MEDICC Review, Volume: 19, Issue: 1, Published: 2017
  • May You Live in Interesting Times

  • About the Contributors

  • Peer Reviewers

  • Cuba’s Family Doctor-and-Nurse Teams: A Day in the Life

    Gorry, Conner
  • Antituberculosis Drug Resistance in Pulmonary Isolates of Mycobacterium tuberculosis, Cuba 2012–2014

    Lemus, Dihadenys; Echemendía, Miguel; Díaz, Raúl; Llanes, María Josefa; Suárez, Lourdes; Marrero, Antonio

    Abstract in English:

    ABSTRACT INTRODUCTION Systematic surveillance of antituberculosis drug resistance allows identification of multidrug-resistant and extensively drug-resistant isolates of Mycobacterium tuberculosis. Surveillance studies of antituberculosis drug resistance systematically conducted in Cuba for over 15 years have revealed low circulation of multidrug-resistant tuberculosis, under 1% in new cases. OBJECTIVE Characterize antituberculosis drug resistance in isolates of M. tuberculosis recovered from patients with pulmonary tuberculosis in Cuba in 2012–2014. METHODS The nitrate reductase assay was used to test 997 isolates of M. tuberculosis for sensitivity to isoniazid and rifampicin. Isolates identified as multidrug resistant were tested for sensitivity to isoniazid, rifampicin, streptomycin, ethambutol, ofloxacin, amikacin, kanamycin and capreomycin by the proportion method, as well as genetic resistance mutations in rpoB, katG, inhA, gyrA, rrs and embB genes, using GenoType MTBDRplus and MTBDRsl commercial kits. RESULTS Some 95.6% of isolates from new cases and 89.6% of isolates from previously treated patients were sensitive to isoniazid and rifampicin. Multidrug resistance was found in 0.8% of new and 5.2% of previously treated patients, a statistically significant difference. One extensively drug-resistant isolate was detected among previously treated cases. All isolates examined with the molecular method had mutations in the rpoB gene, which is associated with resistance to rifampicin; only seven showed mutations in the katG gene and one in the inhA gene associated with isoniazid resistance. In one isolate, we found mutations in both gyrA and rrs genes, which are associated with resistance to fluoroquinolones and second-line injectable drugs and therefore, extensive resistance. CONCLUSIONS Results corroborate the low frequency of multidrug-resistant and extensively resistant M. tuberculosis strains in Cuba and highlight the need for continuous improvement of surveillance of antituberculosis drug resistance in Cuba.
  • Perceived Barriers to Adherence to Tuberculosis Infection Control Measures among Health Care Workers in the Dominican Republic

    Chapman, Helena J.; Veras-Estévez, Bienvenido A.; Pomeranz, Jamie L.; Pérez-Then, Eddy N.; Marcelino, Belkys; Lauzardo, Michael

    Abstract in English:

    ABSTRACT INTRODUCTION Health care workers have an increased risk of infection due to occupational Mycobacterium tuberculosis exposure, including multidrug-resistant strains. Health care workers’ risk of developing tuberculosis is greater than that of the general population, whether in low-, intermediate- or high-incidence countries. Adherence to infection control measures (administrative controls, environmental controls, and personal respiratory protection) is essential to reduce risk of disease transmission between suspected tuberculosis patients and health care workers, but for different reasons, both objective and subjective, adherence is low. Identifying the causes of low adherence is a prerequisite to effective programming to reduce risk. OBJECTIVE Identify perceived barriers to adherence to tuberculosis infection control measures among health care workers in the Dominican Republic. METHODS During August 2014, a qualitative study was conducted in two tertiary-level hospitals in different regions of the Dominican Republic. A semi-structured interview guide of nine questions was developed, based on the scientific literature and with consensus of clinical experts. Nine semi-structured interviews were conducted with a purposive sample of seven physicians (five men, two women) and two baccalaureate nurses (both women) working in the emergency medicine, internal medicine or nursing departments of those institutions. Question topics included clinical experience of M. tuberculosis infection and disease; knowledge of disease transmission and preventive practices; clinical management strategies; and perceptions of effectiveness of directly observed treatment, short-course, and disease coping strategies. RESULTS Perceived barriers were described as: 1) sense of invincibility of health care workers; 2) personal beliefs of health care workers related to direct patient communication; 3) low provider-to-patient ratios in hospitals; 4) absence of tuberculosis isolation units for patients within hospitals; and 5) limited availability of protective masks for health care workers. CONCLUSIONS Our results highlight that perceived barriers at the individual or institutional level may hinder how health care workers understand and comply with preventive strategies to reduce risk of tuberculosis transmission. Addressing these barriers by strengthening infection control program infrastructure and implementing educational interventions within institutions may reduce risk of nosocomial tuberculosis transmission to health care workers.
  • Historical Overview of Leprosy Control in Cuba

    Beldarraín-Chaple, Enrique

    Abstract in English:

    ABSTRACT INTRODUCTION Leprosy, an infectious disease caused by Mycobacterium leprae, affects the nervous system, skin, internal organs, extremities and mucous membranes. Biological, social and environmental factors influence its occurrence and transmission. The first effective treatments appeared in 1930 with the development of dapsone, a sulfone. The main components of a control and elimination strategy are early case detection and timely administration of multidrug therapy. OBJECTIVES Review the history of leprosy control in Cuba, emphasizing particularly results of the National Leprosy Control Program, its modifications and influence on leprosy control. EVIDENCE ACQUISITION The historiological method was applied using document review, complemented by interviews with experts on leprosy and its control. Archived documents, medical records, disease prevalence censuses conducted since 1942, and incidence and prevalence statistics for 1960–2015 from the Ministry of Public Health’s National Statistics Division were reviewed. Reports and scientific literature published on the Program and the history of leprosy in Cuba were also reviewed. DEVELOPMENT Leprosy has been documented in Cuba since 1613. In 1938, the Leprosy Foundation was created with ten dispensaries nationwide for diagnosis and treatment. The first National Leprosy Control Program was established in 1962, implemented in 1963 and revised five times. In 1972, leper colonies were closed and treatment became ambulatory. In 1977, rifampicin was introduced. In 1988, the Program instituted controlled, decentralized, community-based multidrug treatment and established the criteria for considering a patient cured. In 2003, it included actions aimed at early diagnosis and prophylactic treatment of contacts. Since 2008, it prioritizes actions directed toward the population at risk, maintaining five-year followup with dermatological and neurological examination. Primary health care carries out diagnostic and treatment activities. The lowest leprosy incidence of 1.6 per 100,000 population was achieved in 2006. Since 2002, prevalence has remained steady at 0.2 per 10,000 population. Leprosy ceased to be considered a public health problem in Cuba as of 1993. In 1990–2015, 1.6% of new leprosy patients were aged <15 years. At present, late diagnosis of cases exceeds 20%, which leads to a high percentage of grade 2 disability in such patients. Spontaneous physician visits by already symptomatic patients surpassed 70% of cases diagnosed in 2010–2015. CONCLUSIONS Actions undertaken after initial detection of leprosy in Cuba failed to control it. Effective control began in 1963, with the implementation of the National Leprosy Control Program, whose systematic actions have had an impact on trends in leprosy, reflected in WHO’s 1993 declaration that leprosy was no longer a public health problem in Cuba.
  • Cuba’s Aging and Alzheimer Longitudinal Study

    Llibre-Rodríguez, Juan de Jesús; Valhuerdi-Cepero, Adolfo; López-Medina, Ana M.; Noriega-Fernández, Lisseth; Porto-Álvarez, Rutbeskia; Guerra-Hernández, Milagros A.; Bosch-Bayard, Rodolfo I.; Zayas-Llerena, Tania; Hernandez-Ulloa, Elaine; Rodríguez-Blanco, Ana L.; Salazar-Pérez, Enrique; Llibre-Guerra, Juan C.; Llibre-Guerra, Jorge J.; Marcheco-Teruel, Beatriz

    Abstract in English:

    ABSTRACT Aging and Alzheimer is a prospective, longitudinal cohort study involving 2944 adults aged ≥65 years from selected areas in Cuba’s Havana and Matanzas Provinces. This door-to-door study, which began in 2003, includes periodic assessments of the cohort based on an interview; physical exam; anthropometric measurements; and diagnosis of dementia and its subtypes, other mental disorders, and other chronic non-communicable diseases and their risk factors. Information was gathered on sociodemographic characteristics; disability, dependency and frailty; use of health services; and characteristics of care and caregiver burden. The first assessment also included blood tests: complete blood count, blood glucose, and liver function, lipid profile and ApoE4 genotype (a susceptibility marker). In 2007–2011, the second assessment was done of 2010 study subjects aged ≥65 years who were still alive. The study provides data on prevalence and incidence of dementia and its risk factors, and of related conditions that affect the health of older adults. It also contributes valuable experiences from field work and interactions with older adults and their families. Building on lessons learned, a third assessment to be done in 2016–2018 will incorporate a community intervention strategy to respond to diseases and conditions that predispose to dementia, frailty and dependency in older adults.
  • In Defense of Clinical Autopsy and Its Practice in Cuba

    Espinosa-Brito, Alfredo D.; Mendoza-Amat, José Hurtado de

    Abstract in English:

    ABSTRACT There has been a notable decrease in the global practice of clinical autopsy; the rate has fallen to below 10%, even in high-income countries. This is attributed to several causes, including increased costs, overreliance on modern diagnostic techniques, cultural and religious factors, the emergence of new infectious diseases and negative attitudes on the part of doctors, even pathologists. Alternative methods to autopsy in postmortem studies have been developed based on imaging, endoscopy and biopsy (all quite expensive). These methods have been used in developed countries but never as effectively as the classic autopsy for identifying cause of death and potential medical errors. Although Cuba has also seen a decrease in its autopsy rates, they remain comparatively high. Between 1996 and 2015, there were 687,689 hospital deaths in Cuba and 381,193 autopsies, 55.4% of the total. These autopsies have positively affected medical care, training, research, innovation, management and society as a whole. Autopsies are an important tool in the National Health System’s quest for safe, quality patient care based on the lessons learned from studying the deceased.
  • Enhancing Political Will for Universal Health Coverage in Nigeria

    Aregbeshola, Bolaji S.

    Abstract in English:

    ABSTRACT Universal health coverage aims to increase equity in access to quality health care services and to reduce financial risk due to health care costs. It is a key component of international health agenda and has been a subject of worldwide debate. Despite differing views on its scope and pathways to reach it, there is a global consensus that all countries should work toward universal health coverage. The goal remains distant for many African countries, including Nigeria. This is mostly due to lack of political will and commitment among political actors and policymakers. Evidence from countries such as Ghana, Chile, Mexico, China, Thailand, Turkey, Rwanda, Vietnam and Indonesia, which have introduced at least some form of universal health coverage scheme, shows that political will and commitment are key to the adoption of new laws and regulations for reforming coverage. For Nigeria to improve people’s health, reduce poverty and achieve prosperity, universal health coverage must be vigorously pursued at all levels. Political will and commitment to these goals must be expressed in legal mandates and be translated into policies that ensure increased public health care financing for the benefit of all Nigerians. Nigeria, as part of a global system, cannot afford to lag behind in striving for this overarching health goal.
  • Making Travel to Cuba Work for Health and Sustainable Development

    Gorry, Conner
Medical Education Cooperation with Cuba Oakland - California - United States