Tuberculosis and Travel Nicole J. Cohen, MD TB Morbidity & Mortality Review February 18, 2014 National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine
U.S. Federally Quarantinable Communicable Diseases Cholera Diphtheria Infectious tuberculosis Plague Smallpox Yellow fever Viral hemorrhagic fevers Severe acute respiratory syndrome (SARS) Novel or reemerging influenza causing or with potential to cause a pandemic Presidential Executive Order 13295, as amended by Executive Order 13375 2
Contact Investigations (CIs)
Purpose of Travel-related CIs Identify exposed travelers Notify travelers about their potential exposure Inform local public health authorities to facilitate preventive or follow-up public health actions Evaluate exposed travelers for infection or immunity Provide post-exposure vaccine or prophylactic antibiotics, if indicated
Criteria for Initiating CI Index case diagnosed 3 months after travel AND Airplanes: Sputum smear positive AND cavitation on CXR Ships: Sputum smear positive OR cavitation on CXR OR Both settings: Multidrugresistant isolate Flight 8 hours long (gate-to-gate) Air TB CI seating chart
Contact Investigation Processes Airplanes DGMQ: Obtains passenger contact information Distributes to state health departments via Epi-X Health departments locate and evaluate passengers Ships CI typically coordinated by ship, especially for crew DGMQ provides guidance, informational materials, and technical support Health departments provide clinical and lab support, locate and evaluate disembarked passengers as needed
Travel Restrictions and Interventions
Do Not Board (DNB) list Definitions Travel restriction tool: Prevents people who meet specific criteria from obtaining a boarding pass for any flight inbound to, outbound from, or within the United States Implemented by the Transportation Security Administration (TSA) * Does not prevent passengers from boarding ships, trains, or buses. 8
Lookout (LO) list Definitions, cont. LO issued with every DNB Intervention tool: Alerts Customs officers of a person who may pose a public health threat who attempts to enter the country Prompts notification to CDC Quarantine Station staff when such persons attempt to enter the United States Applies at airports, seaports, and land borders Implemented by Customs and Border Protection (CBP) 9
Three Criteria for DNB/LO Addition (all three criteria must be met) 1 Infectious or likely infectious 2 Noncompliant with public health recommendations or unaware of diagnosis 3 At risk of traveling on a commercial flight or of traveling internationally 10
One Criterion for DNB/LO Removal 1 Removal is facilitated when person is determined to be NONINFECTIOUS 11
Three Phases of DNB/LO Process* Adding Determine DNB/LO eligibility Hold a DNB/LO call with state and local health departments (S/L HD), QS, and TRIA Place on DNB/LO lists if criteria are met and approved by CDC and DHS During Monitor and follow up with patient regularly Provide clinical updates to QS Removing Determine when non-infectiousness is reached Remove from DNB/LO lists Continue patient follow up as appropriate *Managed by CDC s Travel Restrictions and Intervention Activity (TRIA) 12
Health Department Roles Contacts jurisdictional QS for initial consult Provides updates on patient medical status Shares responsibility with QS for case management Notifies QS when patients meet removal criteria Continues case management after DNB/LO removal and alerts QS if new concerns develop 13
Traveler who: When to Notify CDC Recently traveled while infectious with TB (consider criteria) Intends to travel while infectious with TB
CDC Quarantine Station Jurisdictions AK Seattle Anchorage San Francisco WA OR No.CA NV So.CA Los Angeles San Diego ID UT AZ MT WY El Paso CO NM ND SD NE KS North TX West TX Minneapolis OK MN IA East TX MO AR WI LA Chicago IL MS IN MI KY TN AL Detroit OH WV GA PA SC MD NY VA NC FL VT NH NJ MA CT ME RI New York Newark Atlanta Boston Philadelphia Washington DC Honolulu Dallas Houston Miami GU HI CDC Quarantine Station (n=20) PR San Juan http://www.cdc.gov/quarantine/ 15
Questions? ncohen@cdc.gov For more information, please contact: Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636) / TTY: 1-888-232-6348 Web: www.cdc.gov 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