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CDC Warns: Border Crossers May Expose US Population To Infectious Diseases Such As Tuberculosis

Picture overlooking El Paso border with microscopic picture of tuberculosis overlayed

Borders, Budgets, and the Rising Risk of Disease

Is there a perfect storm brewing along our nation’s southern border?  Let’s take a look at the numbers in El Paso, Texas where I recently visited:

  • There are 27 million crossings per year alone at the El Paso Point of Entry (POE)
  • Cuts to federal funding including a 50% reduction in the  Early Warning Infectious Disease Program as well as 12.5% cuts to critical preparedness and response funding;
  • Texas is second in the nation for number of tuberculosis cases, the majority of which are found near the border  and many of the cases involve tuberculosis strains that are drug resistant
  • The bordering country, Mexico, was the source of the last global influenza pandemic

So is this a bad situation getting worse or a ticking bomb?

An Invisible Public Health Structure

Border Patrol talking with Dr. Ali Khan at the El Paso border crossingEarlier this month I visited the El Paso POE and came away thoroughly impressed by the professionalism of the Customs and Border Protection. I met many of those “boots on the ground” local public health folks who work on the Texas/Mexico border and who shared with me how the border has been neglected with minimal resources for years. Staff have been forced to live by that old credo “do more with less” to safeguard not only the communities living along the border, but the nation itself.

During my trip I also had the distinct honor to meet and chat with a lawmaker who really understood the importance of border health—U.S. Rep. Silvestre Reyes, D-Texas who notes, “A border crosser with an infectious disease can be anywhere in the United States within 36 hours.”  Congressman Reyes knows that the border is a challenging environment with many barriers including different priorities for the two countries who share the border, different public health systems, travel restrictions, language, and politics.  Additionally, our public health teams must contend with new and emerging infectious diseases, an economic crisis where budget cuts have decimated public health programs that man the border, and gaps in preparedness.

Disease Threats

Dave Daigle and Dr. Ali Khan of CDC stand for a picture with El Paso Health OfficialsWhile in El Paso, I also met with Dr. David Lakey, Commissioner of Texas Department of State Health Services who discussed his concerns about tuberculosis and other infectious diseases around the border.  Lakey pointed out that Texas is second only to California with tuberculosis cases and that these cases are higher near the border than other parts of the state.  Lakey said that in the poor communities along the border, people are less likely to get early treatment and often times they travel back and forth across the border and are not able to complete their treatment routine which leads to drug-resistant tuberculosis.  Clearly the border is a challenge for those seeking to control infectious diseases.

Valley Fever

In addition to tuberculosis, an emerging disease called coccidiodomycosis or “Valley Fever” seems to be on the rise in this border region.  Valley Fever is caused by inhalation of fungal spores that live in the desert soil; the spores can be dispersed by high winds.  We see between 10,000 and 15,000 new cases diagnosed in Arizona each year, but very few cases are diagnosed across the Arizona-Mexico border, even though we know that pathogens don’t stop at borders.  What is more likely than the pathogen stopping at the border is that health-care providers and laboratories are not trained to recognize and diagnose Valley Fever, allowing it to spread further.

Hard Questions and the Way ahead

Cars driving through the El Paso border crossingHow do we conduct surveillance and create sustainable bi-national systems for early warning infectious disease surveillance recognizing that there are 250-400 million northbound legal border crossings a year and that 25% of the US population and 35% of the Mexican population resides in the ten combined Border States?  Is doing more with less really the answer?  If so, then what can we no longer afford to do?  Moving forward we must work to implement guidelines or a process for both countries to coordinate on epidemiological events.  We require a bi-national border system for case reporting and communication and outbreak investigations and responses.  And finally we must do a better job linking and integrating existing bi-national border efforts.

To learn more about CDC’s Division of Global Migration and Quarantine, which works to prevent the introduction, transmission, and interstate spread of communicable diseases into the United States and its territories, visit: http://www.cdc.gov/ncezid/dgmq/

Tell Us What You Think

Do you live in a border state? Had you ever thought about the importance of public health at our borders? How do you think the nation needs to address the issue of budget cuts and possible disease threats?

*This blog post was originally published at Public Health Matters Blog*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

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