Directly Observed TherapyDirectly Observed Therapy Prescribed by a physician and required by policy Prescribed by a physician and required by policy

for all public and private patientsfor all public and private patients Strategy to ensure Strategy to ensure uninterrupteduninterrupted TB drug TB drug

therapy by a therapy by a trainedtrained ORW ORW Directly Directly observeobserve patient patient swallowing eachswallowing each andand

everyevery dose of prescribed TB drugsdose of prescribed TB drugs

Anywhere mutually agreed uponAnywhere mutually agreed upon

DOT regimes: daily, 2xW, 3xW, 5xW…DOT regimes: daily, 2xW, 3xW, 5xW…

Until the completion of prescribed therapy

Patient being observed by D.O.T. outreach Patient being observed by D.O.T. outreach workerworker

““El paciente que es observado por D.O.T. excede a El paciente que es observado por D.O.T. excede a trabajador” trabajador”

Contact Investigation; Screening

Investigación del contactos

Screening in Jails and PrisonsScreening in Jails and Prisons

Mobile Unit X-ray Digitizerused in screening high risk locations

Contact investigation in Brownsville, TexasContact investigation in Brownsville, TexasInvestigacion de contactosInvestigacion de contactos

Mask fitting for staffMask fitting for staff

Improved TB lab capabilityImproved TB lab capability

Infection control and MDR Infection control and MDR treatment by consultation at South treatment by consultation at South

Texas HospitalTexas Hospital

Before the binational projects Before the binational projects started:started:

No understanding of the other system, No understanding of the other system, protocols, contact investigation, or the protocols, contact investigation, or the use of BCG or INHuse of BCG or INH

““Drop-in” of dying MDR patients in Drop-in” of dying MDR patients in WIC waiting rooms with small childrenWIC waiting rooms with small children

No means of referral or coordinating No means of referral or coordinating patients who immigratepatients who immigrate

Communication difficultCommunication difficult

No information on drug resistance No information on drug resistance rates in Mexicorates in Mexico

No information of resistance by No information of resistance by culture on individual patientsculture on individual patients

No consistent MDR treatment nor No consistent MDR treatment nor available medicationsavailable medications

No permits to transfer specimens No permits to transfer specimens to US or supplies to Mexicoto US or supplies to Mexico

In 1993:

Binational successes and Binational successes and achievementsachievements

TATB: political will to consider the TATB: political will to consider the problem of MDR-TB and cooperation problem of MDR-TB and cooperation at the national levelat the national level

Reynosa technical committeeReynosa technical committee DOT almost universalDOT almost universal Provide cultures for border cities in Provide cultures for border cities in

TampsTamps Equipment for X-ray, lab, infection Equipment for X-ray, lab, infection

controlcontrol Signed agreementsSigned agreements USAID fundingUSAID funding

Rates by Age Groups

0-04 5-09 10-14 15-19 20-24 25-34 35-44 45-54 55-64 >64

Age group (years)

0

5

10

15

20

25

30

35Rate per 100,000 population

1999 1994

Pediatric Rates

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Year

0

2

4

6

8

10

12

14Rate per 100,000 population

White Hispanic African American

14 years and younger

Number of TB Cases inNumber of TB Cases inU.S.-born vs. Foreign-born U.S.-born vs. Foreign-born

Persons Persons United States, 1991-2001United States, 1991-2001

0

5000

10000

15000

20000

1991 1993 1995 1997 1999 2001

U.S.-born Foreign-born

No

. o

f C

ases

TB Case Rates in TB Case Rates in U.S.-born vs. Foreign-born U.S.-born vs. Foreign-born

Persons, United States, 1991-Persons, United States, 1991-20012001

0

10

20

30

40

1991 1993 1995 1997 1999 2001

U.S. Overall U.S.-born Foreign-born

Cas

es p

er 1

00,0

00

Note: Case rates for 2000 and 2001 based on an extrapolation from the March 2000 U.S. Census Bureau Current Population Reports.

Percent of Tuberculosis Cases That Percent of Tuberculosis Cases That Are Foreign-born, Texas 1995-2001Are Foreign-born, Texas 1995-2001

2832

3438 39

41 43

1995 1996 1997 1998 1999 2000 2001

Year Reported

0

10

20

30

40

50Percent

Source: TB Elimination Division, TDH Foreign Born in TX in 2000 14.9%

Estimated HIV Coinfection in Persons Estimated HIV Coinfection in Persons Reported with TBReported with TB

United States, 1993-2000United States, 1993-2000

0

10

20

30

1993 1994 1995 1996 1997 1998 1999 2000

All Ages Aged 25 - 44

% C

oin

fect

ion

Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group.

Primary Anti-TB Drug Resistance Primary Anti-TB Drug Resistance United States, 1993-2001United States, 1993-2001

0

5

10

1993 1994 1995 1996 1997 1998 1999 2000 2001

Isoniazid MDR TB

% R

esis

tan

t

Note: Based on initial isolates from persons with no prior history of TB.MDR TB defined as resistance to at least isoniazid and rifampin.

Primary MDR TB Primary MDR TB United States, 1993-2001United States, 1993-2001

0

100

200

300

400

500

1993 1994 1995 1996 1997 1998 1999 2000 2001

0

1

2

3

No. of Cases Percentage

Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.

No. of Cases Percentage

Primary Isoniazid Resistance in Primary Isoniazid Resistance in U.S.-born vs. Foreign-born Persons U.S.-born vs. Foreign-born Persons

United States, 1993-2001United States, 1993-2001

02468

101214

1993 1994 1995 1996 1997 1998 1999 2000 2001

U.S.-born Foreign-born

Per

cen

tag

e

Note: Based on initial isolates from persons with no prior history of TB.MDR TB defined as resistance to at least isoniazid and rifampin.

TDH – PHR 11

Population Cases Rates

Cameron 60 336,339 17.8

Hidalgo 80 546,651 14.6

Starr 7 64,579 10.8

Webb 43 188,224 22.8

Border Counties – TB Cases & Rates for 2000

Border Counties – TB Cases

& Rates for 2001

Population Cases Rates

Cameron 55 344,588 16.0

Hidalgo 74 565,188 13.1

Starr 19 67,506 28.1

Webb 31 194,353 16.0

County Number of Cases

2001Population

Rate

Aransas 3 19,893 15.1

Bee 4 26,639 13.5

Brooks 1 9,106 11.0

Cameron 55 344,588 16.0

Duval 0 14,941 0.0

Hidalgo 74 565,188 13.1

Jim Hogg 0 6,570 0.0

Jim Wells 1 40,246 2.5

Kenedy 1 535 186.9

Kleberg 1 32,632 3.1

Live Oak 1 10,111 9.9

CountyCounty Number ofNumber of

CasesCases2001 2001

PopulationPopulationRateRate

McMullenMcMullen 00 869869 0.00.0

NuecesNueces 2626 320,833320,833 8.18.1

RefugioRefugio 00 8,1748,174 0.00.0

San PatricioSan Patricio 44 69,94569,945 5.75.7

Starr Starr 1919 67,50667,506 28.128.1

WebbWebb 3131 194,353194,353 16.016.0

WillacyWillacy 00 20,37920,379 0.00.0

ZapataZapata 22 13,86313,863 14.414.4

Region TotalRegion Total 223223 1,769,3711,769,371 12.612.6

State Total 1,643 20,698,441 7.9