A presentation on tuberculosis control efforts in Cuba vs. Haiti. Presented for my class Intensive Study of Public Health Services in Cuba, June 25, 2015.

1. Tuberculosis Control
in Cuba & Haiti
Kathryn Cicerchi, Colorado School of Public Health
June 25, 2015
Photo:one.org

2. 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

3. 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

4. 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

5. 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)

6. Health Systems
Cuba
 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)

7. National TB Control Programs
Cuba
 $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)

8. National TB Control Programs
Cuba
 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

9. 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

10. Burden of Disease, 2012
Cuba Haiti
Source: WHO 2015

11. Mortality
Cuba
 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

12. 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

13. 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

14. Lessons Learned
 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

15. Questions?
Photo: Los Angeles Times

16. 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.

17. 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.
 Gonzalez, E. R., & Armas, L. (2012). New indicators proposed to assess tuberculosis control and
elimination in Cuba. MEDICC Review, 14(4), 40-43.
 Jacquet, V., Morose, W., Schwartzman, K., Oxlade, O., Barr, G., Grimard, F., & Menzies, D. (2006).
Impact of DOTS expansion on tuberculosis related outcomes and costs in Haiti. BMC Public
Health, 6(209). doi:10.1186/1471-2458-6-209
 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.
 Ministere de la Sante Publique et de la Population (MSPP), Haiti. (2015). Report de cas, cholera.
 Montoro, E., Lemus, D., Echemendía, M., Armas, L., González-Ochoa, E., Llanes, M. J., &
Valdivia, J. A. (2006). Drug-resistant tuberculosis in Cuba. Results of the three global
projects. Tuberculosis, 86, 319-323. doi:10.1016/j.tube.2006.01.013
 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

18. 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
 The World Bank. (2014, January 1). Investing in people to fight poverty in Haiti. Retrieved from
www.worldbank.org/en/topic/poverty/publication/beyond-poverty-haiti
 The World Factbook. (2015, June 17). Haiti. Retrieved from
https://www.cia.gov/library/publications/the-world-factbook/geos/ha.html

19. References
 UNDP. (n.d.). UNDP country impact: Haiti. Retrieved from http://www.undp-globalfund-
capacitydevelopment.org/home/country-impact/latin-america-the-caribbean/haiti.aspx
 UNESCO Institute for Statistics (UIS). (2013). Adult and youth literacy: National, regional and global trends, 1985-2015.
Retrieved from UNESCO website: http://www.uis.unesco.org/Education/Documents/literacy-statistics-trends-1985-
2015.pdf
 United Nations Development Program. (2013). Human Development Index and its components. Retrieved from
http://hdr.undp.org/en/content/table-1-human-development-index-and-its-components#m
 USAID. (2015, January 28). Education in Haiti. Retrieved from http://www.usaid.gov/haiti/education
 World Health Organization (WHO). (2015, January). Cuba: WHO statistical profile. Retrieved from
http://www.who.int/gho/countries/cub.pdf?ua=1
 World Health Organization (WHO). (2015, March). Tuberculosis. Retrieved from
http://www.who.int/mediacentre/factsheets/fs104/en/
 World Health Organization (WHO). (n.d.). Country profile: Cuba. Retrieved from http://www.who.int/countries/cub/en/
 World Health Organization (WHO). (n.d.). Cuba tuberculosis profile. Retrieved from
http://www.who.int/countries/cub/en/
 World Health Organization. (2014, October 6). TB data visualizations, Cuba. Retrieved from
http://www.who.int/tb/country/data/visualizations/en/
 World Health Organization. (2015). Global Health Observatory data, health workforce data. Retrieved from
http://www.who.int/gho/health_workforce/physicians_density/en/
 World Health Organization. (n.d.). Haiti tuberculosis profile. Retrieved from http://www.who.int/countries/hti/en/