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 Health care workers have an increased risk of infection due to occupational Mycobacterium tuberculosis exposure, including multidrug-resistant strains. Health care workers’ risk of developing tuberculosis is greater than that of the general population, whether in low-, intermediate- or high-incidence countries. Adherence to infection control measures (administrative controls, environmental controls, and personal respiratory protection) is essential to reduce risk of disease transmission between suspected tuberculosis patients and health care workers, but for different reasons, both objective and subjective, adherence is low. Identifying the causes of low adherence is a prerequisite to effective programming to reduce risk.
OBJECTIVE Identify perceived barriers to adherence to tuberculosis infection control measures among health care workers in the Dominican Republic.
METHODS During August 2014, a qualitative study was conducted in two tertiary-level hospitals in different regions of the Dominican Republic. A semi-structured interview guide of nine questions was developed, based on the scientific literature and with consensus of clinical experts. Nine semi-structured interviews were conducted with a purposive sample of seven physicians (five men, two women) and two baccalaureate nurses (both women) working in the emergency medicine, internal medicine or nursing departments of those institutions. Question topics included clinical experience of M. tuberculosis infection and disease; knowledge of disease transmission and preventive practices; clinical management strategies; and perceptions of effectiveness of directly observed treatment, short-course, and disease coping strategies.
RESULTS Perceived barriers were described as: 1) sense of invincibility of health care workers; 2) personal beliefs of health care workers related to direct patient communication; 3) low provider-to-patient ratios in hospitals; 4) absence of tuberculosis isolation units for patients within hospitals; and 5) limited availability of protective masks for health care workers.
CONCLUSIONS Our results highlight that perceived barriers at the individual or institutional level may hinder how health care workers understand and comply with preventive strategies to reduce risk of tuberculosis transmission. Addressing these barriers by strengthening infection control program infrastructure and implementing educational interventions within institutions may reduce risk of nosocomial tuberculosis transmission to health care workers.
KEYWORDS Health care providers, infection control, infectious disease transmission, health care associated infection, nosocomial infection, Mycobacterium tuberculosis occupational exposure, occupational health, qualitative research, tuberculosis, Dominican Republic
INTRODUCCIÓN Para alcanzar la meta de eliminar la tuberculosis como problema de salud pública en Cuba, deben comprenderse bien la evolución epidemiológica de la enfermedad y las estrategias diseñadas para prevenirla y manejarla hasta la fecha. En este contexto se introdujeron cambios en el Programa Nacional de Control de la Tuberculosis de Cuba en 1970.
OBJETIVO Revisar los antecedentes y la evolución de la estrategia de Cuba para controlar la tuberculosis, los cambios implementados en la revisión del Programa en 1970 y su impacto en la evolución posterior de la enfermedad en Cuba.
MÉTODOS Se revisaron los artículos publicados sobre la historia del control de la tuberculosis en Cuba, conjuntamente con documentos de archivo y registros médicos. Para el estudio se seleccionaron documentos relativos a la situación de la tuberculosis pulmonar en Cuba, que incluían la adopción de medidas para hacer frente a la enfermedad y su extensión, con énfasis en el período del Programa. Se realizaron entrevistas a informantes claves.
RESULTADOS La lucha de Cuba contra la tuberculosis comenzó en Santiago de Cuba con la creación de una Liga Anti-Tuberculosa local en 1890. Los cambios estratégicos introducidos en el sector de la salud pública en Cuba, que enfatizaban la promoción de salud y la prevención de enfermedades, llevaron a la creación en 1959 del Departamento de Tuberculosis, que implementó el primer Programa Nacional de Control de la Tuberculosis en Cuba en 1963. Este programa se reorganizó completamente en 1970. El Programa Nacional de Control de Tuberculosis (1963) incluía una red de 27 dispensarios de tuberculosis, 8 sanatorios y 24 laboratorios de bacteriología. El diagnóstico se basaba en criterios de las imágenes radiográficas. La incidencia era de 52.6/100.000 en 1964 y alcanzó 31.2 en 1970. El Programa se actualizó en 1970 para incluir dos cambios importantes: el requisito de confirmación bacteriológica del diagnóstico y el tratamiento ambulatorio supervisado directamente, totalmente integrado dentro de los servicios de salud. Para 1971, la incidencia se había reducido a 17.8/100 000 y en 1979, llegó a 11.6. La disminución se interpreta como resultado de la mayor especificidad del diagnóstico microbiológico. El control de la tuberculosis ha seguido avanzando, y alcanzó una tasa de incidencia de 6.1/100 000 en 2012 y una tasa de mortalidad de 0.3/100 000 en 2013.
CONCLUSIONES Las modificaciones introducidas en el Programa Nacional de Control de la Tuberculosis en 1970 permitieron los resultados exitosos de las siguientes décadas: la reducción de la incidencia y la mortalidad por tuberculosis. Estos resultados también permitieron a las autoridades sanitarias proponer la eliminación de la enfermedad en Cuba como un objetivo real.
PALABRAS CLAVE Historia de la medicina, tuberculosis, epidemiología, control de enfermedades transmisibles, salud pública, Cuba
INTRODUCTION To reach the goal of eliminating tuberculosis as a public health problem in Cuba, the epidemiological evolution of the disease and of strategies designed to prevent and manage it to date must be well understood. In this context, in 1970, changes were introduced in Cuba’s National Tuberculosis Control Program.
OBJECTIVE Review background and evolution of Cuba’s strategy for tuberculosis control, the changes implemented in the 1970 revision of the Program, and their impact on the subsequent evolution of the disease in Cuba.
METHODS Published articles on the history of tuberculosis control in Cuba were reviewed, along with archival documents and medical records. Documents concerning the situation of pulmonary tuberculosis in Cuba, including measures adopted to address the disease and its extent, were selected for study, with an emphasis on the period of the Program. Interviews with key informants were conducted.
RESULTS Cuba’s fight against tuberculosis began in Santiago de Cuba, with the creation of a local Anti-Tuberculosis League in 1890. Strategic changes introduced by Cuba’s public health sector, stressing health promotion and disease prevention, led to the 1959 creation of the Tuberculosis Department, which implemented Cuba’s first National Tuberculosis Control Program in 1963. This Program was completely reorganized in 1970. The National Tuberculosis Control Program (1963) covered a network of 27 tuberculosis dispensaries, 8 sanatoriums and 24 bacteriology laboratories. Diagnosis was based on radiographic imaging criteria. Incidence was 52.6/100,000 in 1964 and reached 31.2 in 1970. The Program was updated in 1970 to include two major changes: the requirement for bacteriological confirmation of diagnosis and directly-observed outpatient treatment fully integrated into health services. By 1971, incidence was down to 17.8/100,000, and further reduced to 11.6 in 1979. The decrease is interpreted as the result of the greater specificity of microbiologic diagnosis. Tuberculosis control continued to make progress, reaching an incidence rate of 6.1/100,000 in 2012 and mortality rate of 0.3/100,000 in 2013.
CONCLUSIONS Changes introduced in the National Tuberculosis Control Program in 1970 led to the successful results achieved in later decades, reducing tuberculosis incidence and mortality. These results also allowed health authorities to propose elimination of the disease in Cuba as a current objective.
KEYWORDS History of medicine, tuberculosis, epidemiology, communicable disease control, public health, 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
