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Tuberculosis At The Border: Doctors Issue Warnings Of 'drug-resistant Strains'

Cases of tuberculosis (TB) — an illness that kills more people than any other infectious disease — rose in the U.S. During 2022, per the Centers for Disease Control and Prevention (CDC). And some doctors are concerned that limitations of testing at the border could be partly to blame for the surge.

In 2021, the disease infected nearly 11 million people and caused 1.6 million deaths worldwide, according to the World Health Organization (WHO).

Tuberculosis is a highly contagious disease caused by a bacterial infection. It primarily affects the lungs, but can also affect the brain, kidneys and spine. 

Required testing may have limitations: CDC

The CDC states that all refugees ages two and older must be tested for tuberculosis before entering the U.S.

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"By law, refugees diagnosed with an inadmissible condition are not permitted to depart for the United States until the condition has been treated," the agency states on its website. 

Some doctors are concerned that limitations of testing at the border could be partly to blame for the rise in tuberculosis cases. (iStock)

The CDC uses its Electronic Disease Notification (EDN) system to notify federal, state and local health departments of any immigrants and refugees who are found to have medical conditions that require follow-up.

There are limitations to that process, however.

"By design, the EDN system only collects information for the approximately 10% of immigrants who have an overseas medical classification," explained Neha Sood, health communication specialist for the CDC in Atlanta, Georgia, in a statement to Dr. Marc Siegel, clinical professor of medicine at NYU Langone Medical Center and a Fox News medical contributor. 

"Human error likely caused some losses, resulting in possible underestimates of immigrants with medical classifications."

"Thus, DHS [Department of Homeland Security] data were used to approximate the immigrant denominators."

There is also some degree of human error that comes into play, Sood added.

"Because data transfer for immigrants during the study period primarily relied on staff at ports of entry to correctly review, retain and route paper forms for each immigrant with a medical classification, human error likely caused some losses, resulting in possible underestimates of immigrants with medical classifications," she said.

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While health departments are "encouraged and provided incentives" to share the results of immigrants' testing with the CDC, Sood said there is always the chance of "underreporting."

She added, "The proportion of immigrants, refugees and eligible others who completed a post-arrival examination might be higher than indicated in this report."

Although the CDC has "comprehensive surveillance systems" to track communicable diseases within the U.S., the agency does not track diseases by immigration status, Sood explained.

Tuberculosis is a highly contagious disease that primarily affects the lungs, but can also affect the brain, kidneys and spine.  (Spencer Platt/Getty Images)

Linda Yancey, M.D., a specialist in infectious disease who is affiliated with Memorial Hermann Health System in Houston, Texas, said she regularly sees people who have screened positive for the disease and need treatment to prevent developing symptomatic illness.

"Tuberculosis is quite common in Texas, especially in the big cities," she told Fox News Digital. "Houston is an international port of entry, so we get people from TB-endemic areas coming here frequently."

Most of the imported tuberculosis cases seen at Memorial Hermann are among people coming from Africa and the Indian subcontinent, Yancey said. 

"People can be exposed to TB years before they become contagious."

"This is why immigrants coming into the U.S. Are screened at the time of entry," she said.

"People can be exposed to TB years before they become contagious," she went on. "By doing early screening, we are able to treat people long before they develop severe pneumonia."

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Immigrants who have positive screenings are given three to four months of pills to protect their TB from developing into an illness, Yancey said.

In a 2022 study by the University of Texas, researchers analyzed patterns in tuberculosis patients who had been diagnosed when crossing into the U.S. From the Mexican state of Tamaulipas, which serves as a "migration waypoint."

A diagnosis of tuberculosis can be made via a skin test or a blood test. (iStock)

The study, which was published in the Journal of Immigrant and Minority Health, found that an average of 30% of immigrants screened positive for tuberculosis over an eight-year period.

Immigrants with tuberculosis may be less likely to get successful treatment due to various factors, the study authors also wrote in a discussion of their findings.

The barriers to treatment that were cited included mobile living conditions, economic constraints, fear of deportation and the policy of the host country to provide free TB therapies.

Drug-resistant tuberculosis poses treatment challenge

Another concern is the type of TB that potentially could be coming into the U.S.

James Hodges, M.D., an internist in Waco, Texas, is concerned that immigrants are bringing in a drug-resistant strain of the disease.

"Immigrants who are positive for tuberculosis are more likely to have a drug-resistant type."

"I have found that immigrants who are positive for TB are more likely to have a drug-resistant type," he told Siegel.

"This is likely due to the over-the-counter meds and antibiotics that are available in Mexico and other central and South American countries — these patients have incompletely treated coughs on their own," Hodges continued. 

"This is becoming more common with the last two years of an open border," Dr. Hodges of Waco, Texas, said of drug-resistant tuberculosis cases entering the United States of America.  (iStock)

"This is becoming more common with the last two years of an open border."

Tuberculosis treatments need to be "specialized, complex regimens," Dr. Siegel explained. "Here in the U.S., we use INH, Rifampin, PZA, Ethambutol and others. If you use an over-the-counter antibiotic that only partially treats TB, resistance is more likely to emerge."

Facts about tuberculosis symptoms, diagnosis and treatment 

Exposure to tuberculosis is very common, but only about 20% to 30% of people who are exposed to it become infected, according to Mount Sinai.

Most new infections occur when bacteria enter the air after the infected person coughs or sneezes, and is then breathed in by someone else.

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A majority of people who get the infection will have no symptoms and are not contagious, which is known as "latent tuberculosis."

Those who have "active infections" develop the disease, experience symptoms and can potentially spread it to others.

During the first stage of TB, most people don't experience any symptoms, though some may have a mild fever, cough and/or fatigue.

During the first stage of TB, most people don't experience any symptoms, but some may have a mild fever, cough and/or fatigue. (iStock)

Patients who develop an active infection — either immediately after the primary infection or after months or years of a latent infection — may experience coughing (sometimes with blood or mucus), chest pain, pain when breathing or coughing, fever, chills, weight loss, night sweats, loss of appetite and/or fatigue, according to the Mayo Clinic's website.

Some people may develop extrapulmonary tuberculosis, which is when the infection spreads from the lungs to affect other parts of the body. 

"If you have tuberculosis and you're treated, your outlook is good if you've followed directions and taken your medications for as long as you should and in the way you were told."

There is currently no vaccine for TB available in the U.S. 

Diagnosis can be made via a skin test or a blood test.

For those who have positive screenings, additional tests — including chest X-rays, CT scans and lab analysis of lung fluid — can determine the extent of the infection and the impact on the lungs, according to the Cleveland Clinic website.

For those who have positive screenings, additional tests — including chest X-rays, CT scans and lab analysis of lung fluid — can determine the extent of the infection and the impact on the lungs. (iStock)

There are multiple treatments available for both latent and active tuberculosis, Yancey said.

"For latent disease, we treat with drugs like rifampin, rifapentine and isoniazid," she said. "People only need to take the pills for three to four months."

For active disease, additional pill options include pyrazinamide, ethambutol, moxifloxicin and linezolid, Yancey said. 

There is also an injectable option called amikacin.

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"Because we have so many different options to treat TB, drug shortages are very seldom an issue," Yancey said. "If one drug is in short supply, we have multiple effective alternative regimens."

Medications are typically taken for a period of at least six to nine months. 

If left untreated, the disease can be fatal.

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"If you have tuberculosis and you're treated, your outlook is good if you've followed directions and taken your medications for as long as you should and in the way you were told," the Cleveland Clinic's website indicates.

People who experience chest pain, severe headache, seizures, confusion, difficulty breathing, bloody mucus or blood in the urine or stool should seek emergency medical care right away, per the Mayo Clinic.

Melissa Rudy is health editor and a member of the lifestyle team at Fox News Digital. 

Millions Could Soon Have Access To Lifesaving Tuberculosis Drug Following Online Uproar

In a move welcomed by advocates, a treatment for multi-drug resistant tuberculosis could soon become more accessible for millions of people worldwide.

Although tuberculosis is uncommon in the U.S., it is the top infectious disease killer worldwide after COVID-19, claiming an estimated 1.6 million lives in 2021, according to the World Health Organization.

A lifesaving drug called bedaquiline, when used along with other medications, works to kill the bacteria that causes multi-drug resistant tuberculosis (MDR-TB). While the drug's primary patent was set to expire this week, allowing less-expensive generic versions to be manufactured and distributed, Johnson & Johnson, which makes and markets bedaquiline under the brand name Sirturo, had planned to utilize a secondary patent to extend their control of it until the end of 2027, advocates say.

In a now-viral YouTube video, author and advocate John Green protested Johnson & Johnson's patent extension on bedaquiline and rallied his 4.5 million Twitter followers to pressure the company to change course.

Amid the Twitter uproar, Stop TB Partnership – a United Nations-hosted organization that works to address tuberculosis worldwide – announced a partnership with the pharma giant to "tender, procure, and supply generic versions of SIRTURO® (bedaquiline) for the majority of low- and middle-income countries, including countries where patents remain in effect."

Researchers have estimated prices of generic versions of bedaquiline could be up to 94% lower than current costs, with large-scale manufacturing.

The availability of the generic drug could provide six million people with treatment over the next four years, according to Carole Mitnick, Sc.D., a professor of global health and social medicine at Harvard Medical School and a senior research associate at Partners in Health.

While advocates celebrated the news, Johnson & Johnson said the partnership was already in the works prior to the media uproar and that it was "false to suggest" that patents were being used to prevent broader access to bedaquiline.

"We've been in lengthy discussions with the Global Drug Facility regarding access to bedaquiline. We had our first meeting with them at the beginning of this year and reached an agreement on June 13," a Johnson & Johnson spokesperson told ABC News via email.

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Pharmaceutical companies often file for patent extensions on their drugs to prevent market competition, a strategy called "evergreening." However, advocates say this system hinders access to affordable medicines globally, sometimes for many years after a drug is first launched.

"Patents are supposed to last for a limited period of time. After that, competitors should enter the market to drive prices down. But that's not what's happening," said Robin Feldman, professor of law at University of California Law San Francisco. "Instead, drug companies pile new protections onto their drug to extend that protection."

Patents serve a key role, however, by incentivizing innovation. "Companies fund an extraordinary amount in researching and producing and we want to encourage companies to engage in that research. The patent is a reward for that successful research," Feldman added.

But Feldman's research shows that here in the U.S., an estimated 78% of drugs with new patents in the Food and Drug Administration's records were evergreening extensions for existing drugs.

John Green, who created the YouTube video addressing the bedaquiline issue, told ABC News he was first exposed to the devastation of tuberculosis during a trip to Sierra Leone.

"When I was there, I met a young man who looked to be my son's age, who looked 9 at the time but was in fact 16 and was just really emaciated, stunted by really severe multi-drug resistant tuberculosis," said Green.

"Then when I got home, I started to wonder why I didn't know more about this disease that kills more people than HIV. Kills more people than malaria and war and cholera combined, every year," he added.

"Despite causing millions of deaths each year and the avail of treatment and vaccines, tuberculosis remains a largely ignored global health issue," said John Brownstein, Ph.D., ABC News contributor and chief innovation officer at Boston Children's Hospital.

The disease is much rarer in the U.S. Compared to other countries. There were an estimated 8,300 reported cases of tuberculosis in 2022, with rates steadily declining since the early 1990s, according to the Centers for Disease Control and Prevention.

A vaccine exists to protect against tuberculosis and is typically given to young children in countries where the disease is more common. But the vaccine does not always fully protect against infection.

"[Tuberculosis] disproportionately affects people who are most impoverished and most marginalized. It is highly stigmatized and has a lot of overlap with important chronic diseases like HIV and diabetes," Harvard Medical School's Carole Mitnick said.

Tuberculosis is curable with antibiotics. However, people in lower-income countries have a higher risk of developing an infection that is resistant to multiple medications.

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Nearly 500,000 new cases of MDR-TB occur each year and only about one in three people with the disease accessed treatment in 2021, according to the World Health Organization. Those infection numbers have been trending upward, which scientists attribute to the impact of the COVID-19 pandemic.

Advocacy groups like Doctors Without Borders and Partners in Health, who for years have been pushing for greater access to tuberculosis medications, called for more action to ensure patients have better access to them.

"We reiterate our call on [Johnson & Johnson] to publicly announce it will not enforce any secondary patents on bedaquiline in any country with a high burden of TB, and withdraw and abandon all pending secondary patent applications for this lifesaving drug," Doctors Without Borders said in a press release.

In answer to an ABC News request to respond to the Doctors Without Borders statement, Johnson & Johnson said, in part, that it was "deeply committed to patient needs around the world, particularly in providing access to innovation for the most vulnerable populations in low- and middle-income countries," and highlighted what it said were the company's "broad access efforts" in providing bedaquiline to those who need it.

"This includes entering into a collaboration in June this year with the Stop TB Partnership's Global Drug Facility ("GDF") – the largest procurer of TB medicines – which enables them to invite potential generic suppliers and purchase generic versions of SIRTURO® 100mg," the statement further declared.

The Johnson & Johnson statement did not specifically address bedaquiline patents and patent applications.

"I think it's a profoundly unacceptable injustice," Green said of the overall bedaquiline access issue. "And we need to react appropriately. And to see that over the last few days has been extremely encouraging to me."

Tuberculosis-Infectious Woman Refuses To Get Treatment And Isolate, Putting Public At Risk

A women in Tacoma, Washington, who has tuberculosis (TB), has been refusing treatment and was ... [+] spotted taking public transit and going to a casino. (Photo: Getty)

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When you have a contagious disease like tuberculosis (TB), refusing treatment and refusing to isolate are not personal choices. Such choices affect not only you but also everyone around you, at least those with nostrils or mouths. That's why there is now a warrant for the arrest of a woman in Tacoma, Washington, as reported by KOMO News. She has TB yet for over a year now has refused to be treated or to be isolated. That's two not-to-be's that be bad for preventing the spread of TB. Although Pierce County judge Philip Sorenson signed off on that arrest warrant last month, that TB move doesn't appear to be having much effect as the woman was recently spotted taking public transit and going to a casino.

This has been an "If at first you don't succeed, try, try again fifteen times" situation. So far, there have been 16 court orders for this woman to submit to the Tacoma-Pierce County Health Department (TPCHD) for involuntary detention, testing, and treatment. This has meant that a whole lot of taxpayer money has gone into getting one person to take steps to protect not only her own health but also the health of those around her. This would mean taking a medication called isoniazid (INH) in combination with three other drugs: rifampin, pyrazinamide and ethambutol. While treatment would last three to nine months, she would have to stay isolated no longer than 45 days or until testing has shown that she is no longer contagious.

TB can result when you breathe in Mycobacterium tuberculosis bacteria that's exhaled by someone who is infected. So if you are infected, you can spread Mycobacterium tuberculosis into the air by coughing, speaking, or singing the Doors song, "Break on Through to the Other Side" or any song for that matter. When you air such infectious grievances, they can hang in the air for others to breath into their lungs. This is why those with active TB are often kept in negative pressure rooms. In this case, negative pressure doesn't mean being in a room with someone who is telling you to do something because you suck. Instead, it's a room where the air pressure inside is lower than the air pressure outside the room. As a result, whenever the door is opened, this pressure difference effectively sucks air into the room so that any dangerous airborne pathogens don't leave the room.

This chest X-ray shows pulmonary tuberculosis, interstitial infiltration in the left upper lung due ... [+] to Mycobacterium Tuberculosis infection (Photo: Getty)

getty

Getting TB is not to be a fun thing. The infection can ravage your lungs as well as other parts of your body such as your kidneys, spine, and brain. Typical symptoms include a chronic cough, coughing up sputum or blood, and chest pain. You may become weak and fatigued, suffer fever, chills, and night sweats, and lose your appetite and weight. You may have any combination of these symptoms. Of course, these symptoms aren't always specific to TB. For example, just because you lose your appetite after watching that vomiting scene in the 2011 movie Bridesmaids doesn't necessarily mean that you have TB.

You can be infected with Mycobacterium tuberculosis without having symptoms. This is called latent TB. When you have latent TB, you aren't infectious. However, you should still get treatment because latent TB could always become active TB.

Now, TB treatment is not like eating a hot dog. Once you start, you had better finish the entire course. Ending treatment early could end up selecting for and promoting Mycobacterium tuberculosis that's resistant to antibiotics. Taking the full course of treatment makes it more likely that you will wipe out all the Mycobacterium tuberculosis in your body and not just the weaker ones.

Speaking of hot dogs, not too many people relish getting TB. It can be a killer, and not in a positive sense of the word. The World Health Organization (WHO) indicates that "A total of 1.6 million people died from TB in 2021," and that "Worldwide, TB is the 13th leading cause of death and the second leading infectious killer after COVID-19." While TB in its early stages is very treatable, those who go untreated may have a 50% probability of dying.

So it would totally make sense to get treated if you are infected with Mycobacterium tuberculosis. And it would totally make sense for others to want you to get treated if you are infected with Mycobacterium tuberculosis. After all, no one should say, "It would be great for there to be more TB."

As they say, it's all fun and games until someone gets TB. You can cry freedom all you want, but that doesn't mean that you have the freedom to put others in danger.

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