Tuberculosis from Mycobacterium bovis in Binational Communities, United States

The incidence in San Diego is increasing and is concentrated mostly in persons of Mexican origin

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

The close geographical proximity of San Diego and Tijuana, the stark contrast between their distinct economies and levels of socio-economic development, and the ease and magnitude of cross-border exchange between these two metropolitan areas, demand our undivided attention. According to the San Diego Association of Governments (SANDAG), over 60 million persons cross into San Diego from Tijuana at the San Ysidro border crossing each year. In fact, many have come to agree that the San Diego-Tijuana border region does not identify with one particular country, but rather has a broader identity of its own. The blending of economic, social and cultural activities in this region charges us to find bi-national solutions to the unique bi-national issues facing the region. One such regional issue we must confront is that of tuberculosis (TB). Both California and Baja California have TB incidence rates that are much higher than the national rates of their respective countries. Furthermore, Tijuana reports approximately 4 times as many new TB cases per year than does San Diego. There is an urgent need to confront 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 benefit both Mexico and the United States. Importantly, as an air-borne infection, successful models of TB control will have applicability to other emerging diseases threats that require cross-border solutions, such as H1N1.TB is a subtle and complex chronic infectious disease that can remain dormant for years after the initial infection. Once active or reactivated, TB often takes weeks or months to be diagnosed correctly, allowing for ongoing exposure and transmission to others. The World Health Organization (WHO) estimates that 2 billion people, or one-third of the global population, are currently infected with the M. tuberculosis bacilli. Of those infected, it is estimated that 1 in 10 will develop the active, contagious form of disease at some time in their lives, and those with active TB will infect an average of 10 to 15 people per year if they are not treated. Likely an underestimate, over 600 cases of pulmonary TB were confirmed and reported annually in Tijuana in 2006 and 2007 with an overall rate of 46 per 100,000 inhabitants, which is substantially higher than rates in neighboring Mexican states. In the last decade, there has been an average of over 300 new TB cases per year in San Diego County, of which nearly 40% were born in Mexico. This estimate is likely to understate the influence of Mexico on the TB case load in San Diego, since USborn, Hispanic TB cases are not identified in TB surveillance data as being of Mexican origin. Nevertheless, these cases have significant interaction with Mexico when they, or their contacts, cross the border for social, cultural and economic reasons. Prior to the discovery in 1946 that streptomycin cured TB, the disease claimed the lives of half its victims. Hopes of eradicating TB grew when a 6-month course of daily drug treatment was found to be highly effective for curing TB and rates of disease began to drop worldwide. However, interrupted or inconsistent treatment, combined with the AIDS epidemic, led to the emergence of drug resistant strains of TB bacteria that could no longer be cured with first-line antibiotics, and rates of TB began to increase in the 1980s. To date, the WHO and other agencies have documented cases of TB that are resistant to standard first-line antibiotics and second-line antibiotics in all regions of the world, including the US-Mexico border region. This reverses years of progress in TB control as successful management of drug resistance requires more sophisticated laboratory capacity, educated personnel and access to significantly more expensive drugs. Importantly, drug resistance is completely preventable with appropriate diagnosis that includes drug sensitivity testing and programs like directly observed therapy (DOT) that ensure patients are on proper treatment regimens and do not interrupt therapy or miss doses. Until a vaccine or single-dose treatment is discovered, our best hope for preventing TB from returning to an untreatable disease depends on accurately diagnosing and completely treating patients with TB.Like the disease itself, the costs of TB are complex and difficult to quantify. The direct costs can be described in terms of infrastructure - diagnostic laboratories and equipment, clinic and hospital units appropriately designed for infection control, and surveillance systems; personnel - trained laboratory technicians, informed healthcare providers, DOT workers, contact investigators, and surveillance system managers; and consumables - laboratory reagents, anti-TB medications, infection control supplies, and educational materials. Indirect costs include lost wages for those infected, decreased productivity by employers, and disruption to the community affected by contact tracing activities. We estimate that TB costs in San Diego amount to be at least $21.3 million annually, which includes approximately$12.7 million in lost earnings for patients due to their disease. Beyond the loss of earned wages is the loss by San Diego employers in productivity. Workforce productivity is impacted in several ways by TB. Most significant is that TB symptoms are slow to develop and many infected individuals continue day-to-day activities for weeks or months before their disease is detected, potentially exposing large numbers of contacts at work, home and in the community to TB. This results in additional infections in the workplace and disruptions due to the extensive contact tracing activities that need to take place after a workplace infection. The costs presented here include the major measurable factors and costs to San Diego, but, while high, are certainly an underestimate of total costs. They do not include the substantial hidden costs of lost productivity to employers or other more subtle losses like loss of income to school districts due to scheduled absences for children with TB; nor do they account for other social costs related to stigmatization or infected individuals and their contacts. Importantly, there is consensus for what constitutes a comprehensive TB control program: the WHO DOTS program. This strategy includes early detection of cases, contact tracing, accurate diagnosis through bacterial culture and drug sensitivity testing, uninterrupted access to effective drugs, and DOT. Although incidence rates are declining globally and domestically, the number of cases worldwide is increasing due to population growth and the emergence of resistance threatens to reverse the advances to date. Thus, there is an urgent call by multiple political and professional organizations for a coordinated global response. While the San Diego-Tijuana region is impacted by the growing challenges of TB, this is a preventable and treatable disease and there is tremendous potential to contribute and participate in an international mobilization of public health, clinical personnel, business leaders and communities to effectively combat the disease.Economic analyses clearly indicate that US investment in TB control in Mexico can be a cost-effective means of controlling TB in the United States. Given the epidemiology of TB in the San Diego- Tijuana border such economic benefits are likely to be true for this bi-national region. While this is so, the active involvement of both private businesses and governmental agencies will be required to make this a reality. Successful working models in which businesses located in high TB-incidence areas have taken a lead role in TB control programs already exist through the work of member companies of the Global Business Coalition for HIV, Tuberculosis and Malaria (GBC). This novel approach to address emerging high impact threats through private-public partnerships provides a promising model that can be adopted in the US-Mexico border region

Hypothyroidism among military infants born in countries of varied iodine nutrition status

<p>Abstract</p> <p>Background</p> <p>Iodine deficiency is a global problem representing the most common preventable cause of mental retardation. Recently, the impact of subtle deficiencies in iodine intake on children and pregnant women has been questioned. This study was designed to compare hypothyroidism among infants born to US military families in countries of varied iodine nutrition status.</p> <p>Methods</p> <p>A cohort design was used to analyze data from the Department of Defense Birth and Infant Health Registry for infants born in 2000-04 (<it>n </it>= 447,691). Hypothyroidism was defined using ICD-9-CM codes from the first year of life (<it>n </it>= 698). The impact of birth location on hypothyroidism was assessed by comparing rates in Germany, Japan, and US territories with the United States, while controlling for infant gender, plurality, gestational age, maternal age, maternal military status, and military parent's race/ethnicity.</p> <p>Results</p> <p>Hypothyroidism did not vary by birth location with adjusted odds ratios (OR) as follows: Germany (OR 0.82, [95% CI 0.50, 1.35]), Japan (OR 0.67, [95% CI 0.37, 1.22]), and US territories (OR 1.29, [95% CI 0.57, 2.89]). Hypothyroidism was strongly associated with preterm birth (OR 5.44, [95% CI 4.60, 6.42]). Hypothyroidism was also increased among infants with civilian mothers (OR 1.24, [95% CI 1.00, 1.54]), and older mothers, especially ages 40 years and older (OR 2.09, [95% CI 1.33, 3.30]).</p> <p>Conclusions</p> <p>In this study, hypothyroidism in military-dependent infants did not vary by birth location, but was associated with other risk factors, including preterm birth, civilian maternal status, and advanced maternal age.</p

Latent Tuberculosis Infection in a Migrant Agricultural Community in Baja California, Mexico

The objectives were to estimate the prevalence and identify correlates of latent tuberculosis infection (LTBI) among residents of a migrant agricultural community in San Quintín, Baja-California, Mexico. Residents completed a questionnaire and had their blood tested for LTBI using the QuantiFERON®-TB Gold In-Tube (QFT) assay. Among 133 participants, 39.8% (95% CI 31.5–48.7%) tested QFT-positive. Having crossed the U.S.-Mexican border since living in San Quintin (P = 0.03), consuming unpasteurized milk (P = 0.02) and receiving health care at IMSS-Oportunidades in the last 6 months (P = 0.03) were independently associated with QFT-positivity. High LTBI prevalence in this community emphasizes the need for TB education and LTBI treatment for its residents. Association with travel to the U.S. suggests the potential for TB transmission across borders. Higher QFT-positivity among those consuming unpasteurized milk could indicate M. bovis infection, previously reported among Mexican migrants living in U.S. border cities

Healthcare Barriers of Refugees Post-resettlement

The majority of refugees spend the greater part of their lives in refugee camps before repatriation or resettlement to a host country. Limited resources and stress during residence in refugee camps can lead to a variety of acute and chronic diseases which often persist upon resettlement. However, for most resettled refugees little is known about their health needs beyond a health assessment completed upon entry. We conducted a qualitative pilot-study in San Diego County, the third largest area in California, USA for resettling refugees, to explore health care access issues of refugees after governmental assistance has ended. A total of 40 guided in-depth interviews were conducted with a targeted sample of informants (health care practitioners, employees of refugee serving organizations, and recent refugee arrivals) familiar with the health needs of refugees. Interviews revealed that the majority of refugees do not regularly access health services. Beyond individual issues, emerging themes indicated that language and communication affect all stages of health care access—from making an appointment to filling out a prescription. Acculturation presented increased stress, isolation, and new responsibilities. Additionally, cultural beliefs about health care directly affected refugees’ expectation of care. These barriers contribute to delayed care and may directly influence refugee short- and long-term health. Our findings suggest the need for additional research into contextual factors surrounding health care access barriers, and the best avenues to reduce such barriers and facilitate access to existing services

Use of lead-glazed ceramic ware and lead-based folk remedies in a rural community of Baja California, Mexico

© 2016, © The Author(s) 2016. Background: Lead exposure from lead-glazed ceramics (LGCs) and traditional folk remedies have been identified as significant sources of elevated blood lead levels in Mexico and the United States. This study took place from 2005 to 2012 in a rural community in Baja California, Mexico. Objectives: 1) Investigate the knowledge, attitudes, and practices related to lead and lead exposures from LGCs and two lead-based folk remedies (azarcon and greta); and 2) evaluate a pilot intervention to provide alternative lead-safe cookware. Methods: A baseline household survey was conducted in 2005, followed by the pilot intervention in 2006, and follow-up surveys in 2007 and 2012. For the pilot intervention, families who reported using LGCs were given lead-safe alternative cookware to try and its acceptance was evaluated in the following year. Results: The community was mostly of indigenous background from Oaxaca and a high proportion of households had young children. In 2006, all participants using traditional ceramic ware at the time (n = 48) accepted lead-safe alternative cookware to try, and 97% reported that they were willing to exchange traditional ceramic ware for lead-safe alternatives. The use of ceramic cookware decreased from over 90% during respondents’ childhood household use in Oaxaca to 47% in 2006 among households in Baja California, and further reduced to 16.8% in 2012. While empacho, a folk illness, was widely recognized as an intestinal disorder, there was almost universal unfamiliarity with the use and knowledge of azarcon and greta for its treatment. Conclusion: This pilot evaluation provides evidence 1) for an effective and innovative strategy to reduce lead exposure from LGCs and 2) of the feasibility of substituting lead-free alternative cookware for traditional ceramic ware in a rural indigenous community, when delivered in a culturally appropriate manner with health education. This strategy could complement other approaches to reduce exposure to lead from LGCs

Exploring the relationships between dengue fever knowledge and Aedes aegypti breeding in St Catherine Parish, Jamaica: a pilot of enhanced low-cost surveillance

Dengue fever has re-emerged as an increasingly significant global health threat amid diminishing resources pledged for its control in developing nations. Efforts to limit breeding of the dengue vector are often hampered by lack of community awareness of the disease. Sixty-eight households in St Catherine Parish, Jamaica completed a pilot knowledge, attitude, and practice questionnaire as part of a routine container survey for presence of larvae. Infestation levels were high according to traditional indices (Breteau index = 325); however, general knowledge of dengue symptoms, breeding sites, and preventive practices was low. After examining the links between demographic characteristics, dengue knowledge, and the number of breeding sites per house, higher educational achievement was associated with higher dengue knowledge, but also with more unprotected containers. Overall dengue knowledge was not associated with household container counts. Spatial statistics identified weak clustering of larvae-positive containers, and larvae were concentrated in three key container types. Residents may only understand the role of certain container types, and significant gaps in general knowledge of the disease may inhibit vector control. This pilot demonstrates the feasibility of conducting inexpensive, rapid assessment of community knowledge and breeding levels for local governments lacking the resources for a more methodologically robust vector assessment strategy