Risk of Deadly TB Exposure Grows Along U.S.-Mexico Border

The Tijuana General Hospital TB Clinic in Mexico is working to treat drug-resistant strains of tuberculosis. Many people with the deadly disease enter the U.S. from Mexico. WSJ's Betsy McKay reports. Photo: Sandy Huffaker/The Wall Street Journal- Video.

Cars line up at the Tijuana crossing. More than 150 million people each year cross the U.S.-Mexico border, creating an enormous challenge to health officials trying to control a rise in drug-resistant tuberculosis cases.

TIJUANA, Mexico—He was like many people in their early 20s, at least the type with spiky black hair and two lip rings. Four years ago, while living in this teeming border city, Gonzalo Garcia says he spent free time in the U.S., to shop, meet girls, and "hang out." He had no idea he was developing a potentially deadly form of tuberculosis.

Exactly how long he had it will never be known. He says he started losing weight and becoming tired and tried to get help. But it took a year before a doctor finally figured out what was wrong: He had a drug-resistant strain of TB. "Many doctors said I was just fine," said Mr. Garcia, sitting in the clinic where he was cured.

To this day, it isn't clear if he infected anyone on either side of the border while he was contagious. But his tale illustrates a nagging concern among health officials who say the 2,000-mile border between the U.S. and Mexico could become a breeding ground for one of the hardest forms of TB to treat. Already, both California and Texas, as well as some states on the Mexico side of the border, have unusually high rates of drug-resistant TB.

"This is a very hot region" for drug-resistant TB, said Rafael Laniado-Laborin, chief of Tijuana General Hospital's tuberculosis clinic and laboratory, who has had an influx of new patients recently—including one who recently returned from the U.S. and is in the middle of treatment. With tuberculosis of any form, people can get around until the disease is quite advanced. "You will go and work and move around," he said. "You will transmit the disease before you know you're sick."

To be sure, the actual number of cases in the U.S. and Mexico is still small and the rates of multidrug-resistant TB—or MDR—are nowhere near as severe as India, China, or Eastern Europe, where drug-resistant TB is at epidemic proportions. In 2011, the most recent year available, Mexico had 467 MDR-TB cases, the World Health Organization estimates, while the U.S. had 124, according to the Centers for Disease Control and Prevention. Almost half of the U.S. cases came from California and Texas. Health officials say it is crucial to jump on prevention now, because the disease is transmitted airborne and can spread quickly.

"We're all connected by the air we breathe," said Thomas Frieden , director of the CDC, and a TB expert who successfully battled a major outbreak of multidrug-resistant TB in New York City in the 1990s, then spearheaded India's TB-fighting program for the World Health Organization.

Gonzalo Garcia has struggled with drug-resistant tuberculosis while living in Tijuana. He doesn't know when he contracted the disease.

In its drug-resistant forms, TB can still be fatal, and the treatment may be painful, requiring up to two years or more of medication and potentially months of isolation. Costs are steep too; according to a recent CDC study, treatment on average in the U.S. was about $140,000 and ran as high as $700,000.

For health officials, the challenge of trying to control an airborne disease along an area as large as the U.S.-Mexico border is enormous. More than 150 million people cross the border each year. Many, like Mr. Garcia, go back and forth to work, or to play, with visas that allow short trips in the border region. Two CDC quarantine stations sit along the border to deal with health concerns. "TB is the most common disease we get called about," said Steve Waterman, chief of the CDC's U. S-Mexico unit in the agency's Division of Global Migration and Quarantine.

The U.S.-Mexico border is "not like the Berlin Wall," said David Shirk, director of the Trans-Border Institute at the University of San Diego. "It's one region." That means people live on one side of the border and run a business on the other, and shoppers from both countries frequent the same malls, he said.

In the Mexican state of Baja California, officials are treating three cases of XDR-TB, a rare but severe form of the disease in which a patient's TB is resistant both to the two most potent drugs for treatment as well as some drugs used to treat drug-resistant TB, said Dr. Laniado-Laborin. Six new cases of this type were reported in the entire U.S. in 2011.

North of the border, in San Diego, the overall TB rate is around twice the U.S. national average. Los Angeles is grappling with its worst TB outbreak in a decade, and police have been reminded to use face masks when encountering those who are sick. "You can learn from San Diego how things could play out in the heartland of America," says Richard Kiy, chief executive of International Community Foundation, a public foundation that supports treatment of drug-resistant TB patients at Dr. Laniado-Laborin's clinic and elsewhere in Baja California.

Officials say that when drug-resistant cases show up in the U.S., there is often a Mexico connection. Of San Diego's 14 multidrug-resistant TB cases between 2007 and 2011, half were either from Mexico or had a Mexico link based on the particular strain of the disease, said Kathleen Moser of the county's Health & Human Services Agency, which sees many patients who live and work on both sides of the border.

Part of the problem, of course, is that Mexico's rate of TB infection is much higher—in some cases 10 times higher. The resistant strains begin to breed, experts say, when doctors there give patients similar drug regimens over and over. Other times, patients who aren't supervised closely abandon treatment before they are cured.

To fight problems like these, San Diego County and Baja California formed a cross-border partnership in 2006, Puentes de Esperanza, with government and private funding. It has treated 44 patients to date, paying for drugs, lab work and close supervision of patients to be sure they stick with their treatment.

But federal funding for the $600,000 program ran out last year when the U.S. Agency for International Development shifted money away from Mexico to other countries with more severe TB problems. Other programs were affected too, and each can play an important role. At one USAID-funded program that trained hospitals in Mexico, for example, hospitals were taught to separate infectious TB patients from others. When it started, "we found people with TB, HIV and pneumonia in the same room," says Jose Antonio Martinez, who was a consultant on the project.

Funding isn't the only issue. As a key part of prevention efforts, U.S. experts have regularly crossed the border in California and Texas to keep tabs on and help patients directly. But drug-related violence along parts of the U.S.-Mexico border has shot up, forcing workers to consult only from the U.S. side. Among them is Barbara Seaworth, the medical director of a TB center in San Antonio, who stopped a few years ago after making the trips for nearly 20 years.

For the first time, she says, a patient of hers failed treatment twice. "I am very concerned our outcomes aren't as good when I cannot personally evaluate patients," Dr. Seaworth said.

Here in Baja California, the battle to manage TB continues on several fronts. Rosa Herrera, manager of the state's TB program, said the country has made important progress diagnosing and treating the drug-resistant strains, with better labs and stronger drugs. Still, the state has only four TB-specialist doctors to deal with 2,000 cases of TB, half of which are in Tijuana. "We have limited resources," said Dr. Herrera, who herself contracted TB while working in an emergency room.

A mile south of the border, Dr. Laniado-Laborin said some of his patients have been on and off the same TB drugs for years—unaware that this is the kind of behavior that can spawn drug-resistant strains. Skipping doses, even briefly, gives TB a chance to mutate and defend itself against medications. "Many patients who come here have been treated many times with the same drug regimen," Dr. Laniado-Laborin said.

Among them is Mr. Garcia, who believes he contracted TB from coughing passengers on a Tijuana city bus. By the time he found Dr. Laniado-Laborin—from a desperate search he did on his own—he had taken the same TB drug regimen twice, growing more ill rather than better each time. Dr. Laniado-Laborin put him on a new drug regimen; he declared Mr. Garcia to be out of the woods about a month ago. Without Dr. Laniado-Laborin, Mr. Garcia said, "I would have died."

Another patient appears to have taken his drug-resistant TB to the U.S. and brought it back. He is now in Dr. Laniado-Laborin's care. "It's unlikely he was infected in the U.S." given the strain of TB he has, the doctor said. A U.S.- funded binational program called CureTB also run out of San Diego County's health agency, helped find the man temporary housing in Baja California, because the kind of care he needs is difficult to get near his home in the south of Mexico, Dr. Laniado-Laborin said.

Maria Melero, a 43-year-old former waitress with thick, curly shoulder-length hair who lives in Tijuana, was diagnosed with TB in 2005. A doctor put her on a standard regimen of four TB drugs with instructions to take them regularly at a local health center.

Ms. Melero abandoned the treatment after three months. Patients in the U.S. who refuse treatment can be jailed, but Mexico by law can't compel patients to take their drugs. Ms. Melero blames the disruptions in her life caused by her use at the time of cocaine and crystal meth—a habit she gave up as her TB took hold.

In 2009, after going on and off TB drugs twice more, she was referred to Dr. Laniado-Laborin. She was losing weight and struggling to breathe. He collected a specimen of her TB germs and sent it through Puentes to San Diego, which had it analyzed. Her peripatetic treatment had spawned resistance. She now carried multidrug-resistant TB.

She started a new drug regimen, but ran into more complications when her body didn't absorb all the medicines properly. The cross-border team of Puentes doctors, which includes Dr. Laniado-Laborin and Dr. Moser, ran more tests. They found that she had advanced to "extensively" resistant, XDR tuberculosis.

Dr. Laniado-Laborin, Dr. Moser, the CDC and other experts devised yet another regimen for her. But because of her extensive resistance to treatment, they were now running out of drugs to choose from. Puentes brought her to San Diego for two months of in-depth testing.

Living alone there, Ms. Melero said, she got lonely at times. Her son, who was living in San Bernardino, Calif., wasn't allowed to visit her, she said. "I missed my family a lot," she said.

She returned to Tijuana feeling much better—so much so, in fact, that she moved in with a boyfriend who lived a 30-minute climb up a hill. That disrupted her treatment yet again. She tried repeatedly to kick out a health worker who brought her medicines and made sure she took them, saying her boyfriend wanted to give her the drugs himself. Eventually, Puentes staff and her mother persuaded her to move down off the hill. "I was not an easy patient," she said.

Her Puentes doctors also worried about her large family, which includes about 50 grandchildren. Members who live in Mexico and the U.S. would gather at the family home in Tijuana when Maria was there sick. Some of the young children were infected. "I have much fear of leaving my treatment and getting [TB] back again," she said recently, seated on the patio at the Tijuana home she shares with 14 family members as laundry fluttered nearby. "I don't want that," she said.

Now feeling well, she takes her medicines daily while her health worker observes her by Skype—a process called "directly observed therapy"—to be absolutely sure she takes her drugs on schedule. To be fully cured, this must continue for up to another full year.

U.S. officials strongly support directly observed therapy. They say it is the best way to make sure patients stick to their schedule and don't miss any doses of their drugs. "No program can treat MDR TB faster than a bad program can make MDR TB," said Dr. Frieden.

Mexico also calls for directly observed therapy. But it can be costly and time consuming. About 30% of patients in Mexico don't complete their TB treatment, said Dr. Laniado-Laborin. The country lacks enough health workers to offer directly observed therapy to every patient, said Martin Castellanos, director of Mexico's National TB Program. "It is not possible—we have almost 20,000 people with tuberculosis," he said. Still, he said, Mexico's rate of curing TB patients has risen the past three years to 87%, with guidelines calling for more supervision of drug regimens for drug-resistant patients. TB control is a "priority" for Mexico's government, he said.

—Arian Campo-Flores contributed to this article