EPIDEMIOLOGY OF TUBERCULOSIS IN THE CARIBBEAN A Bird s Eye View Brendan C Bain, DM, MPH, FRCPE Consultant: Infectious Diseases and Public Health IUATLD Course on Using Epidemiology for Data-driven Decision-making in TB Programs, Denver, CO Feb 24, 2016 I have no known Outline of presentation The Caribbean geography and politics Prospects for eliminating autochthonous TB in the Caribbean Summary 1
Learning Objectives Upon completion of this training, participants will be able to: Identify three mainland countries which are considered part of the Caribbean Discuss the strengths and limitations of epidemiological data from Caribbean countries Explain how health systems strengthening could benefit epidemiologic practice and improve patient outcomes in the Caribbean A bird s eye view THE CARIBBEAN THE CARIBBEAN Ethnicities; Languages 2
THE CARIBBEAN - Geography and Politics 40 million people 29 nations, + several v. small territories Cuba (11M), Dominican Republic (10M) and Haiti (10M) largest; longest independent Several other recently independent countries Many tiny dependent territories Mix of ethnic groups, languages, cultures Much population movement THE CARIBBEAN - Geography and Politics Cuba and the Dominican Republic are often listed as part of Latin America Most English-speaking countries belong to CARICOM (the Caribbean Economic Community) Suriname belongs to CARICOM and UNASUR (Union of South American Nations) Some Francophone countries in the Caribbean are departments of France From available data EPIDEMIOLOGY OF TUBERCULOSIS IN THE CARIBBEAN 3
New TB cases per 100,000 population Estimated TB Incidence per 100,000 pop. (2014) Top 10 Caribbean countries Haiti Haiti Guyana Guyana Dominican Dominican Republic Republic Suriname Suriname Belize Belize St. St. Vincent Vincent & & Grenadines Grenadines Trinidad Trinidad & & Tobago Tobago Bahamas Bahamas St. Lucia St. Lucia Antigua & Barbuda Antigua & Barbuda 60 38 37 24 22 12 9.1 7.6 103 200 0 0 50 50 100 100 150 150 200 200 250 250 Source: Global Tuberculosis Report 2015, WHO Estimated TB Incidence (2014) Comparison with North America Suriname 38 Mexico 21 Canada Jamaica USA 5.2 4.7 3.1 0 10 20 30 40 Source: Global Tuberculosis Report 2015, WHO Trends in Estimated TB Incidence: Caribbean countries on S. American mainland, 1990-2011 Source: TB in the Americas 2013 4
... Trends in Estimated TB Incidence: USA and Canada, 1990-2011 Source: Tuberculosis in the Americas: Regional Report 2012, PAHO/WHO Trends in Estimated TB Incidence per 100,000 pop., 1990-2011 Source: Tuberculosis in the Americas: Regional Report 2012, PAHO/WHO Trends in Estimated TB Incidence in Caribbean island countries 1990-2011 New TB cases per 100,000 population...... Source: Tuberculosis in the Americas: Regional Report 2012, PAHO/WHO 5
The Americas: Trends in Estimated TB Mortality, 1990-2011 TB Deaths per 100,000 population Source: Tuberculosis in the Americas: Regional Report 2012, PAHO/WHO Childhood TB Notification Rates (0-14 years) in five sub-regions of the Americas, 2011. Source: Tuberculosis in the Americas: Regional Report 2012, PAHO/WHO MDR TB Data (Selected Countries, 2014) COUNTRY Pop. (Mil.) All Notified Cases (rate per 100,000) Haiti 10.00 15,963 (.16) Dom Rep 10.35 4,605 (.046) Cuba 11.05 742 (.007) Guyana 0.764 648 (.006) Suriname 0.573 158 (.001) Belize 0.341 87 (.0008) Received DST No. (% of notified cases) Lab. confirmed MDR-TB No. (% of cases tested) 182 (1.1) 91 (50) 470 (10.2) 93 (19.8) 366 (49.3) 10 (2.7) 41 (6.3) 4 (9.8) 102 (64.6) 9 (8.8) 4 (4.6) 1 (25) Source: Global Tuberculosis Report 2015, WHO 6
HIV and TB Stoked by HIV, TB remains a substantial cause of mortality in developing countries despite available cure for this disease. Charles, Macarthur and Pape, Jean William, 2006 Percentage of persons with TB disease with known HIV status, 2014 Cuba Trinidad &Tobago Suriname Jamaica Guyana Haiti Dominican Republic Belize Bahamas 56 73 72 92 91 88 99 99 97 0 20 40 60 80 100 120 Percentages Source: Global Tuberculosis Report 2015, WHO Top 8 Caribbean Countries by estimated HIV prevalence among incident TB cases, 2014 Trinidad & Tobago Dominican Republic Belize 40 Bahamas Suriname Guyana Jamaica Haiti 19 25 25 24 23 29 36 0 10 20 30 40 50 Source: Global Tuberculosis Report 2015, WHO 7
Using Epidemiology and a systems approach PROSPECTS FOR ELIMINATING AUTOCHTHONOUS TB IN THE CARIBBEAN What should we do? How should we do it? The Six WHO Building Blocks for strengthening Health Systems Human Resources Finances Leadership and Governance (Stewardship) Strategic Information Equipment, Facilities & Supplies Service Delivery 8
An optimal health system for TB LEADERSHIP, MANAGEMENT, OVERSIGHT SURVEILLANCE WORKFORCE CAPACITY AND COMPETENCY LABORATORY PRACTICE INFORMATION AND DATA SYSTEMS CASE INVESTIGATION ORGANIZATION AND SYSTEMS CAPACITY Adapted from the Public Health Foundation, Washington, DC Some Good News for TB programs July 2013 Launch of the Caribbean Public Health Agency (CARPHA) Merger of five Caribbean health institutions New laboratory strengthening programs CARPHA CDC Caribbean MedLabs Foundation Opportunities for research 26 Challenges to TB program success Diverse Situational Factors Political instability in some places State of Public Health Services Variable HIV/TB program collaboration The Built Environment Overcrowded living/working conditions + poor ventilation Variation in Poverty and Education levels Natural disasters Competition with other health issues Non-communicable diseases Emerging infectious diseases Finances 9
SUMMARY Thinking from a Managerial Viewpoint The countries with the largest populations and with overcrowded cities have the highest burden of TB A systems strengthening approach is likely to help countries toward the goal of eliminating endogenous TB Competition with other health concerns tends to lower interest in TB Cross-program collaboration offers practical advantages Thinking from an Epidemiologic Viewpoint Caribbean data tends to get lost in Global Reports because of regional grouping We must continue to highlight TB Epidemiology in the worst affected countries maintain action plans to tackle risk factors and reduce the burden of disease Several Caribbean countries are close to eliminating TB 10
EPIDEMIOLOGY OF TUBERCULOSIS IN THE CARIBBEAN A Bird s Eye View THANK YOU medical.educational2015@gmail.com 11