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An interesting read. Taken from ProMed, Harvard


TUBERCULOSIS, XDR - USA: TEXAS ex NEPAL
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A ProMED-mail post
<http://www.promedmail.org>;
ProMED-mail is a program of the
International Society for Infectious Diseases <http://www.isid.org>;

Date: Fri 1 Mar 2013
Source: The Wall Street Journal [edited] <http://online.wsj.com/article/SB10001424127887323978104578332461533970412.html?KEYWORDS=BETSY+MCKAY>;


In medical isolation in South Texas, 100 miles or so from Mexico's border, is a man who embodies one of U.S. health officials' greatest
worries: He is the 1st person to cross and be held in detention while infected with one of the most severe types of drug-resistant tuberculosis known today.

His 3-month odyssey through 13 countries -- from his homeland of Nepal through South Asia, Brazil, Mexico, and finally into Texas -- shows the way in which dangerous new strains of the disease can migrate across the world unchecked.

Tuberculosis, an ancient, fatal airborne disease, has been treatable for decades with a cocktail of drugs. However, shoddy medical practices worldwide have enabled the bacteria to mutate and, in some cases, become all but untreatable. In recent months, The Wall Street Journal has exposed widening TB drug resistance in hot spots like India and shown that the U.S. is surprisingly unprepared for the growing global problem. Most U.S. cases of drug-resistant TB occur in people who were born abroad, according to the Centers for Disease Control and Prevention (CDC).

The Nepalese man detained at the U.S. border carries a particularly deadly strain, XDR, "extensively drug-resistant" TB. His TB is resistant to at least 8 of the 15 or so standard drugs, according to a U.S. government description of the case reviewed by the Journal. His XDR strain has been seen only once before in the U.S., in another patient of Nepalese origin, according to the government description.

The Nepalese patient was taken into custody by the U.S. Border Patrol in late November 2012 as he tried to cross the border illegally near McAllen, Texas, according to Department of Homeland Security (DHS) officials. The government declined to name him. He was transferred 5 days later to an Immigration and Customs Enforcement detention facility in Los Fresnos, Texas and put into "medical isolation" with suspected tuberculosis, according to ICE (Immigration & Customs Enforcement). He has since been moved to another ICE detention facility in Pearsall, Texas with more medical staff, ICE said. He is the 1st XDR-case in ICE custody.

Twelve Border Patrol agents were tested for the disease, but none contracted it from the patient, a Customs and Border Protection (CBP) official said. Casual contact doesn't necessarily lead to infection, though it depends in part on how much time is spent in tight quarters with a patient and how much the patient coughs, spreading bacteria into the air. It remains unclear whether other people in custody with the Nepalese detainee might have been infected. By the time the Border Patrol learned of his infection, other people detained with him would have been transferred elsewhere, the CBP official said. Detainees who are suspected of being ill are placed in cells by themselves.

Given how far and wide the patient ventured -- he took a flight of more than 8 hours to Brazil and also traveled by car, boat and on foot
-- his case was reported to the World Health Organization as having potentially widespread public-health impact. Now, officials in the 13 countries the man visited along the way must try to track down thousands of people he likely came into contact with to see whether any were infected.

That will be a challenge. "We will try to investigate where he was,"
said Martin Castellanos, director of Mexico's national TB program. But reconstructing his precise route through Mexico, or any country, will be difficult and perhaps impossible, he said. Dr. Castellanos says he was told the man spent time in a migrant community in Reynosa, across the border from Texas. But migrants typically linger there only "for a week, 2 weeks," he said, before moving on. "For sure, no one who was there in November 2012 is there now," he said.

The WHO's Stop TB Department said it is working with the CDC to inform affected countries about people who may have been exposed to the man.
It is also trying to get more details on potentially infected people in those countries who have been reached by local authorities. DHS and the CDC declined to discuss details of the man's case, citing patient privacy. The man declined an interview request from the Journal made through ICE. He also declined to sign a privacy waiver allowing officials to release details of his treatment and his immigration case, ICE said.

XDR-TB is a particularly dangerous form of the disease that is resistant not only to the 2 most potent TB drugs but also to a handful of 2nd-line drugs. It is rare in the U.S.: Only 6 cases were reported in 2011, according to the CDC. But it is a growing threat in countries including India and South Africa, where it has been found all over the country. The risk to the world is that the disease will migrate outward from these hot spots. Treatment options for XDR-TB are limited and can themselves be toxic. ICE officials screen patients for TB -- both regular and multidrug-resistant varieties -- when they arrive at a detention facility. "We prepare for it and look for it," an ICE medical official said. They find one or 2 cases of multidrug-resistant TB a year, the official said.

How long the man will remain in care in the U.S. is unclear. Treatment can last for years, but TB patients aren't infectious for the entire course of treatment. Detainee patients aren't normally kept until they are completely cured. However, infectious patients aren't deported on commercial flights or by any other means that "could be a danger to anyone," the official said.

One risk, of course, is that a patient won't have enough drugs or medical expertise to complete the treatment he or she needs once deported to another country. TB strains can become increasingly drug-resistant if a patient's treatment regimen is interrupted, even briefly. This is one way that drug-resistant TB has emerged over time.
The Migrant Clinicians Network, an Austin, Texas nongovernmental organization, helps arrange for deported patients to continue their treatment in their home countries. U.S. officials also often send patients home with a supply of the TB drugs they need, particularly to countries where supplies are uneven. Arranging care for drug-resistant patients is complicated, said Ed Zuroweste, the Migrant Clinicians Network's chief medical officer. "XDR is hugely difficult," he said.
"You really have to have experts to treat someone like that."

Nepal is known for innovative health programs, including some to fight TB. But like many countries, it has struggled with drug-resistant forms. Nepal reported more than 35 000 TB cases in 2011, and 2.9 percent of new and 12 percent of previously-treated TB cases are multidrug-resistant, according to WHO data.

[Byline Betsy McKay]

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[Multidrug-resistant tuberculosis (MDR TB) is a form of tuberculosis
(TB) that is resistant to at least isoniazid plus rifampin, the 2 most potent first-line drugs used for the treatment of tuberculosis.
Extensively drug-resistant TB (XDR TB) is a form of TB resistant to isoniazid and rifampin, as well as resistant to any fluoroquinolone and at least one of the 3 2nd-line injectable anti-TB drugs (amikacin, kanamycin, or capreomycin).

TB due to strains resistant to anti-TB drugs in addition to isoniazid, rifampin, a fluoroquinolone, and the one of the 2nd-line injectable anti-TB drugs is still classified as extensively drug resistant tuberculosis (XDR-TB), according to a January 2012 WHO document (<http://www.who.int/tb/challenges/mdr/tdrfaqs/en/index.html>;).

Inadequate or improper use of the anti-TB medications favor the emergence drug resistant organisms. Drug-resistant TB is also more common in people who develop TB disease again after being treated for TB disease in the past, or come from areas of the world where drug-resistant TB is common. Drug-resistant TB requires more extensive chemotherapy, involves drug therapy over more extended periods of time, is more often unsuccessful, is more expensive, and is more often fatal than drug-susceptible TB.

In the U.S., the number of reported TB cases in 2011 was the lowest recorded since national reporting began in 1953, and the percentage of MDR TB cases among those with no previous history of tuberculosis (primary MDR TB) declined by 60 percent, from 2.5 percent of culture-confirmed TB cases in 1993 to 1.0 percent in 2005
(<http://archinte.jamanetwork.com/article.aspx?articleid=773435>;) and has remained around that level since then (<http://www.cdc.gov/tb/publications/factsheets/statistics/TBTrends.htm>;).

The proportion of primary MDR TB cases disproportionately affects foreign-born persons in the United States. Since 1997, the percentage of U.S.-born patients with primary MDR TB has remained below 1.0 percent. However, of the total number of reported primary MDR TB cases, the proportion occurring in foreign-born persons increased from
25.3 percent (103 of 407) in 1993 to 82.7 percent (81 of 98) in 2011 (<http://www.cdc.gov/tb/publications/factsheets/statistics/TBTrends.htm>;).
For persons with a previous history of TB, the percentage with MDR TB in 2010 was approximately 4 times greater than among persons not previously treated for TB (<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm>;).

Four cases of extensively drug-resistant TB or XDR-TB (all occurring in foreign-born persons) have been reported in the U.S. for 2011 (<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm>;).

McAllen is a city located at the southern tip of Texas on the Rio Grande River across the Mexican city of Reynosa, about 70 miles (110
km) west of the Gulf of Mexico
(<http://en.wikipedia.org/wiki/McAllen,_Texas>;). Texas is the 2nd most populous and the 2nd largest of the 50 states in the USA (<http://en.wikipedia.org/wiki/Texas>;). A HealthMap/ProMED-mail interactive map showing the location of Texas in the south-central USA can be accessed at <http://healthmap.org/r/5KKL>;. - Mod.ML]

[see also:
2012
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Tuberculosis - Australia: (QL) ex Papua New Guinea 20121020.1355085 Tuberculosis - UK: increasing drug resistance 20120709.1194280 Tuberculosis, MDR - India: (MH) 20120426.1114435 Tuberculosis, MDR - Nigeria: (GO) 20120310.1066620 Tuberculosis, MDR - worldwide: rates 20120206.1034331 Tuberculosis, TDR - India (04): (MH) fatal 20120119.1015543 Tuberculosis, TDR - India (03): (MH) fatal 20120117.1012906 Tuberculosis, TDR - India (02): (KA) RFI 20120113.1009005 Tuberculosis, TDR - India: (MH, KA) 20120110.1005663
2011
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Tuberculosis, drug resistance - North Korea (03): comment, BCG coverage 20111124.3440 Tuberculosis, drug resistance - North Korea (02): background
20111116.3382
Tuberculosis, drug resistance - North Korea 20111113.3358 Tuberculosis - Ireland: (LN) prison, hospital 20111024.3165 Tuberculosis, drug resistance - South Korea 20110827.2610 Tuberculosis - Pakistan: increased incidence 20110618.1866 Tuberculosis, drug resistance - Finland: (SK) 20110324.0935
2010
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Tuberculosis - UK: resurgence 20101223.4522 Tuberculosis, children - UK: use of BCG vaccine 20100717.2386
2009
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Tuberculosis, XXDR - USA: FL ex Peru 20091230.4387 Tuberculosis, MDR - China 20090114.0151
2008
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Tuberculosis, XDR - Austria ex Romania 20080803.2373 Tuberculosis, MDR, XDR - Peru 20080412.1337 Tuberculosis, XDR - Namibia 20080403.1231 Tuberculosis, XDR - UK (Scotland) ex Somalia 20080322.1094 Tuberculosis, MDR, XDR - Worldwide: WHO 20080228.0813 Tuberculosis, MDR - South Africa 20080208.0521 Tuberculosis, MDR - Papua New Guinea 20080206.0478 Tuberculosis, XDR - Botswana, South Africa 20080118.0222
2007
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Tuberculosis, XDR, MDR: genome sequences 20071122.3780 Tuberculosis - Uganda (02): MDR, susp. RFI 20071004.3284 Tuberculosis - Uganda: deadly strain, RFI 20071002.3255 Tuberculosis, XDR - South Africa (11): fugitives 20071002.3251 Tuberculosis, XDR - South Africa (10): Western Cape 20070627.2071 Tuberculosis, XDR - worldwide [phone].2034 Tuberculosis, XDR - South Africa (09): Western Cape 20070604.1805 Tuberculosis, XDR, airplane exposure - multicountry (03)
20070601.1778
Tuberculosis, XDR, airplane exposure - multicountry (USA, France, Canada, Czech Rep.) 20070529.1738 Tuberculosis, XDR - South Africa (08): Western Cape 20070425.1349 Tuberculosis, XDR, 2003-2006 - Europe (Germany, Italy) 20070403.1132 Tuberculosis, XDR - South Africa (07): Eastern Cape 20070326.1044 Tuberculosis, XDR, 1993-2006 - USA 20070322.1005 Tuberculosis, XDR - South Africa [phone].0959 Tuberculosis, XDR, 1991-2003 - Spain 20070302.0738 Tuberculosis, XDR - South Africa [phone].0717 Tuberculosis, XDR - South Africa [phone].0638 Tuberculosis, XDR - South Africa [phone].0504 Tuberculosis, XDR - worldwide 20070205.0456 Tuberculosis, XDR - South Africa [phone].0375 Tuberculosis, XDR - South Africa: interventions 20070126.0349] .................................................ml/msp/mpp
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