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TB Notes Newsletter

No. 4, 2005

International Update

Binational Referral System for Migrating TB Patients Pilot Project
(Binational Card Project)

The Binational Card project is a collaborative effort between CDC and the National Tuberculosis Program (NTP) in Mexico to improve continuity of care for TB patients migrating across the border. Providing continuous, effective TB care along the U.S./Mexico border is a particular challenge owing to frequent border crossings by many patients and subsequent complications in tracking them. Effective care necessitates good communication and coordination between local U.S. TB programs and their counterparts in Mexico. To facilitate coordination, CDC, along with the U.S.-Mexico Border Health Commission, the U.S. Health Resources and Services Administration (HRSA), the Pan American Health Organization (PAHO), the U.S. Agency for International Development (USAID), and the Coldwell Foundation, has funded the Card Project, a collaborative effort among CDC’s DTBE, the Mexico Ministry of Health through the National TB Program of the Mexico National Center for Epidemiological Surveillance and Disease Control (CENAVECE), the U.S.-Mexico Border Health Commission, the Texas Department of State Health Services, the California Department of Health Services, the San Diego County Health and Human Services Agency and its CureTB program, the Texas Department of State Health Services TB program, the El Paso City-County Health and Environmental District, the Migrant Clinicians Network and its TBNet program, USAID, PAHO, the Department of Health and Human Services (HHS), HRSA, the U.S. Department of Immigration and Customs Enforcement (ICE), the binational TB prevention and control project “JUNTOS,” Ten Against TB, La Fe Community Health Center, and pilot sites on both sides of the border.

Operational since March 2003, and built upon the experience and systems of referral and counter-referral of the San Diego County Health and Human Services Agency’s CureTB program and the Migrant Clinicians Network’s TBNet program, the Binational Card Project is intended to allow eligible patients to receive seamless TB care, regardless of their immigration status. In each country, providers use the referral systems to register eligible patients in a central database (one database in the United States [CureTB] and one in Mexico) and provide essential data about their treatment.  Providers notify the referral system on their side of the border when patients anticipate a move to another location. The referral system then forwards treatment information to the referral agency on the other side of the border, which in turn notifies a TB care provider in the destination location, promoting continuity of care. A Binational Card bearing a toll-free telephone number, to be carried by the participating patients, complements the referral network and facilitates patient access to the referral network from either side of the border. The Binational Card does not bear the patient’s name, but has instead a unique identifying number used by providers and referral agencies for tracking purposes. The intent of the Binational Card Project is to ensure completion of therapy by the targeted population.

As of January 2005, almost 800 Cards had been distributed in Mexico and almost 500 in the United States. Training activities have been conducted at all sites for this project, and posters, brochures, and a flipchart have been developed to educate patients and providers about it. Patients who have traveled across the border from either side to the other have been able to be tracked and provided with follow-up care owing to the Card project. Furthermore, this project has become an integral part of TB management in ICE detention centers in the United States.

We have completed a formal evaluation of this project to measure the impact and to ensure that the project is practical, feasible, and effective in a real-world setting before implementation is scaled up to include other diseases or other sites. Data sources for the evaluation included monthly progress telephone conferences, site visits, national surveillance and project databases, focus groups, and interviews. Key project stakeholders were also interviewed. To assist in the evaluation, a private consulting firm, Batelle Memorial Institute, was hired. The results of this evaluation were shared with stakeholders at a U.S.-Mexico Border Health Commission–sponsored binational celebration of World TB Day, on April 4, 2005, in El Paso. Preliminary results revealed that of the 793 patients receiving the Card in Mexico, 17 moved to the United States during treatment. Of the 488 patients receiving the Card in the United States, 147 moved to Mexico during treatment. The evaluation showed that the project protocol was implemented consistently on each side of the border; however, prescribed data exchanges between nations did not occur routinely. Pilot-site staff and patients agreed the project provided a valuable service to patients by increasing awareness of the importance of continuity of care and providing a mechanism to refer patients. Local collaborative networks among TB care providers, including those in ICE detention centers or state and local correctional facilities, were established or strengthened through this project. Further, it may be possible to use treatment outcomes recorded for project patients to update the respective national surveillance systems for patients previously thought to be lost to follow-up or transferred.

Results of the evaluation were used to inform discussions about the future of this project. As a result of this evaluation, the project will continue and expand, with assistance from CDC, local U.S. health departments, the U.S.-Mexico Border Health Commission, and USAID-Mexico, with modifications currently being made to the data collection and communication and referral systems, and eligibility criteria, for both sides of the border.  

We feel that the considerable efforts have been necessary and successful in achieving a consensus on how to move forward on this somewhat complex binational project.  Both countries’ public health systems see the establishment of the binational referral and information system for tuberculosis as a critical step for responding to identified TB needs in the region, as representing strong consensus for binational collaboration, as a way to improve treatment outcomes, and as providing a model for other similar settings or other diseases in this setting. 

For more information, contact Dr. Elizabeth Ferreira at (52)(55) 26146433 or or Dr. Kayla Laserson at (404) 639-5334 or

—Reported by Kayla Laserson, ScD
Div of TB Elimination


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