Read PROCEEDINGS: UNITED STATES-MEXICO BINATIONAL INFECTIOUS DISEASE CONFERENCE text version

Proceedings Report of the U.S.-México Binational Infectious Disease Conference

June 28-30, 2010

2010

San Antonio, Texas

Providing international leadership to optimize health and quality of life along the United StatesMéxico Border

ACKNOWLEDGEMENTS

A special thanks to the following individuals for their invaluable time, expertise, and assistance provided to the U.S.­México Binational Infectious Disease Conference, sponsored by the United States-México Border Health Commission (BHC) and coordinated through the Texas Office of Border Health and the BHC Outreach Office of the Texas Department of State Health Services, in partnership with the Chihuahua Outreach Office of the Secretariat of Health of Chihuahua. Technical Organizing Committee: Co-Chairs Dr. Allison Banicki, and Dr. Edgar Farias; Dr. Ronald J. Dutton; Dr. Ethel Palacios Zavala; Raul Sotomayor; Dr. Steve Waterman; Maureen Fonseca-Ford; Dr. Juan Ruiz; Charles Lacy-Martinez; Dr. Joanna Frausto; Dr. Indalecio Juárez Moreno; Katharine PerezLockett; and Clint Matthews. Administrative and Logistics Planning: Kathie Martinez and Dr. Elisa Aguilar. Conference Support: Dr. Elisa Aguilar and Calixto Seca who served as the mistress/master of ceremonies; numerous speakers, panelists, and poster presenters who provided technical content and helped stimulate discussion of key binational and border issues surrounding infectious diseases; panel moderators Dr. Jay McAuliffe and Dr. Gudelia Rangel; all those who assisted during the conference as facilitators, scribes, note takers, and as helpers with registration, timekeeping, and computers as follows: Susan Ayala, Dr. Eduardo Azziz-Baumgartner, Pilar Bernal Pérez, Adriana Corona Luevanos, Stephanie DeLong, Dr. Miguel Escobedo, Rita Espinoza, Rita Flores León, Maureen Fonseca-Ford, Jorge Gallegos, Dr. Fernando Gonzalez, Dr. Olga Henao, Dr. Mario Holguin, Dr. Elizabeth Hunsperger, Ivonne Mendez, Dr. Saleem Kamili, Dr. Grace Kubin, Dr. Norma Luna Guzmán, Lucia Hernández Rivas, Azi Maroufi, Samuel Martin, Jose Moreira, Michelle Murtaza-Rossini, Lori Navarrete, Katharine Perez-Lockett, Clelia Pezzi, Flor Puentes, Dr. Jaime Romo, Dr. Juan Ruiz, Dr. Rocio Sánchez Díaz, Calixto Seca, Monica Sovero, Teresa Ulrich, Dr. Steve Waterman, Rachel Wiseman, and Conschetta Wright. Resource Provisions: The Center for Global Health, Centers for Disease Control and Prevention, for providing a copy of the draft Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest for inclusion in the meeting packet and in the proceedings. Contracted Support: Maya Interpreting for interpretation services; Robin Scott of Open Circle Consulting for help with facilitation; Richard Wines and Roger Wines of Ro-Jer Enterprises for recording the conference; and Julie Nordskog of The Global Good for transcription and for writing the initial draft of the proceedings.

ii

TABLE OF CONTENTS Acknowledgements ....................................................................................................................................... ii Executive Summary ...................................................................................................................................... 1 Overview of Conference ............................................................................................................................... 3 Purpose...................................................................................................................................................... 3 Opening Remarks...................................................................................................................................... 3 Presentation Summaries ................................................................................................................................ 3 Federal Perspectives on Binational Collaborations................................................................................... 3 Sharing of Epidemiological Information across Borders: Federal Perspectives ....................................... 4 Sharing of Epidemiological Information across Borders: International Health Regulations.................... 4 Sharing of Epidemiological Information across Borders: State Perspectives ........................................... 4 Lightning Talks (Day 2)............................................................................................................................ 4 Laboratory Testing and Application of Laboratory Results to Epidemiological Analysis ....................... 5 Infectious Disease Detection and Surveillance ......................................................................................... 5 Outbreak Response ................................................................................................................................... 5 Lightning Talks (Day 3)............................................................................................................................ 5 Summary of Priority Issues and Objectives .................................................................................................. 5 Panel Discussion on Binational Communication ...................................................................................... 5 Reports from the Breakout Groups ........................................................................................................... 6 Summary of Recommendations .................................................................................................................... 8 Action Items for Follow-Up...................................................................................................................... 8 Closing Remarks ..................................................................................................................................... 10 Discussion and Next Steps .......................................................................................................................... 11 Appendices.................................................................................................................................................... 1 Appendix A: Registered Participant Directory ..................................................................................... A-1 Appendix B: List of Organizations and Acronyms ............................................................................... B-1 Appendix C: Conference Agenda ......................................................................................................... C-1 Appendix D: Individual Presentation Summaries ................................................................................. D-1 Appendix E: Panel Discussion on Binational Communication............................................................. E-1 Appendix F: Breakout Groups and Their Participants .......................................................................... F-1 Appendix G: Matrices from the Breakout Groups ................................................................................ G-1 Appendix H: Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest.................................................................................................................................. H-1

iii

EXECUTIVE SUMMARY

The United States-México Border Health Commission (BHC) conducted the U.S.-México Binational Infectious Disease Conference, hosted by the Texas Office of Border Health and the BHC Outreach Office, in partnership with the Chihuahua Outreach Office of the Secretariat of Health of Chihuahua, on June 28-30, 2010, in San Antonio, Texas, in response to a recommendation approved by the XXVII Border Governors Conference. The purpose of this conference was to convene federal, state, and local partners from the United States and México to address border binational aspects of disease surveillance and the health impact of infectious diseases in both countries and discuss potential solutions to these common problems. Conference participants represented federal agencies, state and county health departments, and laboratories in all ten U.S. and México border states (Arizona, Baja California, California, Chihuahua, Coahuila, New Mexico, Nuevo León, Sonora, Tamaulipas, and Texas) as well as additional states located outside the border (Aguascalientes, Chiapas, Hidalgo, and Veracruz). Also present were representatives from the following organizations: the Pan American Health Organization of the World Health Organization (PAHO-WHO); the BHC; the Health Ministry of México; the Diagnostic and Epidemiological Reference Institute (InDRE) of México; the U.S. Department of Health and Human Services' (HHS) Office of Global Health Affairs (OGHA); the Centers for Disease Control and Prevention (CDC); and the Assistant Secretary for Preparedness and Response (ASPR). Representatives from the Public Health Agency of Canada and other organizations also participated. In total, the conference was attended by 156 participants. In December 2008, a U.S.-Mexico Binational Infectious Disease Epidemiology and Laboratory Surveillance Meeting took place in El Paso, Texas. At that time, matrices were developed to identify existing collaborations and challenges to binational epidemiology in several disease-specific areas. During the 2010 Binational Infectious Disease Conference, attendees were likewise organized into four disease-specific breakout groups: 1) tuberculosis (TB), HIV and sexually transmitted diseases (STDs), and hepatitis; 2) food security and public health (including foodborne diseases); 3) acute respiratory diseases; and 4) emerging diseases (including vector-borne and zoonotic diseases). Participants updated these matrices with current collaborations, pending issues, and new priorities in infectious disease surveillance, prevention, and intervention. Presentations focused on surveillance, epidemiology, and outbreak investigations of infectious diseases and included information on the challenges, lessons learned, and next steps toward improving binational collaboration in border health. The agenda also included an interactive panel discussion on the challenges surrounding binational communication. The following recommendations were identified from the work groups during the 2010 U.S.-México Binational Infectious Disease Conference: (1) Work towards formal approval of the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest and develop protocols for implementation. (2) Evaluate potential legal barriers for binational cooperation and communication and develop a plan to reduce or eliminate these barriers. (3) Encourage sustained funding to support binational collaboration in surveillance and epidemiology of infectious diseases. (4) Work towards resolving issues with the transportation of specimens, reagents, medicines, and medical or laboratory supplies across borders.

1

(5) Assess the need along the border for additional training in epidemiology, laboratory techniques, and protocols for implementation of the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest and the International Health Regulations. (6) Evaluate current influenza surveillance networks in border communities and determine whether additional sentinel surveillance sites or other surveillance efforts are needed. (7) Review migration patterns between the United States and México and determine whether additional surveillance efforts are needed along the border or in other areas of high cross-border mobility. It is anticipated that the work groups established, or other work groups as may be established, will continue to review issues of border/binational concern. The products of these work groups will be reported and further elaborated on at the U.S.-México Border Binational Infectious Disease Conference in 2011.

2

OVERVIEW OF CONFERENCE

Purpose The purpose of the U.S.-México Binational Infectious Disease Conference, sponsored by the U.S.-México Border Health Commission (BHC), was to convene federal, state, and local partners from both sides of the U.S.-México border to address critical infectious disease issues impacting the border region and discuss potential solutions to address those problems. The conference was hosted by the Texas Office of Border Health and the BHC Outreach Office, in partnership with the Chihuahua Outreach Office of the Secretariat of Health of Chihuahua, on June 28-30, 2010, in San Antonio, Texas. Opening Remarks Dr. David Lakey, Commissioner, Texas Department of State Health Services (DSHS), and Dr. Raymundo Verduzco, Secretary of Health, Coahuila, both BHC members, provided opening remarks. Dr. Lakey described the U.S.-México border as the "busiest in the world" in terms of truck and human crossings. He stated that 15 percent of the U.S. population and 18 percent of the Mexican population live along the border. He also stated that the border faces many infectious disease threats in the region such as tuberculosis (TB), foodborne illnesses like salmonellosis, mosquito-borne illnesses like dengue, or possible pandemics like the 2009 influenza A H1N1 virus. He further stated that border health collaboration faces many challenges including differences in language and culture, high-mobility in the population, operational differences between México and the United States, and limited resources. He concluded by saying that both countries need to improve sharing data and information across borders, building laboratory capabilities, and working to improve systems. Dr. Verduzco emphasized Coahuila's commitment to support border health and stressed the importance of binational collaboration between México and the United States. He stated that this collaboration requires the participation of all, including individuals, institutions, and governments. Dr. R.J. Dutton, Director, Texas DSHS Office of Border Health, provided an overview of the historical milestones related to border infectious diseases. He noted that a key predecessor to the present conference was the 2008 U.S.-Mexico Binational Infectious Disease Epidemiology and Laboratory Surveillance meeting in El Paso, Texas. He also stated that the BHC plans to host a second U.S.-México Border Binational Infectious Disease Conference in 2011.

PRESENTATION SUMMARIES

While some presentations and plenary sessions are summarized in this proceedings report, complete summaries of individual presentations are available in Appendix D. Federal Perspectives on Binational Collaborations Speakers representing México and the United States provided an overview of international, binational, and border collaborations related to infectious diseases. Specific initiatives were discussed as representative examples with several presentations summarized below: Dr. Celia Alpuche Aranda, General Director, InDRE, Health Ministry of México, reviewed the collaboration efforts between México and the United States during specific infectious disease outbreaks as well as general surveillance. She informed that infectious diseases can profoundly impact economic and social well-being and that public health programs for prevention and control are essential to national security and stability, emphasizing that binational concerns extend beyond the border region. Dr. David Swerdlow, Senior Advisor for Epidemiology, the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), reviewed the structure and

3

recent activities of the Binational Technical Work Group, formed to facilitate discussions on technical matters in public health and promote binational collaborations between the United States and México. Its major focus is developing binational protocols to implement the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest. He stated that clear protocols are needed for communication of events classified as a public health emergency of international concern (PHEIC). Dr. Steve Waterman, Senior Medical Epidemiologist, U.S.-Mexico Unit, Division of Global Migration and Quarantine (DGMQ), CDC, summarized the history, achievements, and new collaborations of the Border Infectious Disease Surveillance (BIDS) project, which began in 1999. He stated that one ongoing effort is a binational data system that will provide messaging capability and will interface with existing national and state data systems. He also stated that moving reagents and specimens across borders continues to be a major challenge but that existing border and binational surveillance efforts can be strengthened by improved integration. Dr. Ethel Palacios, Director of Epidemiological Surveillance of Non-Transmissible Disease and Coordination of International Projects, General Directorate of Epidemiology (DGE), Health Ministry of México, focused on two major international collaborations involving the United Sates and México: the EWIDS project and the North American Leaders Summit (NALS). She stated that EWIDS-México funding helped build epidemiological surveillance capacity, enhanced diagnostic laboratory capacity, and improved information technology systems and training. NALS, which follows the North American Security and Prosperity Partnership (SPP), is moving forward with a review of the North American Plan for Avian and Pandemic Influenza and a reorientation to focus on multiple health threats. Mr. Raul Sotomayor, Senior International Health Program Analyst, ASPR, HHS, described several international health initiatives that involve infectious disease preparedness and response: NALS, EWIDS, the Global Health Security initiative, and the International Health Regulations (IHR). He stated that the U.S. National Health Security Strategy (NHSS) was published in December 2009, and ASPR is developing an implementation plan. Three of ten specific objectives in the NHSS are related to ASPR's work with EWIDS. Sharing of Epidemiological Information across Borders: Federal Perspectives Speakers from México and the United States discussed barriers to sharing epidemiological information, including importation/exportation issues and legal challenges. The Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest were identified as a way to share information more easily and efficiently across borders. Sharing of Epidemiological Information across Borders: International Health Regulations In this session, speakers from PAHO-WHO, México, and the United States considered ways to implement the IHR. The IHR were identified as a way to help with the rapid notification of a PHEIC such as a pandemic. Sharing of Epidemiological Information across Borders: State Perspectives The Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest recognize the need for state-to-state and local-to-local communications across the border. Border state representatives shared their experiences and lessons learned with regard to state-to-state binational communication of public health events. Lightning Talks (Day 2) Day 2 opened with seven 5-minute presentations or "lightning talks." These short talks focused on outbreak investigations of vector-borne, foodborne, and infectious diseases in the border states and, in some cases, involving cross-border collaboration.

4

Laboratory Testing and Application of Laboratory Results to Epidemiological Analysis Plenary presentations on laboratory testing and application of results to epidemiological analyses focused on advances made in collaborative initiatives and increased capacity in laboratories achieved through acquisition of equipment, technology, and training. Infectious Disease Detection and Surveillance Presentations in this session focused on specific examples of infectious disease detection and surveillance, including influenza surveillance in the first two U.S. jurisdictions to detect the pandemic influenza A (H1N1) strain. Outbreak Response Speakers in this session presented best practices in outbreak response, including outbreaks with binational or other multijurisdictional aspects. Lightning Talks (Day 3) These lightning talks focused on the epidemiology of several infectious diseases: hepatitis A, salmonellosis, Chagas disease, and measles. Specific outbreaks with binational aspects were discussed in the case of salmonellosis and measles.

SUMMARY OF PRIORITY ISSUES AND OBJECTIVES

Panel Discussion on Binational Communication The following public health leaders, representing the federal, state, and local levels of the United States and México, as well as the federal government of Canada, served as moderators and panelists: Moderators: Dr. Jay McAuliffe, Center for Global Health, CDC Dr. Gudelia Rangel Gómez, BHC, México Section Dr. Celia Alpuche Aranda, InDRE, Health Ministry of México Dr. Ethel Palacios Zavala, DGE, Health Ministry of México Dr. Steve Waterman, DGMQ, CDC André La Prarie, Public Health Agency of Canada Dr. José Luís Alomía Zegarra, Health Service of Sonora Robert Guerrero, OBH, Arizona Department of Health Services Dr. Pablo Gilberto López Rodríguez, Sanitary Jurisdiction No. IV, Reynosa Dr. Hector Gonzalez, City of Laredo Health Department

Panelists:

During the panel discussion on binational communication, moderators fielded questions from the audience. Panel members responded to direct questions and were encouraged to discuss freely as time allowed. Discussion centered on barriers to effective binational communication and possible solutions to improve binational communication related to infectious disease epidemiology and surveillance. Several panelists emphasized the need to implement the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest. Questions on import/export difficulties were frequently posed. Concern was also expressed about maintaining adequate funding to support binational collaboration in epidemiology and surveillance through EWIDS and other mechanisms. (See Appendix E for a detailed summary of the discussion in "Q & A" format.)

5

Reports from the Breakout Groups Participants were given the opportunity to choose from one of the following breakout groups during registration (See Appendix F for group participant lists): · TB/HIV/STDs/hepatitis · Food security and public health, including foodborne and diarrheal diseases · Respiratory and flu-like illness · Emerging, vector-borne, and zoonotic diseases The objective of the first breakout session was to identify current collaborations and problems. During the second breakout session, participants proposed potential solutions and additional opportunities for collaboration. Using the matrices developed in 2008, participants updated information on current collaboration, pending issues, and new priorities on Day 2. Information not related to the matrix but relevant to the discussion was captured on flip charts and by assigned note takers. Each group designated a spokesperson to present results on the following day. Final conference sessions involved breakout group reports, as well as a discussion of the results and action items for follow-up. (See Appendix G for group matrices completed during the breakout sessions.) Breakout reports are summarized as follows:

TB/HIV/STDs/Hepatitis

Existing projects included the Puentes de Esperanza project in Tijuana which provides treatment for complicated TB patients. Pending issues identified for this project was the lack of medications, the need to expand project services, the need to continue improving project sustainability, and overall funding to support the project. Another issue addressed was cross-border continuity of care. The root of the problem was limitations in the ability to provide the information and organization around referrals for mobile patients, especially detention center patients held by U.S. Immigration and Customs Enforcement (ICE) and in other contract facilities. Participants also reported that in acute TB and binational TB projects, agencies need to create information, standardize data systems, and implement data and referral management. Access to secondline drugs can also be a challenge. Also mentioned was the Directly Observed Therapy Surveillance (DOTS) initiative and the need to inventory resources. Other ongoing projects cited were the Project Juntos and the New MexicoChihuahua TB Pilot Project. New projects included the Heartland Multi-Drug Resistant Tuberculosis (MDR-TB) Project and the México TB Infection Control Project. Pending HIV/AIDS issues included a need to inventory existing binational collaborations. Participants also identified the need to introduce basic high risk group information into each country's information systems. With respect to hepatitis projects, they identified the need to better address logistical support issues and pursue ongoing integration/collaboration on border infectious disease hepatitis surveillance. Other issues identified included the need for agencies to build on and share information systems to improve surveillance and the need to enhance laboratory capacity with a goal of establishing diagnostic standards and resolving barriers to imports of lab specimens. Participants requested that the results of the CDC pilot project on specimen import-export be disseminated and emphasized the need to convene a panel of high-level agency representatives to develop and implement solutions.

6

Food Security and Public Health (foodborne diseases)

Participants decided to first survey and document current foodborne activities to identify strengths, weaknesses, and gaps and determine ways to enhance capacity in surveillance and response. Areas of concentration identified were surveillance, laboratories, information technology, education, and health promotion. With this inventory, the next step was to develop strategies to enhance capacity. Details to consider included funding, legal aspects, adoption of protocols, information exchange agreements, and, potentially, a memoranda of understanding among binational agencies to advance their work. Participants proposed identifying contact persons for these activities and forming subgroups. These groups would be organized by monthly calls with one face-to-face meeting per year to assess the status of work.

Acute respiratory diseases, including pandemic influenza

Because the H1N1 pandemic accelerated the work planned for surveillance and response to influenza, the pilot projects of 2008 were quickly implemented and became binational. However, the group identified mores issues to address such as the import/export of specimens and weekly data reporting. The group reported using the CDC-PAHO Generic Protocol for Influenza Surveillance. One action item is to communicate among the sentinel sites to ensure cases are being processed so that responses are meaningful and homogeneous. An open question centered on pandemic response and whether public health officials still believe in containment. New items for consideration included sharing existing health promotion materials for Spanish speakers and disseminating best practices over the month following the conference. Participants identified that sentinel sites established during the H1N1 pandemic have produced highquality data and that it would be useful to use these surveillance sites to better understand trends in cases presented. These sites also offer an opportunity to perform burden of disease analysis, such as rates of severe hospitalization and mortality. This is part of a regional push to integrate surveillance so policies for presentation and control can be imported. A closely-related issue identified was the need to examine vaccine coverage on both sides of border. Vaccine effectiveness for prevention and the cost effectiveness of vaccines in some of these sites can also be examined. With this data, models to interrupt transmission and morbidity can be developed. Participants will continue implementing legionella surveillance and building laboratory capacity, and a group from CDC will go to México to improve laboratories. Also identified was the need to continue coccidioidomycosis surveillance, which was proposed in 2008 but was interrupted by the influenza pandemic, and hope to propose concrete measures next year to move forward with coccidioidomycosis surveillance.

Emerging infectious diseases, including vector-borne diseases

Cross-border collaboration readily exists in surveillance with influenza, vector-borne diseases, like rickettsia and rabies, and foodborne diseases. Pending actions include creating a homogenized list of notifiable diseases, to include case definitions, at a trinational level (Canada, México, and the United States). Participants also identified the importance of creating an ongoing work group. A need exists to activate new surveillance sites and increase monitoring of other diseases like rotavirus, rabies, West Nile virus, and zoonotic diseases. New priorities identified included establishing sentinel sites with high cross-border mobility. Participants also identified the importance of considering migratory patterns in all surveillance reporting. In addition, they also identified the need to enhance and increase surveillance among tribal communities. Other items identified included the need to increase membership in Epi-X (CDC-managed system for secure electronic communication about epidemiological events) and include zoonotic diseases

7

information; the need to explore the most effective means of real-time communication in response to outbreaks; the need to define which information needs to be shared and with what frequency; and the need to establish protocols for communication at the binational and trinational levels, to include central México due to travel patterns.

Laboratories

While a separate breakout group was not designated for laboratory issues, some shared concerns on this topic were identified. There are many existing collaborations between InDRE and the CDC. At present there are CDC-InDRE trainings on rickettsia and biosecurity. Pending issues include defining a list of illnesses of binational interest. The group agreed on the present need to enhance laboratory capacity (InDRE and the state public health laboratories) in molecular methods and in the principal illnesses of interest. New priorities included building capacity in InDRE, as well as binational surveillance in state laboratories. Future areas for training included emerging diseases and the use of EpiX and WebX. In terms of health promotion, the participants identified the need to share flyers on TB and develop bilingual information on dengue, vector control, and health promotion in general.

SUMMARY OF RECOMMENDATIONS

Action Items for Follow-Up Dr. Steve Waterman and Lucia Hernández Rivas, InDRE, presented their synopses of breakout group results, made recommendations, and moderated group discussions. Dr. Waterman's presentation also identified cross-cutting issues. The following is a breakout synopsis of Dr. Waterman's group results' summary: 1. TB/HIV/STDs/Hepatitis a. Current projects: continuity of care, drug resistant case treatment; panel physician Directly Observed Therapy (DOT); and culture and drug susceptibility study in México b. New projects: flagship study of molecular resistance of TB; binational network to treat multidrug resistant (MDR) TB; assessment and training on infection control in México; building TB lab capacity and quality control; cross-border collaboration on migrants and HIV; and evaluation of binational TB projects c. Next steps: improve binational referrals to include information systems; review ongoing TBrelated legal issues; and establish protocols and timelines for implementation 2. Foodborne Diseases a. Current projects: analysis of salmonella surveillance in México, surveillance exchange among border states, and PAHO training courses b. New projects: review foodborne surveillance; develop protocols for binational outbreaks; increase scope of surveillance in México; create a matrix of case definitions for foodborne illnesses; assess and increase laboratory capacity, epidemiology training, and Epi-X alerts; and inventory bilingual health promotion materials c. Next steps: disseminate findings on salmonella surveillance analysis 3. Respiratory Diseases a. Current projects: updating the North American pandemic influenza plan, border/binational influenza reports, and respiratory disease laboratory training

8

b. New projects: disease burden/vaccine coverage analysis, inventory of bilingual health promotion materials, legionella laboratory training, and binational surveillance of coccidioidomycosis pilot c. Next steps: develop and incorporate influenza surveillance protocols, continue laboratory training for existing and emerging infectious diseases, use resources under CDC-México cooperative agreement to study cost-effectiveness of vaccines 4. Emerging Vector-borne and Zoonotic Diseases a. Current projects: rickettsial surveillance, BIDS, web-based platform for rabies surveillance, and laboratory training b. New projects: enhanced brucellosis surveillance, exchange of viruses for molecular studies, exchange of health promotion materials, binational malaria surveillance, and binational collaboration on Chagas disease c. Next steps: expand binational surveillance sites and continue laboratory training 5. Cross-Cutting Issues Binational Technical Work Groups: A need exists for ongoing binational work groups organized around specific diseases. These work groups would address and implement actions in the following areas: a. Protocols: Groups in the breakout sessions, regardless of disease(s) of interest, generally highlighted the need to develop protocols for binational cases (case definitions) and for binational outbreak investigations. b. Communication: Maintain effective and timely communication in binational cases. It was suggested that teams develop diagrams of communication pathways. c. Training: Continued training is needed in both epidemiology and laboratories on existing and emerging infectious diseases. d. Surveillance: Improve and introduce innovative strategies. Laboratories need to build surge capacity in preparedness for pandemics. e. Barriers: Legal barriers and customs barriers (to specimens and reagents) need to be resolved through information-sharing and new policymaking. f. Resources: The infrastructure for binational communication, including information technologies, needs to be utilized effectively and expanded. In addition to surveillance data, binational counterparts can share resources such as health promotion materials.

Lucia Hernandez Rivas provided the following recommended guidelines for the work groups: Each work group should define its lines of action. For each line of action, the group should develop a list of specific activities and identify milestones and indicators that will allow for the development of a quarterly report. Each line of action should identify a representative responsible for follow-up. There should also be one or more individuals identified as the responsible party for each work group to ensure follow-up and generate precise information. Conference participants agreed with L. Hernández Rivas and identified the responsible individuals for each work group before the conference close. They also agreed that there should be special work groups formed for laboratory and cross-cutting issues. Group leaders and members, including at least one representative from each country, were self-nominated or nominated by consensus as follows:

9

Follow-Up with Work Groups Emerging Infectious/Zoonotic Diseases · US ­ Karen Ferran (California) · MX ­ Rita Flores · US ­ Elizabeth Hunsperger Laboratory · US ­ Sonia Montiel · MX ­ Lucia Hernandez Food Safety and Foodborne Diseases · US ­ Olga Henao · MX ­ Carmen Guzman

Preparedness for and Response to Acute Respiratory and Flu-Like Diseases · US - Eduardo Azziz-Barmgartner · US - Charles Lacy-Martinez (Arizona) · MX ­ Pilar Bernal Cross-Cutting Issues · MX - Ethel Palacios · US - Steve Waterman · US - Allison Banicki (Texas) · US - Maureen Fonseca

TB, HIV, STDs, Hepatitis · US ­ Miguel Escobedo · MX ­ Norma Luna

These six work groups, and/or other work groups as may be established, will continue to complete the matrices and follow-up on other pending issues. The groups will provide information and recommendations to implement the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest and the International Health Regulations. The Binational Technical Work Group will involve subject matter experts from both countries and include border state representatives and also address local interests. Closing Remarks Ethel Palacios and Allison Banicki led the closing session. Dr. Palacios expressed hope that all partners will move forward binational work with the lessons of the H1N1 pandemic in mind. Dr. Palacios also stated that México recognizes that the border states have much to contribute to the binational discussion due to their daily experiences. She concluded by saying that binational collaborations transcend the border, and participants from all parts of the country will be instrumental in future binational initiatives. Dr. Banicki identified several recurring themes throughout the conference. Among them was the distinctive use of the terms "border" and "binational." She stated that there is general recognition that binational issues extend beyond the border region, but it also remains clear that significant health disparities remain between border and non-border regions. In short, the border region is both border and binational and the impact of border issues on binational policy cannot be avoided. Both governments have made clear their understanding of this issue by the creation and support of the BHC framework and role. There is federal recognition of special border status, as demonstrated by the existence of other unique border programs like BIDS and EWIDS. Points to consider from binational communication discussions included concerns over ongoing funding for programs such as EWIDS and BIDS; import/export challenges; and legal barriers to cross-border collaboration. Distant counties and states can learn from the particular experiences of the border region given the unique experience in the region. The next steps following this conference are for the work groups to develop working protocols to implement the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest and the International Health Regulations. It was made clear that border states are ready to make contributions to the development of these protocols through this inclusive mechanism or other appropriate borderspecific frameworks as may be needed.

10

Dr. María Teresa Zorrilla Carcaño, the Executive Secretary of the México Section, BHC; Dan Reyna, General Manager, U.S. Section, BHC; and Dr. Ronald J. Dutton, Director, Texas Department of State Health Services, Office of Border Health, provided closing remarks. These speakers thanked the conference coordinators, volunteers, and participants. They also applauded and encouraged the ongoing efforts of conference participants to meet, discuss, and communicate results and make recommendations to the Binational Technical Work Group, the BHC, and state and federal health agencies. Dr. Dutton thanked the BHC for their sponsorship and their attending delegates for their support.

DISCUSSION AND NEXT STEPS

The 2010 U.S. Binational Infectious Disease Conference provided extensive information to attendees, in terms of presentations and posters (46 presentations and 12 posters total) that outlined distinctive features of the public health systems in the United States and México, as well as best practices and lessons learned for the epidemiology and surveillance of infectious diseases of binational concern. Participants heard perspectives from all levels of government, from border states and border communities, and from public health workers operating outside of the border region. Discussion on how to improve border and binational communication also took place. Smaller work groups defined by types of infectious diseases provided the opportunity for more interaction as participants reviewed the current status of surveillance and epidemiology and considered the best next steps. Throughout the rest of 2010-2011, it is anticipated that the work groups will continue to review issues of binational concern in conjunction with the Binational Technical Work Group or other work groups. The products of these work groups will be reported and further elaborated at the Second Annual U.S.-México Border Binational Infectious Disease Conference in 2011.

11

APPENDICES

Appendix A: Registered Participant Directory This directory includes the names of actual participants in the conference. It does not include the names of persons who registered but did not attend. PARTICIPANT DIRECTORY

Last name Adams Aguilar First name Barbara Elisa Dra. Prefix Title Regional Epidemiologist Coordinadora Estatal Chihuahua Epidemiologo Estatal Directora General Adjunta del Instituto de Diagnóstico y Referencia Epidemiológicos EWIDS Epidemiologist Coordinador de Vigilancia Epidemiologica Administrative Assistant to Office of Border Health Director Medical Epidemiologist Organization Texas Department of State Health Services CSF Email Address [email protected] [email protected] Phone Number 956-4215559 01152 656639-08-63 / 64 662-2188674 5255 534111-01

Alomía Zegarra Alpuche Aranda

José Celia

Dr. Dra.

Servicios de Salud de Sonora InDRE, SS, México

[email protected] [email protected]

Alva

Herminia

Aranda Lozano

Jose Luis

Dr.

Texas Department of State Health Services Health Services Region 11 ISESALUD

[email protected]

956-4215560 664 638-7311 512-4587675

[email protected]; [email protected] [email protected]

Ayala

Susan

Texas Department of State Health Services, Office of Border Health U.S. Centers for Disease Control & Prevention, Influenza Division

AzzizBaumgartner

Eduardo

Dr.

[email protected]

404-2598831

A-1

Baker Banicki Barkey

Duiona Allison Anthony Dr.

Senior Management Official Epidemiologist Specialist, Emergency Preparedness and Response Coordinator

Centers for Disease Control & Prevention Texas Department of State Health Services, Office of Border Health Association of Public Health Laboratories (APHL)

[email protected] [email protected] [email protected]

512-4587111 ext. 6399 512-4587675 240-4852716

Bates Bejarano Ramirez

Joanne Veronica Ing.

Benfield Bernal Pérez

Aaron Rosalía Pilar

Dr. M. en C.

Besser Blair Blank Bueno Rosas

John Patrick Eric Martha Alicia

Dr Cmdr. Dr. Dra.

Burnham

Suzanne

Dr.

Directora del Laboratorio Estatal de Salud Pública, Baja California Molecular Biology Group Manager Coordinadora Federal para la Vigilancia de Influenza,SS, México Deputy Chief, EDLB Director, Respiratory Diseases Principal Consultant Coordinador Estatal BIDS, Jefe de Vigilancia Epidemiologica Agroterror Preparedness

City of El Paso Public Health Preparedness Laboratorio Estatal Baja California

[email protected] [email protected]

915-7715792 52 686 24829-92

Texas Department of State Health Services Dirección General de Epidemiología SS

[email protected] [email protected]

512-4587735 53371812

Centers for Disease Control & Prevention Naval Health Research Center Association of Public Health Laboratories (APHL) Servicios de Salud de Chihuahua

[email protected] [email protected] [email protected] [email protected]

404-6392549 619-7674842 573-4620173 01-614-43999-00 etx 21656 512 4587111 x 6360

Texas Department of State Health Services

[email protected] us

A-2

Cantey Carmona Aguirre Castellanos

Paul Santos Daniel Luis Gerardo

Dr. Dr. Dr.

Medical Epidemiologist Médico Epidemiologo Medical Epidemiologist Head, Infectious Diseases, Dept. of Pediatrics PHEP Branch Manager Program Manager Quimico Bacteriologo Parasitologo (Q.B.P.) Manager, Microbiological Sciences Branch CDC Program Coordinator for WHO Global Foodborne Infections Network Subsecretario de Fomento Sanitario Director Subsecretario de Servicios de Salud

Chacon

Enrique

Dr.

Centers for Disease Control & Prevention Secretaria de Salud de Tamaulipas Pan American Health Organization / U.S.- Mexico Border Office Hospital General Tijuana

[email protected] [email protected] [email protected]

[email protected]

404-6393448 834-3150301 915-8455950 Ext 2531 526646346820 512-4973928 915-8347690 614-4-11-3315 512-4587592 404-6393332

Connor Corona Luevanos Covián Lugo

Sallie Adriana Sonia QFB

Texas Department of State Health Services Texas Department of State Health Services Office of Border Health Region 9/10 Laboratorio de Salud Publica en el Estado de Chihuahua Texas Department of State Health Services WHO Global Foodborne Infections Network, CDCDivision of Foodborne, Waterborne, and Enteric Diseases Secretaria de Salud de Coahuila Texas Department of State Health Services Office of Border Health Secretaria de Salud de Coahuila

[email protected] [email protected] [email protected]; [email protected] [email protected] x.us [email protected]

Delamater

Elizabeth

Dr.

DeLong

Stephanie

Duron Martinez Dutton Elizalde Herrera

Jorge Alberto R.J. Francisco

Dr. Dr. Dr.

[email protected]; [email protected] [email protected] [email protected]

844-430-8844 512-4587675 844-438-8330

A-3

Escobar López

Roman

M. en C.

Escobedo Escobedo Espinoza Evanson Farias Farias

Miguel Luis G. Rita Amanda Edgar Alberto

Dr. Dr.

Subdirector Técnico en el Laboratorio Estatal de Salud Pública de Sonora, México Medical Officer Regional Director HSR 9/10 Epidemiologist Epi-X Training Coordinator Jefe del Departamento de Epidemiología, del Edo. De Coahuila Directora de Información Epidemiológica Program Manager Director Responsable de Laboratorios de Vinculación de Proyectos Epidemiologist OBH HSR 11 Program Manager

Laboratorio Estatal de Salud Pública

[email protected]

66-22-18-7555 ext. 116

Dr.

Centers for Disease Control & Prevention, Division of Global Migration & Quarantine Texas Department of State Health Services Texas Department of State Health Services Centers for Disease Control & Prevention Secretaría de Salud de Coahuila

[email protected] [email protected] [email protected] [email protected] [email protected]

915-8345951 915-8347681 512-4587676 404-6607815

Fernandez Canton Ferran Flores Flores Leon

Sonia B.

Dra.

DGE, SS, México

[email protected]

52-55-53371644 619-6883187 956.648.0543 53-37-1670

Karen Isidore Rita

Dr. Dr. M. en C.

EWIDS/California Department of Public Health International Valley Health Institute DGE-InDRE,SS, México.

[email protected] [email protected] [email protected]

Fonseca-Ford Fournier Frausto

Maureen Marta Joanna Dr.

Border Epidemiologist

Centers for Disease Control & Prevention Texas Department of State Health Services Office of Border Health EWIDS, California Department of Public Health

[email protected] [email protected] [email protected]

619-6925510 956-4215591 619-6880110

A-4

Galindo Galindo

Edgar Ivan

QBP

Director

Laboratorio Estatal de Salud Publica de Nuevo León

[email protected]; [email protected]

Gallegos Garcia Garcia García Cantú Gaul Gomes-Moreira Gonzalez Gonzalez Marron Gonzalez Guerra Guerrero Baquedano

Jorge Dina Oda Abelardo Linda K. Jose Fernando J. Marcos Hector F. Sandra Fernanda Dr. Ing. Dr. Dr. Dr. Dr.

Epidemiologist Epidemiologist EWIDS Epidemiologist Doctor Epidemiologist Binational Coordinator Lead Epidemiologist Coordinador IT Director of Health Regional Medical Director Analista de proyecto Salud en la Frontera/EWIDS Project Analyst Chief, Office of Border Health Directora de DX y Referencia InDRE.

City of El Paso Department of Public Health Texas Department of State Health Services City of Laredo Health Department CSF Texas Department of State Health Services Texas Department of State Health Services - Office of Border Health City of El Paso, Department of Public Health Dirección General de Epidemiología City of Laredo Health Department Texas Department of State Health Services Health Service Region 8 Fundación México - Estados Unidos para la Ciencia (FUMEC)

[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

8183614411, 83613955, 83613956, 83602770 915-7715804 956-4215556 956-7631804 81-83453429 818342-5336 512-4587676 512-4587675 915-7715808 52-55-533717-88 956-7954920 210-9492003 52-55-52-0005-62

Guerrero Guzman Bracho

Robert Maria del Carmen Dra.

Arizona Department of Health Services InDRE

[email protected].gov [email protected]

520-7703110 55-53-96-5013

A-5

Henao Herbold Hernandez Hernández Hernández Rivas Hernandez Rodriguez

Olga L. John Sara Lyssette Samuel Martín Lucia Jorge Sebastian

Dr. Dr.

Doctoral Epidemiologist Faculty Public Health Technician-EWIDS Ing. Sistemas Computacionales Químico Farmacobiologo Subdirectos de Calidad y Educacion en Salud y Coordinador de la Comison en Tamaulipas Medical Epidemiologist Public Health Director Coordinador de Relaciones Institucionales Serology Diagnostic Lab Director Epidemiologist, PhD, MPH Subdirectora de Vigilancia Epidemiológica, Chiapas México Médico

Ing. QFB Dr.

Centers for Disease Control & Prevention University of Texas-School of Public Health City of Laredo Health Department Dirección General de Epidemiología InDRE Comisión de Salud fronteriza en Tamaulipas

[email protected] [email protected] ORG [email protected] [email protected] [email protected] [email protected]; [email protected] rg

404-7042080 210-2194771 956-7632786 01-55-53-3717-89 52-55-53-9649-86 01152-834318-6300 ext.20622

Hicks Hill Holguin Bonilla

Lauri Michael Mario

Dr.

Dr.

Centers for Disease Control & Prevention El Paso Department of Public Health Comisión de Salud Fronteriza México-Estados Unidos Centers for Disease Control & Prevention EWIDS Secretaria de Salud

[email protected] [email protected] [email protected]

404-6392204 915-7715702 01-656-6390863 787-706 2472 619-6880111 961-6189250 ext 44066 656-6123162

Hunsperger Iniguez-Stevens Jarquin Estrada

Elizabeth Esmeralda Leticia

Dr. Dr. Dra.

[email protected] [email protected] [email protected]

Jimenez Fierro

Maria Guadalupe

Dra.

Médico Border Infectious Disease Surveillance

[email protected]

A-6

Juárez Islas

Victor

Biol.

Kamili Kriner Kubin

Saleem Paula Grace

Dr.

Responsable de Epidemiologia en el Laboratorio Estatal de Salud Publica del Edo. De Coahuila Team Leader Epidemiologist

Estado de Coahuila

[email protected]

Centers for Disease Control & Prevention Imperial County Public Health Texas Department of State Health Services

[email protected] [email protected] [email protected]

Dr.

La Prairie Lacy-Martinez Lakey Leiva Leon Varela

André Charles (Chaz) David Mauricio E. Jaime Dr.

Dr.

Laboratory Emergency Preparedness Branch Manager Health Emergency Liaison Officer Program Manager, EWIDS Commissioner Chief Director Genl de Coordinacion Sectorial Epidemiologist Epidemiologist I Jefe del Departamento de Virología Médico Coordinador Técnico del Proyecto BIDS

404-6394431 760-4824904 512-4587552

Public Health Agency of Canada Arizona Department of Health Services Texas Department of State Health Services California Office of Binational Border Health Secretaria Salud de Sonora

[email protected] [email protected] [email protected] [email protected] [email protected]

Lopez Lopez Lopez Martinez

Adriana Karla Irma Dr. QFP.

Centers for Disease Control and Prevention Imperial County Public Health Department InDRE Secretaria de Salud

[email protected] [email protected] [email protected]

202-2054755 520-6286536 512-4587675 916-3277774 01152-662217-4132 or 4136 or 4139 404-6398369 760-4824702 01-52-55-5341-14-32 899-9242037 55-53-37-1744

Lopez Rodriguez Luna Guzmán

Pablo Gilberto Norma Irene

Dr. Dra.

Secretaria de Salud de Tamaulipas Dirección General de Epidemiología

[email protected] [email protected]

A-7

Maroufi Martinez

Azi Kathie

Epidemiologist II Coordinator, Programs & Special Initiatives Program Consultant

Mase

Sundari R

Dr.

Matthews McAuliffe Medrano Mendez Millard

Clint Jay Belinda Ivonne Ann Dr Dr.

Public Health Advisor Regional Coordinator, Americas Epidemiologist EWIDS public health technician Associate Professor

County of San Diego Health & Human Services Agency Texas Department of State Health Services - Office of Border Health Centers for Disease Control and Prevention/Division of TB Elimination/Field Services and Evaluation Branch Centers for Disease Control & Prevention Centers for Disease Control & Prevention Hidalgo County Health & Human Services Texas Department of State Health Services - HSR 9/10 Texas A&M School of Rural Public Health - South Texas Center San Diego County/CDC San Diego Quarantine Station BIDS SST

[email protected] gov [email protected]

619-5156620 512-4587675 404-6395336

[email protected]

[email protected] [email protected] [email protected] [email protected] [email protected]

404-6397638 404 6397467 956-3182426 915-8347690 956-6686320 619-6925787 0155-53-4275-50 x 283 867-7121464 (NEXTEL 52*11*12097 ) 210-9492002 915-8347690

Montiel

Sonia

Morales Jimenez Morales Rueda

Ricardo Julio Cesar

TLC Dr.

BIDS Binational Laboratory Coordinator Laboratorista Clínico Epidemiologo Jurisdiccional

[email protected]

[email protected] [email protected] OM

Morrow

Gale

Deputy Regional Director EWIDS Epidemiologist

Murtaza-Rossini

Michelle

Health Service Region 8 Texas Department of State Health Services Texas Department of State Health Services

[email protected]

[email protected]

A-8

Navarrete Nguyen Nichols Nieto Palacios Zavala

Lorraine An Joanna J. Nancy Ethel Dra.

Binational Operations Coordinator CSTE Fellow MIH Health Tech Data Entry Directora de Vigilancia Epidemiológica de Enfermedades No Transmisibles y Vinculación de Proyectos Internacionales. Directora del Laboratorio Estatal de Salud Pública del Estado de Veracruz Quimico Farmaco Biologo BIDS Epidemiologist Public Health Advisor Senior Medical Officer Health Communications Specialist Program Specialist Médico - depto Epidemiologia

U.S.-México Border Health Commission Centers for Disease Control and Prevention Texas Department of State Health Services Hidalgo County Health & Human Services DGE, Secretaria de Salud, México

[email protected] [email protected] [email protected] [email protected] [email protected]

915-5321006 404-6397159 210-9492064 956-3182426 5255-53-3716-70

Parissi Crivelli

Aurora

M. en C.

Secretaria de Salud/Veracruz

[email protected]

52-229-9812859

Perez Puente Perez-Lockett Pezzi Philen Portillo

Carlos Gabriel Katharine Clelia Rossanne M. Julissa

QFB

Dr.

Secretaria de Salud de Tamaulipas New Mexico Department of Health Centers for Disease Control & Prevention, US- Mexico Unit Centers for Disease Control & Prevention Centers for Disease Control and Prevention Texas Department of State Health Services Secretaria de Salud

[email protected]; [email protected] [email protected] [email protected] [email protected] [email protected]

834-31-50301 575-5285103 619-6925667 404-6394350 404-6397762 915-8347687 868-8-22-5522

Puentes Ramirez Aguilera

Flor Sara Dra.

[email protected] [email protected]

A-9

Rangel Reed Regan Rey Reyes Santillan Reyna Robinson Rodriguez Trujillo Rodriguez-Lainz Romo Rosales Rubio

Gudelia Dan Joanna Araceli Lucrecia Margarita Dan Laura E. Alfredo

Dra.

Coordinadora Estatal de Baja California Systems Analyst MD, MPH, FAAP Career Epidemiology Field Officer Médico General. General Manager, U.S. Section Zoonosis Control Veterinarian Médico Epidemiologo Migrant Health Specialist Médico General U.S. Section Member- Arizona Public Health Preparedness Director Bi National Liaison Chief, Preparedness and Response Section -

Comisión de Salud Fronteriza México-Estados Unidos Centers for Disease Control & Prevention (IT Contractor) Centers for Disease Control & Prevention Centers for Disease Control & Prevention Instituto de Salud del Estado de Aguascalientes U.S.-México Border Health Commission Texas Department of State Health Services Region 11 Secretaria de Salud Tamaulipas

[email protected]; [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

01152-664634-6511 404-6394391 404-6394341 512-4587111 x3023 01-449-9-1079-21 y 22 915-5321006 956-4443222 01-834-3186300 ext 20523 619-6928406 664-1202883 520-6260720 956-3182426 956-3182426 510-6203036 -

Dr.

Dra.

Dr. Dr.

Alfonso Jaime Cecilia Evangelina

Dr. Dr. Dr.

Centers for Disease Control & Prevention Division of Global Migration & Quarantine SS U.S.-México Border Health Commission Hidalgo County Health & Human Service Hidalgo County Health & Human Services California Department of Public Health DGRI Secretaria de Salud

[email protected] [email protected] [email protected] [email protected]

Ruiz Ruiz

Diana Juan D. Dr.

[email protected] [email protected]

Ruiz

Osorio

Lic.

[email protected]

A-10

Sánchez Mendoza Sarkar Seca, Jr. Shapiro Silva Smith Smith Sotomayor

Miroslava Sahotra Calixto Craig Marisol Jennifer Brian R. Raul E

Dra. Dr.

Doctor en Ciencias Professor EWIDS Binational Planner Acting Director Office of the Americas EWIDS Border Epidemiologist Surveillance Officer Regional Medical Director Senior International Health Analyst CSTE Fellow Director, National Coordinating Center Médico Senior Advsor for Epidemiology Binational TB Project Manager EWIDS Laboratory Liaison

Laboratorio Estatal de Salud Pública de Hidalgo University of Texas at Austin Texas Department of State Health Services U.S. Department of Health & Human Services EWIDS California San Diego County Border Infectious Disease Program Texas Department of State Health Services U.S. Department of Health & Human Services, Assistant Secretary for Preparedness and Response Centers for Disease Control & Prevention, US-Mexico Unit Public Health Law Network, William Mitchell College of Law Secretaria de Salud de Chihuahua National Center for Infectious & Respiratory Diseases/Centers for Disease Control & Prevention Texas Department of State Health Services Texas Department of State Health Services S.S.CH. (BIDS)

[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

Dr. Dr.

01-771-71658-12 512-2323800 830-7584241 202-2601733 619-6088674 619-5424012 956-4215504 202-4015837 619-6928052 651-6957615 656-311-9107 404-6391329 956-4230130 512-4587111 ext. 3475 656-613-5248

Dr.

Sovero Stier Suarez Perez Swerdlow

Monica Dan Roberto Alejandro David Dr. Dr.

[email protected] [email protected] [email protected] [email protected]

Tafolla Telles Treviño

Cynthia F. Vanessa Silvia Estela QBP

[email protected] [email protected] [email protected]

Químico BIDS , Ciudad Juárez

A-11

Ulrich Uribe Esquivel

Teresa María Guadalupe Lissete Lic.

Epidemiologist Licenciada en Derecho Coordinadora de Apoyo a Laboratorios ante una Pandemia de Influenza EWIDS Senior Epidemiologist Secretario de Salud Asistente Tecnico de Proyectos de Vinculación Médico

Texas Department of State Health Services Secretaría de Salud

[email protected]

210-3554957 [email protected]; [email protected]; [email protected] [email protected] 55-344-72897

Valenzuela Fabris

QFB

InDRE: Instituto de Diagnóstico y Referencia Epidemiológicos

VazquezErlbeck Verduzco Rosan Villalón Chávez

Martha Raymundo S. Marco Antonio

Dr. Dr. Lic.

California Office of Binational Border Health/EWIDS Secretaria de Salud de Coahuila DGE

[email protected] [email protected] x ; [email protected] [email protected]

619-6880152 844-438-8330

Villarreal Herrera Waterman Wiseman Worley Wright

Ana María

Dra.

Servicios de Salud, Nuevo León

[email protected]; [email protected] [email protected] [email protected] [email protected] [email protected]

Stephen Rachel Nina Conschetta

Dr.

Senior Medical Epidemiologist Epidemiologist EWIDS Border Planner CDC/CSTE Epidemiology Fellow

Zhou Zorrilla Carcaño Zúñiga

Weigong Maria Teresa Maria Luisa

Dr. Dra. Dr.

Branch Chief IRMH Secretaria Ejecutiva, Seccion México Associate Professor

Centers for Disease Control and Prevention Texas Department of State Health Services Texas Department of State Health Services-HSR 11 Centers for Disease Control & Prevention El Paso Quarantine Station/ Texas Department of State Health Services Centers for Disease Control & Prevention Comisión de Salud Fronteriza Mx-EU University of California, San Diego

01-81-15-9406-23;81-307055 619-6925659 512-4587111 x2632 956-3188171 915-8345960 404-6394297 55-36110767 / 68 619-8891489

[email protected]; [email protected] [email protected] g.mx [email protected]

A-12

Appendix B: List of Organizations and Acronyms English acronym APHL ASPR BIDS BSL BTWG CDC CIOSC CNPHI CSTE DGMQ DOTS DSHS DST EPA Epi-X EWIDS English Association of Public Health Laboratories Assistant Secretary for Preparedness and Response Border Infectious Disease Surveillance Biosafety Level Binational Technical Working Group Centers for Disease Control and Prevention Canadian Integrated Outbreak Surveillance Centre Canadian Network for Public Health Intelligence Council of State and Territorial Epidemiologists Division of Global Migration and Quarantine Directly Observed Treatment (or Therapy), Short-course Texas Department of State Health Services Drug Susceptibility Testing Environmental Protection Agency Epidemic Information Exchange Early Warning Infectious Disease Surveillance Spanish Spanish acronym

Tratamiento Acortado Estrictamente Supervisado

TAES

Proyecto de fortalecimiento de la Alerta Temprana para la Vigilancia Epidemiológica de Enfermedades Infecciosas en la frontera México - Estados Unidos

FDA GFN H1N1

HHS HIV

Food and Drug Administration Global Foodborne Infections Network Influenza viruses are characterized by Hemagglutinin and Neuraminidase sub-types. H1N1 was the viral characterization for the 2009 pandemic strain. Department of Health and Human Services Human Immunodeficiency Virus

B-1

IATA IHR ILI IMD IPAPI KAP LRN MDR NALS NCIRD NHRC OGHA PAHO PHAC PHEIC PHIN SARI SPP

International Air Transport Association International Health Regulations Influenza-Like Illness Invasive Meningococcal Disease International Partnership on Avian and Pandemic Influenza Knowledge, Attitude and Practices Laboratory Response Network Multidrug-resistant North American Leaders Summit National Center for Immunization and Respiratory Diseases Naval Health Research Center Office of Global Health Affairs Pan American Health Organization Public Health Agency of Canada Public Health Emergency of International Concern Public Health Information Network Severe Acute Respiratory Infection

Reglamento Sanitario Internacional

RSI

Alianza Internacional contra la Influenza Aviar y Pandémica Conocimientos, Actitudes y Prácticas Red de Laboratorios de Respuesta Cumbre de Líderes de América del Norte

CAP RLR

CLAN

Organización Panamericana de la Salud

OPS

STD TB USMBHC WHO

Infecciones Respiratorias Agudas Severas Security and Prosperity Partnership Alianza para la Seguridad y of North America Prosperidad en América del Norte Sexually Transmitted Diseases Tuberculosis Tuberculosis United States - México Border La Comisión de Salud Fronteriza Health Commission México- Estados Unidos World Health Organization Organización Mundial de la Salud Acuerdo para el Fortalecimiento de las Acciones de Salud Pública en los Estados Centro Nacional de Programas Preventivos y Control de Enfermedades Federal Commission for the Comisión Federal para la Protection against Sanitary Risk Protección contra Riesgos Sanitarios Dirección General de Epidemiológia

IRAS ASPAN

TB CSFMEU OMS AFASPE

CENEPRECE

COFEPRIS

DGE

B-2

National Institute of Respiratory Diseases National Institute of Public Health

Instituto Nacional de Diagnóstico y Referencia Epidemiológicos Instituto Nacional de Enfermedades Respiratorias Instituto Nacional de Salud Publica Laboratorio Estatal de Salud Pública La Ley General de Salud Laboratorio Nacional de Salud Pública Programa Nacional para la Prevención y Control de la Tuberculosis Sistema Nacional de Vigilancia Epidemiologica Secretaría de Salud Sistema Único de Información para la Vigilancia Epidemiológica

InDRE INER INSP LESP LGS LNSP PNT

SINAVE SS SUIVE

B-3

Appendix C: Conference Agenda

AGENDA United States ­ Mexico Binational Infectious Disease Conference Hilton Palacio del Rio, 200 S. Alamo, San Antonio, TX 78205 28-30 June 2010 Objectives: Convene a forum of federal, state and local partners from the USA and Mexico to address the binational aspects of infectious disease surveillance and the impact of infectious diseases on health in both countries with a goal of clearly documenting common problems and seeking the best solutions to address those problems. Day 1 Monday, June 28 8:15 ­ 9:00 Registration Inauguration and Opening Remarks 9:00 ­ 9:30

Dr. David Lakey Commissioner, Texas Department of State Health Services Member, United States ­ Mexico Border Health Commission Dr. Raymundo S. Verduzco Rosán Secretary of Health, Coahuila Member, United States ­ Mexico Border Health Commission

Purpose and Objectives of Meeting 9:30 ­ 9:45

Dr. Ronald J. Dutton Director, Office of Border Health, Texas Department of State Health Services

Plenary ­ Federal perspectives on binational collaborations Federal overview of binational collaborations in public health - The Mexican perspective 9:45 ­ 10:15

Dr. Hugo López Gatell Ramírez and Dr. Celia Alpuche Aranda [NOTE: Dr. López Gatell did not attend, so Dr. Alpuche delivered the entire presentation.] Directors General of Epidemiological Surveillance and of the Diagnostic and Epidemiological Reference Institute (InDRE), Health Ministry of Mexico

10:15 ­ 10:30

Review of Binational Technical Infectious Disease Work Group meeting and federal overview of binational collaborations in public health - The U.S. perspective

Dr. David Swerdlow, National Center for Immunization and Respiratory Diseases (NCIRD), Office of Infectious Diseases (OID), Centers for Disease Control and Prevention (CDC)

10:30 ­ 10:45

Examples of binational collaborations in public health: tuberculosis and foodborne diseases

C-1

· ·

Review of the binational tuberculosis summit meeting Update on binational collaborations in foodborne disease

Dr. Sundari Mase, Program consultant, Division of Tuberculosis Elimination (DTBE), Field Services and Evaluations Branch, Centers for Disease Control and Prevention (CDC) Dr. Olga Henao, Epidemiologist, Foodborne Diseases Active Surveillance Network (FoodNet), Centers for Disease Control and Prevention (CDC)

Last-minute addition to the program: Hospital triage system for adult patients using an Influenza-Like Illness scoring system during the 2009 pandemic--Mexico Dr. Eduardo Azziz-Baumgartner, Centers for Disease Control and Prevention (CDC) The need to broaden the focus of binational surveillance 10:45 ­ 11:05

Dr. Rocío Sanchez Díaz [NOTE: Dr. Sanchez did not attend; this presentation was given by Dr. Celia Alpuche] Deputy Director of Special Surveillance Systems for Infectious Diseases, General Directorate of Epidemiology, Health Ministry of Mexico

11:05 ­ 11:25

BREAK Border Infectious Disease Surveillance (BIDS) program update

Dr. Steve Waterman Lead, US-Mexico Unit, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC)

11:25 ­ 11:45

Early Warning Infectious Disease Surveillance (EWIDS) Project Mexico and North American Leaders Summit (NALS) ­ Future perspectives from the Mexican view 11:45 ­ 12:05

Dr. Ethel Palacios Zavala Director of Epidemiological Surveillance of Non-transmissible Diseases and Coordination of International Projects, General Directorate of Epidemiology, Health Ministry of Mexico

NALS and EWIDS update from the Assistant Secretary for Preparedness and Response (ASPR), U.S. Department of Health and Human Services (HHS) 12:05 ­ 12:25

Raul Sotomayor Senior International Health Program Analyst, International Team, Assistant Secretary for Preparedness and Response (ASPR), Office of the Secretary, U.S. Department of Health and Human Services (HHS)

12:25 ­ 1:40

Lunch Plenary ­ Sharing of epidemiological information across borders: federal perspectives Importation- Exportation Issues

1:40 ­ 1:55

QFB Lucía Hernández Rivas, Director of Support Services, Diagnostic and Epidemiological Reference Institute (InDRE), Health Ministry of Mexico

1:55 ­ 2:10

New information production processes in Mexico and their implications for binational issues

Dr. Sonia Fernández Cantón, Director of Epidemiological Information, General Directorate of Epidemiology, Health Ministry of Mexico

C-2

Cross-border legal preparedness 2:10 ­ 2:25

Dan Stier, Director, National Public Health Law Network, Public Health Law Center, William Mitchell College of Law

2:25 ­ 2:40

Legal considerations for developing an implementation plan for the Guidelines for USMexico Coordination on Epidemiologic Events of Mutual Interest

Lic. Guadalupe Uribe Esquivel, Consulting Director, General Directorate of Judicial Matters, Health Ministry of Mexico

2:40 ­ 2:55

Status of draft Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest

Dr. Jay McAuliffe, Regional Coordinator for the Americas, Center for Global Health, CDC

Plenary ­ Sharing of epidemiological information across borders: International Health Regulations 2:55 ­ 3:10 Binational communication while complying with the mandates of the International Health Regulation (2005)

Dr. Luis Gerardo Castellanos, Pan American Health Organization/World Health Organization

ASPR and CDC collaborations on the International Health Regulations 3:10 ­ 3:25

Raul Sotomayor, Assistant Secretary for Preparedness and Response (ASPR), Office of the Secretary, U.S. Department of Health and Human Services and Dr. Steve Waterman, Centers for Disease Control and Prevention (CDC)

3:25 ­ 3:40

The importance of implementing International Health Regulations: activities at Ports of Entry

Lic. Marco Villalón Chávez, Project Coordinator Assistant, General Directorate of Epidemiology, Health Ministry of Mexico

3:40 ­ 3:55

BREAK Plenary ­ Sharing of epidemiological information across borders: state perspectives

3:55 ­ 4:10

Electronic system for cross border communication on public health concerns

Chaz Lacy-Martinez, EWIDS Program Manager, Arizona Department of Health Services

Exchange of epidemiological information in the border region 4:10 ­ 4:25

Dr. Martha Alicia Bueno Rosas, Head of Epidemiology Department, Chihuahua State Health Services

4:25 ­ 4:40 4:40 ­ 4:50

Binational case reporting in California and Baja California

Dr. Martha Vasquez Erlbeck, Border Epidemiologist, California Department of Public Health

BREAK Panel discussion on binational communication Moderators:

4:50 ­ 5:55

Dr. Jay McAuliffe, Regional Coordinator for the Americas, Center for Global Health, CDC Dr. Gudelia Rangel Gómez, State Coordinator for Baja California, United States ­ Mexico Border Health Commission, Mexico Section and Researcher, Colegio de la Frontera Norte

C-3

Panelists:

Dr. Celia Alpuche Aranda, Director General of the Diagnostic and Epidemiological Reference Institute (InDRE), Health Ministry of Mexico Dr. Ethel Palacios Zavala, Director of Epidemiological Surveillance of Non-transmissible Diseases and Coordination of International Projects, General Directorate of Epidemiology, Health Ministry of Mexico Dr. Steve Waterman, Lead, US-Mexico Unit, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC) André La Prairie, Public Health Agency of Canada Dr. José Luis Alomía Zegarra, State Epidemiologist in the Unit of Epidemiological Surveillance (UVE), Health Services of Sonora Robert Guerrero, Director, Office of Border Health, Arizona Department of Health Services Dr. Pablo Gilberto López Rodríguez, Epidemiologist, Health Jurisdiction No. IV, Reynosa Dr. Hector Gonzalez, Director, City of Laredo Health Department

5:55 ­ 6:00

Closing for Day 1 Poster session and social (cash bar) Posters displayed: Knowledge, attitudes, and practices among border crossers regarding consumption and health risks of unpasteurized Mexican-style cheese: January­April 2009 An Nguyen, DGMQ, CDC and CSTE; Daniel Fishbein, DGMQ, CDC; Miguel Ocana, DGMQ, CDC; Jane Keir, SRA International, Inc.; Noelle-Angelique Molinari, DGMQ, CDC; Steve Waterman, DGMQ, CDC Interim results: Antimicrobial resistance In Shigella isolates along the US - Mexico border Jennifer Smith, BIDS San Diego, Public Health Foundation Enterprises; Alba Phippard, BIDS Borderwide, Public Health Foundation Enterprises; Akiko Kimura, California Department of Public Health; Paula Kriner, Imperial County Public Health Department; Karla Lopez, Imperial County Public Health Department; Gerry Washabaugh, San Diego County Public Health Laboratory

6:00 ­ 7:15 Upper Rio Grande Foodborne Disease Surveillance Assessment (August-November 2009) Flor Puentes, Adriana Corona, Luis Escobedo; Texas Department of State Health Services, Region 9/10 Active surveillance of gastrointestinal and respiratory illness among inter-state bus travelers, El Paso TX: December 2007-July 2008 Flor Puentes, Adriana Corona, Luis Escobedo; Texas Department of State Health Services, Region 9/10 An evaluation of severe acute respiratory infection (SARI) surveillance--Imperial County, California, 2009-2010 Monica Sovero, Karla Lopez, Paula Kriner, Stephen Waterman. CDC-CSTE, Imperial County

C-4

Crisis and Emergency Risk Communication during H1N1 Response, El Paso Texas Carla Alvarado and Joanne Bates, El Paso City Health Department Baja California/California border outpatient provider ILI surveillance network Esmeralda Iniguez-Stevens, Verónica Bejarano, Leticia Wong, Martha Lorena Nava, Carlos Bazan, Joanna Frausto, Marisol Silva, Martha Vazquez-Erlbeck, Karen Ferran, Michael Welton, Aline Dang, Mauricio E. Leiva IHEAL: Incarcerated Health Education for Addictive Lifestyles Disease Prevention Team of Region 5, New Mexico Department of Health Update on rabies surveillance and planned joint activities for 2010/2011 Brett W. Petersen, Jesse D. Blanton, Andres Velasco-Villa, and Charles E. Rupprecht; Centers for Disease Control and Prevention Early Warning Infectious Disease Surveillance (EWIDS) program in Texas Health Services Region 8 accomplishments Calixto Seca and Teresa Ulrich, Texas Department of State Health Services, Region 8 Enhancing the Tamaulipas­south Texas epidemiological information exchange Herminia Alva, Texas Department of State Health Services, Region 11; Alfredo Rodríguez Trujillo, State Health Services of Tamaulipas, Mexico; Allison Banicki, Office of Border Health, Texas Department of State Health Services The CDC US-Mexico Unit United States ­ Mexico Unit, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention Day 2 Tuesday, June 29 7:30 ­8:00 8:00 ­ 9:00 Registration Lightning talks (up to 5 minutes each) Rocky Mountain spotted fever in the South West

Dr. Joanna Regan, Medical Officer, Rickettsial Zoonoses Branch, CDC

Tick surveillance in Imperial County, CA, in response to the Rocky Mountain spotted fever outbreak in Mexicali, Baja California

Paula Kriner, Epidemiologist, Imperial County Public Health Department

PulseNet and its influence on foodborne disease outbreak investigations in Texas

Dr. Aaron Benfield, Molecular Biology Group Manager, Texas Department of State Health Services

Meningococcal disease in Tijuana/San Diego

C-5

Dr. Enrique Chacon-Cruz, Chief of Infectious Diseases, Department of Pediatrics, General Hospital of Tijuana, University of Xochicalco

Results and lessons learned from the first year of severe acute respiratory infection (SARI) surveillance at hospitals in Imperial County

Dr. Karla Lopez, Imperial County Public Health Department

NOTE: The following presentation was not given, due to the early departure of the Tamaulipas delegation following the assassination of Dr. Torre Cantú. Successful strategies of the prevention and control of pandemic influenza A (H1N1)

Dr. Alfredo Rodríguez Trujillo, Head of Epidemiology Department, State Health Services of Tamaulipas, Mexico

Laboratory response to the influenza A(H1N1) pandemic

Dr. Liz Delamater, Manager, Microbiological Sciences Division, Texas Department of State Health Services

Port of entry influenza Knowledge, Attitudes and Practice (KAP)

Conschetta Wright, CSTE fellow, El Paso Quarantine Station

Plenary ­ Laboratory testing and application of laboratory results to epidemiological analysis Diagnostic laboratory capabilities in binational collaborations: InDRE's new BSL3 Laboratory and the LRN

M. en C. Rita Flores León, Coordinator of International Projects, General Directorate of Epidemiology and InDRE, Health Ministry of Mexico

9:00 ­ 9:15

9:15 ­ 9:30

USA-Canada laboratory cooperation and possibilities for joint laboratory initiatives with Mexico

Dr. Eric Blank, Association of Public Health Laboratories

9:30 ­ 9:45 9:45 ­ 10:00

Updating influenza diagnostic capacity in InDRE

M. en C. Irma López Martínez, Head of Virology, InDRE, Health Ministry of Mexico

New capacities at the Public Health State Laboratory - future regional perspective

M. en C. Román Escobar López, Deputy Director of the state public health laboratory, Sonora

Diagnostic capacity of the Coahuila state laboratory 10:00 ­ 10:15 10:15 ­ 10:30

Biologist Victor Juárez Islas, Coordinator of Epidemiology in the State Public Health Laboratory, State Health Services of Coahuila, Mexico

BREAK Plenary ­ Infectious disease detection and surveillance Update on dengue surveillance and diagnostics

10:30 ­ 10:45

Dr. Elizabeth Hunsperger, Section Chief, Serology Diagnostics and Viral Pathogenesis Research Laboratory, Dengue Branch, Centers for Disease Control and Prevention

Legionnella in Cozumel - A binational experience 10:45 ­ 11:00

Dr. Rocío Sánchez Díaz, Deputy Director of Special Surveillance Systems for Infectious Diseases, DGE, Health Ministry of Mexico [NOTE: Dr. Sánchez did not attend; this presentation was given

C-6

by M. en C. Rita Flores León.]

11:00 ­ 11:15 11:15 ­ 11:30 11:30 ­ 11:45 11:45 ­ 1:00

Lessons learned from the Border Influenza Surveillance Network

Katharine Perez-Lockett, New Mexico Department of Health

Pandemic influenza A (H1N1) detection in southern California, March-April 2009

Paula Kriner, Imperial County Health Department

Surveillance for pandemic influenza A (H1N1) in Texas

Rita Espinoza, Texas Department of State Health Services

Lunch Plenary ­ Outbreak response Binational collaboration during the influenza A (H1N1) pandemic

1:00 ­ 1:15

M. en C. Pilar Bernal Pérez, Federal Influenza Surveillance Coordinator, DGE, Health Ministry of Mexico

1:15 ­ 1:30

Pandemic influenza A (H1N1) investigations in Texas in 2009

Dr. Sandra Guerra, Texas Dept of State Health Services, Region 8

Rotavirus in Chiapas: Exploring binational collaborations on the other Border 1:30 ­ 1:45

Dr. Leticia Jarquín Estrada, Deputy Director of Epidemiological Surveillance, Chiapas State Health Department, Chiapas, Mexico

1:45 ­ 2:00

Multijurisdictional issues in the investigation of foodborne outbreaks in Texas

Dr. Linda Gaul, Texas Department of State Health Services

2:00 ­ 2:15

NOTE: The following presentation was not given, due to the early departure of the Tamaulipas delegation following the assassination of Dr. Torre Cantú. Successful strategies of the prevention and control of dengue

Dr. Alfredo Rodríguez Trujillo, Head of Epidemiology Department, State Health Services of Tamaulipas, Mexico

Explanation of process for breakout groups 2:15 ­ 2:30 2:30 ­ 2:45

Dr. Allison Abell Banicki, Office of Border Health Epidemiologist, Texas Department of State Health Services

BREAK Breakout groups to identify current collaborations and problems · TB, HIV, STD, hepatitis · Food security and public health (including foodborne and diarrheal diseases) · Preparedness for and response to acute respiratory diseases including pandemic influenza · Emerging infectious threats (including vector-borne diseases) BREAK Breakout groups to propose potential solutions and further opportunities for collaboration

2:45 ­ 4:15

4:15 ­ 4:30 4:30 ­ 5:30

C-7

· · · · Day 3

TB, HIV, STD, hepatitis Food security and public health (including foodborne and diarrheal diseases) Preparedness for and response to acute respiratory diseases including pandemic influenza Emerging infectious threats (including vector-borne diseases)

Wednesday, June 30 8:00 ­ 8:30 Lightning talks (up to 5 minutes each) Changing epidemiology of hepatitis A in Texas

Rachel Wiseman, Texas Department of State Health Services

Salmonellosis outbreak in CA associated with travel to Baja California, Mexico or shopping at a Mexican grocery chain

Azi Maroufi, Epidemiologist, County of San Diego Health and Human Services Agency

Chagas Disease in the United States

Dr. Paul Cantey, Medical Epidemiologist, CDC

Outbreak investigations for measles

Chaz Lacy-Martinez, EWIDS Program Manager, Arizona Department of Health Services

8:30 ­ 9:30

Reports from breakout groups Discussion of results from breakout groups Moderators:

Dr. Steve Waterman, Centros para el Control y Prevención de Enfermedades de Estados Unidos QFB Lucía Hernández Rivas, Directora de Servicios y Apoyo Técnico, InDRE, México

9:30 ­ 10:00

10:00-10:15

BREAK Action items for follow-up Moderators:

Dr. Steve Waterman, Centers for Disease Control and Prevention QFB Lucía Hernández Rivas, Director of Services and Technical Support, InDRE, Mexico

10:15 ­ 11:15

Summary of meeting and next steps 11:15 ­ 11:45 11:45 ­ 12:00

Dr. Ethel Palacios, General Directorate of Epidemiology, Health Ministry of Mexico Dr. Allison Abell Banicki, Texas Department of State Health Services

Closing

C-8

Appendix D: Individual Presentation Summaries Given the number of speakers and amount of information emerging from this conference, it is not possible to provide complete details on all presentations within the confines of these proceedings. Whereas some talks and plenary sessions are summarized briefly, the content of other presentations is provided in more detail as representative of the interests and objectives of the conference. A. Plenary ­ Federal Perspectives on Binational Collaborations Federal overview of binational collaborations in public health ­ The Mexican perspective, Dr. Hugo López Gatell Ramírez and Dr. Celia Alpuche Aranda, Directors General of Epidemiological Surveillance and of the Diagnostic and Epidemiological Reference Institute (InDRE), Health Ministry of Mexico [Presented by Dr. Alpuche Aranda] Dr. Alpuche Aranda discussed the collaborative work between México and the U.S. in response to surveillance and several infectious disease outbreaks. In the context of globalization, any type of event can pass from one side to the other side of the border in fewer than twenty-four hours. We have many ports of entry and many international flights. Not only do we need to track diseases, but we also need to analyze information and provide information to the public dynamically. In addition to epidemiological surveillance, we need epidemiological intelligence to have better impact with health programs. Prevention of infectious disease also depends on early warning. Infectious diseases can have great economic impact, social impact, and impact in many other instances. Health programs are essential for national security and stability. Dr. Alpuche reviewed the institutional structure within which epidemiological surveillance activities take place in Mexico. Examples of collaboration between México and the U.S. include programs such as Border Infectious Disease Surveillance (BIDS), Early Warning Infectious Disease Surveillance (EWIDS), North American Leaders Summit (NALS), and influenza and tuberculosis (TB) surveillance. The binational exchange of information to guide and to evaluate illness prevention and control programs requires a commitment to quality information, timely communication, transparent information, shared responsibility, and an understanding that "binational" concerns go beyond the border region. The challenges to public health are to maintain and improve existing information, to perform surveillance of diseases that do not exist (because they have been controlled but could re-emerge), and to build appropriate knowledge or "epidemiological intelligence." Review of Binational Technical Infectious Disease Work Group meeting and federal overview of binational collaborations in public health ­ The U.S. perspective, Dr. David Swerdlow of the National Center for Immunization and Respiratory Diseases (NCIRD), Office of Infectious Diseases (OID), Centers for Disease Control and Prevention (CDC) The purpose of the Binational Technical Work Group (BTWG) is to improve health in the U.S. and México in areas that are the most interrelated. It is a forum to facilitate discussions on technical matters in public health and to promote binational collaborations. There are two technical sections: one on Infectious Diseases and the other on Non-communicable Diseases. The technical sections will have a country coordinator from each partner, including non-federal partners. The Coordinating Committee will have annual meetings to review issues of binational interest, propose new areas of collaboration, review ongoing technical collaboration, facilitate binational public health actions, and respond to other public health needs of binational interest. The objective of the initial meeting of the BTWG, held on June 21, 2010, was to discuss the implementation of the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest in areas including binational case reporting, communication protocols, and outbreak investigations.

D-1

In terms of binational communication protocols, the purpose is to implement pathways, with U.S.-México guidelines for communication from federal to federal, state to state, and local to local entities. The work group identified the need to have clear protocols for communication in cases of a Public Health Emergency of International Concern (PHEIC), including details such as points of contact, phone numbers, e-mails, mechanisms for secure communication, and flow charts. The BTWG acknowledged that these protocols will differ depending on the situation and that state and local partners are critical to the implementation of binational guidelines. Examples of binational collaborations in public health: tuberculosis and foodborne diseases Dr. Sundari Mase, Program Consultant, Division of Tuberculosis Elimination (DTBE), Field Services and Evaluations Branch, CDC, presented a review of the Binational Tuberculosis Summit, followed by Dr. Olga Henao, Epidemiologist, Foodborne Diseases Active Surveillance Network (FoodNet), CDC, who provided an update on binational collaborations in foodborne disease. Dr. Sundari Mase reported on the Binational Tuberculosis Summit Meeting in Atlanta, Georgia on June 24, 2010. She also reviewed the epidemiology of TB along the U.S.-México border. Dr. Mase pointed out the TB rates in border states exceed the national average in both countries. She noted the differences between the TB cases in Mexican-born versus U.S.-born cases. For case management and therapy completion, binational referrals are a priority. Case follow-up, documentation and communication need to improve. A Division of Tuberculosis Elimination (DTBE) flagship project is to implement rapid, pointof-care molecular testing for drug-resistant TB upon diagnosis in two Mexican border cities. The longterm goals of the project are to build capacity for rapid testing for drug resistance, improve patient outcomes by early diagnosis and treatment, better understand the epidemiology of drug resistance in México, and enhance collaboration between the U.S. and México National TB programs. Dr. Olga Henao provided an update on binational collaborations in foodborne disease. Current binational activities include the exchange of reports and announcements of outbreaks. In addition, the U.S. and México have undertaken enhanced surveillance of Salmonella. This program received US$50,000 in funding, and its objectives addressed improving serotyping, laboratory capacity, communication, and dissemination of reports based on surveillance and investigations of outbreaks. To date, the project protocol has been developed and reviewed by a workgroup. The current focus is to develop a description of the most common salmonella serotypes and their probable involvement in foodborne illness outbreaks. PulseNet International and the Global Foodborne Infections Network (GFN) are international networks for the exchange of information on enteric diseases. México and the U.S. have been very active in PulseNet. Lessons Learned from the implementation of an Influenza Scoring System during the 2009 H1N1 Pandemic, Dr. Eduardo Azziz-Baumgartner, CDC Influenza Division Dr. Baumgartner explained a scoring system developed to determine whether patients required further testing and treatment for H1N1 during pandemic. This program was implemented at a public hospital in Guadalajara. The public's response to the pandemic was a surge in patients going to doctors and hospitals for treatment, but there were limited resources. To determine who would receive treatment for acute respiratory infections, the hospital staff took the patient's medical history and diagnostics, and determined a score on this basis. Dr. Baumgartner concluded that the scoring system was effective to identify those requiring treatment for acute respiratory infections during the H1N1 pandemic. The need to broaden the focus of binational surveillance, Dr. Celia Alpuche Aranda (presented in lieu of Dr. Rocío Sanchez Diaz)

D-2

Dr. Alpuche mentioned several instances in which there has been extensive binational collaboration. These include Salmonella surveillance, a ricketsiosis outbreak, and TB programs. México received great support during the H1N1 outbreak. Personnel from the CDC came to México in the early stages of the event to provide training and support in epidemiology and laboratories. The experience during the outbreak brought new perspectives, a new platform, and new diagnostic capacity throughout México. Other cases of outbreak in tourism situations, such as an outbreak of legionella in Cancun, require binational collaboration. New areas for collaboration include bioterrorism and emerging diseases, where México has participated in training programs offered by the CDC. The binational commitment to information exchange to prevent and control diseases should focus on quality of information, timely communication, transparency of information, shared responsibility, and an understanding that "binational" health concerns extend beyond the border region. Border Infectious Disease Surveillance (BIDS) program update, Dr. Steve Waterman, Lead, USMexico Unit, Division of Global Migration and Quarantine, CDC Border Infectious Disease Surveillance (BIDS) began in 1999 with the goal of establishing a binational surveillance system and network for infectious diseases. The accomplishments of BIDS include enhanced surveillance, improved lab and epidemiology infrastructure in the border region, improved cross-border communication, the first and ongoing border/binational infectious disease meetings, early detection of outbreak, and the development of the first binational web-based surveillance system. However, BIDS faces many challenges, including limited funding. The BIDS system, the EWIDS program, and other collaborators played a role in the identification of the first pandemic influenza H1N1 isolates. Current BIDS surveillance covers Hepatitis A through E, febrile exanthems, and febrile neurologic illnesses (such as West Nile Virus). Surveillance is also in place for ILI/SARI (influenza-like illnesses) and for enteric diseases. Dr. Waterman summarized recent BIDS surveillance data. The data show an increase in hepatitis in México and a decrease in the U.S. due to a vaccination campaign. Dr. Waterman noted interesting differences when comparing the epidemiology of hepatitis A infection in México compared to the U.S., particularly in terms of the incidence of pediatric hepatitis. New collaborative activities between México and the U.S. include programs for enhanced surveillance of salmonella, enteric disease surveillance, expanded SARI surveillance, molecular hepatitis surveillance, and a new virus discovery project. México's InDRE and the U.S. CDC are collaborators in these last two programs listed. Several BIDS reports and publications are planned on topics, such as surveillance of viral hepatitis, clinical epidemiology of dengue hemorrhagic fever, and influenza surveillance on the U.S.México border. A binational data system is planned to include web-based system modules on influenza and foodborne diseases. The vision is to link the U.S. Public Health Information Network (PHIN) with México's Single Platform (Plataforma Única). This data system also will include fields to identify binational cases and additional fields for data relevant to binational cases, such as travel. It will have messaging capability between national and state data systems, as well as mechanisms for using existing data systems to populate the binational system and generate reports. Significant challenges remain to achieve the optimal management of binational infectious diseases. In addition to the need for timely information sharing, we need to resolve the difficulties in moving reagents and specimens across the border. Existing binational efforts require integration, by systematizing notification and outbreak investigations and by integrating overlapping U.S-sponsored projects. Lastly,

D-3

some dedicated resources are necessary for communication, labor, and logistics to make binational management of infectious disease a success. The Binational Technical Work Group (BTWG) was formed to work on the Guidelines based on protocols for binational communication, reporting, and investigations. There are a variety of CDC collaborations with the Health Ministry of México on infectious diseases (TB, foodborne diseases, influenza/respiratory diseases, HIV), on laboratory capacity, enhanced surveillance platforms, epidemiologic training, migrant health and information systems for early warning. BIDS actually cross-cuts a lot of these same areas. BIDS is moving toward systems of collaboration instead of ad hoc actions such as increased integration of border surveillance initiatives. And the BIDS program wants to use this information to develop interventions and have more impact in the context of North America. Early Warning Infectious Disease Surveillance (EWIDS) Project Mexico and North American Leaders Summit (NALS) ­ Future Perspectives from the Mexican View, Dr. Ethel Palacios Zavala, Director of Epidemiological Surveillance of Non-transmissible Diseases and Coordination of International Projects, General Directorate of Epidemiology, Health Ministry of Mexico Dr. Palacios Zavala's presentation emphasized advances in international collaborations and their binational relevance, specifically in the case of EWIDS-Mexico as well as the NALS summit. Dr. Palacios said it is very important to recognize that programs operate on distinct levels of collaboration: binational programs, such as EWIDS; multinational, such as NALS; and global, such as the World Health Organization (WHO). EWIDS-Mexico is a funding mechanism to implement the strategies for Early Warning in the epidemiological Surveillance of Transmissible Diseases of the National System of Epidemiological Surveillance (SINAVE). The total funding was $5 million dollars. DGE ­InDRE (General Directorate of Epidemiology-Institute of Diagnostic and Epidemiological Reference) received US$1.2 million) and the state and local (jurisdictional) laboratories and epidemiology in six northern border states of México received US$2.6 million. The remaining funds of US$1.2 million were reserved to be used after completion of the first phase of the project for purposes agreed upon by the authorities of both countries. The duration of the project is from 2003 to 2011. The first phase was completed in February 2007 and the second phase will be complete in February 2011. The four focus areas of EWIDS are: (1) epidemiological surveillance, (2) building diagnostic capacity in the laboratories, (3) information technologies (IT), and (4) education and training. Milestones were reached at the local, state, and federal levels with the modernization of IT systems and laboratory equipment as well as added capabilities in laboratories and personnel. Phase II emphasized the development and launch of the Early Warning System for SINAVE, to be implemented at the federal level and in Mexico's six northern border states. Training has continued in surveillance and early warning and they plan to complete the required operational training for InDRE to be included in the Reference Laboratory Network (LRN). Dr. Palacios also spoke on the North American Leaders Summit (NALS). NALS, formed in 2009, was preceded by the North American Security and Prosperity Partnership (SPP) of 2005. The objectives of the SPP were to increase prosperity by promoting North American competitiveness and improving the quality of life of their citizens. Among the programs to be implemented were efforts to facilitate border crossing as well as to support and coordinate on public health.

D-4

Also relevant to U.S.-México binational collaboration was the development of two additional mandates: protocols (MOU) for support and mutual assistance during cross-border emergencies and the North American Plan for Avian and Pandemic Influenza (NAPAPI). Both of these mandates were followed and substantiated during the H1N1 influenza pandemic. Following the first NALS summit in 2009, the Technical Workgroup on Health began to review and update their work plan. The next steps of NALS include a review of the North American Plan for Avian and Pandemic Influenza, a reorientation of focus on multiple health threats, and to expand collaboration on preparedness and response to chemical, biological, and radio-nuclear threats. Topics to be addressed regarding the border should include identifying new opportunities for cross-border collaboration, finding solutions to the problem of moving biological materials across borders, and collaborating on the implementation of International Health Regulations at border crossings. NALS (North America Leaders Summit) and EWIDS update from the Assistant Secretary for Preparedness and Response (ASPR), U.S. Department of Health and Human Services, Raul Sotomayor, Senior International Health Program Analyst, International Team, ASPR, Office of the Secretary, U.S. Dept. of Health and Human Services Mr. Sotomayor provided a detailed organizational chart of the U.S. Health and Human Services. The Assistant Secretary for Preparedness and Response (ASPR) is the lead agency for emergency support in case of disaster. ASPR's main partners are the CDC and Office of Global Health Affairs (OGHA). This office has leadership in international health policy. H1N1 served as a catalyzing event that brought together the three North American countries on a health sector agenda. HHS proposed to add health security under the North America Leaders Summit. Mexico's SS, Canada's PHAC, and the U.S. HHS have agreed to prioritize and update the North American Plan for Avian and Pandemic Influenza. The Guidelines are a bilateral document, but it has the potential to serve as a blueprint for a trilateral document. Mr. Sotomayor provided an overview of the Early Warning Infectious Disease Surveillance (EWIDS) program. U.S. funding was US$ 38.6 million in the last seven years, with over US$29 million invested in the four border states. EWIDS-Mexico funding will surpass US$5 million from 2006 to 2011. The goals are to develop an early warning system, develop laboratory capacity, and train personnel in early warning and biosecurity. The EWIDS model has been used in Africa and Latin American countries. The National Health Security Strategy (NHSS) was published in December 2009 and ASPR is working on an implementation plan. Three of ten specific objectives of the NHSS are related to ASPR's work with EWIDS. The common area among NALS, EWIDS, the Global Health Security Initiative, and the International Health Regulations is health security through infectious disease preparedness and response readiness. B. Plenary ­ Sharing of Epidemiological Information across Borders: Federal Perspectives Importation-Exportation Issues, QFB Lucía Hernández Rivas, Director of Support Services, Diagnostic and Epidemiological Reference Institute (InDRE), Health Ministry of Mexico Import and export regulations can be highly complex, especially when infectious substances or other potentially dangerous items are involved. QFB Hernandez presented a table identifying the problems associated with import/export, what has been done about them, and what remains to be done to resolve the issues. Efforts are being made to simplify processes and to train personnel. Another proposal is to

D-5

develop a procedures manual for the import/export of reagents and biological samples between the U.S. and México. Organization of the Information System in Mexico and its Potential to Support Binational Projects, Dr. Sonia Fernández Cantón, Director of Epidemiological Information, General directorate of Epidemiology, Health Ministry of Mexico The purpose of Dr. Fernandez's presentation on the Health Information System was to show the contents of the Mexican National Health Information System, in order to assist in its utilization and analysis in terms of its potential for the support of binational projects. Dr. Fernandez displayed a chart showing the organization of SUIVE, the Epidemiological Information System. This was followed by an organizational chart of the National Health Information System. Her conclusions were that México has large amounts of health information that could ensure the implementation of important projects of binational interest. México should use and analyze the institutional information that already exists and resist creating parallel systems. The challenge is for México to get the system to describe health as a whole, giving the complete context to health phenomena. Cross-border Legal Preparedness, Dan Stier, Director, National Coordinating Center, Public Health Law Network, William Mitchell College of Law Mr. Stier previously worked with the public health law program at the CDC. When he first started, he discovered that some laws were an obstacle to being able to work across the border. Sometime later, he began working with U.S. states and again heard that legal issues were an obstacle to working across borders. Other obstacles include different languages, culture, and legal systems. The U.S. and México do share legal principles and can educate each other to overcome problems. He observed that to protect against infectious disease, public health needs legal authority for certain activities, such as epidemiologic tracking and isolation and quarantine. Public health also needs legal authority for intergovernmental cooperation including cooperation across borders. Mexico's constitution refers to health investigations. The Ministry of Health is responsible for national surveillance systems and disease notification. Mr. Stier cited several Mexican laws that he finds very similar to those in the U.S. He concluded that mutual understanding of a common legal foundation can assist in strengthening and expanding the relationship between public health officials and attorneys in the three North American countries. Legal considerations for developing an implementation plan for the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest, Lic. Guadalupe Uribe Esquivel, Consulting Director, General Directorate of Judicial Matters, Health Ministry of Mexico México's judicial system is based on the supremacy of the constitution. The constitution guarantees the right to the protection of health. It establishes that Federal Legislative Power is the only body that can legislate material affecting general health. The Ministry of Health is obligated to dictate preventative measures in case of epidemics or danger of an invasion of illnesses. There should be coordination between the federal entity (state) and the Ministry of Health. Lic. Uribe reviewed specific articles that dictate the jurisdiction on the federal, state, and local levels and laws in matters of general (public) health, access, surveillance, and related topics. International health is governed by the General Law of Health (LGS), Mexico's Official Regulations (normas), treaties, and international conventions.

D-6

The Council on General Health is tied directly to the executive branch of government. It is charged with adding to the list of priority infectious and non-infectious diseases. The National Committee for Health Security deals with prevention and response to epidemiologic emergencies. The Health Ministry acts in epidemiologic surveillance. Among its six divisions is the General Directorate of Epidemiology (DGE). The Ministry coordinates the National Health System, which in turn oversees the National Council on Health. The legal framework for importing reagents, medicines, and equipment is subject to the laws for customs as well as to the laws regarding health. It is also subject to the regulations of COFEPRIS. The regulations on epidemiologic surveillance are presently being reviewed and updated with respect to infectious diseases. Presidential decrees were declared at the time of the H1N1 pandemic ordering various actions to prevent, control, and combat transmission of the influenza virus. The current project is to implement the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest and to make the criteria uniform for sharing information with the U.S. Status of draft Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest, Dr. Jay McAuliffe, Regional Coordinator for the Americas, Center for Global Health, CDC In 2001, México proposed a new work group for epidemiologic surveillance. The work group first met in 2002, and decided the objective was to proceed with a set of protocols for how the CDC/HHS and SS should collaborate on epidemiologic events of joint interest. This work group held annual meetings and periodic work encounters involving the CDC, Food and Drug Administration (FDA), border states, and CSTE on the U.S. side. Participating on the México side were the DGE, COFEPRIS, and border states. The Guidelines for U.S. Mexico Coordination on Epidemiologic Events of Mutual Interest were completed in late 2006. Its general principles are-- · · · · · · Need to share information Timely sharing and quality of information Communication pathways Joint action to respond Difference between health systems Respect for sovereignty and national laws

The Guidelines are not legally binding. They do offer a framework and scope for collaboration on epidemiologic events, specifically in terms of binational cases, binational outbreaks, potential bioterrorist events, laboratory-related issues and public health communications. The CDC also gave the internal clearance to the Guidelines and submitted them to the U.S. Department of Health and Human Services (HHS) for clearance, but nothing more happened at that time. It is now the understanding that HHS has given clearance and preliminary notice of signing at the upcoming U.S.-México Border Health Commission meeting in July 2010. A Binational Technical Work Group has been formed to implement the Guidelines and develop binational protocols. These protocols will facilitate inter-agency information sharing, identification of binational cases, binational investigations, emergency communications, laboratory collaborations and the coordination of information release to the public. [Postscript: Signing did not occur as anticipated during the July 2010 USMBHC meeting.]

D-7

C. Plenary ­ Sharing of Epidemiological Information across Borders ­ International Health Regulations Binational communication while complying with the mandates of the International Health Regulation (2005), Dr. Luis Gerardo Castellanos, Pan American Health Organization (PAHO)/World Health Organization (WHO) ASPR and CDC collaborations on the International Health Regulation (2005), Raul Sotomayor, Senior International Health Program Analyst, International Team, ASPR, Office of the Secretary, U.S. Dept. of Health and Human Services and Dr. Steve Waterman, Lead, US-Mexico Unit, Division of Global Migration and Quarantine, CDC The importance of implementing International Health Regulations: activities at Ports of Entry, Lic. Marco Villalón Chávez, Project Coordinator Assistant, General Directorate of Epidemiology, Health Ministry of Mexico Summary: This plenary session provided details on specific legal constraints and oversight affecting the sharing of epidemiological information across borders. Dr. Castellanos explained that the International Health Regulations (IHR) are binding to all 194 member countries in the World Health Organization (WHO), whose aim is to help the international community prevent and respond to acute public health risks across borders. He concluded that the international exchange of information is essential to public health and will save time, money, and lives. Dr. Castellanos cited the Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest as a good example of comprehensive and collaborative efforts of two neighboring countries willing to share and indicated that WHO is eager to use this example as a viable good practice in international public health. Raul Sotomayor described the role of ASPR with respect to international health regulations. It is the office within HHS that is in charge of emergency response. ASPR monitors and receives information from various partners and reports responses to the WHO. He also explained the divisions within HHS and their respective responsibilities, including the CDC as the technical public health agency assessing public health emergencies of international concern (PHEIC). Dr. Waterman outlined the procedures used by the U.S. government to detect, assess, and report a PHEIC. He commented on the need for local, state, and federal public health authorities to collaborate to improve the ability of surveillance systems to report possible PHEICs under the IHR. Lic. Villalón stated that the international health regulations went into effect in 2007. Land bridges and border regions are considered "hot zones" for disease transmission, and there are 26 border crossings along the México-U.S. border. It is important to establish formal agreement between the two sides of the border to implement the basic capacity as dictated by the IHR. One complication to doing so at land border crossings is the lack of resources. D. Plenary ­ Sharing of Epidemiological Information across Borders: State Perspectives The binational electronic disease reporting system: Arizona & Sonora, Chaz Lacy-Martinez, EWIDS Program Manager, Arizona Department of Health Services Exchange of epidemiological information in the border region, Dr. Martha Alicia Bueno Rosas, Head of Epidemiology Department, Chihuahua State Health Services

D-8

Binational case reporting in California and Baja California, Dr. Martha Vasquez-Erlbeck, Border Epidemiologist, California Department of Public Health Summary: The plenary session on sharing epidemiological information across borders from the states' perspective provided specific examples of how U.S. and Mexican states collaborate and communicate with each other. Chaz Lacy-Martinez explained how the information system, or "Health Services Gateway" (formerly known as SIREN), shared by Arizona and Sonora allows them to share information on binational cases and has enhanced collaboration. He noted some issues with language and made observations about the database fields in identifying binational cases of interest. Chihuahua, according to Dr. Bueno Rosas, has worked closely with Las Cruces, New Mexico and uses the BIDS database to communicate with the CDC. Dr. Vazquez-Erlbeck reported that California and Baja California seek strategies to address shared public health issues in the region. They note that information sharing is critical and want to increase binational case reporting. She described current systems used by San Diego and Imperial counties to report binational cases and explained how a new electronic system will improve the identification and reporting of binational cases diagnosed outside of the border counties. E. Lightning Talks (Day 2) Day 2 opened with seven five-minute presentations, or "lightning talks," including the following: · · Rocky Mountain spotted fever in the Southwest, Dr. Joanna Regan, Medical Officer, Rickettsial Zoonoses Branch, CDC Tick surveillance in Imperial County, CA in response to the Rocky Mountain spotted fever outbreak in Mexicali, Baja California, Paula Kriner, Epidemiologist, Imperial County Public Health Department PulseNet and its influence on foodborne disease outbreak investigations in Texas, Dr. Aaron Benfield, Molecular Biology Group Manager, Texas DSHS Meningococcal disease in Tijuana/San Diego, Dr. Enrique Chacon-Cruz, Chief of Infectious Diseases, Department of Pediatrics, General Hospital of Tijuana, University of Xochicalco Results and lessons learned from the first year of severe acute respiratory infection (SARI) surveillance at hospitals in Imperial County, Dr. Karla Lopez, Imperial County Public Health Department Laboratory response to influenza A (H1N1) pandemic, Dr. Liz Delamater, Manager, Microbiological Sciences, Branch, Texas DSHS Port of entry influenza Knowledge, Attitudes and Practice (KAP), Conschetta Wright, CSTE fellow, El Paso Quarantine Station

· · ·

· ·

These lightning talks focused on outbreak investigations of vector borne, foodborne, and infectious diseases in border states and, in some cases, involving cross-border collaboration. Dr. Regan and Ms. Kriner each discussed the surveillance and investigation of the vector-borne Rocky Mountain spotted fever transmitted by ticks residing on untreated dogs in North Carolina and Imperial County, CA/Mexicali, BC respectively. Dr. Chacon-Cruz discussed the surge in cases of invasive meningococcal disease (IMD) in Tijuana, BC and the active search for IMD in Tijuana and San Diego leading to the launch of a national surveillance network. Dr. Benfield's presentation highlighted how the PulseNet online database, maintained by the CDC, allows investigators in Texas to upload typing and subtyping of bacteria as well as demographic information that assists them in identifying outbreaks. Dr. Karla Lopez detailed the lessons learned in Imperial County

D-9

where hospitals have been integrated into severe respiratory infection (SARI) surveillance. Dr. Liz Delamater spoke of the laboratory response of Texas DSHS to the surge in demand caused by the H1N1 pandemic. Ms. Conschetta Wright reported on the 2009-2010 survey of Knowledge, Attitudes and Practices surrounding H1N1 at border crossings in El Paso (TX) and San Ysidro (CA). F. Plenary ­ Laboratory Testing and Application of Laboratory Results to Epidemiological Analysis · Diagnostic laboratory capabilities in binational collaborations: InDRE's new BSL3 laboratory and the LRN, M. en C. Rita Flores León, Coordinator of International Projects, General Directorate of Epidemiology and InDRE, Health Ministry of Mexico USA-Canada laboratory cooperation and possibilities for joint laboratory initiatives with Mexico, Dr. Eric Blank, Association of Public Health Laboratories Updating influenza diagnostic capacity in InDRE, M. en C. Irma López Martínez, Head of Virology, InDRE, Health Ministry of Mexico New capacities at the Public Health state laboratory ­ future regional perspective, M. en C. Román Escobar López, Deputy Director of the state public health laboratory, Sonora Diagnostic capacity of the Coahuila state laboratory, Biologist Victor Juárez Islas, Coordinator of Epidemiology in the State Public Health Laboratory, State Health Services of Coahuila, Mexico

· · · ·

Summary: Presentations for the plenary on laboratory testing and application of results to epidemiological analyses focused on the advances made in collaborative initiatives and the increased capacity in laboratories achieved through acquisition of equipment, technology, and training. M. en C. Rita Flores Leon discussed the building and future plans of InDRE's new BSL3 (Biosecurity Level 3) laboratory. Dr. Eric Blank emphasized Canada's experience with public health networks and possibilities for APHL collaboration with Mexico. M. en C. Irma López Martínez spoke of advances in virological surveillance and diagnostic capacity at InDRE following the H1N1 pandemic. Similarly, state public health laboratory capacity has increased greatly in Sonora and Coahuila, as explained by M. en C. Román Escobar López and Biol. Victor Juarez. G. Plenary ­ Infectious Disease Detection and Surveillance · · Update on dengue surveillance and diagnostics, Dr. Elizabeth Hunsperger, Section Chief, Serology Diagnostics and Viral Pathogenesis Research Laboratory, Dengue Branch, CDC Legionella in Cozumel, a binational experience, M. en C. Rita Flores León, MS, INDRE, Health Ministry of Mexico-SSA, Mexico [M. en C. Flores spoke in lieu of Dr. Rocío Sánchez Díaz] Lessons learned from the Border Influenza Surveillance Network, Katharine Perez-Lockett, New Mexico Department of Health Pandemic influenza A (H1N1) detection in southern California, March-April 2009, Paula Kriner, Imperial County Health Department Surveillance for pandemic influenza A (H1N1) in Texas, Rita Espinoza, Texas DSHS

· · ·

Summary: The presentations in this session focused on specific examples of infectious disease detection and surveillance. Dr. Hunsperger presented on the epidemiology of dengue in Puerto Rico. M. en C.

D-10

Flores described the investigation and response to the outbreak of legionella contracted by U.S. tourists vacationing in Cozumel, México. Ms. Perez-Lockett shared the lessons learned in creating and maintaining the border influenza surveillance network in New Mexico. Ms. Kriner of California and Ms. Espinoza of Texas presented information on the detection and surveillance of H1N1 in their respective border states during the 2009 pandemic. H. Plenary ­ Outbreak Response Binational collaboration during the influenza A (H1N1) pandemic, M. en C. Pilar Bernal Pérez, Federal influenza Surveillance Coordinator, DGE, Health Ministry of Mexico The chronology of the H1N1 pandemic, as presented by M. en C. Bernal, began on March 14, 2009 with the first notification of outbreak in La Gloria, Veracruz. México notified the U.S. and Canada on April 12th, and a national alert in México was launched on April 17th. Authorization was granted to send samples to the CDC and Canada to analyze the unknown pathogen. Binational actions taken by the U.S. and México as a result of the pandemic included the periodic, systematic, and consistent exchange of information. Personnel from the CDC and the Global Outbreak Alert and Response team were sent to México to assist the General Directorate of Epidemiology (DGE), the Diagnostic and Epidemiological Reference Institute (InDRE), the National Institute of Public Health (INSP) and National Institute of Respiratory Diseases (INER). The information gaps and challenges include the need for systematic plans for the analysis of epidemiological information and for a methodology of outbreak investigation. M. en C. Bernal concluded that México and the U.S. should continue the actions set in motion by the outbreak and consolidate collaboration. Pandemic influenza A (H1N1) investigations in Texas in 2009, Dr. Sandra Guerra, Regional Director, Texas DSHS, Region 8 The initial influenza A (H1N1) case in Texas was discovered in Guadalupe County just outside of San Antonio, after the first case of H1N1 was reported in California. This was two days before they received information coming from México. There were shortages in the H1N1 response in nurses and in epidemiologists as well as public health professionals to investigate cases. They had limited laboratory ability to confirm cases, and there was initially a delay in getting things confirmed by the CDC. The Texas lab was a surveillance lab and had to switch to become a diagnostic lab. The procedures to impose isolation measures were challenging. With public school closures there was a domino effect, because children were then grouped together in childcare groups while parents worked. Younger children still went to daycare and teenagers out of school hung out in groups in malls and other sites. They also found a negative impact on those children that depended on the school lunch system. Limited information was available to bilingual populations. There were challenges in the distribution of the H1N1 vaccine. As the pandemic went on, distribution plans were modified to increase the authority of local communities to decide how to allocate their vaccine. Lessons learned: · · It was difficult to communicate with doctors across the state. The public health laboratory cannot be a diagnostic lab for the entire state.

D-11

· · · · ·

The surge capacity required contractors for higher pay than employees, creating a morale issue. The illness was difficult to detect via current hospital-based surveillance systems. The initial Texas cases were detected in military clinics where influenza testing was part of the protocol. Isolation of communities was difficult due to domino consequences. People are often scared of treatment/prevention more than the disease when mortality is low. Use of the 211 statewide information line was very helpful.

Rotavirus in Chiapas: Exploring binational collaborations on the other border, Dr. Leticia Jarquín Estrada, Deputy Director of Epidemiological Surveillance, Chiapas State Health Department, Chiapas, Mexico The state of Chiapas, which borders Guatemala, experienced a rotavirus outbreak in early 2010. The virus had a novel genotype identified by InDRE, and this genotype was not covered by the present rotavirus vaccine. Health officials protected the public through-- · · · · · · · Surveillance by a health committee, including door-to-door searching for cases Timely diagnostics by the laboratory. They sent daily samples to the state lab, although it was five or six hours away Timely studies of outbreaks Sanitary vigilance, such as chlorination of the water and public education Environmental monitoring Medical treatment Health promotion, through informing mothers and broadcasting messages on the radio and TV

Multijurisdictional issues in the investigation of foodborne outbreaks in Texas, Dr. Linda Gaul, Epidemiologist, Emerging and Acute Diseases Branch, Texas DSHS Dr. Gaul explained that the Texas health department system is very decentralized. There are 254 counties in Texas and 64 have a local health department. If there is no county health department, then the Texas Department of State Health Services (DSHS) will act as the health department. Local health departments serve 83% and the state health department serves 17% of the Texas population. Jurisdictional health departments are responsible for disease surveillance, case investigations, outbreak investigations, and reporting to DSHS and CDC. When there are multi-state outbreak investigations, notifications are sent by the CDC or by the other states to Texas DSHS in Austin. DSHS Austin coordinates outbreak investigation activities within Texas. Local or regional health departments conduct case-patient interviews and return the information to DSHS Austin. Issues limiting local health department participation in multistate outbreak investigations may include understaffing, undertrained staff, multiple priorities, political concerns, and policies that do not permit staff to work outside of normal business hours. Specific efforts aimed at improving outbreak response in Texas include an FDA-funded effort to create rapid response teams. Texas DSHS also hired an epidemiologist exclusively to conduct case-patient interviews. This should provide greater consistency in interviews and faster feedback to regulatory partners on implicated foods.

D-12

I. Lightning Talks (Day 3) The opening session on Day 3 was comprised of four short talks as follows (topic, presenter, title, affiliation): · · Changing epidemiology of acute hepatitis A in Texas, Rachel Wiseman, Epidemiologist, Texas DSHS Salmonellosis outbreak in California associated with travel to Baja California, Mexico or shopping at a Mexican grocery chain, Azi Maroufi, Epidemiologist, County of San Diego Health and Human Services Agency Chagas disease in the U.S., Dr. Paul Cantey, Epidemiologist, CDC Outbreak investigation for measles, Chaz Lacy-Martinez, EWIDS Program Manager, Arizona Department of State Health Services

· ·

These lightning talks provided information on the epidemiology and specific outbreak investigations on infectious, foodborne, and vector-borne diseases. Presentations by Mr. Lacy-Martinez and Ms. Maroufi focused on specific outbreaks, how the respective diseases were tracked, and the binational aspects of investigation and response. Both cases shed light on need for binational communication and protocols. Ms. Wiseman's presentation tracked the epidemiology of Hepatitis A in Texas and demonstrated the effectiveness over time of a vaccine campaign targeting children. Dr. Cantey discussed the need for greater diagnosis and treatment of vector-borne Chagas disease, which affects populations on both sides of the border although little is known about its epidemiology in the U.S.

D-13

Appendix E: Panel Discussion on Binational Communication Moderators: Dr. Jay McAuliffe, Center for Global Health, CDC Dr Gudelia Rangel Gómez, BHC, México Section Dr. Celia Alpuche Aranda, InDRE, Health Ministry of México Dr. Ethel Palacios Zavala, DGE, Health Ministry of México Dr. Steve Waterman, CDC André La Prarie, Public Health Agency of Canada Dr. José Luís Alomía Zegarra, Health Service of Sonora Dr. Roberto Guerrero, OBH, Arizona Dept. of Health Services Dr. Pablo Gilberto López Rodríguez, Health Jurisdiction No. IV, Reynosa Dr. Hector Gonzalez, City of Laredo Health Department

Panelists:

During the panel discussion on binational communication, the moderators fielded questions from the audience of conference participants. Panel members responded to direct questions and were encouraged to discuss freely as time allowed. The following is a condensed version of the discussion in "Q & A" format. Q: Why have the Guidelines taken so long to be in place, especially since Mexico approved them in 2007? Is the hold-up with CSTE (Council of State and Territorial Epidemiologists)? J. McAuliffe, U.S. - No, CSTE has been an active advocate for the Guidelines to be put forward. The delaying point was at the Department of Health and Human Services. We believe we've worked out a common understanding of the Guidelines and they will now be moving forward. Q: What is the import/export process for reagents from the U.S. to Mexico, for example El PasoCiudad Juarez? C. Alpuche, Mexico- I think Lucia Hernandez gave us a broad review of this issue and the answer is very simple. There is no process that we can follow from A to B to C for this to be fast and effective. As she said, a permit comes from the Federal Commission for the Protection against Sanitary Risk (COFEPRIS), in the Mexican case, to acquire import/export of products and officially this takes 40 days, which is completely impractical. And for this reason, the actual practice is something of a "black market", [transported] in cars, in pockets, and whatever it has to be. And it is for this reason that in InDRE we have applied ourselves to the task of reviewing the process and the relationship with COFEPRIS to resolve this issue. This is the project Lucia Hernandez Rivas just presented. Q: What is the future of funding for EWIDS? R. Sotomayor, U.S. - I don't know. EWIDS is discretionary funding. It is not earmarked. I advocate every year for it and, with your help and the information you send me, I use that to validate the importance of EWIDS with our decision makers. We have programs internationally, and the cross-border aspects are very important to me and to the leadership in the department. As long as I can defend EWIDS I will, but I can't promise anything. C. Alpuche, Mexico- For Mexico, it is important to recognize that we want more permanent support from our side. For this reason, the strengthening of the accord for public health called AFASPE (Acuerdo para el Fortalecimiento de las Acciones de Salud Pública en los Estados), an initiative of Dr. Mauricio Hernandez in this administration, has lead to a change in the paradigm for epidemiological surveillance. And $240 million Mexican pesos were invested last year in epidemiological surveillance. This year we have another $240 million Mexican pesos distributed throughout the country, not just the border region, for investment in epidemiological surveillance

E-1

and restructuring IT. The program we have does not have funds for human resources and this is something we need to work on. Q: During the pandemic, President Calderon's decree to facilitate the import/export of materials related to the response to H1N1 was not respected on the border. Why? E. Palacios, Mexico- There was a presidential decree and that had to filter down to all the operative levels of the sectors involved to liberate the flow of reagents across the border. Despite the fact that the decree facilitated the situation on paper, some specific sites told us that they had to consult with their administrative and technical sections before honoring it. Nevertheless, various sites did utilize the decree. This heterogeneity in procedure is something we also need to work on. We should focus on coordination among sectors and emphasize the ability to follow processes in the same manner in all border locations. This is not only a problem resulting from the pandemic, but it is also an everyday problem we need to work on. Q: What are the barriers to effective binational communication? Institutional recognition of need? Political issues that interfere? Not knowing with whom to communicate? Lack of protocol standardizing communications? Concerns with legality? A. La Prairie, Canada- There are barriers, but at the same time it has gotten better. The networks of the laboratories post-H1N1 have improved quite a bit. Raul [Sotomayor] and I were in Seattle about a month ago talking about a pan-border strategy for Canada, and at the same time there occurred a measles outbreak and another respiratory outbreak at a hospital with fourteen deaths and it was unsure what the cause was. In both cases it was very difficult to share information even from the local level to the state/province level, let alone to the federal level. So the challenges continue to exist. We see that horizontal communications are fine, but vertically there is a challenge and that is where the work is still needed. H. Gonzalez, U.S. - It is critical for us to have a system that does address a policy (for communications). We are going to do it and we have done it. H1N1 was the newest event, but we have been doing it with TB. And there are two systems. That does make it a challenge, even though we have built very good relationships, and you have to by having constant discussions, meetings, and trainings together. That facilitates it. If we did have a one policy that meets all, that would help. R. Guerrero, U.S. - A good clarification to make is whether we are talking about a flow of information from north to south or from south to north. They are two completely different systems. Currently, we have a lot of information southbound because we don't have many of the same barriers our counterparts do. Of course, we respect the laws and regulations. But we should clarify whether we are talking about south-north, north-south, or both. E. Palacios, Mexico ­ If we are speaking of communication, in Mexico's case a very relevant point is the language aspect. Sometimes even though we manage the language, the technical discussion gets to a level where meaning can get lost. It is also important to establish what the priorities are and what our interest is. Is it really a shared interest or is it a unilateral interest in collaboration? Also it is important to have an understanding of the consequences. What happens if I share information: what is the consequence on my side and on the side of my colleague? On the other hand, there are confidential and ethical issues that affect how we communicate. The first thing we have to do is sit down with our counterpart and decide what it is we want to share and why. In this way we can have a better understanding and fewer errors when we share information. J.L. Alomía, Mexico- The early warning system has to work with notification in real time. In Sonora, operational personnel in epidemiology are often over-tasked. We must consider that the

E-2

lack of human resources, not necessarily at the state level but at the operational level, many times affects binational communication. Q: Are there examples of what has impeded binational communication? It would be interesting to have examples from both the state and the federal levels. J.L. Alomía, Mexico- In Sonora, we have had instances where information has come to us late in or an indirect way. But among the principal limits is the fact that laws affecting the flow of information are different on each side of the border and this generates barriers. For example, there are counties with their own laws, as well as state laws, and federal laws. And the same can happen on this side. And this can impede whether information gets to us in the timeliest manner. H. Gonzalez, U.S. - It comes down to having a policy and the regulations sometimes serve as a barrier themselves. We had a case, referred from the quarantine station, of a person with multidrug resistant TB who was coming back to the U.S. and held at the port of entry. Working very well with CDC and the Department of State Health Services, our staff goes to the port of entry and works with doing all of the communication, all the training, and all the disease control we need to do. We even walk the person to the middle of the bridge with our counterparts so that we continue to do the treatment and make sure all the protective measures are done. This is something we do all the time. But here the regulations of México came into play, because there was only so much we could do to detain this person to make sure he was treated along with the person's two positive children. Because we have the informal relationship, we did the one-on-one and were actually able to make sure this person got treated. But if we strictly followed the regulations, this person would have been able to go free [without treatment]. The communication was there and the actions were taken. But, again, I think we need a policy that sets the tone once and for all. R. Guerrero, U.S ­ An outcome of the 2007 Border Governors' Conference Health Work Table was the request that the Guidelines be finalized and implemented, and in 2007 there was a joint resolution that the border states in preparation for the eventual implementation of the Guidelines would also start to develop protocols for communication. Prior to those protocols, there were a lot of gaps and times when communication didn't happen when perhaps it should have. Arizona and Sonora did include binational communication in our pandemic preparedness plan for the state, and the plan talked about how our states would communicate. It is a living document. And the last time we exercised it strongly with H1N1 we were able to see that we needed to make modifications to it. Those policies or protocols were very useful to us in determining how and when we communicate and to whom. S. Waterman, U.S. - I wanted to comment on situations where information might not be shared. On the U.S. side, a lot of the counties and states away from the border really don't have the institutional recognition of this being an issue. Not only that, but they may get some piece of information which suggest that it should be communicated binationally, but they don't get enough information for it to be useful on the other side. This really speaks again to the issue of educating the country. We've been talking about having webinars in the US with the CSTE and the National Association of State and Territorial Health Officials (ASTHO), educating them about the process of putting in place the system and defining the information necessary to having an effective communication system.

E-3

Q: What is needed to have binational communication on "epi" events really become an effective practice? What would it take for state health departments to develop a uniform electronic surveillance and reporting systems across states, both horizontally (between states) and vertically (between countries)? S. Waterman, U.S ­The process of developing a policy, a system, and a consensus at local, state, and federal levels about how we should go about codifying this-- and having protocols, and the incorporation of data fields (such as birth outside the country, how long in the country, and travel histories) in order to make sure binational cases are adequately identified at the source-- is the way to start. With this meeting, the Binational Technical Work Group, and all the efforts of the states with their various organizations and border health offices, we are headed in the right direction. A. La Prairie, Canada- Much like the U.S. -Mexico border, in Canada everybody has their own systems. I think earlier on we abandoned the possibility of harmonization as an option. The systems are just too different and people are too entrenched. So Plan B has been sort of mutual access. But mutual access only gets you so far because you are still dealing with different systems, different nomenclature, and you're asking people to manage two lists. It is still a challenge. It's been easier for Canadians to sign onto the EpiX system than for Americans to get onto the Canadian system (CNPHI), which seems to involve a lot of extra steps. C. Alpuche, Mexico- If we don't talk about the concepts, definitions, and protocols of what we need to exchange information, then no matter how sophisticated and well-developed the platform, it won't work to exchange information. We actually like the Canadian CNPHI system ­ it has an interface that makes it easy to extract information from different sources. We need to define protocols of what we want to communicate so that we can begin to establish the interfaces for the various platforms. This is not easy, but we need to start somewhere. H. Gonzalez, U.S. ­ We have a good start with EWIDS ­ it already has a good foundation. I agree that we need to further develop protocols that codify the exchange of information. We just need to make it quicker and simpler to use the data. For example, with my counterpart in Nuevo Laredo, we watch the weekly EWIDS reports constantly. A year ago when we had a significant increase in dengue, my first flag was the EWIDS report. The only problem was the two-week lag. We have a good program with EWIDS ­ we just need to reinforce it. E. Palacios, Mexico ­First, it is very important to define the use and priority of the information that we want to share. The concepts should inform how the system is developed. Second, we need to be able to use existing systems. Data mining is an enormous field that is developing. And finally what we develop has to be flexible and adaptable. P. Lopez, Mexico ­ Speaking as an operational level person, I am interested in families, students, workers, and others who cross the border regularly. We have a weekly bulletin in with we exchange disease information with the United States [Texas]. In my work, for disease control we need something practical and simple so that we can intervene in a timely fashion. At the operational level on the border, we need something for rapid, real-time communication. This is what we as epidemiologists need ­ a system for rapid communication so we can take action in a timely and effective manner. R. Guerrero, U.S. - We have so many different platforms (in the U.S.). Different states have different systems. México has one up on us because they have one system, the Plataforma única. A private sector corporation located in our building developed software that allowed both the

E-4

Missouri and Kansas systems to talk to each other and mine the information needed. There are solutions, and they are possibly in the private sector or government contracts. C. Alpuche, Mexico- We have a single system, Plataforma única. But even within our single system, I cannot always connect multiple events involving the same individual. For example, I can have a patient in the TB module, and the diabetes module, and the cancer module; those three platforms do not speak to one another. This exemplifies the difficulties even within a single system in connecting different elements of the system. I understand that you have the challenge of connecting systems from each state. We have to find interfaces that make this information more fluid. Q: How would you describe the current status of binational communication in your agency? J. Alomia, Mexico ­ Between Arizona and Sonora, communication is very good. We are able to use the Arizona platform, and we also communicate directly by telephone or email. Our communication reinforces epidemiological surveillance. It is very good, but we can still work to improve it. H. Gonzalez, U.S. ­ We need to continue seeking a system in which every level of the network is included ­ federal, state, local. We must not forget local, because that is where everything is managed from. We can develop relationships through joint meetings and trainings. We need to foster confidence in the system of information exchange. It is good to develop protocols and policies. Nonetheless, at times nothing works and we have to use Nextel (phone service provider in Mexico), cell phones, fax, email, radio. We used radio during H1N1 and still use it. We'll continue exchanging information in whatever manner we have to. E. Palacios, Mexico ­ Binational communication is too heterogeneous. There are neighboring states that communicate with each other very well, and other areas where communication is not as developed. We need to exchange information efficiently; communication procedures are not institutionalized everywhere. We are at a very important moment for binational and international communication. There is a guide on how to institutionalize binational/international information exchange at all levels from local onwards. This is not a bad moment at all for binational communication; we need to try implementing the Guidelines. A. La Prairie, Canada- Two years ago I was involved in a study of the procedures we had to respond to events of importance. For the most part, the agency uses social networks to determine what's going on in Canada and internationally; if certain key individuals were no longer there, communication would be impaired. It's important to establish standards of practice and to recognize that a great deal of communication in public health is through social networks. So you have to invest in them; people don't want to pass information on unless they trust the recipient. We need to continue having meetings like this one. Without trust, the electronic systems will not work. Q: If there is no feedback when information is provided, then reporting progressively diminishes. After providing information from one country to another, to what extent does one learn that something happened as a result? S. Waterman, U.S. ­ I think the best examples are the TB programs in both countries. There is a long history of collaboration in TB across the borders. San Diego County Health Department created "Cure TB" and the Migrant Clinicians Network in Texas created the TB Net, a binational referral and case management system. That was formalized further by México with the binational TB Card project going back several years, in which protocols were established in both countries to exchange information. It's not

E-5

a perfect system but there is reasonably good follow up that we get on patients that move between countries and we can determine completion of therapy rates although we still need to improve it. E. Palacios, México ­ Feedback is an essential component of a communication system. It helps keep information flowing and it is also a way to automatically evaluate the utility of sharing information by seeing the consequences or results of sharing information. We need to take feedback into account when developing a communication system. P. Lopez, Mexico ­ Returning again to the operational level, we may not be receiving an official communication but instead a "social" communication. For example, we had some cases of pertussis diagnosed in the U.S. We received information from the U.S., and this allowed us to implement control measures where they lived [in Mexico]. The control measures were implemented independently of the fact that the cases were diagnosed in the U.S. and we were able to break the chain of transmission. R. Guerrero, U.S. ­ The question of how do you close the loop of communication is one that we have discussed in the Office of Border Health in Arizona with our border counties. The counties send us information and we transmit it to our counterparts in Sonora. What I decided with our staff is that we must have an answer from the county in 10 days, even if the answer is that there is no information available. That has helped our counties to better communicate with us and they know that they don't have an open case. C. Alpuche, Mexico ­ Another example of rapid cross-border communication is measles. We can rapidly detect an imported case and work quickly to implement control measures to avoid an outbreak. H. Gonzales, U.S. ­ Commenting further on the TB model discussed by Steve Waterman, we had PAHOsponsored training between the TB and HIV staff to use the TB model in HIV. We have binational HIV patients as well and the feedback [between countries] is absolutely essential. Q: In a presentation, California showed a significant growth in the number of binational cases. Do you see any risk to a `too liberal' definition of binational cases leading to excess of binational work? R. Guerrero, U.S. ­ In many cases, when we weren't getting a response back from our counterparts, the reason was that the case was just too general or vague. For example, we might learn that a person crossed the border, ate at a few unspecified restaurants, and came home ­ is that a binational case or not? We redefined it so that if there was indeed information that could be investigated, then we would share it with our counterparts. But if the information was too vague, it could waste our counterpart's time to contemplate any sort of investigation. We might identify a vague communication as "for your information." E. Palacios, Mexico- The level of sensitivity of systems is being discussed. At one time the system was so sensitive that it seemed impossible to manage. Managing the concept of early warning, such that it perfectly related with surveillance systems, is an art that we are learning to design and operate. The pandemic taught us major lessons with regard to how sensitive and how specific the components of the system need to be. We learned that it is useful to do surveillance for clusters for pneumonia, but that we might not have to investigate all of the clusters since we have mathematical models, estimates, projections, and risk calculations that allowed us to draw conclusions. It is something we need to re-think. Q: Why does the problem continue with reagents, medicines, and transport media that cannot cross the border (due to customs barriers)? When is this going to resolved? C. Alpuche, Mexico- Q. Lucia Hernandez explained this step by step. There is no automated system in customs. We have brought this issue to the highest levels and are exerting our maximal effort to resolve the problems. We are analyzing what happens step by step and we are looking for solutions.

E-6

S. Waterman, U.S. - This is a difficult issue and I know there have been real problems moving specimens across the border. The two Secretaries of Health agreed to establish pilot processes that would be uniform along the border to move biologic specimens across the border at various points of entry. The protocol was developed by Homeland Security. It was piloted during the last 3 months of 2009. The CDC designed a survey tool that has been mailed out to the various partners on the U.S. side, just on importation into the U.S. The reports on that will be out shortly. There is clearly a need to continue to work with the customs organization and with Homeland Security. ASPR is taking the leadership to try to make this process more efficient and it's part of NALS goals to address this issue. It is a complicated issue that public health agencies have different concerns than do national security agencies, and there is also some concern over paying customs fees. It will take negotiation and discussion to solve this. A. La Prairie, Canada ­ Policy communication is also important. When I think about H1N1, I think of some of the discrepancies in policies over vaccines (with or without adjuvants; when we vaccinate for seasonal flu), school closures, etc. Policy is where we really need work and now is the time, when we are reviewing our pandemic strategies. We need to talk now before we reach our next problem.

E-7

Appendix F: Breakout Groups and Their Participants This appendix lists the groups that conference attendees chose at the time of registration. Some attendees may have ended up participating in a different group from the one chosen at registration. Some conference attendees did not select any group at the time of registration. Other attendees selected more than one group at the time of registration; it is not known in which group they actually participated. Names are shown as they were signed on the group registration lists. TB, HIV, STDs, hepatitis Food security and public health (including foodborne and diarrheal diseases) John Besser Daniel Carmona Sallie Connor Stephanie DeLong Linda Gaul Martha Vazquez Erlbeck Roman Escobar Luis Escobedo Edgar Farias Farias Joanna Frausto Dina Garcia Hector Gonzalez Fernanda Guerrero Olga Henao Lucia Hernandez Rivas Mario Holguin Victor Juarez Islas Jaime Leon Varela Azi Maroufi Lori Navarette Ever Osorio R Aurora Parissi Crivelli Katharine Perez-Lockett Flor Puentes Jaime Romo Diana Ruiz Lourdes Sandoval Jennifer Smith Preparedness for and response to acute respiratory diseases including pandemic influenza Jose Luis Alomia Zegarra Eduardo AzzizBaumgartner Pilar Bernal Perez Patrick Blair Fco Elizalde Rita Espinoza Jorge Gallegos Marcos Gonzalez Marron Lauri Hicks Chaz Lacy-Martinez Adriana Lopez Karla Lopez Azi Maroufi Samuel Martin Hernandez Belinda A. Medrano Sonia Montiel Nancy Nieto Juan Ruiz Trudi Shim Marisol Silva Silvia E. Trevino Teresa Ulrich Lissette Valenzuela Rachel Wiseman Emerging infectious threats (including vector-borne diseases)

Elisa Aguilar Jose Luis Aranda Duiona Baker Veronica Bejarano Martinez Eric Blank Martha Alicia Bueno Adriana Corona Luevanos Liz Delamater Miguel Escobedo Edgar Farias Farias Edgar Ivan Galindo Abelardo Garcia Fernando Gonzalez Carmen Guzman Bracho Michael Hill Maria GPE Jimenez F Victor Juarez Saleem Kamili Mauricio Leiva Norma Luna Guzman Sundari Mase Jose Moreira Gale Morrow Clelia Pezzi Julissa Portillo Gudelia Rangel Cheris Rohr-Allegrini Miroslava Sanchez

Jose Luis Aranda Allison Banicki Anthony Barkey Joanne Bates Veronica Bejarano Aaron Benfield Paul Cantey Luis Castellanos Sonia Fernandez Karen Ferran Isidore Flores Rita Flores Leon Maureen Fonseca Oda Garcia Sara Lyssie Hernandez Elizabeth Hunsperger Esmeralda IniquezStevens Leticia Jarquin Estrada Paula Kriner Grace Kubin Grace Kubin Andre LaPrairie Irma Lopez Martinez Pablo Gilberto Lopez Clint Matthews Ivonne Mendez Ricardo Morales Michele MurtazzaRossini

F-1

TB, HIV, STDs, hepatitis

Food security and public health (including foodborne and diarrheal diseases) Ana Maria Villarreal María Teresa Zorrilla

Preparedness for and response to acute respiratory diseases including pandemic influenza

Emerging infectious threats (including vector-borne diseases)

Calixto Seca Monica Sovero Vanessa Telles Maria Luisa Zuniga

An Nguyen Ethel Palacios Zavala Calros G. Perez Puente Brett Peterson Rossanne Philen Sara Ramirez Aguilero Joanna Regan Lucrecia Reyes Santillan Alfredo Rodriguez Trujillo Jaime Rome Evangelina Rubio Rocio Sanchez Diaz Sahotra Sarkar Dan Stier Roberto Suarez Conschetta Wright Weigong Zhou

Conference attendees who did not choose a group (in addition, some persons did not sign-in when registering): Celia M Alpuche Aranda Robert Guerrero John Herbold Ann Millard Cecilia Rosales Steve Waterman

F-2

Appendix G: Matrices from the Breakout Groups The matrices are included in the following order: 1. 2. 3. 4. TB, HIV, STD, hepatitis Food security and public health (including foodborne and diarrheal diseases) Preparedness for and response to acute respiratory diseases including pandemic influenza Emerging infectious threats (including vector-borne diseases)

Note: Each breakout group has a matrix for current collaborations and problems, followed by another matrix for potential solutions and further opportunities for collaboration.

G-1

Binational Infectious Disease Meeting / Reunión Binacional sobre Enfermedades Infecciosas San Antonio, TX, 28-30 June 2010 / 28-30 de junio, 2010

SESIÓN DE DISCUSIÓN 1 / BREAKOUT SESSION 1:

Identificar las colaboraciones actuales y los problemas / Identify current collaborations and problems

Group: TB/HIV/STD/Hepatitis

Colaboraciones actuales / Current Collaborations Vigilancia epidemiológica / Epidemiology Surveillance TB: Drug resistance TB Project in Tijuana and Mexicali (Puentes de Esperanza). Pendientes principales / Main Pending Issues TB: Need to extend the project to Ensenada, Kathy wants to extend the model, may already be in Imperial and San Diego county. Kathie working with the CDC. Prioridades nuevas / New Priorities Improve the mechanisms of binational reference and cross-reference of patients with TB. Extend to other municipalities of the states. Sustainability - how will we get funding? Fuente de financiamiento / Funding Source Otros aspectos / Other Issues Solutions USAID, Baja California, Tijuana and s i Diego jurisdiction. Nonprofits? Maquiladores? (Large factories in Mexico, fortune 500 companies) Catalog successful

TB: Rotary TB Center of Excellence - very successful program

Expansion of laboratory, evaluating the laboratory infrastructure

Sustainability?

Rotary international y Tamaulipas Ministry of Health (or State lab?)

G-2

TB: The Binational TB card (a multi-national TB patient tracking and referral project designed to work with mobile, underserved populations

Concept behind this project needs to be addressed in a broader context (the idea that we should be collaborating and organizing around case management and referral mechanisms).

Meet and greets (TB patients being repatriated should be met by public health officials). Strengthen patient referral and surveillance system between CURE-TB and the DGAE TB module. Guarantee a secure link between the two systems. Maybe change the name.

Cure Tb and CDC.

This is a problem because people were afraid of having the card, so people aren't using the card. international coordination at the state, local and federal level

DOT(TAES)

Expansion of the community strategy in Renoysa, Saltillo, and Matamoros and in the US.

Do an inventory and characterize new DOT methods to expand them in a cost effective manner. Strengthen communication/coordin ation. Assure reporting in the system

USAID, MOH

DOTMania: Outpatient clinics funded by CD Juarez panel physicians for US immigrants from US immigrants - treatment for TB in Mexico a TB culture services.

Laboratory accreditation in process. Discuss with InDRE and Dr. Castellanos

Find out the status of DOT in Veracrus from Drew Posey

Cure TB: work with patients deported or moving back to Mexico

Improve referrals by creating information system that includes list from Cure TB patients returning to Mexico.

Standardize Data systems

CDC

Juntos Flagship on Molecular Resistance of TB. (NEW) Photovoices CDC will send bullets of information CDC

Extend to 10 States in Mexico (should be 13 states)

Consider the needs in terms of development, risk communication, and health promotion related to infectious disease.

USAID?

G-3

Mexico Drug resistance study

Specimens have been received by CDC to be tested for drug resistance (?. Quality control for lab testing

This program is close to being completed.

New Mexico binational TB project

Pilot testing for surveillance and management of TB patients from Nueve Casas Grandes and New Mexico

Funded by commission

Project coordinator has been hired and the project is starting, project is virtually done.

NEW Binational US network group for the treatment of MDR TB cases.

US experts listen to MDR TB cases from Mexican doctors, make recommendations. Multiple conferences, identified problems and needs.

Challenges with the TB patients listed (MONICA)

USAID?

NEW Mexico infection control project. needs assessment, training for infection control.

Sustainable funding needed.

Sustainable funding needed. One year funding from USAID.

HIV/AIDs: PAHO is working with some border states to study diabetes, HIV and TB. Address this at the border level mostly.

HIV/TB - exchanging more information about HIV and TB. National data, starting with the border. Better referral of patients. Organize non-profit groups, improve collaboration between them and between public health groups (governmental and non-governmental). Trainings, assessments of community programs that have been successful. Interest from the US in sharing social communication programs. Develop a list of community level projects that are most successful with migrants on both sides of the border. Share results of HIV rapid tests on both sides of the border.

More collaboration projects in the communities that target high risk groups. TB/HIV rapid testing, do both at the same time for high risk people (detained people, etc)

HIV among truckers...see above. Risk group for above.

Hepatitis: Project BIDS.

Two projects being started in InDRE with the hepatitis group at CDC. 1) Molecular epidemiology of Hep A and B 2) BIDs

G-4

Hepatitis in captive populations, IDUs and MSMs?

Assess the development of a strategy to measure the connection between hepatitis C and HIV

Laboratorio / Laboratory Intercambio de información / Exchange Information IT

Educación y formación de recursos humanos / Training and human resource development

Promoción de la salud / Health Promotion

Aspectos legales / Legal Issues

G-5

Binational Infectious Disease Meeting / Reunión Binacional sobre Enfermedades Infecciosas San Antonio, TX, 28-30 June 2010 / 28-30 de junio, 2010

SESIÓN DE DISCUSIÓN 2 / BREAKOUT SESSION 2:

Proponer posibles soluciones y más oportunidades de colaboración / Propose potential solutions and further opportunities for collaboration

Group: TB/HIV/STD/Hepatitis

Prioridades / Priorities Objetivos / Objectives Acciones principales / Key Actions Fecha límite para completarse / Timeline Áreas o personas responsables / Responsible Areas or person Vigilancia epidemiológica / Epidemiology Surveillance Catalog successful ongoing collaborations. 1) Finalize list of successful collaboration projects for HIV/AIDs 2) Finalize CDC evaluations of binational projects: SD-TJ, ELP/Juarez, and Rio Grande ValleyTambohulas Define a group of people for each site to collaborate on each evaluation (evaluation team). Develop timeline. Identify evaluation team members from CDC and states. Evaluations take place at end of August. Evaluations take place at the end of August Evaluation team members from CDC and states

HIV projects Unify existing information systems both for case management and surveillance systems

list projects, list people involved in each project. look formats of existing systems, look at the platforms being used by the existing systems. Don't reinvent the wheel, integrate what is already there. Establish or strengthen coordination between information systems between the US and Mexico.

By end of August have a list of projects. Feb 1, 2011

State and local, CDC Expert group that will follow up and provide recommendations.

G-6

Laboratorio / Laboratory

Establish diagnostic standards and technical

Strengthen laboratory diagnostic capacity

Training, supervision, prepare a list of competencies for lab personnel. Cross testing between labs and CDC. CDC lab validation. have a free flow of samples between cdc, indre, and local labs to ensure quality

Ongoing, 3 months

State and local health, APHL

Establish a system that is efficient for transporting samples and reagents (materials) across the border.

Pilot project started on American side, establish a mechanism to ensure the assessment of the pilot project and evaluated the results on the American side. On the Mexican side, improve relationships with customs, expedite process.

Develop an international group to study the problem and come up with solutions.

End of August

CDC, CBP, FDA, InDRE,

Intercambio de información / Exchange Information IT

Educación y formación de recursos humanos / Training and human resource development

Promoción de la salud / Health Promotion

Aspectos legales / Legal Issues

G-7

Binational Infectious Disease Meeting / Reunión Binacional sobre Enfermedades Infecciosas San Antonio, TX, 28-30 June 2010 / 28-30 de junio, 2010

SESIÓN DE DISCUSIÓN 1 / BREAKOUT SESSION 1:

Identificar las colaboraciones actuales y los problemas / Identify current collaborations and problems

Group: Food security and public health (including foodborne and diarrheal diseases)

Colaboraciones actuales / Current Collaborations Pendientes principales / Main Pending Issues Prioridades nuevas / New Priorities Fuente de financiamiento / Funding Source Otros aspectos / Other Issues

G-8

Vigilancia epidemiológica / Epidemiology Surveillance

No formal borderwide agreement but have some formal and informal state-tostate agreements for surveillance (TXTamaulipas, AZSonora, CA-Baja, NM-Chihuahua) ; 2010: Binational Health Council: Cross Border sister cities; BEST (Border Epidemiology Surveillance Team): Data information sharing between TXNM-Chih; Border Enteric Surveillance and Testing (BEST) (Harlingen (BIDS); EWIDS Conference calls Border Wide in the US side; 2010: Continued support of lab based surveillance and sharing and data analyses; communication with press: how to disseminate information in a timely manner; improve communication among different agencies-health aspect and regulatory aspect and environmental;

Establish a collaboration system. Basic bilingual epi course under dev bet TX and Tamaulipas (April/May 2009 - in collaboration with PAHO), Meeting in Jan to determine curriculum and location of courses, have decided on 4 courses (2 in MX and 2 in US).

Foodborne illness notifications, define binational case information, and case definition, design a form which both countries could use for reporting cases. Broaden communication among laboratories. Foodborne illness surveillance- define concentrated list of pathogens (Listeria). · Develop a summary of foodborne surveillance activities in the border region ­ what is done, what is reported, and laboratory capacity. · Determine strengths and weaknesses of existing systems and ways to enhance existing systems. · Develop a borderwide protocol for information sharing between jurisdictions in US and Mexico regarding foodborne diseases/pathogens, including outbreak investigation and follow up information on binational cases investigated. 2010: Improve regulatory and communication between Mex and US (ex. USDA to inform other agencies);

G-9

InDRE-PulseNet (MX staff at CDC 2 weeks working on PFGE techniques). Work exchange among laboratories Chihuahua and NM for work on PFGE (2008). Cholera program in Mexico has a sampling system.BSL-2 labs in multiple states on both sides of border ­ many with capacity to do enteric pathogen isolation, BSL-3 lab being planned in Reynosa, Tamaulipas

InDRE-PulseNet. Identification of pathogens to investigate. 2010: Mex: Salmomella, E. cloi, and Shigella; description of flow isolates

InDRE-PulseNet. Strengthen MX labs so every positive Salmonella sample is sent to be stereotyped. e parallel systems and data comparisons. Broaden collaboration among epidemiologists. Define analytic framework. Define work algorithm. Broaden the cholera surveillance system to include a group of pathogens to be reported. Strengthen state laboratories (stereotyping capacity), molecular (InDRE). Evaluate what is done in each country's lab network.

Consortium on TB (Nuevo Santander TB trackers), ongoing program with Tamaulipas,have received funds to build level 3 lab in Reynosa, has implication for future projects (2009)

Laboratorio / Laboratory

Collaboration between InDRE and CDC for subtyping. MX and US both participate in PulseNet; 2010: New BSL 3 Lab in InDRE (Sonora); COFEPRIS (Alimentos de potencia peligrosos); Integration of regulations to include before epi surveillance is conducted

· Assess laboratory capacity in the region to do testing for human and outbreak-related food specimens o Falls under the development of a summary of foodborne surveillance activities in the border region · Enhance laboratory capacity through training at national, state, and local level o Strengthen state laboratory capacity through state training by partners. o Promote professional exchange between laboratorians o Formalize quality assurance of labs · Develop guidelines for establishing an investigative team (CDC-SINAVE/InDRE, state level lab and epidemiology representation) for overseeing/coordinating timely sharing of information and specimens between laboratories. Utilize existing guidelines as the basis for these guidelines. · Continued collaboration between InDRE and CDC for subtyping / PulseNet

G-10

Intercambio de información / Exchange Information IT

Weekly information exchange between NM and Chihuahua. TX and Tamaulipas have weekly disease report that includes foodborne illness reports. Epi-X available for use (list specific to region). AZ and Sonora have electronic reporting system. Multiple states already sharing weekly reportable diseases reports

information sharing between US/MX

· Disseminate analysis results, protocols, notification of events of interest in a rapid and effective manner

Educación y formación de recursos humanos / Training and human resource development

WHO-GSS courses on salmonella and other FB pathogens. InDRE-CDC biosecurity workshops. Various courses are available at the state level and national level on how to do foodborne disease surveillance and how to investigate foodborne disease outbreaks.

Formalize the support provided by CDC and InDRE; 2010: FDA, Departments of Agriculture; COFEPRIS, Sagarpa, etc.;Baja Cal. (EWIDS); (agrotourism) Training Course; Basic bilingual epi course under dev bet TX and Tamaulipas (posponed) (April/May 2009 - in collaboration with PAHO), Meeting in Jan to determine curriculum and location of courses, have decided on 4 courses (2 in MX and 2 in US).

Course being developed can include FB component. Education on Listeria and quesos frescos · Train epidemiologists and laboratorians on foodborne disease surveillance; Workforce Development; EPI Ready; EHTER

G-11

Promoción de la salud / Health Promotion

CA did study to better understand listeria and queso fresco, developed brochures based on studies on queso freso and listeria - shared with MX. AZ also working on education materials. Informal collaborations among states. Each country has health promotion system.

Establish collaboration to design and use materials for health promotion. Tie promotion activities with epidemiology and determinant monitoring. Informal collaborations among states. Each country has health promotion system.

Aspectos legales / Legal Issues

G-12

Binational Infectious Disease Meeting / Reunión Binacional sobre Enfermedades Infecciosas San Antonio, TX, 28-30 June 2010 / 28-30 de junio, 2010

SESIÓN DE DISCUSIÓN 2 / BREAKOUT SESSION 2: Proponer posibles soluciones y más oportunidades de colaboración / Propose potential solutions and further opportunities for collaboration

Group: Food security and public health (including foodborne and diarrheal diseases)

Prioridades / Priorities Objetivos / Objectives Acciones principales / Key Actions · Form work group to develop a summary of foodborne surveillance activities in the border region ­ what is done, what is reported, and laboratory capacity. Provide recommendations for coordination of surveillance activities. Fecha límite para completarse / Timeline Áreas o personas responsables / Responsible Areas or person Vigilancia epidemiológica / Epidemiology Surveillance · Develop a summary of foodborne surveillance activities in the border region ­ what is done, what is reported, and laboratory capacity. (binational) · Disseminate findings from analysis of existing data in Mexico re: Salmonella (in process from existing vibrio cholera surveillance and outbreak investigations). o 1-year - Results to be distributed at next year's meeting

G-13

o Determine strengths and weaknesses of existing systems and ways to enhance existing systems.

· Develop a matrix for case definitions of communicable diseases (including foodborne-related diseases) for both sides of border. · Create protocol for coordination of binational outbreak investigations that includes epidemiology, laboratory, and environmental health. · Clarify what a binational case is. Add binational questions to questionnaires for foodborne disease cases / outbreak investigations and pilot test on both sides of border.

· Form work group to develop guidelines for coordination and timely information sharing during investigations of binational outbreaks. Includes recommendations on how to designate binational cases, identify binational outbreaks, and how to follow up. · Pilot test outbreak investigation guidelines by all interested local, state, or federal health entities

o Group will meet in one month (to allow time to identify participants) and will have protocol ready for piloting within 6 months.

o Steve Waterman and Ethel Palacios to help identify group members from border states o Joan (NM) o Contact person: US and MX state OB leads 2010: Develop Workgroups (provide guidance and structure) with specific names and phone numbers; Set a meeting date;present to public health authorities; possibly sub commitee of Binational technical Infectious Disease Workgroup

G-14

· Develop a borderwide protocol for information sharing between jurisdictions in US and Mexico regarding foodborne diseases/pathogens, including outbreak investigation and follow up information on binational cases investigated. 2010:

· Develop protocols to share information with different regulatory agencies on either side of the border (i.e. FDA, COFEPRIS) · Identify high-priority foodborne pathogens o Identify one pathogen to concentrate on. Suggested priority: salmonella ­ due to availability of preexisting data from the U.S. and availability of data from Mexico in near future.

· Define a list of highpriority pathogens and establish priority pathogens for study o Timeline: Now o Pathogens designated: Salmonella Campylobacter Shigella Shiga toxin producing E coli (including O157). Vibrio cholerae Vibrio parahaemolyticus Listeria Brucella Clostridium botulinum Hepatitis A o Priority pathogen for projects in 2009: Salmonella

o Available for use in 6 months. Testing will occur as OBs occur.

G-15

Laboratorio / Laboratory

· Assess laboratory capacity in the region to do testing for human and outbreak-related food specimens o Falls under the development of a summary of foodborne surveillance activities in the border region · Enhance laboratory capacity through training at national, state, and local level (include surveillance) o Strengthen state laboratory capacity through state training by partners. o Promote professional exchange between laboratorians o Formalize quality assurance of labs · Develop guidelines for establishing an investigative team (CDC-SINAVE/InDRE, state level lab and epidemiology representation) for overseeing/coordinating timely sharing of information and specimens between laboratories. Utilize existing guidelines as the basis for these guidelines. · Continued collaboration between InDRE and CDC for subtyping / PulseNet (characterizing)

· Laboratory personnel to participate in work group to develop a summary of foodborne surveillance activities in the border region ­ what is done, what is reported, and laboratory capacity. o 1-year - Results to be distributed at next year's meeting o Steve Waterman and Ethel Palacios to help identify group members from border states · Develop guidelines for establishing an investigative team (SINAVE-federal and state representatives, and US federal and state level lab and epidemiology representation) for overseeing/coordinating timely sharing of information and specimens between laboratories. Utilize existing guidelines as the basis for these guidelines. o Responsible Parties: DGE/InDRE, CDC · Laboratory personnel will participate in work group to establish guidelines for outbreak investigations. · Identify appropriate personnel to attend upcoming training courses (State or national level courses) o Timeline: TBD (depends on upcoming courses) o Persons responsible: State lab directors?

Intercambio de información / Exchange Information IT

· Disseminate analysis results, protocols, notification of events of interest in a rapid and effective manner

· Use Epi-X as a platform for alerts and general information exchange. · Identify secure method(s) for sharing confidential case information 2010: Develop strategy of communication

· Ensure all participants have digital certificate and equipment necessary to access Epi-X. Explore mechanism for providing translation of messages. · Identify secure method(s) for sharing confidential information

o Timeline: Pending o Timeline: One year

o Person(s) responsible: Steve Waterman and Ethel Palacios o Person(s) responsible: ?

G-16

Educación y formación de recursos humanos / Training and human resource development

· Train epidemiologists and laboratorians on foodborne disease surveillance 2010: identify needs/trainings based on needs assessment

· Build on existing efforts to include foodborne disease lectures/exercises in upcoming education/training programs · Identify key representatives from border states to participate in trainings/educational efforts · Ensure dissemination of information regarding foodborne investigation tools and ensure the ability to include partners from both sides of border.

· Add foodborne disease module to upcoming basic epi courses · Disseminate information on trainings / educational opportunities. · Share educational materials · Coordinate dissemination of public information regarding binational events

o Timeline: Depends on courses

o Persons resp: Course planners?

Promoción de la salud / Health Promotion

· Evaluate what resources exist in the region

· Share existing resources available on both sides of the border.

o Timeline: Within next 6 months, provide (post on Epi-X?) copies of existing materials/brochures.

Aspectos legales / Legal Issues

2010: formalize collaboration

G-17

Binational Infectious Disease Meeting / Reunión Binacional sobre Enfermedades Infecciosas San Antonio, TX, 28-30 June 2010 / 28-30 de junio, 2010

SESIÓN DE DISCUSIÓN 1 / BREAKOUT SESSION 1:

Identificar las colaboraciones actuales y los problemas / Identify current collaborations and problems

Group: Preparedness for and response to acute respiratory diseases including pandemic influenza

Colaboraciones actuales / Current Collaborations Vigilancia epidemiológica / Epidemiology Surveillance 1. Implement influenza Sentinel Surveillance in 4 US/6 Mexico Border States using established influenza case definition. sharing weekly ILI data an s producing a weekly ILI border report. COMMENT: Pilot Completed; Implement into 4 States; Share information in real time Pendientes principales / Main Pending Issues Technical Support Prioridades nuevas / New Priorities Fuente de financiamiento / Funding Source Otros aspectos / Other Issues

Getting approval

Share weekly ILI data Implement a weekly border wide report

EWIDS and BIDS Resources available for influenza surveillance (NRHC)

G-18

2. Testing of 100% of negative influenza samples from SAR hospitalized patients and BC. COMMENT: Delete

To get a representative number of positive influenza samples from BC Svere Acute Respiratory Patients

Other respiratory disease laboratory trainings

NAVY Resource Center and CDC

Possibility of expanding to other states or sites within BC

3. CDC/HHS To collaborate with Mexico Secretariat of Health and Canada Ministry of Health on updates to the Pandemic Influenza Response Plans (NAPAPI)

Federal to Federal revisions with input from states and provinces along the US-Canada and USMexico borders (consider Binational Technical Workgroup for revisions)

Update/Revise pandemic response plans based on lessons learned from Influenza A (H1N1) pandemic.

COMMENT: Delete because is completed. Ongoing collaboration. Chronic disease astma.

Laboratorio / Laboratory

Exchange ILI samples between cross-border state public health laboratories per quality control measures Weekly exchange of surveillance data

Crossing specimens and reagents across the international borders

Develop border-wide protocols for crossing of specimens and reagents legally and efficiently across the international border

Intercambio de información / Exchange Information IT

Need to connect data with US & MX and issue binational surveillance report

G-19

Educación y formación de recursos humanos / Training and human resource development Promoción de la salud / Health Promotion

Aspectos legales / Legal Issues

G-20

Binational Infectious Disease Meeting / Reunión Binacional sobre Enfermedades Infecciosas San Antonio, TX, 28-30 June 2010 / 28-30 de junio, 2010

SESIÓN DE DISCUSIÓN 2 / BREAKOUT SESSION 2:

Proponer posibles soluciones y más oportunidades de colaboración / Propose potential solutions and further opportunities for collaboration

Group: Preparedness for and response to acute respiratory diseases including pandemic influenza

Prioridades / Priorities Objetivos / Objectives Acciones principales / Key Actions CDC to meet with Imperial County to discuss feasability of project Fecha límite para completarse / Timeline 10/31/2010 Áreas o personas responsables / Responsible Areas or person Vigilancia epidemiológica / Epidemiology Surveillance Develop methodology to determine disease burden, vaccine cost-effectiveness, and vaccine coverage level for flu To develop data analysis protocol for sentinel surveillance data to answer questions about disease burden, vaccine costeffectiveness, and vaccine coverage level for flu To improve lab capacity for Legionella in Mexico Eduardo, Imperial County

Laboratorio / Laboratory

Train Mexico laboratorians on legionella testing

To identify laboratorians at CDC Legionella Lab willing to travel to Mexico to provide training

9/1/2010

Laurie Hicks and Celia Apuche

G-21

Establish a pilot project for coccidiomycosis and lab capacity for it if necessary

Steve Waterman

Intercambio de información / Exchange Information IT

Review existing federal and state educational flu materials used by both countries

To have an effective and consistent educational materials on flu prevention binationally

To gather the materials from state and federal agencies, review and select the best ones

8/1/2010

Eduardo, Alfonzo Rodriguez, and Promotorio Salud

Educación y formación de recursos humanos / Training and human resource development Promoción de la salud / Health Promotion

Aspectos legales / Legal Issues

G-22

Binational Infectious Disease Meeting / Reunión Binacional sobre Enfermedades Infecciosas San Antonio, TX, 28-30 June 2010 / 28-30 de junio, 2010

SESIÓN DE DISCUSIÓN 1 / BREAKOUT SESSION 1:

Identificar las colaboraciones actuales y los problemas / Identify current collaborations and problems

Group: Emerging infectious threats (including vector-borne diseases)

Colaboraciones actuales / Current Collaborations Vigilancia epidemiológica / Epidemiology Surveillance H1N1 collaboration; Univ of TX collaborations in north TX-looking for vectors for various diseases; continue for at least 5 more years; Pendientes principales / Main Pending Issues increased/continued/perman ent monitoring of rotavirus, rabies, WNV, dengue, brucellosis, chagas; determine binational case definitions; Prioridades nuevas / New Priorities rethink the mobility and fluidity of the border community (extending far into country on both sides) Fuente de financiamiento / Funding Source CDC, local/state HDs, PAHO, SS, SAGARPA; EWIDS has helped support surveillance; need to continue EWIDS funding in US and province a new EWIDS award to MX Otros aspectos / Other Issues introduction of Chikengunya into the /Americas. How do we prepare all countries with the vector to respond?

G-23

continuing BIDS project in west TX; focus shifted to enteric diseases; project with Tamps-TX has been completed; MX and PAHOjoint agreement to eliminate measles; training to start surveillance for polio binationally; EWIDS rikettsia surveilliance in Imperial and San Diego counties (mayaug 2009)

training and resources; transfer of knowledge; need established protocols; consider surveillance for reemerging diseases along the border (measles, rubella);

make connections with other states not immediately on the border but have binational cases; changing geographies of disease, most moving north;

PAHO, WHO, private sector, Bill Gates foundation, GDD, CARSO, Telmex foundation

need to increase collaboration with tribal groups; surveillance non specific events (preparedness);

rabies surveillance along the border with CDC; now webbased system RAB-ID can also gather geotemproal information; going live this year (2010); willing to collaborate system with MX data; 2 collaborations in El Paso, TX-working group for animal surveillance (meets monthly, zoo, Ft Bliss, MX); brucillosis-2011 CDC will have funds to do projects with border states; denguereportable dx in US;no current collaboration with Juarez directly with rabies or bruceillosis; mostly with just vector monitoring and surveilliance; rikettsia-CDC works with Mexicali and hope to continue sharing information and resources; Mexicali has implemented control actions, continues to fumigate and give education; cases are decreasing;

la region centro de mexico: consideramos la necesidad a compartir informacion para el control de enferedades y seguimiento de pacientes con bases juridicas disponibles

considerar finaciamiento para la construccion de capacidades en la frontera sur-sureste; ELC grant

EpiX membership

Laboratorio / Laboratory

MX lab collaborates with CDC lab-ID rabies cases and conducts training for staff;

strengthen support with InDRE to increase capacity/knowledge;

fortalecimiento capacidad lab con pruebas moleculares y confirmetoria para chagas

CDC, local/state HDs, PAHO, SS, SAGARPA

limitations on state employees to cross border for meetings and training; burden on MX partners to always travel to US

G-24

InDRE has received training and exchange and is ready to respond; Juarez receive support from Austin for lab testing;

standaradiazation/harmoniza tion of dengue testing at all levels (local, state, fed) in all latin american countries

increawsing and stardardize testing for rickettsia; improved malria surveillance as MX approaches elimination; sharing real time or near real time about diease with focal transmission; blood safety (chagas) testing in the US; foci of infection in US/ MX; implementacion de capacidaddes de lab para identificacion de patogenos desconocidos; contar con capacisdad dx para patogenos de origen africano; mundial futbol en sudafrica-safaris y enfermedades asociadas

preparation for possible dengue vaccine; accptaqnce of coutnirews of the use of a dengue vaccine; fucntion of vector control when dengue vaccine is implementes

sharing virus strains for research; analysis for moledular epi studies for dengue; molecular typing of rabies; virus variaence; rickettisa-CDC/ MX continue to share reagents, infor, and help MX increase testing capabileites Intercambio de información / Exchange Information IT El Paso-software package from ABS trying to recruit providers about notifiable conditions and using this reporting system;

develop training to be distrubted via web or CD; hacer videos de tecnicas de laboratorio para capacitaciones

should define larger collaborations between US/MX

CDC, local/state HDs, PAHO, SS, SAGARPA

ArboNet system for WNV and for dengue also; Educación y formación de recursos humanos / Training and human resource development Intercambio de informacion de casos binacionales identificados; exchange of information on identified binational cases.; collaboration with CSTE and local university for epi fellows and interns evaluation of point of care testing for dengue and the utility at the regional hospital level of health care CDC, local/state HDs, PAHO, SS, SAGARPA incluir las frontera sur en los palnes binacionales; la region centro se intersa en participar en los proyectos trinacionales y poder aportar infomacion que se traduzca en acciones de salud publica

MX/US univ have set up www.disease vectors.org Promoción de la salud / Health Promotion El Paso educate public with media campaigns and website; Mexico has traveler's health education but it may not be reaching the target populations; MXclean patio program?; health education programs in schools to education children how to better distribute health information along the border how do we educate this mobile population (social media, etc.); provide health education that patient can also give to family as primary prevention CDC, local/state HDs, PAHO, SS, SAGARPA AZ law about undocumented people makes it difficult to contact/educate

Knowing and sharing what is done in Mexico, learning what the U.S is doing. Integrating our health promotion activities.

develop materials that can be disseminated by using the community; target children for health education/prevention

dar informacion en los puntos de entrada; collaborate with NGOs

G-25

promocion de salud: capacitar a maestros para difusion escolar Aspectos legales / Legal Issues Canada created diagram of how reporting takes place from local to state, federal, international level and compared protocols; what level should we share the data? need to increase collaboration with tribal groups should there be sanctions established?

privacy geomapping issues; makes it difficult to track how dx (dengue) may be moving; hospitals/clinics/providers may lack sense of urgency reporting notifiable conditions

G-26

Binational Infectious Disease Meeting / Reunión Binacional sobre Enfermedades Infecciosas San Antonio, TX, 28-30 June 2010 / 28-30 de junio, 2010

SESIÓN DE DISCUSIÓN 2 / BREAKOUT SESSION 2:

Proponer posibles soluciones y más oportunidades de colaboración / Propose potential solutions and further opportunities for collaboration

Group: Emerging infectious threats (including vector-borne diseases)

Prioridades / Priorities Objetivos / Objectives Acciones principales / Key Actions Fecha límite para completarse / Timeline Áreas o personas responsables / Responsible Areas or person Vigilancia epidemiológica / Epidemiology Surveillance data sharing; determine disease to share; determine how often; clear comparison of case definitions; increase surveillance on zoonotic disease; maybe active surveillance; chagas disease in canine and human population; lyme disease; many non-reportable diseases are still important along the border establish guidelines and protocols for reporting and informing binational partners of outbreaks immediately; determine if certain disease endemic to border region can be added to reportable conditions lists for each states; expand focus beyond border health due to mobility and globalization create standardized forms for reporting and notifying binational partners; perhaps use BIDS system to disseminate data for outbreak detection; expand access and dissemination of information; partner with CSTE, dept of state, DHS; for a working group to include other key partners (legal, law enforcement)

Laboratorio / Laboratory

surge capacity and training plan in the event of an outbreak or pandemic

G-27

continue to host training for MX counterparts; identify needs to continue training Intercambio de información / Exchange Information IT alternative methods for those without access to computer increasing internet access to jurisdictions to better the dissemination of information

improve remote trainings; determine which trainings need to be provided in person

investigate the usefulness of fax, text message to send information

Educación y formación de recursos humanos / Training and human resource development Promoción de la salud / Health Promotion education of border population, travelers, and hard to reach populations; how do we share the effective programs with our posters outside of a conference social media (facebook, twitter), bus advertising, Aspectos legales / Legal Issues to share info about effective health education programs and materials with other states use EpiX forum to disseminate effective health education materials; secure access to EpiX for MX partners; are there alternatives to using the internet for sharing this info

approach companies like western union, bus companies

G-28

Appendix H: Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest Pre-release version approved by the United States Department of Health and Human Services in spring 2010. 1 Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest Developed by the Core Group on Epidemiologic Surveillance and Information Sharing Health Working Group, US-Mexico Binational Commission

1. Introduction In 2002, within the framework of the Health Working Group of the US-Mexico Binational Commission, representatives from the U.S. Department of Health and Human Services and Mexico's Secretaria de Salud established a binational group on Epidemiologic Surveillance and Information Exchange to address issues of interest to both countries. With the objective of better defining how the two countries should collaborate on epidemiologic events of mutual interest, this binational group has elaborated the present document to provide a set of common guidelines. The United States and Mexico have a rich tradition of collaboration on epidemiologic events involving the two countries, including infectious disease outbreaks, diseases associated with products from the other country, and the continuity of care for patients with tuberculosis traveling between the two countries. A joint Border Infectious Disease Surveillance project has been in place for several years, and an Early Warning Infectious Disease Project was initiated in 2004. The Binational TB Card Project facilitates healthcare provider access to information on TB patients traveling between the two countries to ensure continuity of therapy. Closely linked to these collaborations, public health professionals from the two countries have regularly sought to keep their counterparts apprised of relevant epidemiologic events. However, clear standards have not yet been established for what information should be shared and how the sharing should take place. The Core Group on Epidemiologic Surveillance and Information Sharing of the US-Mexico Binational Commission Public Health Working Group has chosen to formulate such a set of guidelines with the objectives of better institutionalizing the exchange of information on epidemiologic events of mutual interest, and promoting collaborative responses when appropriate. Recognizing that productive collaboration already occurs between many `Sister Cities' along the USMexico border and between neighboring states, it should be emphasized that the present Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual Interest (Guidelines) should facilitate continued existing binational cooperation, while at the same time fostering more systematic and comprehensive sharing of information at all levels of government. These Guidelines focus primarily on coordination between the public health agencies/units which have primary responsibility for epidemiologic surveillance. They do not seek to define coordination between agencies/units with major regulatory functions, for which agreements have already been established. These guidelines emerged shortly following the adoption by the World Health Assembly on May 23, 2005 of the International Health Regulations (IHR), designed to "better respond to the increasing interaction between countries of the world, and to the changing nature of public health threats". The Guidelines directly address IHR Article 44 - Collaboration and Assistance ­ which affirms that "State Parties shall undertake to collaborate with each other" for identifying, investigating and responding to events, for providing technical and logistic support, and in other ways. However, the present document

1

This document was endorsed by the Department of Health and Human Services in March 2010.

H-1

extends beyond the scope of the IHR ­ which targets public health emergencies of international concern by presenting guidelines for the sharing of epidemiologic information between the two countries regarding all epidemiologic events of mutual interest. It is not limited to public health emergencies of international concern, but seeks to maximize the capacity of each country to respond to all epidemiologic events of mutual interest. To identify those cases of infectious diseases which are of interest to both countries, this document uses the term "binational case" to refer to an individual with a confirmed or probable case of a notifiable infectious disease, and: · · · · who has recently traveled or lived in the neighboring country, or had recent contact with persons who lived or traveled in the neighboring country; or who is thought to have acquired the infection in the neighboring country or have been in the neighboring country during the incubation period of the infection and was possibly contagious during this period; or who is thought to have acquired the infection from a product from the other country; or whose case requires the collaboration of both countries for the purposes of disease investigation and control.

This document includes sections addressing the following: · · · · General Principles which orient the Specific Guidelines The Legal Framework for such binational coordination The Scope of Epidemiologic Events to which these guidelines are meant to apply Specific Guidelines for different classes of epidemiologic events

These Guidelines are meant to serve as a standard of conduct for public health agencies and their staff in responding to epidemiologic events of shared interest to both countries. While the Guidelines are not binding, it is planned they will lead to the development of shared protocols to facilitate their full implementation. 2. General Principles The guidelines of this document are based on the following principles: 2.1. The Need to Share Information The primary mission of public health agencies of the US and Mexico is to protect and promote the health of their citizens. However, epidemiologic events involving both countries ­ by geographic proximity, by cross-boundary movement of their citizens, or by exchange of their products ­ require the sharing of information between counterpart institutions. Such sharing has the objectives of providing information about potential risks and facilitating an appropriate response for the protection of the health of the public, in whichever country they reside. Adequate preparation for the risks of bioterrorism or other public health emergencies further requires that well-functioning channels of communication be established prior to the occurrence of such an event, to facilitate effective sharing of crucial information, and articulation of coordinated responses, to ensure the greatest protection possible of the public's health. In addition to sharing information to directly protect the public's health, counterpart agencies are also expected to share information on other public health matters affecting both countries, such as revised policies on travel or imported products from the other country. Such alterations in one country's positions

H-2

will create important demands on the public health agency of the other country, for which they should be as well prepared as possible to respond. 2.2 Timely Sharing of Information The value of epidemiologic information is closely linked to its timeliness. When needed, the sharing of such information between the US and Mexico should occur in a time frame which allows the other country to respond to the specific health need in as timely a manner as possible, maximizing the potential for effective public health action to prevent avoidable disease, disability and mortality. As such, information shared may be preliminary in nature and subject to change as events evolve. Preliminary information should be clearly communicated as such, and should not be disseminated outside the purview of relevant public health authorities unless by mutual agreement. 2.3 Quality of Information The value of the epidemiologic information being shared depends on its accuracy and completeness. The national and state public health authorities of both countries need to commit to providing the most comprehensive and current epidemiologic information available. 2.4 Communication Pathways Clearly defined pathways between public health agencies of the US and Mexico for communication of such epidemiologic information are needed to ensure rapid delivery to the appropriate agency and a high potential for action based on the information. When a specific need for binational information exchange arises, public health agencies at the local, state or federal levels of one country should communicate with their counterpart agency of the same level in the other country (i.e., local-local, state-state, or federalfederal). This should be conducted in parallel with communication to national partners, as defined by national policies. Communication to other levels of government (local-state, state-federal) is the responsibility of the agencies of each country, not of agencies in the neighboring country. Thus, once an agency in the second country is notified of an epidemiologic event, the responsibility lies with that same agency to notify partner public health agencies of the same country, unless specific guidelines dictate otherwise. While communications transmitted in the language of the other country are encouraged, those receiving communications should be sufficiently fluent in the language of the other country to understand messages composed in that language. 2.5 Joint Action to Respond to an Epidemiologic Event When an epidemiologic event occurs involving both countries and both have an interest in investigating the event (such as an outbreak investigation), the two countries should make a determined effort to conduct the investigation together. In this situation, the national public health agency of the country in which the study will take place has jurisdiction and will assume the coordinating role. Each country should be expected to provide the technical and financial support needed for its participation. Sharing of resources, eg. laboratory testing, may be necessary, is highly encouraged, and should be negotiated in a timely fashion. The timeliness of the investigation should be accorded a high priority by both countries. When rapid action is appropriate, the deployment of the team in the country where the outbreak is occurring should not be slowed by the delayed mobilization of the corresponding team from the other country. 2.6 Differences between Health Systems The roles of public health agencies of the United States and Mexico at the different levels of government are not always the same. In the United States, the public health sector is primarily state-based, while Mexico's health system is more centrally directed by the national Secretaria de Salud. Such differences must be taken into consideration in mounting the necessary responses when the two countries face an epidemiologic event requiring collaboration.

H-3

2.7 Respect for the Sovereignty and Laws of Each Country The responsibility for all public health responses to binational epidemiologic events lies with the public health agencies of the country where the respective activities will take place. All parties recognize the need for these same public health agencies to operate within the legal framework established by that country. If legal barriers are identified which limit the capacity of public health agencies to collaborate with counterpart agencies of the other country in the most effective way, such barriers should be addressed by the appropriate authorities with the objective of maximizing the benefit to the public's health in each country. 3. Legal Framework The following section reviews the legal framework currently in place for implementing these guidelines, from the perspective of the US federal and state governments and the government of Mexico. Federal and State Governments of the United States The Public Health Service Act (42 USC § 241 et seq) provides the Department of Health and Human Services (HHS) with a broad authority to conduct activities relating to the prevention and control of diseases and injuries. It also authorizes HHS to participate with other countries in cooperative endeavors to advance health sciences and improve the health of Americans. Requirements for disease reporting are typically defined in laws at the state and local level. The Centers for Disease Control and Prevention (CDC), however, together with the Council of State and Territorial Epidemiologists (CSTE) have defined a national list of notifiable diseases, and states provide information on these diseases to CDC's National Notifiable Diseases Surveillance System. In addition, ships and airlines are required by federal regulation to report deaths or ill passengers to CDC quarantine stations. CDC also operates various surveillance systems that track particular disease problems of national interest. The Privacy Act (5 USC § 552a) regulates certain terms of use by federal agencies of "systems of records" which include personal identifying information, as might apply to surveillance databases. While the Act sets controls on the terms by which federal agencies can gather, maintain, disseminate personal information, it also defines circumstances in which disclosure of information is permissible without the subject's consent. This includes disclosure "to a person pursuant to a showing of compelling circumstances affecting the health or safety of an individual" and pursuant to a routine use as defined in the system of records published by the agency. The system of records applicable to most of CDC's surveillance projects, "Epidemiologic Studies and Surveillance of Disease Problems" authorizes, among other things, disclosure to "cooperating medical authorities." The Freedom of Information Act (FOIA, 5 USC § 552) allows persons to request access to federal agency records. It applies only to federal records, though US states have their own equivalent statutes. The FOIA provides access to all federal agency records except for those records (or portions of records) that are protected from disclosure. While FOIA protects certain classes of information from disclosure, it would not appear to restrict the sharing of public health information with counterparts in Mexico as described in this document. The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule regulates how "covered entities" ­ e.g. healthcare providers, health plans, health billing services ­ use and disclose certain individually identifiable health information. While CDC is not considered a "covered entity," some state and local health departments may be. The HIPAA Privacy Rule recognizes the legitimate need for public health authorities and others responsible for ensuring public health and safety to have access to "protected health information" (PHI) to carry out their public health mission. The Privacy Rule permits covered entities to disclose PHI, without authorization from the subject, to public health authorities (e.g.,

H-4

CDC, State and local health departments) that are legally authorized to receive such reports for purposes of preventing or controlling disease, injury, or disability. This includes, for example, reporting of disease or injury; reporting vital events, such as births or deaths; and conducting public health surveillance, investigations, or interventions. At the direction of a public health authority, covered entities may disclose PHI to a foreign government agency that is acting in collaboration with a public health authority [45 CFR 164.512(b)(1)(i)]. Each state must review its laws relating to these guidelines to determine whether legal authority exists to exchange public health information and to collaborate in other ways with counterparts in Mexico on epidemiologic issues of mutual interest. Some states have examined their legislation, seeking to identify potential barriers to the sharing of epidemiologic information with Mexico. 2,3 All states are encouraged to complete an analysis of their laws for this purpose. In those cases where barriers are identified, states are encouraged to consider new legislation that would provide such authority, based on the value of such collaboration for the improvement of public health in our countries. The US Constitution, Article I, section 10, states in relevant part that "No state shall, without the consent of Congress, enter into any agreement or compact with another state, or with a foreign power..." With the approval of the State Department, however, states have the ability to enter into "non-binding" cooperative arrangements with each other and with their Mexican counterparts. Current plans to share epidemiologic information should be able to proceed under such arrangements. In summary, US federal legislation permits the sharing of epidemiologic information with a foreign country for the prevention or control of disease, with necessary restrictions based on confidentiality. Each state needs to review its own legislation to determine whether barriers exist to the exchange of such information. If present, this legislation should be reconsidered to ensure that state public health officials have the needed authority to improve the public's health through the sharing of such information. With the requisite authority under state law, states would be constitutionally permitted to enter into cooperative arrangements with each other and with Mexican states for the purpose of sharing epidemiologic information. Government of Mexico The legal framework of Mexico for epidemiologic surveillance is defined by an extensive set of determinations which include the Mexican Constitution, laws, regulations, decrees, agreements, norms, and decisions of the National Epidemiologic Surveillance Council (Annex 1). These legal instruments, created by or with the collaboration of the Secretaria de Salud, (SSA) indicate the steps to be taken to notify epidemiologic events within the country as well as the procedures to share such information with other countries ruled by the International Health Regulations. Other US-Mexico Collaborations HHS and SSA have established Memoranda of Cooperation in health and in epidemiology, respectively. The first defined one of the areas of cooperation as being "Health and human information systems, including telecommunications, statistical methodologies, and information exchange." The second specified the activities to include "Development and implementation of protocols in support of

Barriers to Binational Cooperation in Public Health between Texas and Mexico, Office of Border Health, Texas Department of Health, 2001 3 Annual Border Health Status Report, 2001: Barriers to California-Mexico Collaboration in Public Health, California Office of Binational Border Health, California Department of Health Services

2

H-5

epidemiological surveillance which are of mutual interest" and exchange of resources, including "jointly acquired public health information." In 2000 the US and Mexico signed an agreement creating the US-Mexico Border Health Commission. Among the functions to be carried out by the Commission is "to conduct or support a binational, publicprivate effort to establish a comprehensive and coordinated system, which uses advanced technologies to the maximum extent possible, for gathering health-related data and monitoring health problems in the United States -Mexico Border Area." The agreement contemplates significant state involvement in the Commission's activities, with the health officers from each of the ten border states serving as ex-officio members of the Commission, together with 14 other representatives from the border states of each country. Other existing mechanisms for collaboration between governments of the two countries on public health issues include the US-Mexico Binational Commission, the US-Mexico Food Safety Cooperative Agreement, the Border Governor's Conference, the Pan American Health Organization (PAHO) El Paso Field Office, border state Memoranda of Understanding, and Binational Health Councils of border Sister Cities. Joint public health collaborations are in place between the two countries in the areas of tuberculosis (Binational TB Case Management and Referral System), infectious disease surveillance (Border Infectious Disease Surveillance ­ BIDS, Early Warning Infectious Disease Surveillance ­ EWIDS), and others. In conclusion, the legal frameworks of the two countries at the national level allow for the exchange of information, as proposed in these guidelines. States will need to determine how their legislation relates to the Guidelines provided here. Numerous interfaces are already in place between health authorities of the US and Mexico, reflecting the need and desire to assist each other in confronting shared public health challenges.

4. Scope of Epidemiologic Events The purpose of this chapter is to characterize the scope or range of epidemiologic events for which both countries agree that exchange of epidemiologic information is appropriate. It is understood that the information to be shared by one country be such that it leads to or facilitates action in the second country which will be of direct benefit to the health of the population of one or both countries. This would include: A. Cases of disease identified in one country for which there is evidence or reason to suspect an epidemiologic link to the other country, including diseases detected in animals, or that such a link may occur in the future due to expected cross-border travel; B. Similarly, the identification of risk factors for disease in one country which may lead to disease in the other country. Types of epidemiologic events which meet these criteria include the following: · · · A probable or confirmed case of a severe or otherwise important vector-borne infection occurring in the border region of a border state (e.g. dengue or West Nile Virus encephalitis) A probable or confirmed case of a severe or otherwise important infectious disease with high potential for spread to the other country Infections in animals in the border region with potential for spread of severe disease to humans

H-6

· · · · · ·

A probable or confirmed case of severe disease suspected of having been intentionally spread Disease outbreaks which involve both countries at the time of discovery or which have a significant potential for spread to the other country Outbreaks of disease associated with travel or migration to the other country Outbreaks of disease or chemical contamination associated with food or other products originating in the other country Environmental health emergencies affecting both countries Binational cases of notifiable diseases

There is a tremendous interaction between the US and Mexico in the Border region, reflected by the more than 242 million northbound passenger crossings registered in 20044. While the physical proximity and intense interaction of the two countries in the Border region raises the risk of shared exposure to diseasecausing agents by citizens from both countries, binational travel and commerce are capable of carrying such exposures far beyond the border. The potential of an epidemiologic event to be binational must be considered throughout the full reach of both countries. 5. Specific Guidelines This section presents specific guidelines for different types of events and for different areas of collaboration. 5.1 Binational Cases As stated earlier, a binational case refers to an individual with a confirmed or probable case of a notifiable infectious disease who may have acquired or may transmit the disease in the other country, or who may require binational collaboration for investigation and/or control. An example of a binational case is a person with tuberculosis under treatment who crosses the border during the course of his or her medical care and public health follow-up. Such a binational TB case is thus at risk for interruptions in treatment with the consequent possibility of transmitting TB to others, as well as of developing drug resistant tuberculosis. Based on the "Need to Share Information" (General Principle 2.1) identification of binational cases by public health authorities warrants the sharing of relevant information with counterparts of the neighboring country to assist in finding other cases, to limit the risks of further disease transmission, and to ensure adequate control of the disease among identified cases. 1. Identification of Binational Cases - The determination of whether or not a person with a notifiable disease is a binational case requires obtaining information which currently is not routinely gathered. States should encourage health professionals making disease notifications of the need to explore whether cases are binational, especially in settings where this is more probable (locations with considerable travel between the countries, migrant populations, etc.). In the future, public health authorities should consider the value of incorporating information specifically designed to identify binational cases with the other information to be routinely reported. Questions designed to elicit such information should be prepared as part of the implementation phase of these Guidelines. 2. Notification of Binational Cases - Recognizing that binational cases, by definition, imply a public health risk to the neighboring country and usually require prompt public health action, binational cases of notifiable infectious diseases should be promptly reported to the appropriate public health official(s) in the neighboring country. Public health authorities of both countries will need to become familiar with the list of conditions which are notifiable in each country.

4

U.S. Department of Transportation, Transportation Statistics Annual Report (Washington, DC: 2005)

H-7

3. Information on Binational Cases - When necessary, the information shared on binational cases should be sufficient to allow appropriate public health follow-up of the case to take place. In some circumstances, this may entail sharing patient identifying information. Following the public health laws and privacy regulations of both countries, information exchange needs to be handled confidentially. 4.Timely Reporting of Binational Cases - Time frames need to be agreed upon by both countries for reporting binational cases to public health authorities. Urgently notifiable conditions should be reported within 24 hours of first identification. 5. Procedures for Notification of Binational Cases - Clear mechanisms of notification should be agreed to by public health officials of both countries, at the different levels of government, which specify: · · · Counterpart agency and corresponding office to notify Channels for communication which minimize delay in receiving the notification Information to be included regarding the binational case(s)

6. Follow-up Information on Binational Cases - The two countries should exchange follow-up information on binational cases so that the effectiveness of binational case notification and coordinated case investigations can be determined. 5.2 Binational Outbreaks The term outbreak is considered to represent a significant increase over the expected number of cases of a specific notifiable disease or other health problem in a given population over a given time period. The number of cases required to consider a cluster of disease cases an outbreak thus obviously depends on historical epidemiologic data and diagnostic criteria and laboratory resources. A single case of a rare disease, such as rabies or an "eradicated" disease such as smallpox, may constitute an outbreak, while numerous cases of more common diseases such as HIV/AIDS or tuberculosis may be required to be considered an outbreak. Newer diagnostic capabilities such as molecular fingerprinting techniques can identify a cluster of illnesses with indistinguishable molecular fingerprints; epidemiological investigation is then used to find links between these illnesses in the cluster. This combination of molecular fingerprinting and epidemiological investigation has identified numerous outbreaks, including widely dispersed outbreaks that would otherwise have gone undetected. An outbreak is considered binational: · · · when disease exposures occur in one country to visitors or migrants of the other country, when disease is associated with products from the other country, or when cases appear in border settings involving the population from both countries.

Upon recognition of a binational outbreak, if new cases continue to appear or exposure to causal agents persists, a rapid response is needed to accurately diagnose the illness, to determine the scale of the outbreak, to identify significant risk factors, and/or to implement appropriate control measures. Coordination between public health agencies of the two countries is essential for meeting the needs of all relevant parties and to achieve the most effective use of available resources. 1. Preparing for Binational Outbreaks - Pre-event preparations that should be made include: · Exchange of lists of binational contacts at the local, state, and federal levels · Contact information which provide for round-the-clock availability · Mechanisms for communication in both Spanish and English · Communications protocols for notification of public health officials and planning of needed responses · Mechanisms for the transport of specimens or needed supplies through US and Mexico customs

H-8

2. Communications for Binational Outbreaks - Once a binational outbreak is identified, the appropriate public health officials should be notified, following a pre-defined communications protocol. The public health authorities from each country should share the available data, and take a decision on the most appropriate response, including an agreement whether to initiate a binational investigation. 3. Collaborative Investigations of Binational Outbreaks - Upon binational concurrence to conduct a binational investigation or response effort, a binational oversight team of public health officials from the two countries should meet. Unless defined otherwise, the coordination of the investigation will be the responsibility of the lead public health authority where the outbreak is to be investigated. The oversight team will be responsible for or coordinate: · choosing the members of the binational field investigation team, including a lead from each country · field work preparation, including arrangements for any necessary travel, personal protective gear, prophylaxis, and availability of supplies and equipment · planning and implementation of the investigation · content of health alerts and press releases · determination of control measures based on information provided by field staff 4. Resources for Collaborative Investigations - Funding needed for the travel of investigation participants will be the responsibility of their home public health agency. Primary resources needed for the investigation itself will be the responsibility of the lead public health agency where the investigation takes place. In the absence of needed supplies or investigative capacity (e.g. select laboratory exams), sharing of resources between counterpart agencies is strongly encouraged. 5. Binational Cooperation in Sharing Epidemiology Resources ­ National and state public health agencies are encouraged to share informational and other resources designed to strengthen the epidemiology and response capacity of binational counterparts. Joint participation in multinational agencies (e.g. PAHO) and NGOs (e.g. TEPHINET) provides additional opportunities to identify such needs and appropriate tools which have been developed.

5.2.1 Foodborne Disease Outbreaks

Foods are responsible for many infections and toxic exposures. Within the United States foodborne diseases are estimated to be responsible annually for 76 million illnesses and 5000 deaths. The growing international trade of agricultural products has correspondingly been associated with outbreaks due to pathogens transmitted by foods imported from another country. The United States and Mexico have collaborated in responding to several such outbreaks. The organization of governmental roles in food safety often includes multiple agencies in both the health and agricultural sectors, and at the federal, state and local levels. To facilitate needed collaboration, a clear definition of the different roles of such agencies needs to be understood by neighboring countries, including the responsibility of each in responding to outbreaks of foodborne diseases. At the national level within the United States, the CDC is responsible for surveillance of human illness caused by foodborne disease and for epidemiological and laboratory investigation of outbreaks of foodborne illness. The United States Department of Agriculture (USDA) is responsible for regulating meat, poultry, and processed egg products. The Food and Drug Administration (FDA) is responsible for regulating all other foods, which includes seafood, dairy products, fruits, vegetables, and shell eggs, among other products.

H-9

At the state level in the US, the foodborne illness surveillance and investigation responsibility rests with the health agency at the state and local level, while the regulatory responsibility may rest with the agriculture department or the health department at the state level or the local health agency at the local level. When states want assistance from the CDC for foodborne outbreak investigations, state officials must make a formal request to CDC since CDC does not have the authority to send investigators without an invitation from state officials. In the event of an inter-state or international foodborne outbreak, the FDA and/or USDA would be contacted in order to cooperate with multiple jurisdictions in coordinating the outbreak investigation, including traceback, trace-forward and potential product recall. At the local government level in the US, there is wide variation in food safety roles and responsibilities among the 3000 local health agencies. In many localities, sanitarians have the primary responsibility for investigating reports of foodborne illness related to food service establishments, whereas in other localities reports of foodborne illness are investigated by state officials and the local sanitarians serve in a secondary support role. Within Mexico, as an agency of the Secretaria de Salud, the Federal Commission for Protection against Sanitary Risks (COFEPRIS) is legally responsible for conducting tracebacks of food products associated with foodborne disease. When informed by the United States of a foodborne disease outbreak associated with a product from Mexico, COFEPRIS coordinates internally and externally with other government agencies, according to the nature of the event. COFEPRIS has a Memorandum of Understanding signed with the FDA, as well as with Canadian agencies, for coordination of action in outbreaks of binational interest, to share information, to establish communication contacts and to prepare joint press releases. As part of this trilateral framework procedures for quick and efficient response to address all emergencies are in place to provide protection to the citizens within the three countries. The complexity of institutional organization on food safety in both countries creates an important need for collaboration between federal, state, and local authorities across international borders. Foodborne disease outbreaks often imply the need for two or more stages of investigation. The first stage is the primary epidemiologic and environmental investigation which ideally will identify the agent, the food vehicle and how the food became contaminated. Traceback of the food vehicle will indicate whether it is a domestic or imported product. In the latter case, and if the food product is suspected to have been contaminated at its point of origin, further traceback investigation of the implicated food product will determine its source. Additional investigation may identify how the food product became contaminated, where the most effective opportunity for future prevention exists and the need for regulatory action. These investigations represent important opportunities for collaboration between the two countries. 1. Regulatory Responsibilities in Foodborne Disease Outbreaks - Given that tracebacks and product recalls resulting from foodborne disease outbreaks fall under the legal responsibility of regulatory agencies, sharing of information needs to be conducted in accordance with the duties of those agencies and within the framework of the existing agreements between the food regulatory agencies in Mexico and the United States. 2. Trade-related Implications - Recognizing the important trade-related implications of foodborne outbreaks, epidemiologic conclusions need to be based on highly reliable scientific methods providing results which are shared with counterpart agencies in the other country. 3. Advanced Diagnostic Technologies - The use of advanced technologies (eg. pulsed field gel electrophoresis) for subtyping of human and food isolates will be encouraged, as well as the sharing of findings from such technologies with counterparts in the two countries.

H-10

4. Confidentiality and Information Sharing - Public health agencies and food safety regulatory agencies are legally obliged in both countries to maintain the confidentiality of patient identification and trade secret information. However, quickly sharing specific information among relevant agencies in both countries on the number and locations of persons who have become ill, the associated epidemiologic information implicating food vehicles, as well as the point of origin and total distribution of the implicated foods, is important to the rapid, appropriate and effective response to a binational outbreak of foodborne disease. The parameters that define which data must be shared and the conditions under which data sharing can legally occur should be determined in advance of binational food safety emergencies.

5.3 Potential Terrorist Events Recent events have forced the United States to recognize that intentional use of biologic, chemical or radiologic/nuclear agents to harm people of this country is a risk which it must be prepared to face. The possibility of introduction of such agents by way of the US-Mexico border or the release of an agent in one country with transmission to the other makes this an issue of interest to both countries. Such a scenario could foresee the appearance of cases in the border region which would require close binational coordination. The suspicion or identification of such an event as being intentional would lead to the involvement of law enforcement and potentially other agencies outside the health sector, with which national public health agencies would need to cooperate, as defined in national emergency response plans. Since disease arising by intentional spread may well appear without previous notice, health officials need to be aware of suggestive features of such an incident, including the following: · · · · · · · · · An outbreak of an unusual syndrome or disease, compatible with agents associated with bioterrorism, especially when occuring in a discrete population. Many cases of unexplained diseases or deaths. More severe disease than is usually expected for a specific pathogen or failure to respond to standard therapy. A disease that is unusual for a given geographic area or transmission season. Multiple simultaneous or serial epidemics of different diseases in the same population. Unusual strains or variants of organisms or antimicrobial resistance patterns different from those circulating. Similar genetic typing of agents isolated from distinct sources at different times or locations. Intelligence of a potential attack claims by a terrorist or aggressor of a release, and other evidence suggesting terrorist intent. Other unusual situations5,6

1. Emergency Communications Channel - The program units for public health emergencies in the two countries, including their directors, should be known to each other. Both program units should have a mechanism permitting direct contact on a continuous basis (i.e. 24 hours/day, 7 days/week, 365 days/year).

5 6

Recognition of Illness Associated with the Intentional Release of a Biologic Agent, MMWR 2001 Oct 19;50(41):893Recognition of Illness Associated With Exposure to Chemical Agents -- United States, 2003, MMWR 2003 Oct

897. 3;52(3):938-940.

H-11

2. Communication of Suspected Incident - Suspicion of any intentional health incident which presents a risk to citizens of the other country is to be urgently communicated to the counterpart agency responsible for such emergencies. 3. Ongoing Information Exchange - As such an incident evolves, information should be regularly exchanged at commonly decided intervals between corresponding public health emergency program units of both countries. 4. Resource Sharing in Emergencies - In preparation for such potential events, agreements should be established between the public health authorities of the two countries ­ including local, state and federal levels ­ regarding the sharing of health resources during public health emergencies, together with expedited clearance procedures for cross-border transfer of such resources by immigration and custom officials, when such a public health emergency is formally declared. 5. Adherence to Outbreak Guidelines - Cooperation in the investigation of such incidents is strongly encouraged and should follow the same guidelines as for naturally occurring outbreaks. 6. Quarantine of Foreign Citizens - In the event that a quarantine is considered necessary by the public health agency of a country that will include citizens of the other country, this decision will be communicated urgently to the counterpart public health agency of the other country. The public health agency enacting the quarantine needs to recognize the special needs of citizens of the other country who are caught outside their place of residence, while still ensuring the effectiveness of the quarantine measure. 5.4 Laboratory Issues Laboratories serve a unique role in both surveillance and investigation of health problems. The purpose of this section is to establish guidelines for laboratories when significant health events of binational interest occur mandating a collaborative response by both nations. The availability of laboratories and the complexity of testing which those laboratories are capable of performing vary along the length of the border in the two countries. This may lead to periodic use of laboratories by border clinicians or patients in the neighboring country. In addition, disease outbreaks or emergency preparedness plans may lead to decisions to share laboratory resources. In such cases, minimizing the time required for laboratory diagnosis and confirmatory testing is critical to timely identification of health problems and disease outbreaks so that appropriate and timely control measures can be implemented. This is particularly important when considering bioterrorism events and outbreaks of highly communicable diseases such as pandemic influenza or Severe Acute Respiratory Syndrome (SARS) which have the potential to cause substantial health, social, and economic problems. Each of the specific items detailed below must be addressed in establishing an efficient, highly functional, binational framework for laboratories to develop the needed capabilities for responding capably to disease outbreaks and other health challenges impacting both countries. 1. Binational Reporting of Notifiable Diseases - When a laboratory in one country analyzes or examines specimens from a person residing in the other country, and obtains a positive result for a reportable condition, this information needs to be routinely communicated to the appropriate public health officials where the tested individual resides. The mechanism for making this communication needs to be determined by state public health agencies working in coordination with public and private laboratories within its jurisdiction and with its counterparts in the neighboring country.

H-12

2. Transport of Laboratory Samples through Customs - In cases where specimens of public health interest need to be carried across the border for testing in a laboratory of the other country, mechanisms need to be established to assure expedited passage through customs, since excessive delay may compromise the quality of the specimen and the ability to obtain an accurate diagnosis. This is likely to require an advance agreement among the involved agencies, including the customs authority, specifying a clearly defined protocol to be followed for the rapid, cross-border transport of a set of specimens. 3. Standards for Sample Transport - Specimens being sent for testing in the neighboring country need to follow national and international standards for the labeling, packaging and transport of such material. In laboratories which may participate in such collaborative testing, specific training on implementation of these standards should be provided to responsible personnel in these areas, together with written instructions. 4. Authorized Request for Laboratory Testing - Submission of samples for diagnostic testing by a laboratory of the neighboring country should be preceded by communication between authorized public health officials of the two countries, with approval of the receiving laboratory. Upon arrival of the specimen, confirmation should be sent to the agency submitting the specimens for testing. In situations where there is potential for the laboratory to be sent a large number of specimens, the receiving laboratory should establish a triaging policy which defines the priority of received samples for urgent testing, and inform referring agencies of this policy. 5. Reporting of Laboratory Results - Laboratory results are to be communicated promptly to the requesting public health agency on a confidential basis. Only the agency submitting specimens for testing is authorized to publicly communicate the findings. When appropriate, specific protocols may be agreed upon which dictate alternate procedures. 6. Binational Laboratory Collaboration - Collaborative activities between cross-border laboratories is encouraged to enhance the scope of diagnostic capabilities available and the quality of the services provided. This may include training, provision of equipment, supplies and/or reagents, and participation in quality assurance programs. As with cross-border transport of specimens, agreements between public health agencies and customs authorities should be established to define protocols which facilitate the passage of such material. Roles of national and state public health agencies for coordination of such activities need to be defined by each country. 5.5 Public Health Communications As expressed throughout this document, successful binational exchange of epidemiologic information for public health depends on timely and clear communication of accurate information between appropriate public health authorities of the U.S. and Mexico. Failure to do so can result not only in an inadequate public health response to prevent and control disease among binational populations, but also to misunderstandings between officials and the populations of both countries. Such misunderstandings can undermine mutual trust and confidence and can create distorted and unequal perceptions of the epidemiologic situation affecting the two countries. For these reasons, establishing clear mechanisms and protocols for public health communications between the two countries is paramount. Communications between Public Health Agencies 1. Existing Information Sources - To facilitate the exchange of information recommended in this document, public health agencies should consult and subscribe to those information outlets provided by the other country (e.g. publications, press releases, Boletín Epidemiología, Health Alert Network, Epi-X).

H-13

2. Inter-Agency Communications - Direct communications between corresponding programs and staff of counterpart agencies is encouraged (e.g. to contact a known staff member in the measles unit to report a case of binational interest). However for cases when program staff are not known or cannot be reached, or for emergencies and other broader issues of common interest, counterpart agencies of the two countries should each have a telephone contact number and email address which is staffed at all times for such communications. In the case of binational events requiring continued collaboration, the communications offices of counterpart agencies should be in regular contact, exchanging relevant information and coordinating the release of information to the public. Release of Information to the Public 3. Harmonization of Public Information - In cases of binational epidemiologic events, information released to the public by the two countries regarding the event, risk factors and preventive measures, should be consistent, based on the best available scientific evidence of the event itself, and the pathogens or substances involved. Ideally, the population of each country should receive such information from their public health authorities in the same time period, to avoid creation of unexpected demands on public health authorities from one-sided releases, and to reinforce their credibility to the public. 4. Sharing of Information for the Public - In the case of a binational public health emergency or outbreak affecting the population of both countries, copies of information made available to the public by the respective public health agency should be shared with the counterpart agency of the other country. In non-emergency circumstances, such information should be made available on request. 5. Travel Notices - Travel notices are posted by public health authorities to provide information to travelers, the public, healthcare providers and public health authorities regarding outbreaks of disease of public health significance. The character of the notification is based on four criteria relating to disease transmission, containment measures, quality of surveillance, and quality and accessibility of medical care. In the case of such travel notices or other communications to the public which could have negative impact on trade, the counterpart agency should be given prior notice of the action to be taken and the evidence supporting that decision for their review and, if appropriate, their response. 6. Next Steps The intent of the Core Group on Epidemiologic Surveillance and Information Sharing is that the completion of the Guidelines be followed by the elaboration of a set of protocols to guide the implementation of these recommendations by the public health agencies of the two countries. This process should be undertaken with broad binational participation of the major public health agencies at the state and federal levels. Finally, the Core Group considers it likely that the present set of Guidelines will evolve over time, based on the experience accumulated in their implementation, and the identification of new or revised needs. In anticipation of this, the Core Group will review this document annually, to assess its continued validity, and to update the Guidelines as needed. Acknowledgments These Guidelines are the product of the Core Group on Epidemiologic Surveillance of the Health Working Group, US-Mexico Binational Commission. They were written under the coordination of the following individuals: - Cuauhtemoc Mancha, Dirección General de Epidemiología, Secretaria de Salud

H-14

- Jay McAuliffe, Coordinating Office of Global Health, CDC, Department of Health and Human Services - Pablo Kuri Morales, Director, Dirección General de Epidemiología, Secretaria de Salud - Steve Waterman, Division of Global Migration and Quarantine, National Center for Infectious Diseases, CDC, Department of Health and Human Services (HHS) The following individuals have contributed significantly to the drafting and/or review of this document: -Dr. Rigoberto Aranda, Dirección General de Comunicación Social, Secretaría de Salud -Miguel Betancourt, Dirección General de Epidemiología, Secretaria de Salud -Chris Braden, Diarrheal and Foodborne Disease Branch, National Center for Infectious Diseases, CDC, HHS -Gil Chavez, Council of State and Territorial Epidemiologists -Joanne Cono, Coordinating Office of Terrorism Preparedness and Emergency Response, CDC, HHS -Q.A. María Esther Díaz, COFEPRIS, Secretaría de Salud -RJ Dutton, Office of Border Health, Texas Department of State Health Services -M B Elvira Espinosa Gutiérrez, COFEPRIS, Secretaría de Salud -Jack Guzewich, Center for Food Safety and Applied Nutrition, FDA, HHS -Eva Holland, Office of General Counsel, CDC, HHS -Luis Anaya, Dirección General de Epidemiología, Secretaria de Salud -Richard Kellogg, Bioterrorism and Response Program, National Center for Infectious Diseases, CDC, HHS -Karl Klontz, Center for Food Safety and Applied Nutrition, FDA, HHS -Jim Misrahi, Office of General Counsel, CDC, HHS -Ellen Morrison, Office of the Commissioner, FDA, HHS -Chris Peters, California Department of Health -Morris Potter, Center for Food Safety and Applied Nutrition, FDA, HHS -Julie Rawlings, Office of the State Epidemiologist, Texas Department of State Health Services -Alfonso Rodriguez, California Department of Health -Shah Roohi, Coordinating Office of Terrorism Preparedness and Emergency Response, CDC, HHS -Don Sharp, Food Safety Program, National Center for Infectious Diseases, CDC, HHS -Dan Stier, Public Health Law Program, CDC, HHS -Rob Tauxe, Division of Foodborne and Diarrheal Diseases, National Center for Infectious Diseases, CDC, HHS -Ignacio Villaseñor, Instituto de Diagnóstico y Referencia Epidemiólogicos, Secretaria de Salud -Michelle Weinberg, Division of Global Migration and Quarantine, National Center for Infectious Diseases, CDC, HHS -Chad Wood, Emergency Communication Branch, National Center for Health Marketing, HHS

H-15

2

Annex: Mexico's Legal Framework for Epidemiologic Surveillance 1. Constitution of Mexico Article 4. Fourth paragraph. 2. Laws General Health Law. Articles: 17B, 133, part II, Chapter II of "Infectious Diseases" 134 to 157, 181, 353, 358, 359, 360 and 408 and others relating to epidemiologic issues. Federal Law for the control of Chemical Precursors, Essential Chemical Products and Machinery for Producing Capsules, Tablets and Pills Official Journal of the Federation 26 Dec 1997. Biosafety Law on Genetically Modified Organisms Official Journal of the Federation 18 Mar 2005. 3. Regulations Regulation of the General Health Law regarding International Sanitary Issues. Official Journal of the Federation 18 Feb 1985. Errata Official Journal of the Federation 10 Jul 1985. Regulation of the General Health Law regarding Sanitary Control for the Disposition of Organs, Tissues, and Human Cadavers. Official Journal of the Federation 20 Feb 1985. Errata Official Journal of the Federation 09 Jul 1985. Alterations Official Journal of the Federation 26 Nov 1987. Regulation of the General Health Law regarding Delivery of Medical Care Services. Official Journal of the Federation 14 May 1986. Regulation of the General Health Law regarding Health Research. Official Journal of the Federation 06 Jan 1987. Regulation of the General Health Law regarding Public Health Control of Activities, Establishments, Products and Services. Official Journal of the Federation 18 Jan 1988. Regulation on Health Supplies Official Journal of the Federation 04 Feb 1998. Corrections Official Journal of the Federation 19 Sep 2003. Regulation on Public Health Control of Products and Services. Official Journal of the Federation 09 Aug 1999. Regulation on Registrations, Authorizations of Importation and Exportation and Export Certificates of Insecticides, Plant Nutrients and Substances and Toxic or Dangerous Materials. Official Journal of the Federation 28 Dec 2004.

H-16

4. Plans and Programs National Development Plan 2001-2006. Official Journal of the Federation 30 May 2001. National Health Programa 2001-2006 Official Journal of the Federation 21 Sep 2001.

5. Decrees Decree which establishes the basis of coordination for the Secretaries of Commerce and Industry, of Agriculture and Water Resources, of Urban Development and Ecology and of Health, that should be observed in regard to Insecticides, Fertilizers, and Toxic Substances. Official Journal of the Federation 15 Oct 1987. Decree by which is created an administrative organ under the Secretaría de Salud denominated the National Blood Transfusion Center Official Journal of the Federation 21 Jan 1988. Decree by which is created the National Vaccination Council Official Journal of the Federation 24 Jan 1991. Corrections Official Journal of the Federation 05 Jul 2001. Decree by which is changed the National Council for AIDS Prevention and Control. Official Journal of the Federation 05 Jul 2001. Decree by which is created the National Bioethics Council. Official Journal of the Federation 07 Sep 2005.

6. Executive Agreements Agreement by which is created the Inter-Institutional Commision on Health Research. Official Journal of the Federation 19 Oct 1983 Agreement by which is created the Inter-Secretarial Commision on Biosafety and Genetically Modified Organisms Genéticamente Modificados. Official Journal of the Federation 05 Nov 1999.

7. Secretarial Agreements Agreement Number 43. By which is created the Health Research Committee. Official Journal of the Federation 11 Jan 1985. Agreement by which instructions are made known for the uniform and comprehensive procedure to which is subjected the Secretaries of Commerce and Industry, of Agriculture and Water Resources, of Urban

H-17

Development and Ecology, in the resolution of requests for authorizations for licenses, permissions, and registries of insecticides, fertilizers, and toxic substances. Official Journal of the Federation 07 Dec 1988. Agreement Number 130. By which is created the National Committee for Epidemiologic Surveillance. Official Journal of the Federation 06 Sep 1995. Agreement that establishes the classification and coding of merchandise whose importation is subject to regulation by those agencies which make up the Inter-Secretarial Commission for the Control of the Process and Use of Insecticides, Fertilizers, and Toxic Substances. Official Journal of the Federation 29 Mar 2002. Modification Official Journal of the Federation 01 Apr 2005. Agreement by which is established certification of the geographic areas that have achieved elimination of transmission of canine rabies. Official Journal of the Federation 16 Mar 2004. Agreement by which is established certification of the geographic areas which have achieved elimination of transmission of malaria. Official Journal of the Federation 16 Mar 2004. Agreement by which is created the National Committee of the Tuberculosis Action Program. Official Journal of the Federation 16 Mar 2004. Agreement by which is made known the instructions and forms for the authorization of importation and exportation of insecticides, plant nutrients and dangerous substances and materials. Official Journal of the Federation 15 Sep 2005. 8. Decisions of the General Public Health Council Agreement by which is established that public institutions of the national health system should purchase interchangeable generic medications. Official Journal of the Federation 07 Jun 2002. Basic List and Catalog of Medications 1996. Official Journal of the Federation 15 Nov 1996. Clarification Official Journal of the Federation 13 Feb 1997. First update Official Journal of the Federation 16 May 1997. Second update Official Journal of the Federation 21 Jun 1997. Third update Official Journal of the Federation 27 Oct 1997. Fourth update Official Journal of the Federation 09 Jul 1998. Fifth update Official Journal of the Federation 02 Jun 1999. Sixth update Official Journal of the Federation 08 Dec 1999. Seventh update Official Journal of the Federation 25 Apr 2000. Eighth update Official Journal of the Federation 07 Feb 2001. Ninth update Official Journal of the Federation 11 Feb 2002. Tenth update Official Journal of the Federation 12 Apr 2002. Eleventh update Official Journal of the Federation 01 Aug 2002. Twelfth update Official Journal of the Federation 03 Oct 2003. Fourteenth update Official Journal of the Federation 16 Jan 2004. Fifteenth update Official Journal of the Federation 25 Feb 2004.

H-18

Sixteenth update Official Journal of the Federation 19 Jul 2004. Seventeenth update Official Journal of the Federation 31 Aug 2004. Eighteenth update Official Journal of the Federation 27 Oct 2004. Nineteenth update Official Journal of the Federation 13 Oct 2004. Twentieth update Official Journal of the Federation 17 Mar 2005. Twenty-first update Official Journal of the Federation 19 May 2005. Twenty-second update Official Journal of the Federation 11 Jul 2005. Twenty-third update Official Journal of the Federation 06 Sep 2005. Twenty-fourth update Official Journal of the Federation 11 Nov 2005. Twenty-fifth update Official Journal of the Federation 26 Dec 2005. Basic List and Catalog of Biological Products and Reagents of the Health Sector 1997. Official Journal of the Federation 29 Sep 1997. First update Official Journal of the Federation 16 Mar 1998. Second update Official Journal of the Federation 20 Jul 1998. Third update Official Journal of the Federation 06 May 1999. Fourth update Official Journal of the Federation 22 Dec 1999. Fifth update Official Journal of the Federation 03 Nov 2000. Sixth update Official Journal of the Federation 13 Mar 2002. Seventh update Official Journal of the Federation 12 Apr 2002. Eighth update Official Journal of the Federation 06 Aug 2002. Catalog of Interchangeable Generic Medications Official Journal of the Federation 17 Aug 1998. First update Official Journal of the Federation 12 Oct 1998. Second update Official Journal of the Federation 26 Nov 1998. Third update Official Journal of the Federation 10 Mar 1999. Fourth update Official Journal of the Federation 20 Sep 1999. Fifth update Official Journal of the Federation 20 Dec 1999. Sixth update Official Journal of the Federation 05 Apr 2000. Seventh update Official Journal of the Federation 19 Feb 2001. Eighth update Official Journal of the Federation 29 Jul 2002. Ninth update Official Journal of the Federation 30 Jul 2002. Tenth update Official Journal of the Federation 08 Apr 2003. Eleventh update Official Journal of the Federation 23 Apr 2003. Twelfth update Official Journal of the Federation 14 Oct 2003. Thirteenth update Official Journal of the Federation 16 Oct 2003. Fourteenth update Official Journal of the Federation 10 Nov 2003. Fifteenth update Official Journal of the Federation 28 Nov 2003. Sixteenth update Official Journal of the Federation 16 Dec 2003 Seventeenth update Official Journal of the Federation 02 Feb 2004. Eighteenth update Official Journal of the Federation 04 Mar 2004. Nineteenth update Official Journal of the Federation 23 Mar 2004. Twentieth update Official Journal of the Federation 14 May 2004. Twenty-first update Official Journal of the Federation 14 Jun 2004. Twenty-second update Official Journal of the Federation 13 Aug 2004. Twenty-third update Official Journal of the Federation 01 Oct 2004. Twenty-fourth update Official Journal of the Federation 17 Nov 2004. Twenty-fifth update Official Journal of the Federation 13 Apr 2005. Twenty-sixth update Official Journal of the Federation 22 Jul 2005. Twenty-seventh update Official Journal of the Federation 23 Sep 2005.

H-19

Twenty-eighth update Official Journal of the Federation 12 Oct 2005. Twenty-ninth update Official Journal of the Federation 26 Oct 2005. Thirtieth update Official Journal of the Federation 11 Nov 2005. Thirty-first update Official Journal of the Federation 22 Dec 2005. Thirty-second update Official Journal of the Federation 03 Jan 2006. Agreement by which is established the Prevention and Health Promotion Strategy during the Stages of Life. Official Journal of the Federation 23 Oct 2003. Basic List and Catalog of Diagnostic Materials. Official Journal of the Federation 30 Jan 2004. First update Official Journal of the Federation 04 Jun 2004. Second update Official Journal of the Federation 30 Sep 2004. Third update Official Journal of the Federation 11 Feb 2005. Fourth update Official Journal of the Federation 13 Jun 2005. Fifth update Official Journal of the Federation 26 Dec 2005. 2005 Edition of the Basic List and Catalog of Diagnostic Materials. Official Journal of the Federation 16 Jan 2006. Agreement by which is established the Commission for Definition of Treatments and Medications Associated with Diseases that Result in Catastrophic Costs. Official Journal of the Federation 28 Apr 2004. Agreement by which is established the obligatory application in the public and private institutions of the National Health System, of the substantive and strategic components and components of the Action Program Startout Even in Life and of epidemiologic surveillance of maternal deaths. Official Journal of the Federation 01 Nov 2004. Agreement by which are established the general obligatory measures for the prevention, care and control of HIV/AIDS in the public institutions of the National Health System. Official Journal of the Federation 12 Nov 2004.

9. Official Mexican Norms Included here are all the Official Mexican Norms emitted to the present, but as per federal law, these are in effect for five years from the date of emission, in which time they need to be revised or will become inactive. National Advisory Committee on Standardization of Public Health Regulation and Promotion. SSA1. Official Mexican Norm NOM-003-SSA2-1993, on the use of human blood and its components for therapeutic ends. Official Journal of the Federation 18 Jul 1994. Errata Official Journal of the Federation 23 Feb 1996. Clarification Official Journal of the Federation 08 Sep 1994.

H-20

Official Mexican Norm NOM-012-SSA1-1993, public health requirements that private and public supply systems of water for human use and consumption public should follow. Official Journal of the Federation 12 Aug 1994. Official Mexican Norm NOM-020-SSA1-1993,Environmental Health. Criteria for evaluating air quality in regard to ozone (O2). The level of ozone concentration defined as a measure of protection of the population's health. Official Journal of the Federation 23 Dec 1994. Project Modification Official Journal of the Federation 31 Jul 2000. Official Mexican Norm NOM-022-SSA1-1993 Environmental Health. Environmental criteria for evaluating air quality in regard to sulfur dioxide (SO2). The level of sulfur dioxide (SO2) in ambiental air as a measure of protection of the population's health. Official Journal of the Federation 23 Dec 1994. Official Mexican Norm NOM-59-SSA1-1993, good production practices for chemical-pharmaceutical establishments engaged in the production of medications. Official Journal of the Federation 31 Jul 1998. Clarification Official Journal of the Federation 01 Feb 1999. Official Mexican Norm NOM-115-SSA1-1994, Goods and Services. Method for determining the presence of staphylococcus aureus in foods. Official Journal of the Federation 25 Sep 1995. Official Mexican Norm NOM-199-SSA1-2000, Environmental Health. Levels of lead in blood and actions as criteria to protect the health of populations exposed occupationally. Official Journal of the Federation 18 Oct 2002. Official Mexican Norm NOM-220-SSA1-2002, Installation and operation of pharmacosurveillance. Official Journal of the Federation 15 Nov 2004.

NATIONAL ADVISORY COMMITTEE OF STANDARDS FOR DISEASE PREVENTION AND CONTROL. Official Mexican Norm NOM-006-SSA2-1993 for the prevention and control of tuberculosis in primary health care. Official Journal of the Federation 26 Jan 1995. Modification Official Journal of the Federation 31 Oct 2000. Modification Project Official Journal of the Federation 02 Sep 2004. Modification Official Journal of the Federation 27 Sep 2005. Official Mexican Norm NOM-010-SSA2-1993, for the prevention and control of HIV infection. Official Journal of the Federation 17 Jan 1995. Modification Project Official Journal of the Federation 22 Sep 1999. Modification of the Norm Official Journal of the Federation 21 Jun 2000. Official Mexican Norm NOM-011-SSA2-1993, for the prevention and control of rabies. Official Journal of the Federation 25 Jan 1995. Modification Official Journal of the Federation 24 Jan 2001.

H-21

Official Mexican Norm NOM-016-SSA2-1994, for the surveillance, prevention, control and treatment of cholera. Official Journal of the Federation 05 Oct 2000. Official Mexican Norm NOM-017-SSA2-1994, for epidemiologic surveillance. Official Journal of the Federation 11 Oct 1999. Official Mexican Norm NOM-021-SSA2-1994, for the surveillance, prevention, and control of the tenia/cysticercosis complex in primary health care. Official Journal of the Federation 21 Aug 1996. Modification Project: Official Journal of the Federation 11 Sep 2000. Official Mexican Norm NOM-021-SSA2-1994, for the prevention and control of the teniasis/cysticercosis in primary health care. Modification Official Journal of the Federation 21 May 2004. Official Mexican Norm NOM-022-SSA2-1994, for the prevention and control of brucellosis in man in primary health care. Official Journal of the Federation 30 Nov 95. Modification Project: D.O.F: 27 Jun 2000. Modification Official Journal of the Federation 02 Feb 2001. Official Mexican Norm NOM-026-SSA2-1998, for epidemiologic surveillance, prevention and control of nosocomial infections. Official Journal of the Federation 26 Jan 2001. Notice of Cancellation Official Journal of the Federation 26 Nov 2003. Official Mexican Norm NOM-027-SSA2-1999, for the prevention, control and elimination of leprosy. Official Journal of the Federation 17 Jan 2001 Official Mexican Norm NOM-029-SSA2, for the epidemiologic surveillance, prevention and control of leptospirosis in man. Official Journal of the Federation 02 Feb 2001. Official Mexican Norm NOM-032-SSA2-2002, For the epidemiologic surveillance, prevention and control of vector-borne diseases. Official Journal of the Federation 21 Jul 2003. Official Mexican Norm NOM-036-SSA2-2002, Prevention and control of diseases. Application of vaccines, toxoids, sera, antitoxins, and immunoglobulins in man. Official Journal of the Federation 17 Jul 2003. Clarification Official Journal of the Federation 20 Jan 2004. Official Mexican Norm NOM-039-SSA2-2002, For the prevention and control of sexually transmitted infections. Official Journal of the Federation 19 Sep 2003. Official Mexican Norm NOM-041-SSA2-2002, For the prevention, diagnosis, treatment, control and epidemiologic surveillance of breast cancer. Official Journal of the Federation 17 Sep 2003.

H-22

10. Other juridic orders Criteria for the certification of geographic areas that have achieved elimination of canine rabies transmission. Official Journal of the Federation 19 Aug 2005.

11. International Decisions Decree by which is approved Prohibition of the Development, Production and Storage of Bacterial Weapons (Biologic) and Toxins and on their Destruction; approved during the XVI normal session during the United Nations General Assembly. Official Journal of the Federation 04 Apr 1973. Enactment Decree of the Convention on the Prohibition of the Development, Production, Storage and Use of Chemical Weapons and on their Destruction. Official Journal of the Federation 05 Oct 1994. Decree by which is approved the Cartagena Protocol on the Security of Biotechnology of the Convention on Biologic Diversity, adopted in Montreal, on January 21, 2000. Official Journal of the Federation 01 Jul 2002.

H-23

I-1

Information

PROCEEDINGS: UNITED STATES-MEXICO BINATIONAL INFECTIOUS DISEASE CONFERENCE

111 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

66855


You might also be interested in

BETA
Visio-CDPH-Org-Chart 5 16 13.vsd
PROCEEDINGS: UNITED STATES-MEXICO BINATIONAL INFECTIOUS DISEASE CONFERENCE