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

Burden of Disease, 2012Cuba Haiti

Source: WHO 2015

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

Questions?

Photo: Los Angeles Times

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.

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References Gonzalez Ochoa, E., Rosco Oliva, G. E., Borroto Gutierrez, S., Perna Gonzalez, A., & Armas

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References Navarrete, A. (1943). Present tuberculosis status in Cuba. CHEST, 9(2).

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