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The US-Mexico Border Infectious Disease Surveillance Project

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The US-Mexico Border Infectious Disease Surveillance Project RESEARCH The U.S.-Mexico Border Infectious Disease Surveillance Project: Establishing Bi-national Border Surveillance Michelle Weinberg,* Stephen Waterman,* Carlos Alvarez Lucas,† Veronica Carrion Falcon,† Pablo Kuri Morales,† Luis Anaya Lopez,† Chris Peter,‡ Alejandro Escobar Gutiérrez,§ Ernesto Ramirez Gonzalez,§ Ana Flisser,¶ Ralph Bryan,* Enrique Navarro Valle,# Alfonso Rodriguez,** Gerardo Alvarez Hernandez,†† Cecilia Rosales,‡‡ Javier Arias Ortiz,§§ Michael Landen,¶¶ Hugo Vilchis,## Julie Rawlings,*** Francisco Lopez Leal,††† Luis Ortega,‡‡‡ Elaine Flagg,* Roberto Tapia Conyer,† and Martin Cetron* for the Border Infectious Disease Surveillance Project Working Group1 In 1997, the Centers for Disease Control and Prevention, as one large metropolitan area for the local community (Figure the Mexican Secretariat of Health, and border health officials 1). From an epidemiologic perspective, the border population began the development of the Border Infectious Disease Sur- must be considered as one, rather than different populations on veillance (BIDS) project, a surveillance system for infectious two sides of a border; pathogens do not recognize the geopolit- diseases along the U.S.-Mexico border. During a 3-year period, ical boundaries established by human beings. The border a binational team implemented an active, sentinel surveillance region has a population of approximately 11 million people system for hepatitis and febrile exanthems at 13 clinical sites. The network developed surveillance protocols, trained nine (2), many of whom cross the border daily to work, shop, attend surveillance coordinators, established serologic testing at four school, seek medical care, or visit family and friends (3,4). Mexican border laboratories, and created agreements for data The border population also includes persons who pass tran- sharing and notification of selected diseases and outbreaks. siently through the region and others who come the area to BIDS facilitated investigations of dengue fever in Texas- work in maquilas, the border factories. The region has experi- Tamaulipas and measles in California–Baja California. BIDS enced tremendous population growth. During 1993–1997, the demonstrates that a binational effort with local, state, and fed- U.S. border population grew by 1.8% annually, more than dou- eral participation can create a regional surveillance system that ble the national U.S. average of 0.8%, while the Mexican bor- crosses an international border. Reducing administrative, infra- der population has grown by 4.3% per year, almost three times structure, and political barriers to cross-border public health the national Mexican annual growth rate of 1.6% (2,5). Popu- collaboration will enhance the effectiveness of disease preven- lation growth has been spurred by increased economic oppor- tion projects such as BIDS. tunities after the North American Free Trade Agreement was implemented in 1994. Currently, an estimated 3,300 maquilas, employing >1 million workers, are located along the border he 2,000-mile U.S.-Mexico border is one of the world’s (6,7). The proliferation of border factories has generated a Tbusiest international boundaries. An estimated 320 million wave of internal migration of persons from other regions of people cross the northbound border legally every year (1). The Mexico and Central America toward the border (8). U.S.-Mexico border is a unique region where the geopolitical From Mexico’s perspective, the border encompasses some boundary does not inhibit social and economic interactions nor of the country’s most economically prosperous states. In con- the transmission of infectious diseases among residents on each side of the border. Some border cities (such as El Paso 1 Members of the Border Infectious Disease Surveillance Project Working Group: and Ciudad Juarez) are separated by a short distance and serve Elisa Aguilar, Carlos Alonso, Adam Aragon, Enid Argott, Greg Armstrong, Rafael Ayala, Joan Baumbach, Beth Bell, William Bellini, Baltazar Briseño, Sergio Lopez Cabrera, Ahmed Calvo, Richard Campman, Patricia Cantu, Ernestina Castillo, Gary Clark, Nolvia Cortez, Raquel Coto, Jose Armando Covarrubias, Leta Craw- *Centers for Disease Control and Prevention, Atlanta, Georgia, USA; †Secretaria ford-Miksza, Bruce Elliot, Martha Vazquez Erlbeck, Miguel Escobedo, Howard de Salud, Mexico City, Mexico; ‡San Diego County Health and Human Services Fields, Maria Guadalupe Jimenez Fierro, Robert Garcia, Carlos Gonzales, Min- Agency Public Health Laboratory, San Diego, California, USA; §Instituto de Diag- erva Diaz de Leon Gonzalez, Louise Gresham, Lucina Gutierrez, W. Lee Hand, nóstico y Referencias Epidemiológicas, Mexico City, Mexico; ¶Universidad Nacio- Aurora Hiles, Debra Horensky, Wendi Kuhnert, Ericka Larquito, Miguel Angel nal Autonoma de Mexico, Mexico City, Mexico; #Instituto de Servicios de Salud Lopez, Jose Luis Aranda Lozano, Luis Gonzalez Madrigal, Jorge Magaña, Jay Publica de Baja California, Mexicali, Baja California, Mexico; **California Depart- McAuliffe, Gabriel Martinez, Miguel Angel Vaca Marin, Berta Isabel Mendoza, ment of Health Services, San Diego, California, USA; ††Secretaria de Salud Pub- Mercedes Gameros Mercado, Sonia Montiel, William L. Nicholson, Efren Ornelas, lica, Hermosillo, Sonora, Mexico; ‡‡Arizona Department of Health Services, Eladio Pereira, Michael Purdy, Enrique Davis Ramirez, Gail Randolph, Susan Tucson, Arizona, USA; §§Servicios de Salud de Chihuahua, Chihuahua, Chihua- Reef, Willy Rios-Araico, Mark Rodriguez, Alfonso Ruiz, Rosalba Ruiz, Joaquin hua, Mexico; ¶¶New Mexico Department of Health, Santa Fe, New Mexico, USA; Salcedo, Ana Isabel Vidal Sandate, Elsa Sarti, Ana Maria Sato, David Schnurr, ## Border Epidemiology Center, Las Cruces, New Mexico, USA; ***Texas Depart- William Slanta, Brian Smith, Alejandro Suarez, Juan Treviño, Nohemi Martha ment of Health, Austin, Texas, USA; ††† Servicios de Salud de Tamaulipas, Castro Valdez, Yvonne Vasquez, , Roberto Vazquez, Kathy Villa, Abedón Segura Ciudad Victoria, Tamaulipas, Mexico; ‡‡‡Pan American Health Organization, El Villareal, Consuelo Villalon, Maria Luisa Volker, Vance Vorndam, Laura Walls. Paso, Texas, USA Emerging Infectious Diseases • Vol. 9, No. 1, January 2003 97 RESEARCH transmission of infectious diseases that move easily through the geopolitical boundary. The Border Infectious Disease Surveillance (BIDS) project was designed to bridge this surveillance gap by forming part- nerships among institutions in both countries serving the region and bringing together each country’s complementary experiences in syndromic and laboratory-based surveillance. This report describes the establishment of a binational surveil- lance system for hepatitis and febrile exanthems along the U.S.-Mexico border. Figure 1. The Rio Grande River separates the border between Ciudad Project Mandate Juarez, Chihuahua, Mexico, and El Paso, Texas, USA. In June 1997, the United States–Mexico Border Health Association and the U.S. Council of State and Territorial Epi- trast, the U.S. border region is among the poorest areas in the demiologists passed resolutions to support surveillance for United States, with >30% of families living at or below the infectious diseases and emerging infectious diseases along the poverty level (8). Along the Texas border, an estimated U.S.-Mexico border (24,25). The Centers for Disease Control 350,000 or more people live in 1,450 unincorporated areas and Prevention (CDC) and the Mexican Secretariat of Health known as colonias, which lack adequate sanitation infrastruc- spearheaded efforts to initiate the project and formalized an ture (8). agreement to establish BIDS through a memorandum of coop- The large population movement, limited public health eration in epidemiology. A binational team of local, state, and infrastructure, and poor environmental conditions contribute to federal epidemiologists, laboratory scientists, and public increased incidence of certain infectious diseases (8–11) Anal- health officials met to organize and define project objectives. ysis of data from the U.S. National Notifiable Diseases Sur- Decisions were made by consensus among the participants. veillance System for 1990 through 1998 showed increased risks for certain foodborne, waterborne, and vaccine-prevent- Site Selection able diseases in U.S. counties within 100 kilometers of the The team selected four sister city groups that had previ- border, compared with nonborder states. These data show a ously collaborated on binational projects (Figure 2). Local and two- to fourfold greater incidence of hepatitis A, measles, state health departments identified one or more clinical facili- rubella, shigellosis, and rabies and an eightfold greater inci- ties in each city. The U.S. institutions are four primary-care dence of brucellosis in border counties than in nonborder clinics and three tertiary care hospitals. The Mexican sites states (11). Studies have identified the importance of cross- comprise two general hospitals and four primary-care clinics. border movement in the transmission of various diseases, The primary-care institutions service 10,000–20,000 acute- including hepatitis A (12,13), tuberculosis (14–18), shigellosis care visits per site annually, while the hospitals service (19), syphilis (20), Mycobacterium bovis infection (21), and 23,000–51,000 acute-care visits per site annually. brucellosis (22,23). Despite the high prevalence of infectious diseases and Surveillance Strategy increasing movement of people across the borders,
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