As covid grabbed the world’s attention, Texas’ efforts to control TB slipped

Reviewed by Emily Henderson, B.Sc.Feb 16 2023

Narciso Lopez has spent more than two decades working to control the spread of tuberculosis in South Texas. He used to think that when patient traffic into the clinics where he worked was slow, that meant the surrounding community was healthy. But when the covid-19 pandemic hit in early 2020, that changed.

In a matter of months, patients seeking care at the county's two clinics dropped by half. "And then I wasn't getting any at all," he said.

As covid gripped the world's attention, Lopez began to focus on a parallel concern: whether TB was being overlooked along the Texas-Mexico border.

"I knew there had to be TB cases out there; they just weren't being found," Lopez said in a recent interview.

Before 2020, advances to eradicate TB, which is spread person-to-person through the air, were underway globally. It was considered by many public health experts to be a feasible goal, since tools are available to identify and treat it. But the prevalence of the disease in Mexico, and immigration along the border, has made it a longtime health concern in these communities.

In areas with high immigrant traffic, such as Cameron County, TB is a serious health concern. Cameron sits at the southernmost tip of Texas, and each year millions of people cross to and from Mexico at the four border crossings in the Brownsville region. Brownsville is the county's seat and largest city. In 2019, before covid, Texas' 32 border counties had an average TB incidence of 8.4 cases per 100,000 people — more than double that of the state overall, and nearly triple the national rate.

Since the pandemic began, though, some tuberculosis clinics in border areas have been performing fewer tests, receiving fewer referrals from local hospitals and providers, and treating fewer patients. Lopez and others who do this public health work every day on the ground agree it's not likely less TB is circulating. Instead, they say, covid testing and treatment have claimed so much attention and energy that TB has been pushed off the radar, threatening to reverse decades of progress in eliminating it.

Lopez said his county's tuberculosis department usually gets around 40 to 60 patients a year. "And then, all of a sudden, we went down to 20 during the covid pandemic," he said. The numbers seem to be bouncing back. In 2022, Lopez said, the county's clinics saw 35 TB patients. But that's still lower than pre-pandemic levels.

Hidalgo County, which neighbors Cameron to the west, experienced a similar trend in 2020, when its number of confirmed TB cases was cut in half from the previous year, dropping from 71 cases to 36, according to Jeanne Salinas, tuberculosis program manager of the county health department. The county also performed hundreds fewer TB tests.

Since 2020, Salinas said, tuberculosis has been "overlooked" as a diagnosis for patients reporting "prolonged cough or cough with blood, losing weight, having fevers." After covid became everyone's overriding concern, these patients — who included new immigrants as well as people who regularly traveled across the border for work or to visit family on the other side — were tested for covid. Salinas said it was only if the symptoms persisted that patients would perhaps be evaluated for tuberculosis. This lag time allowed the illness to progress in individual patients and potentially spread in the community.

This reflects a nationwide trend. According to the Centers for Disease Control and Prevention, U.S. tuberculosis incidence rates "decreased steadily" from 1993 to 2019. In 2020, though, there was a "sharp" decline of nearly 20% in recorded cases, which the CDC materials suggest may be due to "delayed or missed TB diagnoses or a true reduction in TB incidence related to pandemic mitigation efforts and changes in immigration and travel." But because TB is more contagious than covid (its particles stay in the air longer), steps like masking and distancing are less effective. So, Salinas argues the former.

Convincing people of the need to test for TB was difficult even before covid, Lopez said. For starters, some health workers wrongly considered the illness a nonissue. That tuberculosis and covid share similar symptoms became another complication. When doctors and other health professionals saw those symptoms, their first concern was covid. And for a while, it was their only concern.

Other issues are diagnosis and treatment. Samples for covid rapid tests, and even the more sensitive and expensive PCR tests, can be collected with a simple nasal swab. TB screening is more invasive, done with either a skin test that requires a follow-up visit to a health professional or a blood draw that is tested in a lab. At the height of the pandemic, Lopez said, providers were so focused on getting people in and out of clinics and hospitals quickly that taking the time to conduct TB screenings wasn't a priority.

Though TB is a curable disease, its treatment can require up to a year of prescribed antibiotics, which experts say adds to the urgency of detecting cases early on.

The Texas Department of State Health Services says on its website that tuberculosis rates are "higher along the Texas-Mexico border" than in the rest of the state. Dr. Armando Meza, chief of infectious diseases at Texas Tech University Health Sciences Center in El Paso, said that's because "almost all cases of tuberculosis in the United States are coming from immigrants."

Dr. Linda Villarreal, a former Texas Medical Association president who is a member of the group's Border Health Caucus, added that many people live in Mexico but work in Texas, and vice versa, "so with that comes perhaps unclear health issues and exposure."

There's yet another snag. Tuberculosis, Villarreal explained, is especially hard for people's immune system to suppress if they also have other health issues, and the border is a hot spot for diabetes and other chronic health conditions like hypertension or heart disease.

Covid, itself, is something of a comorbidity because it can make people more susceptible to tuberculosis. Some of her patients have had both illnesses, Salinas said. She suspects some who died of covid may have had tuberculosis as well, or instead.

Border areas tend to be impoverished, and "TB is a disease of the poor," Texas Tech's Meza said. "And who is poor in this country? The minorities, the immigrant populations, the mentally ill who live in close gatherings and shared common spaces." Not to mention people who are uninsured and can't afford health care.

Meza said he drives by the border often, and when he does, he sees crowds waiting on the Mexican side in Juárez, hoping to get across. If they do, he said, he hopes they get proper health screenings and care.

"To me, that's what I'm afraid of more than covid," Meza said. "If there is no change systematically, then that's when things can get more complicated."