Tuberculosis Control in Cuba and Haiti
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Transcript of Tuberculosis Control in Cuba and Haiti
Tuberculosis Control in Cuba & HaitiKathryn Cicerchi, Colorado School of Public HealthJune 25, 2015
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Tuberculosis Infectious disease caused by mycobacterium
tuberculosis
Most commonly attacks lungs Can attack any part of the body, such as kidneys, spine,
brain
Can be fatal if not treated properly Second greatest killer worldwide due to single infectious
agent In 2013, 9 million people contracted active TB and 1.5
million died
Two types of infection: Latent Active
Sources: CDC, WHO 2015
Latent TB 1/3 of the world’s population is infected, though most
are not ill and cannot transmit TB
Walled off by healthy immune system
Many with latent TB never progress to active disease
Those who do: Become sick within days of infection Can develop active TB years later when immune system
compromised (malnutrition, diabetes, HIV co-infection)
Lifetime risk of progressing from latent TB to active disease is 10% (WHO)
Sources: CDC, WHO 2015
Active Tuberculosis Symptoms:
Coughing (sputum, blood) Chest pains Weakness Weight loss Fever Night sweats
Spread person to person through droplets
Treatable with antibiotics
Risk factors: extreme poverty, lack of health care, poor environmental and hygienic conditions (overcrowding)
Drug resistance (MDR-TB and XDR-TB) now a major worldwide concern
Sources: CDC, WHO 2015
Background & Health Indicators
Cuba
11.26 million population
77% urban
Life expectancy at birth: 79.3 years
Years of healthy life: 67 years
Aging population with median age of 40 (2013)
2014 HDI: 45/187 countries
1.7% unemployment (2008, PAHO)
GNI per capita: $19,844 (2013)
Haiti
10.3 million population
56% urban
Life expectancy at birth: 63.1 years
Years of healthy life: 52 years
Young population with median age of 22 (2013)
2014 HDI: 168/187 countries
39% (rural)- 49% (PaP) unemployment
GNI per capita: $1,636 (2013)
Health SystemsCuba
Free, universal care
Based on primary care
Consultorios, polyclinic in every community
Highly integrated system
500,294 workers in health sector
6.7 physicians per 1,000 population (2015, WHO)
Haiti
700 primary care facilities &10 departmental hospitals with half of health facilities concentrated in Port-au-Prince
Health system faces complex organizational & managerial problems Limited availability Poor quality
Fragmented system supported by thousands of NGOs and private groups
0.25 physicians per 1,000 population (1998, WHO)
National TB Control ProgramsCuba
$27 million budget in 2012
Directly observed therapy, short course (DOTS) in place as of 1982
Currently 100% DOTS coverage
Family physician responsible for case finding, treatment (DOTS), contact tracing, community education
Haiti
$12 million budget in 2012 5% domestically, 34%
internationally, 61% unfunded
DOTS coverage only 37% as of 2002
Global Fund grant of $13.6 million through 2011 to increase DOTS coverage to 80% (progress inadequate)
Current Global Fund grant of $21.6 million to expand DOTS coverage to 70% through community organizations & fund 100% of anti-TB meds (promising progress)
National TB Control ProgramsCuba
Active surveillance
Decentralized labs
Newborn vaccination (BCG)
Active contact tracing All cases investigated Contacts checked for
respiratory symptoms Contacts meeting certain
criteria are treated prophylactically with isoniazid
Local doctors perform all case finding, treatment, prophylaxis, education
Haiti
Working on improving surveillance system, supported by CDC
CDC supporting improving lab quality and capacity
BCG vaccination recommended (55% in 2010)
Much of contact tracing provided by NGOs, CHWs More transient population
makes tracing and follow up difficult
Treatment supported by NGOs
Current Situation
Incidence (23x higher)
206 per 100,000 population
Prevalence (19.5x higher)
254 per 100,000 population
Incidence
9.3 per 100,000 population
Prevalence
19.5 per 100,000
population
Cuba Haiti
Source: WHO 2015, rates as of 2013
MortalityCuba
TB not a major cause of death
Mortality rate of 0.33 per 100,000, excluding HIV (WHO, 2014)
Haiti
TB is 9th major cause of death, 2.8% of all deaths in 2012 (WHO)
TB is 4th cause of death for children under 5 (PAHO, 2012)
Mortality rate of 26 per 100,000 population, excluding HIV
MDR-TB & HIV Co-Infection
MDR-TB
Estimated 390 cases Only 81 detected (21%) 59 confirmed cases treated
with second-line drugs (73%)
TB/HIV Highest prevalence of HIV
among TB cases in the region at 42% (PAHO, 2013)
81% of notified TB cases tested for HIV- 20% were positive
MDR-TB
Estimated 11 cases 8 cases detected (73%) 8 confirmed cases treated
with second-line drugs (100%)
TB/HIV Increasing 83% of notified TB cases
tested for HIV- 9% were positive
Cuba Haiti
TB Elimination in Cuba?Cuba is on track to eventually eliminate
tuberculosis Low rates of MDR-TB Relatively low HIV co-infection
Efforts need to focus on adjusting indicators to be more sensitive
Improve case detection by focusing on vulnerable groups within Cuba
Increase quality of preventive services
Keep an eye on MDR-TB and HIV co-infection
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Lessons LearnedDrag picture to placeholder or click icon to add TB can be controlled in low-resource settings with strong
health system
In Haiti, TB is both a cause and symptom of underdevelopment
Recommendations for Cuba Procure/make adequate supply of second-line TB drugs to
control MDR-TB before resistance spreads Target vulnerable groups Increase funding for final stretch toward elimination
Recommendations for Haiti Strengthen health system Increase funding—and completely fund— TB programs Commence aggressive active case finding and prophylactic
treatment for active and latent disease Improve vaccination Strengthen supply chain of first- and second-line drugs
References Abreu, G., Gonzalez, J. A., Gonzalez, E., Bouza, I., Velazquez, A., Perez, T., . . .
Sanchez, L. (2011). Cuba's strategy for childhood tuberculosis control, 1995-2005. MEDICC Review, 13(3), 29-34.
Al Jazeera America. (2014, December 29). Drug-resistant tuberculosis patients face dwindling treatment options. Retrieved from http://america.aljazeera.com/articles/2014/12/29/drug-resistant-tuberculosis.html
Association of Schools of Public Health. (1907). Cuba: Tuberculosis in Cuba. Free sanitarium for tuberculous patients to be established. Public Health Reports (1896-1970), 22(24). Retrieved from http://www.jstor.org/stable/4559252
CDC Division of Tuberculosis Elimination (CDC/DTBE). (2012, September 14). DTBE in Haiti. Retrieved from http://www.cdc.gov/tb/topic/globaltb/haiti.htm
Centers for Disease Control and Prevention (CDC). (2012, March 13). Basic TB facts. Retrieved from http://www.cdc.gov/tb/topic/basics/default.htm
Centers for Disease Control and Prevention (CDC). (2014, April 1). Drug-resistant TB. Retrieved from http://www.cdc.gov/tb/topic/drtb/default.htm
Charles, M., Charles Vilbrun, S., Koenig, S. P., Hashiguchi, L. M., Marcelle Mabou, M., Ocheretina, O., & Pape, J. W. (2014). Treatment outcomes for patients with MDR-TB in post-earthquake Port-au-Prince, Haiti. American Journal of Tropical Medicine and Hygeine, 91(4), 715-721. doi:10.4269/ajtmh.14-0161
Farmer, P., Gardner, A. M., Hoof, H. C., & Mukherjee, J. (2011). Haiti after the earthquake. New York: Public Affairs.
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References Gonzalez Ochoa, E., Rosco Oliva, G. E., Borroto Gutierrez, S., Perna Gonzalez, A., & Armas
Perez, L. (2009). Tuberculosis mortality trends in Cuba, 1998 to 2007.MEDICC Review, 11(1), 42-47.
Gonzalez, E., Armas, L., & Llanes, M. J. (n.d.). Progress towards tuberculosis elimination in Cuba. The International Journal of Tuberculosis and Lung Disease,11(4), 405-411.
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Ministere de la Sante Publique et de la Population (MSPP), Haiti. (2015). Report de cas, cholera.
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Murray, C., DeJonghe, E., Chum, H., Nyangulu, D., Salomao, A., & Styblo, K. (1991). Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries. Lancet, 338, 1305-1308. doi:10.1016/0140-6736(91)92600-7
National Alliance of State & Territorial AIDS Directors (NASTAD). (2015, May 26). Reinforcing integrated HIV and tuberculosis case-based surveillance in Haiti. Retrieved from http://www.nastad.org/blog/reinforcing-integrated-hiv-and-tuberculosis-case-based-surveillance-haiti
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References Navarrete, A. (1943). Present tuberculosis status in Cuba. CHEST, 9(2).
doi:10.1378/chest.9.2.175
Ocheretina, O., Morose, W., Gauthier, M., Joseph, P., D'Meza, R., Escuyer, V. E., . . . Fitzgerland, D. W. (2012). Multidrug-resistant tuberculosis in Port-au-Prince, Haiti. Rev Panam Salud Publica, 31, 221-224.
Pan American Health Organization (PAHO). (2012). Health in the Americas: Cuba Country Volume. Retrieved from http://www.paho.org/saludenlasamericas/index.php?option=com_docman&task=doc_view&gid=125&Itemid=
Pan American Health Organization (PAHO). (n.d.). Tuberculosis. Retrieved May 20, 2015, from http://www.paho.org/hq/index.php?option=com_topics&view=article&id=59&Itemid=40776&lang=en
Pan American Health Organization. (2013). Tuberculosis in the Americas: Regional report. Epidemiology, Control and Financing.
The Global Fund. (n.d.). The Global Fund grant portfolio: Haiti's response to tuberculosis, HTI-304-G04-T. Retrieved June 24, 2015, from http://portfolio.theglobalfund.org/en/Grant/Index/HTI-304-G04-T
The Global Fund. (n.d.). The Global Fund grant portfolio: Strengthening and improvement of DOTS strategy in Haiti, HTI-911-G08-T. Retrieved June 24, 2015, from http://portfolio.theglobalfund.org/en/Grant/Index/HTI-911-G08-T
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References UNDP. (n.d.). UNDP country impact: Haiti. Retrieved from
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