Preventing and Controlling Tuberculosis Along the U.S.-Mexico Border
Work Group Report
The following CDC staff members prepared this report:
Mark N. Lobato, M.D.
J. Peter Cegielski, M.D., M.P.H.
Division of Tuberculosis Elimination
National Center for HIV, STD, and TB Prevention
in collaboration with the following Tuberculosis Along the U.S. - Mexico Border
Work Group members:
Work Group Coordinators
Daniel P. Chin, M.D., M.P.H.
California Department of Health Services
Berkeley, California
Miguel A. Escobedo, M.D., M.P.H.
Texas Department of Health
El Paso, Texas
Kathleen S. Moser, M.D., M.P.H.
Tuberculosis Control and Border Health Services
San Diego, California
Noreen L. Qualls, Dr.P.H.
Division of Tuberculosis Elimination
National Center for HIV, STD, and TB Prevention, CDC
Eileen E. Schneider, M.D., M.P.H.
Division of Tuberculosis Elimination
National Center for HIV, STD, and TB Prevention, CDC
Gary L. Simpson, M.D., Ph.D., M.P.H.
New Mexico Department of Health
Santa Fe, New Mexico
Work Group Participants
Lynda S. Alfonso
County Department of Health
Las Cruces, New Mexico
Nancy J. Binkin, M.D., M.P.H.
Division of Tuberculosis Elimination
National Center for HIV, STD, and TB Prevention, CDC
Rose F. Bramble
New Mexico Department of Health
Santa Fe, New Mexico
Charlotte Clunn
Imperial County Health Department
El Centro, California
Susan E. Good
Arizona Department of Health Services
Phoenix, Arizona
Reuben M. Granich, M.D., M.P.H.
California Department of Health Services
Berkeley, California and Division of Applied Public Health Training
Epidemiology Program Office, CDC
Dianne Grider
Yuma County Health Department
Yuma, Arizona
Jennifer L. Hallum, M.D.
Pima County Health Department
Tucson, Arizona
Laura S. Knowles, M.S.P.H.
County of Los Angeles Health Services
Los Angeles, California
Marcos Longoria, M.D.
Houston Health and Human Services
Houston, Texas
Eugene McCray, M.D.
Office of the Director
National Center for HIV, STD, and TB Prevention, CDC
Gloria R. Peña
City of Laredo Health Department
Laredo, Texas
J. Allen Reinarz, M.D.
Texas Department of Health
Austin, Texas
Michael J. Reynolds, M.D.
Fresno County Health Department
Fresno, California
Patricia M. Simone, M.D.
Division of Tuberculosis Elimination
National Center for HIV, STD, and TB Prevention, CDC
Brian R. Smith, M.D., M.P.H.
Department of Health
Harlingen, Texas
Jeanne R. Smithpeter, M.S.N.
New Mexico Department of Health
Santa Fe, New Mexico
Sherry Stotler, M.S.
Maricopa County Health Department
Phoenix, Arizona
Eugene J. Tamames
Texas Department of Health
San Antonio Texas and Division of Tuberculosis Elimination
National Center for HIV, STD,
and TB Prevention, CDC
Charles E. Wallace, Ph.D., M.P.H.
Texas Department of Health
San Antonio, Texas
Stephen H. Waterman, M.D., M.P.H.
California Department of Health Services
Berkeley, California
Penny C. Weismuller, Dr.P.H.
Disease Control Health Care Agency
Santa Ana, California
Summary
Converging factors contribute to elevated tuberculosis (TB) incidence
and complicate case management in the U.S. states bordering Mexico. These
factors include a) Mexico's higher TB rate; b) low socioeconomic status and limited
access to health care in the border area; c) frequent border crossings and travel in
the United States for employment, commerce, health services, and leisure;
d) language and sociocultural differences; and e) lack of coordinated care
across health jurisdictions on both sides of the U.S.-Mexico border. Prevention
and control efforts that address the challenges created by
border-crossing populations require collaboration among local, state, and national TB
control programs in both countries. In June 1999, to facilitate future discussions
with Mexican counterparts, CDC convened a meeting of TB control officials from
the four U.S. states bordering Mexico (i.e., California, Arizona, New Mexico,
and Texas) to address TB prevention and control in the border area. Focus
areas included a) surveillance needs, b) case management and therapy completion,
c) performance indicators and program evaluation, and d) research needs.
Meeting participants' deliberations and resulting proposals for action by CDC and state
and local TB control programs are detailed in this report.
INTRODUCTION
During 1994--1998, approximately 3.9 million legal immigrants entered the
United States. Of those immigrants, 16.5% were from Mexico, the leading country of birth for
all legal immigrants, and 5% were from seven countries in Central America
(1). Additionally, an estimated 2.7 million persons from Mexico and Central America live in the
United States without documentation of citizenship or visas
(2). Persons from these countries contribute substantially to U.S. tuberculosis (TB) morbidity.
TB disease among foreign-born persons living in the United States is increasing.
In 1999, 43% (7,553) of the 17,531 TB cases reported in the United States were
among foreign-born persons, compared with 24% (6,262) of the 25,701 cases reported in
1990. In 1999, Mexico was the country of origin for 23% (1,753) of all foreign-born persons
with TB. Of TB cases among Mexican-born persons, three fourths were reported from the
four U.S. states bordering Mexico: California, 820 cases; Texas, 364 cases; Arizona, 67
cases; and New Mexico, 17 cases (3). In 1999, TB cases among Mexican-born persons
represented approximately 25% of all reported TB in the four border states. Incidence of
TB was higher for the majority of border counties than the national TB rate.
TB is brought into the United States from Mexico and Central America in three
ways: a) persons with active TB disease move northward across the border; b) persons
with latent TB infection experience active disease after arrival in the United States; or c)
U.S. residents touring Mexico, including immigrants, acquire TB disease after returning to
the United States (4--7). After a person with TB enters the United States, further
transmission might occur, which contributes to TB morbidity in the United States directly
from source patients and indirectly from their contacts.
Converging factors contribute to elevated TB incidence and complicate TB
control efforts along the U.S.-Mexico border. Mexico's higher TB rate of approximately 27
cases/100,000 population, compared with that of the United States, and the migratory
flow across the border result in elevated TB incidence in the geographic areas most
affected by cross-border immigration. Low socioeconomic status, crowded living conditions,
and limited access to health care increase the risk for TB transmission on both sides of
the border. Frequent bilateral border crossings and movement within the United
States contribute to delays in TB diagnosis and impede treatment completion. Language
and sociocultural differences also contribute to delays in seeking care and influence
adherence to treatment (8,9). Coordinating TB case management across an international
border is complicated, and among certain TB patients, outcomes are compromised.
Ultimately, lowering TB rates in the border area and reducing racial and ethnic
disparities of TB disease depend on identifying and treating infected persons on both
sides of the border until patients are cured. Therefore, TB prevention and control efforts
along the U.S.-Mexico border require the cooperation of local, state, and national TB
control programs in both countries, including strategies for coordinated interventions and
funding to ensure that adequate resources are available (Box).
To begin addressing this public health problem, the TB Along the U.S.-Mexico
Border Work Group was formed. In June 1999, staff of CDC's National Center for HIV, STD,
and TB Prevention/Division of Tuberculosis Elimination convened a meeting of TB
control officials from Arizona, California, New Mexico, and Texas to develop a coordinated
domestic strategy. After reviewing the epidemiology of the TB epidemic from national
and local perspectives, the work group focused on a) surveillance needs, b) case
management and therapy completion, c) performance indicators and program evaluation, and
d) research needs. For each of these topics, the participants identified key problems,
objectives, and resources needed to enhance TB prevention and control efforts along
the border. The following programmatic actions for federal agencies and state and local
TB control programs were then identified:
establishing a consensus case definition for a binational TB case and
assessing the need for a registry of binational cases;
improving the clinical care of binational TB patients and their close contacts in
the border states by expanding existing activities and developing new programs
for TB diagnosis and case management to ensure treatment completion;
creating evaluation tools for TB prevention and control efforts, including
contact investigations and targeted testing of populations at high risk; and
setting research priorities.
This report contains the work group's proposals regarding these programmatic
actions. These proposals are not CDC directives, but they should be regarded as a
starting point for public health practice and TB prevention and control interventions.
BACKGROUND
Geographic Characteristics of the U.S.-Mexico Border
The U.S.-Mexico border is approximately 2,000 miles long and separates four
U.S. states --- California, Arizona, New Mexico, and Texas --- from six Mexican states ---
Baja California Norte, Sonora, Chihuahua, Coahuila, Nuevo León, and Tamaulipas
(Figure 1). Approximately 1 million persons cross the U.S.-Mexico border daily. Major
metropolitan areas straddle the border, including San Diego-Tijuana (population: 4 million persons),
El Paso-Ciudad Juarez (1.9 million), Laredo-Nuevo Laredo (0.4 million),
Brownsville-Matamoros (0.5 million), and Harlingen/McAllen-Reynosa (1 million). Two of these
areas, San Diego-Tijuana and El Paso-Ciudad Juarez, account for 40% of daily border
crossings. Although they are legally separate cities, these sister cities have become closely
integrated binational and bicultural communities by sharing social, environmental, and
economic interests and problems.
Counties along the U.S.-Mexico border are among the poorest economically in
the United States. Approximately one third of U.S. border families live at or below the
poverty line compared with a national average of 11%
(10,11). An estimated 400,000 persons live in the United States along the Texas border in
colonias (i.e., semirural communities) without access to public drinking water or wastewater systems.
Unemployment rates in the border area are approximately threefold higher than those in
the rest of the United States. A total of 10 of 24 counties evaluated along the
U.S.-Mexico border are medically underserved and of low socioeconomic status
(12). During 1990--1996, communicable diseases other than TB (i.e., brucellosis, measles, hepatitis A,
hepatitis B, mumps, pertussis, salmonellosis, and shigellosis) occurred at higher rates in
U.S. border counties than in nonborder counties
(13). Diabetes, which increases the risk
for TB, is also more common among Hispanics and American Indians compared with
non-Hispanic whites (14).
TB Rates in the Border Area
TB rates among border communities are higher than the rates for their
respective states overall (Figure 2, Table
1). During 1998--1999, the average TB rates/100,000
population were 22.9 in Laredo and 39.7 in Nuevo Laredo, compared with 8.7 in Texas
and 33.1 in Tamaulipas. Rates in other border-city pairs were 21.8 in Brownsville and 70.3
in Matamoros; 15.1 in McAllen and 43.9 in Reynosa; and 10.1 in El Paso and 17.8 in
Ciudad Juarez (Eugene J. Tamames, Texas Department of Health, personal
communication, July 2000). The TB rate in San Diego County was 10.3/100,000 population, but
among Hispanics of predominately Mexican descent, the rate was 23.5 cases/100,000
population, higher than the state rate of 12.9 for Hispanics (Reuben M. Granich, M.D.,
M.P.H., California Department of Health Services, personal communication, July 2000). A
1998 tuberculin testing program in one San Diego County school district identified a 32%
skin-test--positive rate among Mexican-born high school students
(15).
Overall TB incidence is higher in Mexico than in the United States. The 1999
incidence of pulmonary TB in Mexico was 17 cases/100,000 population nationally and 27.1
cases/100,000 population along the U.S.-Mexico border (Elizabeth Ferreira, M.D.,
Mycobacterium Prevention and Control Program of Mexico, personal communication, July
2000).
Adjusting for underreporting, the World Health Organization estimates the incidence
of pulmonary TB in Mexico to be 45 cases/100,000
(16).
Prevalence of drug-resistant TB strains increases concerns regarding the
cross-border spread of TB. In 1997, CDC and the Secretariat of Health of Mexico conducted
a population-based survey to gather data regarding TB drug resistance for the three
Mexican states of Baja California Norte, Sinaloa, and Oaxaca
(17). In those Mexican states, drug-resistance rates for
>1 of the first-line drugs (i.e., isoniazid, rifampin, or
pyrazinamide) used among new and retreatment patients with sputum-smear--positive
pulmonary TB were 13% and 51%, respectively. However, one study demonstrated that
limiting drug-resistance surveillance to acid-fast bacilli smear-positive cases might
underestimate the rate of primary drug resistance in Mexico
(18). Similarly, retreatment patients were more likely than new patients to have isolates of multidrug-resistant TB (i.e.,
resistance to isoniazid and rifampin) (2.4% and 22%, respectively). In 1997, in contrast,
1.4% of culture-positive patients in the United States had multidrug-resistant TB
(19).
Characteristics of TB Cases Reported from U.S.
States Bordering Mexico*
During 1993--1998, the four border states reported to CDC a total of 8,661 TB
cases among Mexican-born persons. The proportion of TB cases among Mexican-born
persons from counties bordering Mexico was similar for Arizona (43%), New Mexico (41%),
and Texas (42%); however, the proportion was substantially lower for California (14%).
A higher proportion of cases were among Mexican-born persons aged 15--44 years;
otherwise, characteristics were similar between Mexican-born and U.S.-born TB
patients (Table 2).
Data reported to CDC during 1993--1998 confirm higher drug-resistance rates
among Mexican-born TB patients than among U.S.-born TB patients. Ninety five percent
(5,756) of reported culture-positive TB cases among Mexican-born persons and 92% (12,969)
of cases among U.S.-born persons without a previous history of TB had initial
drug-susceptibility test results for isoniazid and rifampin. Of these, 9.1% of initial isolates from
Mexican-born persons and 4.4% of those from U.S.-born persons were resistant to isoniazid
at least; 1.4% of initial isolates from Mexican-born persons and 0.6% of isolates from
U.S.-born persons were multidrug-resistant TB.
During 1993--1998, date of arrival in the United States was reported for 89% of
TB cases among foreign-born persons from the four border states. Approximately 54%
of Mexican-born TB patients resided in the United States for
>5 years before their TB was diagnosed; 14% of Mexican-born TB patients had lived in the United States for <1
year before their TB was diagnosed.
During 1995--1997, a study was conducted of TB cases reported among
foreign-born Hispanics from eight U.S. counties bordering Mexico and seven urban nonborder
counties in the four border states (20). Results from that study regarding the migration
practices of TB patients in the border area demonstrated that, compared with patients
from nonborder counties, foreign-born Hispanic TB patients
had lived in the United States longer (17 versus 11 years);
more often had immigrated from Mexican border communities (62%
versus 25%);
more often had returned to Mexico weekly (38% versus 2%) or during the past
12 months (72% versus 47%); and
more often had been born in Mexico (94% versus 80%).
SURVEILLANCE NEEDS
To better understand the epidemiology of TB cases along the U.S.-Mexico
border, surveillance needs (e.g., development of a case definition and TB registry for
binational cases) should be addressed.
Case Definition
No standard surveillance definition for a binational TB case is in use by border
TB control programs; thus, using a uniform case definition would enable standardized
data collection and increase accuracy in data analysis and comparison. A standardized
case definition should be flexible enough to encompass all factors related to binational
TB patients and the health providers who serve them, yet specific enough to facilitate
accurate, consistent reporting. Additionally, the binational TB case definition should
enable collaboration with Mexico's programs and public health providers who might use a
different TB case definition than that used in the United States.
Work Group Proposal
The work group defines a binational TB case as one that meets the U.S. or
Mexican case definition for active TB disease
(21,22) plus one of the following criteria:
Optimal case management requires communication or collaboration with
TB control programs or health-care providers on the opposite side of the border.
For example, a TB control program in the United States would transfer clinical
or laboratory data, refer a patient for treatment completion, or share information
for contact investigation with a Mexican TB control program.
The case-patient is a contact of a binational TB case-patient or is the TB
source case-patient for contacts on the opposite side of the U.S.-Mexico border.
Registry of Binational TB Cases
U.S. TB control programs along the border identify locally defined binational cases
in their own TB registries, but none maintains local or statewide electronic records
for these cases. An electronic registry of binational TB cases available to all programs
would a) enhance documentation of the number of TB cases not included in the annual
TB morbidity count, b) facilitate sharing of up-to-date clinical data (e.g., prior anti-TB
drug treatment), and c) improve case management of binational TB cases.
Fundamental requirements for creating an electronic binational TB case registry
are a standard case definition and key database variables. Those key database
variables should reflect the unique characteristics of binational TB cases. Critical variables
include information regarding the frequency and duration of border crossings before and
during treatment, INS custody and disposition, anti-TB drug treatment regimen, drug
resistance, treatment using directly observed therapy, and beginning and ending
treatment dates. Creating a binational TB case database also requires decisions regarding
responsibility for database development and maintenance,
data validation and security,
ability to link with other databases,
ease of modification and updating,
data analysis capability,
report-generation capability,
patient confidentiality, and
cost.
The work group proposes the following three options for developing a unified
registry of binational TB cases:
CDC's TB Information and Management System
(TIMS). TIMS is a comprehensive software for surveillance, patient management, and
program evaluation that is used by U.S. state health departments to report TB
surveillance data to CDC. In each jurisdiction, TIMS can be adapted for local use as a registry
of binational TB cases via the user-defined variable option. Advantages include
the current availability of the system throughout the United States.
Disadvantages include the necessary computer support, confidentiality, and the
current limitations to directly link TIMS with other jurisdictions in the United
States; however, indirect links are possible by using exported data sets from TIMS.
Internet-based system. An Internet-based system, modeled on fully
operational existing systems (e.g., OpenEMed ** [formerly TeleMed], which was developed
by Los Alamos National Laboratory and National Jewish Medical and
Research Center), could provide a secured database of binational TB case records
available for viewing and updating. Such a system would have advantages for
following and managing patients whose TB care spans multiple locations in the
United States and Mexico. An Internet-based system would require data
security, analytic capabilities, ability to link with existing databases, platform-
and operating-system independence, and users' ability to access a secured
Internet site. Additional information is needed regarding feasibility, cost,
maintenance, data security, data integrity, and access to data in English and Spanish.
Existing binational program databases. Electronic databases from
existing binational referral and follow-up programs could be used. CURE-TB and TB
Net are two such programs that have electronic databases, but they use
different software and formats. In addition, their primary function is patient follow-up
and management rather than surveillance.
Work Group Proposals
CDC should
work with TB control programs in the United States and Mexico to a) verify
the need for a unified registry of binational TB cases; and b) determine if an
existing system could be modified for broader use and interfaced to reliably and
securely share information or if a new system should be developed.
work with TB control programs, if developing a registry, to a) define the
registry variables, b) ensure data security and validation, and c) analyze registry data
to monitor case trends and identify populations at high risk.
review current public health laws and clarify which surveillance data can
be shared among TB control programs in the United States and Mexico.
State and local TB control programs should
collaborate with one another and CDC to determine a) the feasibility of
creating and maintaining a secure registry of binational TB cases, b) the sharing
of responsibilities for maintaining and updating the registry, and c) what would
be ideal mechanisms for data sharing, security, and use.
collaborate with one another and CDC to determine a) the type of
database template to use, b) the primary function of the database (e.g., surveillance,
case management, or both), and c) key variables to be included. If an
Internet-based database is preferred, the collaborators should first assess users'
Internet-access capabilities and the costs for ensuring Internet access for users of the
surveillance system.
consider adding variables to the locally defined fields in TIMS to identify
and follow trends among binational TB cases to facilitate data comparison
among jurisdictions.
work with CURE-TB, TB Net, and other binational referral and follow-up
systems to avoid duplication of effort and improve case referral, follow-up,
and documentation of patients' medical histories.
CASE MANAGEMENT AND THERAPY COMPLETION
Optimal TB case management includes prompt disease diagnosis, close
monitoring of medical regimens, assurance of adherence to treatment, and identification and
evaluation of close contacts. Each of these strategies becomes more difficult when case
management must be coordinated among health jurisdictions, particularly
across international borders. Because the highest percentage of foreign-born TB patients
living in the United States comes from Mexico, shared case management could occur
frequently between the two countries. Coordination mechanisms should address
differing national case definitions, national protocols, priorities, and resources as well as
cultural and language differences. In the immediate U.S.-Mexico border area, case
management involves substantial numbers of persons moving across the border as often as daily.
TB patients who live on one side of the border might have their disease diagnosed or
treated in the adjacent country; therefore, investigation of close contacts often involves
school, work, and social settings on both sides of the border. Limited forums exist for
disseminating information regarding successful case-management strategies across
international borders. Ongoing coordination among TB control programs in border areas is vital,
and local efforts to enhance these relationships should be encouraged.
Finding and Managing Active TB Cases
U.S. and Mexican citizens cross the border for TB diagnosis and treatment
without routinely notifying health departments of either country of their origin or
destination. Additionally, immigrants from Mexico and Central America who do not have
documentation of citizenship or visas are not screened for active TB. Case management might
be compromised because of gaps and changes in treatment and failure to share clinical
and diagnostic information, perform timely contact investigations, and promote
therapy completion (23). Improved communication among TB agencies and health-care
providers at local, state, national, and international levels is needed to ensure effective
case management and to coordinate care and completion of therapy.
Work Group Proposals
CDC should
review privacy laws and clarify what case-specific information can be
shared among health departments and private health-care providers in the United
States and Mexico for providing clinical care.
determine, for those Mexican and Central American immigrants identified
during immigration screening as possibly having TB, the number who complete
their diagnostic evaluation and treatment. The number of legal immigrants who
are required or advised but fail to appear at the health department for testing
and evaluation should also be determined.
State and local TB control programs should
develop new or strengthen existing partnerships with counterpart
health departments in Mexico to report and refer active TB case-patients and
close contacts who cross the U.S.-Mexico border for case management.
Also, procedures should be developed for referrals among U.S. and
Mexican nonborder TB control programs, including use of CURE-TB and TB Net.
facilitate partnerships with health-care providers of TB patients on both sides
of the U.S.-Mexico border. Partnership agreements (e.g.,
memoranda-of-understanding) should include timely reporting of active TB cases,
treatment outcome evaluations to improve completion of therapy, educational
material distribution, and training sessions for private health-care providers to
improve the recognition of TB symptoms and the evaluation of symptomatic
persons. Further, health-care providers along the U.S.-Mexico border should have
current guidelines for the care, treatment, and referral of active TB case-patients and
for seeking expert consultation for drug-resistant cases.
document effective strategies that can be used in other communities for
cross-border notification of active TB case-patients and close contacts. These
strategies should be shared formally and informally at meetings or through publications
and the Internet.
establish links with physicians (i.e., civil surgeons and panel physicians)
who evaluate immigration applicants and with community-based
organizations (CBOs) to conduct case-finding activities and provide information for
those persons in need of local TB services.
develop and evaluate activities to inform communities and educate
family members of TB patients regarding the availability of local services and
reevaluate those activities regularly.
identify potential barriers to establishing rapport with binational TB patients
and then develop case-management practices that actively address these barriers.
Funding To Provide Direct Services
TB control programs use their financial resources to provide services along the
U.S.-Mexico border. Certain U.S. health departments have memoranda-of-understanding
with Mexican health departments to provide diagnostic and therapeutic services in
Mexico. Other health departments provide services to Mexican TB patients in the United
States or facilitate co-management of patients who work or live on both sides of the
border. However, current Health Care Financing Administration (HCFA) regulations only
permit reimbursement for emergency care to persons without documentation of citizenship
or visas, but when these persons fail to complete TB treatment, the health of the U.S.
public is at risk. Ensuring treatment completion for active TB disease is a priority for TB
control programs. In addition, treatment of latent TB infection is cost-effective in reducing
the burden of disease and limiting future spread of TB infections
(24).
Work Group Proposals
CDC should
work with border TB control programs to address case-management
priorities and ensure that activities are evaluated against established goals, objectives,
and outcomes. Border states will need guidance regarding federal funding sources
for TB case-management and program evaluation activities.
collaborate with HCFA to explore amending Medicaid regulations to allow
funding for TB treatment to cure for persons without citizenship or visa documentation
but who otherwise would be eligible for Medicaid.
State and local TB control programs should
emphasize technical assistance, quality improvement, and enhanced
follow-up and communication to co-manage binational patient care in their interactions
with Mexican counterparts.
Ensuring TB Patient Care While in INS Custody
In 1996, approximately 5 million immigrants were living in the United States
without documentation of citizenship or visas
(25). As with legal immigrants, Mexico was
the leading country of origin for undocumented foreign-born immigrants, accounting for
an estimated 54% of the total number and 54% of the estimated annual increase
(25). Approximately 2 million immigrants were living in California without documentation
of citizenship or visas, and 700,000 more were living in Texas. In 1996,
approximately 73,000 undocumented immigrants (73% from Mexico) were expelled through the
judicial process, and 1.6 million (99% from Mexico) were expelled through an INS
procedure known as "voluntary return under safeguards." All such persons are detained in
custody under INS observation until their departure. Although the exact proportion of INS
detainees having TB is unknown, the rate of active TB disease among Mexican-born
persons without documentation of citizenship or visas could be higher than Mexico's
national average. For example, at the Port Isabel, Texas, facility in 1998, 14 persons had active
TB disease, a rate of 116 cases/100,000 detainees, which is substantially higher than
the rate in Mexico (Abraham Miranda, M.D., personal communication, October 2000).
Because standard data regarding the disposition and outcomes of TB patients in
INS custody are not collected, the magnitude of this problem is unknown. In addition,
the majority of detainees are housed in local jails and state prisons, each of which has its
own TB screening policies and relationships with TB control programs. Detainees are
transferred frequently between facilities, and certain facilities might not transfer
medical records containing TB status information.
Another barrier to TB patient care while in INS custody is the lack of
communication among TB control programs, federal agencies, and local and state facilities that
house INS detainees. Immigrants without documentation of citizenship or visas might be
released to the community or deported to their country of origin without notification
of medical staff providing care to TB patients while in INS custody or the local health
department. Also, undocumented immigrants might return to the United States after release
in their country of origin. INS has no system for informing local TB programs regarding
the disposition of active or suspected TB cases. Resulting lapses in treatment can lead
to continued TB transmission and development of drug-resistant TB.
Work Group Proposals
CDC should
discuss the INS system, problems related to TB patients in INS custody, and
areas for collaboration with INS, USPHS/Division of Immigration Health Services,
and local, state, and federal correction agencies.
clarify what case-specific information can be shared legally among
health departments, private health-care providers, and INS. Legalities of
ensuring completion of therapy by TB patients slated for exclusion or deportation
should also be determined by the legally responsible agencies.
consult with USPHS/Division of Immigration Health Services regarding
policies and practices for TB case reporting; discharge planning, including notification
of Mexican consulates; continuity of care; and notification of local TB
control programs for community contact investigations for active and suspected
TB cases.
work with INS to develop a system for monitoring and collecting data
regarding active and suspected TB patients in INS custody (e.g., number of cases
identified, length of treatment before release, drug-resistant TB, arrangements for
ongoing care, location of release, and rate of return to the United States). These
data should be shared with health departments.
State and local TB control programs should
create liaisons with local INS officials to provide educational materials
regarding TB to personnel who work directly with detainees, ensure timely reporting
of active and suspected TB cases, establish referral systems to increase
continuity and completion of treatment, and provide medical consultation as needed.
work with local facilities housing INS detainees to ensure that systems are in
place for identifying, isolating, and treating active and suspected TB patients.
identify barriers to therapy completion after patients with active TB are
released from INS custody and assess the impact of measures to maintain continuity of
TB care among detainees or deportees.
collaborate in developing Spanish-language materials that specify the
locations of local TB services, including binational TB referrals, that do not
require documentation of residence status and that state that confidentiality will
be maintained. These materials should be given to TB patients in INS custody and
to TB patients who do not have citizenship or visa documentation and are
therefore at risk for being detained by INS.
PERFORMANCE INDICATORS AND PROGRAM EVALUATION
Performance Indicator: TB Testing Among Border Populations
Unlike immigrants with citizenship or visa documentation, immigrants to the
United States from Mexico without such documentation are not screened upon entry for
TB disease, human immunodeficiency virus (HIV) infection, and other health conditions
that influence the risk for progression from latent TB infection to active disease.
Previously uninfected immigrants from Mexico sometimes acquire latent TB infection after
settling in U.S. communities that have a high prevalence of TB. Targeted testing of specific
populations at high risk is one strategy for finding and treating binational patients who
arrive in the United States with active TB disease or who are at risk for progression to
active disease (26,27). Priority groups for targeted testing and completion of treatment
include a) persons with HIV infection or other medical conditions (e.g., diabetes) that increase
the risk for active TB disease, b) medically underserved persons (e.g., incarcerated
persons or persons from areas of low socioeconomic status), and c) immigrants from Mexico
who have lived in the United States for <5 years
(27). However, identifying, evaluating, and treating to completion the close contacts of infectious TB patients should remain a
higher priority than targeted testing of certain populations. Screening of populations at low
risk is strongly discouraged.
Work Group Proposals
CDC should
assist in developing tools to evaluate the cost-effectiveness of targeted
testing programs.
evaluate the usefulness of surveillance data and epidemiologic investigations
for defining populations in border communities with a high prevalence of latent
TB infection.
develop an ethnographic and epidemiologic profile of persons at risk for
TB, investigate the health beliefs and care-seeking patterns of those at risk,
and define the patterns for TB transmission to other populations.
State and local TB control programs should
evaluate outcomes for persons who have been started on treatment for latent
TB infection, stratified by ethnicity and place of birth.
establish working relationships and formal memoranda-of-understanding
with providers who serve targeted populations (e.g., correctional facilities,
managed care organizations, HIV clinics, and migrant health clinics) to evaluate
the effectiveness of testing and treatment practices.
seek partnerships with CBOs, schools, work sites, and others to evaluate
and improve the testing of recent immigrants and treatment-completion rates
for those person with active TB disease.
train private providers who serve targeted populations regarding techniques
of tuberculin skin testing and educate them regarding the importance of
appropriate treatment for latent TB infection.
inform communities of immigrants without documentation (e.g., through
Spanish-language community radio announcements) that persons who have or
believe they have active TB disease or latent TB infection can be evaluated and
treated with confidentiality.
Performance Indicator: Laboratory Support
Sharing laboratory data regarding binational TB patients whose disease was
diagnosed in Mexico should be a critical component of case management for TB patients
in the United States. In addition, laboratory data for binational TB patients should be
linked with U.S. surveillance data. However, transfer of laboratory data among programs
requires a secure, confidential information system. Laboratory facilities in certain
Mexican border health departments lack the equipment and infrastructure to confirm diagnosis
of TB bacteriologically (cultures are not routinely performed by Mexican TB control
programs along the border). Collaboration between Mexican and U.S. laboratories
could increase Mexico's expertise in diagnosing TB disease and enhance their quality control.
Work Group Proposals
CDC should
work with state and local TB control programs to develop key variables
for reporting laboratory data; these variables should be incorporated in the
proposed registry of binational TB cases.
continue working with the Mexican National Public Health Laboratory
Program and U.S. and Mexican border states to build laboratory quality and
proficiency testing.
State and local TB control programs should
seek opportunities, in collaboration with CDC, to strengthen TB
diagnostic capabilities in Mexican border states, with an emphasis on improving
smear microscopy and culture capability consistent with Mexican TB control
policies. Suggested support activities include improving quality control, training
for technicians, and identifying funding resources for equipment.
Performance Indicator: Contact Tracing
Contact tracing is a critical but complex component of identifying persons who
have active TB disease or who have latent TB infection and are at high risk for
experiencing active TB disease. Contact tracing for binational TB patients can be made even
more complex by a patient's reluctance to divulge contacts, even to bicultural outreach
workers (28). Binational patients fear the stigma of disease and the possible social and
legal repercussions of a TB diagnosis (e.g., loss of housing, employment, and income or
legal action against persons without citizenship or visa documentation). Also, lack of
experience with or understanding of preventive health models, cultural beliefs regarding
causes of TB other than a germ-based etiology, and self-medication approaches to
treatment (e.g., use of herbal products) might interfere with adherence to public health interventions
(29).
Health-care providers and public health officials might be unsympathetic
regarding the problems of border-crossing patients, which can limit the effectiveness of
contact tracing. Further, TB contact investigators might lack training in necessary
interviewing skills for eliciting personal information from patients. Investigators might fail to
understand patients' motivations, priorities in relation to a TB diagnosis, and adherence
to program guidance. Language and cultural barriers can hinder communication even
further. Lack of understanding of the social patterns of binational patients can impede
contact tracing. As a result, the traditional contact-tracing concentric-circle model
(30) might not be effective in identifying close contacts because of differing social patterns.
Deficiencies in communication among public health jurisdictions can hinder contact
investigations, especially if coordination must span international borders. Finally, protocols
for contact tracing differ between the United States and Mexico
(22,31,32).
Work Group Proposals
CDC should
develop, in conjunction with state and local TB control programs,
standardized, linguistically and culturally appropriate contact interview questions intended
to elicit contact information regarding cross-border social networks and
extended family structures.
work with state and local health departments to develop a culturally
sensitive interview training program for TB contact investigators. Training
programs should emphasize principles of reflective listening
(33--35), and their content should be based on studies of hard-to-reach populations.
support a sociobehavioral study of binational TB patients' priorities,
motivations, and expectations, and the ways in which these affect adherence to
recommended TB evaluation and treatment. Key issues include binational patients'
experience with health care in their country of origin and in the United States, reasons
for moving to the United States, and perceptions regarding government agencies.
State and local TB control programs should
work with CDC on projects designed to enhance the understanding of TB
patients' culture, experiences, opinions, motivations, and concerns.
designate a liaison to work with other jurisdictions in coordinating
contact investigations across state and international borders, within a context of
differing
protocols and policies in Mexico. The usefulness of patient interviews in
the United States to identify close contacts in Mexico should be evaluated.
collaborate with CBOs that serve binational TB patients to determine if
techniques used in other screening programs (e.g., use of nonprofessional community
health workers as liaisons and educators) could enhance contact tracing.
seek to benefit from other public health programs in understanding the
social networks in the community and to acquire new, more effective
interview techniques.
Program Evaluation
Performance of TB control programs among binational populations has not
been characterized adequately in terms of prevention and treatment interventions
because program evaluation requires sharing the three performance indicators as
discussed previously. These indicators should be based on a hierarchy of programmatic goals:
a) measurable outcomes of TB diagnosis and treatment for persons with active disease,
b) efficient processes for ensuring the completion of treatment of persons with TB, and
c) adequate infrastructure for the system that delivers TB services.
Work Group Proposals
CDC should
work with local, state, and federal agencies with expertise in TB control
and program evaluation to agree on and disseminate a framework for
program evaluation designed explicitly for binational TB cases. Specific
performance indicators should correlate with the priority goals and activities identified
during that process.
evaluate state-based and other binational TB control programs,
including binational referral and follow-up systems, by applying the performance
indicators included in the evaluation framework.
assist in devising tools for evaluating contact investigations of binational
cases and determine the operational outcomes and cost-effectiveness of
expanding contact investigations beyond close contacts.
State and local TB control programs should
develop and share instruments for collecting data regarding
program performance indicators and set objectives on the basis of those indicators.
Pilot testing of the indicators to determine their usefulness and validity would
be needed during the development process.
use program performance indicators and the evaluation framework,
including indicators based on standards of practice, to document needed resources.
RESEARCH NEEDS
Identifying Strategies To Eliminate TB Disease
As TB incidence declines in the United States, public health strategies must
extend beyond traditional TB control measures to activities that will eliminate TB disease
(31). These strategies should include active case finding, targeted testing and treatment
of populations at high risk for latent TB infection, and promotion of regional TB
control efforts along the U.S.-Mexico border. Despite advances made during the 1990s,
applied public health research is needed to identify the best strategies for eliminating TB disease.
Applied research to improve TB control efforts along the U.S.-Mexico border
must address two groups distinguished by their pattern of movement and the
health-care systems that serve them. The first group consists of binational patients and their
close contacts for whom recent or ongoing cross-border travel affects case
management, contact tracing, and source-case investigation. The second group consists of
patients who acquired TB in Mexico or Central America, and their contacts in the United
States, whose case management is less complicated by international travel, but who
might migrate between jobs in the service, construction, and agricultural industries in
defined patterns in the United States (Figure 3). This group might benefit from targeted
testing and treatment for latent TB infection. For example, during the early 1990s, among
Mexican-born persons seeking adjustment of their residency status in Denver, Colorado,
an estimated 40% had tuberculin skin tests indicating that they had latent TB
infection, compared with an estimated 4% of the U.S. population
(36).
Work Group Proposals
CDC should
assist state and local TB control programs in analyzing surveillance data
and conducting studies to identify trends, opportunities, and knowledge gaps
related to binational TB patients.
advise policy makers, public health program personnel, researchers,
funding organizations, and others regarding priorities for public health research
on binational TB cases in the context of the national TB prevention and
control program.
assist researchers in minimizing duplication and encourage immediate,
effective developments in applied public health research regarding TB.
State and local TB control programs should
increase use of local data and experience to advise CDC and state and
local authorities regarding the epidemiology of TB among binational
populations, practical problems in TB control, and emerging situations that might
require attention or action.
evaluate the efficiency of TB prevention and control activities and
update performance indicators as needed.
in collaboration with health-care providers, define the contributions
of subpopulations to TB morbidity in their jurisdictions. The role of
congregate settings (e.g., correctional institutions, shelters, dormitories, migrant
worker camps, and hospitals) in facilitating TB transmission among these
populations should also be assessed.
Areas for Additional Research
Binational TB case surveillance. Although national surveillance data
have included ethnicity since 1980 and country of origin since 1993, these variables
do not capture the information needed to determine whether a TB case could
be classified as binational. Furthermore, data are not collected routinely
regarding the movement of TB patients to, from, or within Mexico, except for the date
of entry into the United States. Therefore, determining the problem's
magnitude, contributions of different groups, or relative risk attributable to specific
risk factors is not possible. Without this information, assessing the burden of
TB disease by geographic region and targeting prevention and control
efforts accordingly is inefficient.
Delayed treatment. Rapid disease diagnosis and prompt initiation of
treatment are critical in curbing TB transmission within the community. Anecdotal
evidence based on clinical experience implies that binational patients' disease is
diagnosed and treated at more advanced stages of illness than that of other patients.
Such patients might visit two or more health-care providers before treatment
is started. Research is needed to determine the true frequency of these cases
and, if elevated, to identify the risk factors.
Treatment completion. Mobility of binational patients within the United
States and bilaterally across the U.S.-Mexico border complicates the continuity
of treatment and decreases the rate of treatment completion. Only limited
data regarding the outcomes of binational cases and the factors that contribute
to satisfactory outcomes have been published
(23,37,38). Also unclear is the extent to which resources should be directed toward developing and
evaluating methods to ensure that treatment is completed. Without this knowledge,
methods are unreliable for determining a) which aspects of the clinical and public
health management of binational TB cases are beneficial, b) which aspects should
be encouraged, and c) which aspects should be improved, modified, or abandoned.
Drug resistance. Limited data regarding drug resistance among Mexican
TB patients in both countries have been published
(18,39,40). Clinicians who serve TB patients from Mexico report high levels of drug resistance, but no clearly
defined, population-based data have been compiled to determine the incidence
or prevalence of drug-resistant TB among binational patients. Moreover,
only recently has Mexico adopted standards for retreating patients and
started promoting directly observed therapy. Research is needed to determine levels
of drug resistance and risk factors contributing to drug resistance among TB
patients from Mexico.
Contact investigation. Mexican policies and practices for contact tracing
differ from those of the United States, and thorough contact tracing, testing,
and treatment of latent infection might be difficult or impossible in
foreign jurisdictions. Highly mobile patients might have contacts in multiple locations
in the United States, complicating the identification, testing, and treatment
of latently infected persons as well (Figure 4). Data are needed to quantify the
extent to which these considerations affect binational populations
(41,42). Information regarding the cost-effectiveness of contact tracing would enable efforts to
be directed effectively.
Targeted testing. Foreign-born residents and visitors from countries having
a high incidence of TB, including Mexico and Central America, can be at risk
for latent TB infection or active TB disease. With the exception of the
required radiologic screening of applicants for immigrant visas and for adjustment
of immigration status (43), no systematic procedures have been applied to
test foreign-born persons for latent TB infection. Although certain approaches
have been attempted at the local level, conclusive cost-outcome or
cost-effectiveness data are limited
(36,44,45). Therefore, how best to target binational
populations for testing and treatment of latent infection is unknown as is reaching
subgroups who might provide opportunities for TB prevention and ensuring completion
of treatment (46). Historically, treatment-completion rates for latent TB
infection have been lower than for active TB disease, making necessary the
reassessment of existing strategies for treatment of latent TB infection. Evaluating
which strategies are cost-effective will be critical.
Work Group Proposals
CDC should
work with state and local TB control programs to determine the extent to
which reported TB morbidity in the United States originates in Mexico and
Central America by focusing on geographic areas and populations that have high rates
of binational TB cases.
collaborate with state and local TB control programs to assess and
quantify delays in completing treatment and factors that contribute to delays.
work with state and local TB control programs to determine the magnitude
and impact of mobility among binational patients on treatment completion and
health outcomes.
determine the epidemiology of drug-resistant TB among binational patients.
State and local TB control programs should
collaborate with public health and social scientists to develop and
evaluate innovative methods for tracing, testing, and treating contacts of
binational patients. Studies should compare new strategies with past practices.
in accordance with new CDC guidelines for targeted testing and treatment
of latent infection (47), a) develop methods to identify persons at high risk for TB
who would benefit from treatment of latent TB infection, if detected; b) test
these persons for latent TB infection; and c) treat to completion latently
infected persons. Identifying persons at risk for latent TB infection could be done on
the basis of local epidemiologic profiles or other methods. Cost and outcomes
or effectiveness of strategies should be assessed as an integral component of
this research.
Acknowledgments
We acknowledge the following persons for their contributions throughout the
preparation of this report: E. Elizabeth Ferreira, M.D. and Mario Martinez Gonzalez, M.D., Mexico's
TB Prevention and Control Program; Anna Flisser Steinbruch, Ph.D., Mexico's National
Public Health Laboratory Program; Gene Migliaccio, Dr.P.H., Division of Immigration Health
Service, U.S. Public Health Service; Newton E. Kendig, M.D., Federal Bureau of Prisons; Chris
Marcey, Immigration and Naturalization Service; L. Massae Kawamura, M.D., Advisory Council for
the Elimination of TB; Sonia Contreras, M.S., CURE-TB; John Byrd, TB Net; Patricia Hassakis
and Luis Ortega, border health offices; Diana E. Weil, M.D., World Bank; Jeff P. Taylor, M.P.H.,
Texas Tuberculosis Control Program; Sarah E. Royce, M.D., M.P.H., California Tuberculosis
Control Branch; George W. Rutherford, M.D., M.P.H., California TB Elimination Advisory
Committee; Barbara J. Hummel, Colorado TB Prevention and Control Program; David E. Griffith,
M.D., University of Texas Health Center; Lee W. Riley, M.D., University of California; and from
CDC, John C. Ridderhof, M.D., Public Health Practice Program Office; Tony D. Perez, Division
of Quarantine; Jay F. McAuliffe, M.D., M.P.H., Office for Global Health; Louis Salinas,
M.P.A., National Center for HIV, STD, and TB Prevention; and John J. Seggerson, M. Elsa
Villarino, M.D., and H. Mack Anders, Division of TB Elimination.
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*
Unless otherwise noted, information in this
section is based on national TB surveillance data reported by state programs to
CDCs Division of Tuberculosis Elimination.
BOX. Selected cooperative tuberculosis (TB) control activities
along the U.S.-Mexico border, including binational projects, case-referral
systems, and initiatives for TB surveillance and laboratory training
Texas-Mexico Border Projects
In 1991,
the Texas Department of Health
established three projects to provide case
management for TB patients and their
contacts who live or work in both the United States and Mexico. Projects include
Project Juntos (serving El Paso-Ciudad
Juarez and Las Cruces, New Mexico, West
Texas, and Ojinaga in Chihuahua); Los Dos
Laredos (Laredo-Nuevo Laredo area); and
Grupo Sin Fronteras (lower Rio Grande
Valley, including the Brownsville-Harlingen-McAllen
area in Texas and the Matamoros-Reynosa
area in Mexico). The three projects managed 884 binational TB patients and their contacts through 1998
and continue to provide laboratory support
for diagnosis and case management
through cooperative relationships among
TB control programs on both sides of the
border.
Arizona-Sonora Binational Projects
Three cross-border projects were established
in 1996 by Arizona Department of
Health Services in collaboration with the
Sonora, Mexico, state health department.
Serving Santa Cruz County-Nogales,
Cochise County-Agua Prieta, and Yuma
County-San Luis Rio Colorado, the projects
monitor multidrug-resistant TB, provide
directly observed therapy, conduct
outreach for patients who have missed
clinic visits and who frequently travel
across the border, and provide Sonora with
support from the Arizona State Laboratory
Services.
California-Baja California Norte TB Committee
Since
the mid-1980s, representatives from
public and private TB control programs in
San Diego, Los Angeles, and Imperial
Counties, and Baja California Norte have
been discussing management of binational
cases, planning joint activities (e.g.,
binational training), providing outreach to
practitioners and pharmacists, developing
educational materials, and conducting
media campaigns.>
Imperial-Mexicali Binational TB Projects
Two
annual events, a farm worker health
information fair in Calexico, California, and
a binational TB symposium for health-care
personnel in Mexicali, Baja California Norte,
provide information regarding TB, tuberculin
skin testing, and other health screenings.
A binational TB social marketing
campaign focuses on recognizing TB
symptoms and encourages early evaluation
through radio and television announcements
and billboards in the
Imperial and Mexicali Valleys.
CURE-TB
CURE-TB, operated by the San Diego
County TB control program since 1994, is a
joint U.S.-Mexico referral system designed
to improve the continuity of care for
patients with active TB disease and their
contacts who are at high risk. The project
provides education and assistance to
patients who move between Mexico and
the United States during the course of
their treatment. The system also notifies
providers in both countries of a patients
arrival in their communities and facilitates
the exchange of patients clinical information.
During 19972000, CURE-TB referred
250 active TB patients and 372 contacts for
testing and treatment. In 1999, 80% of the
active TB patients referred had completed
or continued their treatment.
TB Net
Based in Austin, Texas, and operated by
the Migrant Clinicians Network,* TB Net
assists persons who have difficulty
gaining access to medical services and
facilitates coordinated treatment by
multiple providers. The program provides
patients with a portable medical record and
referrals to nearby TB clinics and provides
health-care practitioners with a centralized
repository of medical information. During
1996March 2000, TB Net assisted 139
persons with active TB disease and 522
persons with latent TB infection.
National TB Genotyping and Surveillance Network
Organized in 1996 by health officers from the
four U.S.
and six Mexican border states and representatives from
nongovernmental organizations, Ten Against TB is
designed to strengthen binational collaboration,
enhance laboratory capacity, improve and
coordinate epidemiologic studies, optimize
case management, and promote public and
health-care provider awareness regarding TB.
Ten Against TB
In collaboration with Mexicos
national
public health laboratory program, CDC and
the Association of Public Health Laboratories
provide training in the border area.Participants
include staff from the six Mexican border states, four U.S. borderstates, and the National Laboratory
Training Network. In addition to providing
training in culture methods, CDC and
Mexico are collaborating on national
proficiency testing for >500 laboratories
that perform acid-fast bacilli microscopy in
Mexicos Secretaria de Salud system. That
program involves onsite assessment
combined with slide proficiency tests to
determine technical ability.
U.S.-Mexico Border TB Laboratorian Binational Training Project
Binational Training Project
The U.S. Health Resources and Services
Administration, the Pan American Health
Organizaiton, the U.S.-Mexico Border
Health Association, the U.S.-Mexico
Binational Commission, the U.S.-Mexico
Border Health Commission, the Border XXI
Program, state and local health departments,
and universities collaborate on
diverse projects to enhance TB control
efforts along the U.S.-Mexico border.
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