Tuberculosis in Big. ... the case of Tijuana, Baja California BINATIONAL HEALTH WEEK

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1 BINATIONAL HEALTH WEEK Tuberculosis in Big Cities... the case of Tijuana, Baja California Dr. Jesús Felipe González Roldán General Director of CENAPRECE San Francisco, Ca., October 2015 Source: Dahlgren & Whitehead Model

2 Incidence and Mortality from Respiratory Tb México Tasa Tasa de incidencia TB P Tasa de mortalidad TB P Fuente: SS, DGE: Anuarios de Morbilidad, * Preliminar. Mortalidad: SS/DGIS/CUBOS de Información Dinámica, Población CONAPO.

Respiratory TB incidence, Mexico 2014 TASA* >24 14.9 23.9 7.

3 Respiratory TB incidence, Mexico 2014 TASA* > <7.10 Nacional l 13.6 *Tasa por 100 mil habitantes Fuente: Plataforma Única de Información/SUIVE/DGE/SS. Preliminar /02/2015. Población CONAPO Proyección

Respiratory TB mortality, México, 2013 >4.12 3.32-4.11 2.

4 Fuente: DGIS Cubos dinámicos de mortalidad año 2013, Población CONAPO Proyección Respiratory TB mortality, México, 2013 > Nacional l 1.6 Tasa por cada 100,000 habitantes.

5 Priority municipalties MUNICIPIO CASOS TBP % TASA LUGAR POR TASA 1 Tijuana Acapulco Mexicali Culiacán Veracruz Centro Hermosillo Cd. Juárez Tapachula Monterrey Ensenada Reynosa Guadalajara Nuevo Laredo Matamoros Cajeme Mazatlán Guadalupe Benito Juárez Coatzacoalcos Tuxtla Gutierrez Ahome Tampico Zapopan Puerto Vallarta ,799 ESTADO Baja California 3 Chiapas 2 MUNICIPIO Ensenada Mexicali Tijuana Tapachula Tuxtla Gutiérrez Chihuahua 1 Cd. Juárez Guerrero 1 Acapulco Jalisco 3 Nuevo León 2 Quintana Roo Sinaloa 3 Guadalajara Puerto Vallarta Zapopan Guadalupe Monterrey 1 Benito Juárez Ahome Culiacán Mazatlán Sonora 2 Tabasco Cajeme Hermosillo 1 Centro Tamaulipas 4 Veracruz 2 TOTAL 25 Matamoros Nuevo Laredo Reynosa Tampico Coatzacoalcos Veracruz More of 300 cases cases cases In this municipalties represent 36% of total cases in RTB.

public services Barriers to healthcare access Fragmentation

6 Social Determinants of Health Urban sprawl Aggravating factors for tuberculosis in Large Cities Lack of basic public services Barriers to healthcare access Fragmentation of healthcare providers HIV, drugs addiction, migration, homelessness

7 Colombia Bogotá: Rafael Uribe locality Perú Lima: El Agustino and San Juan de Lurigancho districts Brasil Guarulhos: Region IV Guatemala: Guatemala City Mexico Tijuana Jurisdiction TB Focus Cities in Latin America

8 Tijuana, B.C., Mexico

9 Tijuana Overview BC: 3,155,700 / 71,450 km² (12) 1,826 new TB cases (all forms) in 2013 Tijuana: 2,026,518/ km² 970 new cases of TB World's busiest border crossing More than 150,000 border crossings / day - 50,000 vehicles - 25,000 pedestrians "Aquí empieza la Patria" Source: INEGI, Población CONAPO

10 TB Project in Big Cities Proposal incorporates: The three levels of government Providers of public and private healthcare People living with TB and affected communities

11 Phase I: February to August 2014 TB in Big Cities Implementation Total new cases of TB all forms: 799

798 3 50.618 8.16 7 6.48 6 8,9 65 89,3 7,8 49 96,8 TOTAL 241.413 32.

12 Tijuana: Selected areas of study AREA S Population Surface Population density TB Cases TB Incidence * , , , ,3 7, ,8 TOTAL , ,1 * Per 100,000 inhabitants Source: INEGI 2010 & Plataforma Única de TB, 2013 N

13 AREA 1 # AGEBS: % (n705) # of TB cases: % (n 799) TB Incidence : per 100,000 Selected Area 1

II Phase III Mexico TB literature review

14 PHASE II : DECEMBER 2014 TO MAY STUDIES IN 3 STEPS Phase 0 Phase I Phase II Phase III Mexico TB literature review I. Mapping providers Risk characterization among the population Strategic Plan for intersectorial coordination WHO proposed methodology Survey of health establishments Identifying barriers to healthcare Strategic plan for health sector coordination APR-MAY FEB - MAR JAN - FEB DEC

POPULATION HEALTH PARTNER CHARACTERIZATION OF TIJUANA DIMENSION I: SOCIAL

Internacional Migration Deportation Lawful Unlawful Formal Informal Pavement

investment Food Steet Lighting Water, electricity, sewage Garbage and noxious

Support services Tobacco Sale, consumption and distribution Organized crime El

15 POPULATION HEALTH PARTNER CHARACTERIZATION OF TIJUANA DIMENSION I: SOCIAL COMPONENTS BASIC SANITATION MIGRATION DRUGS EMPLOYMENT Internal Migration Internacional Migration Deportation Lawful Unlawful Formal Informal Pavement Human Settlement Recidivists Temporary shelters Alcohol Drug kinds Foreign investment Food Steet Lighting Water, electricity, sewage Garbage and noxious fauna Expelling sates Poverty and marginalization Social support networks Support services Tobacco Sale, consumption and distribution Organized crime El Bordo Region Sweatshops Convenience stores Economic profits Clothing Used Cars Excess paperwork Public security

SOCIO SANITARY CHARACTERIZATION OF TIJUANA DIMENSION III: HEALTH STRATEGIES MEDICAL TOURISM REGULATION OF HEALTH SERVICES EXTENDED COVERAGE Outpatient cosmetic clinics

16 SOCIO SANITARY CHARACTERIZATION OF TIJUANA DIMENSION III: HEALTH STRATEGIES MEDICAL TOURISM REGULATION OF HEALTH SERVICES EXTENDED COVERAGE Outpatient cosmetic clinics Ambulatory units Hotel - Hospitals Health Risk Asessment Accreditation and Certification of establishments Mobile Medical Units Seguro Popular International Patient Safety Goals

Level Road from cough to the cure INDIVIDUAL AND COMMUNITY Low perception of risk Long disease evolution Little reaction False confidence Botanical centers (Alternative medicine) Trained personnel

17 Level Road from cough to the cure INDIVIDUAL AND COMMUNITY Low perception of risk Long disease evolution Little reaction False confidence Botanical centers (Alternative medicine) Trained personnel Sparing drug expenses Long waiting times Stigma and discrimination 80% lab work done outside Health Units Lack of samples Few Chest X rays performed Initial Treatment acceptance Fear medicine in children Relocation costs Time spent Early improvement False address TBreluctance addictions 46% Address change Ideal behavior 1. IDENTIFY SIGNS AND SYMPTOMS 2. SEEKING ATTENTION 3. CARE IN PUBLIC HEALTH UNITS 4. COMPLETE DIAGNOSIS 5. HOME TREATMENT 6. COMPLETE TREATMENT AND MONITORING 7. HEALING S YSTEM No health promotion No publicly available information Lack of use of media Training and sensitization Lack of training for first level personnel Selling of Rifater Pharmacies with attending physician on the rise Profit motives Unregulated laboratories performing bacilloscopy Lack of interest by the private sector Few available surveys Coughers ignored in hospital waiting rooms No discussion dynamics Chronic Medicine treatments Lack of participation by preventive medicine services Ongoing care and ER services ignore TB patient No SR separation No risk awareness or assesment First level units with zero TB+ cases 70% of diagnosis done in hospitals Hospitals Laboratory BK Unsupervised LESP Lab. No scheduled Laboratories verified without tabular results 30% contact study No home visit 4 of 55 US 41% of TB + Cases Not applicable PPD TB % Supervised treatment 20% No adjustment pediatric treatment Isoniazid missing Reference Hospital without insurance Known only single platform Tracking BK 30-80% LESP without training and counseling program Treatment success 62% BK cured 38% More dropouts than reported

18 INTERSECTORAL COORDINATION PLAN TO IMPROVE TB CONTROL IN TIJUANA Increase and strengthen promotion and early detection of TB cases the first level of healthcare to break chain of infection Comprehensive patient management, accurate studying and management of contacts of people with TB, establishment of working public-private partnerships, adherence to guidelines and regulations

19 INTERSECTORAL COORDINATION PLAN TO IMPROVE TB CONTROL IN TIJUANA MAIN OBJECTIVE Ensuring access to healthcare to all TB patients in Tijuana, B.C. SPECIFIC OBJECTIVES 1. Promoting TB awareness and recognition among the general population 2. Guaranteeing timely detection of pulmonary TB cases among public institutions 3. Fostering TB awareness among private healthcare providers and institutions 4. Regaining lost leadership and improving collaboration among all the areas within the Jurisdiction

PHASE III: 21 22 JULY, 2015 TB STRATEGIC PLANNING WORKSHOP CONSULTANT: DR. RICARDO HIRATA OKAMOTO KEISEN CONSULTORES, MEXICO.

20 PHASE III: JULY, 2015 TB STRATEGIC PLANNING WORKSHOP CONSULTANT: DR. RICARDO HIRATA OKAMOTO KEISEN CONSULTORES, MEXICO. METHODOLOGY Initiative developed by the United States-Mexico Border Health Commission Participants: 28 (all levels of government) Participatory planning Strategic mapping REVIEW AND UPDATE OF THE STRATEGIC PLAN FOR IMPROVEMENT OF TUBERCULOSIS Plenary session came up with: main and specific objectives, lines of action Goals achieved within a 100 day period

21 PROJECT CHARACTERISTICS STRENGTHS PAHO initiative for Latin America Stages (3 large) International reach PAHO-WHO participation Support for external consultancy Considerable financial support

22 PROJECT CHARACTERISTICS STRENGTHS (2) Products An accurate analysis and assessment of the epidemiological situation Six documents submitted to PAHO-WHO and NTP (includes action plans) Intersectoral meetings Conducted in May, 2015 Partnerships established between the public health sector and other organizations

23 What comes next? Securing Political Commitment Ensuring material, human and financial resources Follow-up by PAHO and the NTP Project operationalization Reducing personnel change and rotation Ensure commitment of local authorities Strengthening management and operation of the TB Program in Baja California

Summary of Global Perspectives

Baja California: California`s Partner José Guadalupe Osuna Millán Baja California State Governor October 2009 World Economic Outlook Summary of Global Perspectives Percentage change last year, except interest