Tuberculosis in the Americas

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Tuberculosis in the Amer

PART I: CONTROL1

LIERARY

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Introduction

In 1973 and 1978 PAHO evaluated 2,3the status of the tuberculosis control programs in Latin America (which has 60 per cent of the population of the Americas, and which reports 87 per cent of new cases and 93 per cent of deaths due to the disease in the Region). A new survey was made in 1980, in which all countries and territories in the Region participated. Data from the three evaluations have been used to analyze the tuberculosis situation and the status of the control programs.

The approach to tuberculosis control has undergone significant changes in the last decade. Perhaps the most important has been a change in attitude among health professionals toward the feasibility of integrating tuber-culosis control activities in the general health services and simplifying control methods.

IPart 1: Epidemiology, of this report was published in the last issue of the Epidemniological Bullerin. Vol. 2, No. 5, 1981.

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PAHO Document CD/TB3, 1974. Rev. 1. Survey of the Present State of Integration of Tuberculosis Control Activities in the General Health Services in Latin America, 1974.

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PAHO Document III SRT/1 1, 1979, presented at the III Regional Seminar on Tuberculosis: Chemotherapy, 1979.

In 1972, the III Special Meeting of Ministers of Health of the Americas recommended as an objective for the 1972-1981 decade the reduction by 50-65 per cent in mortality due to tuberculosis. This would be achieved by vaccinating children under 15 years of age with BCG vac-cine, and simultaneously searching for and giving spe-cialized treatment to tuberculosis patients in the general health services. The goals aimed at vaccinating 80 per cent of the 0-15 year-old group with BCG, treating all detected cases of tuberculosis, utilizing particularly out-patient medical care services, and performing bacillo-scopies in 60-75 per cent of those presenting respiratory symptoms of over four weeks' duration. All these activities should be integrated in qualified general health services.

The policy of integration was postulated in 1962 at the Congress of the Latin American Union of Societies of Phthisiology (Guatemala), in 1964 by the Organization and Member Governments at the XV Meeting of the Di-recting Council (Mexico), and in the same year at the I Re-gional Seminar on Tuberculosis (Venezuela). All coun-tries in the Region have adopted integration within their general health services as the recommended control strat-egy.

IN THIS ISSUE . . .

* Tuberculosis in the Americas * Human Plague in 1980

* Diseases Subject to the International Health Regulations

* Acute Hemorrhagic Conjunctivitis in the Americas

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Review of the Malaria Eradication Program in Panama

* Yellow Fever in Bolivia, 1980

* Epidemiology of Leprosy in Rio Grande do Sul, Brazil, 1975-1980

* Reports of Meetings and Seminars * Calendar of Meetings

* Publications

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Increased coverage of the population and a greater ac-cesibility to control measures indicate that integration is proceeding well; however, activities to control quality of work through supervision and evaluation have been less satisfactory, and, except for a few countries, program-ming of case-finding and treatment activities with de-fined goals is a recent development. In some countries, when integration of program activities was implemented, the financial and professional resources released from previously existing vertical structures were not used to strengthen the central managerial teams, and in some in-stances these were weakened or even cancelled, thus reducing technical support for general services.

The following problems encountered in the integration of control activities within general health services were re-ported in 1973 and 1978: resistance to change by both specialized personnel and staff of the general health serv-ices; insufficient training or frequent turnover of person-nel; irregularity in obtaining supplies; and insufficient personnel and transportation for adequate prograrn supervision. In the 1980 survey no significant changes in the availability of training personnel were reported. The resistance to change by specialized personnel which was the major problem confronting integration, dropped from 65 per cent of the countries in 1973 to 24 per cent in 1978. Resistance to additional duties and exposure to risk by general health services personnel was reduced from 60 to 35 per cent. Participation of the countries in the Expanded Program on Immunization (EPI) and the Re-volving Fund of EPI has contributed to increasing' the regularity in the supply of drugs and BCG vaccine, and to reducing problems of funding, importation, and distribution.

Case-finding

Regional recommendations on case-finding assign high priority to the systematic collecting of a sputum sample from all symptomatic adults attending the general health services. While these recommendations have been accepted by most countries, implementation (including estimates of the number of persons to be examined and cases to be dis-covered by each health service) has progressed slowly

dur-ing the decade.

Results of case-finding depend on the active questioning by health personnel regarding symptoms, definition of "symptomatic," laboratory resources, and the physicians' selection of "probable" cases for bacteriologic examina-tions. This is reflected in the proportion of symptomatics found among those appearing for consultation and the pro-portion of bacteriologically positive cases among persons examined; both proportions vary from 1 to 10 per cent in different countries.

Information on reported cases according to place where

diagnosis was made (Table 1) and where treatment started (Table 2) reflects the extent of integration and changes in attitude. However, because of variations in the composi-tion of the sample, in the number of countries responding to a particular item, and in the total number of question-naire respondents, only large differences in figures or pro-portions between the surveys may be considered signifi-cant.

Figure 1 includes data on reported cases, by method of diagnosis, in several countries of the Americas in 1973, 1978, and 1980. The number of bacteriologic diagnoses by smear examinations increased as a result of the greater number of diagnoses performed in general health services, especially in peripheral units without specialists or ra-diologic equipment. In that figure, "Other methods" in-clude diagnoses made without bacteriologic or radiologic methods, as well as cases without the required informa-tion. The increase in diagnoses performed by bacteriologic and radiologic methods in the 1980 survey is due mainly to the inclusion of the United States, where resources are

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Treatment

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BCG Vaccination

Since BCG vaccination has recently been incorporated into the Expanded Program on Immunization, coverage has been increased to include the 2-6 months-of-age

group.

From 1977 to 1978, 14 Latin American countries re-ported 9,748,687 live births and 3,017,052 BCG vaccina-tions of children under one year of age (30.9 per cent of the total). Vaccination coverage in this group has in-creased from 20.9 per cent, according to the 1973 survey, to an average of 42 per cent estimated in 1980. In all countries the standard intradermal method of vaccina-tion is systematically used.

A study of 18 Latin American countries indicated five in 1980 with BCG coverage of 50 to 74 per cent in chil-dren under one year of age and four with over 75 per cent coverage.

Tuberculosis treatment has undergone significant changes in the last several years. Various countries have adopted short course chemotherapy either as a partial or a general measure; fully supervised treatment is

gradu-ally being recognized as useful and feasible, and, al-though there are still too many beds for tuberculosis treatment in many countries, hospitalization has de-creased significantly.

Data on the number of patients treated with each regi-men are not available at this time. This is due to the fact that the change to short course chemotherapy has taken

place only in the last two years; moreover, in many coun-tries the disease is treated by private practitioners who do not follow standard recommendations.

The trend to reduce hospital beds for tuberculosis pa-tients has continued in the last three years. Bolivia, Brazil, Colombia, Costa Rica, Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, Panama, Para-guay, and Uruguay reported an overall reduction of

offi-Training

In the Region, annual international courses on the epi-demiology and control of tuberculosis are held in Argen-tina, Brazil, Chile, Cuba, and Mexico, and a Regional Course on the bacteriology of tuberculosis at the Pan American Zoonoses Center in Argentina. In 1979, 235 professionals were trained in these courses, 29 of whom came from other countries.

In addition, each country has periodic courses and seminars on tuberculosis, according to the needs for per-sonnel training and program evaluation. All these courses are supported by PAHO/WHO consultants and fellowships.

Supervision and Evaluation

A tuberculosis control program requires proper super-vision to ensure the quality and efficiency of the

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tion. In 1978, three countries out of 17 reported that no supervision could be provided for the tuberculosis pro-gram in the general health services. Of the rest, nine countries provided supervision under a program drawn up at the beginning of the year, and in the other five, supervision was provided without prior programming in response to the needs of the moment. Supervisory per-sonnel was specialized in tuberculosis in six countries, multipurpose health services in one, and both types in the other seven.

Health laboratories in most countries provide supervi-sion for smear examinations either directly, where the supervisor observes the work in visits to local laborator-ies, or indirectly, where the local laboratory periodically sends slides to the regional or central laboratory.

In general, program evaluations are done in national or regional seminars comprised of several political units; in a country, and in some countries a yearly report of data and conclusions is published. However the quality and the operational or epidemiological emphasis of the evalu-ations vary from country to country and there is no stand-ard evaluation method generally accepted in the Americas.

gressing well and appears to have resulted in extended coverage, increased bacteriologic diagnosis, and reduced hospital treatment. The introduction of new and more po-tent drugs has decreased the duration of treatment. Super-vised administration of drugs has been recognized as feasi-ble and useful in controlling the completion of treatment and in lessening costs in short course chemotherapy through intermittent treatments schedules.

Abandonment of treatment by the patient, loss of con-tact by the health services, inadequate training of periph-eral genperiph-eral services personnel, and lack of supervision ap-pear to be the current major deficiencies of the programs. A more active management is needed to supervise and evaluate the programs, as well as to train and support the general health services personnel in order to achieve more effective tuberculosis control programs in the near future.

(Source: Tuberculosis Control Program, Communicable Diseases Unit, Division of Disease Prevention and Control, PAHO.)

Summary

Integration of tuberculosis control activities in the gen-eral health services of the Region of the Americas is pro..

0 Human Plague in 1980

In 1980 a total of 505 cases of human plague were re-ported to the World Health Organization, resulting in 56 deaths. The corresponding figures for 1979 were 881 cases and 30 deaths (Figure 1).

Cases of human plague in Africa were reported in four countries: Angola (for the first time since 1975), Kenya, Madagascar, and the United Republic of Tanzania. The 1980 totals (80 cases and 20 deaths) were roughly the

same as in previous years, except for 1979 when 471 cases and 12 deaths were reported.

In the Anmericas. an increase in the number of notified cases was observed, particularly in South America, where 142 cases and seven deaths were reported, com-pared with the 23 cases and two deaths recorded in 1979 (Table 1). This increase was due mainly to change in diag-nostic criteria in Brazil where 98 cases (and no deaths)