United States–México

Border Health Commission

Binational Collaboration and Infectious Disease Surveillance 

along the U.S.-México Border

A White Paper 

April 4, 2011
United States – México Border Health Commission

Providing Leadership on Border Health Issues to—

Facilitate Identification, Study, and Research

Be a Catalyst to Raise Awareness

Promote Sustainable Partnerships for Action

Serve as an Information Portal

The mission of the United States-México Border Health 

Commission is to provide international leadership to optimize 

health and quality of life along the 

United States - México border.
 Infectious Disease Surveillance along the U.S.-México Border

United States-México Border Health Commission

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Background

The purpose of this white paper is to review some of the challenges and advances made toward binational 

collaboration in infectious disease surveillance along the U.S.-México border region to inform local, state, 

and federal public health officials in their efforts to improve binational and cross-border collaboration. This

paper also presents a number of cross-cutting issues produced by the work groups formed before and during 

the initial U.S.-México Binational Infectious Disease Conference, sponsored by U.S.-México Border Health 

Commission (BHC), in San Antonio, Texas, held on June 28-30, 2010, and reviews the need to support the 

implementation of the proposed Guidelines for US-Mexico Coordination on Epidemiologic Events of Mutual 

Interest.

The U.S.-México Border Region

The U.S.-México border is approximately 2,000 miles long and includes four U.S. states (Arizona, 

California, New Mexico, and Texas) and six Mexican states (Baja California, Sonora, Chihuahua, Coahuila, 

Nuevo León, and Tamaulipas). The border region extends from the international boundary 62 miles (100 

kilometers) north and south into the territory of each country. An estimated 15 million people live in the 

region, with border residents comprising 2.4 percent of the U.S. population and 6.9 percent of México’s 

population.

1

The border region has a highly mobile population that includes 26 ports of entry between México and the 

United States.

2 Several conditions that may affect the transmission of infectious diseases or efforts to control 

them are prominent in the U.S.-México border region, including poverty and high levels of migration.

3

Rates of some infectious diseases are notably higher in the border region as well. In 2007 the rate of 

tuberculosis in U.S. border counties was 9.8 cases per 100,000, well above the national rate of 4.4 per 

100,000.

4,5 México’s national level of tuberculosis was 16.4 cases per 100,000 in 2007, compared to 28.3 per 

100,000 in the northern border region of México.

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Infectious Diseases

The World Health Organization defines infectious diseases as those “caused by pathogenic microorganisms, 

such as bacteria, viruses, parasites or fungi; the diseases can be spread, directly or indirectly, from one person 

to another. Zoonotic diseases are infectious diseases of animals that can cause disease when transmitted to 

humans.”7 Examples of infectious diseases under surveillance that cause outbreaks in the U.S.-México 

border region include influenza, dengue fever, salmonellosis, tuberculosis, and HIV. 

Infectious disease surveillance, outbreak investigations, and interventions in binational cases require timely 

and effective collaboration across borders by public health professionals in epidemiology, laboratories, and 

health care. Infectious disease events also require the involvement of public health agencies and 

policymakers at the local, state, and national levels. Border health, particularly in the case of pandemics or 

potential bioterrorism, can profoundly impact social, economic, and national security.

History of Binational Collaboration in Infectious Diseases

Active U.S.-México collaboration in public health dates back to at least 1936. A list of major initiatives 

impacting the border region and both countries follows:8

1936: U.S. Representative R. Ewing Thomason proposes a bill for a U.S.-México border 

public health district.

1943-present: The Pan American Health Organization (PAHO) supports border infectious disease 

activities.
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1942-2010: The U.S.-Mexico Border Health Association (USMBHA) supports border infectious 

disease activities.

1991-present: The earliest binational tuberculosis projects are established.

1997-present: The Border Infectious Disease Surveillance (BIDS) program is established.

2003-present: The Early Warning Infectious Disease Surveillance (EWIDS) program is 

established.

2005: The U.S.-México Border Health and Infectious Disease Conference is held in El 

Paso, Texas.

2007: The Security and Prosperity Partnership of North America (SPP) Trilateral 

Workshop on EWIDS is held in El Paso, Texas.

2008: The U.S.-México Binational Infectious Disease Epidemiology and Laboratory 

Surveillance Meeting is held in El Paso, Texas.

2010: The U.S.-México Binational Infectious Disease Conference, sponsored by the BHC,

is held in San Antonio, Texas.

As indicated by the above events and activities, improved communication and collaboration among 

binational and cross-border governmental entities and organizations is essential for effective infectious 

disease surveillance and response systems.

Another step toward improving communication and collaboration among binational and cross-border 

government entities and organizations included initial discussions around the Guidelines for US-Mexico 

Coordination on Epidemiologic Events of Mutual Interest (Guidelines for short), which occurred in 1981 by 

the U.S.-Mexico Binational Commission, and provided a framework for working groups in multiple sectors, 

including health. The Binational Commission’s Health Working Group focused on immunizations, aging, 

migrant health, substance abuse and tobacco, women’s health, and epidemiologic surveillance.

In 2001, México proposed a new work group for epidemiologic surveillance. The Binational Commission 

Core Group on Epidemiologic Surveillance first met in 2002 and decided to proceed with a set of guidelines 

for how the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human 

Services (HHS) and the Secretaría de Salud (Health Ministry of México) should collaborate on 

epidemiologic events of mutual interest. Participants from the U.S. side included CDC, the Food and Drug 

Administration (FDA), border states, and the Council of State and Territorial Epidemiologists (CSTE).

Participants on the México side included the Dirección General de Epidemiología (General Directorate of 

Epidemiology [DGE]), Comisión Federal para la Protección contra Riesgos Sanitarios (Federal Commission 

for the Protection against Sanitary Risk [COFEPRIS]), and border states.

An updated version of the Guidelines was completed in late 2006. Some of the general principles include the

following: 

• need to share information

• timely sharing and quality of information 

• joint action to respond

• respect for sovereignty and national laws

While the Guidelines are not proposed to be legally binding, they offer a framework and scope for 

collaboration on epidemiologic events, specifically in terms of border and binational cases, outbreaks, 

potential bioterrorist events, laboratory-related issues, and public health communications.
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The Guidelines take into account the legal requirements of both nations and the need for information 

exchange at the federal, state, and local levels. The U.S.-México Binational Technical Work Group, formed 

to provide federal leadership and promote public health collaboration between the United States and México, 

has taken on the task of developing binational protocols to implement the Guidelines. This group, including 

federal and state members from the United States and México, first met in June 2010. 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.

HHS approved a draft of the Guidelines in the summer of 2010, and an updated version is currently 

undergoing review by both countries. It is anticipated that formal approval by both countries will occur in the 

near future. 

Advances in Cross-Border and Binational Collaboration

Programs such as the Border Infectious Disease Surveillance (BIDS) and Early Warning Infectious Disease 

Surveillance (EWIDS) have resulted in great advances in cross-border and binational collaboration on 

infectious diseases. The goal of the BIDS program is to establish a binational surveillance system and 

network for infectious diseases, fill knowledge gaps on unknown and emerging diseases, and exchange 

surveillance and epidemiological data, among other related objectives. BIDS accomplishments include 

enhanced surveillance, improved laboratory and epidemiology infrastructure in the border region, improved 

cross-border communication, early detection of outbreaks, and the development of the first binational webbased surveillance system. As part of BIDS, CDC has also provided training to lab personnel in México

dating back to 1999. 

The EWIDS initiative was proposed by the U.S.-México Border Health Commission (BHC) in 2003 and 

established in 2004 utilizing discretionary funding provided by the HHS Assistant Secretary for Preparedness 

and Response (ASPR) and administered through CDC. ASPR has provided funding to the four U.S. border 

states and México to support intrastate, interstate, and binational capacity for active infectious disease 

surveillance, laboratory testing, and preparedness and response. 

Numerous infectious disease surveillance and preparedness and response exercises, laboratory testing and 

trainings, and real-life response activities have been carried out in the U.S.-México border region. Activities 

occur at the regional and state levels and in binational settings involving U.S. and México federal health 

authorities as well as academic and private sector partners. EWIDS investments in México have provided 

information technology, laboratory equipment, and training that will support the implementation of the Early 

Warning System for the Sistema Nacional de Vigiliancia Epidemiología (National Epidemiological 

Surveillance System [SINAVE]), to be launched first in México’s six northern border states.

Between federal fiscal years 2003 and 2010, the four U.S. southern border states received over $29 million in 

funding to implement cross-border activities. EWIDS support has built a foundation for a coordinated 

binational system for infectious disease epidemiology, surveillance, improved laboratory analyses, notifiable 

disease reporting, and collaborative health emergency response in the U.S.-México border region. For more 

information on EWIDS, refer to the BHC’s EWIDS project white paper, U.S. Border States Early Warning 

Infectious Disease Surveillance Project, available on the BHC website at www.borderhealth.org. 

Cross-Cutting Issues in Binational Health Collaboration

The 2010 U.S.-México Binational Infectious Disease Conference provided an opportunity for border health 

professionals to revisit priorities and bring new post-H1N1 pandemic perspectives to these challenges and to 

identify solutions. Experts gathered in interest-specific work groups: (1) tuberculosis, HIV and other sexually 

transmitted diseases, and hepatitis; (2) foodborne illnesses; (3) acute respiratory diseases; and (4) emerging 
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diseases, including vector-borne diseases. Each group considered its existing programs and next steps toward 

improving cross-border collaboration in their field and, as a result, a number of cross-cutting issues were 

identified:

o Binational Technical Work Group should establish ongoing subcommittees organized around 

specific disease categories to continue the work started at the binational meetings in 2008 (El Paso) 

and 2010 (San Antonio). These work groups would seek solutions and implement actions to improve 

binational and border collaboration.

o Protocols are needed to clarify and improve processes for binational cases (case definitions) and 

outbreak investigations. Communication protocols for local to local, state to state, and federal to 

federal cross-border exchange of information are also needed to implement the general principles 

identified in the Guidelines.

o Communication should be more effective and timely in binational cases. One solution may be to 

develop diagrams of communication pathways. Additional information technology and interfaces for 

health information systems need to be developed.

o Training in both epidemiology and laboratory techniques related to existing and emerging infectious 

diseases is an ongoing need.

o Surveillance can be improved with innovative strategies. Existing surveillance networks and sites 

should be evaluated to determine whether additional surveillance efforts are needed in border 

communities or other areas of high cross-border mobility. Laboratories need to build surge capacity 

in preparedness for pandemics.

o Barriers in legal systems and import/export of biologic specimens, reagents, medicines, and medical 

or laboratory supplies need to be resolved through sharing information and, in some cases, making 

new policies.

o Resources and funding need to be utilized effectively and expanded to build infrastructure. In 

addition to surveillance data, binational counterparts can share resources such as bilingual and 

bicultural health promotion materials.

The disease-specific work groups formed during the 2010 U.S.-México Binational Infectious Disease

Conference, or other work groups which may be formed by the BHC in conjunction with the border states,

will ensure appropriate follow-up on the proposed programs and priorities as well as implementing action 

items such as developing the necessary protocols that will serve to improve cross-border and binational 

communication and coordination. 

These findings are intended to guide the established work groups in implementing the proposed Guidelines 

for US-Mexico Coordination on Epidemiologic Events of Mutual Interest. The work groups, whether 

binational or border/binational, are expected to report on their progress at the 2011 U.S.-México Border 

Binational Infectious Disease Conference and further advance those specific plans that will benefit improved 

communication and coordination of all critical border/binational infectious disease events. 
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 1 U.S. Census Bureau. (n.d.) Population Estimates Vintage 2009. Retrieved February 2, 2011 from

http://www.census.gov/popest/counties/counties.html.

Instituto Nacional de Estadística y Geografía. (2011). Censo de Población y Vivienda 2010. Retrieved 

February 2, 2011 from http://www.inegi.org.mx/sistemas/TabuladosBasicos/preliminares2010.aspx. 

There were 7,449,024 residents of the 44 U.S. border counties and 7,709,765 residents of the 80 México 

border municipios, using the border counties and municipios as defined by the U.S.-México Border Health 

Commission. The national populations were 307,006,550 for the USA (50 states plus the District of 

Columbia) and 112,322,757 for México (32 federal entities).

2 U.S. Customs and Border Protection. (2008). List of 8 CFR Vessel and Land Ports for Alien Entry and 8 

CFR Ports of Entry for Aliens Arriving by Aircraft. Retrieved February 1, 2011 from 

http://www.cbp.gov/xp/cgov/toolbox/ports/. 

3 United States-México Border Health Commission. (2010). Border Lives: Health Status in the United 

States–México border region. El Paso, TX: United States-México Border Health Commission. Retrieved 

from http://www.borderhealth.org/files/res_1534.pdf. 

4 Centers for Disease Control and Prevention. (2008). Reported Tuberculosis in the United States, 2007.

Atlanta, GA: U.S. Department of Health and Human Services, CDC. Retrieved from 

http://www.cdc.gov/tb/statistics/reports/2007/default.htm. 

5 Texas Department of State Health Services. (2010). Infectious Disease Control Unit-Tuberculosis Statistics.

Retrieved from http://www.dshs.state.tx.us/idcu/disease/tb/statistics/default.asp.

New Mexico Department of Health. (n.d.) New Mexico Health Data. Retrieved from 

http://nmhealth.org/ERD/HealthData/tb_data.shtml. 

Arizona Department of Health Services, Bureau of Epidemiology and Disease Control, Office of Infectious 

Disease Services. (2009). Tuberculosis Surveillance Report Arizona 2007. Phoenix, AZ: Arizona Department 

of Health Services. Retrieved from 

http://www.azdhs.gov/phs/oids/tuberculosis/pdf/2007_Tuberculosis_Surveillance_Report.pdf.

California Department of Public Health. (2010). Tuberculosis Disease Data. Retrieved from 

http://www.cdph.ca.gov/data/statistics/Pages/TuberculosisDiseaseData.aspx. 

6 United States-México Border Health Commission. (2010). Frontera Saludable 2010. Reporte de Medio 

Plazo. Frontera Norte de México. Tijuana, México: United States-México Border Health Commission. 

Retrieved from http://www.borderhealth.org/files/res_1637.pdf. 

7 World Health Organization. (2011). Infectious Diseases. Retrieved from 

http://www.who.int/topics/infectious_diseases/en/. 

8 Opening remarks by R.J. Dutton, Director, Office of Border Health, Texas Department of State Health 

Services, at the U.S.-México Binational Infectious Disease Conference. San Antonio, TX. June 28, 2010.
The United States–México Border Health Commission

Providing Leadership on Border Health Issues to –

Facilitate Identification, Study, and Research

Be a Catalyst to Raise Awareness

Promote Sustainable Partnerships for Action

For additional information please visit our website at www.borderhealth.org.

 United States–México Comisión de Salud Fronteriza

 Border Health Commission México-Estados Unidos

 211 N. Florence, Suite 101 Avenida Durango No. 247, 4o piso

 El Paso, TX 79901 Col. Roma Norte, Delegación Cuauhtémoc

 Tel: (915) 532-1006 C.P. 06700 México, D.F.

 Fax: (915) 532-1697 Tel./Fax (01152-55) 3611-0765

 Toll Free (866) 785-9867 www.saludfronteriza.org.mx

 www.borderhealth.org