MDR outbreak hits Texas, but who will claim it?
MDR outbreak hits Texas, but who will claim it?
More than 200 cases found since 1994
An outbreak involving more than 200 cases of multidrug-resistant tuberculosis is under way along the south Texas/Mexico border, creating a problem in treatment and stirring a philosophical debate about bugs and international boundaries.
Many inhabitants of the area and victims who contract the disease are "binational," meaning they belong to a highly mobile workforce whose members spend their lives traveling back and forth across the border, tending to jobs and family obligations that aren’t restricted by national boundaries.
Though preliminary analysis suggests many of the cases consider their primary residence to be the United States, not Mexico, some Texas public health officials say they feel hemmed in between tight budgets and anti-immigration politics and are unable to provide the expensive treatment needed for all the victims identified.
"So far, we’ve been bearing the cost, but it’s gotten to the point where we’ve talked about a moratorium on continued treatment," says Michael Kelley, MD, MPH, chief of the bureau for com-municable diseases at the Texas Department of Health. "We simply don’t have the money to do it. And neither does Mexico."
Critics charge the problem isn’t money but political considerations that have kept public health budgets reined in too tightly. Texas finished 1996 with a surplus of more than $900 million, notes Jeffrey Starke, MD, associate professor of clinical pediatrics at Baylor University in Houston. "It’s simply erroneous to say the state doesn’t have the money," says Starke. "And it’s immoral and unconscionable not to provide care for people in Texas who have TB."
Arguments that providing care will draw increasing numbers of immigrants sick with resistant forms of TB that their own countries can’t afford to treat is beside the point, Starke says. "I doubt people limit their comings and goings across the border according to whether they have MDR-TB," he says. "Besides, they’re coming anyway."
What is known about the 200 cases suggests they are transmitting the disease to others. Teresa Lightner, MD, a staff physician at South Texas Hospital in Harlingen, has helped treat 44 binational MDR cases so far. Of those, almost half list the United States, not Mexico, as their primary residence, she says.
The victims do not appear to be dying quickly either. Since 1994, when the cases began to be identified, only three (or four, according to Mexican death records) have died.
Of 60 case records Lightner and physicians in Mexico have studied together, 45% represent instances of primary resistance (which signifies the infection was passed from person to person), not secondary resistance acquired through the course of inadequate treatment.
One factor that may especially favor a relatively higher rate of transmission is that most victims are mainstream members of society, says Lightner. "We don’t have the HIV-infected, the homeless, the intravenous drug users, or alcoholics here," she says. "These are otherwise healthy young people, many of them mothers and fathers, and they work and function in the community in a way we’ve not seen before in U.S. outbreaks of MDR-TB."
In one instance, Mexican physicians report that a single case of MDR-TB on their side of the border (in the Mexican state of Tamaulipas) has led to 17 other people undergoing PPD skin-test conversions. Thirteen of the converters are children; three of the adults are already symptomatic for disease.
Lightner recalls another patient, an older man she treated at South Texas Hospital who weighed only 80 pounds. He was coughing profuse amounts of sputum, and appeared far too sick to be functioning. Yet every day, he still managed to get to work at a tortilla factory he owned and then sell his wares at a market.
"You can politicize this issue all you want," Lightner says. "But the real questions are simple: Who is transmitting? What are they transmitting? And who are they transmitting it to?"
Even so, a widespread feeling exists in Texas that providing care to binationals, especially those with MDR-TB who have little hope for a cure in Mexico, will only draw more patients, state TB officials say. Whether that is an important factor is one question Kelley thinks could be answered by a study he and a physician in Mexico hope to begin soon.
On the Mexican side, the study also needs to determine what proportion of the total TB cases the 200 cases represent. "We don’t know yet what the denominator is for those 200 cases," Kelley says. "We urgently need to find that out." Perhaps, he adds, transmission will be linked to a site, or sites a jail or hospital where simply instituting environmental controls could fix the problem.
On the Texas side, a study could help establish whether cases turning up there were infected here in the United States or in Mexico, and whether the victims are drawn to Texas by the prospect of work or by the availability of health care services.
It’s important to remember, too, that the 200 cases didn’t turn up all at once. But over a period of three years, Kelley emphasizes. They were discovered through the Binational TB Project, a cooperative venture between the United States and Mexico funded by the Centers for Disease Control and Prevention (CDC).
In the beginning, Kelley explains, the project was not intended to provide treatment for TB patients but simply to train health care workers along the border in Mexico in how to provide directly observed therapy and how to conduct contact investigations.
But since Mexico doesn’t routinely check for drug resistance (and lacks the means to do so), the project began providing some laboratory services as well. That’s when the 200 MDR cases began turning up in the Mexican state of Tamaulipas, which lies across the border from Texas’ two southernmost counties, Cameron and Hidalgo.
The 200 cases are centered around two border towns in Tamaulipas Matamoros, adjacent to Brownsville, TX, and Reynosa, across the border from McAllen, TX.
In addition to the MDR-TB cases in Tamaulipas, Texas officials this year spotted another worrisome trend. In both Cameron and Hidalgo counties, rates of MDR-TB doubled in the past year, Kelley says. The numbers involved are very small, making it hard to draw any meaningful conclusions about their sustainability and significance, he adds.
In 1995, 1.2% of all TB cases in Cameron and Hidalgo were multidrug-resistant; that same year, the proportion of MDR-TB in the rest of the state made up 0.8% of the total cases. In 1996, by comparison, 4.5% of the two counties’ cases were multidrug-resistant; in the rest of Texas, MDR cases represented only 1.5% of the total.
"We’re only talking about eight to 10 cases a year, so when you graph it, the line can jump all over the place," Kelley says. "But still, it’s a big jump for one year."
It’s worth noting, too, that none of the other binational project sites have turned up MDR case totals nearly as startling as those coming out of Tamaulipas. "Clearly, there are a lot of cases down there," Kelley says. "And they’re going untreated because there aren’t the resources to treat them."
For now, Texas TB control programs on the border are economizing as much as possible, Kelley says. Physicians are setting tight priorities, allotting resources first to the binationals judged to be most at risk for transmitting to Americans.
They also are cutting costs by providing as much of the treatment as possible on an outpatient basis. An outpatient clinic in Harlingen for patients with resistant disease provides treatment, takes referrals from other local facilities, and ensures that patients will consistently get the most effective care possible, says Kelley.
Key to the outpatient clinic’s success is its use of percutaneous intravenous central catheterization, or PICC lines, says Kelley. Harlingen physicians are beginning to realize response rates approaching 100%, at a remarkably low per-case cost down from $250,000 to $100,000 per patient. (For details on the use of PICC lines, see story p. 140.)
Even so, Lightner says she is feeling increasing pressure not to start treatment on new cases. As a doctor, she is pained at having to turn away sick people. As someone entrusted with the public health, she says, she is terrified.
For now, she struggles to find ways to make a case for more money for her clinic and has been working single-handedly since March to produce enough data to get the attention of someone with the power to delegate funds.
"At first, New York City didn’t have any money for their outbreak either," she says. "So I figure I have to try to do what they did: first, they got very accurate numbers. Second, they got their commissioner of health to be their advocate in bringing in other entities for funding."
Federal agencies that provide money for public health services may not appreciate that Texas faces a unique predicament, says James Elkins, chief administrator for the state’s chest-hospital system. "I don’t want to sound like we feel neglected," he says. "But I think people forget that here we don’t have sea or air to divide us from other countries; what we have is land, and land is not that hard to cross."
Despite (or perhaps because of) that difference, when Elkins recently asked the Texas state legislature for money to begin renovations in the state’s chest hospitals, lawmakers replied by asking for a study and a long-range plan.
To Kelley and Elkins, the implication was clear. "We could end up with adequate facilities," Kelley says. "Or they could decide we simply don’t need chest hospitals anymore."
Elkins, choosing his words as delicately as if he were stepping through a mine-field, puts it this way: "The truth is that we’ll potentially be asking for money that may, potentially, be used to treat binational cases."
To Starke, the chest-hospital situation is symptomatic of Texas politicians’ sense of priorities. "Public-health decisions in this state are being made on the basis of politics," he says. "And that’s always wrong."
Nor is waiting for the feds to ride to the rescue the appropriate response, Starke adds. "I don’t care where the money comes from," he says. "I’m sick of state and local health departments always depending on the CDC to solve their problems. The state of Texas puts pitifully little into public health. If there isn’t money elsewhere, then Texas needs to spend the money."
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