Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 29
3
Drug-Resistant Tuberculosis
in the Russian Federation
Key Messages
• he breakdown of the Soviet Union exacerbated TB by increasing
T
unemployment, poverty, migration, and social unrest, but the situ-
ation has been slowly improving over the past decade.
• n the other hand, the incidence of MDR TB has continued to
O
increase, as has infection with HIV and coinfection with HIV and
TB.
In Russia and the former Soviet Union, TB has been an acute problem.1
Today, the official estimate of the incidence of TB is about 82 to 83 per
100,000 population. According to Perelman, not all cases are diagnosed,
however, and not all patients are registered as incident cases; thus this
estimate is an underestimation of the true burden of disease.2 The estimate
of 82 to 83 cases per 100,000 population also is an average that includes
an incredibly diverse population and thus is not very revealing. Russia is
a vast country, and the incidence of TB differs as much as tenfold among
1 Thisintroductory text and the following section are based on the presentation of Mikhail
Perelman, Moscow Medical Academy.
2 In Russia, estimated TB incidence (new and relapse cases) in 2009, including TB-HIV
coinfection, was 106 per 100,000 population (confidence interval 89-125) (WHO, 2010c).
29
OCR for page 30
30 DRUG-RESISTANT TUBERCULOSIS IN RUSSIA
geographic regions. It is higher in the eastern portion of the country, with
the highest rates in the Russian Far East adjacent to Mongolia, China, and
Japan. Areas in that part of the country have an incidence ten times that
of Moscow.
Before the breakdown of the Soviet Union, the prevention and treat-
ment of TB were under stringent federal control. After the breakdown,
many events occurred to exacerbate the problem of TB. Dislocations in the
economy made the population poorer, and poverty is a risk factor for TB.
Unemployment and crime rates worsened considerably, which encouraged
the spread of TB in communities and the prison population. High levels
of migration into the country also contributed to the spread of TB, as did
military conflicts and the overall degradation of the health care system,
which loosened previously stringent controls on the level of disease in the
population.
Perelman explained that over the last decade, the TB situation in the
Russian Federation has slowly improved. The number of new cases is some-
what lower, and both morbidity and mortality have been on the decline.
A HISTORICAL PERSPECTIVE
In 1943−1944, the Soviet Union received its first lot of penicillin, which
was used by the military on the front lines. As early as 1944, the chief
surgeon of the Red Army wrote about drug resistance after the potency of
penicillin had declined substantially. When penicillin was recently reintro-
duced, however, it was much more effective, said Perelman.
Before drug therapy became available, TB was treated in Russia through
surgery, which saved hundreds of thousands of lives. The surgery option
also was used extensively in Scandinavia, France, and the United States, as
described in journals such as the Annals of Surgery. Today, better diagnostic
and surgical capabilities are available, such as surgery using state-of-the-art
visual technologies. In Russia, from 12,000 to 14,000 surgical operations
for TB are performed per year, and surgical treatment is about 85 percent
effective. According to Perelman, however, the need for surgery is at least
25,000 cases, so the number of surgeries needs to double. In addition, sur-
gery is complex and expensive and requires specialized departments and
personnel who are aware of the TB problem.3
The proper approach to TB in Russia today, said Perelman, is for
every person suspected of having TB to undergo a general medical
checkup, including a chest examination. Russia did not accept DOTS
3 In Russia, surgery is considered a component of treating patients with chronic TB that
has been unresponsive to antimicrobial therapy, as well as newly diagnosed TB patients with
complications, drug resistance, and/or intolerance to anti-TB drugs (Perelman, 2000).
OCR for page 31
31
DRUG-RESISTANT TUBERCULOSIS IN THE RUSSIAN FEDERATION
in its initial version, and Perelman believes this was a good decision. If
DOTS had been implemented, he suggested, the medical checkup would
have been abandoned. Today about 50 percent of new cases in Russia are
reviewed by x-ray, which provides good data with very little irradiation
because digital systems are used. Also, treatment of patients under DOTS
was supposed to be a short course. Perelman believes that patients left
the program undertreated, and this short course was one of the reasons
for the broad spread of MDR TB. Perelman stated that MDR TB also
can result if treatment is discontinued based on sputum tests without
consideration of cavities in lungs. Finally, he suggested that abandoning
luminescent microscopy or treatment in sanatoriums would not have been
appropriate in Russia.
An integrated approach to TB is important for prevention, said
Perelman. If all people had a high standard of living and education on how
to maintain their health, TB would be much less likely to spread. At present,
complex combination treatment is needed and is most effective.
EPIDEMIOLOGY OF TB IN THE RUSSIAN FEDERATION4
Yakimova observed that TB remains a very serious problem in Rus-
sia. Approximately 320 new TB cases appear each day, and 64 deaths are
associated with the disease.
The basic reasons for the TB epidemic in Russia are socioeconomic,
medical, and biological, Yakimova stated. Socioeconomic causes include
such factors as low living standards, unemployment, and migration. Medi-
cal causes include late detection, a lack of anti-TB therapy (especially
second-line therapy), a shortage of laboratories, and insufficient infection
control. Biological causes include the spread of MDR TB and HIV and the
continuing adaptation of M.tb. to antibiotics.
International experts estimate that about 50,000 people in Russia have
MDR TB. Between 40 and 70 percent of newly detected TB cases occur
in socially vulnerable groups, including the homeless, the unemployed,
migrants, and people with drug and alcohol dependencies (see Chapter 7).
The incidence of TB among the unemployed is 750 per 100,000 unem-
ployed people, compared with 45 per 100,000 employed people. Children
from socially vulnerable groups contract TB 10 to 20 times more frequently
than other children.
Altogether in Russia, 117,227 cases of TB were detected in 2009,
which is equivalent to 82.6 per 100,000 population. This figure represents
a decrease of 2.9 percent relative to 2008. The incidence among children
4 Thissection is based on the presentation of Marina Yakimova, Central TB Research Insti-
tute, Russian Academy of Medical Sciences.
OCR for page 32
32 DRUG-RESISTANT TUBERCULOSIS IN RUSSIA
younger than 15 was 14.7 per 100,000, a decrease of 3.9 percent relative
to 2008. The incidence among men is 2.8 times higher than that among
women (Figure 3-1). Among all cases of TB in Russia, 12 percent occur in
people incarcerated by the Ministry of Justice.
The incidence of TB grew markedly in Russia during the 1990s as the
economy of the country deteriorated (Figure 3-2). As noted above, how-
ever, the incidence of the disease differs markedly across the country, with
some Russian territories accounting for a disproportionate number of cases.
Therefore, suggested Yakimova, a single approach will not be appropriate
for all populations. TB incidence and mortality in Russia’s prisons have fallen
dramatically over the past 10 years, from 4,347 cases per 100,000 prisoners
and detainees, with 238 deaths, in 1999 to 1,308 per 100,000 prisoners and
detainees, with 80 deaths, in 2008. Detection and treatment also have low-
ered the percentages of people with TB in Russia who suffer the destructive
pulmonary form of the disease.
214.7
Men
200.00 190.4
Women
Men, not incarcerated
170.3
Women, not incarcerated
Incidence per 100,000 Population
160.7
150.00 156.4
158.5
93.1
100.00
50.00
0.00
0–14 15–24 25–34 35–44 45–54 55–64 65>
Age
FIGURE 3-1 TB incidence by gender and age rises to a peak between ages 25 and
Figure 3-1.eps
34.
SOURCE: Yakimova, 2010.
OCR for page 33
33
DRUG-RESISTANT TUBERCULOSIS IN THE RUSSIAN FEDERATION
FIGURE 3-2 TB incidence and mortality rose in the 1990s and have declined slightly
since.
Figure 3-2.eps
SOURCE: Yakimova, 2010.
bitmap can’t be edited
(suggest redraw)
The effectiveness of detection and diagnosis varies among regions
within the Russian Federation. Estimated detection rates are below 50 per-
cent overall—“lower than we would like,” said Yakimova. In some regions
of the Russian Federation, many cases of TB go undetected. Detection is
important because it determines the reservoir of patients who can serve as
a source of infection for the general population.
Nevertheless, TB mortality has decreased in the past 5 years in the
Russian Federation, as has the proportion of TB cases detected after the
subject’s death. An emphasis on TB in national and regional health pro-
grams has contributed to this decrease, with a new TB early detection and
prevention program starting in 2010. Preventive measures, including infec-
tion control and vaccination or prophylactic chemotherapy, must be clearly
designed and organized, Yakimova stated. The identification and treatment
of TB cases, particularly for people with infectious forms of the disease, are
critical to prevention. Other steps Yakimova recommended are:
• c
reating an integrated system for delivering TB health care, focus-
ing on prevention and early diagnosis;
• d
esigning and implementing initiatives to encourage TB testing
among vulnerable groups;
OCR for page 34
34 DRUG-RESISTANT TUBERCULOSIS IN RUSSIA
• i
ncreasing the vigilance of general practitioners, family doctors,
and specialists offering outpatient care;
• i
mplementing directly observed therapy at all stages of TB health
care;
• d
esigning and implementing uniform treatment and diagnostic
standards in TB health care;
• m
aking improvements in diagnostic methods, combination therapy
regimens, and rehabilitation (medical, social, and psychological);
• e
xpanding facilities that offer an alternative to inpatient treatment,
such as outpatient, day patient, and home care;
• p
roviding training and retraining for specialists offering prophylac-
tic, therapeutic, and diagnostic services to TB patients as continu-
ing education;
• i
mproving the physical condition and technology of medical facili-
ties offering TB care and equipping them with modern medical and
diagnostic equipment;
• g
uaranteeing the availability of good-quality first- and second-line
therapies; and
• i
ncreasing the effectiveness of TB prevention initiatives (such as
decontamination) in TB centers.
NATIONAL MDR TB SURVEILLANCE SYSTEM5
Full reporting of MDR TB has been ongoing in the Russian Federation
since 1999, said Skachkova. This period has seen the gradual development
of recording and reporting, epidemiological analysis and research, cohort
analysis, legislation, and training. The last annual review of surveillance
data was in 2008.
The recording of MDR TB underwent a change at the beginning of
2010. More detailed case records were instituted, and experts were tasked
to review data and ensure accuracy. Laboratory documents also were col-
lected and reviewed by the Ministry of Health. New forms are being intro-
duced for recording MDR TB and the effectiveness of MDR TB treatment.
Furthermore, a new project is being implemented for continuous tracking
of TB patients and risk groups. These changes have enabled much more
precise and accurate reporting of not only MDR but also XDR TB cases.
An assessment of MDR TB data that began last year has made it pos-
sible to calculate the primary incidence and prevalence of pulmonary MDR
TB. Review of these data in turn makes it possible to evaluate the success
rates for MDR TB treatment. The guidelines are that a minimum of 85
5 Thissection is based on the presentation of Elena Skachkova, Central Research Institute
for the Organization and Informatization of Health Care, Russian Federation.
OCR for page 35
35
DRUG-RESISTANT TUBERCULOSIS IN THE RUSSIAN FEDERATION
TABLE 3-1 MDR TB Data from the Russian Federation, 2007−2009
2007 2008 2009
Newly detected cases of culture- 35,449 35,573 36,679
positive pulmonary TB
Relapse cases of culture-positive 5,820 6,224 6,159
pulmonary TB
Newly detected cases investigated 31,560 34,241 33,540
for drug susceptibility
Percentage of newly detected cases 89% 91.1% 91.4%
investigated for drug susceptibility
Relapse cases investigated for drug 5,151 5,489 5,554
susceptibility
Percentage of relapse cases 88.5% 88.2% 90.2%
investigated for drug susceptibility
Resistance identified to any drug, 10,056 11,365 12,116
newly detected patients (31.9%) (33.2%) (36.1%)
Resistance identified to any drug, 2,307 2,757 3,016
relapse cases (44.8%) (50.2%) (54.3%)
MDR TB identified, newly detected 4,085 4,656 5,193
cases (12.9%) (13.6%) (15.5%)
MDR TB identified, relapse cases 1,280 1,580 1,869
(24.8%) (28.8%) (33.7%)
SOURCE: Skachkova, 2010.
percent of culture-positive patients should be investigated. Also, with effec-
tive TB prevention, widespread drug susceptibility testing, and widespread
treatment, the incidence of pulmonary MDR TB should not exceed 1.5
per 100,000 population, and prevalence should not exceed 9 per 100,000.
More than 90 percent of newly detected culture-positive TB cases are
now investigated for drug susceptibility in the Russian Federation (Table
3-1). The percentage of newly detected cases with resistance to any drug
has increased in recent years, to 36 percent in 2009, while the resistance
to any drug among relapsed cases rose to 54 percent in 2009. MDR TB
was identified in 15.5 percent of newly detected cases and in 33.7 percent
of relapse cases.
Together, these trends point to an increase in the number of MDR
TB cases over the past decade (Figure 3-3). This increase is related to the
expansion of drug susceptibility testing and to improved investigation of
drug-resistant TB. It is also due in part to an increase in the number of
unsuccessfully treated patients and to a lack of directly observed treatment.
OCR for page 36
36 DRUG-RESISTANT TUBERCULOSIS IN RUSSIA
No. of MDR TB patients MDR TB prevalence
35,000 25.0
20.5
30,000
18.6
17.2 20.0
29,031
16.8
15.9
26,448
25,000
14.1 14.1
Number of Patients
24,445
24,055
12.5
12.4
22,820
Prevalence
15.0
20,000
20,519
20,326
9.5
18,282
18,190
8.6
15,000
10.0
13,998
12,645
10,000
5.0
5,000
0 0.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
FIGURE 3-3 The number of MDR TB patients has continued to grow in the Russian
Federation during the 21st century.
Figure 3-3.eps
SOURCE: Skachkova, 2010.
Today a culture exam is performed in 97 percent of all patients. How-
ever, questions remain about the completeness and reliability of the result-
ing data since not all of the patients have positive culture results, and the
quality of the samples is not 100 percent reliable.
Data from some parts of the Russian Federation also are not very
reliable, according to Skachkova, especially where laboratory capacity is
lacking. As this capacity is increased, incidence rates will increase as well.
And with an overall incidence of MDR TB of 4 per 100,000 population,
the rate of new cases remains significantly higher than the national goal of
1.5 per 100,000 population.
