Budget cuts hit TB clinics at the border

Dr. Rafael Laniado-Laborin and research assistant Rebeca Cazares study a chest X-ray showing the lungs of a tuberculosis patient at Tijuana’s TB clinic. Laboratory equipment and TB treatment techniques in Tijuana have improved significantly in recent years due to a partnership between San Diego and Baja California called Puentes de Esperanza. Funding for the program is set to end in July. Photo: Julissa McKinnon/California Health Report

Even though many Californians think of tuberculosis as a foreign problem, experts say the cough and sneeze-surfing bacteria remains a risk in the state.

Funding for disease control is shrinking, but tuberculosis is still spreading, and mutating new and increasingly lethal strains. The most drug-resistant variety of tuberculosis or TB known to science emerged a few months ago in India. Because it appears immune to every TB drug out there, scientists have dubbed it TDR TB, short for totally drug-resistant tuberculosis.

It’s only the latest in a string of increasingly tough-to-cure TB strains with obscure acronyms: first came MDR TB (multi-drug resistant tuberculosis) followed soon enough by XDR TB (extensively drug-resistant TB). All TB strains are easily contagious, an infected person can spread them by coughing, sneezing or simply exhaling.

When TB-stricken areas go ignored, this slowly but certainly puts more of the population at risk, especially in places like California that are magnets for migration from poorer countries with comparatively higher TB rates, said Dr. Rafael Laniado-Laborin, director of the TB clinic in Tijuana, Mexico.

“It becomes a public health issue because these drug-resistant strains are extremely difficult and expensive to cure and easily transmissible,” Laniado-Laborin said. “The only thing you have to do to acquire a TB infection is breathe.”

“In tight times the natural inclination is to cut budgets and look at other priorities,” said Dr. Kathy Moser, director of San Diego County’s TB control program. “But we’ve seen if there’s very little focus on an infectious, airborne disease like TB, it can come back.”

The Global Fund to Fight AIDS, Malaria and Tuberculosis announced that it won’t be issuing any new grants until 2014 due to a shortfall in donations, according to a November press release.

Instead of raising a target $20 billion by late 2010, the organization, which funds about two-thirds of the world’s international TB programs, gathered about $11.7 billion.

Budgets for TB control are also shrinking at the state and national level.

Between 2010 and 2012 the TB control budget for the U.S. Centers for Disease Control and Prevention dropped $4.7 million to a five-year low of $140 million in 2012, according to figures from the agency. Meanwhile the California Department of Public Health’s budget for addressing TB fell eight percent or $1.4 million between 2007-08 and 2009-10. The yearly budget has recovered about $209,000 since then, amounting to $16.2 million for TB control in 2011-12, according to department figures.

One of the first areas that disease control agencies tend to cut in a budget crunch is foreign outreach, said Richard Kiy, president of the International Community Foundation, a non-profit focusing on several humanitarian issues in Latin America including TB.

One example of an international TB effort that is about to lose U.S. funding is the Puentes de Esperanza program, a partnership between San Diego County and Baja California that has improved laboratory equipment, staffing levels and treatment techniques at clinics in Mexicali and Tijuana. Both of these Mexican border cities are struggling with rising rates of drug-resistant TB.

The Puentes program began in 2006 with $500,000 from the U.S. Agency for International Development, Rotary International and San Diego’s Lash foundation and has cured 90 percent of the MDR TB cases it’s taken on since.

Funding for Puentes is scheduled to end in July, but Laniado-Laborin says that’s too soon. He said Mexico is not yet able to sustain the new systems established by Puentes, which include lab testing to identify drug-resistant strains and staff to track patient’s medical intake and ensure precise dosing, Laniado-Laborin said.

The program is a lifeline for TB patients across Mexico with some driving two consecutive days to the Tijuana clinic from other states like Sinoloa and Sonora. Laniado-Laborin said people cross the distance because TB treatment in many parts of Mexico is severely lacking.

Health centers or private doctors that are well-intentioned but not as well-trained in treating drug-resistant TB are known for giving inadequate prescriptions that often end up making the TB bug more resilient.

Timothy Rodwell, an assistant professor with UC San Diego who studies TB control, said building sound treatment programs for drug-resistant TB not only saves individual lives but protects the population at large.

“If you’re not treating MDR properly then you have people walking around the community spreading it to others,” Rodwell said.

Even with Puentes, the numbers of TB cases along Mexico’s northern border have been steadily rising from 1,275 in Baja California in 2006 to 1,547 cases in 2010. Tijuana has the highest concentration of TB not just in the state of Baja but in all of Mexico with 53.5 cases per 100,000 people.

Laniado-Laborin said the imbalance is partly due to the fact that Tijuana is better-equipped than other parts of Mexico to test and report TB cases. Besides that, Tijuana is a draw for migrants from all over Mexico, many of whom end up living in the city in cramped quarters and unsanitary conditions, where contagious diseases can spread easily, he said.

Tijuana’s TB woes also present a problem for San Diego. The two cities share the world’s busiest border, where about 50,000 cars and 25,000 pedestrians cross from Mexico into California everyday, according to counts by the San Diego Association of Governments.

Consequently, scientists are starting to track drug-resistant TB strains in Mexico to see if these same strains turn up in California patients using DNA fingerprinting, Rodwell said. About 1.4 percent of California’s 2,324 TB cases in 2010 were drug-resistant, according to the latest counts by the California Department of Public Health.

Until recently, San Diego County’s TB caseload was gradually declining from 315 in 2006 to 222 cases in 2010. The most recent tally in 2011 counted 263 TB cases, an 18.5 percent increase from the previous year. Health officials say they are still checking whether a miscount may have occurred.

In the meantime, San Diego County isn’t planning on putting any of its limited funding toward the Puentes program. Funding for its TB control program was cut 15 percent between 2008-09 and 2009-10. Since then it’s recuperated some of those funds, receiving about $6.8 million in 2011-12 for countywide TB control and treatment, according to San Diego County figures.

“We’ve seen that even a fairly level budget is akin to a declining budget because things get more expensive from year to year,” Moser said, referring to everything from lab reagents and drugs to gasoline for department vehicles.

So far, the hope for sustaining Puentes and other foreign TB outreach appears to lie with philanthropic organizations and private donors.

It would take about $200,000 annually to sustain Puentes in both Tijuana and Mexicali, said Kiy of the International Community Foundation, which is leading a fundraising effort to keep Puentes alive.

“If we want to control TB now it has to be treated everywhere,” Laniado-Laborin said.

The last drug engineered specifically for TB came out in 1967. The product, called rifampicin, costs only $50 for a complete six-month treatment and is excellent for beating back a good old-fashioned strain of drug-responsive TB. However, the only remedies available for the newer drug-resistant strains weren’t specially designed to fight TB, so treatment can be hit-or-miss and costs can soar.

On average, treating one case of MDR TB costs $100,000 to $200,000, which yields a 60 to 90 percent chance of cure. Treating an XDR TB patient can cost upwards of $600,000 with a 30 to 50 percent chance of recovery, according to information from the California Department of Public Health.

Note: An earlier version of this story said that drug resistant TB in California had been found to originate in Mexico. Actually, scientists are still conducting DNA fingerprinting to determine the origin of the strain.

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