WHO’s 2015 End Tuberculosis Strategy can succeed only through universal health coverage, social protection, poverty alleviation and effective multisector actions to tackle social determinants in general. The pediatric age group is particularly vulnerable to tuberculosis and historically neglected worldwide. However, this group is a priority within Cuba’s National Tuberculosis Control Program that has functioned since 1970, and Cuba is considered a low-incidence country with rates <7 per 100,000 population since 2011. Tuberculosis incidence in children aged <15 years is <1 per 100,000, similar to that reported in high-income countries and representing less than 2% of total cases in Cuba. Since 1999, no deaths from tuberculosis, coinfection with HIV or resistance to the two first-line TB drugs have been reported in affected children, and most diagnosed cases correspond to early, primary forms of the disease. These results place Cuba among the countries on track to eliminate TB by 2050. This article reviews the pillars and components of the 2015 End TB Strategy and the strategies developed by the National Tuberculosis Control Program that enabled Cuba to bring incidence below the 2035 targets of WHO’s End TB strategy. The article also proposes other actions Cuba can take, despite limited resources, to eliminate TB, particularly in the pediatric age group.

KEYWORDS Tuberculosis, communicable disease control, disease control programs, preventive health services, child health, World Health Organization, Cuba

INTRODUCTION Tuberculosis is the second leading cause of infectious-disease death worldwide, after AIDS. Most tuberculosis patients in Cuba have pulmonary TB and recovery rates are high. When TB chemotherapy fails, the most common adverse outcome is death.

OBJECTIVE Determine survival patterns in a cohort of pulmonary TB patients in Cuba.

METHODS A retrospective cohort study was conducted of pulmonary TB patients who were notified and treated in Cuba in 2009 and 2010. Time elapsed between diagnosis and death was examined. Patient survival was analyzed with the Kaplan–Meier method and comparisons were made with the log-rank estimator; an adjusted Cox model was used to analyze risk of death.

RESULTS The study included 1339 patients, of whom 71.7% were aged 25–64 years and 77.4% were men. Infectious pulmonary tuberculosis was the most common form (75.6%). Only a small number of patients (5.7%) presented TB/HIV coinfection. Ninety-four deaths were reported, 55% during the first 60 days of treatment. Lower survival rates were observed among men (HR 1.87, 95% CI 1.02–3.45), patients coinfected with HIV/AIDS (HR 6.25, 95% CI 3.46–11.31), and patients aged ≥48 years (HR 3.93, 95% CI 2.41–6.40).

CONCLUSION The preponderance of deaths early in TB treatment course may be related to diagnostic and/or treatment delays. Older age at diagnosis, male sex and TB/HIV coinfection increase risk of death.

KEYWORDS Pulmonary tuberculosis, HIV/AIDS, mortality, survival, case fatality, Cuba

Following 48 years of successful operation of the National Tuberculosis Control Program, Cuban health authorities have placed tuberculosis elimination on the agenda. To this end some tuberculosis control processes and their indicators need redesigned and new ones introduced, related to: number and proportion of suspected tuberculosis cases among vulnerable population groups; tuberculosis suspects with sputum microscopy and culture results useful for diagnosis (interpretable); and number of identified contacts of reported tuberculosis cases who were fully investigated. Such new indicators have been validated and successfully implemented in all provinces (2011–12) and are in the approval pipeline for generalized use in the National Tuberculosis Control Program. These indicators complement existing criteria for quality of case detection and support more comprehensive program performance assessment.

KEYWORDS Tuberculosis, detection, monitoring, surveillance, contact tracing, disease outbreaks, program evaluation, quality indicators, Cuba

INTRODUCTION Following a tripling of tuberculosis incidence in Cuba between 1991 and 1994 (from 4.7 to 14.7 per 100,000), the National TB Control Program was revamped in 1995 and the National Reference Center for Childhood TB and Provincial Childhood TB Commissions were created as a strategy for addressing this emerging health problem.

OBJECTIVE Assess the impact of Cuba’s new strategy for TB control in children aged <15 years during the period 1995–2005.

METHODS A descriptive review of health services and systems was conducted in Cuba, examining 157 cases of TB diagnosed in children aged <15 years during the period 1995–2005 and comparing impact and process indicators for selected years (1995, 2000, and 2005). Impact indicators included reduction in: a) incidence; b) serious forms (peritoneal, meningeal, miliary, combined); c) mortality; and d) case outcomes (cure, death, treatment drop-out, treatment failure). Process indicators were proportion of cases with: a) microbiological tests; b) knowledge of infection source; c) diagnoses obtained through adult case contact tracing; d) time to diagnosis <60 days; and e) post-mortem diagnoses.

RESULTS During the period 1995–2005, TB rates in children aged <15 years fell by 50% (from 1.0 to 0.5 per 100,000), more evident in children <10 years. The Havana rate was three times the national rate. Diagnosis was post-mortem in three serious cases (1.9%); there were four deaths (2.5%), none after 2000. Only seven children (4.5%) had serious forms, none after 2002. Except for cases diagnosed post-mortem, all children received treatment directly supervised by health personnel. Cure rate was 99.4%; there were no treatment drop-outs or chronic cases; one relapse was reported (0.6%). Knowledge of infection source increased to 90% over the selected years. Microbiological tests were conducted in 90% of cases, with isolation in 30.9%. No isolate was drug‑resistant, nor were there reports of infectious contacts with resistance. We found no HIV coinfection. At the end of the study, time to diagnosis of ≥60 days persisted in 40% of cases.

CONCLUSIONS Creation of a National Reference Center for Childhood TB and Provincial Childhood TB Commissions has contributed to improved TB diagnosis and control in children aged <15 years, achieving incidence similar to that during the period prior to TB re-emergence and to those of some developed countries. Improvements are needed in the work and systematic training of health personnel, especially at the primary health care level, in order to eliminate TB as a national health problem by 2015.

KEYWORDS Tuberculosis, tuberculosis/diagnosis, tuberculosis/epidemiology, tuberculosis/mortality, tuberculosis/prevention and control, tuberculosis/therapy, child health services, Cuba

Introduction Tuberculosis (TB) is a major cause of illness and death throughout the world. The World Health Organization’s Global Plan to Stop TB 2006-2015 proposes that countries cut TB mortality by half compared to 1990 rates. In Cuba, TB mortality declined steadily throughout the 20th century, particularly after 1960.

Objective Describe TB mortality distribution and trends in Cuba from January 1998 to December 2007 by infection site, sex, age and province, and determine progress towards the WHO’s 2015 target for TB mortality reduction.

Methods A time series ecological study was conducted. Death certificates stating TB as cause of death were obtained from the Ministry of Public Health’s National Statistics Division, and population data by age group, sex, and province were obtained from the National Statistics Bureau. Crude and specific death rate trends and variation were analyzed.

Results TB mortality declined from 0.4 per 100,000 population in 1998 to 0.2 (under half the 1990 rate) in 2007. Clinical forms of the disease, both pulmonary and extrapulmonary, also declined. The highest mortality rates were found in males and in the group aged ≥ 65 years. Rates were also highest in the capital, Havana, with extreme values of 0.73 and 0.39 per 100,000 population at the beginning and end of the period, respectively. Conclusions Deaths from TB declined steadily compared to total deaths and deaths caused by infectious diseases. The Global Plan to Stop TB target was met well ahead of 2015. If this trend continues, TB is likely to become an exceptional cause of death in Cuba.

Keywords Lung diseases, tuberculosis, mortality, communicable diseases, trends, Cuba