Workshop Summary 

Infectious Disease Prioritization for 

Multijurisdictional Engagement at the 

United States Southern Border Region

This report was authored by CDC, with input from Arizona 

Department of Health Services, California Department of Public 

Health, New Mexico Department of Health, Texas Department of 

State Health Services, and other participating health departments.

CS 321518-A September 2021 
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Photo 1. Woman and her daughter receiving Zika prevention health education. Photo credit: Maureen Fonseca-Ford

DISCLAIMER

The findings and conclusions in this report are those of the authors and do not necessarily represent the 

official position of the Centers for Disease Control and Prevention. 
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TABLE OF CONTENTS

Participating Organizations ................................................................................................................... 1

Summary................................................................................................................................................... 2

Background .............................................................................................................................................. 3

Workshop Methods ................................................................................................................................. 5

Criteria Selected for Ranking Infectious Diseases ................................................................................................ 7

Results ....................................................................................................................................................... 9

Table 1. Description of priority infectious diseases at the US southern border region

selected by voting members using a multijurisdictional process in the Infectious 

Disease Prioritization Workshop conducted in September 2018.................................................................. 10

Key Themes and Next Steps ................................................................................................................. 12

Coordination ............................................................................................................................................................ 12

Surveillance.............................................................................................................................................................. 13

Laboratory ................................................................................................................................................................ 13

Outbreak Response and Preparedness................................................................................................................ 14

Health Communication, Education, and Outreach ............................................................................................ 14

Appendix A: US Border Counties ......................................................................................................... 15

Appendix B: Overview of the One Health Zoonotic Disease Prioritization Process ..................... 16

Appendix C: Infectious Disease Prioritization Workshop Participants for the 

US Southern Border Region ................................................................................................................. 17

Appendix D: Ranked Disease List and Scores from the Infectious Disease Prioritization 

Workshop for the US Southern Border Region................................................................................................ 19

Appendix E: The Criteria and Questions with Associated Weights Used for 

Ranking Infectious Diseases at the US Southern Border Region, and Scores 

for the Corresponding Answers to Questions.................................................................................... 20

Appendix F: Key Themes and Next Steps for Prioritized Diseases ..................................................... 22

References .............................................................................................................................................. 27
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Photo 2. Santa Elena Canyon, Big Bend National Park, Texas and Mexico border
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PARTICIPATING ORGANIZATIONS

Arizona Department of Health Services 

California Department of Public Health

New Mexico Department of Health

Texas Department of State Health Services

Imperial County Public Health Department

San Diego County Health and Human Services Agency

United States Health and Human Services Agency, Office of Global Affairs

Centers for Disease Control and Prevention (CDC)

Division of Global Migration and Quarantine, US-Mexico Unit (DGMQ, USMU)

Division of Vector-borne Diseases (DVBD)

Office of Public Health Preparedness and Response (OPHPR)

One Health Office
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SUMMARY

The first of two purposes of the two-day Infectious Disease Prioritization Workshop was to identify 

and prioritize endemic and emerging infectious diseases in the US southern border region of mutual 

concern to US federal and state partners. Diseases to be considered were those that can be introduced 

and amplified, or cause an outbreak, because of movement of people, products, or animals between 

the United States and Mexico. The second purpose was to develop plans to address gaps in surveillance, 

response, or other relevant activities for the prioritized diseases. This initiative followed the One Health 

Zoonotic Disease Prioritization Process, a mixed methods prioritization process developed by the US 

Centers for Disease Control and Prevention (CDC).1,2

During a pre-workshop webinar, representatives from US federal agencies and from state and local public 

health agencies within the southern border states reviewed, discussed, and agreed on an initial list of 

20 infectious diseases to go through the prioritization process. These diseases were drawn from a larger 

list developed during previous border health initiatives. During the workshop, representatives defined 

criteria for prioritization, developed questions to characterize each disease by the criteria, and assigned 

weights to each criterion. Using this semi-quantitative process, followed by a qualitative review for final 

ranking, participants identified four infectious diseases or disease groupings as priorities. The workshop 

identified preliminary recommendations for potential collaborative actions, with further discussion during 

three post-workshop webinars. The resulting prioritized infectious diseases for the US southern border 

region are tuberculosis, Aedes mosquito-transmitted arboviral diseases (dengue, chikungunya, Zika), 

enteric diseases (Vibrio spp., Listeria monocytogenes, nontyphoidal Salmonella (NTS), Brucella spp.), and 

rickettsioses (R. rickettsii, R. typhi, R. parkeri). 

Working to control infectious diseases in a border region requires international collaboration and 

communication. While this disease prioritization initiative established a portfolio of mutual US state 

and federal domestic infectious disease priorities for the purposes of joint action and focus, many of 

the prioritized diseases are also being addressed as shared US-Mexico interests. Next steps will involve 

binational forums and activities. If the disease prioritization initiative moves the border health agenda 

forward, such an approach could be useful in a binational context.

Photo 3. Infectious Disease Prioritization Workshop Participants. Photo credit: Maureen Fonseca-Ford 
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BACKGROUND

The United States and Mexico share a 1,954 mile-long land border, which extends from the Pacific Ocean 

to the Gulf of Mexico.3 Four southern US states share a border with Mexico: California, Arizona, New Mexico, 

and Texas.4 People from all over the world cross the US southern land border from Mexico to visit or to 

live in the United States. Some pass through the border region in transit to other areas, and others remain 

in the border region. Many people who live in the region regularly move between the United States and 

Mexico to visit, work, shop, and seek services. In 2016, there were 185 million northbound border crossings 

(from Mexico to the United States) at 25 land ports of entry. One of these, in San Ysidro (San Diego 

County), California, is one of the world’s busiest border crossings.5 The movement of people, animals, and 

products between the two countries creates a binational environment, interconnected by close social and 

economic ties, and a unique epidemiologic region for detecting, preventing, and controlling infectious 

diseases and their binational spread. In this report, we define the US southern border region (hereafter 

called “the border region”) as the 44 US counties within 100 km of the Mexico border6 (Appendix A). The 

border region has many adjacent “sister” cities flanking the US–Mexico border, such as those shown in 

the map below. The three largest US metropolitan areas in the border region are San Diego, California 

(population 1.4 million), El Paso, Texas (population 690,000), and Laredo, Texas (population 257,000).7

Figure 1. The US-Mexico Border Sister Cities. Image credit: EPA—https://www.epa.gov/usmexicoborder

In 2015, 7.7 million people lived in the 44 US counties that comprise the border region.* Most border region 

residents are Hispanic;8 in several border counties, over 90% are Hispanic.9 Border states are also among the 

five states with the largest Native American populations.10 There are 25 federally recognized Native 

American reservations in the border counties,11 and the Tohono O’odham tribal nation physically spans the 

US-Mexico border.12 US border states are home to 9 million foreign-born persons from Spanish-speaking 

* The Mexican side of the border is nearly as populous; in 2015, 6.7 million lived in 80 Mexican border municipalities.
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countries, including 7.4 million born in Mexico and 

another 1.2 million born in Central America. The 

border states have 8.1 million Spanish speakers with 

limited English proficiency.9

Several border counties are among those with 

the highest rates of poverty in the United States, 

and some rural communities lack running water, 

electricity, and sewers, particularly in South 

Texas.13–15 Border counties also have higher levels of 

uninsured individuals than the national average, and 

most of the border counties are designated Health 

Professional Shortage and Medically Underserved 

Areas for primary medical care.11,16 San Diego, the 

most populous border county (population 3.2 

million), has relatively low levels of poverty and 

differs significantly for many health and economic 

indicators from other parts of the border region.

Various climate zones are present in the 

border region, but in general, the border 

region is hot and dry. The zones range 

from arid and semi-arid to humid and 

subtropical in parts of the Lower Rio 

Grande Valley near the Gulf Coast. While 

several large metropolitan areas such 

as Phoenix and Tucson, Arizona, and 

El Paso, Texas, are in deserts, irrigation 

and drainage associated with farming 

and landscaping allow mosquitoes to 

persist in what might otherwise be an 

inhospitable environment for them. The 

two major rivers in the region are the 

Colorado River and the Rio Grande. Each 

state also has higher elevations with 

mountain ranges with snowfall.17

The states and counties along the 

US southern land border, and certain 

populations living within them, such as 

Hispanics, have had higher incidence 

of some infectious diseases, likely 

due in part to the flow of people and 

products between the United States 

and Mexico.18–20 To better address 

border region infectious disease 

challenges related to population 

mobility, an Infectious Disease 

Prioritization Workshop for the border region was 

held September 27–28, 2018, in San Diego. The 

workshop used a multijurisdictional approach to 

identify infectious diseases of greatest mutual 

concern across the border region and to plan 

collaborative activities with relevant agencies. 

CDC’s Division of Global Migration and QuarantineUS-Mexico Unit and One Health Office coordinated 

the effort. This prioritization process used the 

CDC-developed One Health Zoonotic Disease 

Prioritization Tool and Process (Appendix B).1

To build capacity to conduct future border region 

prioritization workshops, CDC’s One Health 

Office trained three US-Mexico Unit (USMU) 

staff to facilitate the workshop and nine on the 

methodology. 

Photo 4. The United States Mexico International Border Wall between 

Sunland Park New Mexico and Puerto Anapra, Chihuahua Mexico.
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WORKSHOP METHODS

The mixed methods disease prioritization process 

developed by CDC has been described in detail in 

previous publications and is illustrated in Appendix B.

1,2

An initial pre-workshop step was to identify voting 

members for decision-making. This workshop had 

12 voting members: two health authority leads 

from each of the four border states, and four federal 

representatives. In addition, each represented 

jurisdiction was able to invite or confer with subject 

matter advisors to inform their voting decisions and 

could invite other interested parties to observe. 

Voting members had broad expertise in infectious 

disease epidemiology, technical knowledge, 

familiarity with agency priorities and operational 

activities, and decision-making authority for their 

agency. At least one of each state’s voting members 

was familiar with the border region. See Appendix C

for a list of participants and their roles.

Photo 5. Coordination between federal and local public 

health partners. Photo credit: Christine Fonseca-Perez

The first step of the prioritization process was to 

identify a list of infectious diseases of concern 

for the US southern border region. These were 

defined as diseases that can be introduced and 

amplified or cause an outbreak in the United 

States because of movement of people, products, 

or animals across the border. CDC developed this 

list based on binationally notifiable conditions 

in the 2016 Operational Protocol for U.S.-Mexico 

Binational Communication and Coordination 

on Disease Notifications and Outbreaks

established by the US-Mexico Binational Technical 

Work Group.21 CDC refined the list based on 

considerations including: the rarity and burden 

of disease in the 44 US border counties, the 

degree to which spread of the disease might be 

affected by population mobility, the existence 

of disparities in the disease epidemiology for 

border region subpopulations (e.g., Hispanic 

ethnicity), and diseases for which border regionspecific resources are already dedicated (e.g., 

enhanced surveillance for influenza through 

the CDC’s Border Infectious Disease Surveillance 

Program [BIDS]).22,23 Agency representatives, 

including voting members and advisors, reviewed, 

discussed, and agreed upon the infectious 

disease list during a series of webinars before 

the in-person workshop. That list of 20 infectious 

diseases, shown in Appendix D, was considered 

during the prioritization workshop. During the 

two-day workshop, participants jointly identified 

five criteria for quantitative ranking of these 

20 infectious diseases. Once the five criteria 

were developed, one categorical question was 

developed for each criterion through group 

discussion. Questions were developed to best 

measure each criterion. All questions were ordinal 

and had either binomial (yes/no) or multinomial 

(1%–5%, 5%–10%, 10%–20%, etc.) answers. 

Participants also considered data availability in 

defining the answers, as each question needed a 

known answer for each disease. The ordinal nature 

was necessary for the scoring process, and each 

answer choice was given a score determined 

by the participants. Voting members then 

individually ranked their preferences for the relative 

importance of each criterion. A facilitator entered 

each voting member’s rankings into the One 

Health Zoonotic Disease Prioritization Tool, and 
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a group weight for each criterion was calculated. 

The criteria and weights assigned to each are 

listed below and in Appendix E. Facilitators 

and participants answered each question for 

each infectious disease using information from 

published or internal agency sources. Data for 

the United States and Mexico were identified 

through an extensive pre-workshop review 

of over 450 publications and websites. Health 

departments provided information that was not 

readily or publicly available, particularly county 

data. Data on incidence, prevalence, morbidity, 

and mortality, and additional relevant information 

were collected for the 20 infectious diseases. If 

information for a particular infectious disease was 

not available for the border counties, data for the 

border states were used. If state data were not 

available, regional data were used; and if regional 

data were not available, national data were used. 

After scoring of all diseases, decision tree analysis 

was used to determine the ranked disease list. 

Each weighted criterion was applied across each 

question’s answers for each disease and then 

normalized across criteria. The scores for all five 

questions for each disease were then summed. The 

largest raw score was then normalized, giving that 

disease a normalized score of 1. See Appendix D for 

a complete listing of raw and normalized scores for 

all diseases that were considered for prioritization.

On day two of the workshop, the diseases 

with their raw and normalized scores were 

discussed. Workshop participants then used the 

ranked disease list to decide on a final list of 

priority diseases (Table 1). Based on qualitative 

considerations, the 12 voting members agreed 

to group some of the prioritized diseases into 

categories to develop the final prioritized list. 

This final qualitative step allowed for additional 

discussion, nuance, and practical considerations 

to create a final short list of infectious diseases for 

priority action and development of collaborative 

next steps. 

Photo 6. Brainstorming during a Zika outbreak. Photo credit: Maureen Fonseca-Ford
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CRITERIA SELECTED FOR RANKING INFECTIOUS DISEASES

The criteria for ranking infectious diseases selected by the voting members are listed in order of importance 

below (and in Appendix E).

1. Pandemic/epidemic potential 

This criterion was assessed using state-level 

data. Diseases with at least one (≥1) outbreak 

in each of the four US southern border states 

received the highest score of 4. Diseases with 

multiple outbreaks (>1), but which did not 

occur in each of the four US southern border 

states, received a score of 3. Diseases with only 

one outbreak in any US southern border state 

received a score of 2. Diseases with either no 

outbreaks in US southern border states but at 

least one outbreak in Mexico, or no outbreaks 

in US southern border states or Mexico but 

potential for an outbreak, received a score of 1.

2. Presence and rate of disease

This criterion was assessed by comparing rate 

data for only the US southern border counties 

with populations >100,000** with national 

rates, by state. Diseases for which all four states 

had a border county with an incidence rate 

(2017, or most recent available data) greater 

than the national incidence rate received a 

score of 3. If less than four states had a border 

county with incidence greater than the national 

incidence rate, the disease received a score 

of 2. If no states had a border county with 

incidence higher than the national incidence 

rate, the disease received a score of 1. 

3. Impact on human health

This criterion was assessed by a combined 

consideration of death, disability, and 

hospitalization. If the disease had a significant 

case fatality rate (CFR) (≥ 5%, untreated) AND 

had (significant disability-adjusted life years 

(DALYs) [at least one per 100,000 population/

year or 0.1 log-scale per case/year] OR a 

significant hospitalization rate (≥ 10%)), the 

disease received the highest score of 3. If the 

disease had a CFR ≥5% BUT DALYs at <1 per 

100,000 population/year or <0.1 log-scale 

per case/year AND hospitalization rate <10%, 

then the disease received a score of 2. A 

disease also received a score of 2 if the CFR 

<5% AND DALYs were at least one per 100,000 

population/year or 0.1 log-scale per case/

year AND hospitalization rate ≥10%. If the 

disease had a CFR <5% AND (DALY at <1 per 

100,000 population/year or <0.1 log-scale per 

case/year OR hospitalization rate <10%), then 

the disease received the lowest score of 1. 

4. Capacity

This criterion was assessed using expert 

opinion by having the two voting members 

from each state complete a questionnaire 

about unmet needs in their state for each 

disease. Participants defined an unmet need as 

no or poor laboratory capacity (from collection 

of samples to reporting) including nonuse of 

available technology OR insufficient staffing 

OR another substantial gap that is generally 

not present outside the border region. If all 

four states had an unmet need, the disease 

received the highest score of 5. If three states 

had an unmet need, the disease received a 

score of 4. If two states had an unmet need, 

the disease received a score of 3. If one state 

had an unmet need, the disease received a 

score of 2. If no states had an unmet need, 

the disease received the lowest score of 1. 

** These included California (San Diego and Imperial counties); Arizona (Cochise, Pima, and Yuma counties); New Mexico (Doña Ana 

and Santa Cruz counties), and Texas (Cameron, El Paso, Hidalgo, and Webb counties). An exception was also made to combine and 

evaluate the rates for Maverick and Val Verde counties in Texas (border counties with populations of ~50,000) to ensure geographic 

consideration of vast rural areas with very low populations along the Texas-Mexico border.
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5. Effective prevention and control measures

This criterion was assessed using expert 

opinion by having the two voting members 

from each state complete a questionnaire 

about surveillance, prevention, or control 

measures (e.g. vaccine, treatment other 

than supportive care) and interventions 

(beyond vaccine or treatment, such as case 

management, vector control, or infection 

control) in their state for each disease. If 

surveillance was in place in the state AND 

effective prevention and control measures 

were available in the state AND an intervention 

was available in each of the four southern 

border states, the disease received the highest 

score of 3. Diseases also received a score of 3 if:

• there were established surveillance systems 

AND effective prevention and control 

measures for the disease in all four southern 

border states;

• there were established surveillance systems 

AND an intervention available for the disease 

in all four southern border states;

• there were an intervention available AND 

effective prevention and control measures for 

the disease in all four southern border states.

If there was established surveillance only 

OR prevention/control measures only 

OR an intervention only available in all 

four border states, the disease received 

a score of 2. If there were no established 

surveillance systems, prevention/control 

measures, or interventions, or they were 

available in some states but not others, the 

disease received the lowest score of 1.

Photo 7. Measles messaging at the US-Mexico land border.
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RESULTS

Federal and state health officials agreed upon a 

prioritized list of four infectious diseases or disease 

groups:

1. Tuberculosis

2. Aedes mosquito-transmitted arboviral 

diseases (dengue, chikungunya, Zika)

3. Enteric diseases (Vibrio spp., Listeria 

monocytogenes, nontyphoidal Salmonella, 

Brucella spp.)

4. Rickettsioses (R. rickettsii R. typhi, R. parkeri) 

The final ranking of each disease and the raw and 

normalized scores for each disease are presented 

in Appendix D, where the top prioritized infectious 

diseases selected by the voting members are 

shown in bold. The ranking reflects the consensus 

that tuberculosis should be the top priority for 

the border region. There was also consensus 

that dengue was appropriately ranked in the 

top five infectious disease concerns. However, 

because surveillance and response for other Aedes 

mosquito-transmitted arboviral diseases were 

intertwined, voting participants opted to prioritize 

all Aedes mosquito-borne arboviruses as a group. 

Similarly, participants agreed that vibriosis was 

reasonably ranked in the top five diseases and 

that other enteric diseases with greater incidence 

(salmonellosis) and border-region specific risk 

factors (brucellosis and listeriosis) may be grouped 

with vibriosis for practical purposes. A majority 

of voting members also agreed that, despite the 

relatively low ranking of rickettsioses, the current 

epidemiologic situation in the border region 

(ongoing Rocky Mountain spotted fever epidemics 

in northern Mexico, and the significant burden of 

typhus in Texas) warranted their prioritization over 

several of the vaccine-preventable diseases. The 

epidemiology of the selected diseases in the border 

region is described in Table 1.

Photo 8. Young girl getting a bandage after receiving her flu shot.
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Table 1. Description of priority infectious diseases at the US southern border region† selected by voting members using a 

multijurisdictional process in the Infectious Disease Prioritization Workshop conducted in September 2018

Infectious Disease/

Causative Agent

Human Disease Burden in the 

Southern Border Region Diagnostics, Treatment, and Prevention

Tuberculosis (TB)/

Mycobacterium 

tuberculosis, M. bovis

TB is endemic in the border region. California 

and Texas report the most TB disease cases 

in the nation and have among the highest 

incidence rates (5.2 and 4.0/100,000).24 Among 

border counties with populations >100,000, 

Imperial County, California, reports the highest TB 

incidence of 21.2/100,000, followed by Cameron 

County, Texas, with a rate of 12.3/100,000.25–28

Nationally, TB incidence is 2.8/100,000.24

In 2017, border counties reported a total of 562 

TB cases.25–28

Nationally, M. bovis represents 1.4% of all reported 

TB morbidity, but it accounts for up to 6% in 

border counties such as San Diego.24,29

TB is diagnosed via the presence of acid-fast 

bacilli on microscopy or culture, histopathology, 

or identification via nucleic acid amplification.30 TB 

is treated with a multidrug regimen for between 

6 to 24 months, depending on the resistance 

pattern.31 Treating latent tuberculosis infection 

can prevent progression to active disease, and 

accurate screening tests are available.32

Contact investigation is a critical component 

of TB control. In the border region, contact 

investigation, and treatment of TB disease or 

latent tuberculosis infection, often requires 

enhanced efforts to coordinate with Mexico to 

fully identify contacts and provide continuity of 

care for persons moving back and forth between 

countries.

If left untreated, tuberculosis has a 10-year case 

fatality of 70%.33

Aedes-transmitted 

arboviruses/dengue, 

Zika, chikungunya 

viruses

Autochthonous dengue virus transmission 

has become more frequent in the continental 

United States and in the border region since 

1980.34 Dengue outbreaks in south Texas, and 

most recently a 2015 travel-associated outbreak 

in Arizona, have occurred in association with 

dengue epidemics in northern Mexico.35-37

Dengue has also recently spread to new areas 

of northern Mexico.38,39 In US border counties, 

dengue cases are infrequent (26 in 2016), with 

rates ranging from 0 to 1.5/100,000)40–42 and 

typically associated with travel to endemic areas.43

However, studies suggest that dengue is likely 

underdiagnosed in the border region.39

Chikungunya and Zika viruses have circulated 

in the Americas since 2014 and 2015 44,45, 

respectively, but in the US southern border 

region, cases have been sporadic and mostly 

associated with travel. There have been no known 

chikungunya outbreaks in the border counties. 

In 2016, there was a small outbreak of local 

mosquito-transmitted Zika in Brownsville, Texas.46

Aedes aegypti, the principal mosquito vector of 

all three viruses, has expanded its geographic 

distribution in the southern United States, and 

the southern US border has reported year-round 

Aedes aegypti mosquito populations from Texas to 

Arizona.36,47

Diagnosis is made by nucleic acid amplification, 

antibody testing (IgG, IgM), and plaque reduction 

neutralization testing for all three diseases.48–50

Treatment is supportive care. 

Although asymptomatic or mild dengue infection 

is more common, there are severe manifestations 

such as dengue shock syndrome. While there 

is no pharmaceutical treatment, with early 

detection and proper care, less than 1% of 

patients die.30 Without appropriate supportive 

care, the case fatality rate can reach 10%.51

Prevention measures include using insect 

repellent, wearing long-sleeved shirts and long 

pants, and controlling mosquitoes indoors and 

outdoors.52,53

† The US southern border region has been defined as the 44 US counties within 100km of the Mexico border, originally laid out by 

the 1983 La Paz Agreement. The term “border counties” is also used in this report to refer to the US southern border region.
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Infectious Disease/

Causative Agent

Human Disease Burden in the 

Southern Border Region Diagnostics, Treatment, and Prevention

Enteric diseases/

Vibrio spp., Listeria 

monocytogenes, 

nontyphoidal 

Salmonella spp., 

Brucella spp. bacteria

Nontyphoidal Salmonella (NTS) infection is 

common in the US southern border counties, 

with rates as high as 23.5/100,000 population 

in large border counties in 2016, presenting a 

significant burden of disease.54-56 Vibrio, Listeria, 

and Brucella spp. infections are much less 

common. Among border states, 2016 brucellosis 

rates ranged from .01 to .2/100,000 population 

and vibriosis and listeriosis rates both ranged 

from .1 to .3/100,000.54-57

NTS outbreaks are common. Listeria and Vibrio

outbreaks have also occurred in all 4 border 

states in the past 10 years. There have been 3 

brucellosis outbreaks in California and Texas in 

the past 10 years.58

Enteric disease diagnosis is typically made 

through culture of stool, blood, cerebrospinal 

fluid (CSF), etc. Culture-independent diagnostic 

testing (CIDT) may also be used for some enteric 

diseases.59 NTS is the most common cause of 

bacterial diarrheal illness and is diagnosed by 

stool culture or CIDT; systemic infections can 

be diagnosed by culture of normally sterile 

body sites such as blood and CSF. While Listeria 

monocytogenes can cause diarrheal illness, the 

main concern is systemic infection, which is 

diagnosed by culture of blood and CSF. Vibrio 

vulnificus is diagnosed by wound or blood culture, 

while Vibrio cholerae and other Vibrio spp. that 

cause gastrointestinal illness are diagnosed with 

stool culture. Brucellosis can be diagnosed with 

the microagglutination test (BMAT) serology for 

B. abortus, B. melitensis, and B. suis.

60 Treatment 

varies by disease but includes antibiotics. Enteric 

diseases are prevented through good sanitation 

and hygiene and avoidance of contaminated food 

and water, contact with high-risk animals, and ill 

persons 61

Case fatality rates (CFRs) for these diseases are 

.5% for salmonellosis, 2% for brucellosis, and 

18% for invasive listeriosis.30,62 Of Vibrio infections, 

V. vulnificus has the highest mortality, with an 

estimated CFR of 34.8%.63

Rickettsioses/R. 

rickettsii, R. typhi,

 R. parkeri bacteria

Spotted fever group rickettsioses (SFGR) are 

transmitted by ticks infected with R. rickettsii, 

R. parkeri, and other closely related bacteria; 

in 2016, Texas reported 87 cases, Arizona 

reported 27, and California reported 14 

confirmed and probable SFGR cases.64

Large outbreaks of Rocky Mountain spotted fever 

(RMSF) have occurred on 

Native American reservations in Arizona.65 Cases 

and outbreaks in Arizona have been attributed to 

the vector Rhipicephalus sanguineus (the brown 

dog tick),66 which occurs widely throughout the 

United States, including California and Texas.67,68

RMSF epidemics have been ongoing in the 

Mexican border states of Baja California and 

Sonora, with binational cases occurring in 

California and Arizona, posing a continual risk in 

the border region.69

R. typhi causes flea-borne (murine) typhus, which 

mostly occurs in Texas and California. In Texas, 

cases have been most frequent in South Texas, 

where it is endemic.70 Since the mid-2000s, the 

number of typhus group rickettsioses reported 

in Texas has increased significantly, and the 

geographic distribution of cases has expanded. In 

2016, Texas reported 134 cases in border counties 

out of 364 cases statewide.54

Rickettsioses are diagnosed via serology, 

polymerase chain reaction, immunohistochemistry, histopathology, or cell culture and 

are treated with doxycycline.65,71 No vaccine is 

available. Minimizing arthropod exposure (fleas 

and ticks), using insect repellents, and wearing 

protective clothing serve as prevention tools.71

Of the rickettsioses, RMSF is the most severe. 

In the United States, the CFR for SFGR (based 

on surveillance data) is roughly 0.5%. However, 

CFRs from reviews of RMSF cases range from 5% 

to 10%.66

Murine typhus is usually self-limiting but can 

be fatal when treatment is delayed 72, and 

complications can be severe.73
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KEY THEMES AND NEXT STEPS

After finalizing the list of priority infectious diseases, 

workshop participants discussed recommendations 

and further actions that could be jointly taken 

to address the diseases. During the workshop, 

participants identified opportunities for improving 

coordination, surveillance, laboratory approaches, 

outbreak response and preparedness, and health 

education for the prioritized diseases in the border 

region. In a series of discussions after the workshop, 

partners determined potential next steps to address 

those opportunities for improvement and gave each 

next step a priority level from 1 to 3. Some of the 

highest-priority activities were initiated after the 

workshop, and efforts to conduct all the activities 

will be pursued over the next 5 years.

The summary that follows highlights the 

consistently prioritized recommendations. Though 

non-binding, they represent ways to jointly address 

the prioritized infectious diseases. A complete 

listing of all key themes and identified opportunities 

is shown in Appendix F. 

COORDINATION

Participants identified a need to better coordinate 

initiatives to address the priority diseases between 

agencies involved in public health in the border 

region. Such initiatives include CDC’s Binational 

Border Infectious Disease Surveillance (BIDS) 

Program, the US-Mexico Binational Technical 

Working Group (BTWG), the U.S.-Mexico Border 

Health Commission (BHC), and multiple city/state/

region binational meetings and committees. This 

would ensure synergy and optimize resource 

use between agencies with similar interests in 

preventing and controlling infectious diseases. 

Following the workshop, participants planned 

to look for ways to harmonize the existing 

coordinating mechanisms and leverage best 

practices and resources to address the prioritized 

diseases as well as relevant challenges, such as 

antimicrobial resistance and insecticide resistance.

Participants also proposed a gap analysis for TB 

and the prioritized enteric diseases to identify 

areas of need in surveillance, laboratory capacity, 

preparedness, and communication/outreach, and 

to develop comprehensive approaches to address 

those gaps. As a first step, participants will convene 

a workgroup to discuss the scope and process 

of a border-wide gap analysis, beginning with TB 

prevention and control, and potentially exploring 

surveillance and control efforts for the prioritized 

enteric diseases in future years.

Photo 9. Backpackers shopping in a Mexican street market.
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SURVEILLANCE

Identifying binational disease clusters allows for a 

more complete understanding of the scope and 

nature of regional disease transmission and should 

lead to improved bilateral control strategies. As 

such, participants felt the identification of binational 

outbreaks/clusters of the priority diseases was 

an important area of work. US border states and 

counties are in varying stages of developing 

systems to identify binational cases, clusters, and 

outbreaks. Therefore, multiple approaches may 

need to be taken. As a first step, participants 

proposed to assess current systems and identify 

best practices for identifying transmission patterns 

and emerging clusters in the border region for 

each disease. Participants will also explore various 

information platforms to develop a system for 

monitoring reports of outbreaks in Mexico that 

would supplement existing official reporting 

mechanisms. And finally, participants would review 

border state/county TB and enteric disease clusters 

and drug-resistant cases as well as pediatric TB 

case investigations that may require binational 

collaboration. 

Photo 10. Tick collection in field using flagging method.

Photo credit: Alba Phippard

Providers that serve populations that cross the USMexico border are critical in disease surveillance 

and control strategies. Participants agreed on 

the importance of engaging relevant healthcare 

providers to ensure case identification and reporting 

mechanisms are optimal for monitoring infectious 

diseases among mobile populations. As a first 

step, participants will work to develop approaches, 

including potential thresholds, to alert border 

region community health centers serving mobile 

populations about increases in Aedes mosquito 

populations, and cases or outbreaks of Zika, dengue, 

or chikungunya, to stimulate and increase testing of 

patients with acute febrile illness.

Participants additionally identified a need 

to strengthen surveillance for vector-borne 

diseases and vector presence in the border 

region through active surveillance approaches. 

Participants in regions with higher levels of risk 

will discuss the feasibility of expanding syndromic 

sentinel surveillance for acute febrile illness with 

confirmatory testing at key sites in the border 

region. Some of CDC’s BIDS Program sites conduct 

active sentinel surveillance with confirmatory 

laboratory testing for vector-borne diseases along 

the border and could be expanded to increase 

active surveillance in the border region. 

LABORATORY

Participants proposed reviewing and implementing 

approaches to strengthen surveillance and 

laboratory practices for antimicrobial resistance in 

the border region, while working to ensure that 

culture-independent diagnostic testing (CIDT) does 

not reduce high-quality public health surveillance 

in the border region. Nationally, foodborne disease 

outbreak surveillance has transitioned to whole 

genome sequencing (WGS), which is expected 

to improve efficiency and precision in identifying 

clusters and outbreaks. However, current state 

and local resources are insufficient to ensure WGS 

is performed on all isolates. Increasing the use of 
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CIDT would limit the ability to perform WGS on 

specimens if no cultures were available. A critical 

next step will be for participants to discuss the 

potential impact of WGS on surveillance in the 

border region, identification of binational cases 

and outbreaks of the prioritized diseases, and 

related antimicrobial resistance. 

OUTBREAK RESPONSE AND 

PREPAREDNESS

Participants identified cross-agency coordination 

as the key to address preparedness, foster 

awareness of emerging public health issues, and 

encourage collaboration in the border region. 

In particular, coordination between US border 

states and counties and Mexico is critical to 

maintaining comprehensive preparedness and 

response plans. Multiple existing collaborations 

and forums, such as BTWG, BIDS, BHC, and state 

and local binational groups have developed 

strong foundations for continued work that should 

be leveraged and grown. Near-term next steps 

include using the multiple forums to discuss 

issues such as transporting specimens across 

the border, capacity building (through tabletop 

exercises), data sources important for preparedness 

activities, and mechanisms to strengthen outbreak 

response. Participants will also initiate a formal 

review of the Operational Protocol for US-Mexico 

Binational Communication 

and Coordination on Disease 

Notifications and Outbreaks. 

Finally, participants will 

work to clarify and leverage 

preparedness work being 

done at the local, state, 

and federal levels for the 

prioritized diseases.

HEALTH COMMUNICATION, 

EDUCATION, AND OUTREACH

Significant proportions of border region residents 

may require or prefer health information in Spanish 

and may even seek or regularly get information 

from Mexican sources. Participants identified 

several near-term opportunities to improve 

health education, communication, and outreach 

for Spanish-speaking populations with limited 

English proficiency for the prioritized diseases. 

First, participants proposed to create a platform 

for regularly sharing translated and validated 

educational and prevention materials between 

agencies in border communities, and to seek 

opportunities to harmonize educational information 

with Mexico. Second, participants recommended 

working to ensure educational materials for 

Spanish-speaking border populations are tested 

for accuracy, cultural appropriateness, and 

understanding, which are all critical for messaging. 

Finally, participants identified a need to explore 

avenues and approaches for best disseminating 

targeted public health information to Spanishspeaking and other specific border populations, 

which might vary depending on the disease.

Photo 11. The Rio Grande River 

on the US/Mexico Border in Big 

Bend National Park, Texas.
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APPENDIX A: US Border Counties

Defining the border region is complex, and 

there are multiple definitions serving different 

purposes.6 The 1983 La Paz Agreement defined 

it as the area that extends 100 kilometers north 

and south of the international border. On the 

US side, that strip traverses 48 US counties. 

However, to report infectious disease data 

consistent with the Border Health Commission74

and other public health entities, in this report 

US border counties have been defined as the 

44 listed and shown in the map below; La 

Paz, Maricopa, and Pinal county, Arizona, and 

Riverside county, California have been excluded. 

Photo 12. Woman crossing the United States-Mexico border 

with a dog. Photo credit: Maureen Fonseca-Ford

Arizona: Cochise, Pima, Santa Cruz, Yuma 

California: Imperial, San Diego 

New Mexico: Doña Ana, Grant, Hidalgo, Luna, 

Otero, Sierra 

Texas: Brewster, Brooks, Cameron, Crockett, Culberson, Dimmit, Duval, Edwards, El Paso, Frio, Hidalgo, 

Hudspeth, Jeff Davis, Jim Hogg, Kenedy, Kinney, La Salle, Maverick, McMullen, Pecos, Presidio, Real, Reeves, 

Starr, Sutton, Terrell, Uvalde, Val Verde, Webb, Willacy, Zapata, Zavala
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APPENDIX B: Overview of the One Health Zoonotic Disease 

Prioritization Process‡

Goals of the OHZDP Process

► To use a multisectoral, One Health approach to

1. Prioritize zoonotic diseases of greatest concern

2. Develop next steps and action plans to address the

priority zoonotic diseases in collaboration with One

Health partners

ONE HEALTH ZOONOTIC DISEASE

PRIORITIZATION PROCESS

One Health recognizes the connection between human, 

animal, and environmental health.

The One Health Zoonotic Disease Prioritization (OHZDP) process brings together representatives from 

human, animal, and environmental health sectors, as well as other relevant partners, to prioritize 

zoonotic diseases of greatest concern for multisectoral, One Health collaboration in a country, region, 

or other area. This process uses a transparent approach and incorporates equal input from all represented One Health sectors working at the human-animal-environment interface.

CS306732-A

Expected Outcomes of the OHZDP Process

• A list of priority zoonotic diseases of greatest concern agreed upon by all represented One Health sectors

• Recommendations for next steps and action plans for multisectoral, One Health engagement to address

the priority zoonotic diseases

• Understanding of the roles and responsibilities of all represented One Health sectors

• The creation or strengthening of multisectoral, One Health coordination mechanisms and networks

• A report highlighting the outcomes of the workshop to help advocate for One Health priorities

• Connects representatives from human, animal,

and environmental health sectors and other

relevant partners, building a foundation of trust

that strengthens multisectoral, One Health

collaboration, coordination, and communication

• Prioritizes zoonotic diseases using equal input

from all represented One Health sectors

through a transparent and collaborative process

• Supports the creation or strengthening

of multisectoral, One Heath coordination

mechanisms

• Helps participants focus limited resources to

build capacity and collaboratively address the

priority zoonotic diseases

• Adaptable to local context, since participating

voting members determine criteria relevant to

their country, region, or other area

• Scalable for use at the subnational, national,

and regional levels, and can be adapted to

apply to other infectious diseases and One

Health issues

• Informs assessments, planning efforts, or

strategy development relevant to One Health

(for example, World Health Organization’s

International Health Regulations [2005]

and World Organisation for Animal Health

Performance of Veterinary Services Pathway)

• Provides real-time outcomes such as the list of

priority zoonotic diseases, next steps and action

plans, and a formal workshop report

Benefits of the OHZDP Process

Accessible information: https://www.cdc.gov/onehealth/what-we-do/zoonotic-disease-prioritization/fact-sheet.html

This method was modified to prioritize infectious diseases for the border region, including both zoonoses 

and other diseases.

‡ www.cdc.gov/onehealth/what-we-do/zoonotic-disease-prioritization
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APPENDIX C: Infectious Disease Prioritization Workshop 

Participants for the US Southern Border Region

Voting Members

# Name Organization Title/Position

1 Ken Komatsu Arizona Department of Health Services State Epidemiologist

2 Shane Brady Arizona Department of Health Services Deputy State Epidemiologist

3 Margarita Santibañez California Department of Public Health Epidemiologist

4 Esmeralda Iniguez-Stevens California Department of Public Health Epidemiologist

5 Sandra Melman New Mexico Department of Health Epidemiologist

6 Salina Torres New Mexico Department of Health Epidemiologist

7 Jennifer Shuford Texas Department of State Health Services Medical Officer

8 Allison Banicki Texas Department of State Health Services Epidemiologist

9 Kathy Moser CDC/NCEZID§/DGMQ¶/US-Mexico Unit Medical Epidemiologist

10 Sam Groseclose CDC/Office of Public Health Preparedness and 

Response

Associate Director for Science

11 Michelle McConnell Health and Human Services Agency/Office of the 

Secretary/Office of Global Affairs

Health Attaché, Mexico

12 Steve Waterman CDC/NCEZID/Division of Vector-borne Disease Dengue Branch Chief

Advisors/Observers

# Name Organization Title/Position

13 David Torres Texas Department of Health Services Epidemiologist

14 Dianne Escotto CDC/NCEZID/DGMQ/US-Mexico Unit Public Health Management 

Specialist

15 April Fernandez California Department of Public Health Chief of the Office of Border Health

16 Marian Fierro Imperial County Public Health Department Epidemiologist

17 Carla Tyler Texas Department of State Health Services—Region II Epidemiologist

18 Cory Arrouzet CDC/NCEZID/DGMQ/US-Mexico Unit Council of State and Territorial 

Epidemiologists Fellow

19 Alfonso Rodriguez-Lainz CDC/NCEZID/DGMQ/US-Mexico Unit Epidemiologist

20 Rosy De los Santos Texas Department of State Health Services/Office of 

Border Public Health

Office of Border Public Health 

Program Manager

21 Tom Sidwa Texas Department of State Health Services/Zoonosis 

Control Branch

State Veterinarian

22 Paula Kriner Imperial Country Public Health Department Epidemiologist

23 Justine Kozo San Diego County Health and Human Services 

Agency/Office of Border Health

Chief of the Office of Border Health

§ National Center for Emerging and Zoonotic Infectious Diseases

¶ Division of Global Migration and Quarantine
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# Name Organization Title/Position

24 Maureen Fonseca-Ford CDC/NCEZID/DGMQ/US-Mexico Unit Quarantine Public Health Officer

25 Elsa Villarino CDC/NCEZID/DGMQ/US-Mexico Unit Country Director, Mexico

26 Olivia Arizmendi Border Infectious Disease Surveillance—California Epidemiologist

27 Alba Phippard CDC/NCEZID/DGMQ/US-Mexico Unit Epidemiologist

28 Crystal Clements CDC/NCEZID/DGMQ/US-Mexico Unit Oak Ridge Institute for Science 

and Education Fellow

29 Freida Adams New Mexico Department of Health Chief of the Office of Border Health

Facilitators

# Name Organization Title/Position

30 Grace Goryoka CDC/NCEZID/One Health Office Health Scientist

31 Kristina Angelo CDC/NCEZID/DGMQ/Travelers Health Medical Epidemiologist

32 Sonia Contreras CDC/NCEZID/DGMQ/US-Mexico Unit Quarantine Public Health Officer

33 Sonia Montiel CDC/NCEZID/DGMQ/US-Mexico Unit Public Health Analyst

34 Alina Shaw CDC/NCEZID/DGMQ/US-Mexico Unit Health Communications Specialist

Workshop Organizers

Name Organization Title/Position

Alba Phippard CDC/NCEZID/DGMQ/US-Mexico Unit Epidemiologist

Thomas Gray CDC/NCEZID/DGMQ/US-Mexico Unit Public Health Analyst

Crystal Clements CDC/NCEZID/DGMQ/US-Mexico Unit ORISE Fellow

Kathy Moser CDC/NCEZID/DGMQ/US-Mexico Unit Unit Lead, Medical Officer

Grace Goryoka CDC/NCEZID/One Health Office Health Scientist, CDC Facilitator

Kristina Angelo CDC/NCEZID/DGMQ/Travelers’ Health Branch Medical Epidemiologist, CDC Facilitator

Casey Barton Behravesh CDC/NCEZID/One Health Office Director
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APPENDIX D: Ranked Disease List and Scores from the Infectious 

Disease Prioritization Workshop for the US Southern Border Region

Infectious diseases considered for prioritization. The infectious disease priorities selected by the voting 

members are shown in bold. 

Rank Infectious Disease Raw Score Normalized Final Score

1 Tuberculosis 1.266686081 1

2 Vibriosis 1.237911983 0.977283955

3 Hepatitis A 1.218692442 0.962110866

4 Dengue 1.193208165 0.941992008

5 Syphilis 1.164434067 0.919275963

6 Listeriosis 1.159788977 0.915608843

7 Pertussis 1.151600921 0.909144688

8 Chickenpox 1.151600921 0.909144688

9 Influenza 1.142046364 0.901601732

10 Rickettsioses 1.115085159 0.880316896

11 Campylobacteriosis 1.102252014 0.870185621

12 Salmonellosis (nontyphoidal) 1.102252014 0.870185621

13 Shiga Toxin-Producing Escherichia coli 1.102252014 0.870185621

14 Zika 1.090956151 0.861267971

15 Shigellosis 1.007741664 0.795573331

16 Hepatitis B 0.991800712 0.782988561

17 HIV infection 0.959930039 0.75782789

18 Chikungunya 0.947096894 0.747696614

19 Brucellosis 0.918322796 0.724980569

20 Chagas 0.707818409 0.558795443
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APPENDIX E: The Criteria and Questions with Associated 

Weights Used for Ranking Infectious Diseases at the US 

Southern Border Region, and Scores for the Corresponding 

Answers to Questions

1. Pandemic/epidemic potential (criterion weight = 0.307)

Question: What is the number of outbreaks (defined by the Council for State and Territorial 

Epidemiologists’ case definition) in the US southern border states in the past 10 years?

Answer:

■ At least one outbreak has occurred in all four US southern border states (4)

■ Multiple outbreaks, but outbreaks have not occurred in all four US southern border states (3)

■ Only one outbreak in any US southern border state (2)

■ No outbreaks in the US southern border states but at least one outbreak has occurred in 

Mexico (country) OR no outbreaks have occurred in US southern border states or Mexico 

(country) but there is potential for an outbreak (1)

2. Presence and rate of disease (criterion weight = 0.249)

Question: Is the highest reported incidence rate (2017, or most recent available data) from 

the US southern border counties (within each state, and only for those counties 

with population >100,000 persons) greater than the national incidence rate?

Answer: 

■ Yes, all four states have a higher incidence rate (3)

■ Yes, less than four states have a higher incidence rate (2)

■ No states have a higher incidence rate (1)

3. Impact on human health (criterion weight = 0.230)

Question: Does the disease have a significant case fatality rate (untreated, ≥5%), and does 

it have significant disability-adjusted life years (DALY)s (at least one per 100,000 

population/year or 0.1 log-scale per case/year) or a significant hospitalization rate 

(≥10%) for the disease?

Answer: 

■ CFR ≥5% AND DALY at least one per 100,000 population/year or 0.1 log-scale per case/year 

OR hospitalization rate ≥10% (3)

■ CFR ≥5% but DALY at <1 per 100,000 population/year or <0.1 log-scale per case/year AND 

hospitalization rate <10% (2)

■ CFR <5% AND DALY at least one per 100,000 population/year or 0.1 log-scale per case/year 

AND hospitalization rate ≥10% (2)

■ CFR <5% AND DALY at <1 per 100,000 population/year or <0.1 log-scale per case/year OR 

hospitalization rate <10% (1)
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4. Capacity (criterion weight = 0.115)

Question: Is there an unmet need in a given state in the border region (unmet need is 

defined as no or poor lab capacity [from collection of samples to reporting] 

including nonuse of available technology) OR insufficient staffing OR another 

substantial gap that is generally not present outside the border region)?

Answer:

■ Four states have an unmet need (5)

■ Three states have an unmet need (4)

■ Two states have an unmet need (3)

■ One state has an unmet need (2)

■ No states have an unmet need (1)

5. Effective prevention and control measures (criterion weight = 0.099)

Question: Are established surveillance systems in place in the state OR effective prevention 

and control measures (vaccine, treatment—but not supportive care) available in 

the state OR a potential intervention (beyond vaccine or treatment, such as case 

management, vector control, infection control, etc.) available in the state for this 

disease in all four southern border states?

Answer:

■ Surveillance AND prevention/control measures AND potential intervention were available in 

all four southern border states (3)

» OR prevention/control measures AND potential intervention were available in all 

four southern border states

» OR surveillance AND prevention/control measures were available in all four southern 

border states

» OR Surveillance AND potential intervention were available in all four southern 

border states

■ (Only surveillance available OR only prevention/control measures available OR only 

potential intervention available) in all four southern border states (2)

■ No surveillance, prevention/control measures, or potential interventions, OR they were 

available in some states but not all (1)
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APPENDIX F: Key Themes and Next Steps for Prioritized Diseases 

The table below summarizes opportunities and actions identified in discussions during and after the 

workshop through analysis of existing processes. These opportunities and potential next steps represent 

an informal roadmap to addressing gaps in multiagency coordination for the prioritized diseases. Creating 

these non-binding recommendations was a first step in brainstorming action items. Follow-up will bring 

together additional subject matter experts and other stakeholders to refine and move forward with specific 

action items.

Coordination Activities

Identified Opportunity Rationale Considerations Potential Next Steps

Enhance existing mechanisms 

for coordinating initiatives 

between the US federal, state, 

and local agencies involved in 

public health activities in the 

US-Mexico border region to 

address the priority diseases.

Ensure synergy and optimize 

resource use between 

agencies with similar interests 

in preventing and controlling 

infectious diseases in the 

border region.

Existing mechanisms include

• CDC’s Binational Border 

Infectious Disease 

Surveillance (BIDS) 

Program;

• Binational Technical 

Working Group (BTWG);

• U.S.-Mexico Border Health 

Commission (BHC); and

• Border sister-city/state/

region binational meetings 

and committees.

General Next Steps 

Explore opportunities to harmonize existing 

mechanisms (BHC, BIDS, BTWG) to further coordinate, 

leverage best practices, and reduce duplication of 

efforts. 

• Work with the BTWG on broadening partner 

participation on monthly teleconferences by 

including, based on the meeting topic and goal, 

different federal, state, and local partners and 

subject matter experts and decision-makers in 

programs such as STD/HIV, TB, and healthcareassociated infections.

• Work with BTWG to address topic areas specific to 

priority infectious diseases, and regularly exchange 

surveillance information on resistance trends 

including insecticide resistance.

• Identify and leverage resources for annual face-toface meetings of local, state, and federal partners 

involved in border/binational health.

Conduct gap analysis for 

priority diseases in the border 

region to inform development 

of comprehensive approaches.

A structured method 

for identifying gaps in 

surveillance, laboratory 

capacity, preparedness 

and response, and health 

communication and outreach 

will facilitate planning and 

resource acquisition for areas 

of greatest need.

With regard to the vectorborne diseases, two Regional 

Centers of Excellence (COEs) 

funded by CDC work within 

the border region: the Pacific 

Southwest COE and the 

Western Gulf COE. There was 

no consensus on need for gap 

analyses for the prioritized 

enteric diseases. 

Arboviruses and Rickettsioses Next Steps

• Identify the priorities of the Regional COEs working 

in the border region and coordinate to determine 

the need for a border region gap analysis for 

vector-borne diseases. Surveillance needs could 

include a survey of the number of laboratory 

tests for arboviruses from suspected human 

cases being performed in state and local public 

health laboratories along the border and by major 

commercial laboratories, or a survey of state public 

health laboratories regarding the availability of 

arbovirus diagnostics testing and kits.

TB/Enteric Diseases Next Steps

• Convene a workgroup to discuss scope and process 

of a borderwide gap analysis, beginning with TB 

prevention and control, and potentially exploring 

surveillance and control efforts for the prioritized 

enteric diseases in future years.

Share state models for 

exchanging public health data 

electronically with Mexican 

health jurisdiction partners.

Sharing public health 

information with Mexico 

electronically may improve 

completeness and timeliness 

of data exchange, leading to 

more timely binational public 

health response.

Arizona Department of 

Health Services’ MEDSIS is 

an example of an electronic 

disease surveillance system 

that allows direct bilateral 

information sharing between 

the border states of Arizona 

and Sonora. There are other 

international data platforms, 

such as CDC’s PulseNet, which 

may also improve collaborative 

surveillance efforts. 

General Next Steps 

• Share information and materials for existing models 

in the border region.

• Identify utility of existing US-Mexico cross-border 

data sharing platform and explore data-sharing 

projects between other countries.
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Surveillance Activities

Identified Opportunity Rationale Considerations Potential Next Steps

Prioritize identification of 

binational outbreaks/clusters 

of priority diseases.

Identifying binational disease 

clusters allows for a more 

complete understanding of the 

scope and nature of regional 

transmission and should lead 

to improved bilateral control 

strategies.

US border states and counties 

are in varying stages of 

developing systems to identify 

binational cases, clusters, and 

outbreaks. Therefore, multiple 

approaches may need to be 

taken.

General Next Steps

• Clarify current systems and identify best practices 

for each prioritized disease, to identify transmission 

patterns and capture emerging clusters across the 

border region.

Arboviruses and Rickettsioses Next Steps

• Work with Mexico to better identify and respond 

to clusters and outbreaks, for example, by routinely 

sharing surveillance data and further leveraging 

binational forums for focused discussions on 

surveillance and control. VectorSurv, a vector data 

sharing partnership of vector control agencies, 

although not international, now spans several states 

including California, and could be explored as a 

means for data sharing in the border region and 

with Mexico.

• Explore platforms such as Spanish and English 

ProMed, CDC’s Red Sky, HealthMap, and Canada’s 

Global Public Health Intelligence Network, and 

develop a system to monitor reports of outbreaks 

in Mexico.

Enteric Diseases Next Steps

• Review border state/county clusters and drugresistant cases that may require collaboration.

TB Next Steps

• Review border state/county clusters and pediatric 

case investigations that may require collaboration.

Engage relevant healthcare 

providers to ensure 

surveillance and reporting 

mechanisms are in place for 

monitoring infectious diseases 

among mobile populations. 

Populations that cross the 

US-Mexico border and those 

otherwise linked to Mexico 

may have increased risk of 

exposure to the prioritized 

diseases. Providers that serve 

these groups are critical in 

surveillance and control 

strategies and should be 

included in education and 

outreach efforts.

Community health centers, 

individual providers, and 

Department of Homeland 

Security (DHS) facilities 

near the border are central 

to healthcare provision for 

mobile populations and their 

networks. Other relevant 

providers include those in 

binational health insurance 

networks and travel medicine 

clinics. 

General Next Steps

• Work with DHS to improve understanding of DHS 

agencies public health notification systems and 

identify collaborative opportunities to enhance 

surveillance among both employees and immigrant 

populations. 

• Convene workgroup to discuss strategies for 

engaging community healthcare providers on 

disease reporting (e.g., provider education on 

diagnosis and reporting, assessments of current 

reporting activities, and quality improvement) and 

general provider knowledge on the prioritized 

diseases.

• Share among partners the results of physician 

knowledge, attitude, and belief/practice surveys to 

inform the development of educational information 

for physicians. 

Arboviruses Next Steps 

• Develop approaches, including potential thresholds, 

to alert border region community health centers 

serving mobile populations about increases in Aedes

mosquito populations, or cases or outbreaks of Zika, 

dengue, or chikungunya, to stimulate and increase 

testing of patients with acute febrile illness.

Rickettsioses Next Steps

• Develop additional approaches to better integrate 

veterinary and public health surveillance and 

systematize cross-reporting between sectors.

• Implement strategies to educate providers on 

the diagnostic tests and testing requirements for 

rickettsioses, as well as appropriate treatment.
INFEC TIOUS DISEASE PRIORITIZATION FOR MULTIJURISDIC TIONAL ENGAGEMENT

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Surveillance Activities (Continued)

Identified Opportunity Rationale Considerations Potential Next Steps

Create a web-based dashboard 

for selected notifiable 

diseases with county level 

and aggregated border 

region data for increased 

understanding of case counts, 

rates, and trends in the border 

region. Dashboard features 

could include mapping and 

interactivity depending on 

resources and feasibility.

Epidemiologic data are 

typically available only at state 

and county levels. Border 

health stakeholders would 

benefit from the ability to 

easily visualize, access, and 

analyze data for the border 

region at the county level and 

as an epidemiologic unit and 

compare them with nonborder counties or regions.

Border health stakeholders 

may have diverse data needs 

and uses, necessitating broad 

participation to develop a 

product that meets the needs. 

Existing tools can serve as 

models, including 

CDC’s NCHHSTP Atlas Plus 

mapping and visualization 

tool for HIV, hepatitis, STD, 

and TB; CDC Wonder; Arizona 

Disease Data, Statistics 

& Reports; Arizona Flu & 

Respiratory Syncytial Virus 

Reports; and PulseNet for 

foodborne illnesses. 

General Next Steps 

• Establish a workgroup to discuss 

» Feasibility, resources, and required partners;

» Inclusion of data from non-border counties to show 

true scope and pattern of disease burden; and 

» Variables for inclusion.

• Explore how other programs have shared data 

through web-based applications.

Implement or strengthen 

active surveillance for 

prioritized vector-borne 

diseases and vector presence 

in the border region.

Active surveillance for the 

prioritized vector-borne 

diseases can identify cases 

that might otherwise go 

undiagnosed, allowing for 

earlier detection of cases, 

outbreaks, and emerging or 

re-emerging diseases.

CDC’s Border Infectious 

Disease Surveillance Program 

conducts active sentinel 

surveillance with confirmatory 

laboratory testing for 

vector-borne diseases at 

select sites along the border 

and could be expanded 

in the border region. 

Participatory surveillance is 

another approach, invoking 

observations and reports from 

the public. Mobile phone 

apps such as Kidenga and 

The Tick App could be used 

for arboviral disease and 

vector surveillance.

Arboviruses and Rickettsiosis Next Steps

• Discuss feasibility of expanding syndromic 

sentinel surveillance for acute febrile illness with 

confirmatory testing at key sites in the border 

region.

• Convene border agency partners to explore and 

further operationalize participatory surveillance for 

vector-borne diseases and vector presence in the 

border region.

Laboratory

Identified Opportunity Rationale Considerations Potential Next Steps

Review and implement 

approaches to strengthen 

surveillance and laboratory 

capacity to detect 

antimicrobial resistant-bacteria 

in the border region.

Ensure that cultureindependent diagnostic 

testing (CIDT) does not reduce 

high-quality public health 

surveillance in the border 

region. 

Antimicrobial resistance is 

a threat to global health 

security. The United States 

has developed a National 

Strategy for Combating 

Antibiotic-Resistant Bacteria, 

which includes strengthening 

national surveillance and 

international collaboration. 

Because cross-border 

healthcare access is common, 

there may be increased 

opportunities to introduce 

antibiotic-resistant pathogens 

between countries in border 

locations. Increasingly, clinical 

laboratories use CIDT for rapid 

diagnosis; yet lack of cultures 

can limit typing and resistance 

testing.59,75

Nationally, foodborne outbreak 

surveillance has transitioned 

to whole genome sequencing 

(WGS), which is expected 

to improve efficiency and 

precision in identifying clusters 

and outbreaks. WGS is one of 

the laboratory analyses that 

require an isolate from culture. 

In addition, state and local 

resources are insufficient to 

ensure WGS of all isolates. 

CDC’s FoodNet has surveyed 

clinical laboratories since 

2012 to assess changes in 

diagnostic testing practices. 

A recent FoodNet analysis of 

these survey data identified 

the largest percent increases 

in CIDT use for Salmonella and 

Shigella.

76 Such surveys could 

inform a border region-specific 

approach to address CIDT 

challenges. 

Enteric Diseases and TB Next Steps 

• Identify venues (BTWG, face-to-face meetings) that 

can be used to discuss WGS and its potential impact 

on surveillance in the border region. Topics for 

discussion include:

» How state health departments are managing ability/

inability to conduct WGS for enteric specimens and 

the prioritization of specimens for testing;

» Time delays inherent in WGS;

» Possibility that gaps in enteric surveillance will 

widen with WGS and fewer outbreaks will be 

identified;

» How best to use WGS to investigate highest 

priority clusters; and 

» How to engage with Mexican partners to identify 

cross-border clusters.

Enteric Diseases Next Steps 

• Assess diagnostic methods used for enteric disease 

surveillance to ensure identification of outbreaks 

and drug resistance.

• Identify current and best practice state regulations 

for culture and susceptibility testing of priority 

diseases where use of CIDT can limit identification of 

resistant strains.

• Assess ways to improve timeliness of enteric disease 

confirmatory testing.
INFEC TIOUS DISEASE PRIORITIZATION FOR MULTIJURISDIC TIONAL ENGAGEMENT

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Outbreak Response and Preparation Activities

Identified Opportunity Rationale Considerations Potential Next Steps

Continue to use the BTWG 

and face-to-face meetings to 

work with partners, including 

Mexican counterparts, to 

address preparedness, foster 

awareness of emerging public 

health issues, and encourage 

collaboration.

Engagement and coordination 

between US border 

jurisdictions and with Mexico 

are critical to developing and 

maintaining comprehensive 

preparedness and response 

plans and activities for the 

border region.

Existing collaborations and 

forums such as BHC, BTWG, 

and multiple local groups have 

developed a strong foundation 

for continued work that should 

be leveraged and grown. 

Additionally, CDC supports 

states in preparedness work 

through the Public Health 

Emergency Preparedness 

Cooperative Agreement, 

and the Epidemiology 

and Laboratory Capacity 

Cooperative Agreement.

General Next Steps

• Use existing forums as platforms to discuss

» Solutions to ongoing challenges with specimen 

transport across the border for public health 

purposes (both routinely and during an 

outbreak);

» Preparedness and response capacity building, 

through tabletop exercises (e.g., for introduction 

of yellow fever), and sharing best practices 

(including regional plans);

» Data sources (e.g., US federal detention data 

and Mexico’s national surveillance system) 

that are important for outbreak response and 

preparedness activities; and 

» Mechanisms to coordinate and leverage 

prevention messaging between partners to 

strengthen outbreak response and investigations.

• Review use of the Operational Protocol for U.S.-

Mexico Binational Communication and Coordination 

on Disease Notifications and Outbreaks and regional 

plans to inform revision and strengthening.

• Clarify, leverage, and coordinate with preparedness 

work being done at the local, state, and federal 

levels for the prioritized diseases.

Expand, standardize, and 

maintain mosquito surveillance 

to improve description of the 

geographic distribution of 

Aedes mosquitoes and where 

transmission is likely to occur.

Aedes mosquito presence 

is dynamic and dependent 

on many factors in the 

border region. Additionally, 

surveillance methods for 

these mosquitoes may vary 

even within states. The 

ever- changing mosquito 

distribution and inconsistent 

surveillance leads to gaps in 

knowledge of mosquito-borne 

disease risks.

Vector-Borne Disease Regional 

Centers of Excellence aim 

to address surveillance, 

prevention, and response 

of emerging vector-borne 

diseases. Additionally, CDC, 

the COEs, and others held an 

epidemic prediction initiative

to predict the monthly 

presence of Ae. aegypti and 

Ae. albopictus in a subset of 

US counties in 2019. Such risk 

assessment efforts may help 

identify with greater precision 

where border surveillance 

efforts are most needed.

Arboviruses Next Steps

• Recommend that Vector-Borne Disease Regional 

COEs include New Mexico in their surveillance 

activities, when feasible.

• Share resources related to risk modeling and 

forecasting challenges and perhaps create a risk 

assessment for border states.

• Better disseminate information about Mexico’s 

surveillance and data.

• Engage with the Vector-Borne Disease Regional 

COEs through BTWG and others to identify 

opportunities for collaboration and harmonization 

(e.g., virologic surveillance in mosquitoes).

Enhance follow-up with 

patients or contacts who 

cross the border or who are 

deported before treatment 

completion or after exposure.

Patients diagnosed with an 

infectious disease who cross 

the US-Mexico border may be 

at risk for gaps in treatment 

or continued infectiousness. 

While programs such as 

CureTB work to enhance 

continuity of TB care, there 

are limited initiatives, 

resources, and mechanisms for 

comprehensive TB program 

integration (e.g sharing 

information about proven 

or possible clusters and joint 

contact tracing). Similar gaps 

remain for other infectious 

diseases. 

Existing efforts include BIDS 

binational case reporting 

activities, TB contact 

projects in California and 

Texas, CureTB, and “meetand-greets” coordinated 

by Arizona Department of 

Health Services staff.

TB and Enteric Diseases Next Steps

• Leverage existing cross-border projects to establish 

best practices and continuing challenges in crossborder contact tracing infrastructure.

• Improve educational approaches for persons 

who leave the United States from custody before 

completing treatment for or after exposure to TB 

and potentially other priority diseases.
INFEC TIOUS DISEASE PRIORITIZATION FOR MULTIJURISDIC TIONAL ENGAGEMENT

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26

Outbreak Response and Preparation Activities (Continued)

Identified Opportunity Rationale Considerations Potential Next Steps

Develop and implement 

evidence-based methods to 

evaluate population mobility 

and healthcare use patterns 

among US-Mexico border 

crossers.

Understanding cross-border 

healthcare use in the 

US-Mexico border region 

is important for controlling 

infectious diseases, designing 

educational campaigns, and 

combating the emergence 

and spread of drug-resistant 

organisms. 

Some surveys, although dated 

and incomplete, suggest 

that crossing the border 

for healthcare services may 

be quite common in some 

border communities or 

subpopulations. It would be 

important to capture both 

geographic variation within 

the border region as well as 

subpopulation variation, such 

as for Hispanics and foreignborn individuals.

General Next Steps

• Convene workgroup(s) to discuss strategies for 

capturing mobile populations’ healthcare-seeking 

patterns..

Health Education Activities

Identified Opportunity Rationale Considerations Potential Next Steps

Improve health education and 

outreach for Spanish-speaking 

border populations with 

limited English proficiency. 

Significant proportions of 

border region residents 

may require or prefer health 

information in Spanish.

Spanish-speaking border 

region residents may also seek 

or regularly get information 

from Mexican sources.

General Next Steps

• Create opportunities and a platform for regularly 

sharing validated educational and prevention 

materials in border communities.

• Seek opportunities to harmonize educational 

information with Mexico. 

• Formalize an information gathering process from 

border states and counties so that materials can be 

developed through CDC that are specific for border 

region Spanish speakers and that can be edited by 

state and local health departments, if necessary, for 

both emergency response and non-response times.

Ensure education materials 

for Spanish-speaking 

border populations are 

tested for accuracy, cultural 

appropriateness, and 

understandable messages.

Translation of educational 

content alone does not ensure 

that the content will be 

understood by or is culturally 

appropriate for the intended 

audience. Cultural validation 

and testing are critical to 

optimize messaging.

Health departments rarely 

have the resources for health 

communication specialists to 

develop culturally appropriate 

educational content intended 

for specific subpopulations.

General Next Steps

• Review existing health education information 

accessible to the border regions for the priority 

diseases to assess availability, accuracy, and cultural 

appropriateness of Spanish-language content.

• Share and assess the communication components 

of border region emergency response plans to 

assess outreach to Spanish-speaking border 

populations and make recommendations if needed.

• Identify and collaborate with community groups 

(such as Ventanillas de Salud) to test materials for 

translation accuracy and cultural appropriateness. 

• Explore possible avenues and approaches to 

determine the best ways of disseminating targeted 

public health information. Some avenues that can 

be explored are 

» Social media;

» Community health representatives, community 

health workers, and other community leaders or 

health champions; and 

» Community networks, agencies, and 

organizations such as physician and border 

clinic networks, schools, tribal governments, and 

Ventanillas de Salud.
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Photo 13. Doctor talking to a little girl.
https://www.cdc.gov/usmexicohealth