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Mobile Mexican Workers At Risk for TB in California

Mobile Mexican workers TB


By Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

Earlier this year at a National TB Controllers meeting, California Department of Public Health researchers Tessa K. Mochizuki, MPH, Pennan M. Barry, MD, MPH, and Lisa Pascopella, PhD, MPH presented a poster entitled, “Tuberculosis among Migrant Workers in California, 2001-2015.” The analysis presented in the poster compared mobile workers with tuberculosis (TB) to workers with TB in other occupations. The analysis used TB surveillance data and was restricted to those born in Mexico. The data are telling about TB incidence and treatment among mobile workers such as agricultural workers in California, and demonstrate the need for programs like Health Network, the bridge case management program for mobile patients provided by Migrant Clinicians Network (MCN). 

Since 1996, MCN’s Health Network has case managed over 12,000 mobile patients; over 2,100 have been cases of active tuberculosis. Health Network Associates have helped these mobile patients maintain continuity of care, not only throughout the United States, but to 110 other countries, with a documented treatment completion rate of over 84 percent.

“This California study confirms what has long been believed by mobile health experts: that mobile agricultural workers are at high risk for tuberculosis and should be actively screened for TB,” said Ed Zuroweste, MD, Co-Chief Medical Officer for MCN. “MCN’s Health Network remains ready to assist any clinician who has a mobile patient with either TB infection or TB disease.”

The California Department of Public Health (CDPH) provided some comment on the contents of the poster, the results of the study, and the implications for clinicians serving mobile populations. The following has been edited for brevity and clarity.

MCN: Why did you decide to study TB among mobile workers in California?
CDPH: Previous literature has suggested that mobile workers are at risk for tuberculosis and may not have consistent access to health care, which could lead to challenges in TB diagnosis and treatment. California reports the largest number of TB cases among mobile workers in the US. In order to ensure effective TB care and TB prevention for all Californians, it is important to understand TB epidemiology in specific populations, like mobile workers.

MCN: What preliminary results can you share with us?
CDPH: Mobile workers differ from other employed TB cases from Mexico. Examples of differences included being more likely to report alcohol use, being more likely to have had contact with an infectious TB patient, and [being] more likely to move during TB treatment. These differences may mean that specialized approaches to identifying TB and supporting mobile workers through treatment may be needed. However, we also found that more mobile workers have completed treatment in recent years such that their completion rates no longer differ from other workers.

MCN: What are the implications of your work for clinicians serving mobile populations, like mobile agricultural workers?
CDPH: There are more than 2,000 cases of TB reported each year in California. When TB is diagnosed in a mobile worker, special care is needed to ensure that workers can complete TB treatment, especially when moving from one location to another. Additionally, TB can be prevented through testing for and treating latent TB infection. This testing is indicated for persons with close or prolonged contact to an infectious TB case. Additionally, the California Department of Public Health (CDPH) and the United States Preventive Services Task Force recommends testing and treatment for latent tuberculosis infection (LTBI) among all persons born in countries with an elevated rate of TB.

MCN: What should clinicians take away from this?
CDPH: Most cases of tuberculosis in California are a result of progression of LTBI to active TB disease. From this analysis, we found that more than half of the mobile workers with TB had been in the US for at least six years. This means that there could be opportunities to prevent tuberculosis among mobile workers through testing and treatment for LTBI. Once active TB is ruled out, treatment for LTBI should be considered. There are short-course regimens available that may be more feasible for mobile worker patients.

MCN: What are the next steps for this project?
CDPH: We are still considering publication of these results. CDPH will continue to monitor TB cases in mobile workers including treatment completion.

Learn more about Health Network, including how clinicians can enroll their own mobile patients for any health concern, at: The California Department of Public Health’s Tuberculosis Control Branch is at: Pages/TBCB.aspx


Health Network and PRAPARE
In 2016, just as PRAPARE was set to launch, Migrant Clinicians Network was beginning to develop its new database to better serve patients enrolled in Health Network, MCN’s bridge case management program. Over the course of the following year, MCN configured the new database to allow for the integration of PRAPARE data, in which one health center’s PRAPARE data can be transferred to the next health center, as a mobile patient moves.
“When we started thinking about that data and [Health Network] case management work, so much of case management isn’t just ‘are you taking your medication every day?’ It’s more about, ‘How can I help you access care and manage your health in general?’” explained Anna Gard, RN, who assisted MCN in the development of the new database. “One piece of this is: ‘Let me help you find a health center.’ But the larger pieces around effective case management are, ‘How are you going to get there? Is there public transportation? How are you going to pick up your medications if you live in a hostile community and you’re afraid of leaving the house?’ PRAPARE gives a structured format to capture [these] data, in a form that’s been tested and validated.”
As more health centers provide case management and chronic care management to address the social determinants of health, Gard noted, integration of the PRAPARE data with Health Network, a virtual case management, seemed to make sense. Now, the Health Network team is working to fit PRAPARE into their own workflow.
Saul Delgado, Health Network Data Specialist, who has been integral in building and launching Health Network’s new case management system, notes that asking such personal questions over the phone, when a patient doesn’t have transferrable PRAPARE data from a previous health center, can be challenging. “When we call, the patient doesn’t know you. They’re very scared to answer these kinds of personal questions, whereas when you go the clinic, you at least see the nurse or case worker face-to-face,” he explained. But he recognizes the utility of the data, and has developed the PRAPARE data screens within the database to be easily accessed from the main patient information screen. With drop-down menus, Health Network Associates can populate the information they hear from patients, like how many people live with them in their household, or if they’re worried about losing their home. The information, either attained from a previous health center or inputted by a Health Network Associate, will be transferred when the mobile patient gets to his or her next destination, just as the basic medical records do.
“Health centers are doing more to integrate social and behavioral determinants of health, and we’re recognizing that all of those things have to be integrated with care management. So we’re on the forefront,” Gard concluded.

MCN Streamline Winter 2019

Read this article in the Winter 2019 issue of Streamline here!

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