Cases of tuberculosis (TB) — an illness that kills more people than any other infectious disease — rose in the U.S. during 2022, per the Centers for Disease Control and Prevention (CDC). And some doctors are concerned that limitations of testing at the border could be partly to blame for the surge.
In 2021, the disease infected nearly 11 million people and caused 1.6 million deaths worldwide, according to the World Health Organization (WHO).
Tuberculosis is a highly contagious disease caused by a bacterial infection. It primarily affects the lungs, but can also affect the brain, kidneys and spine.
Required testing may have limitations: CDC
The CDC states that all refugees ages two and older must be tested for tuberculosis before entering the U.S.
TEXAS CITY REPORTS SYPHILIS OUTBREAK AMID 'LIMITED SUPPLY' OF PENICILLIN DRUG
"By law, refugees diagnosed with an inadmissible condition are not permitted to depart for the United States until the condition has been treated," the agency states on its website.
Some doctors are concerned that limitations of testing at the border could be partly to blame for the rise in tuberculosis cases. (iStock)
The CDC uses its Electronic Disease Notification (EDN) system to notify federal, state and local health departments of any immigrants and refugees who are found to have medical conditions that require follow-up.
There are limitations to that process, however.
"By design, the EDN system only collects information for the approximately 10% of immigrants who have an overseas medical classification," explained Neha Sood, health communication specialist for the CDC in Atlanta, Georgia, in a statement to Dr. Marc Siegel, clinical professor of medicine at NYU Langone Medical Center and a Fox News medical contributor.
"Thus, DHS [Department of Homeland Security] data were used to approximate the immigrant denominators."
There is also some degree of human error that comes into play, Sood added.
"Because data transfer for immigrants during the study period primarily relied on staff at ports of entry to correctly review, retain and route paper forms for each immigrant with a medical classification, human error likely caused some losses, resulting in possible underestimates of immigrants with medical classifications," she said.
While health departments are "encouraged and provided incentives" to share the results of immigrants’ testing with the CDC, Sood said there is always the chance of "underreporting."
She added, "The proportion of immigrants, refugees and eligible others who completed a post-arrival examination might be higher than indicated in this report."
Although the CDC has "comprehensive surveillance systems" to track communicable diseases within the U.S., the agency does not track diseases by immigration status, Sood explained.
Tuberculosis is a highly contagious disease that primarily affects the lungs, but can also affect the brain, kidneys and spine. (Spencer Platt/Getty Images)
Linda Yancey, M.D., a specialist in infectious disease who is affiliated with Memorial Hermann Health System in Houston, Texas, said she regularly sees people who have screened positive for the disease and need treatment to prevent developing symptomatic illness.
"Tuberculosis is quite common in Texas, especially in the big cities," she told Fox News Digital. "Houston is an international port of entry, so we get people from TB-endemic areas coming here frequently."
Most of the imported tuberculosis cases seen at Memorial Hermann are among people coming from Africa and the Indian subcontinent, Yancey said.
"This is why immigrants coming into the U.S. are screened at the time of entry," she said.
"People can be exposed to TB years before they become contagious," she went on. "By doing early screening, we are able to treat people long before they develop severe pneumonia."
WHY ANTIBIOTICS MAY NOT HELP PATIENTS SURVIVE THEIR VIRAL INFECTIONS: NEW RESEARCH
Immigrants who have positive screenings are given three to four months of pills to protect their TB from developing into an illness, Yancey said.
In a 2022 study by the University of Texas, researchers analyzed patterns in tuberculosis patients who had been diagnosed when crossing into the U.S. from the Mexican state of Tamaulipas, which serves as a "migration waypoint."
Homelessness: The Overlooked Public
Health Crisis
American Military University
By Steven Masone
PBHE211
December 25, 2022
Plagues, TB, and Urban Cities Crisis With Homelessness
History records most of the plague and other epidemics were urban city problems due to overcrowding and contaminated food and water supplies. This is aggravated by the living conditions that cities typically ignore, and shows we are sitting on a time bomb of several deadly epidemics that homeless camps and even shelters will be ground zero at in many Urban areas here and abroad. In Los Angeles, in the skid row district, there have been cases of bubonic plague from rats with diseases that are more associated with the middle ages, than with today’s public health’s fight against disease. Typhus, Hepatitis A and Shigella, not to mention tuberculosis and bubonic plague, are on the rise in homeless camps where sanitation is non-existent. This paper will attempt to use the data available to address the coming health crisis if homelessness in Urban areas are not dealt with and solved concerning curbing poor sanitation and infestations of rats and fleas. India statistics show 532K deaths from Covid -19, versus 1.1 million in the USA. USA deaths doubled India deaths. India has almost 4 the population of the USA. Was the population of India more protected by better immune systems, or are there other combined factors fewer died because of covid? Diet has much to do with American’s being
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overweight and unhealthier with the high risk comorbidities that added to our death rate. Could India’s 5% obesity vs US at 41% be a factor to the disparity that is between the death rates?
Before examining Urban cities in the USA, we will look at Mumbai, India slums in order to first understand how the most TB infected country in the world with an abnormally high drug resistant TB, got to the crisis level they are at. India of course has a caste system that keeps their
lowest caste of untouchables in slums. While India’s caste system is thousands of years old, it wasn’t until 1950, three years after independence from Britain, did their new secular constitution outlaw discrimination against the Dalit aka ‘untouchables’. Yet, like in America, minorities still suffer from poverty and lack access to healthy alternatives that keeps them down and in impoverished conditions. Dharavi district in Mumbai are the biggest slums in Asia, and in 1896 had one of the worst epidemics that killed over half of the slum population. Almost 60% of Mumbai’s population live in the slums.
In America, the states with the largest homeless population are California, Texas,
New York, and Florida. If these states were to have epidemics that caused their economies to crash, (via mass exodus) America would lose her place as the economic leader in the world. Or worse, while crippled, our enemies help with our further destruction via biological warfare. The homeless and crime increase in Portland Oregon, saw 11,000 people move out of Portland in 2020-2021, in just one year. Imagine if an epidemic of bubonic plague (or other deadly disease) from unsanitary conditions broke out there.
Antimicrobial Resistance in India’s Environment 3
The world saw the speed that Covid-19 spread into all the world recently. There was no vaccine or proven viral treatment to stop the pandemic that brought the world to lock itself down. A Super-MTB outbreak resistant to antibiotics would spread faster as symptoms could take weeks before someone gets sick and diagnosed, and all that time infecting others, will prove to be catastrophic to world health. According to the World Health Organization and the CDC, India’s
high rate of multidrug-resistant tuberculosis (MDR-TB) contributes to one-fourth of the world's overall rate. So, considering India’s the most populated nation in the world, antibiotics in the water system and agricultural products people eat, the perfect storm is on the horizon. One would have thought poorer countries did not use antibiotics as much as the more developed countries do, but India’s data on how much they use is not available. However, a CDC report states; “Antibiotic-resistant pathogens and their genes have been found in (India) streams, rivers, lakes, and oceans. They can often be traced back to discharge flowing from hospitals, farms, or sewage systems. Even properly functioning wastewater treatment systems may not fully remove resistant pathogens and their genes.” The TB pathogen has mutated its DNA to fight the antibiotics
are trying to kill it. India statistics show 532K deaths from Covid -19, versus 1.1 million in the USA. USA deaths doubled India deaths. India has almost 4 x the population of the USA. Was the population of India more protected by better immune systems, or are there other combined factors fewer died because of covid? Diet has much to do with American’s being overweight and unhealthier with the high risk comorbidities that added to our death rate. Could India’s 5% obesity vs US at 41% be a factor to the disparity that is between the death rates?
The New American Slums 4
As a young boy I often would travel through a skid row area in the cities I lived in. One such area was the Tenderloin District in San Francisco. Low income elderly lived in the low income apartments, and the homeless stayed in shelters at night, and sought their alcohol and drugs on the streets until checking back in shelters at night. The homeless were not allowed to loiter on streets during business hours. Now the homeless defecate on the streets and sidewalks without interference.
The common denominator between the Mumbai slum and homeless slum-like camps of the homeless in America is the way pathogens pass their infectious disease to others. If obesity makes Covid-19 more deadly, then an infection like TB that attacks the lungs, and is resistant to antibiotics, will wreak havoc where Covid-19 and Omicron also are weakening the immune systems of those at high health risks. Pneumonia resistant to antibiotics will further complicate a recovery from ‘ multidrug-resistant tuberculosis’ (MDR-TB). Obviously the infestations of rodent populations with fleas spreading TB. This is called the chain of infection, and it has six paths of spreading into a community. I have worked with the homeless for over 30 years and have helped house over 400 homeless veterans into permanent homes. The Urban homeless camps, shelters, and extreme weather shelters are mis-managed by too many disorganized Non-profits and have created a co-dependency between the homeless getting the help they need, and the non-profits getting the grant money they want. If a shelter has too many rules, like no drug use, threats of violence, no leaving to smoke cigarettes, and open and closing hours are better at another Non-Profit shelter, the one with the fewest homeless gets the least financial grants to pay their staff , especially top managers.
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Tenderloin circa 1980’s 
Tenderloin 2021
So, they all let the “inmates run the asylum.” Back-packs are not checked for weapons and contraband, and sexual assaults happen frequently in these extreme weather shelters where the sleeping areas are co-ed. Drug dealers check in to sell their poison and leave when sold out. Shooting up heroin in the bathrooms without cleaning up their blood and body fluids is a nightly ritual. Overdoses are common. Predators, robbers, thieves, and violent mentally ill persons terrorize the innocent homeless whose paths they cross daily. Portland's downtown area has always had a problem with rats as most Urban Port Cities do. According to an expert report, rats have increased 400% in the last 5 years, and the only pest control the city is doing is setting traps. One report claims they have only 60 traps set for the entire city, and they do not use poison. While homeless people move in and out from city to city, their growth fluctuates. The Metro Portland area has an estimated 10,000 homeless. With the economy in recession and inflation on the rise, the homeless growth obviously is going to cause a spurt in more people
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losing housing. Behind much of the causes of homelessness is substance abuse, and the crime that goes with addicts committing thefts to pay for their drugs. In 2015, the Bubonic Plague exploded in cases recording 5x’s the average yearly case rate. No one knows what caused the increase. Rural wilderness places like Yosemite Park in California have rodents that carry the plague and cases typically are found there. However, more and more cases cannot be traced to its origins. Unlike Mumbai, Portland Oregon Homeless Fortunately have access to cleaner water. Unfortunately, Portland has high levels of Antibiotic Resistant genes in its water like all of the nation has. Mumbai (Bombay) had a bubonic pneumonic plague outbreak in 1994 that caused much controversy as many claimed it was not the plague, when other scientists insisted it was. The last extreme weather shelter I worked at was plagued by an upper respiratory virus. Hundreds had caught this disease and staff were calling in sick to the point we did not have enough to operate safely. This had happened in the midst of the early break out of Covid 19. The average age of those in the shelter was 25-35. History shows many government agency’s responses to crises do so in a ‘knee jerk’ clumsy fashion if there are no templates that were used to have concrete plans and policies with efficacious proven science to act quickly and gain trust from the panicked public.
Pneumonia caused by Mycobacterium Tuberculosis
Resistant Antibiotics also inhibit the efficacy of the treatment for pneumonia, one of the most prevalent upper respiratory afflictions in the Homeless population. Previously in this paper we looked at the obesity in America perhaps a reason causing more deaths to Covid-19 than in India which has 4x the population. Obesity, naturally, is not rampant in the homeless population. However, poor nutrition and unsanitary conditions is, and can cause immune systems to be at
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risk to some of the same dangers of obesity. India was chosen for this paper because until 1950, they were a British Colony/Territory that occupied India as the British did to the American Colony. As the UK began Age is a factor as India's average age is 26.8 years, while the US is 38.5 and Brazil is 33.2 years, as of late 2020. link. Among other Southern Asian nations, Pakistan has an average age of 22 years and Bangladesh, 27.9 years. However, a younger age average of around 10% less than the USA average still does not explain India being 4 x more populated than the US, but suffering half the amount of deaths that India did. Other than a breakthrough in genetics, an effective Vaccine for the most deadly form of TB is not as effective as hoped. Vaccination is the most cost-effective public health interventions. The only available vaccine against TB, is Bacille Calmette-Guérin (BCG), and it provides very limited protection against pulmonary TB, the most prevalent and contagious form of the disease. Poverty is where this dilemma may be solved if research does not find more specific epidemiological causation factors. In America, there is no doubt the homeless and the mentally ill among them, with substance abuse, Hep-A-B & C, HIV and sharing breathing spaces, are among the poorest groups in America. Because of the crime against each other, and outside violent offenders threatening the weaker homeless, a new strategy of small groups 10-20 living together in giant makeshift tents and structures so “safety in numbers” protects them more, we can see bad things come from this shift in the homeless culture .This shift to large inclosed spaces could spark outbreaks of not only MDR-TB, but also other respiratory infections that will depress their immune systems. The saving grace of why we haven’t seen worse health conditions among the homeless is that they get out into the community to collect cans & bottles or whatever they do to support their drug habits everyday. One of the main reasons (other than addictions) it is hard to get homeless into
8
treatment is their “Hustle.” Their ‘hustle’ is routinely collecting cans, panhandling, etc. They are just as addicted to their routine hustle as they are the actual high from drugs. Any successful treatment should include understanding what they do to survive is their job, and that is a last vestige of their view of self worth. Substituting survival mode actions into a treatment plan is essential for breaking the “tape” that is running in their heads that they must ‘hustle’ or not survive. If they lose their job, it has to be replaced with a new one.
Many homeless sleeping together in limited breathing spaces may change the dynamics for the worse. Cities are building giant tent shelters for asylum seekers all over the country. These immigrants have not been thoroughly medically cleared, and as many will become part of the homeless population, which will exacerbate the potential spread of bugs and illnesses from
around the world. The great “melting pot” may bring more health issues and dangers than anyone can forecast. Another upside to our public health position post-pandemic, is that we now sanitize our hands and are maintaining most of the protocols we found successful in fighting the Covid-19 virus. Older people are much more proactive in staying in touch with primary physicians and adjusting their diets and anything that helps improve their immunity.
( Below example of group tents in Portland, Or)
Civilian Stand Downs? 9
Veteran Stand Downs are usually annual events where VA staff and volunteers provide food, clothing, legal matters handled, health screenings, for homeless and at-risk Veterans.Veterans housing solutions, employment, substance abuse treatment, mental health counseling and many other services are available.This template has worked for years in the homeless veteran population, and can be very effective for the general homeless population with a few adjustments and tailored for specific environments in urban to rural areas. While there is no direct evidence I found showing obesity and poor diet of Americans caused more Covid-19 deaths, than India’s, does not mean evidence will not be found. The UK and USA, with most of our genetics coming from our three major European migrations, are the top nations with highest deaths from pandemic. India is third highest but 4x the population of the US. Somewhere in this mix is a correlation point of genetic or biological reason India’s deaths were lower even though the cases were close in number. We have several ideas of where the virus came from, and the Asian locales may have an answer why a south asian country like India might have a stronger immunity against indigenous animals that can infect humans. History tells us time and time again how a new pathogen to a new world can kill hundreds of thousands or millions. Most likely to occur in our homeless camps if we don’t act soon. It will be expensive to health-check most homeless populations, but too costly if we don’t.
REFERENCES
G Geltner, The Path to Pistoia: Urban Hygiene Before the Black Death, Past & Present, Volume 246, Issue 1, February 2020, Pages 3–33, https://doi.org/10.1093/pastj/gtz028
News, E. J. | K. O. M. O. (2019, June 19). Paradise lost: Homeless in Los Angeles. WBMA. Retrieved December 21, 2022, from https://abc3340.com/news/nation-world/paradise-lost-homeless-in-los-angeles-06-19-2019
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Young, R., & Mitchell, J. (2019, April 3). Medieval diseases are mounting a comeback, specialists say. what are the causes? Here & Now. Retrieved December 21, 2022, from https://www.wbur.org/hereandnow/2019/04/03/medieval-diseases-typhus-comeback
Kaushal, J., & Mahajan, P. (2021). Asia's largest urban slum-Dharavi: A global model for management of COVID-19. Cities (London, England), 111, 103097. Asia's largest urban slum-Dharavi: A global model for management of COVID-19 - ScienceDirect
https://www.cdc.gov/onehealth/in-action/understanding-antibiotic-resistance-in-water.html
https://www.cdc.gov/tb/topic/populations/homelessness/default.htm
Wei, M., Yongjie Zhao, Zhuoyu Qian, Biao Yang, Xi, J., Wei, J., & Tang, B. (2020). Pneumonia caused by Mycobacterium tuberculosis. Microbes and infection, 22(6-7), 278–284. https://doi.org/10.1016/j.micinf.2020.05.020
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