1. Directly Observed Therapy  Prescribed by a physician and required by policy for all public and private patients  Strategy to ensure uninterrupted TB drug therapy by a trained ORW  Directly observe patient swallowing each and every dose of prescribed TB drugs  Anywhere mutually agreed upon  DOT regimes: daily, 2xW, 3xW, 5xW… Until the completion of prescribed therapy

3. Patient being observed by D.O.T. outreach worker “El paciente que es observado por D.O.T. excede a trabajador” Patient being observed by D.O.T. outreach worker “El paciente que es observado por D.O.T. excede a trabajador”

4.  Contact Investigation; Screening  Investigación del contactos

5. Screening in Jails and Prisons

6. Mobile Unit X-ray Digitizer used in screening high risk locations

7. Contact investigation in Brownsville, Texas Investigacion de contactos

8. Mask fitting for staff

9. Improved TB lab capability

10. Infection control and MDR treatment by consultation at South Texas Hospital

11. Before the binational projects started:  No understanding of the other system, protocols, contact investigation, or the use of BCG or INH  “Drop-in” of dying MDR patients in WIC waiting rooms with small children  No means of referral or coordinating patients who immigrate  Communication difficult

12.  No information on drug resistance rates in Mexico  No information of resistance by culture on individual patients  No consistent MDR treatment nor available medications  No permits to transfer specimens to US or supplies to Mexico In 1993:

13. Binational successes and achievements  TATB: political will to consider the problem of MDR-TB and cooperation at the national level  Reynosa technical committee  DOT almost universal  Provide cultures for border cities in Tamps  Equipment for X-ray, lab, infection control  Signed agreements  USAID funding

14. Rates by Age Groups 0-04 5-0910-1415-1920-2425-3435-4445-5455-64>64 Age group (years) 0 5 10 15 20 25 30 35 Rate per 100,000 population 19991994

15. Pediatric Rates & & & & & & & & & & & & $ $ $ $ $ $ $ $ $ $$ $ 198819891990199119921993199419951996199719981999 Year 0 2 4 6 8 10 12 14 Rate per 100,000 population WhiteHispanicAfrican American $& 14 years and younger

16. Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, 1991-2001 No. of Cases

17. TB Case Rates in U.S.-born vs. Foreign-born Persons, United States, 1991- 2001 Cases per 100,000 Note: Case rates for 2000 and 2001 based on an extrapolation from the March 2000 U.S. Census Bureau Current Population Reports.

18. Percent of Tuberculosis Cases That Are Foreign-born, Texas 1995-2001 28 32 34 38 39 41 43 1995199619971998199920002001 Year Reported 0 10 20 30 40 50 Percent Source: TB Elimination Division, TDH Foreign Born in TX in 2000 14.9%

19. Estimated HIV Coinfection in Persons Reported with TB United States, 1993-2000 % Coinfection Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group.

20. Primary Anti-TB Drug Resistance United States, 1993-2001 % Resistant Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.

21. Primary MDR TB United States, 1993-2001 Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin. No. of Cases Percentage

22. Primary Isoniazid Resistance in U.S.-born vs. Foreign-born Persons United States, 1993-2001 Percentage Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.

23. TDH – PHR 11

24. PopulationCasesRates Cameron 60336,33917.8 Hidalgo 80546,65114.6 Starr 764,57910.8 Webb 43188,22422.8 Border Counties – TB Cases & Rates for 2000

25. Border Counties – TB Cases & Rates for 2001 PopulationCasesRates Cameron 55344,58816.0 Hidalgo 74565,18813.1 Starr 1967,50628.1 Webb 31194,35316.0

26. CountyNumber of Cases 2001 Population Rate Aransas319,89315.1 Bee426,63913.5 Brooks19,10611.0 Cameron55344,58816.0 Duval014,9410.0 Hidalgo74565,18813.1 Jim Hogg06,5700.0 Jim Wells140,2462.5 Kenedy1535186.9 Kleberg132,6323.1 Live Oak110,1119.9

27. County Number of Cases2001PopulationRate McMullen08690.0 Nueces26320,8338.1 Refugio08,1740.0 San Patricio 469,9455.7 Starr1967,50628.1 Webb31194,35316.0 Willacy020,3790.0 Zapata213,86314.4 Region Total 2231,769,37112.6 State Total1,64320,698,4417.9