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

1. Tuberculosis in Cuba
Control & Opportunity for Elimination
Kathryn Cicerchi, Colorado School of Public Health
May/June 2015

2. 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

3. 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)
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
 Associated with extreme poverty, lack of health
care, poor environmental and hygienic conditions
(overcrowding)
Sources: CDC, WHO 2015

5. TB in Cuba
 TB 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

6. TB in Cuba
 Before 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

7. 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

8. 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

9. NTCP Success
 By 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

10. Re-Emergence of TB
 Despite 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

11. Re-Emergence of TB
 Cuban 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

12. Re-Emergence of TB
 Following re-intervention, decrease from
14.7/100,000 in 1994 to 7.2 per 100,000 in 2003

13. 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)

14. Current Situation
Source: PAHO, 2013

15. Elimination
 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

16. HIV Co-Infection
Source: PAHO, 2013

17. 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.

18. 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/