Microbiologists from Mexico at South Texas Hospital Lab “Microbiólogos de México en el laboratorio de South Texas Hospital”

TB infection  Populations in US more likely to have TB infection –Foreign born from countries where more people have TB disease –Inmates of correctional facilities –Residents of low income neighborhoods –Substance abusers –Homeless

Tuberculosis Patient characteristics, Characteristic Non-border counties Border counties National origin Foreign-born35.0%59.0% Born in Mexico46.4%87.7% Risk factors HIV infection10.9%6.4% Homeless7.2%3.4% Incarceration11.3%9.2% Diabetes10.2%24.5% Alcohol abuse15.8%12.9% IV drug abuse2.1%1.8%

Tuberculosis Patient characteristics, Characteristic Non-border counties Border counties Race White23.0%3.5% African-American29.2%0.4% Hispanic37.0%94.3% Other10.8%1.8% Age Group (yrs) 19 and younger8.8%16.7% %26.8% %28.0% 60 and older21.1%28.5%

Barriers to TB Elimination  Importation of Cases  AIDS/TB  Drug Resistance  Unmotivated/Noncompliant Patients  Undetected Cases

TB Infection  TB infection means that tubercle bacilli are in the body but under control  TB infection detected by tuberculin skin test (Mantoux test)

TEXAS DEPARTMENT OF HEALTH PUBLIC HEALTH REGION 11 NO TINE TEST

Comparison of TB Infection and TB Disease Symptoms PPD Skin test Chest x-ray M. Tuberculosis Contagious Effective treatment TB Infection No Positive Stable Dormant No One drug TB Disease Yes Positive Worsening Rapid growth Yes Multiple drugs

PPD 95% of Positive PPD’s in persons with BCG over 5 years earlier is really 95% of Positive PPD’s in persons with BCG over 5 years earlier is really TB Infection BCG fades with time.

Preventive Therapy  Substantially reduces infected person’s risk of developing clinical tuberculosis  Consists of 6-12 months of daily isoniazid  9 months preferred  Patients must be monitored monthly for symptoms of toxicity and compliance

High-Risk Groups to Target for Preventive Therapy (Regardless of age)  Infants and Persons with HIV Infection  Close contacts of infections tuberculosis cases  Recent skin test converters (Or 10mm increase for persons< 35 years old) Estimate the likelihood of completion before starting

Who Is A Suspect?  Cavitary disease  Positive smear  Fibronodular or miliary with symptons  TB drugs contemplated

Predominate Site of Disease SitePulmonaryLymphaticPleural Bone and/or Joint GenitourinaryMiliaryMeningealPeritonealOtherPercentage<

Culture Before Therapy  Sputa  Gastric  Urine  Biopsy: direct to pathology, no preservative

Smear Examination  Strongly consider TB in patients with smears containing acid-fast bacilli (AFB)  Use follow-up smear examinations to assess patient’s infectiousness and response to therapy  Expect results within 24 hours of specimen collection  Use the entire clinical picture and be alert to false positives and false negatives

Infectiousness  Greater in patients who:  are coughing,  are undergoing cough-inducing or aerosol-generating procedures, or  have sputum smears positive for acid- fast bacilli and they  are not receiving therapy,  have just started therapy ( 2-12 weeks) or  have a poor clinical or bacteriologic response to therapy.  Return to public contact depends on risk to others.

Risk of Inhaling Mycobacterium Tuberculosis 1. Concentration of viable bacteria in the air 2. Volume of contamination air inhaled 3. Duration of breathing contaminated air

Increased Number Of Viable Bacteria In The Air: 1. Cavitary disease 2. Smear-positive disease 3. Cough 4. Time until isolation 5. Time until effective treatment

Chest Radiograph  Abnormalities often found in apical or posterior segments of upper lobe or in segments of lower lobe  May have unusual appearance in HIV- infected persons with pulmonary TB  Cannot confirm diagnosis of TB, but may used to rule out pulmonary TB in a person with a positive skin test reaction and no symptoms of disease

Standard TB Treatment Use Four (4) Drugs for Initial Therapy INHRIFEMBPZA* Use of Insufficient Drugs or Doses is Often Fatal *PZA is only effective for first two months but essential for six-month treatment *Not used during pregnancy in U.S.

Never treat “a little TB” with a single drug. Nunca trate “un poquito de tuberculosis” con una sola medicina. Never treat “a little TB” with a single drug. Nunca trate “un poquito de tuberculosis” con una sola medicina.

Currently Available and Experimental Agents for Tuberculosis Chemotherapy Experimental drugs (variable efficacy and toxicity; not approved in the United States for use in tuberculosis)  Rifabutin (ansamycin LM-427  Ofloxacin  Ciprofloxacin  Clofazimine

Second-Line Drugs  Cycloserine  Ethionamide  Kanamycin  Capreomycin  Para-aminosalicylic acid  Amikacin

Challenges  Border communication network with secure web site and health alert network  Exchange information on all missing patients as they often cross the border  Specimens, medications, patients crossing US and Mexico customs and immigrations  Provision of affordable MDR medication  Border center of excellence with experts  Attention to jails and high risk populations  Contact investigation and prevention  Infection control to protect patients and staff  Training of public and private clinicians

La Frontera Chica: Rio Grande-Camargo, Roma-Miguel Aleman

South to INS or north to TCID in San Antonio? Hasta el sur a INS o norte al hospital in San Antonio?