The U.S.-Mexico border infectious disease surveillance project: establishing binational border surveillance. (Research).
In 1997, the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. , the Mexican Secretariat of Health, and border health officials began the development of the Border Infectious Disease Infectious disease
A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. Surveillance (BIDS) project, a surveillance system for infectious diseases infectious diseases: see communicable diseases. along the U.S.-Mexico border. During a 3-year period, a binational bi·na·tion·al
Of, relating to, or involving two nations. team implemented an active, sentinel surveillance system for hepatitis and febrile febrile /feb·rile/ (feb´ril) pertaining to or characterized by fever.
Of, relating to, or characterized by fever; feverish. exanthems at 13 clinical sites. The network developed surveillance protocols, trained nine surveillance coordinators, established serologic testing at four Mexican border laboratories, and created agreements for data sharing The ability to share the same data resource with multiple applications or users. It implies that the data are stored in one or more servers in the network and that there is some software locking mechanism that prevents the same set of data from being changed by two people at the same time. and notification of selected diseases and outbreaks. BIDS facilitated investigations of dengue fever dengue fever (dĕng`gē, –gā), acute infectious disease caused by four closely related viruses and transmitted by the bite of the Aedes mosquito; it is also known as breakbone fever and bone-crusher disease. in Texas-Tamaulipas and measles in California-Baja California. BIDS demonstrates that a binational effort with local, state, and federal participation can create a regional surveillance system that crosses an international border. Reducing administrative, infrastructure, and political barriers to cross-border public health collaboration will enhance the effectiveness of disease prevention projects such as BIDS.
The 2,000-mile U.S.-Mexico border is one of the world's busiest international boundaries. An estimated 320 million people cross the northbound border legally every year (1). The U.S.-Mexico border is a unique region where the geopolitical ge·o·pol·i·tics
n. (used with a sing. verb)
1. The study of the relationship among politics and geography, demography, and economics, especially with respect to the foreign policy of a nation.
a. boundary does not inhibit social and economic interactions nor the transmission of infectious diseases among residents on each side of the border. Some border cities (such as El Paso El Paso (ĕl pă`sō), city (1990 pop. 515,342), seat of El Paso co., extreme W Tex., on the Rio Grande opposite Juárez, Mex.; inc. 1873. and Ciudad Juarez) are separated by a short distance and serve as one large metropolitan area for the local community (Figure 1). From an epidemiologic perspective, the border population must be considered as one, rather than different populations on two sides of a border; pathogens do not recognize the geopolitical boundaries established by human beings. The border region has a population of approximately 11 million people (2), many of whom cross the border daily to work, shop, attend school, seek medical care, or visit family and friends (3,4). The border population also includes persons who pass transiently through the region and others who come the area to work in maquilas, the border factories. The region has experienced tremendous population growth. During 1993-1997, the U.S. border population grew by 1.8% annually, more than double the national U.S. average of 0.8%, while the Mexican border population has grown by 4.3% per year, almost three times the national Mexican annual growth rate of 1.6% (2,5). Population growth has been spurred by increased economic opportunities after the North American Free Trade Agreement North American Free Trade Agreement (NAFTA), accord establishing a free-trade zone in North America; it was signed in 1992 by Canada, Mexico, and the United States and took effect on Jan. 1, 1994. was implemented in 1994. Currently, an estimated 3,300 maquilas, employing >1 million workers, are located along the border (6,7). The proliferation of border factories has generated a wave of internal migration of persons from other regions of Mexico and Central America Central America, narrow, southernmost region (c.202,200 sq mi/523,698 sq km) of North America, linked to South America at Colombia. It separates the Caribbean from the Pacific. toward the border (8).
[FIGURE 1 OMITTED]
From Mexico's perspective, the border encompasses some of the country's most economically prosperous states. In contrast, the U.S. border region is among the poorest areas in the United States, with >30% of families living at or below the poverty level (8). Along the Texas border, an estimated 350,000 or more people live in 1,450 unincorporated areas known as colonias, which lack adequate sanitation infrastructure (8).
The large population movement, limited public health infrastructure, and poor environmental conditions contribute to increased incidence of certain infectious diseases (8-11) Analysis of data from the U.S. National Notifiable Diseases Surveillance System for 1990 through 1998 showed increased risks for certain foodborne, waterborne, and vaccine-preventable diseases in U.S. counties within 100 kilometers of the border, compared with nonborder states. These data show a two- to fourfold greater incidence of hepatitis A Hepatitis A Definition
Hepatitis A is an inflammation of the liver caused by a virus, the hepatitis A virus (HAV). It varies in severity, running an acute course, generally starting within two to six weeks after contact with the virus, and lasting no , measles, rubella rubella or German measles, acute infectious disease of children and young adults. It is caused by a filterable virus that is spread by droplet spray from the respiratory tract of an infected individual. , shigellosis Shigellosis Definition
Shigellosis is an infection of the intestinal tract by a group of bacteria called Shigella. The bacteria is named in honor of Shiga, a Japanese researcher, who discovered the organism in 1897. , and rabies rabies (rā`bēz, ră`–) or hydrophobia (hī'drəfō`bēə), acute viral infection of the central nervous system in dogs, foxes, raccoons, skunks, bats, and other animals, and in and an eightfold eightfold
1. having eight times as many or as much
2. composed of eight parts
by eight times as many or as much
Adj. 1. greater incidence of brucellosis brucellosis (br'səlō`sĭs) or Bang's disease, infectious disease of farm animals that is sometimes transmitted to humans. in border counties than in nonborder states (11). Studies have identified the importance of crossborder movement in the transmission of various diseases, including hepatitis A (12,13), tuberculosis (14-18), shigellosis (19), syphilis (20), Mycobacterium mycobacterium
Any of the rod-shaped bacteria that make up the genus Mycobacterium. The two most important species cause tuberculosis and leprosy in humans; another species causes tuberculosis in both cattle and humans. boris infection (21), and brucellosis (22,23).
Despite the high prevalence of infectious diseases and increasing movement of people across the borders, no surveillance system had been established to assess the border population as a geographic unit. Gaining an accurate picture of public health needs was limited by the following factors. First, the surveillance case definitions used for public health reporting in Mexico and the United States Relations between the United States and Mexico are among the most important and complex that each nation maintains. They are shaped by a mixture of mutual interests, shared problems, and growing interdependence. are different. Also, laboratory confirmation is often unavailable in the Mexican border states, and therefore reported cases of infectious diseases are defined primarily by clinical findings. In contrast, for the many notifiable diseases in the United States, laboratory confirmation is required, and U.S. surveillance is heavily based on laboratory reporting. This system likely underestimates the true incidence rates. In the past, the two countries have exchanged limited border surveillance data. However, these differences diminish the usefulness of national surveillance data for developing a comprehensive, regional understanding of infectious disease epidemiology in the border areas. A consistent binational perspective is essential to effectively control and prevent the transmission of infectious diseases that move easily through the geopolitical boundary.
The Border Infectious Disease Surveillance (BIDS) project was designed to bridge this surveillance gap by forming partnerships among institutions in both countries serving the region and bringing together each country's complementary experiences in syndromic and laboratory-based surveillance. This report describes the establishment of a binational surveillance system for hepatitis and febrile exanthems along the U.S.-Mexico border.
In June 1997, the United States-Mexico Border Health Association and the U.S. Council of State and Territorial Epidemiologists The Council of State and Territorial Epidemiologists (CSTE) was organized in the USA in the early 1950s in response to the need to have at least one person in each state and territory responsible for public health surveillance of diseases and conditions of public health passed resolutions to support surveillance for infectious diseases and emerging infectious diseases along the U.S.-Mexico border (24,25). The Centers for Disease Control and Prevention (CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation ) and the Mexican Secretariat of Health spearheaded efforts to initiate the project and formalized for·mal·ize
tr.v. for·mal·ized, for·mal·iz·ing, for·mal·iz·es
1. To give a definite form or shape to.
a. To make formal.
b. an agreement to establish BIDS through a memorandum of cooperation in epidemiology. A binational team of local, state, and federal epidemiologists, laboratory scientists, and public health officials met to organize and define project objectives. Decisions were made by consensus among the participants.
The team selected four sister city groups that had previously collaborated on binational projects (Figure 2). Local and state health departments identified one or more clinical facilities in each city. The U.S. institutions are four primary-care clinics and three tertiary care tertiary care Managed care The most specialized health care, administered to Pts with complex diseases who may require high-risk pharmacologic regimens, surgical procedures, or high-cost high-tech resources; TC is provided in 'tertiary care centers', often hospitals. The Mexican sites comprise two general hospitals and four primary-care clinics. The primary-care institutions service 10,000-20,000 acute care visits per site annually, while the hospitals service 23,000-51,000 acute-care visits per site annually.
[FIGURE 2 OMITTED]
After extensive discussions about local and national disease priorities, the team agreed on active sentinel surveillance for hepatitis and febrile exanthem exanthem /ex·an·them/ (eg-zan´them)
1. any eruptive disease or fever.
2. an eruption characterizing an eruptive fever. syndromes. A standard protocol of laboratory testing is performed for specimens from patients who fulfill the clinical entry criteria (Table 1). Patients with acute hepatitis acute hepatitis Clinical medicine Liver inflammation of abrupt onset, which may be due to a viral infection–eg HAV or toxins Clinical Low-grade fever, anorexia, N&V, fatigue, malaise, headache, photophobia, pharyngitis, cough; later, dark urine, light are tested at local laboratories for hepatitis A, B, and C. Depending on the initial results, specimens are tested at CDC for hepatitis D Hepatitis D Definition
Hepatitis D (or delta, the Greek letter "D"), is a form of liver inflammation that occurs only in patients who also are infected by the hepatitis B virus. and E, and confirmatory testing for hepatitis C Hepatitis C Definition
Hepatitis C is a form of liver inflammation that causes primarily a long-lasting (chronic) disease. Acute (newly developed) hepatitis C is rarely observed as the early disease is generally quite mild. is performed. Patients with febrile exanthems are tested locally for measles and rubella. If these tests are negative, the specimens are tested at a state or national reference laboratory for rickettsiae, ehrlichiae, and, in selected areas, Dengue virus dengue virus
A virus of the genus Flavivirus that is the cause of dengue. (DENV DENV Department of Environment (Canada) ).
Many diseases selected for BIDS surveillance have well-defined preventive strategies, including vaccination. In Mexico, measles is targeted for elimination, and rubella vaccination was incorporated into the national vaccination program in 1998 (26). In the United States., rubella outbreaks have occurred among Hispanic immigrants who were not previously immunized (27-30). The south Texas border also represents an important zone for transmission of DENV (31-33) and typhus typhus, any of a group of infectious diseases caused by microorganisms classified between bacteria and viruses, known as rickettsias. Typhus diseases are characterized by high fever and an early onset of rash and headache. (34-36). In the United States, routine vaccination for hepatitis A was recently recommended for children in most of the U.S.-Mexico border region (37). Since laboratory confirmation was not readily available in Mexico, most acute hepatitis was assumed to be acute hepatitis A; however, the extent of hepatitis B Hepatitis B Definition
Hepatitis B is a potentially serious form of liver inflammation due to infection by the hepatitis B virus (HBV). It occurs in both rapidly developing (acute) and long-lasting (chronic) forms, and is one of the most common chronic and hepatitis C infection was unknown. Syndromic surveillance facilitated the monitoring of diseases targeted for elimination as well as identification of emerging infectious diseases, such as hepatitis E Hepatitis E Definition
The hepatitis E virus (HEV) is a common cause of hepatitis that is transmitted via the intestinal tract, and is not caused by the hepatitis A virus. and ehrlichliosis, which have not been previously well studied along the border. The selection of these surveillance conditions was influenced by the need to establish laboratory infrastructure in Mexico; the hepatitis and febrile exanthem testing protocols involve serologic se·rol·o·gy
n. pl. se·rol·o·gies
1. The science that deals with the properties and reactions of serums, especially blood serum.
2. assays with similar equipment and assay techniques. From the practical perspective, sentinel surveillance enabled clinics in several border cities to participate at a reasonable cost. Active surveillance was selected to enhance existing passive surveillance activities in both countries, and, rather than creating a parallel structure, all activities were integrated into state and national reporting systems.
Organizational Structure, Personnel, and Training
The group formed an executive committee and three subcommittees (epidemiology, laboratory, and communications). Nine sentinel site surveillance coordinators, who report to a local health department epidemiologist and a state-based epidemiologist, were hired and trained. The sentinel site coordinators are responsible for interviewing patients, completing data entry, and handling logistical issues such as specimen shipping and tracking. Considerable training was provided for border laboratory personnel. Only one of the Mexican border laboratories had experience performing serologic testing for hepatitis viruses, and none were experienced with testing for measles or rubella viruses. Laboratory scientists from Instituto de Diagnostico y Referencias Epidemiologicas, Mexico City, received training in testing methods for rickettsiae and ehrlichiae.
Improving binational communication systems was critical to project success. In addition to language and cultural barriers, a large gap exists in communications infrastructure between the United States and Mexico. Many Mexican local and state health departments use combined telephone and fax lines and have no Internet access; regularly scheduled conference calls are a principal mechanism for communication. Borderwide meetings are held annually and sister city groups have regional meetings. A binational team of epidemiologists, laboratory scientists, and a representative from the E1 Paso Field Office of the Pan American Health Organization The Pan American Health Organization (PAHO) is an international public health agency with 100 years of experience in working to improve health and living standards of the countries of the Americas. It serves as the specialized organization for health of the Inter-American System. conducts site visits and evaluations.
The movement of equipment, supplies, specimens, and financial resources between the two countries has been difficult and labor-intensive. Logistical issues include the challenges of moving laboratory equipment and supplies into Mexico and specimens across the border into the United States. Several U.S. and Mexican agencies regulate these cross-border movements. Although regulations are established at a federal level, they are often subject to local interpretation. As a result, the BIDS participants work closely with local agencies in their state.
Information-Sharing Protocols and Binational Cases
In the past, sharing of surveillance data has been constrained due to differences in political systems, limited forums in which to share information, and poor comparability of the data. Two protocols were developed to improve information sharing. The first describes the flow of information process in each country. Although the Mexican health sector is currently undergoing decentralization de·cen·tral·ize
v. de·cen·tral·ized, de·cen·tral·iz·ing, de·cen·tral·iz·es
1. To distribute the administrative functions or powers of (a central authority) among several local authorities. , officials from the federal Mexican Secretariat of Health continue to play the major role in reviewing, analyzing, and approving data before information is shared with U.S. counterparts and CDC. In contrast, U.S. local and state data can be shared without federal approval. The second protocol establishes conditions for urgent notification of sister city sites of outbreaks and cases of selected diseases, such as measles. Urgent notification also occurs for cases of binational public health importance, such as a case of hepatitis A in a person who works as a food handler on either side of the border. In the routine disease surveillance systems of both the United States and Mexico, a reportable condition diagnosed at a medical facility on one side of the border, in a patient who lives on the opposite side of the border, may not be included in routine disease reporting, and this information is not usually provided to the neighboring health officials. Data about these binational cases have not been traditionally captured in either country's reporting system. Therefore, binational case definitions were developed for BIDS participants (Table 2).
The project timeline is shown in Table 3. Data collection began in late 1999, and data are currently being analyzed. As of mid-2002, the network had identified 867 persons with hepatitis and hepatitis syndrome (369 in the United States and 498 in Mexico) and 421 persons with a febrile exanthem syndrome (243 in the United States and 178 in Mexico). The project has enhanced local reporting of these conditions. In 2000, BIDS surveillance data from the sentinel site in Tijuana, Baja California, identified 300% more cases of laboratory-confirmed hepatitis A than would have been expected. All hepatitis A cases identified at the San Diego site were binational and were reported to the sister city health department in Tijuana.
The BIDS network has prompted valuable data exchange as well. In 2000, California and Baja California shared important information about measles in California and rubella in both states. The Baja California Health Department used BIDS surveillance data to conduct epidemiologic follow-up and targeted vaccination as part of their efforts to eliminate measles and reduce rubella. In 1999, the Mexican Secretariat of Health, CDC, and health officials from Texas and Tamaulipas conducted the first binational investigation of an outbreak of dengue fever (38).
Consolidation, evaluation, and expansion of BIDS will take place in 2002-2003. The project, which began at 9 sites, has expanded to 13 sites. Continuing efforts will focus on incorporating six new clinical sites and three new border cities (Figure 2). With sufficient expansion, BIDS may be able to calculate population-based incidence rates for selected infectious diseases in some border areas. However, BIDS will continue to deal with the complexities of conducting surveillance among mobile populations and obtaining accurate denominator information for the border region.
Although activities focused initially on hepatitis and febrile exanthems, the project is sufficiently flexible to incorporate other syndromes and diseases, including West Nile virus West Nile virus, microorganism and the infection resulting from it, which typically produces no symptoms or a flulike condition. The virus is a flavivirus and is related to a number of viruses that cause encephalitis. and infectious agents that could be used in bioterrorism events. BIDS continues to improve communications systems and support mechanisms for information exchange.
The BIDS project demonstrates that the development of a binational regional surveillance system for one of the world's busiest geographic boundaries is feasible. Success is highly dependent on extensive U.S. and Mexican local and state involvement; maintaining a balance among the competing priorities of this diverse group of participants continues to be one of the project's greatest challenges. A high level of participation among the group is an essential ingredient in creating a binational, locally-relevant agenda and enhancing long-term project sustainability. The BIDS surveillance system has required flexibility to incorporate local and state reporting requirements, while maintaining sufficient standardization of case definitions, data, and laboratory testing procedures. Dedicated coordination at the federal level of both countries has been essential. Maintaining federal political commitment and funding for the 3-year development and implementation period has been and continues to be critical.
BIDS promotes communication and cooperation through border-wide meetings and the binational subcommittees. The border sister city meetings provide a forum for exchange of ideas and discussion of issues of binational importance, thus strengthening cross-border relationships among counterpart epidemiologists and laboratory staff. Many logistical problems require local solutions best handled by the sister cities working together. Effective problem solving problem solving
Process involved in finding a solution to a problem. Many animals routinely solve problems of locomotion, food finding, and shelter through trial and error. requires coordination and optimal communication among participants. However, this level of effectiveness will not be achieved in the border region until the infrastructure barriers are overcome, including substantial improvements in access to telephones, fax machines, computers, the Internet, and satellite teleconferencing.
BIDS continues to face major obstacles in the movement of equipment, supplies, specimens, and financial resources across borders. These activities are cumbersome and time consuming for all project participants. Accords between the United States and Mexico should be developed to promote cooperation in public health and facilitate sharing of human and other resources and the moving of laboratory specimens across the border; these agreements would substantially enhance border health activities and benefit both countries. The states of Arizona and Sonora cooperated successfully in establishing a shared border health facility in Nogales, Sonora. This state-based model could be replicated in other areas of the border and reinforced with federal policies. To further enhance federal support, we suggest that a joint border field station be established by CDC, the Mexican General Directorate of Epidemiology, and the Instituto de Diagnostico y Referencias Epidemiologicas.
The mandates from the United States-Mexico Border Health Association and the Council of State and Territorial Epidemiologists served as an initiation point for project activities but did not anticipate the need for additional federal-level agreements for data exchange. The BIDS group has drafted guidelines for conducting a binational outbreak investigation and will be implementing these as opportunities arise. Ongoing data collection will enable better characterization of binational cases. However, formal agreements at high levels of government are needed to authorize and endorse the timely binational exchange of epidemiologic and laboratory information about important infectious disease outbreaks and cases that occur along the border at BIDS sites and sites that are not currently part of the BIDS network.
Political changes at the local, state, and federal levels in Mexico frequently lead to changes in public health personnel, resulting in an ongoing need to train and incorporate new personnel into the project; this reality has highlighted the importance of institutionalizing any binational project through high-level formal agreements between the two countries. Weathering political changes is a challenge to infrastructure-building projects, like BIDS, which require several years of investment until tangible results, such as data are available.
To achieve the goal of building border epidemiology and laboratory capacity, BIDS established a system that built on existing strengths in syndromic and laboratory surveillance. The enhancement of border laboratory infrastructure at the Mexican sites was a major benefit. Additional support is essential, including stable funding for laboratory supplies and training courses, ranging from laboratory techniques to preventive maintenance of laboratory equipment; implementation of standardized quality control and quality assurance guidelines, such as a voluntary blinded proficiency testing program for selected tests; and a telephone consultation service with a toll-free telephone number A toll-free, Freecall, Freephone, or 800 number is a special telephone number, in that the called party is charged the cost of the calls by the telephone carrier, instead of the calling party. to help staff address the problems.
Syndromic surveillance for hepatitis and febrile exanthems will allow us to estimate the magnitude of public health problems along the border, for example, acute hepatitis B and hepatitis C; determine the geographic distribution of diseases, such as typhus, ehrlichiosis, and dengue dengue
or breakbone fever or dandy fever
Infectious, disabling mosquito-borne fever. Other symptoms include extreme joint pain and stiffness, intense pain behind the eyes, a return of fever after brief pause, and a characteristic rash. ; detect outbreaks; evaluate control measures, such as immunization immunization: see immunity; vaccination. efforts to prevent measles, rubella, and hepatitis A and the reduction of breeding sites for mosquitoes that transmit dengue; and monitor emerging infections, such as hepatitis E, and generate hypotheses about these diseases that can be further studied. Systematic collection of surveillance data on binational cases will also better define the contribution of mobile populations to disease transmission.
As a model for true binational cooperation along the border, BIDS is a starting point from which a comprehensive infrastructure can be developed to accurately assess the health status of border residents and other migrants who come through the area. Ultimately, data provided by BIDS will be useful in the development of more effective prevention and control strategies for infectious diseases in this unique region.
Table 1. Entry criteria for active sentinel surveillance Hepatitis Illness with jaundice or dark urine, or illness [greater than or equal to] 6 days without jaundice and [greater than or equal to] 3 of the following: abdominal pain, acholic stools, nausea or vomiting, fever, anorexia Febrile exanthem Fever and nonvesicular rash, or an illness >3 days with fever but no rash, cough, and diarrhea Table 2. Case criteria for a binational case of hepatitis or a febrile exanthem Binational case (at least one of the following): Person with hepatitis or febrile exanthem who traveled or lived in neighboring country during incubation period for suspected or confirmed disease. Person with hepatitis or febrile exanthem who had contact with persons who traveled or lived in neighboring country during incubation period for suspected or confirmed disease. Case for which binational cooperation is needed for case investigation, case management, or both. Table 3. Timeline for implementation of Border Infectious Disease Surveillance project 1997 Mandate and objectives, site selection 1998 Binational planning, surveillance protocol with case definitions and data collection instruments 1999 Laboratory protocols and infrastructure; epidemiology training 2000-2001 Pilot data collection 2002-2003 Evaluation, consolidation, site expansion
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Address for correspondence: Michelle Weinberg, Division of Global Migration and Quarantine, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E03, Atlanta, GA 30333, USA; fax: 404-498-1633, e-mail: firstname.lastname@example.org
Michelle Weinberg, * Stephen Waterman, * Carlos Alvarez Lucas, ([dagger]) Veronica Carrion Falcon, ([dagger]) Pablo Kuri Morales, ([dagger]) Luis Anaya Lopez, ([dagger]) Chris Peter, ([double dagger]) Alejandro Escobar Gutierrez, ([section]) Ernesto Ramirez Gonzalez, ([section]) Ana Flisser, Ralph Bryan, * Enrique Navarro Valle, (#) Alfonso Rodriguez, ** Gerardo Alvarez Hernandez, ([dagger])([dagger]) Cecilia Rosales, ([double dagger])(double dagger]) Javier Arias Ortiz, ([subsection]) Michael Landen, ([paragraphs]) Hugo Vilchis, (##) Julie Rawlings, *** Francisco Lopez Leal LEAL. Loyal; that which belongs to the law. , ([dagger])([dagger])([dagger]) Luis Ortega, ([double dagger])([double dagger])([double dagger]) Elaine Flagg, * Roberto Tapia Conyer, ([dagger]) and Martin Cetron * for the Border Infectious Disease Surveillance Project Working Group (1)
* Centers for Disease Control and Prevention, Atlanta, Georgia, USA; ([dagger]) Secretaria de Salud, Mexico City, Mexico; ([double dagger]) San Diego County Health and Human Services Noun 1. Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Department of Health and Human Services, HHS Agency Public Health Laboratory, San Diego, California, USA; ([section]) Institute de Diagnostico y Referencias Epidemiologicas, Mexico City, Mexico; ([paragraph]) Universidad Nacional Autonoma de Mexico, Mexico City, Mexico; (#) Institute de Servicios de Salud Publica de Baja California, Mexicali, Baja California, Mexico; ** California Department of Health Services Department of Health Services may refer to:
(1) Members of the Border Infectious Disease Surveillance Project Working Group: Elisa Aguilar, Carlos Alonso, Adam Aragon, Enid Argott, Greg Armstrong, Rafael Ayala, Joan Baumbach, Beth Bell, William Bellini, Baltazar Briseno, Sergio Lopez Cabrera, Ahmed Calve calve
act of parturition by a cow or other mammal producing a calf as offspring. , Richard Campman, Patricia Cantu, Ernestina Castillo, Gary Clark, Nolvia Cortez, Raquel Cote, Jose Armando Covarrubias, Leta Crawford-Miksza, Bruce Elliot, Martha Vazquez Erlbeck, Miguel Escobedo, Howard Fields, Maria Guadalupe Jimenez Fierro, Robert Garcia, Carlos Gonzales, Minerva Diaz de Leon Gonzalez, Louise Gresham, Lucina Gutierrez, W. Lee Hand, Aurora Hiles, Debre Horensky, Wendi Kuhnert, Ericka Larquito, Miguel Angel Lopez, Jose Luis Aranda Lozano, Luis Gonzalez Madrigal madrigal, name for two different forms of Italian music, one related to the poetic madrigal in the 14th cent., the other the most common form of secular vocal music in the 16th cent. , Jorge Magana, Jay McAuliffe, Gabriel Martinez, Miguel Angel Vaca Marin, Berta Isabel Mendoza, Mercedes Gameros Mercado, Sonia Montiel, William L. Nicholson, Efren Ornelas, Eladio Pereira, Michael Purdy, Enrique Davis Ramirez, Gail Randolph, Susan Reef, Willy Rios-Araico, Mark Rodriguez, Alfonso Ruiz, Rosalba Ruiz, Joaquin Salcedo, Ana Isabel Vidal Sandate, Elsa Sarti, Ana Maria Sato, David Schnurr, William Slanta, Brian Smith, Alejandro Suarez, Juan Trevino, Nohemi Martha Castro Valdez, Yvonne Vasquez, Roberto Vazquez, Kathy Villa, Abedon Segura Villareal, Consuelo Villalon, Maria Luisa Volker, Vance Vorndam, Laura Walls.
Dr. Weinberg is a medical epidemiologist in the Division of Global Migration and Quarantine, Centers for Disease Control and Prevention. Her research interests focus on the epidemiology and prevention of infectious diseases along the U.S.-Mexico border.