JUNTOS Project United StatesMexico Effort Towards Tuberculosis Prevention and Control

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JUNTOS Project United States-Mexico Effort
Towards Tuberculosis Prevention and Control

• Fernando J. Gonzalez, M.D., M.P.H.
• Texas Department of Health
• American Lung Association of Texas
• El Paso, Texas

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Binational TB Prevention and Control Project
JUNTOS

• Tuberculosis History, Pathogenesis. Infection and
  Disease. Facts and factors contributing to the
  raise, Associated conditions
• Border Definition and Contrast of the United
  States-Mexico TB Epidemiology
• Basic components and activities Project JUNTOS
• Experience with binational TB cases and
• associated binational TB activities

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Historical and Epidemiological Perspective

• Barthel equeleton found near Heidelberd (5000 BC)
• Egipcian momies
• Child momie, Nazca Peru (700BC)
• Hipocrates (460 BC)
• Sylvius, Manget, Marten (Tubercule, miliary and
  dinute leving cretures)

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Historical and Epidemiological Perspective

• Sanatorioum Herman Brehmer
• Jean Antonie Villemin TB could be passed humans
  to cattle to rabits
• Robert Koch discovered MTB, 1882, 1905 Nobel.
• Rontgen X rays
• Calmette-Guerin BCG
• Actinomycin (40), Strept (43), PAS (49), INH
  (52),PZA (54) Ciclo (55) ETH (62), RIF (55)

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United States-Mexico Border

• TUBERCULOSIS INFECTION, DISEASE AND TRANSMISSION

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Tuberculosis Infection, Disease and Transmission

• TB or tuberculosis, is an infectious,
  communicable disease that most commonly attacks
  the lungs but may occur in almost any part of the
  body. The causative agent, Mycobacterium TB
  complex (TB, Afr and Bovis), airborne
  transmission. ICD-9 Codes 010-018. ICD-10A15-A19.
  People who have a () TST but not clinical or
  radiological evidence of TB are consider to have
  LTBI

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Tuberculosis Infection and Disease
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United States-Mexico Border

• Tuberculosis Facts and Contributing Factors to
  the Rise

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Tuberculosis Facts

• TB is second biggest killer including 250,000
  children
• In America half a million cases per year, 75,000
  deaths
• TB is the biggest infectious disease\ killer
• In the next 20 years 1 billion will be infected,
  200 million new cases and 35 million will die

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Tuberculosis Facts

• 75 of the cases productive groups (15-54)
• Vulnerable groups
• Each TB cases losses 3-4 months of work
• TB kills more women than all the other maternal
  death causes combined
• 95 of the cases and 98 of deaths ocuur in
  developing countries

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Tuberculosis Facts

• 30 of the world population have been in contact
• 1 from each 10 will develop TB
• 10-15 infected by each case
• 8 million cases per year
• 20 million cases currently
• 20,00 cases per day
• 1 death each 10 seconds

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Tuberculosis Facts

• Someone in the world is newly infected with TB
  every second
• Nearly 1 of the worlds population is newly
  infected with TB each year
• One third of the worlds population is currently
  infected with TB
• 5-10 infected with TB will become infectious at
  some time (NO HIV)

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Tuberculosis Facts

• TB kills about 2 million people each year
• More than 8 million people become sick with TB
  each year
• About 2 million occur in Sub-Saharan Africa
• About 3 million occur in South east-Asia
• About 250 thousand occur in Eastern Europe

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Factors Contributing to the Rise
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PopulationEl Paso, Texas Ciudad Juarez,
Chihuahua

• Year El Paso Cd. Juarez
• 1900 10,000 8,212
• 1920 22,000 19,457
• 1940 55,024 48,881
• 1960 276,995 270,279
• 1980 625,259 900,000
• 2000 679,622 1,600,000

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Factors Contributing to the Rise

• Freight Private
• Pedestrians Carriers Vehicles
  Totals
• 2000 5,472,292 725,064 16,645,268
  22,842,624
• 1999 5,676,087 657,664 15,735,525
  22,069,276
• 1998 4,966,406 591,258 15087,443
  20,645,107
• 1997 4,400,105 596,538 15,246,499
  20,243,142

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Factors Contributing to the Rise

• HIV and TB infected is many times more likely to
  become ill with TB, than someone infected with
  TB-HIV(-)
• Poorly managed programs
• a.- poorly supervised treatment
• b.-Incomplete treatments (inconsistent or
• partial)
• c.-Wrong treatments
• d.- Supplies are unreliable

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Binational TB Prevention and Control Project
JUNTOS

• UNITED STATES-MEXICO
• BORDER DEFINITION AND LOCATION

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United States-Mexico Border

• The United States-Mexico border extends nearly
  1,920 miles (about 3,090 km) between the Gulf of
  Mexico and the Pacific Ocean.
• The 1983 La Paz Agreement defined the border area
  as a corridor extending 100 kilometers on each
  side of the international boundary. (Protection
  and improvement of the environment in the border
  area, 1983).

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United States-Mexico Border
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United States-Mexico Border

• Epidemiology

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TB IncidenceUnited States, 1997-2001
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Reported TB Cases United States, 1981-2001
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Cases per 100,000TB Morbidity Number of TB
Cases inU.S.-Born Vs. Foreign-born Persons,
United States 1991-2001
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Reported TB Cases, U.S., 2001
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TB IncidenceMexico, 1997-2001

• Year Cases Rate
• 1997 21,957 20.6
• 1998 18,032 18.7
• 1999 16,881 17.2
• 2000 15,649 15.7
• 16,323 16.2
• Cases per 100,000

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Reported TB CasesMexico, 1980-2001
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TB IncidenceU.S and Mexico1997-2001
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Pulmonary TB Incidence, U.S. and Mexico Border
Status, 2000

• Incidence

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United States-Mexico Border

• COMPONENTS AND ACTIVITIES
• BINATIONAL TB PREVENTION AND CONTROL PROJECT
• JUNTOS

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COMPONENTS OF THEJUNTOS PROJECT

• Identification of new tuberculosis cases.
• Support current infrastructure of health service.
• Implementation of a binational information
  system.
• Develop an efficient communication system and
  build an electronic binational case registry.
• Develop and enhance program for tuberculosis
  professional training, health promotion and
  disease prevention

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Components and List of ActivitiesDIRECT SERVICES

• Facilitate diagnostic and treatment services
  through existing local TB control programs.
• Access to primary and second-line drugs.
• Facilitate expert consultation through Texas
  Center for Infectious Diseases, South Texas
  Hospital, and National Jewish Hospital (Denver).
• Expedites referrals to other Mexican health
  entities.

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Components and List of ActivitiesDIRECT SERVICES

• Provides DOT and outreach
• Expedites referrals to other Mexican health
  entities
• Expedites inpatient services to several
  Hospitals.

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Juntos Binational Clinical TBCommittee

• Clinical experts meet on monthly basis to
• Offer expert management consultation.
• Facilitate the acquisition of second-line drugs.
• Monitor use of second-line drugs.
• Advocate for the seriousness of the MDRTB
  problem.
• Review difficult TB cases presented by local
  providers.

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Components and List of ActivitiesDIRECT SERVICES

• Smears and cultures are collected and sent for
  identification and drug sensitivity testing to
  the El Paso Health Department and the Texas State
  Laboratory.
• Assistance with local HIV testing.
• Provides support for chest X-Ray services.
• Provides support for TST and PPD

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Components and List of ActivitiesDATA ANALYSIS
AND INFORMATION

• Collect demographic information.
• Collect patient information (age, sex,
  occupation, family status), data base.
• Collect case records.
• Information profiling chronic diseases (diabetes,
  immunosuppressive disorders, HIV status, smear
  and culture results).
• Contact information.

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Components and List of ActivitiesEDUCATION

• TB Conferences (Medical Societies,TCID,ALA,Univers
  ities).
• TB Reporting workshops.
• TAES (DOT) training.
• DOT Training for Binational Workers.
• Develop, reproduce and distribute promotional and
  educational material.
• Student Nurse Rotation.

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Components and List of ActivitiesEDUCATION

• Physician Education.
• Group Presentations.
• Interaction with the Media.
• TB Week.
• World TB Day.
• Infection Control Training.
• Thesis Researchs in collaboration with the local
  and foreign Schools of Public Health

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Project Juntos A Binational Tuberculosis
Prevention and Control Program
by ROBERT GARCIA THESIS Presented to the Faculty
of The University of Texas  Health Science Center
at Houston School of Public Health in Partial
Fulfillment of the Requirements for the Degree
of   MASTER OF PUBLIC HEALTH
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Tuberculosis Cases
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Patient Type
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Age Distribution
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Gender
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Birthplace
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Associated Condition
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Associated Condition Against Gender
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BCG vaccination Status
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Treatment Outcome All Patients
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Treatment Outcome DOT Patients
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Treatment Outcomenon-DOT Patients
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Mean Number of Months in Treatment versus Outcome
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Multiple Drug Resistance(MDR-TB)
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Treatment OutcomeDrug Resistant Cases
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Treatment Outcome non-Drug Resistant Cases
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Findings/Results

• Project Juntos works with patients that meet at
  least one of the criteria of the binational
  case definition (CDC, MMWR, January
  19,2001/50(RR1)1-2
• Patients are referred to the program by other
  health agencies from both countries.
• Often patients having associated conditions/risk
  factors that particularly have more difficulty in
  completing treatment.

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Findings/Results (Cont)

• For the five-year period
• 15 (4.4) reported having HIV/AIDS
• 61 (17.9) patients reported having diabetes
• 46 (13.5) of the patients reported having a
  problem with alcohol
• 23 (6.8) patients reported having a problem with
  drugs
• Note Globally 1 of people are infected with
  HIV/AIDS while approximately 6-8 are afflicted
  with diabetes.

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Findings/Results (Cont)

• Patients with alcohol problems were 5.26 times as
  likely RR5.26, 95 CI (2.79, 9.94), p-value lt
  0.001 to abandon/quit their treatment than
  patients without alcohol problems.
• Patients with drug addiction problems were 3.11
  times as likely RR3.11, 95 CI (1.54, 6.28),
  p-value 0.008 (Fisher exact) to
  abandon/quit their treatment than patients
  without drug addiction problems.

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Findings/Results (Cont)

• Cure rate for patients with (difficult to treat)
  Multi-Drug Resistant tuberculosis was 43.5,
  these patients were 2.58 times as likely
  RR2.58, 95 CI (1.21, 5.54), p-value 0.031
  (Fisher exact) to abandon/quit treatment than
  non-MDR-TB patients
• For Project Juntos, the overall cure rate could
  possibly be over 80 if the proportion of
  patients with alcohol/drug problems or with
  MDR-TB were lower.
• Note Like in many other countries in the world,
  success rates are negatively affected when large
  proportions of their tuberculosis patients have
  associated conditions.

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Findings/Results (Cont)

• 200 (58.8) patients reported having been born
  in a city other than Ciudad Juárez
• 116 patients (34.1) reported having been born in
  Ciudad Juárez
• Note Population growth in Ciudad Juarez is
  primarily due to migration

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Findings/Results (Cont)

• 116 (34.1) of the patients reported living in
  Ciudad Juárez for less than one year while
• 132 (38.8) patients reported living in Ciudad
  Juárez for more than five years further supports
  the view that population growth of Ciudad Juarez
  is due primarily to migration into the city
• Note It also supports the view that many
  patients with TB became infected in a community
  other than Ciudad Juarez before migrating into
  the city.

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Findings/Results (Cont)

• After years of steady decline, the increase in
  the number of patients enrolled in Project Juntos
  during 2001 and 2002 suggests that TB is a
  disease that needs continued public health
  surveillance and program support.
• The overall treatment success (i.e., resulting in
  an outcome of cure) for patients enrolled in
  Project Juntos during the years 1997-2001
  compares favorably with goals set by the World
  Health Organization.

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Findings/Results (Cont)

• The 79.3 microbiologically confirmed cure rate
  in Project Juntos is comparable to treatment
  results for the most recent worldwide cohorts
• From 1995-1999, success rates worldwide have
  remained stable at 77-81 under DOT

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Findings/Results (Cont)

• Participating Institutes Centers for Disease
  Control and Prevention, Pan American Health
  Organization, Secretaria de Salud de Mexico.
• Conclusion Project JUNTOS success and
  accomplishments are due to the dedication and
  hard work of many people on both sides of the
  border. Valuable and needed services have been
  made available to TB patients by Project /JUNTOS.
• Communication and collaboration between TB
  health providers in Mexico and the US have also
  been strengthened through Project JUNTOS efforts.
  

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United States-Mexico Border

• ASSOCIATED ACTIVITIES
• BINATIONAL TB PREVENTION AND CONTROL PROJECT
• JUNTOS

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Migrant Clinicians NetworkTBNet

• Binational TB patient tracking and referral
  project
• Created for migrant farm workers, know it is
  expanding to include homeless, immigration
  detainees, prison parolees or anyone moving
  during their treatment
• Facilitates the tracking and transfer of records
  of those patients and notifies the enrolling
  clinic that the patient has completed treatment

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Migrant Clinicians NetworkTBNet

• Five months 10/20/03 to 03/20/03
• Cases managed 59
• Active TB 34 LTBI 25
• Countries Mexico, Spain, Guatemala, Korea, Ivory
  Coast, China, Ecuador, Indonesia, Nigeria,
  Moroco, Thailand, Russia

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United States-Mexico Border
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U.S.-Mexico Binational TB Referral and Case
Management Project

• The Binational Health Card is the product of the
  political support of both countries and takes
  into consideration the existing experiences of
  other binational referral projects such as CureTB
  and TBNet.

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CURE TB

• Began locally in 1997 and now serves all states
  throughout the U.S. and Mexico
• Main focus is to provide referrals for
  suspect/active cases traveling between the U.S.
  and Mexico for continuity of care.
• Operates via a 1-800 number for patients in both
  countries and for providers in Mexico without
  access to international dialing.

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Websites

• www.cdc.gov/nchstp/tb/
• www.migrantclinician.org/programs/TBNet/tb_article
  s.html
• www.curetb.org/
• www.tdh.state.tx.us/default.htm
• www.r10.tdh.state.tx.us/
• www.texaslung.org

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• La migración hace del migrante un ciudadano del
  mundo
• Beato Juan Bautista Scalabrini
• Juntos
• ..Podemos lograr la diferencia