Inspiring philan thropy bey ond bor ders€¦ · Inspiring philan thropy bey ond bor ders Tim e for...

Tuberculosis in the San Diego-Tijuana Border Region:

Inspiring philanthropy beyond borders

Time for Bi-National Community-Based Solutions

Tuberculosis in the San Diego – Tijuana Border Region2

Acknowledgements

The International Community Foundation (ICF) wishes to extend its appreciation to themany people and institutions that gave of their time, expertise and financial support tomake this report possible. In particular, we would like to thank the California Wellness

Foundation for their generous financial support of this project.

We would also like to thank the many collaborators who provided us with valuable input andadvice to make this report possible, as well as all of the participants who attended our bi-national Tuberculosis workshop last Fall.

Primary Authors

Dr. Stephanie Brodine, SDSU Graduate School of Public Health

Lucy Cunningham, SDSU Graduate School of Public Health

Dr. Miguel Angel Fraga, UABC School of Medicine and Psychology

Dr. Richard Garfein, UCSD Division of Global Public Health

Richard Kiy, International Community Foundation

Julieta Méndez, International Community Foundation

Dr. Kathleen Moser, San Diego County TB Control and Refugee Health

Dr. Héctor Pérez, San Diego County TB Control and Refugee Health

Dr. Timothy Rodwell, UCSD Division of Global Public Health

Jennifer Smith, SDSU Graduate School of Public Health

• • • • • • • • • • •


List of Workshop Participants

Aworkshop entitled, Tuberculosis in the San Diego-Baja California Border Region: Timefor Bi-National Community-Based Solution, was held on November 10th, 2009 at theInternational Community Foundation's headquarters in National City, California. The

participants of the workshop played an integral role in providing valuable input and feedbackon our final report.

Dr. José Lorenzo Alvarado González, Turbotec

Verónica Barajas Keeler, CA Department of Public Health, COBBH/USMBHC

Dr. Carlos Bazán Pérez, SIMNSA

Ing. Quím. Verónica Bejarano, ISESALUD

Dr. José Luis Burgos Regil, UCSD Division of Global Public Health

Sonia Contreras, Scripps Whittier Diabetes Institute

Bobby Cruz, NASSCO

Dr. Sourav Dey, Qualcomm

Dr. Blanca Esther Equihua Félix, UABC

April Fernández, CA Department of Public Health, COBBH

Dr. Karen Ferran, CA Department of Public Health, COBBH/EWIDS

Dr. Priscilla González, SIMNSA

Dr. Rigoberto Isarraráz Hernández, ISESALUD

Dr. Lawrence Kline, Scripps Clinic Medical Group, USMBHC

Dr. Rafael Laniado Laborín, UABC, ISESALUD

Dr. Rosa Alicia Luna, ISSSTECALI

Lic. Calixto Marmolejo Guzmán, Turbotec

Dr. Lawrence Miller, NASSCO

Sonia Montiel, BIDS, San Diego County Public Health Lab

Christina Suggett, SIMNSA

Dr. Steve Waterman, Quarantine and Border Health Services, CDC

Erica Whinston, Qualcomm


Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5I. Introduction: Tuberculosis as an Emerging Pathogen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15II. The Scale and Cost of Tuberculosis in San Diego County . . . . . . . . . . . . . . . . . . . . . . . . . . . 20III. Status of Tuberculosis Control in the San Diego-Tijuana Border Region . . . . . . . . . . . . . . 29

a. Laboratory Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29b. Tuberculosis Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

i. Patient Management and Directly Observed Therapy . . . . . . . . . . . . . . . . 35ii. Medication Supply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

c. Tuberculosis Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41i. Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ii. Contact Tracing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42iii. Prophylaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

d. Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46e. Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

IV. Role of Businesses in Tuberculosis Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55V. Appendix (List of Acronyms) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

List of Figures

IntroductionFigure 1. Tuberculosis incidence in US/Mexico border states

relative to national incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Figure 2. Active Tuberculosis Incidence Rates per 100,000 Inhabitants . . . . . . . . . . . . . 17Figure 3. Active Tuberculosis Incidence Rates in Two Tijuana Subpopulations. . . . . . . 17

Scale and Cost of TuberculosisFigure 1. Trends in Tuberculosis Incidence, 1985-2007. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Figure 2a & b. Trends Foreign-born vs. US-born TB cases

in the United States and San Diego . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

List of Tables

Scale and Cost of TuberculosisTable 1. Examples of Direct and Indirect Costs of Tuberculosis in San Diego. . . . . . . . 21Table 2. Summary of Annual Direct Inpatient and Outpatient TB Costs

in San Diego. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Table 3. Sociodemographics of TB Patients, 1993-2007. . . . . . . . . . . . . . . . . . . . . . . . . . . 24Table 4. Annual Wages Lost to TB Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Table 5. Annual Wages Lost to TB Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

SurveillanceTable 1. Total Pulmonary Tuberculosis Cases in Baja California

and Tijuana by Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Table 2. Total Reported Tuberculosis Cases by Institution in Tijuana,

Baja California, Mexico, 2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51


The close geographical proximity of SanDiego and Tijuana, the stark contrastbetween their distinct economies and levelsof socio-economic development, and the easeand magnitude of cross-border exchangebetween these two metropolitan areas,demand our undivided attention. Accordingto the San Diego Association of Governments(SANDAG), over 60 million persons cross intoSan Diego from Tijuana at the San Ysidroborder crossing each year. In fact, many havecome to agree that the San Diego-Tijuanaborder region does not identify with one

particular country, butrather has a broaderidentity of its own. Theblending of economic,social and culturalactivities in this regioncharges us to find bi-national solutions to theunique bi-national issuesfacing the region. Onesuch regional issue wemust confront is that oftuberculosis (TB). BothCalifornia and BajaCalifornia have TBincidence rates that aremuch higher than thenational rates of theirrespective countries.Furthermore, Tijuanareports approximately 4

times as many new TB cases per year thandoes San Diego. There is an urgent need toconfront this disparity, and address the issue

of bi-national TB control in the San Diego-Tijuana border region to find sustainable,community-based solutions that will benefitboth Mexico and the United States.Importantly, as an air-borne infection,successful models of TB control will haveapplicability to other emerging diseasesthreats that require cross-border solutions,such as H1N1.

TB is a subtle and complex chronic infectiousdisease that can remain dormant for yearsafter the initial infection. Once active or re-activated, TB often takes weeks or months tobe diagnosed correctly, allowing for ongoingexposure and transmission to others. TheWorld Health Organization (WHO) estimatesthat 2 billion people, or one-third of theglobal population, are currently infected withthe M. tuberculosis bacilli. Of those infected,it is estimated that 1 in 10 will develop theactive, contagious form of disease at sometime in their lives, and those with active TBwill infect an average of 10 to 15 people peryear if they are not treated. Likely anunderestimate, over 600 cases of pulmonaryTB were confirmed and reported annually inTijuana in 2006 and 2007 with an overall rateof 46 per 100,000 inhabitants, which issubstantially higher than rates in neighboringMexican states. In the last decade, there hasbeen an average of over 300 new TB casesper year in San Diego County, of which nearly40% were born in Mexico. This estimate islikely to understate the influence of Mexicoon the TB case load in San Diego, since US-born, Hispanic TB cases are not identified in

Likely an underestimate,over 600 cases ofpulmonary TB wereconfirmed and reportedannually in Tijuana in2006 and 2007.

In the last decade, therehas been an average of over 300 new TB cases per year in SanDiego County, of whichnearly 40% were born in Mexico.

Executive Summary

Tuberculosis (TB) in the San Diego – Tijuana Border Region:Time for Bi-National Community-Based Solutions


TB surveillance data as being of Mexicanorigin. Nevertheless, these cases havesignificant interaction with Mexico when

they, or their contacts,cross the border forsocial, cultural andeconomic reasons. Prior to the discovery in1946 that streptomycincured TB, the diseaseclaimed the lives of halfits victims. Hopes oferadicating TB grewwhen a 6-month courseof daily drug treatmentwas found to be highlyeffective for curing TBand rates of diseasebegan to drop

worldwide. However, interrupted orinconsistent treatment, combined with theAIDS epidemic, led to the emergence of drugresistant strains of TB bacteria that could nolonger be cured with first-line antibiotics, andrates of TB began to increase in the 1980s. Todate, the WHO and other agencies havedocumented cases of TB that are resistant tostandard first-line antibiotics and second-lineantibiotics in all regions of the world,including the US-Mexico border region. Thisreverses years of progress in TB control assuccessful management of drug resistancerequires more sophisticated laboratorycapacity, educated personnel and access to

significantly moreexpensive drugs.Importantly, drugresistance is completelypreventable withappropriate diagnosisthat includes drugsensitivity testing andprograms like directlyobserved therapy (DOT)that ensure patients areon proper treatmentregimens and do not

interrupt therapy or miss doses. Until avaccine or single-dose treatment isdiscovered, our best hope for preventing TBfrom returning to an untreatable diseasedepends on accurately diagnosing andcompletely treating patients with TB.

Like the disease itself, the costs of TB arecomplex and difficult to quantify. The directcosts can be described in terms ofinfrastructure - diagnostic laboratories andequipment, clinic and hospital unitsappropriately designed for infection control,and surveillancesystems; personnel -trained laboratorytechnicians,informed healthcareproviders, DOTworkers, contactinvestigators, andsurveillance systemmanagers; andconsumables -laboratory reagents,anti-TB medications,infection controlsupplies, andeducational materials. Indirect costs includelost wages for those infected, decreasedproductivity by employers, and disruption tothe community affected by contact tracingactivities. We estimate that TB costs in SanDiego amount to be at least $21.3 millionannually, which includes approximately $12.7million in lost earnings for patients due totheir disease. Beyond the loss of earnedwages is the loss by San Diego employers inproductivity. Workforce productivity isimpacted in several ways by TB. Mostsignificant is that TB symptoms are slow todevelop and many infected individualscontinue day-to-day activities for weeks ormonths before their disease is detected,potentially exposing large numbers ofcontacts at work, home and in thecommunity to TB. This results in additional

The WHO and otheragencies havedocumented cases of TBthat are resistant tostandard first-lineantibiotics and second-line antibiotics in allregions of the world,including the US-MexicoBorder Region.

Our best hope forpreventing TB from re-emerging as anuntreatable diseasedepends on accuratelydiagnosing andcompletely treatingpatients with TB.

We estimate that TBcosts in San Diegoamount to be atminimum $21.3 millionannually, which includesapproximately $12.7million in lost earningsfor patients due to their disease.


infections in the workplace and disruptionsdue to the extensive contact tracing activitiesthat need to take place after a workplaceinfection. The costs presented here includethe major measurable factors and costs toSan Diego, but, while high, are certainly anunderestimate of total costs. They do notinclude the substantial hidden costs of lostproductivity to employers or other moresubtle losses like loss of income to schooldistricts due to scheduled absences forchildren with TB; nor do they account for

other social costs relatedto stigmatization orinfected individuals andtheir contacts.

Importantly, there isconsensus for whatconstitutes acomprehensive TBcontrol program: theWHO DOTS program.This strategy includesearly detection of cases,contact tracing, accuratediagnosis throughbacterial culture anddrug sensitivity testing,uninterrupted access toeffective drugs, and DOT.Although incidence ratesare declining globally anddomestically, the numberof cases worldwide isincreasing due to

population growth and the emergence ofresistance threatens to reverse the advancesto date. Thus, there is an urgent call bymultiple political and professionalorganizations for a coordinated globalresponse. While the San Diego-Tijuana regionis impacted by the growing challenges of TB,this is a preventable and treatable diseaseand there is tremendous potential tocontribute and participate in an internationalmobilization of public health, clinical

personnel, business leaders and communitiesto effectively combat the disease.

Economic analyses clearly indicate that USinvestment in TB control in Mexico can be acost-effective meansof controlling TB inthe United States.Given theepidemiology of TBin the San Diego-Tijuana border sucheconomic benefitsare likely to be truefor this bi-nationalregion. While this isso, the activeinvolvement of bothprivate businessesand governmental agencies will be requiredto make this a reality. Successful workingmodels in which businesses located in highTB-incidence areas have taken a lead role inTB control programs already exist throughthe work of member companies of the GlobalBusiness Coalition for HIV, Tuberculosis andMalaria (GBC). This novel approach toaddress emerging high impact threatsthrough private-public partnerships providesa promising model that can be adopted in theUS-Mexico border region.

This report highlights five key areas oftuberculosis control in the San Diego-Tijuanaborder region that demand our combined andimmediate attention: laboratory diagnostics,case management, prevention, infectioncontrol and surveillance.

1: Laboratory Diagnostics

For accurate diagnosis and appropriatetherapy, bacterial culture for all suspectedcases and access to drug susceptibilitytesting are imperative. These services arecurrently lacking in both the public andprivate sector health systems in Tijuana and

Smear microscopy iscurrently the standarddiagnostic method foractive TB in BajaCalifornia, yet thismethod fails to detect upto half of the cases withactive pulmonary TB.

While the San Diego-Tijuana region isimpacted by the growingchallenges of TB, this isa preventable andtreatable disease andthere is tremendouspotential to contributeand participate in aninternationalmobilization of publichealth, clinicalpersonnel, businessleaders and communitiesto effectively combat the disease.


Mexicali. Smear microscopy is currently thestandard diagnostic method for active TB inBaja California, yet this method fails to detectup to half of the cases with active pulmonaryTB. Consequently, many individuals withactive TB are misdiagnosed, allowing theirdisease to progress and more contacts to beexposed to infection. The WHO Global StopTB Partnership currently recommends theuse of rapid and sensitive TB diagnostictechniques including cultures to maximizecase detection and to optimize therapythrough drug susceptibility testing. Drugresistant strains of TB are found in BajaCalifornia, including Tijuana, and there isevidence of their transmission within the

community. Yet, due tolack of routine drugsusceptibility testing ofTB isolates, these strainsare not identified in atimely or standardizedmanner. Lack of earlyidentification allowsamplification of drugresistance to occurleading to emergence ofmultiply resistantstrains. Althoughcapacity to conduct firstline drug susceptibilitytesting exists to a limitedextent in Baja Californialaboratories, its use isseverely limited by thesystem's or the patient's

inability to pay for the tests. Conservativeestimates indicate that approximately$122,400 in supplies and $90,000 forpersonnel, per year, are needed to accuratelyidentify, detect and diagnose tuberculosisusing cultures and drug susceptibility testingin Baja California.

2: Case management

Because most people find it difficult to

adhere to aprolonged andexacting treatmentcourse, the WHO, theUS Centers forDisease Control andPrevention (CDC),and the MexicanNational TB Programall endorse DOT forTB patients.However, in BajaCalifornia, aselsewhere, theallocation ofresources to assureappropriate deliveryof DOT services is decided by local healthjurisdictions. Baja California has over 1000active TB patients diagnosed each year.Despite an excellent system of decentralizedhealth care and a history of usingpromotores (community health workers) toattend to community health needs, currentlyavailable resources are inadequate tosupport the DOT strategy in Baja California atthis time. Lack ofDOT for TBtreatment increasesthe likelihood ofinconsistent orabandoned drugtherapy andsubsequently resultsin drug resistance.Employer-supportedprograms that enableemployees to receiveDOT in theworkplace, is oneway of augmentingthe jurisdictionalDOT service network and improving accessfor workers.

An uninterrupted supply of first and secondline drugs is critical to successful TB case

Drug resistant strains ofTB are found in BajaCalifornia, includingTijuana, and there isevidence of theirtransmission within thecommunity. Yet, due tolack of routine drugsusceptibility testing ofTB isolates, thesestrains are notidentified in a timely orstandardized manner.

Conservative estimatesindicate thatapproximately $122,400in supplies and $90,000for personnel, per year,are needed to accuratelyidentify, detect anddiagnose tuberculosisusing cultures and drugsusceptibility testing inBaja California.

Despite an excellentsystem of decentralizedhealth care and a historyof using promotores toattend to communityhealth needs, currentlyavailable resourcescannot fully realize theDOT strategy in BajaCalifornia at this time.


management andpreventing drugresistance. Ad hocregimens are used whenthe medications forstandard regimens arenot available and maylead to poor outcomes,including drug resistanceand relapse. Standardfirst line tuberculosisdrugs are generallyavailable in BajaCalifornia; however,second line drugs arecontrolled by the

National TB Program and require a lengthyand cumbersome process that can take up to6 months for the approval and release of theneeded drugs from Mexico City. A model is inplace for the receipt of second line drugs inBaja California. What is needed is control andmonitoring of the process to ensure futuredrug shipments will continue in a timelymanner. Providers need a rapid andacceptable process for securing completeand appropriate medications for theirpatients who have failed a previous treatmentcourse. Limited national resources requirestrict and often prohibitive controls; thus,alternative strategies for drug delivery areneeded to increase the availability of drugs.

3: Prevention

The most effective method of TB preventionis rapid diagnosis and cure of TB cases.Beyond the technical and resourcelimitations impacting this strategy, patientawareness and reluctance to be diagnosedwith TB can delay their diagnosis andtreatment. There remains a great deal ofmisinformation about TB among the generalpublic. This misinformation causes undueanxiety and fear for individuals whenconfronted with someone who has a TBdiagnosis and often places the patient in a

position of shame and ostracism. Fear ofstigmatization, whether perceived or real,leads patients to hide their diagnosispotentially complicating treatment adherenceand contact tracing efforts. It may alsoprevent infected persons from seeking care,thus prolonging theperiod ofinfectiousness. Thefacts about TB, whenwell communicated,can changeperceptions, leadingto cooperation andsupport in thecontrol of TB at many levels; patient,provider, family, workplace, and community.The Mexican government has recentlystepped-up attention toward tuberculosis.Tuberculosis health education is needed onboth sides of the border for providers,patients, family contacts, and the generalpublic - including business - to ensure anaccurate understanding of diseasetransmission and prevention and to reducestigma andstereotypes aboutthe disease. This isperhaps the mostfeasible and leastcostly manner inwhich business cancontribute to thecontrol of TB-byadding tuberculosiseducation to theagenda.

Mexico's TB controlefforts emphasize detection and treatment ofactive TB cases, but as suggested by theWHO, comprehensive programs forprevention of reactivation of latent TBinfection (LTBI) are necessary to control TB.The cost of a 9-month regimen ofpreventative therapy for LTBI (not disease) isminimal. Although there are policies in place

Employers couldpotentially support DOT-in-the-workplace foremployees who arereturning to work,thereby augmenting thejurisdictional DOTservice network andimproving access for workers.

The most effectivemethod of TB preventionis rapid diagnosis andcure of TB cases.

The facts about TB,when wellcommunicated, canchange perceptions,leading to cooperationand support in thecontrol of TB at many levels.


to treat LTBI among persons with HIV co-infection, this group represents a small

proportion of those athigh risk of TBreactivation, which alsoincludes diabetics,persons with chronicillness and children < 5years old. In addition toexpanding LTBItreatment to individualsat increased risk of TBreactivation, adequatelyfunded programs areneeded to expeditiouslytrack all contacts ofnewly diagnosed TBcases to determine theirneed for treatment of theactive or latent form ofthe disease. Thisincludes cross-border

communication between health departmentsfor notification of potential exposuresbecause of patients who work, live, or travelon both sides of the border. Exposures withinworksites can be prioritized and pilotprojects to have employers assist withworksite testing and treatment can beinitiated.

4: Infection Control

The TB bacterium becomes airborne whenpersons with pulmonary TB cough, sneeze,spit or speak allowing TB to spread easily toothers in closed spaces, such as hospitalsand clinics and thus poses a significant riskto health care workers and patients. TBtransmissions in clinics and hospitals havebeen documented affecting individuals aswell as multiple persons during outbreaks. InTijuana specifically, a well conducted studyat a major hospital over a 4 year periodconcluded that health care workers (HCWs)were 11 times more likely to be infected thanthe general population. Infected HCWs are

particularly problematic because until theyare treated, they may infect co-workers andpatients with other health conditions such asdiabetes mellitus or AIDS that predisposethem to active TB. Thus, routine HCWscreening and education is a critical part ofinfection control.

While effectiveinfection controlguidelines for healthcare settings havebeen published byinternational anddomestic agencies,local-levelassessments areneeded to tailor suchrecommendationsaccording to theneeds and resourcesin each region. Aninitiative, funded bythe US Agency forInternationalDevelopment(USAID), is underway to strengthen theinfection control policies for Mexico,including Baja California. In order toeffectively respond to the resultingrecommendations, Baja California must beprepared and enabled to provide HCWeducation, renovate hospital wards to includeisolation rooms and air handling systems,and purchase the equipment and suppliesnecessary to implement the guidelines. TBscreening programs and personal protectiveequipment, such as N95 masks, will beneeded as well. As an additional benefit,improvements in respiratory infectioncontrol will help prevent transmission ofother respiratory illnesses, such as H1N1influenza.

5: Surveillance

Disease surveillance allows health officials,

Tuberculosis healtheducation is needed onboth sides of the borderfor providers, patients,family contacts, and thepublic - includingbusiness - to ensure anaccurate understandingof disease transmissionand prevention and toreduce stigma andstereotypes about thedisease.

An initiative, funded byUSAID, is underway tostrengthen the InfectionControl policies forMexico including BajaCalifornia. As anadditional benefit,improvements inrespiratory infectioncontrol will help controlother respiratoryillnesses, such as H1N1.


policy makers, and healthcare providers toassess the magnitude of a disease, monitorthe effectiveness of interventions to reducethe incidence of the disease, detectoutbreaks so that appropriate public healthresponses can be taken to bring he diseaseunder control, and ideally to track progresstoward elimination of the disease. AlthoughMexico has a technically sophisticatednational TB surveillance system, there are anumber of ways in which this system could

be enhanced to minimizeunder-reporting of casesand improve follow-updata to better documenttreatment outcomes. Theresponsibility forentering cases intoMexico's TB surveillancesystem varies acrossinstitutions and isfrequently avoided byprivate providers eventhough these providersdiagnose and manage TBcases. Hard copy paperreports require

administrative time to complete and couriersto deliver. In some cases, physicians musttravel to a designated office with their patientfollow-up reports and dictate them while ahealth official enters the data into anelectronic database system. Tijuana's TBControl Program has a reporting requirementprior to releasing government subsidized TBmedications as a way to promote casereporting. However, this may not provide anyincentive for patients of private providersthat can afford unsubsidized medications.

Harmonizing TB reporting responsibilitiesacross institutions and moving towards anaccessible electronic method of reportingwould greatly improve the quality of data andthe possibility for greater patient follow up.Complete surveillance data is essential formonitoring TB trends at both the local and

national level in order to inform policy,implement and evaluate TB control practices,and effectively allocate precious healthcareresources. High quality surveillance data canalso be used to justify requestsfor additional resources in areas of greatest need.

Role of Business in Tuberculosis Control

Cross border collaboration among criticalpublic health authorities, academia andprivate business is essential for thedevelopment and implementation of aneffective TB health education, diagnosis andtreatment program in the San Diego-Tijuanaregion. Local businesses can and mustcontribute to solutions in TB control acrossthe border region.

Because of the unparalleled level ofbidirectional border crossings and growingnumber of cross-border residences andbusinesses, binational partnerships must alsoevolve to address the growing number of TBcases that continueto go unreportedearly on whichincrease the risk andsocietal cost ofworkplace infection.The report highlightsseveral recentexamples of TBcases in San Diegothat have involvedbroad spectrums ofbusinesses innurseries, bio techfirms, manufacturers,nail salons, hotelsand casinos. s anincreased incidenceof TB will have a growing negative impact ona broad spectrum of businesses on bothsides of the border, there is a pressing need

Harmonizing TBreporting responsibilitiesacross institutions andmoving towards anaccessible electronicmethod of reportingwould greatly improvethe quality of data andthe possibility for greaterpatient follow up.

Complete surveillancedata is essential formonitoring trends in TB cases at both thelocal and national levels in order to informpolicy, implement andevaluate TB controlpractices, and effectivelyallocate precioushealthcare resources.


for more pro-active steps to be taken by theprivate sector on both sides of the border.Steps that could be taken include in the SanDiego-Tijuana border region includeworkplace based TB education programs,paid sick leave for infected workers andimproved reporting of TB cases managed byprivate physicians in Mexico.

The report also highlights the cutting edgework of the Global Business Coalition forHIV/AIDS, Tuberculosis and Malaria (GBC), amembership organization established in 2001to bring together major multinationalcorporations to respond to the risk ofinfectious disease in the countries andcommunities where member companies dobusiness. Yet, to date, the emphasis ofGBC's work has been in Africa and South Asiawhere the risk of TB is greatest. Among theover 300 GBC members, there are 12corporations with a presence in the SanDiego-Tijuana border region. Given thegrowing cross-border risk of TB transmission,pro-active steps should be taken by initiate aGBC pilot program in the San Diego-Tijuanaborder region.

Conclusions & Next Steps

On November 10th, 2009, a bi-nationalworkshop entitled, Tuberculosis in the SanDiego-Baja California Region: Time for Bi-national Community-Based Solutions wasconvened at the International CommunityFoundation's headquarters in National City,California. The workshop includedrepresentatives from academia, non-profitorganizations, the private sector andgovernmental agencies at the federal, stateand local levels from both Mexico and theUnited States. The workshop began with aplenary session to provide an overview of thecurrent status of tuberculosis on both sidesof the border, with an emphasis onidentifying ways that private businesses

could pioneer novel solutions to the existingchallenges in TB control. The workshop alsoincluded four break-out sessions thataddressed the following topics: 1) diagnosisand screening, 2) data collection, sharing andnew technologies, 3) coordination of care,and 4) stigma, awareness and education. Thebreak-out sessions provided an opportunityfor representatives across different sectors tobrainstorm possible solutions, next steps andpilot projects that could begin to alleviate theproblems that the border region faces withregards to TB. The potential role ofphilanthropy and expanded cross-borderpublic-private partnerships was also furtherexplored.

In addition to galvanizing partners along theU.S.-Mexico border to begin to prioritizepossible solutions for TB control in theregion, the workshop also provided a forumfor important feedback and input on thisdocument. Several of the key solutions andrecommendations identified to respond toSan Diego-Tijuana's cross-border TBchallenges, will required changes in publicpolicy, increased public sector fundingand/or the expanded commitment andinvolvement of the business communities ofSan Diego-Tijuana as well as thephilanthropic sector. Theserecommendations are summarized below:

TB Cost Analysis

• A detailed cost-analysis of TB in San Diego and Tijuana could provide a more accurate estimate of costs, including trends, as well as opportunities for cost-savings that could be realized with bi-national interventions. Much work remains to be done in better quantifyingthe cost of TB in the Mexican border region and its resulting impacts on U.S. border communities such as San Diego.


Diagnosis and Screening

• Improve detection of active TB through routine TB screening by supplementing the current standard acid fast bacilli (AFB) smear microscopy with specimen concentration, fluorescence microscopyand TB culture.

• Expedite the introduction of drug susceptibility testing (DST) throughout Tijuana and Baja California with the ultimate goal of making DST routinely available to all local hospitals and clinics in the public and private sector. To facilitate this process, laboratories should utilize existing and evolving technologies rather than imposing strictcriteria on tests to be used.

• Remove barriers to treating latent TB infection for contacts and high-risk groups by using assays that are insensitive to BCG vaccination, such as interferon gamma release assays (i.e., QuantiFERON TB Gold or T.Spot TB), to detect candidates for treatment. Prioritization should include high risk groups (e.g., diabetics, HIV co-infection) and contacts of recently diagnosed active TB cases.

• Conduct a pilot program within a business, such as a large maquiladora, to perform QuantiFERON screening for latent TB with a pilot TB prophylaxis program for employees identified as TB infected who are at high risk of progressing to active disease (e.g., diabetics).

Data Collection, Sharing and New Technologies

• Simplify the process of including TB cases in local and national (SINAVE) surveillance systems in Tijuana, with

technologies such as electronic transfer of case information (e.g., email, fax, websites). This would require the placement of computers with internet access in all healthcare facilities that manage TB cases. The computers should be made available for multipurpose use to attain secondary benefits from their placement. Future funding would be used for systems analysis, equipment and training to enhance the existing systems.

• Improve methods for monitoring DOT initiation and completion through the existing surveillance system. Also, explore the feasibility and cost-effectiveness of novel technologies (e.g.,wirelessly monitored pill dispensers) to facilitate and track DOT.

• Develop procedures and systems for sharing TB data between Mexico and the US.

Coordination of Care

• Assure that the cost to patients of laboratory tests, such as repeat TB smear microscopy, imaging studies and monitoring of medications, do not contribute to abandonment of TB therapy.

• Provide strict DOT for all new pulmonary TB patients. In areas where this is not being routinely accomplished, stakeholders including providers, administrators, employers, patients and nurses should be convenedto develop and implement DOT pilot initiatives (e.g., workplace DOT, virtual DOT, inter-institutional agreements, home-based DOT).

• Initiate policies for patients who relapseor fail TB treatment such that review


and oversight of retreatment regimens isperformed by experts in drug resistant TB.

• Training in TB surveillance and management should be implemented forthree key populations: 1) first and second level providers to assure new TBpatients are reported and managed in accordance with approved standards; 2)case management/DOT staff to assure quality outreach services and infection control practices; and 3) patients and family members to engage them as participants in successful treatment andto limit ongoing community transmission.

Stigma, Awareness and Education

• Launch a mass media campaign to educate the public regarding TB, with

an emphasis on reducing stigma, encouraging early detection, limiting theperiod of contagiousness, and heightening awareness of the availability of curative medications.

• Implement a pilot program within a Mexican private or government business that would conduct a KAP survey (Knowledge, Attitudes, Practices) from which draft health education materials could be developedand tested. Ultimately finalized materials could be incorporated into existing occupational health programs at the business sites.

• Explore possible ways for Mexican workers to receive full salary versus partial salary compensation on completion of successful TB therapy.


Tuberculosis (TB) remains a significanthealth burden throughout the world withan unacceptably high annual rate of newTB infections and >2 million deaths fromTB per year. The World HealthOrganization (WHO) estimates that 2billion people, or one third of the globalpopulation, are currently infected withtuberculosis bacilli. Of those infected, it isestimated that 1 in 10 will develop theactive, contagious form of disease at sometime in their lives, and those with activeTB will infect an average of 10 to 15 peopleper year if they are not treated (1). Due tothe large number of potentially infectiousindividuals worldwide and the non-discriminatory airborne transmission oftuberculosis bacilli, it is clear that TB isboth a current and re-emergent globalthreat to the public's health. It is especiallythreatening to the most productivemembers of society, as it mainly affects the working population (1) and is spreadby close contact which can occur in thework place.

A major contributor to the escalating TBthreat is drug resistance to standard first-line antibiotics (multi-drug resistant TB orMDR-TB) and to standard second-lineantibiotics (extremely drug resistant TB orXDR-TB) that has been documented by theWHO in all regions of the world.Additionally, TB that is resistant to all TBmedications (totally drug resistant TB orTDR-TB) was recorded in several countriesfor the first time in 2009. This is reversingyears of progress in TB control assuccessful management of drug resistance

requires more sophisticated laboratorycapacity, educated personnel and accessto significantly more expensive second-linedrugs. From a public health standpoint,drug resistance is important because: 1)individuals with drug resistant TB remaininfectious for longer periods of time,potentially spreading TB to a largernumber of contacts, and 2) fewertreatment options will be available tothose who become infected. Of particularconcern is the appearance of XDR-TB withmultiple cases now documented in the US,a mortality rate of >80%, and treatmentthat can require a combination of surgeryand injection drugs for effective therapy(2). Importantly, drug resistance iscompletely preventable with appropriatediagnosis that includes drug sensitivitytesting and programs like directlyobserved therapy (DOT) that ensurepatients are on proper treatment regimensand improve patient compliance.

Currently, there is no effective preventivevaccine for TB. The BCG vaccine, which isroutinely administered to newborns inMexico, protects children who acquire TBinfection from developing more serious orfatal disease; however it does not preventtransmission or progression from infectionto active pulmonary disease, which is themain source for dissemination of disease inthe community. Therefore, prevention isdependent upon identifying and treatingcases before they transmit tuberculosisbacilli to their contacts, and theprophylactic treatment of contacts withlatent infections before the disease state

I. Introduction: Tuberculosis as an Emerging Pathogen


develops. Despite the lack of an effectivevaccine, TB therapy and control forindividual patients, even those with multi-drug resistant TB, are well-established.However, because TB treatment typicallyrequires combinations of medications and upto a year or more to complete, stable,sustainable programs are necessary tocontrol and ideally eradicate TB.

On a population scale, there is consensus forwhat constitutes a comprehensive TB controlprogram (WHO DOTS program). Strategiesinclude early detection of cases, contacttracing, accurate diagnosis through bacterialculture and sensitivity testing, uninterruptedaccess to effective drugs, and DOT. Althoughincidence rates have started to declineglobally and domestically, with continuedhigh rates and the emergence of resistancethere is an urgent call by multiple politicaland professional organizations for acoordinated global response. While the SanDiego-Tijuana region is impacted by thegrowing challenges of TB, tremendouspotential also exists to contribute andparticipate in the international mobilizationof public health and clinical personnel,

business leaders and communities toeffectively combat the disease.

San Diego and Tijuana share a number ofchallenges in health and emerging infectiousdiseases, including an excessive burden ofTB. Both California and Baja California areapproaching or exceeding TB rates doublethose of their respective nations. In 2008, therate of TB in California (7.0 per 100,000population) was almost double the U.S.national rate (4.2 per 100,000), and the rate ofpulmonary TB in Baja California was morethan double that of the national rate inMexico (40.5 per 100,000 versus 14.1 per100,000) (3, 4). TB rates are even higher inSan Diego (8.4 per 100,000) and Tijuana (over45 per 100,000) (3,5,6). Evidence of theshared impact of TB along the US-Mexicoborder is not surprising given theunparalleled bidirectional border crossings,and growing cross-border residencies andbusinesses being established in bothpopulations. In fact, the San Diego CountyTuberculosis Control Branch reported that in2008, over 70% of TB cases were foreign bornindividuals and over one third of all TB caseswere born in Mexico.

Figure 1.

Tuberculosis Incidence inUS/Mexico Border StatesRelative to NationalIncidence (per 100,000inhabitants), 2008*

CA7.0

AZ3.5

NM3.0

TX6.2

40.5BC

26.4SON 17.1

CHI 16.5COH

19.9NL

31.9TA

San Diego: 8.4

Tijuana: 46.1*

United StatesNational TB Incidence: 4.2

Mexico National TB Incidence: 14.1

FIGURE 1

Source: CDC, 2008; CDPH, 2008; DGEPI Mexico,2008; INEGI, 2005; SINAVE, 2007. *Based on 2007 data. **All United States data isbased on all types of TB and all Mexico data isbased on pulmonary TB only.


The United States-Mexico Border HealthCommission recently released an importantreport, Tuberculosis Along the United States-Mexico Border White Paper, which delineatesboth successful strides and deficiencies intuberculosis control along the entire US-Mexico border. In the San Diego-Tijuanaregion, notable programs such as the CureTBbi-national health cards and the Puentes deEsperanza program are confronting thespecific needs of the border population(additional information about the CureTBprogram is available athttp://www.sdcounty.ca.gov/hhsa/programs/phs/cure_tb/). However, the report alsohighlights the fact that significant challengesstill exist in Mexico, such as insufficient

laboratory diagnostics includingmycobacterium culture and drug sensitivitytesting, limited DOT programs, and pooraccess to second-line drugs (7). In the UnitedStates, ways in which to reach, educate andtreat vulnerable populations for TB, includingthose who did not enter the United Stateslegally, must also be addressed andimplemented.

Economic analyses have clearlydemonstrated that US investment in TBcontrol in Mexico is a cost-effective means ofcontrolling TB in the US (8). Given theepidemiology of TB in the San Diego-Tijuanaborder region this is especially likely to betrue; but major involvement by private

Figure 2.

Active TuberculosisIncidence Rates per100,000 Inhabitants,2008*

Figure 3.

Active TuberculosisIncidence Rates per100,000 Inhabitants inTwo TijuanaSubpopulations

Source: Garfein, R., 2008; INEGI, 2005;Laniado-Laborín, R. & Cabrales-Vargas, N.,2006; SINAVE, 2007.

Rat

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r 10

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ico

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16.519.9

31.9

Active Tuberculosis Incidence Ratesper 100,000 Inhabitants, 2008*

Active Tuberculosis Incidence Ratesin two Tijuana Subpopulations

Rat

e pe

r 10

0,00

0 500.0

400.0

300.0

200.0

100.0

0.0

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46.1

InjectionDrug Users

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GeneralPopulation

Rat

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31.9

Active Tuberculosis Incidence Ratesper 100,000 Inhabitants, 2008*

Active Tuberculosis Incidence Ratesin two Tijuana Subpopulations

Rat

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r 10

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300.0

200.0

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GeneralPopulation

Source: CDC, 2008; CDPH, 2008; DGEPIMexico, 2008; INEGI, 2005; SINAVE, 2007. *Based on 2007 data. **All United States datais based on all types of TB and all Mexicodata is based on pulmonary TB only.


businesses and governmental agencies willbe required to make this a reality. Twoimportant organizations, the Global BusinessCoalition for HIV/AIDS, Tuberculosis, andMalaria (GBC) and the Global Health Initiative(GHI) of the World Economic Forum havesuccessful working models in whichbusinesses located in high TB-incidenceareas have taken a lead role in TB controlprograms. This has led to health benefits foremployees and the community at large, andhas boosted employee morale andproductivity. Positive outcomes of early TBdetection and effective therapy include areduction in absenteeism and turnover andreduced transmission of TB to other workersand family members. Specific strategiesinclude providing TB health education toemployees, implementing diagnosis andonsite treatment programs, and reducingstigma and fear by developing non-discriminatory policies. Some companieshave built local TB control capacity byinvestment in local hospitals, labs or clinicsproviding TB care. This is a novel approachto address emerging high impact threatsthrough private-public partnerships, andprovides a promising model that can beadopted in the US-Mexico border region. TheSan Diego-Tijuana region, with active localand regional coalitions and a substantialprivate and government business presence, is

a perfect area in which to demonstrate thevalidity of this model, which could then betranslated to the rest of the US-Mexicoborder region.

This document opens with a description ofthe pattern and impact of TB in the SanDiego-Tijuana border region, includingestimated costs associated with TB disease.Subsequent chapters are organized by thefive strategies that have been identified ascornerstones of TB prevention and control.These include:

• Laboratory Diagnostics• TB Case Management• TB Prevention• TB Infection Control• TB Surveillance

Each chapter includes backgroundinformation relevant to this region, identifiedneeds with suggested approaches to reducingthem, and the anticipated costs and benefitsof addressing them. Finally, the documentcloses with a chapter on the role ofbusinesses in tuberculosis control. It ishoped that this document will serve as aresource guide and 'roadmap' forstakeholders on both sides of the border thatare committed to improving TB control.


References:

1. World Health Organization, 2008 Tuberculosis Facts (rev. April 2008). Retrieved on June 2, 2009 from http://www.who.int/tb/publications/factsheets/en/index.html

2. Hamilton CD, Sterling TR, Blumberg HM, et al. Extensively Drug-Resistant Tuberculosis: AreWe Learning from History or Repeating It? Clinical Infectious Diseases 45:338-342. 2007

3. County of San Diego Health and Human Services Agency, TB Control Branch. 2001-2008 Comparative Data. Retrieved on February 17, 2010 fromhttp://www.sdcounty.ca.gov/hhsa/programs/phs/tuberculosis_control_program/statistics.html

4. Secretaria de Salud, México, Dirección General de Epidemiología. Anuarios de Morbilidad 1984-2008. Retrieved on February 17, 2010 from http://www.dgepi.salud.gob.mx/anuario/html/anuarios.html

5. SINAVE Plataforma Única de Información Módulo Tuberculosis 2007. 6. Instituto Nacional de Estadistica Geografica e Informatica (INEGI). Conteo de Poblacion y

Vivienda 2005. Retrieved on July 13, 2009 fromhttp://www.inegi.org.mx/inegi/default.aspx?c=10202&s=est

7. The United States-Mexico Border Health Commission. Tuberculosis Along the United States-Mexico Border White Paper (2009). Retrieved on June 2, 2009 fromhttp://borderhealth.org/reports.php?curr=about_us

8. Schwartzman, K., Oxlade, O., Barr, R. G., Grimard, F., Acosta, I., Baez, J., Ferreira, E., Melgen, R. E., Morose, W., Salgado, A. C., Jacquet, V., Maloney, S., Laserson, K., Mendez, A. P., and Menzies, D. "Domestic returns from investment in the control of tuberculosis in other countries," New England Journal of Medicine 353 (2005): 1008-1020.

9. Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria. The State of Business and HIV/AIDS, Tuberculosis and Malaria (2008). Retrieved on June 2, 2009 from http://www.gbcimpact.org/soba

10. Center for Disease Control and Prevention. Tuberculosis. Retrieved on June 2, 2009 from http://www.cdc.gov/tb/

11. Center for Disease Control and Prevention. Reported tuberculosis in the United States, 2008. Retrieved on February 17, 2010 from http://www.cdc.gov/tb/statistics/default.htm

12. Garfein, R, Prevalence of latent tuberculosis infection (LTBI) and active TB among hidden populations at risk for HIV infection in Tijuana, Mexico: Project PreveTB. Public Health Without Borders Conference, October 28, 2008 (San Diego, CA)http://apha.confex.com/apha/136am/techprogram/paper_186931.htm

13. Laniado-Laborín, R., & Cabrales-Vargas, N. (2006). Tuberculosis in healthcare workers at a general hospital in Mexico. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 27(5), 449-452.


Tuberculosis Trends in San Diego CountyIn the last decade, there has been an averageof over 300 new Tuberculosis (TB) cases peryear in San Diego County (1). In 2008, therewere over 8 new TB cases for every hundredthousand people in the county (2), which isdouble the national average of 4 new TBcases per 100,000 people (3). While thenumber of new TB cases in the both the USand San Diego have been decreasing steadily

over the last decade (1,3), the incidence ofTB in San Diego has remained approximatelydouble that of the national average since1993 (Figure 1). While TB trends are complexand multivariate, much of the discrepancywith national incidence is likely due to thelarge number of foreign-born TB cases in SanDiego. While foreign-born individuals fromhigh prevalence TB countries havecontributed an increasing proportion of TB

II. The Scale and Cost ofTuberculosis in San Diego County

U.S.

San Diego

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Inci

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)

Figure 1.

Trends in Tuberculosis Incidence,1985-2007

United States

100%

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Figure 2a & b.

Trends foreign-born vs. US-born TB cases in the United States and San Diego


cases to the US totals since 2001 (Figure 2a),in San Diego, foreign-born individuals havealways made up at least 60% of the TB cases,and that proportion has continued toincrease since the 1990's (Figure 2b). In 2007,80% of new TB cases in San Diego were inindividuals born outside the US.

The San Ysidro border crossing between SanDiego and Tijuana is one of the busiest landborder-crossings in the world, with over 60million crossings annually and 90% of all tripseither starting or finishing in San Diego orTijuana (4). Over the last decade almost half(45%) of the foreign-born TB cases in SanDiego were born in Mexico, with Mexicanimmigrants making up 36% of all San DiegoTB cases in 2007 (1). This is likely anunderestimate of the influence of Mexico onthe TB case load in San Diego as the majorityof US-born, Hispanic TB cases (which are notidentified in TB surveillance data as ofMexican origin) are of also of Mexicandescent and are being exposed to MexicanTB risk factors when they cross into Mexicofor social, cultural and economic reasons.

It has been clearly demonstrated that USinvestment in TB control in Mexico is a cost-effective and efficient manner of reducing TBincidence in the US (5). This is likely to beespecially true in San Diego where many ofthe residents being treated for TB wereprobably exposed to TB risks factors inMexico where the TB prevalence is muchhigher than in the US (see section II, Figure1). What this means for San Diego is that theprevention and treatment of TB, and controlof TB costs have to be managed incollaboration with other public health, non-profit and business partners inTijuana.

Estimating TB Costs in San Diego

TB is a subtle and complex chronic infectiousdisease that can remain dormant for yearsafter an individual has been infected. Once aninfection becomes active, TB disease oftentakes weeks or months to be diagnosedcorrectly and takes a minimum of 6 monthsof daily medication to treat effectively.Treatment can extend to multiple years if theinfecting TB strain is drug-resistant. Thecosts of TB are complex and difficult toquantify. Costs include direct cost such as TBsurveillance, diagnostic equipment, and thecost of treatment; as well as indirect costsincluding lost wages for those infected(Table1) (6). In order to estimate the truecost of TB in San Diego we need tounderstand both the epidemiology of TBcases in the county and the direct andindirect costs of supplies and servicesneeded for preventing, diagnosing andtreating tuberculosis. While the epidemiologyof TB is well understood in San Diego, dataon the local costs of TB are limited. In orderto make an estimate of the costs of TB forthis report we have used local cost estimatesfrom public and private sources whenavailable, but have had to rely heavily onestimates from comparable national andinternational studies to supplement regionaldata. While the cost estimates we included

Type of Cost Examples

Direct Costs

Prevention Education, surveillance,Diagnosis contact tracing

Tuberculin skin testing, chest radiography, TB microscopy, TB culture, TB drug sensitivity testing

Treatment Inpatient/outpatient costs,antibiotics, DOT

Indirect Costs

Lost Wages Unable to work duringLost Potential infectious period

Disabilities and mortalities

Table 1.

Examples of Direct and Indirect Costsof Tuberculosis in San Diego


are likely the major variables driving TBcosts in San Diego, our estimates should beconsidered an underestimate of the true costof TB to San Diego County.

Direct Costs

Diagnosis and TreatmentDepending on the severity of the symptomsand stage at which the disease is diagnosed,TB treatment can be initiated in an inpatientsetting with extensive costs, or if symptomsare less severe, in an outpatient setting with lower costs. Most TB patients in SanDiego are treated with a combination ofoutpatient and inpatient care through thecourse of the disease. Direct TB costs aremost sensitive to the number of days apatient is hospitalized. In order to estimatethe direct cost of TB treatment we haveassumed each patient has both inpatient and outpatient costs. Treatment costsinclude all direct costs of diagnosing and treating TB patients and are based on the specific studies and reportsreferenced below.

Inpatient Treatment Costs

Hospitalization for TB TreatmentBetween 1985 and 2008, there was an averageincidence of 315 new TB cases per year inSan Diego. In 2008, 46% of the new TB caseswere initially diagnosed and treated in thehospital (pers. comm. Marisa Moore, SanDiego TB Control, HHSA). Additionally,according to previous studies (7), 8% ofTB patients were also hospitalized again

sometime during treatment, and somepatients were hospitalized several times (7). For this analysis we combined theseestimates and assumed that at least 54%of all new TB patients (approximately140 TB patients per year) are hospitalizedat least once during their TB treatment.

Drug-resistant TB cases were not includedin this estimate and were handled

separately (see below).

Length of Hospital Stay for TB TreatmentA 2006 study of hospital stays for TB in UShospitals indicated that stays were onaverage three times longer than for othermedical hospitalizations, with a nationalmean of 15 days hospital stay when the TBwas the primary diagnosis (8). This isconsistent with a previous San Diego studywhich showed the average length of stay inthe hospital for TB treatment was 12.5 days(7). We took the mean of these two estimates(13.8 days) as our estimate of the meannumber of days TB patients are hospitalizedin San Diego.

Costs of Hospital Care Average daily costs for hospitalized TBpatients were not available for San Diego.These values were estimated based onaverage national costs for TB hospitalizationsand adjusted for inflation. The median dailycost of a TB hospitalization in the US in 2006was $1,300 per day (8). Adjusted for inflationusing Bureau of Labor Statistics-Medical CareTables (9) that cost was estimated to be$1,459 per day in 2009. Physician charges(inpatient provider costs) were not includedin that estimate, and were an additional costequivalent to 9.59% of hospital costs (Table2) (8,10).

MortalitiesAs a TB diagnosis can take up to two weeks,approximately 2% of TB patients die beforethey are actually diagnosed. These patientswere included in initial hospital costs, butwere excluded from continuing inpatient andoutpatient care costs. Based on San DiegoCounty TB data, an additional 6% of new TBpatients die during treatment. As most ofthese patients die in a hospital we includedthem in total hospital costs but wediscounted their outpatient costs by 50%,assuming most of them died before receivingfull treatment.


Outpatient Treatment Costs

While the specific costs of outpatient TBtreatment were not available for San Diego,these costs have been estimated at a nationallevel. We assumed for this analysis that thenational estimates are similar to San Diego.Direct outpatient treatment costs of drug-susceptible TB in the US, which includeantibiotics, provider costs, diagnostics andpatient compliance monitoring, wasestimated to be $2,300 per patient in 1991(10). Adjusted for inflation, this would be$4,968 in 2009. We are confident this isaccurate as our inflation adjusted estimate isconsistent with the estimate of $4,831 whichwas the average cost per outpatient TB casein Oregon in 2008 (11).

Costs of Drug-Resistant TBDrug-resistant TB (DR-TB) and Multidrug-resistant TB (MDR-TB) cases need to betreated with more expensive medications and require longer and more complicatedinpatient and outpatient treatment periods.For this reason we have estimated DR-TB and MDR-TB direct costs separately. Thesecost estimates were not available for SanDiego and were based on a study of 13 DR-TB patients chosen from across the US in 1994 (12).

Based on San Diego County data between1993 and 2007, approximately 9% of all newTB cases in San Diego have been infectedwith TB bacteria that were resistant to atleast one anti-tuberculous antibiotic (DR-TB),and about 1% was resistant to two of themost effective TB antibiotics; isoniazid andrifampin (MDR-TB). The average outpatientcost of treating mono-resistant TB cases in1991 was $5,000 per patient (6), which was$10,800 per patient in 2009 adjusted dollars.MDR-TB cases were estimated to cost onaverage $44,881 per patient in 1995/96 (12),which was $76,746 per patient in 2009 aftercorrecting for inflation.

Costs of Treating TB SuspectsIn 1991, a study of TB costs in the USestimated that for every TB case correctlydiagnosed and treated, there are anadditional 3.22 cases that go through thediagnosis process and take TB medicationsthat don't have TB (6). These cases areconsidered “TB suspects”, and as the TBdiagnostic process can take months tocomplete, TB suspects take on average threemonths of TB medications before TB is ruledout. This “precautionary” therapy cost(including diagnosis, treatment and followup) was estimated to be $1,400 per TBsuspect in 1991(6), or $3,024 per suspect in2009 inflation adjusted dollars.

Total Annual Direct Costs of TB Diagnosis inSan Diego

Table 2 shows the combined estimate of totaldirect inpatient and outpatient costs of TB inSan Diego is over eight million dollars peryear, or about $27,000 per confirmed TBcase. Approximately 30% of the total directTB costs ($2.7 million) are due to TB casesfrom Mexico. Economic studies have shownthat these costs can be significantlydecreased if the US invests in the detectionand treatment of TB in Mexico wheretreatment and management of the disease ismore cost-effective (5).

Indirect CostsTB is a chronic infectious disease with a slowdisease course, long diagnosis times andtreatment cycles that can stretch from aminimum of six months to multiple years forcomplicated or drug-resistant cases.Consideration of the true costs of TB to SanDiego has to include an estimate of indirectcosts paid by the patients. We estimatedthese costs in terms of lost wages due towork days lost to the diagnosis, treatmentand follow up requirements of TB disease. AsTB causes significant mortalities in working-age adults we also included estimates of the


average cost of salaries permanently lost tothose that died from TB. These estimates are broad averages based on national andinternational estimates of days lost to TB,local estimates of the number of working-ageadults affected by TB and county estimates ofmedian salaries for men and women in SanDiego.

Social Demographics of TB in San DiegoFor the years 1993 through 2007, 61% of theTB cases were male and 69% of cases wereconsidered of working age, between 18 and65 years old (Table 3). As noted in Figure 2b,most of these cases were in foreign-bornindividuals. Half of these foreign-born TB

Inpatient Costs

Total TB cases 315

Non MDR-TB cases 312

MDR-TB cases 3

Cases initially hospitalized (not MDR-TB) 144

Mortalities (dead at diagnosis) 6

Cases hospitalized later (not MDR-TB) 24

Cost of initial hospitalizations $2,899,325

Cost of later hospitalizations $483,221

Inpatient provider costs $324,724

Total MDR-TB costs (input and output) $230,238

SubTotal $3,937,508

Outpatient Costs (non MDR-TB)

Total outpatient cases starting treatment 303

Mortalities (died during treatment) 18

Total outpatients ending treatment 288

Drug susceptible cases 262

Mono-Resistant cases 26

Cost of drug-sensitive cases $1,302,013

Costs of mono-resistant cases $279,936

Cost of susceptible cases that died

during treatment $40,688

Cost of mono-resistant cases that died

during treatment $8,748

SubTotal $1,631,385

TB Suspects Costs

TB Suspects 1,014

Cost of treating TB Suspects $3,067,243

SubTotal $3,067,243

Total Inpatient & Outpatient Costs $8,636,137

Table 2.

Summary of Annual Direct Inpatient and Outpatient TB Costsin San Diego

Table 3.

Sociodemographics of TB Patients,1993-2007. n=5172

Cases %Age<18 yrs 638 12%18-35 yrs 1515 29%36-65 yrs 2064 40%>65 yrs 955 18%SexMale 3161 61%Female 2011 39%EthnicityHispanic 2448 47%Not Hispanic 2724 53%Country of OriginU.S. 1584 31%Mexico 1601 31%Philippines 981 19%Vietnam 303 6%Other Foreign Country 703 14%HomelessNo 4624 89%Yes 376 7%Unknown 172 3%Correctional FacilityNo 4867 94%Yes 296 6%Unknown 9 0.2%


cases came from Mexico and the Philippines(Table 3). Most TB cases were workingindividuals with a permanent residence, withonly a small number from correctionalfacilities (6%).

Wages Lost to TB Morbidity

Working Days Lost to TBThere is no data available on the number ofdays a person with TB loses from work in SanDiego. It was estimated that on average aperson loses 3-4 weeks of work time in theinitial infectious phase of the disease (pers.comm. Kathleen Moser, San Diego TBControl, HHSA) but that does not include theextensive follow up and outpatient treatmenttime taken away from work. The most recentstudy of indirect costs of TB was in 2009 inthe Netherlands where thesociodemographics of TB cases and TBtreatment options are similar to the US (13).In that study the average time away fromwork (including diagnosis, inpatient andoutpatient treatment and follow up) was80.7 days.

San Diego Wages Lost to TBA 2007 San Diego study estimated the medianannual income for males to be $47,955 and

that for females to be $38,680. With anaverage of 260 working days per year weestimated a median daily income of $184 formen and $149 for women (salaries notadjusted for inflation). Total lost wages werecalculated by multiplying the total number ofcases by the average days lost by the mediandaily income (Table 4). We estimated that atotal of $2.8 million of earnings are lostannually to TB morbidity in San Diego.

Wages Lost to TB MortalityFrom 1993 through 2007, there were 442deaths amongst the TB cases in San Diego.Forty eight percent of the total mortalitiesoccurred in working-age individuals (18-65) at an average age of 47 years. This meansthat on average TB patients that died lost 18years of earnings. We applied these averagemortality figures to the mean annual numberof TB cases in Table 5 and calculatedearnings losses using 2007 median salaries in San Diego (not adjusted for inflation). Weestimate that on average TB mortalities arecausing $9.8 million of lost earnings in San Diego annually. As this estimate is aprojection of future earnings and does notinclude inflation it is most certainly anunderestimate.

Table 4.

Annual Wages Lost to TB Morbidity

Total TB cases 315

TB cases in 18-65 yr age group 206

Working age TB cases - males 130

Working age TB cases - females 76

Mean total work days lost to TB 80.7

Mean wages lost - males $1,934,984

Mean wages lost - females $912,431

Total wages lost to TB morbidity $2,847,416

Table 5.

Annual Wages Lost to TB Mortality

Annual working age morts 12

Male Working Morts 9

Female Working Morts 3

Mean age of working age morts 47

Mean working years lost 18

Male lost wages $7,768,710

Female lost wages $2,088,720

Total wages lost to TB mortality $9,857,430


Total Annual Indirect Costs of TB in San Diego

Combining the lost earnings from themorbidity and mortality of TB in San Diego,we estimate that San Diego TB patients arelosing approximately $12.7 million ofearnings per year due to their disease.Beyond the loss of earned wages and taxrevenues is the loss by San Diego employersin productivity. Workforce productivity isimpacted in several ways by TB. Mostsignificant is that TB symptoms are slow todevelop and many individuals infected andinfectious with TB continue day to dayactivities for several weeks before theirdisease is detected. This can result insignificant workplace infections anddisruptions due to the extensive contacttracing activities that need to take place aftera workplace infection. According to theCenter for Worklife Law, this “presenteeism”(workers continuing to work when they areill) accounts for over $180 billion annually inlost productivity for businesses nationally,whereas absenteeism accounts for only $70billion (14). These substantial, but hiddencosts are difficult to estimate in San Diegowhere TB prevalence is one of the highest inthe nation but could be significantly reducedby business involvement in TB managementin both Mexico and San Diego.

Total Direct and Indirect Costs of TB in San Diego

Adding direct costs (Table 2) to indirectcosts (Table 3, Table 4), we estimate that TBis costing a minimum of $21.3 million in SanDiego annually. These costs include themajor measurable factors and costs in San

Diego, but, while high, are certainly anunderestimate of total costs. They do notinclude the substantial hidden costs of lostproductivity to employers or other moresubtle losses like losses to schools that havehad to undergo substantial costs anddisruptions resulting from multiple TB caseinvestigations in recent years (15-17). As over50% of these TB cases are occurring inforeign-born individuals, and over a third ofcases are in individuals from Mexico (Table3), it is critical that San Diego take proactivesteps to work with our international TBcontrol partners to reduce these costs.

RecommendationsWhile we were able to generate a roughestimate of the costs of TB in San Diego, it isimportant to recognize that this falls short ofthe kind of cost analysis or cost-benefitanalysis that could help us determine notonly an accurate estimate of costs, but alsotrends in costs and opportunities for cost-savings. As described in the chapter above,this is particularly relevant in the US/Mexicobi-national region where cost savings willlikely require an understanding of costs onboth sides of the border as well asinterventions in both Mexico and the US toachieve savings.

Cost analyses such as these are driven bydata. While we were able to find much of thedata necessary for a cost estimate in SanDiego, such data was not readily available forTijuana, Mexico. We recommend a formalcost analysis of TB in San Diego and Tijuanato determine the dynamics and potentialcost-savings that might be realized with thetypes of bi-national interventions describedin the remainder of this document.


References:

1. San Diego Health and Human Service Agency (HHSA). Comparative Data: County of San Diego tuberculosis statistics, 2000_2007. Available at: http://www2.sdcounty.ca.gov/hhsa/documents/fctshttables2007V2.pdf (accessed January 14, 2009).

2. San Diego Health and Human Service Agency (HHSA). County of San Diego tuberculosis control program 2008 fact sheet. Available at: http://www.sdcounty.ca.gov/hhsa/programs/phs/documents/Factsheet2008V1.pdf (accessed January 15, 2010).

3. CDC. Trends in tuberculosis--United States, 2008. MMWR Morb Mortal Wkly Rep. 2009;58(10):249-253.

4. San Diego Association of Governments (SANDAG). Economic impacts of wait times at the San Diego-Baja California border. Available at: http://www.sandag.org/programs/borders/binational/projects/2006_border_wait_impacts_execsum.pdf (accessed 2010, February 18).

5. Schwartzman K, Oxlade O, Barr RG, Grimard F, Acosta I, Baez J, Ferreira E, Melgen RE, Morose W, Salgado AC, Jacquet V, Maloney S, Laserson K, Mendez AP, Menzies D. Domestic returns from investment in the control of tuberculosis in other countries. New England Journal of Medicine. 2005;353(10):1008-1020.

6. Brown RE, Miller B, Taylor WR, Palmer C, Bosco L, Nicola RM, Zelinger J, Simpson K. Health-care expenditures for tuberculosis in the United States. Arch Intern Med. 1995;155:1595-1600.

7. Taylor Z, Marks SM, Rios Burrows NM, Weis SE, Stricof RL, Miller B. Causes and costs of hospitalization of tuberculosis patients in the United States. International Journal of Tuberculosis and Lung Disease. 2000;4(10):931-939.

8. Tuberculosis stays in U.S. hospitals, 2006. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb60.pdf (accessed September 24, 2009).

9. Bureau of Labor Statistics. Overview of BLS Statistics on Inflation and Prices. Available at: http://www.bls.gov/bls/inflation.htm (accessed September 15, 2009).

10. Brown RE, Miller B, Taylor WR, Palmer C, Bosco L, Nicola RM, Zelinger J, Simpson K. Health-care expenditures for tuberculosis in the United States. Archives of Internal Medicine. 1995;155:1595-1600.

11. Rubado DJ, Choi D, Becker T, Winthrop K, Schafer S. Determining the cost of tuberculosis case management in a low-incidence state. International Journal of Tuberculosis and Lung Disease. 2008;12(3):301-307.

12. Rajbhandary SS, Marks SM, Bock NN. Costs of patients hospitalized for multidrug-resistanttuberculosis. International Journal of Tuberculosis and Lung Disease. 2004;8(8):1012-1016.

13. Kik SV, Olthof SPJ, de Vries JTN, Menzies D, Kincler N, van Loenhout-Rooyakkers J, Burdo C, Verver S. Direct and indirect costs of tuberculosis among immigrant patients in the Netherlands. Bmc Public Health. 2009;9.


14. Paid Sick Days Is Smart Business. Available at: http://www.hartfordbusiness.com/news9089.html (accessed September 30, 2009).

15. Local High School Possibly Exposed To TB. Available at: http://www.10news.com/news/13298219/detail.html (accessed September 30, 2009).

16. High School Student Diagnosed With TB. Available at: http://www.10news.com/news/16192832/detail.html (accessed September 30, 2009).

17. Chula Vista Student Tests Positive For TB. Available at: http://www.10news.com/news/19650943/detail.html (accessed September 30, 2009)


a. Laboratory Diagnostics

Background: For active TB, it is imperativethat physicians seek to isolate the M.tuberculosis (Mtb) bacterium from patientsdisplaying symptoms that suggest thepresence of active TB. Bacterial isolation isnot only important for confirming thediagnosis of TB, testing the bacterium forresistance to anti-TB medications is criticalfor determining which medications thepatient should be prescribed. Latent TBinfection (LTBI) is diagnosed by detectingimmunologic responses either directly in thepatient (i.e., tuberculin skin testing) or inblood samples tested in a lab (i.e.,QuantiFERON-TB Gold or T.Spot TB assays)indicative of prior infection, plus an absenceof signs, symptoms and bacteriologicevidence of active TB. Use of these tests iscritical for effective TB surveillance,prevention and control; however, availableresources ultimately dictate which tests areperformed.

While Mtb can infect most organs of the body,with limited exception only patients with TBin the lungs or throat can spread theirinfections. Thus, sputum is the mostcommonly tested sample for Mtb. Thedetection of acid-fast bacilli (AFB) in stainedsputum smears examined microscopically isthe easiest and quickest procedure, andprovides the physician with a preliminaryconfirmation of a TB diagnosis. It also gives aquantitative estimation of the number ofbacilli being excreted, which makes itimportant clinically and epidemiologically forassessing the patient's infectiousness. The

sensitivity of AFB smear microscopy can beimproved relatively inexpensively throughthe use of fluorochrome staining andmicroscopy. In addition, centrifuging andconcentrating the sample can increase thelikelihood of detecting Mtb. Negative smears,however, do not preclude tuberculosisdisease. Various studies have indicated thatonly 50% to 80% of patients with pulmonarytuberculosis will have positive sputumsmears. Detectionof Mtb can besignificantlyimproved byplacing the sputumsample into agrowth medium andallowing thebacteria to multiplybefore examiningthe sample for Mtb.In general, thesensitivity ofculture is 80-85%with a specificity ofapproximately 98% (6, 7). Relativeinfectiousness has been associated withpositive sputum culture results and is highestwhen the AFB smear results are also positive (8).

With the exception of Tijuana GeneralHospital, Baja California laboratoriescurrently use smear microscopy as thestandard diagnostic test for TB. Additionally,because few laboratories are equipped tosafely concentrate sputum samples, publicand private laboratories process sputumsmears using a non-centrifuged, non-

III. Status of Tuberculosis Control in theSan Diego – Tijuana Border Region

Mtb bacteria


concentrated specimen (direct technique).Microscopy using fluorochrome staining canincrease the sensitivity; however, due to cost,few laboratories have this capability. Sincesmear microscopy fails to detect up to half ofthe cases with active pulmonary TB, manyindividuals with active TB are not diagnosedand remain in the community able totransmit the disease. Justification given forthis approach is that patients who excretethe highest quantities of bacteria, and thusmost infectious, are being detected.Consequently, TB-infected patients remaininfectious, and are often treated for othersuspected causes of respiratory illnessinvolving treatments with potential forcausing the bacteria they harbor to becomeresistant to antibiotics. Mycobacteriologycultures are performed only in limitedcircumstances as outlined in the Mexicannorms (9); generally after two relapses orfailed courses of therapy. The laboratory inthe Tijuana General Hospital has the basicequipment and staff to perform cultures, butlacking resources for reagents and othersupplies these tests are rarely performed.

The Global Stop TBPartnership currentlyrecommends the use ofrapid and sensitive TBdiagnostic techniquesincluding cultures tomaximize casedetection and tooptimize therapythrough drugsusceptibility testing.

Drug susceptibilitytesting (DST) isperformed by

introducing patient samples into bacteriaculture media with and without individualanti-TB medications and observing whetherthe bacteria continue to grow. Medicationsthat inhibit bacterial growth aresubsequently prescribed to the patient with

the knowledge that they will be effective.Using standard culture methods, this processtakes about one-two months to provideresults, during which time physicians mustpresumptively treat the patient with multipledrugs to avoid producing new resistance.

Enhanced techniques, using liquid culturesystems (e.g., Bactec MGIT), reduce this timeby about half. Drug resistant strains of TB arefound in Baja California, including Tijuana,and there is evidence of their transmissionwithin the community. Yet, due to lack ofroutine DST, patients with these strains arenot identified in a timely or standardizedmanner. Lack of early identification allowsamplification of drug resistance to occurleading to the emergence of multiplyresistant strains. Limited drug susceptibilitytesting for first line drugs (isoniazid,rifampin, ethambutol, streptomycin, andpyrazinamide) can be performed in BajaCalifornia laboratories, when reagents areavailable and patients are willing to pay forthe test.

Susceptibility testing is provided by theNational Institute for Epidemiology andDiagnostics (INDRE) in Mexico City. Thejurisdictional health departments are able tosend sputum samples for first-line drugsusceptibility testing. However, slowturnaround times, contamination issues, and

Mycobacteriology Culture

Drug Susceptibility Testing for Mtb


shipping costs limit the use of this service.Tijuana General Hospital (part of ISESALUD)is equipped with a Bactec MGIT 960 systemand staff trained to conduct rapid first-linesusceptibility testing. All institutions in BajaCalifornia know of the availability of culturesand susceptibilities at the Tijuana GeneralHospital. They also are aware that routineproblems with supplies limit the availabilityof the service. When supplies are notavailable, the samples are sent to San DiegoCounty HHS laboratory for DST. Because ofthe expense borne by the patient (~USD $100per culture if the samples are sent to SanDiego County HHS and up to $350 per cultureif tested in private laboratories) even in these“public” clinics, cultures are rarely ordered.Consequently, of all the TB cases diagnosedthrough ISESALUD in 2007 and 2008, 23(7.3%) and 4 (1.6%), respectively, werecultured and tested for drug susceptibility atthe General Hospital lab (10). Failing to utilizethese resources represents a missedopportunity to provide appropriate care andprevent ongoing transmission of potentiallydrug resistant strains of Mtb in Mexico.Despite the availability of lab equipment andtrained technicians, the cost of testing TBspecimens prohibits providers from usingthese services. Resources are needed toprovide a consistent supply of DST reagentsat affordable prices, as well as changing theculture among physicians to so that theymake DST a routine part of their diagnosticwork-up for TB.

Public labs in Baja California also lackresources to definitively identify the speciesof mycobacteria in TB patients, creating thepossibility that some TB cases aremisclassified as being due to Mtb. Forexample, a recent study from San Diegofound that M. bovis, a strain ofmycobacterium common in cows, accountedfor 45% (62/138) of all culture-positive TBcases in children (<15 years of age) and 6%(203/3,153) of adult cases (11). Almost all of

the cases were among Hispanics who wereborn in Mexico. Since M. bovis responds tomost but not all medications used to treatMtb infection, species identification should beroutine in endemic regions such as BajaCalifornia. Species identification, as well asDST, can lead to spurious results if the testingis not done correctly. Therefore, outsidequality assurance programs are an essentialfeature to ensure accuracy of laboratoryresults. Currently, such programs areinadequate in Mexico, and resources areneeded to build them up.

Screening tests for LTBI are used in contacttracing to determine whether contacts of TBpatients have been infected. Since those whotest positive have a 5% chance of developingactive TB in the first two years and anadditional 5% chance of developing active TBover the remainder of their lifetime,preventive treatment is recommendeddepending upon additional risk factors suchas age, HIV infection, diabetes, and otherconditions that suppress the immune system.Treatment of LTBI reduces the risk ofreactivation by 65%-75% after 6-9 months oftherapy with isoniazid (INH) (1). The mostsignificant advance in TB diagnosis indecades is the in vitro IFN-_ release assays(IGRAs): QuantiFERON TB® Gold and T-SPOT.TB. IGRAs are rapidly replacingcentury-old tuberculin skin testing (TST), forthe detection of TB infection (2, 3, 4). TheTST requires two patient visits; one toadminister the test on the patient's forearm,and another to read the test 2-3 days later; alabor-intensive process prone to missedvisits (5). Further limiting its potential as apredictive indicator, the TST has beenplagued with problems of inter-raterreliability and false-positive results in peoplewho have received bacille Calmette-Guerin(BCG) vaccination, which is ubiquitous inhigh TB prevalence countries such asMexico. The commercially available IGRAsare designed to provide a qualitative


(positive/negative) indicator of Mtb infection,similar to tuberculin skin test (TST), but donot cross-react with the BCG vaccine, makingthem better suited for Mexico. Screening andpreventive treatment are an essentialcomponent of TB control. A limitation of theIGRAs is their increased cost, which is aboutten times that of the TST, although studiesshow that after factoring in administrativecosts, failure to have results read, anddecreased accuracy, the costs of the twotests to detect cases of TB are comparable(12, 13).

Needs: Capacity for reliable, timely, and highquality culture and drug susceptibility testingis currently lacking in Baja California. Theseservices need to be available to the publicsector, as well as the private sector, andproviders in both Tijuana and Mexicali. Giventhe public health importance of drugresistance and ongoing disease transmission,testing should not be dependent on patients'willingness or ability to pay.

Approach: As recommended by theAmerican Thoracic Society and the USCenters for Disease Control and Prevention(14), “All clinical specimens suspected ofcontaining mycobacteria should beinoculated (after appropriate digestion anddecontamination, if required) onto culturemedia for four reasons: 1) culture is muchmore sensitive than microscopy, being ableto detect as few as 10 bacteria/ml of material(8), 2) growth of the organisms is necessaryfor precise species identification, 3) drugsusceptibility testing requires culture of theorganisms, and 4) genotyping of culturedorganisms may be useful to identifyepidemiological links between patients or todetect laboratory cross-contamination.”Creating laboratories via a public-privatepartnership and addressing supply chainissues of reagents and laboratory supplieswill address this goal. Already, there isinterest in the creation of this type of

laboratory from the private sector. Trainingof physicians and laboratory staff would alsoneed to be included. Given that TijuanaGeneral Hospital already has an automatedliquid culture system (Bactec MGIT 960) thatis currently operating at less than 20%capacity, this laboratory could easily acceptsamples for testing from other institutions.With firm commitments of private investmentand public support, such a laboratory couldbe functional within six months. Publicentities, as well as private practitionerswould have access to these services.

Benefits: The availability of TB cultures andspecies identification assays, will allowphysicians to identify TB patients earlier andwith more accuracy. The establishment of alab capable of providing TB cultures anddrug susceptibility testing in a timely andcost-effective manner would ensure earlydiagnosis and appropriate drug therapy. Thishas the additional benefits of minimizingdisease severity, development of new drugresistant strains, and decreasing the periodof infectiousness. This lab would also permitlab-based surveillance through whichjurisdictional authorities would receive datato identify unreported cases and to monitordrug resistance.

Approximate Costs: To achieve the goal ofimproving laboratory capacity in BajaCalifornia to handle diagnostic testing for thestate's 1100-1200 annual TB cases, resourcesare needed for laboratory space andequipment, testing supplies and reagents,technicians and training. Tijuana GeneralHospital already possesses a Bactec MGIT960 system (valued at $78,000) forconducting drug susceptibility testing.Purchasing a second system for Mexicaliwould allow samples from both cities and theoutlying communities that feed into them tobe tested efficiently. All AFB(+) sputumsamples should be sent to the TGHlaboratory for TB cultures ($2/each),


identification of M. tuberculosis complex byGenProbe Amplicor method ($12/each) orother method to rule out growth of non-Mtbbacterium, and first line DST by MGIT($88/each). The annual supply cost toculture, identify and test all isolates for drugsusceptibility in Baja California are estimatedto be $112,200-$122,400. Three full timelaboratory technicians (USD <$10,000/yeareach) will be needed to conduct the testing.Training of laboratory staff and physiciansthrough continuing education courses andcertification of laboratory facilities willsignificantly enhance capacity andacceptability of universal testing. Electronicdata management systems that link providerswith laboratories will facilitate rapidtransmittal of laboratory results and enhancesurveillance capabilities. Through a grantfunded by USAID (15), Tijuana GeneralHospital was the first laboratory in Mexicoequipped to conduct QuantiFERON TB Goldtesting (valued at $10,589). QuantiFERONtesting can be added to contact tracing andscreening of high risk populations (e.g.,health care workers, institutionalizedpersons, and substance abusers) for the costof reagents and technician time(approximately $30/sample).

Recommendations:• Improve detection of active TB through

routine TB screening by supplementing the current standard acid fast bacilli (AFB) smear microscopy with specimen concentration, fluorescence microscopyand TB culture.

• Expedite the introduction of drug susceptibility testing (DST) throughout Tijuana and Baja California with the ultimate goal of making DST routinely available to all local hospitals and clinics in the public and private sector. To facilitate this process, laboratories should utilize existing and evolving technologies rather than imposing strictcriteria on tests to be used.

• Remove barriers to treating latent TB infection for contacts and high-risk groups by using assays that are insensitive to BCG vaccination, such as interferon gamma release assays (i.e., QuantiFERON TB Gold or T.Spot TB), to detect candidates for treatment. Prioritization should include high risk groups (e.g., diabetics, HIV co-infection)and contacts of recently diagnosed active TB cases.

• Introduce laboratory-based reporting to enhance TB surveillance.


References:

1. Jasmer RM, Nahid P, Hopewell PC. Latent Tuberculosis Infection. N Engl J Med 2002,347:1860-1866.

2. Lalvani A. Diagnosing tuberculosis infection in the 21st century - New tools to tackle an oldenemy. Chest 2007,131:1898-1906.

3. Dinnes J, Deeks J, Kunst H, Gibson A, Cummins E, Waugh N, et al. A systematic review of rapid diagnostic tests for the detection of tuberculosis infection. Health Technol Assess2007,11:1-+.

4. Pai M, Riley LW, Colford JM. Interferonn assays-gamma in the immunodiagnosis of tuberculosis: a systematic review. Lancet Infectious Diseases 2004,4:761-776

5. Menzies D, Pai M, Comstock G. Meta-analysis: New tests for the diagnosis of latent tuberculosis infection: Areas of uncertainty and recommendations for research. Ann Intern Med 2007,146:340-354.

6. Morgan, M. A., C. D. Horstmeier, D. R. DeYoung, and G. D. Robers. Comparison of a radiometric method (BACTEC) and conventional culture media for recovery of mycobacteria from smear-negative specimens. J. Clin. Microbial. 1983;18:384-388.

7. Ichiyama, S., K. Shimokata, J. Takeuchi, and the AMR Group. Comparative study of a biphasic culture system (Roche MB check system) with a conventional egg medium for recovery of mycobacteria. Tuberc. Lung Dis. 1993;74:338-341.

8. Yeager, H. J., Jr., J. Lacy, L. Smith, and C. LeMaistre. Quantitative studies of mycobacterial populations in sputum and saliva. Am. Rev. Respir. Dis. 1967;95:998-1004.

9. SDS. Modificación a la Norma Oficial Mexicana NOM-006-SSA2-1993, Para la prevención y control de la tuberculosis en la atención primaria a la salud. http://www.salud.gob.mx/unidades/cdi/nom/m006ssa23.html. Accessed January 21, 2008.

10. SINAVE Plataforma Única de Información Módulo Tuberculosis 200711. Rodwell TC, Moore M, Moser KS, Brodine SK, Strathdee SA. Tuberculosis from

Mycobacterium bovis in binational communities, United States. Emerging infectious diseases. 2008;14(6):909-16.

12. Lambert L, Rajbhandary S, Qualls N, et.al. Costs of Implementing and Maintaining a Tuberculin Skin Test Program in Hospitals and Health Departments. Infect Control Hosp Epidemiol. 2003; 24: 814-820.

13. Nienhaus A, Schablon A, Le Bâcle C, Siano B, Diel R. Evaluation of the interferon-release assay in healthcare workers. Int Arch Occup Environ Health 2007; Jun 29; (Epub ahead of print).

14. American Thoracic Society. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. Crit Care Med. 2000;161:1376-l 395.

15. Garfein RS. Screening and diagnosis for TB among populations at risk for HIV infection in Tijuana, Mexico. 12th Annual Meeting of the International Union Against Tuberculosis and Lung Disease-North American Region. San Diego, CA, February 28-March 1 2008.


b. Tuberculosis Case Management

i. Patient Management and DirectlyObserved Therapy

Background: After the diagnosis of TB ismade, the next step is to assure that eachpatient receives an appropriate course oftreatment. A patient registry will be crucial tosuccessfully treating and following patients.The correct medications must be used, in thecorrect dose, for the correct number ofmonths, and adherence and side effectmonitoring procedures need to be in place.Failure of any of these elements increases therisk of treatment failure, relapse andemergence of drug resistance.

Mexico follows WHO guidelines for TBtreatment. Patients are treated with twomonths of DOT-BAL (a combinationpreparation of INH, rifampin, ethambutol,pyrazinamide) followed by four months ofDOT-BAL-S (a combination preparation of INHand rifampin). Because most people find itdifficult to adhere to a prolonged andexacting treatment course, the WHO, the USCDC, and the Mexican NTP all endorsedirectly observed therapy (DOT) for TBpatients. However, in Baja California, aselsewhere in Mexico, the allocation ofresources to assure that DOT services areadequate is left to local jurisdictions.Because of competing priorities, jurisdictionsoften find it challenging to create andmaintain well-functioning DOT programs.Furthermore, because of resource limitationsthese services often can only reach morestable, easy to manage patients, leaving themost challenging patients inadequatelyserved. Baja California has over 1000 activeTB patients diagnosed each year. Despite anexcellent system of decentralized health careand a history of using promotores(community health workers) to attend tocommunity health needs, currently availableresources cannot fully realize the DOT

strategy in Baja California at this time.

Strict DOT may be used in some cases, butmedications are more often issued in weeklyor longer intervals based on providerassessment of patient reliability, specificbarriers to DOT (e.g., need to return to work,distance from health center, unaccountedcosts of TB treatment etc.), and resources(1). Therefore, many TB patients are on defacto self-administered treatment (SAT).

For patients who fail treatment (i.e., remainsmear positive) or relapse, standardized re-treatment regimens are recommended inaccordance with WHO guidelines. Often,however, re-treatment drugs are not readilyavailable and patients may be temporizedwith partial regimens. The regimens areempiric, thus re-treatment may magnify drugresistance in some cases. Moreover, thepractice of allowing SAT extends to re-treatment patients.

Patient monitoring, to minimize side effectsand prevent serious adverse reactions,reduces the likelihood of patientabandonment and increases overall successof treatment. However, some monitoring tests(e.g., thyroid-stimulating hormone testing,vision screening, etc.) are not covered undercurrent Mexican norms and so are not readilyavailable to patients.

Needs: Assurance of strict DOT for allpatients with TB is needed. The systemneeds to be patient-centered with enoughflexibility to allow access. Centralized anddecentralized strategies can be developed.Treatment support should include assistancewith housing, food, and similar needs whenrequired to maintain patient adherence.

Drug susceptibility testing (DST) and baseline tests should be built into the standarddiagnostic workup, to assure the bestregimen can be selected the first time a


patient is treated. At a minimum, treatmentfailure and relapse should require DSTs priorto initiation of a second course of treatment.Monthly monitoring schedules, attendance toinfection control and routine laboratorytesting should be added to standard policiesto provide guidance to treating physiciansand to enhance access to recommendedmonitoring tools. Training for providers andsupport personnel should be developed toreinforce treatment standards andexpectations. The Global STOP -TBPartnership's Standards of Care and Patient

Rights documents should be folded intopatient care and provider training initiatives.

Approach: DOT strategies should be createdthat are specific to the geography, socialnorms, patient demographics, andinstitutional structures that exist in BajaCalifornia. Supervision, training and supportof DOT and infection control staff are criticalas they are a vital link to understanding thebarriers confronting patients. Written inter-institutional agreements to cooperate in DOTcoverage and resource sharing could be an

Varying Patient Experiences with TB Treatment

Patient One• First diagnosis in 2000 with TB; Treatment through SAT with 1st line drugs; “Cured”• Second diagnosis in 2006 with TB; Treated as new TB infection through SAT with 1st line

drugs; Treatment failure• Third diagnosis in 2007 with MDR-TB; Treatment through DOT with 2nd line drugs through

Puentes de Esperanza program; Continues on treatment

Patient Two• First (incorrect) diagnosis in early April 2009 with a lung condition; Treatment with

antibiotics for 2 weeks; Treatment failure• Second (incorrect) diagnosis in late April 2009 with pneumonia; Treatment with antibiotics

and injections for 2 weeks; Treatment failure• Third diagnosis in May 2009 with TB; Treatment through SAT with 1st line (improper)

drugs; No improvement• Fourth diagnosis pending drug susceptibility testing in August 2009; New treatment

regimen through DOT with 1st line drugs; Continues on treatment

Patient Three• First diagnosis with a lung condition in April 2009; Treatment through SAT with unknown

drugs; abandoned treatment• Second diagnosis with MDR-TB in May 2009; Treatment through DOT; Abandoned

program in August 2009

Patient Four• First diagnosis with TB in August 2004; Treatment through SAT with 1st line drugs;

Treatment intolerance and failure• Second diagnosis with MDR-TB in March 2006; Treatment through DOT with 2nd line

drugs; Treatment failure followed by no treatment due to pregnancy• Third diagnosis with MDR-TB in May 2009; Treatment through Puentes de Esperanza

DOT program with 2nd line drugs; Continues on treatment


important strategic element.

Employers can support DOT-in-the-workplacefor employees who are returning to work,thereby augmenting the jurisdictional DOTservice network and improving access forworkers. Partnerships between IMSS (whichcurrently provides DOT for its patients),private sector, ISESALUD health centers andothers health institutions can be forged tooffer DOT at the closest health center to thepatient's work or residence. Investment intransportation for health workers couldexpand outreach capacity by enabling onepromotora to serve 15 or more patients perday (especially in central urban regions). Cellphone technology and the internet can beused which would allow DOT workers toobserve patients taking their medicationswithout on-site observation generatingsignificant savings in terms of transportationand staff salary costs.

A strategy suggested by the Global Stop TBPartnership is to establish, for eachgeographical area, a group of TB specialistswho can review and strengthen policies,assist in training and provide consultation forindividual patients. Review of non-standardtreatment regimens should be accomplished

by an inter-institutional group to identifyrepeated problems in patient managementand to develop and implement correctivestrategies. Baja California currently has sucha group, the State Committee for DrugResistance (COEFAR), which should besupported and used as a model for otherregions of Mexico.

Benefits: TB patients often fail treatment anddevelop drug resistance, because they cannotadhere to their DOT schedules. In addition,government entities are often unable toaccommodate the work schedules of the TBpatients that they serve, and therefore, donot require strict DOT for employed TBpatients. Thus, patients may abandon or takepartial therapy, creating circumstances wheredrug resistant TB strains may flourish.Expanded access to DOT will likely increasepatient adherence to medications anddecrease the development of drug resistance.Within the workplace, businesses are likely tohave patients with TB who return partiallytreated and who become infectious again inthe workplace. Businesses may currently loseworkers who must choose between gettingtheir DOT and returning to work. Byimplementing DOT at the worksite,businesses can avoid these situations.

DOT Program has Benefits that Extend Beyond Curing TB

While sick with MDR-TB and receiving DOT every day at his home from a communityhealth worker (promotora), a patient who formerly worked as a doctor said he formed strong“links of friendship” with the person who gave him his daily TB medicine. So strong was thelink that he viewed his promotora as a true “angel” and the program, Puentes deEsperanza, which is one of the only programs in Mexico that provides treatment for MDR-TB, his “savior”. He said, “You cannot imagine the gratitude you have when someonereturns your life to you”. After months of treatment, testing negative and release by hisdoctor, he now volunteers as a community health worker for Puentes de Esperanza andhas become an angel to other patients in his same situation.


Recommendations:• Provide strict DOT for all new

pulmonary TB patients. In areas where this is not being routinely accomplished, stakeholders including providers, administrators, employers, patients and nurses should be convenedto develop and implement DOT pilot initiatives (e.g., workplace DOT, virtual DOT, inter-institutional agreements, home-based DOT).

• Ensure repeat sputum samples to confirm conversion to smear negative status, and response to therapy.

• Initiate policies for patients who relapseor fail TB treatment such that review

and oversight of retreatment regimens isperformed by experts in drug resistant TB.

• Training in TB surveillance and management should be implemented forthree key populations: 1) first and second level providers to assure new TBpatients are reported and managed in accordance with approved standards; 2)case management/DOT staff to assure quality outreach services and infection control practices; and 3) patients and family members to engage them as participants in successful treatment andto limit ongoing community transmission.


References:

1. Guzmán-Montes, GY., Ovalles, RH., Laniado-Laborín, R. (2009). Indirect patient expenses for antituberculosis treatment in Tijuana, Mexico: is treatment really free? The Journal of Infection in Developing Countries, 3 (10):778-782.


ii. Medication Supply

Background: An uninterrupted supply of firstand second line drugs is critical to successfulTB case management and control. Ad hocregimens are used when the medications forstandard regimens are not available and maylead to poor outcomes, including drugresistance and relapse. Availability of TBmedications in pharmacies, when they can beobtained without prescription, is also a factorin poor outcomes.

First line medications are generally availablein Baja California. However, becausecombination preparations are the officialformulations, it can be difficult to getindividual first-line medications when neededfor individualized patient management.Standard re-treatment regimens for patientswith treatment failure and relapse followWHO standards, with a four drug regimen ofPZA-ofloxacin-prothionamide-amikacin orkanamycin. The current process for obtainingthese medications requires submittingtreatment history documents and a specimenfor first-line DSTs to Mexico City and awaitinga national-level decision on whether thepatient is accepted. This process can takeover six months and patients are not alwaysapproved. This situation leads to ad hocregimens being used instead of or whileawaiting approval from Mexico City.

Needs: Providers need a rapid andacceptable process for securing completeand appropriate medications for theirpatients who have failed a previous treatmentcourse. Re-treatment regimens should beguided by DSTs to avoid unintentionalmagnification of drug resistance. Policieshave to be created and implemented toassure that appropriate drugs and dosageschedules, and appropriate deliverymethods, are available for every patient.

Approach: Second-line drug regimens are

available from several sources and theMexican National Program is currentlyupdating treatment standards for re-treatment cases. These standards should bereviewed by local physicians who use anysecond-line drugs for treating TB patients. Allre-treatment cases should be reviewed by theBaja California COEFAR in a timely manner toobtain a consensus on the appropriatetreatment regimen. In addition, the need forindividual first-line medications should beassessed by the state TB program, to developstrategies for supplying these when needed.

A model for local receipt of Green LightCommittee-approved second line drugs is inplace in Baja California. The Green LightCommittee reviews applications from DOTS-Plus pilot projects and determines theireligibility for receiving low-priced second linedrugs. To assure that future shipments ofthese medications will continue, BajaCalifornia's health sector needs to develop aninternal oversight system to assure allaspects of patient selection, diagnosis, andmedication use are strictly controlled andmonitored.

Benefits: Expanded access to and consistentsupply of first and second line TB drugs willhelp ensure that patients are treated with theproper drug regimens, which reduces thechance for the development of drugresistance and improves patient outcomes.

Recommendations:• Assure that the cost to patients of

laboratory tests, such as repeat TB smear microscopy, imaging studies and monitoring of medications, do not contribute to abandonment of TB therapy.

• Devise a mechanism for charitable organizations to contribute to the TB drug supply chain, further ensuring an ample supply.


c. Tuberculosis Prevention

i. Health Education

Background: There remains a great deal ofmisinformation about TB among the generalpublic. This misinformation causes undueanxiety and fear for individuals whenconfronted with someone who has a TBdiagnosis and often places the patient in aposition of shame and ostracism. Fear ofsuch stigma, whether perceived or real, leadspatients to hide their diagnosis potentiallycomplicating treatment adherence andcontact tracing efforts. It may also preventinfected persons from seeking care, thusprolonging the period of infectiousness. Thefacts about TB, when well communicated,can change perceptions, leading tocooperation and support in the control of TBat many levels; patient, provider, family,workplace, and community.

Needs: Education to explain, de-stigmatize,and motivate is needed at all levels. Forexample, primary providers need torecognize TB, understand pitfalls intreatment, and know when and how to refer.Patients need to understand their disease,

transmission, treatment, and theirresponsibilities and rights as a person withthis illness. The public, family, andworkmates need information to alleviate fearand allow for acceptance and support of theTB patient.

Approach: Various sectors should identifythe populations that they need to educate.Goals, programs and evaluations should bedeveloped for each initiative. The privatesector is ideally positioned to develop pilotapproaches to educating the general public,and can work with subject matter experts tocreate public and/or worksite campaigns.

Benefits: An aware public and workforce willbecome advocates for their own health andthat of others. Employees who have TB willfeel able to notify employers in order to testand/or inform their co-workers. Employeescould return to work earlier and with lessstress if supported and welcomed back to theworksite because employers and co-workerswill understand how the disease is and is nottransmitted. Employees can adhere to DOTeasier because they would not feel the needto hide their medications or promotora visitsfrom others.

Concern about Stigma, Discrimination & Confidentialityin the Workplace

A resident of San Diego for over 30 years and TB patient expressed differences in attitudessurrounding tuberculosis depending on which side of the border he was on. In Tijuana, hefeels as if “people treat you the same no matter what”, whereas he was unsure of how hewould be treated upon returning to work in San Diego. He said, “Once I go back to work, I willbe able to tell you more about discrimination.” Though he did say that his employer,coworkers and customers have been extremely supportive of him during his illness, he alsomentioned that someone at work had been spreading rumors about his condition and notadhering to confidentiality policies. Educating employees and managers about TB fostersunderstanding and can eliminate the fear of returning to work after a serious illness. Inaddition, strict workplace policies can be put in place to protect employee privacy.


Recommendations:• Launch a mass media campaign to

educate the public regarding TB, with an emphasis on reducing stigma, encouraging early detection, limited period of contagiousness, and awareness of the availability of

curative medications.

• Implement a pilot program within a Mexican private or government business that would conduct a KAP survey (Knowledge, Attitudes, Practices) from which draft health education materials could be developedand tested. Ultimately finalized materials could be incorporated into existing occupational health programs at the business sites.

• Explore possible ways for Mexican workers to receive full salary versus partial salary compensation on completion of successful TB therapy.

ii. Contact Tracing

Background: Each patient with pulmonaryTB is estimated to infect at least 10 peopledepending on the duration and extent of theirdisease. In many countries, investigation ofthose who have been exposed is limited tofinding secondary cases in the home, ratherthan screening and treating for latent

The Value of Tuberculosis Education

Even though her husband had been recently diagnosed, treated and cured of a TB infection, 36year old Maria did not know what TB was, how it was transmitted or how to prevent it - until sheherself was diagnosed for the first time in 2004. After multiple treatment failures, relapses andpainful symptoms, she was diagnosed with MDR-TB, a type of TB she did not even knowexisted. Now, after years of dealing with the illness, she can list the full names of all the drugsthat she takes, various methods of prevention and can even explain what MDR-TB is. Had shebeen equipped with this knowledge beforehand, Maria may have been able to avert adebilitating and costly 5 years with the disease.

Another patient, Pedro, had already been on treatment for his TB disease for 2 months. Hewas still concerned that TB could be sexually transmitted, could not name any of his currentmedications, and did not know whether he was currently positive or negative for TB. There is aneed to make sure TB patients fully understand their condition, giving them more control andresponsibility for the prevention of the spread of disease and for their own successful recovery.

Renewed Dedication toTuberculosis Education

One TB patient said that the Mexicangovernment makes tuberculosis seem likeit is “distant and unlikely” - downplayingthe disease and foregoing importanteducation about symptoms and methodsof prevention. In December 2008, hesays, this began to change for the better.The Mexican government has begun totake TB more seriously and now runsradio and television campaigns to educatethe general public about TB. Tostrengthen this commitment, businessescan also pledge to make sure theirworkforce knows the facts about TB.


infection. As in most TB endemic regions,Mexico adheres to WHO guidelines thatemphasize detection and treatment of activeTB as the primary means of controllingfurther spread of TB. However, in order toaccelerate the decline, the Stop TBPartnership now recommends preventivestrategies such as prophylactic treatment ofLTBI among HIV-infected persons. Testing andtreating high risk contacts to infectious casesshould be considered a standard preventionstrategy where resources are available.

Needs: There is a need for systematicprocedures to perform expeditious contacttracing with every infectious case of activepulmonary TB identified, to include testingfor latent infection among those at higherrisk of developing disease and appropriatetherapy. This includes cross-bordercommunication between health departmentsfor notification of potential exposuresbecause of patients who work, live, or travelon both sides of the border.

Approach: Policies and operationalprocedures for contact tracing should bereviewed in light of new, more specificdiagnostic tests for latent TB infection. Highrisk contacts can be identified as prioritiesfor targeted screening and treatment, such aschildren, immune-compromised, and thoseexposed to MDR disease. Case managementshould be expanded to assure review of thehigh risk contacts, with strategies developedto enhance LTBI treatment. Exposures withinworksites can be similarly prioritized (healthcare settings, shelters, daycare, etc.) andpilot projects to have employers assist withworksite testing and treatment can beinitiated.

Benefits: Recently infected individuals, suchas the contacts from active cases, are mostlikely to develop active disease within thefirst year of infection - making this a cost-effective approach.

iii. Prophylaxis

Background: Up to 95% of healthyindividuals who inhale TB and are infectedwill control the infection and have 'latent' orquiescent TB infection (LTBI). Ten percentwill activate to disease over a lifetime, ormore, if there is any underlying illness suchas diabetes or HIV infection. Treatment oflatent infection is a cornerstone topreventing the activation of TB disease inorder to minimize the risk of spread of TB toothers. In the United States, an estimated 9.6to 14.9 million people are infected with latentTB (1). The number of people in Mexicoliving with LTBI is currently unknown, but arecent study in rural San Quintín, BajaCalifornia, showed that approximately 30% ofthe population was infected, and in the highrisk group of injection drug users in Tijuana,Mexico, 67% had LTBI (2). Additionally, a TSTstudy in Tijuana found a 57% prevalence ofpositive reactors in children, 46% of whomhad never received the BCG vaccination (3).

Latent infection can be diagnosed throughtuberculin skin testing (TST), however incountries where the BCG vaccine is used,such as Mexico, this test is not as reliable.The new QuantiFERON Gold TB test canaccurately detect latent TB, even inindividuals who have received the BCGvaccine. The CDC recommends that all latentTB infections are treated with the standardtherapy of isoniazid for 9 months, under adirectly observed therapy (DOTS) program toensure treatment adherence and completion.Clinical trials have shown a 90% efficacy inpersons compliant with INH standardtherapy. Latent TB infection should only betreated if active TB disease is ruled out.

Needs: Latent TB is not routinely tested for inTijuana. There is a need to target high riskgroups such as those infected with HIV,injection drug users and those with diabetesfor detection of latent TB.


Approach: High risk populations should betested for latent TB infection. To detect latentTB, the TST should be performed, even ifindividuals have previously had a BCGvaccination (4). QuantiFERON testing couldalso be performed on high risk groups. Oncelatent infection is determined and activedisease excluded, standard 9 month INHtherapy should be administered through aDOTS program. In order to more effectivelytreat TB infection, the necessary labequipment, reagents, supplies and drugsshould be available and appropriately trainedpersonnel should be a consistent componentof Mexico's TB prevention and controlprogram.

Benefits: A focused effort on detection andtargeted treatment of latent TB with INH

therapy prevents TB from progressing toactive disease, and proves much more costeffective than complicated multi-drugregimens required to treat active disease.

Recommendations:• Detection and treatment of latent TB

infections in groups at high risk of progression to active disease.

• Conduct a pilot program within a business, such as a large maquiladora, to perform QuantiFERON screening for latent TB with a pilot TB prophylaxis program for employees identified as TB infected who are at high risk of progressing to active disease (e.g., diabetes).


References:

1. American Thoracic Society/Centers for Disease Control and Prevention/ Infectious Diseases Society of America. Controlling tuberculosis in the United States. American Journal of Respiratory and Critical Care Medicine. 2005: 172: 1169-1227.

2. Garfein, R. S., Lozada, R., Liu, L., Laniado-Laborin, R., Rodwell, T. C., Deiss, R., et al. (2009).High prevalence of latent tuberculosis infection among injection drug users in Tijuana, Mexico. The International Journal of Tuberculosis and Lung Disease: The Official Journal of the International Union Against Tuberculosis and Lung Disease, 13(5), 626-632.

3. Laniado-Laborín, R., Cabrales-Vargas, N., López-Espinoza, G., Lepe-Zuñiga, J.L., Quiñónez-Moreno, S., Rico-Vargas, C.E. (1998). Prevalencia de infección tuberculosa en escolares de la ciudad de Tijuana, México. Salud Publica de México, 40(1).

4. American Thoracic Society, Centers for Disease Control and Prevention. Targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med. 2000;161(4 pt 2):S221-S247.


d. Infection Control

Background: It is estimated thatapproximately 60% of patients in Mexico,similar to other countries, with active TBdisease are hospitalized (1). As TB is anairborne pathogen and infection is possiblewith inhalation of as few as 1 organism, theclosed spaces of hospital rooms and wardsplace health care workers (HCW's), visitorsand other hospital patients at high risk foracquiring TB. Medical procedures such ascough inducement or contaminated medicalequipment such as bronchoscopes alsoincrease exposure. Often these patientspresent with advanced disease that is highlyinfectious exposing hospital workers in theemergency room, before the diagnosis issuspected or confirmed. With more subtledisease, diagnosis may be delayed for daysand occur during their hospital stay, whenthey are on a general medicine or pediatricward. In fact, this risk often begins in theoutpatient clinics as patients present withrespiratory symptoms, frequently withmultiple visits before the diagnosis of TB isfinally made.

Microscopic examination of sputum smearsis usually the first and fastest test performedto detect the presence and quantity of acidfast bacilli (AFB) which may indicate TBdisease which can then be confirmed byculture. The American Thoracic Society (ATS)and the CDC defines a positive AFB sputumsmear result as an indication of increasedrisk for infectiousness and recommends 3consecutive sputum smears negative for AFBbefore the patient can be released fromrespiratory isolation (either in a healthcarefacility or at home) (2). It is estimated thatafter 2 months of standard treatment for TB,80% of patients have negative sputumcultures and after 3 months, 90 - 95% willhave negative test results (3). One studyfound that the average time for a patient toconvert from smear positive to smear

negative was 33 days (median: 23 days) (4).These figures illustrate that a patient with TBis on average, infectious for one month, that20% of patients remain infectious after 2months of therapy and between 5-10% remaininfectious after 3 months of therapy.

If the patient still has positive cultures after 3months of standard treatment, the ATS andthe CDC recommend performing drugsusceptibility testing, and after 4 months oftreatment, positive sputum cultures indicatetreatment failure (3). At this point, MDR-TBor XDR-TB are suspect. In patients with MDRor XDR disease, the period of infectiousnessis extended even longer than for TB patientswithout drug resistance. One study foundthat on average, MDR-TB patients havesputum smear conversion at 69 days andculture conversion at 81 days (5). The samestudy found even longer conversion periodsin XDR-TB patients: 130 and 181 daysrespectively. Thistranslates into MDR-TB patientsremaining infectiousfor approximately 2to 3 months andXDR-TB patientsremaining infectiousfor 4 to 6 months.

Transmission of TBin clinics andhospitals has been documented throughstudies in multiple countries. In Tijuanaspecifically, a well conducted study at amajor hospital over a 4 year periodconcluded that HCWs were 11 times morelikely to be infected than the generalpopulation in Tijuana. Disease occurred mostcommonly in physicians in training, followedby physicians, and then nurses (6). As thisstudy focused on persons who developedactive disease; the incidence of acquiringlatent infection would be substantially higher.A recent study of an outbreak of TB among

It takes a minimum of 6to 8 weeks before a HCWcan return to work afterbeing diagnosed with TB,which is a loss of avaluable resource.


HCW's in a Tijuana hospital detected latentTB infection in 33 HCW's, only 2 of whichcompleted the 4 months recommendedtreatment with rifampin (7). A HCW withactive TB is of particular concern as HCW'smay also have delayed diagnosis, withpossible transmission to hospitalizedpatients and outpatients. Also, once a HCW isdiagnosed there is a minimum of 6 to 8 weeksbefore the HCW can return to work, which isloss of a valuable resource.

Infection control is also a major problemoutside of hospital settings. Patients andtheir families have very limited knowledgeabout how TB is spread and so are not awareof how to prevent transmission in their homeor during daily activities. Wearing a mask,limiting excursions, staying off work, andminimizing contact to vulnerable persons isnot routinely done due to lack of informationand practical means to adhere to thesepractices.

Mexican providers also have limited accessto effective infection control means inoutpatient settings. Clinics where TB patientscome for monthly visits and for supervisedtherapy are not engineered for protection ofworkers against airborne illnesses. Workerswho provide in-home DOT are not provided

masks and are not trained on infectioncontrol. Therefore, there is concern amonghealth care workers regarding their personalrisk. This anxiety causes providers to limitinteraction with TB patients, which in turnmakes patients feel stigmatized about theircondition.

Infection control guidelines exist to preventhospital borne transmission of TB andeffectively protect HCW's, patients andvisitors (2, 8). Theseguidelines involvespecifically outlinedadministrative,environmental andrespiratory-protection controlswhich include: 1)development of awritten TB infection-control plan andassigning infection-control responsibilities, 2) proper handlingand sterilization of contaminated equipment,3) HCW training, education and screening, 4)prompt medical assessment and screening ofpatients for cough and suspected TB, 5)putting patients with suspected or confirmedTB in airborne infection isolation (AII) rooms,6) utilizing local and general ventilation, 7)

HEPA Filter


use of HEPA (high efficiency particulate air)filtration or UVGI (ultraviolet germicidalirradiation) for contamination prevention,and 8) training and use of proper respiratoryhygiene and personal protective equipmentsuch as N95 respiratory masks.With emergence of XDR-TB outbreaksprimarily linked to clinic and hospitaltransmission, there is renewed urgency toboth evaluate the efficacy of TB infectioncontrol procedures and initiate widerimplementation of infection controlprograms, applying tailored methodologies.For instance, in countries with high rates ofTB, this would include aggressive screeningof possible active TB cases in crowdedwaiting rooms with a short list of questions.

Since patients with HIV infection are moreprone to transmitting and becoming infectedwith TB, special attention should be given toHIV clinics where patients may expose eachother in waiting areas.

Needs: According to the current TijuanaTuberculosis Coordinator, there are currently5 inpatient facilities and 35 outpatientfacilities spread throughout Tijuana whichtreat and manage TB. Of the 5 that treat

inpatients, two are IMSS(Social Security)facilities which serve thegeneral workingpopulation, 2 are ISSSTE(Social Security forgovernment workers)facilities which servegovernment workers,and 1 is the SSA(Secretary of Health)general hospital whichserves the unemployedand workers in the

informal sector. Of the outpatient facilities, 26are SSA centers, 5 are IMSS facilities, 2 areISSSTE facilities and one is a Municipalmedical center. The vast majority of TB

patients, approximately 70%, are seen by SSAfacilities at the primary care level.

Infection control measures for TB are notoperational within the government hospitalsand clinics managing TB in the Tijuanaregion. The absence of infection controlguidelines was scheduled to be addressed inOctober 2009 by a USAID funded initiative.Also lacking is the provision of personalprotective gear for health care workers (N95respirators or equivalent); screening policiesto identify suspect patients with active TB inhigh risk clinics and hospital departments;increased ventilation and air purificationthrough HEPA filters and ultravioletgermicidal irradiation (UVGI); regularmaintenance of installed devices andequipment; a minimum of 1 AII room for each

N95 Respirator

An Inside Look atInfection Control

In his office at Tijuana General Hospitalwhere he volunteers, a 47 year old doctorhas an N95 mask sitting next to hiscomputer. He has MDR-TB and believeshe originally acquired his infection bycontact with his urgent care patients backwhen he was a practicing physician. Inhis opinion, sufficient training, protectionand adherence to existing TB controlprotocols are not standard practice inMexico. Although he says that TijuanaGeneral Hospital has UV lights andventilation to protect against TB, he fearsit is not enough for only select hospitals totake infection control precautions.Imagining an ideal Mexico, he says hewould like to see all secondary andtertiary care facilities with strong TBinfection control training and protection forhealthcare workers. After becominginfected with TB, he now wears an N95mask whenever he enters a hospital andwhenever he visits a patient.


of the 5 hospitals; infection control educationfor health care workers, including those atcorrectional facilities. Implementation ofthese new guidelines will be highlydependent on the availability of funding.

Approach: Development of Infection Controlguidelines is currently underway. Healthsectors should identify the infection controlsettings that need to be addressed. Goals,risk assessments, implementation steps andevaluations should be developed for eachsetting.

In hospitals, isolation rooms are warrantedfor all suspect and confirmed active cases. A

variety of designs can beused, but each must bedeveloped andmaintained according toenvironmental hygienestandards. Screeningpolicies to identifypotential infectiouspatients need to be putin place and personalprotective gear forhealth care workersneeds to be availableand enforced. Outpatientsettings should bestructured to minimizerisk to practitioner, aswell as other patients.

TB patients need clearinformation andinstructions, as well asthe tools to keepthemselves fromtransmitting disease to

others while infectious. This can be donethrough better dissemination of ISESALUDpatient education materials and providertraining. The private sector can assist bysupporting capital investments for inpatient

and outpatient facilities, and can promotesafe practices (such as “cough” precautions)in work settings, and can support publicinformation campaigns.

Benefits: Preventing the spread of TB inhealth care settings protects workers,visitors and other patients. This isparticularly important for patients with HIVwho are at significantly increased risk ofdeveloping active TB following exposure tothe bacterium. Screening in correctionalfacilities provides an opportunity to identifyand potentially treat individuals withpulmonary TB before they are released backinto the community. Promoting safe practicesin the community, and especially in theworkplace, can improve the health of theworkforce.

Approximate Costs: Costs would includerenovations to provide a minimum of 1 AIIroom at each of the 5 hospitals withproviding TB inpatient care. Expansion ofrespiratory isolation rooms can be achievedthrough installation of UVGI devices in a fewselect rooms of the adult and pediatric wardswithin the 5 inpatient facilities. This wouldcost a minimum of $5,000 per device. Moresophisticated equipment can cost up to$125,000, however the lower cost modelshave been shown to be effective. Theaddition of HEPA filter air purifiers forinpatient respiratory isolation rooms wouldcost an additional $300 - $500 per unit.Personal protective gear (N95 respirators)should be provided for HCWs managingsuspected and confirmed cases of TB at all 35 of the outpatient facilities and the 5hospitals, with each mask costingapproximately $1.25 per mask. Training for HCWs would vary in cost, dependent on intensity and modality. On-linecurriculums are available and trainings could also be incorporated into requiredmedical in-services.

AII Isolation Room Plan

Unit 1

Unit 2


References:

1. Institute of Medicine (U.S.). Committee on the Elimination of Tuberculosis in the United States, & Geiter, L. (2000). Ending neglect : The elimination of tuberculosis in the United States. Washington, D.C.: National Academy Press.

2. Jensen, P. A., Lambert, L. A., Iademarco, M. F., & Ridzon, R. (2005). Guidelines for preventing the transmission of mycobacterium tuberculosis in health-care settings, 2005. MMWR.Recommendations and Reports: Morbidity and Mortality Weekly Report.Recommendations and Reports / Centers for Disease Control, 54(-17), 1-141.

3. Blumberg, H. M., Burman, W. J., Chaisson, R. E., Daley, C. L., Etkind, S. C., Friedman, L. N., et al. (2003). American thoracic Society/Centers for disease control and Prevention/Infectious diseases society of america: Treatment of tuberculosis. American Journal of Respiratory and Critical Care Medicine, 167(4), 603-662.

4. Telzak, E. E., Fazal, B. A., Pollard, C. L., Turett, G. S., Justman, J. E., & Blum, S. (1997). Factors influencing time to sputum conversion among patients with smear-positive pulmonary tuberculosis. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 25(3), 666-670.

5. Eker, B., Ortmann, J., Migliori, G. B., Sotgiu, G., Muetterlein, R., Centis, R., et al. (2008). Multidrug- and extensively drug-resistant tuberculosis, Germany. Emerging Infectious Diseases, 14(11), 1700-1706.

6. Laniado-Laborín, R., & Cabrales-Vargas, N. (2006). Tuberculosis in healthcare workers at a general hospital in Mexico. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 27(5), 449-452.

7. Laniado-Laborín, R., & Navarro-Alvarez, S. (2007). Brote de tuberculosis en trabajadores de la salud en un Hospital General. Rev Inst Nal Enf Resp Mex, 20(3), 189-194.

8. Secretaria de Salud, Subsecretaria de Servicios de Salud, Dirección General de Medicina Preventiva. Para la prevención y control de la tuberculosis en la atención primaria a la salud. México City, México, Publicada en el Diario Oficial de la Federación, 1995. Publication Norma Oficial Mexicana NOM-006-SSA2-1993.


e. Surveillance

Background: Surveillance is one of the pillarsof public health. It allows health officials,policy makers, and healthcare providers toassess the magnitude of the problem that adisease presents, monitor the effectiveness ofinterventions to reduce the incidence of thedisease, detect outbreaks so that appropriatepublic health responses can be taken to bringhe disease under control, and ideally to trackprogress toward elimination of the disease.Tuberculosis surveillance involvesenumeration of TB cases that are diagnosedeither clinically, via laboratory testing, or

both. In 2001, Mexico instituted the SistemaNacional de Vigilancia Epidemiológica(SINAVE), an internet-based nationalsurveillance system that includes TB. Casesdiagnosed in both public and privatehealthcare settings are eligible to be enteredin the system. Through this system,healthcare providers and health officials canenter TB case reports, and depending on thelevel of authorization, users can generatereports at the level of the facility, institution,city, state, and country.

Based on data included in SINAVE from 2006-2007, there were 1,171 and 1,161 reported

2006 2007

Baja California Tijuana Baja California Tijuana

Total n % Total n (%)

Registered Cases 1,171 614 (52.4) 1,161 650 (56.0)

GenderMale 797 419 (52.6) 799 446 (55.8)Female 374 195 (52.1) 362 204 (56.4)

Age0-4 18 8 (44.4) 18 8 (44.4)5-14 34 20 (58.8) 36 14 (38.9)15-24 247 146 (59.1) 236 143 (60.6)25-44 525 296 (56.4) 531 309 (58.2)45-64 270 120 (44.4) 264 141 (53.4)>65 77 24 (31.2) 76 35 (46.1)

SOURCE: SINAVE Plataforma Única de Información Módulo Tuberculosis, Jan-Dec 2006 and 2007.

435 Secretary of Salud (SSA)

80 Mexican Institute of Social Security (IMSS)

1 Institute of Social Security and Services for State Workers (ISSSTE)

14 State Medical Service (SME)

64 Other*

594 Total**

Source: Mexican Secretary of Health, Health Establishments Key (CLUES) http://clues.salud.gob.mx/Source: SINAVE Plataforma Unica de Informacion Modulo Tuberculosis* Includes 57 (89%) cases from State Penitentiary. **Excludes Rosarito and Tecate.

Table 1

Total Pulmonary Tuberculosis Cases in Baja California and Tijuana by Year

Table 2

Total Reported Tuberculosis Cases by Institution in Tijuana, Baja California,Mexico, 2007


cases of TB in Baja California, respectively(Table 1). Tijuana represented over half of thestate's cases in both years (52% and 56%,respectively). Nearly two-thirds of the caseswere male, but the proportion of male casesin Tijuana was similar to that of the state. Theproportion of TB cases between 15-44 yearsold was greater for Tijuana than for the stateas a whole. By far, the largest number ofcases in 2007 was reported by ISESALUD(Table 2), which is not surprising given thatthis institution also supports the state's TBcontrol program. IMSS reported he secondlargest number of cases. Notably, no caseswere reported in SINAVE by any of the city'sprivate medical service providers. The rate ofTB cases in Baja California (40.5/100,000 pop.)is several times higher than in its neighboringstate to the north (7.0/100,000 pop.); ascenario observed in all Mexico/US borderstates (see Figure 1, Chapter 1). However, thedisparity between countries may be evengreater because of underreporting in Mexico.

In Tijuana, underreporting within ISESALUDmight occur in part because physicians fromeach clinic must complete a paper report andsend it via currier to the TB Control Programlocated at the central ISESALUD clinic, wherethe data are entered by an epidemiologistinto the SINAVE system. Reporting isencouraged by requiring the case reportingforms before ISESALUD will release TBmedications provided free-of-charge by theNational TB Control Program; however, this isa passive reporting system that relies on thediagnosing physicians to collect and reportdata about their patients. After the initialreport is filed, physicians are supposed totrack their patients' status and submit follow-up data to the TB Control Program, which isthen entered into SINAVE. However, there isnot fax or internet service available to sendthese forms electronically to the Programoffice. Thus, once a month, physicians arerequired to personally travel to the Programoffice and dictate their follow-up data to an

epidemiologist who enters the data in thesystem. This process can take the physicianaway from their clinic for up to half a dayeach month. In the IMSS system in Tijuana,one provider at each facility is responsible forcollecting TB case data and entering it intothe SINAVE system and making a separatecopy for the Tijuana TB Control Program.Most TB cases are seen in Family Medicine orPulmonology clinics and tracked by theclinic's epidemiologist. However, patients whoare seen in the emergency department cansometimes be missed by the epidemiologist.ISSSTECALI is a smaller system than IMSS, butfollows a similar protocol for reporting TBcases to SINAVE.

Private providers rarely, if ever, report casesof TB to the jurisdictional or national TBcontrol program, because their patients donot need publicly subsidized medication,reporting is time consuming anduncompensated, and providers risk losingpatients. Typically, the only time a patientdiagnosed in the private sector is counted inSINAVE is when the patient is referred toISESALUD for TB care. The incidence of TBamong patients who seek care in the privatesector is likely to be lower than the generalpopulation; however, this is impossible toverify as long as private providers cannoteasily include their cases in the system.

Needs:• Although Mexico has a state-of-the-art,

national TB surveillance system, the responsibility for entering cases varies across institutions. The TB Control Program in Tijuana encourages providers to report their TB cases by requiring providers to documenting each case before the patient is given free TB medications that are provided by the national TB Program.

• TB is not effectively diagnosed (see lab Needs), so only the most overtly infected


patients are detected.

• Patients are not effectively followed up todetermine the outcome of treatment

• Reporting is time consuming, often involves duplicate effort, and is rarely used by private providers.

Approach: TB surveillance in Tijuana couldbe vastly enhanced by making a computerand internet access available in all ISESALUDhospitals and clinics in the city for use byphysicians, epidemiologists, oradministrative personnel to enter their TBcase data directly into SINAVE. The TBControl Program epidemiologist could thenactively monitor TB case reports in thesystem and follow up with physicians to besure their data are complete and accurate.Education programs are needed to informand encourage private providers to reporttheir TB cases. Since each new TB case islikely to infect 10 of his/her contacts, contacttracing is a vital component of an effectiveTB control program. Thus, SINAVE can beused by the TB Control Program staffmembers to identify cases who should beinterviewed and their contacts examined forTB infection.

Benefits: Complete surveillance data isessential for monitoring trends in TB cases atboth the local and national level in order toinform policy, implement and evaluate TBcontrol practices, and effectively allocateprecious healthcare resources. High qualitysurveillance data can also be used to justifyrequests for additional resources in areas ofgreatest need. By enabling more healthcareproviders to directly enter their data intoSINAVE, end-users at all levels (clinic,institution, jurisdiction, state and national)will have faster access to more complete casereporting data. Furthermore, by decreasingthe burden of data entry on Tijuana's TBControl Program staff, they will have more

time to perform quality control checks of thedata, follow-up with providers to ensure thefidelity of the data, analyze the data toidentify trends in TB cases, and conductcontact tracing activities.

Approximate Costs: One-time costs wouldconsist of purchasing computers for eachclinic at a cost of approximately $1500 each.Ongoing costs include: internet access($50/connection); salary support for anepidemiologist to monitor SINAVE data and aDisease Investigation Specialist to follow upwith patients who have incomplete data andconduct contact tracing; ongoing training forphysicians to ensure that they areconsistently entering data for all of their TBcases.

Recommendations:• Simplify the process of including TB

cases in local and national (SINAVE) surveillance systems in Tijuana, with technologies such as electronic transfer of case information (e.g., email, fax, websites). This would require the placement of computers with internet access in all healthcare facilities that manage TB cases. The computers should be made available for multipurpose use to attain secondary benefits from their placement. Future funding would be usedfor systems analysis, equipment and training to enhance the existing systems.

• Improve methods for monitoring DOT initiation and completion through the existing surveillance system. Also, explore the feasibility and cost-effectiveness of novel technologies (e.g., wirelessly monitored pill dispensers) to facilitate and track DOT.

• Develop procedures and systems for sharing TB data between Mexico and the United States, such as public access to online epidemiological data.


References:

1. Schneider E, Laserson KF, Wells CD, Moore M. Tuberculosis along the United States-Mexico border, 1993-2001. Pan American Journal of Public Health. Jul 2004;16(1):23-34.


Background: Cross border collaborationamong critical public health authorities,academia and private business is essentialfor the development and implementation ofan effective TB health education, diagnosisand treatment program in the San Diego-Tijuana region. Local businesses can andmust contribute to solutions in TB controlacross the border region.

The San Diego-Tijuana border region isexperiencing unparalleled bidirectionalborder crossings and growing cross borderresidences and businesses. As a result,addressing the spread of TB must involvepartnership with local businesses on bothsides of the border as the impacts to lostproductivity and potential of infection toothers in the workplace is great.

Sadly, many cases of TB go unreported earlyon so the risk of infection in the workplaceremains an on-going challenge. With theincreasing incidence of multi-drug resistant

(MDR) TB, it is critical that TB in the borderregion be addressed by the businesscommunity before it becomes a crisessituation similar to what countries in Asiaand Africa are experiencing.

Needs: There have been several examples inrecent years of TB cases in San Diego thathave involved a broad spectrum ofbusinesses including nurseries, biotech firms,manufacturers, nail salons, hotels andcasinos. An increasing incidence of TB willhave a growing negative impact on a broadspectrum of businesses on both sides of theborder. Although there are a number ofexisting employer based TB programs invarious parts of the world, there do notappear to be any programs that focusspecifically on a border region. Beyond the absence of workplace educationprograms, the issue of paid sick leave foremployers needs to be actively considered.Today, nearly 40 percent of California's workforce, totaling 5.4 million workers, do not

IV. Role of Businesses inTuberculosis Control


have the right to take paid time off workwhen they are sick, according to data fromthe Institute for Women's Policy Research, orIWPR, in Washington, D.C. (1). Today neither the State of California nor theCounty of San Diego have paid sickworkplace laws although legislation has beenrecently introduced at the State level andFederally making paid sick leave mandatory(2, 3). In the case of San Francisco, jobgrowth in that city was higher than nearlyevery other county in the Bay Area followingpassage of this legislation. Accordingly sucha public policy should be actively consideredby the County of San Diego and supported bylocal chambers of commerce and other tradeassociations to not only to reduce the risk ofTB but other airborne infectious diseasessuch as the H1NI virus. It is worth noting thatin the case of the County of San Francisco,even prior opponents of the paid sick leavelegislation changed their views on the issue.According to Kevin Westlye, director of theGolden Gate Restaurant Association, “Sickleave, especially for people who handle foodfor a living, is an important public policy (4).”While such legislation has provencontroversial and has been opposed by smallbusiness interests, similar legislation shouldalso be considered in the State of BajaCalifornia given the growing workplace risk of

infectious disease in the region (5).

The vast majority of individuals that contractTB are employed and many times may beattending work for weeks prior to beingdiagnosed. TB tends to infect individuals intheir most productive years and is theworld's greatest infectious killer of women ofreproductive age. The spread of TB can havea substantial negative financial impact onbusiness due to lost employee days,disruption at the workplace due to contacttracing, additional costs for employee testingand treatment and a high level of anxietyamongst employees. In addition, especially inMexican businesses, there is a disjointedpath of TB care and treatment. Many largemaquiladoras or assembly plants in Mexicoemploy physicians that may initiatetreatment for the TB patient, but are thenreferred out to government operated healthsystems (IMSS) for treatment. It is notuncommon that treatment initiated by thecompany doctor is different from treatmentgiven by IMSS (personal communication2009). Often employees suspected of havingTB will not seek medical care from IMSSbecause once diagnosed they are placed ondisability and their pay is reduced to 60%.This provides an incentive to seek care froman alternate source such as ISESALUD or a

Infectious at Work?

Patient One: At least one week on the job as a tank cleaner in San Diego with symptomsof cough, weakness and fatigue.

Patient Two: Worked at a factory in Tijuana for three different periods that consisted ofseveral months between multiple relapses of TB.

Patient Three: Immediately went to the doctor upon having symptoms of weakness, fever,cough and fatigue and did not return to work in Tijuana until released by his doctor to do so.

Patient Four: At least one month working as a bar manager in a San Diego hotel withsymptoms of cough, fatigue and weakness.


private physician and continue to work andreceive 100% pay. In addition, concerns aboutmissing work and/or the stigma attached tobeing diagnosed with TB prevents adherenceamong many patients.

Furthermore, the different Mexican healthorganizations (IMSS, ISESALUD) are notrequired to report TB cases to the patient'semployer nor to each other, which creates alarge communication and information gapthat hinders the management of TB. Oneprivate doctor employed by a manufacturingcompany in Tijuana explained that after sherefers a patient/employee to IMSS, she is nolonger responsible for the care, treatment orfollow up of that patient/employee. Only onher own initiative is she able to determinethe treatment regimen and care that thepatient/employee is receiving through IMSS,but this is not required nor expected ofcompany doctors (personal communication2009). Also, when cases of TB are detected bythe Mexican health system, contactinvestigations in the workplace are notcommon practice, and most only take placewithin the home sphere (personalcommunication 2009). This disconnect couldlead to unknown cases of TB in theworkplace and an unnecessarily exposedworkforce.

Another obstacle to effective TB managementand control in workers is the absence ofdirectly observed therapy (DOT) in theworkplace. Currently, TB patients in Mexicowho have returned to work but are stillreceiving treatment cannot receive DOT atthe workplace through the private companydoctor. This means the employee must adjusthis or her work schedule and potentially losework hours due to the necessity of travelingaway from the worksite to receive DOT. Thereare programs which do furnish medicationand clinical oversight at the workplace, suchas the diabetes programs, which suggestsDOT may be feasible.

Approach: Businesses can be effective bysupporting employees diagnosed with acommunicable disease such as TB, byproviding a workplace TB health educationprogram for all employees, and by providingdiagnosis at the workplace as well as on-siteDOT and contact tracing. This will result infewer obstacles for individuals to seek and

US Workers Cross the Border for Healthcare

Two US citizens, one a tank cleaner andthe other a bar manager in San Diego,opted to seek medical care in Tijuanawhen they first had symptoms for TB.One chose to receive healthcare inTijuana because he lacked healthinsurance through work and the otherchose to receive healthcare in Tijuanaprecisely because he had healthinsurance through work - an innovativenew type of insurance in fact, whichcovers cross-border care. However, bothpatients received an incorrect diagnosisand improper treatment from the privatedoctors they chose to see in Tijuana,prolonging their infectiousness with TBand complicating their eventual recovery.Once their TB disease was accuratelydiagnosed with cultures and drugsusceptibility tests - two methods rarelydone in Mexico - and once they weregiven the proper medications through aDOT program - rather than selfadministering their treatment - bothpatients began to successfully recover.

A business that makes the health of itsemployees a priority by offering healtheducation and quality health insurancecoverage, has the opportunity to play a part in earlier and more accurate TB diagnosis, avoiding weeks or possibly months of TB exposure to other employees, customers and thegeneral public.


complete treatment and; therefore minimizethe stigma of the disease. It is important forcompanies to consider developingnondiscrimination policies that can also helpto de-stigmatize TB and other diseases.

Case studies have demonstrated that itmakes good business sense for companies totake an active role in the health of theiremployees, and the workplace is often thebest site for disease prevention andtreatment programs. Business has significantinfluence as well as financial incentives toprotect the health of their employees whobecome sick with TB. Employers can play asubstantial role by:

• Providing workplace health education programs

• Developing fair policies on discrimination/workers rights

• Offering diagnosis and treatment (DOT) at the workplace, where feasible

• Reducing TB transmission to other employees and their families through contact tracing

• Assisting with the coordination/communication with IMSS or ISESALUD (in Mexico)

There are two organizations that have beenidentified that have successfully developed,implemented and evaluated employee basedTB programs in various countries in Africaand Asia including the Global BusinessCoalition on HIV/AIDS, Tuberculosis andMalaria (GBC) and the World EconomicForum (6, 7). The GBC is a membershiporganization created in 2001 to allow large,for-profit international companies to sharetheir expertise and resources to fight specificdiseases including TB, HIV/AIDS and Malaria.The GBC builds public-private partnerships

by bringing together companies and localnon-governmental organizations (NGOs) toaddress pressing public health needs withinthe global communities in which thecompanies operate. The GBC has allowedmember companies to utilize their businessexpertise to improve the public health oftheir employees and the community. It isespecially imperative for a US companyoperating a business in a foreign country todemonstrate to the local government andcommunity that the company is a responsible

A Factory with Potential to Combat TB

One Tijuana factory which employs 300individuals between the ages of 20 and35, is considered a “medium” sizedfactory. It currently has excellentOccupational and General Healthprograms in place, with a private physicianwho works onsite and who seeseverything from tonsillitis to tuberculosis.Once a year, the physician coordinates aHealth Week held during work hourswhich includes cholesterol testing, healtheducation, vaccinations and dentalcleanings, among other offerings, at nocost to the employee. Ninety-eight percentof employees participate in the annualHealth Weeks. In addition to this,employees also receive an annual medicalexam. With the framework already in placeat this factory, latent or active TB testingcould be included in the annual healthweeks or medical exams, and having aprivate physician onsite could facilitateDOT programs in the workplace.

In the industrial area of Otay Mesa ofTijuana, there are approximately 197businesses with 57,000 employees -tremendous potential for businesses totake action against TB and ensure ahealthy workforce.


citizen and cares about the health of themembers of the community.

Another international organization with welldocumented experience in developing andimplementing employee based TB programsis the Global Health Initiative (GHI) of theWorld Economic Forum. GHI was launched in2002 by Kofi Annan, and their mission is toengage business in public-privatepartnerships to tackle HIV/AIDS, TB, Malariaand Health Systems. In 2008, with supportfrom the Eli Lilly MDR-TB Partnership, GHIlaunched two toolkits (one for South Africa,one for China) that aim to boost theinvolvement of companies in tackling the TBcrisis in their respective countries. In SouthAfrica 70% of patients infected with HIV are

also infected with TB, and China hasexperienced a resurgence of TB worsened bythe emergence of MDR-TB and the HIV/AIDSepidemic. The objective of the toolkits is toassist Chinese and South African companiesin the planning and implementing ofworkplace and community TB prevention,care and control programs. According to aspokesperson for Eli Lilly “business has afundamental responsibility towards boththeir employees and the wider community,and for the preservation of their long terminterests by ensuring the nationaldevelopment of human capital to driveeconomic growth-TB has the capacity toundermined all of this.”

Through the use of available TB toolkits

Global Business Coalition for HIV/AIDS, Tuberculosis and Malaria (GBC)(GBCimpact.org)

• Created 2001

• Currently 220 member businesses• 40% provide TB education at the workplace• 33% employ strategies to prevent transmission of active disease• 31% integrate TB and HIV programs• 28% administer treatment in line with national TB programs• 25% promote early identification of TB cases• 19% employ strategies to address MDR and XDR-TB

• Incentives for businesses to join the GBC• Protect their workforce• Educate the workforce about public health issues• Attract local and global talent by being a socially responsible company• Attract and retain customers

• Featured members• Eskom Holdings Company, South Africa

• 32,000 employees with access to a comprehensive TB workplace program which includes surveillance, monitoring and active treatment

of TB through DOTS and education and prevention

• XStrata Coal, South Africa• 8,000 employees have access to HIV and TB workplace programs

and the program extends into the local community through trained outreach workers


successfully utilized in other countries, a TBprogram that meets the unique needs ofbusinesses in the San Diego-Tijuana borderregion can be created and pilot tested.Building on the success of GBC, it isrecommended that GBC member companieswith subsidiaries located in the San Diego-Tijuana border region be approached forparticipation in a regional program focusedon TB prevention and control. Thesecompanies include:

San DiegoEli LillyGlaxo SmithklineNovartisPfizerWalmart

San Diego/TijuanaCitibankCoca ColaPepsico

TijuanaJohnson & JohnsonHSBCUnileverWalmart de Mexico

Based on the initial success in working withGBC member companies a more expansiveprogram can be undertaken to involve otherSan Diego and Tijuana area companies.

Time is of the essence-there is no reason towait until the TB situation in the San Diego-Tijuana region is as dire as the crises inAfrica and Asia. It is imperative to take actionnow to encourage companies to implementworkplace TB programs that focus oneducation, diagnosis, treatment andprevention. It is essential for the businessesin the San Diego-Tijuana border region tobegin to take an active role in TB preventionand control ensuring a win-win scenario fortheir companies, employees and the health ofthe entire community.


References:

1. Dean Calbreath, “With no paid sick leave, workers face grim choices,” San Diego Union, August 10, 2008 http://www.signonsandiego.com/news/business/calbreath/20 080810-9999-1b10dean.html

2. Healthy Families, Healthy Workplace Act of 2008 (AB 2716) and AB 1000 (March 2009)3. Healthy Families Act (H.R. 2460), was introduced by Representative Rosa DeLauro (D-CT)

in May 20094. Scott McDonald, “Paid sick days is smart business”, Hartford Business Journal online,

June 1, 2009 http://www.hartfordbusiness.com/news9089.html5. Human Impact Partners. A Health Impact Assessment of the California (2008)

http://www.humanimpact.org/PSD/6. Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria. The State of Business

and HIV/AIDS, Tuberculosis and Malaria (2008). http://www.gbcimpact.org/soba.Accessed June 2, 2009.

7. World Economic Forum. Global Health Initiative Brochure. http://www.gbcimpact.org/itcs_type/4/12/report. Accessed June 2, 2009.


V. Appendix (List of Acronyms)

a. AFB: ACID FAST BACILLIb. AII: AIRBORNE INFECTION ISOLATION (ROOMS)c. ATS: AMERICAN THORACIC SOCIETYd. BCG: BACILLE CALMETTE-GUERIN (VACCINE) e. CDC: UNITED STATES CENTER FOR DISEASE CONTROL AND

PREVENTIONf. COEFAR: STATE COMMITTEE FOR DRUG RESISTANCE (MEXICO)g. DOT: DIRECTLY OBSERVED THERAPY h. DOT BAL: A COMBINATION PREPARATION OF INH, RIFAMPIN,

ETHAMBUTOL, PYRAZINAMIDEi. DOT-BAL-S: A COMBINATION PREPARATION OF INH AND RIFAMPINj. GBC: GLOBAL HEALTH COALITION FOR HIV/AIDS, TUBERCULOSIS

AND MALARIAk. GHI: GLOBAL HEALTH INITIATIVEl. HCW: HEALTH CARE WORKERSm. HEPA: HIGH EFFICIENCY PARTICULATE AIR (FILTRATION)n. IGRA: IFN-_ RELEASE ASSAYSo. IMSS: MEXICAN INSTITUTE OF SOCIAL SECURITYp. INDRE: NATIONAL INSTITUTE FOR EPIDEMIOLOGY AND

DIAGNOSTICSq. INH: ISONIAZIDr. ISESALUD: STATE PUBLIC HEALTH SERVICES INSTITUTE (MEXICO)s. LTBI: LATENT TUBERCULOSIS INFECTIONt. M.BOVIS: MYCOBACTERIUM BOVISu. MDR-TB: MULTI DRUG RESISTANT TUBERCULOSISv. M.TB: MYCOBACTERIUM TUBERCULOSISw. PZA: PYRAZINAMIDEx. QFT: QUANTIFERONGOLD TB TESTy. SANDAG: SAN DIEGO ASSOCIATION OF GOVERNMENTSz. SAT: SELF ADMINISTERED TREATMENT aa. TB: TUBERCULOSIS bb. TDR-TB: TOTALLY DRUG RESISTANT TUBERCULOSIScc. TST: TUBERCULIN SKIN TESTdd. USAID: UNITED STATES AGENCY FOR INTERNATIONAL

DEVELOPMENTee. UVGI: ULTRAVIOLET GERMICIDAL IRRADIATION ff. WHO: WORLD HEALTH ORGANIZATIONgg. XDR-TB: EXTREMELY DRUG RESISTANT TUBERCULOSIS

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