Tuberculosis in Cuba: Control and Opportunity for Elimination

Tuberculosis in CubaControl & Opportunity for Elimination

Kathryn Cicerchi, Colorado School of Public HealthMay/June 2015

Tuberculosis Infectious disease caused by mycobacterium

tuberculosis

Can be acute, sub-acute or chronic in nature

Most commonly attacks lungs Can attack any part of the body, such as kidneys,

spine, brain

Can be fatal if not treated properly

Two types of infection: Latent Active

Sources: CDC, WHO 2015

Latent Tuberculosis 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 before immune

system can fight off 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)


Active Tuberculosis Symptoms:

Coughing (sputum, blood) Chest pains Weakness Weight loss Fever Night sweats

Spread person to person through droplets

Treatable with antibiotics

Associated with extreme poverty, lack of health care, poor environmental and hygienic conditions (overcrowding)


TB in CubaTB mortality was high throughout Spanish

colonial period

1902: Tuberculosis was main cause of death 4,001 fatalities; 15.7% of total deaths

1907: Special TB wards set up in hospitals to treat extreme cases. Sanitarium set up outside of Havana for the poor.

TB mortality declined throughout 20th century

1943: Mortality rate was estimated to be 65 per 100,000

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TB in CubaBefore the Cuban Revolution in 1959, TB still

caused 1,000 deaths annually

Following the Revolution, an accessible, free, universal health care system established

1962-1963: National Tuberculosis Control Program founded as part of the system


National Tuberculosis Control Program (NTCP)1963-1971: Sanatorial care with continued

assessment and risk evaluation

By 1970: Cuba established decentralized labs capable of sputum smear microscopy

By 1971: Outpatient basis with directly observed treatment (DOT)

1982: Directly observed treatment, short course

National Tuberculosis Control Program (NTCP)Laboratories

Newborn vaccination

Active contact tracing All TB cases systematically investigated Contacts checked for respiratory symptoms Contacts meeting certain criteria are treated

prophylactically with isoniazid

Local doctors perform all case finding, treatments (DOTS), prophylaxis, community education


NTCP SuccessBy 1991, TB incidence was 4.7 per 100,000

Down from 65 per 100,000 in 1965

Reduction in incidence and all serious forms of TB

In children under 15, 85% decrease


Re-Emergence of TBDespite progress, TB began to re-emerge

worldwide in 1990s Worsening social problems Increased drug resistance HIV co-infection Abandonment of control programs

After the breakdown of the Soviet Union, TB incidence in Cuba began to creep up beginning in 1992 14.7 per 100,000


Re-Emergence of TBCuban Ministry of Public Health gave TB top

priority

In addition to prior tactics: Improved surveillance Mandatory notification system Contact investigations beyond household level Supervised control with annual courses for health

personnel

Emphasis on fighting childhood TB


Re-Emergence of TBFollowing re-intervention, decrease from

14.7/100,000 in 1994 to 7.2 per 100,000 in 2003


Declining Mortality 0.4 per 100,000 in 1998 to 0.2 per

100,000 in 2007

Met the WHO’s Global Plan to Stop TB’s 2006-2015 target well in advance (2007)


Current Situation

Source: PAHO, 2013

EliminationCuba 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


HIV Co-Infection

Source: PAHO, 2013

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.

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

Centers for Disease Control and Prevention (CDC). (2012, March 13). Basic TB facts. Retrieved from http://www.cdc.gov/tb/topic/basics/default.htm

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.


References Gonzalez, E. R., & Armas, L. (2012). New indicators proposed to

assess tuberculosis control and elimination in Cuba. MEDICC Review, 14(4), 40-43.

Marrero, A., Caminero, J. A., Rodriguez, R., & Billo, N. E. (2000). Towards elimination of tuberculosis in a low income country: the experience of Cuba, 1962–97.Thorax, 55, 39-45.

Navarrete, A. (1943). Present tuberculosis status in Cuba. CHEST, 9(2). doi:10.1378/chest.9.2.175

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

World Health Organization (WHO). (2015, March). Tuberculosis. Retrieved from http://www.who.int/mediacentre/factsheets/fs104/en/


Tuberculosis in Cuba: Control and Opportunity for Elimination

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