS) and the HHS (which oversees the DIHS). More likely, it would take an act of Congress, says INS spokeswoman Karen Kraushaar.
Plus, there are human rights and foreign-policy ramifications to the situation. Can the United States hold the citizen of another country simply for TB treatment? Practical matters also loom large. Who will pay for treatment? Where will detainees be housed?
At least the numbers look manageable
As far as the expense is concerned, preliminary information-gathering by the ACET working group suggests the numbers of TB patients netted prior to being deported may be manageable, despite the big public-health headaches they cause.
TB screening carried out at nine INS service processing facilities (SPFs) and two detention facilities found 97 cases (both suspect and confirmed) in the year 2000. Of the 97, 57 were culture-confirmed. For 1999, the comparable figures were 80 cases or suspect cases, with 55 culture-confirmed, the working group reported.
Even though 81% of deportees last year were from Mexico, only about one-third of the TB cases came from Mexico, noted the ACET group. The other two-thirds came from other parts of Latin America.
Still, the INS houses lots of detainees at local "contract" facilities, where TB screening may be less scrupulously carried out than at the SPFs and the big detention facilities. New INS regulations enacted in January of this year will change all that within three years; by then, TB screening will be mandatory for all INS detainees, no matter where they are housed, assuming they are kept for at least 24 hours, says Kraushaar. At larger facilities, the INS is moving to teleradiology, or digital chest X-rays.
All told, the tighter screening procedures may net as many as 25% more TB cases, says Geralyn Johnson, DDS, MPH, chief of clinical operations at DIHS. "But that’s just a guess," she adds; there are many other factors in the screening process to take into account.
Tighter screening on the way
For example, even though 50% of INS beds are rented from local jails at $50 a day, the highest throughput occurs at the DIHS-run SPFs. That suggests most TB cases are already being found. Still, Johnson points out, "we know the more we look for TB, the more we’ll find it."
Strictly from a U.S. perspective, the real question is how many deportees with untreated TB are coming back into the country. Here, hard data are elusive. So far, the ACET working group has found that:
• According to the San Francisco TB control program, one in eight deportees with TB were known to have returned.
• According to CURE TB, when 38 cases were examined, 18 patients were lost to follow-up. Of the 20 cases whose whereabouts were known, five (25%) returned.
More reliable data may eventually be available on these "recidivist crossers," says Johnson. Using a system called INS-IDENT, the INS has been collecting fingerprints of people apprehended in border crossings. Recently, the DIHS hired an epidemiologist who plans to begin sifting fingerprint data. Eventually, that will lead to a clearer picture of how much recidivist border-crossing is taking place, she adds.
Also crucial is the question of how many repeat-crossers have drug-resistant disease. If preliminary findings by the ACET working group are on target, the news isn’t good:
• The San Francisco program found three of eight cases deported (38%) had isoniazid-resistant disease.
• At CURE TB, five of 22 cases, or 23%, were drug-resistant — including 4 cases that were INH-resistant and one case that was multidrug-resistant.
Then there are the logistical stumpers. Where would detainees be housed while receiving treatment? Don’t look to the INS, warns Kraushaar. "The INS is not in the detention business," she says. "They’re in the business of moving people" in or out of the country.
Paroling patients into the community or shipping them to a local program to finish treatment are not options either, despite the fact that most deportees seem not to have committed especially injurious crimes.
The INS gives these statistics about last year’s "criminal" deportations:
— 41% of deportees were guilty of drug-related offenses;
— 20% were guilty of "criminal violations of immigration law"
— 8% were guilty of assault;
— 4% were guilty of burglary;
— 4% were guilty of robbery.
Some detainees must be deported
But regardless of the crime’s severity, an immigration law enacted in 1996 mandates that detainees who have served a year or more in a correctional facility must be deported. That applies even if the crime was committed years ago. (The 1996 law has resulted in some law-abiding residents being deported many years after they’d "paid their debt" to society; some states have enacted laws to prevent such after-the-fact removals.)
In addition, not even non-criminal detainees bound for deportation can be released or paroled into the U.S. population simply for TB treatment, say Kraushaar and Johnson. This group of non-criminals includes "voluntary returns" — detainees who opt out of the formal deportation hearing and court appearance by pleading "no contest" to their deportation order. Doing so lets them avoid a black mark on their record, which in turn makes it easier to reapply for immigration.
If all that somehow changed, though, and deportees could be held and treated, Johnson says she can think of one way it could be done: Build some sanitarium-style facilities, and use them to house detainees with TB. "That way, they could be held securely, and still get their TB treatment in a humane setting," she says.