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
Incidence and Mortality from Respiratory Tb México 1990-2014 25.0 20.0 18.2 17.7 20.1 18.3 16.9 15.0 14.1 14.2 13.2 13.5 14.5 15.5 16.0 14.9 14.4 13.6 13.8 12.7 13.3 13.5 13.2 13.5 13.4 13.5 13.6 13.6 Tasa 10.0 6.2 5.0 5.3 5.0 4.6 4.4 4.3 4.1 3.8 3.5 3.1 2.7 2.7 2.4 2.4 1.9 1.9 1.7 1.6 1.7 1.6 1.8 1.8 1.5 1.6 0.0 Tasa de incidencia TB P Tasa de mortalidad TB P Fuente: SS, DGE: Anuarios de Morbilidad, 1990-2014* Preliminar. Mortalidad: SS/DGIS/CUBOS de Información Dinámica, 1990-2013. Población CONAPO.
Respiratory TB incidence, Mexico 2014 TASA* >24 14.9 23.9 7.11 14.8 <7.10 Nacional l 13.6 *Tasa por 100 mil habitantes Fuente: Plataforma Única de Información/SUIVE/DGE/SS. Preliminar 2014 25/02/2015. Población CONAPO Proyección 2010-2050
Fuente: DGIS Cubos dinámicos de mortalidad año 2013, Población CONAPO Proyección 2010-2050. Respiratory TB mortality, México, 2013 >4.12 3.32-4.11 2.52-3.31 1.72-2.51 0.92-1.71 0.2-0.91 Nacional l 1.6 Tasa por cada 100,000 habitantes.
Priority municipalties MUNICIPIO CASOS TBP % TASA LUGAR POR TASA 1 Tijuana 727 12.5 43.5 4 2 Acapulco 603 10.4 72.6 1 3 Mexicali 423 7.3 42.4 7 4 Culiacán 332 5.7 36.1 12 5 Veracruz 322 5.6 56.0 3 6 Centro 250 4.3 37.0 10 7 Hermosillo 246 4.2 29.1 17 8 Cd. Juárez 231 4.0 16.5 23 9 Tapachula 224 3.9 64.7 2 10 Monterrey 220 3.8 18.9 21 11 Ensenada 216 3.7 42.9 5 12 Reynosa 198 3.4 30.0 16 13 Guadalajara 178 3.1 11.9 24 14 Nuevo Laredo 172 3.0 42.5 6 15 Matamoros 172 3.0 33.5 14 16 Cajeme 163 2.8 37.4 9 17 Mazatlán 153 2.6 32.6 15 18 Guadalupe 147 2.5 21.3 19 19 Benito Juárez 135 2.3 18.3 22 20 Coatzacoalcos 134 2.3 41.8 8 21 Tuxtla Gutierrez 124 2.1 20.8 20 22 Ahome 115 2.0 26.0 18 23 Tampico 109 1.9 35.6 13 24 Zapopan 104 1.8 7.9 25 25 Puerto Vallarta 101 1.7 36.2 11 5,799 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 200-300 cases 100-200 cases In this municipalties represent 36% of total cases in RTB.
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
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
Tijuana, B.C., Mexico
Tijuana Overview BC: 3,155,700 / 71,450 km² (12) 1,826 new TB cases (all forms) in 2013 Tijuana: 2,026,518/ 879.2 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
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
Phase I: February to August 2014 TB in Big Cities Implementation Total new cases of TB all forms: 799
Tijuana: Selected areas of study AREA S Population Surface Population density TB Cases TB Incidence * 1 117.997 17.534 6,7 135 114,4 2 72.798 3 50.618 8.16 7 6.48 6 8,9 65 89,3 7,8 49 96,8 TOTAL 241.413 32.187 7,5 249 103,1 * Per 100,000 inhabitants Source: INEGI 2010 & Plataforma Única de TB, 2013 N
AREA 1 # AGEBS: 33 4.68 % (n705) # of TB cases: 135 16.8% (n 799) TB Incidence : 114.4 per 100,000 Selected Area 1
PHASE II : DECEMBER 2014 TO MAY 2015 6 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 2015 2014
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 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 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 +++ 80% 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
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
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. 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
PROJECT CHARACTERISTICS STRENGTHS PAHO initiative for Latin America Stages (3 large) International reach PAHO-WHO participation Support for external consultancy Considerable financial support
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
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