Kathleen Moser, MD County of San Diego, Public Health Services TB and Refugee Health Branch August 21, 2013

A Binational Case

What is a binational case? • Active case who crosses the border while on treatment?

Someone who is deported before the culture comes back positive?

• Active case who has contacts who were exposed on the other side?

• Active case whose contacts move to the other side? • Active case whose specimens are sent across the border? • All of the above?

• CDC-led workgroup: to pilot a definition, for eventual

inclusion in the RVCT.

TB rates in Mexico and disclaimer

Goals

• Identify some of the challenges in TB control along the border.

• Review some of the strategies to address them.

• Discuss how the laboratory is helpful in these efforts.

Differences along the border

Mexico US

Smear Direct, Primary diagnostic method Indirect, Infectiousness

Culture Risk-based use Standard

DST-FLD Risk-based use Standard

DST-SLD National reference lab Decentralized availability

Molecular dx/DST methods: Xpert/MDDR/PSQ/etc

Not generally available Rapid increase in use

Contact tracing

Focus on finding secondary cases and LTBI tx for under 5

Focus on LTBI tx for close contacts

Genotyping Limited to special studies Standard

Similarities along the border

Mexico US

Initial treatment

4 drug combination formulation 4 drugs

Length of initial therapy

6 months 6 months

DOT National standard (usually clinic-based)

National recommendation

Second Line Drugs

Available through centralized mechanism

Available based by local pathways

Case 1

• 51 year old Mexican male hospitalized in San Diego in Fall 2012 with cough, renal failure requiring dialysis.

• Cavitary pulmonary TB, 4+ • Lived with cousin in San Diego, worked as a driver. • Actually…lived in Tijuana with wife and 2 children (10, 7 year old) • CureTB referral to TJHD (Curetb.org)

• GenXpert showed rpo mutation PSQ at MDL showed silent

mutation, but did identify an inhA mutation. • No health insurance, wanted to return home but hard to find

dialysis. If care not secured, often bounce back more ill. • Hospital paid for private dialysis care x 2 months. • Smear and culture negative when discharged in Feb 2013. TJHD

referral. • Died March 7, 2013.

July 2013 - report from Children’s Hospital:

5 month old US born child with altered mental status, seizures: c/w TB meningitis

And…child was living in US/Tijuana. Maternal grandfather died of TB in March… paternal aunt recently diagnosed with TB in Tijuana.

Binational contact follow-up revisited

First family Current family

1, 2yo

1 yo on INH, 13, 16 yo

1,5,6,12yo w/3 women 4 yo

Same mother

Lived with lady while pregnant, on multiple meds, died

Follow-up • 5 month old never visited Case 1. • Frequent visitor to father and aunt’s (2nd case) residence • Doubtful that aunt visited Case 1.

• Aunt was brought across border for sputum. 2+ smear. CDC-DHS collaboration.

• Genotyping, DST for child, assess risk for other children

• Child had PSQ on trach asp (positive culture): no INH mutation • Alerted TJHD and educated family re: other young children

Case 2 • 79 year old Mexican-born male smoker admitted to local hospital with

cough, weight loss, fatigue, abdominal pain. • CXR with LUL mass, bilateral infiltrates, mediastinal/hilar adenopathy. • QFT+ • Could only provide one sputum. • Entered US in 1967, history of TB treated 1968.

• FNA of lung tissue. Granulomas, no AFB. No evidence of malignancy. • Started RIPE. 10 days later, 1+ smear.

• Lived in an assisted living facility. • PSQ on smear+ specimen: katG and rpoB mutations. • MDDR on 1st sputum when culture grew: katG and rpoB mutations +

embB. • Phenotypic DSTs confirmed molecular tests. Partial Emb resistance.

Case 2, cont.

• Had been in assisted living facility 6 weeks, moved from a house close by where he lived for years.

• 87 year old Mexican-born neighbor, no TB history. • QFT 4.89, LUL infiltrate. • Smear negative, Genexpert +, no mutations. • Subsequently 5 positive cultures. PSQ without

mutations and MGIT DST confirmed

• Genotypes did not match

Case 2, cont.

• Travel history of Case 2 – went to rodeos in Baja CA once a year.

• Genotype is unique in US, but matched 2 MDR cases in Baja CA. – 20 year old female from Ensenada who had been

treated in Puentes de Esperanza 2010-2012. – Other with unknown history, died.

• Re-interview asking about Ensenada revealed he

visited large, extended family there.

Case 3

• 44 year old male born in Japan. • Presented with increasing SOB, weight loss,

cough x months. • Cavitary disease on CXR. 2+ smear. • No history of TB treatment. In US x 15 years.

• Started RIPE. Became smear negative at 1

month…and smear 2+ at month 2.

Genotype • Worked as QA floor manager at a maquila in Tijuana x 15

years. • PCR type matched 4 others in San Diego (all Mexico-born)

and in CA 26 others: 3 US born Hisp, 19 Mexico, 1 El Salvador (pansusc)

• Gentype – matches one other in US (in Wisconsin-2008) • Euroamerican family (L4)

• Tested Japanese managers who carpooled. • Notified TJHD re: Mexican workers.

All border TB programs have tried to develop MDR programs with Mexican sister cities.

Incidencia notificada de casos con TB-FR 2000 - 2011

Fuente: MACRO TB-MFR, PNT, DAPP, CENAPRECE 2000-* hasta diciembre de 2011

Estados Notificantes Número de

casos Nuevos de TB FR

VERACRUZ 25 NUEVO LEÓN 21 GUERRERO 16 CHIAPAS 15 BAJA CALIFORNIA 13 CHIHUAHUA 10 PUEBLA 10 TABASCO 10 SONORA 5 TAMAULIPAS 5 DISTRITO FEDERAL 4 JALISCO 4 COAHUILA 3 DURANGO 2 HIDALGO 2 MICHOACÁN 2 QUERÉTARO 2 NAYARIT 1 QUINTANA ROO 1 SAN LUIS POTOSÍ 1

Total Nacional 152

En el 2011: 10 Estados

Concentran 86% de los casos nuevos

Low notification of MDR

Some points

• Mexico is the #1 country of origin/impact for TB cases in the US. Impact cannot be measured by “Mexican-born” alone.

• TB control along the border takes special strategies and daily collaboration.

• Contact investigations that span the border are difficult but necessary and possible.

• Genotyping is helpful in understanding the dynamics of binational transmission.

• Improvements in access to TB diagnostics in Mexico would be helpful to both US and Mexico patients.

“Our lives, our stories, flowed into one another's, were no longer our own, individual, discrete.”