From: "Murray Feshbach" <mmjfeshbach@comcast.net>
Subject: RECENT EFFORT TO DEAL WITH THE TUBERCULOSIS EPIDEMIC IN RUSSIA
Date: Mon, 21 Jan 2008
IMPORTANT AND NECESSARY BUT IS IT SUFFICIENT?
RECENT EFFORT TO DEAL WITH THE TUBERCULOSIS EPIDEMIC IN RUSSIA
With all of Russia’s troubling health problems, the new variants of tuberculosis illness have major implications for Russian society today and in the future.
In January of 2004, a U.S. Centers for Disease Control and Prevention (CDCP) website cited the coordinator of the World Health Organization’s (WHO) TB control program in Russia, Wiecslaw Jakubowiak, to the effect that 1 in 10 new TB cases in some regions of Russia and 1 in 5 new TB cases in the penitentiary system were of Multi-Drug Resistant-TB (MDR-TB). A deputy director of a Moscow Oblast TB hospital which treated “Russia’s most serious TB cases” found that they “are picking up terrifying rates of super-resistant strains [of tuberculosis[.” She also stipulated that “there are no exact figures because laboratories are ill-equipped to assess the true scope of the problem.”
In March 2005, Jakubowiak wrote in a WHO Policy Brief (no. 5), which citicized the TB laboratories of the Russian Federation, “Only 3% of all newly registered TB patients were diagnosed by any bacteriological method and only 2% by microscopy. According to international guidelines, the majority of patients should be detected by microscopy.” Only now is this problem finally being seriously addressed.
In May 2006, WHO issued a formal warning to the leaders of European countries that the spread of tuberculosis could seriously affect their countries. In 2007, they repeated this warning even more forcefully.
In July 2007, the multi-national Stop TB Partnership of WHO issued a lengthy, detailed study of the rapid expansion of both MDR-TB (multi-drug resistant tuberculosis) and XDR-TB (extensively-drug resistant tuberculosis); the former involves cases that are resistant to the principal first-line drugs and the latter also are resistant to specific second-line drugs; there are no third-line drugs. The number of persons in 25 High Burden Drug-Resistant Tuberculosis countries, 13 were in the CIS and Baltic States (with 2 countries Turkmenistan [likely quite high] and Armenia [likely quite low]), not shown in the table. (See the tables at the end of the article.) The share of the reported countries is very high, and that of the Russian Federation very high.
In November of 2007, at an international conference held in Cape Town, South Africa, according to Reuters News Service, Mario Raviglione, Director of the WHO Stop TB Deparment, stated that “some countries in the former Soviet Union were showing an MDR-TB incidence of up to 20 percent, while some European states showed resistance to all second-line TB drugs” (likely in the former CIS and Baltic region). And further, “that the situation reminded health officials of the ‘pre-antibiotic era’ of 1943.” Especially more telling was the fact that the causes included, among others, “underfunding, outdated drugs, a lack of new vaccines and poor diagnostic [work], …especially [with respect to] those infected with both TB and HIV.” A number of steps have been taken to ameliorate the tuberculosis situation in Russia, but while important, they are far from sufficient.
At the end of 2007, a directive was signed by the Chief Public Health Physician of Russia, Gennadiy Onishchenko. This document (postanovleniye) described both the difficulties in the health status of the Russian population, but also the shortages in supplies and facilities to treat tuberculosis, the high levels of TB among various age groups, and the steps initiated to correct this serious situation.
The story first appeared in Interfax of 24 December 2007, then picked up in very early January by the Kaiser Family Foundation website and by Global Health Reporting.org site. These 3 items were relatively short, albeit with important materials from the original Interfax item. However, when the full directive was found on the Sanepidnadzor’s website, many more details became available.
Some background: Russia is the only European state included on a listing of 22 “high-burden countries” for tuberculosis. Furthermore, the official and adjusted new case rates per 100,000 population and especially the TB mortality level and rate in the country, highlighted the seriousness of the stiuation. Moreover, it becomes even more serious when considering the increases in new cases of Multi-Drug Resistant (MDR-TB) and Extremely Drug Resistant (XDR-TB) tuberculosis, The potential for weakened immune systems have already led to serious increases in TB morbidity and mortality which are not just theoretical. When I wrote in January of 2007 for JRL (no. 29), there was no firm information available on the number of cases. Shortly after the JRL article appeared, a Canadian journalist reproted that there were only some 300 or 400 XDR-TB cases in Russia. The July 2007 policy program of the Stop TB unit, determined that the number at that point was 1,915 XDR-TB patients in Russia who needed treatment, or roughly 6 times more in the half year since the first estimate. And these are only those who needed treatment. Likely a likely larger number has been found since that point in time.
A bit more background before getting to the direct matter at hand of the current problems in TB facilities and and a brief summary of what the authorities plan to do.
To demonstrate why Russia is included in the 22 high-burden listing, it has to be understood that WHO defines the presence of a TB epidemic in a given country when the new case rate is 50 cases or more per 100,000 population In 2006, Russia officially recorded 82.4 per 100,000, according to Onishchenko. However, according to the WHO and a leading TB epidemiologist in Russia (Dr. Margarita Shilova), the official figure is understated by some 50% because relapses, recurrences and other recidivist cases are not recorded (for any illness, not just TB) due to the rule that the new case morbidity figures are confined to “the first time in life”; any repeat cases of a given illness are not incorporated in Russian medical statistics. If one were to include repeat cases, theTB rate in Russia would be 119 per 100,000 in 2005 (44 percent higher than the 82.4 figure in 2006), and simultaneously almost triple the threshold point for the WHO definition of an epidemic of TB. (In the United States, the new case rate is about 5 per 100,000 --including multiple diagnoses of TB.) In absolute terms, the number of (adjusted) new cases in Russia is estimated by WHO in 2005 at 170,000 and 13,000 in the United States. (Additional information about incidence of MDR-TB and XDR-TB in Russia and the United States are found in the JRL item cited above, and in my new paper on population and health constraints in the Russian military and the population as a whole, about to be published in a collection of essays prepared for a conference on “Russian Power Structures” held in Stockholm in October of 2007.)
The acute and remarkably poor situation in TB institutions in Russia was first described in the 3 sites noted earlier. The Onishchenko directive contained the following remarks detailing some of the lacunae in tuberculsois facilities (others may be found in the full text of the directive):
“only 9% of [about 600] TB hospitals meet current hygienic standards, 60% need capital repairs, 21% lack either hot or cold running water, and 11% lack a sewage system, …also…42% of [TB] hospitals have inadequate medical equipment and 20% have a shortage of TB drugs.”
The full Onishchenko piece provides additional details about the problems and shortcomings of the tuberculosis treatment facilities.
Among these are:
serious inadequacies in tuberculosis diagnosis; 17% of persons in contact with active TB patients are not regularly followed, while 5% are not followed at all; in 11 regional areas, no more than 34% of all those infected have a final “disinfection” examination; as a result, TB outbreaks in households of “contact individuals” were 10 times greater than in the general population in 2006, at a rate of 783 per 100,000 contact populations; 50% of all anti-tuberculosis facilities do not properly deal with waste water; 65% of the institutions have inadequate space between beds (in 13 regions); a “high proportion” do not have enough bedsheets and laundry capability; and the rate of TB infections among TB hospital personnel amounts to 4.5 times the rate among the general population (ranging among the staff from 1300 to 2500 per 100,000).
Finally, Onishchenko cites the fact that one-half of all persons discharged from the penitentiary system subsequently do not follow-up with needed treatment. They represent a serious reservoir leading to the further spread of active tuberculosis, particularly if (because of lack of complete treatment) it mutates into MDR or XDR-TB.
As a result, when preparing its report on The Global MDR-TB and XDR-TB Response Plan 2007, the Stop TB Partnership of WHO came up with another “High Burden” List. It consists of 25 countries, instead of the 22 cited earlier. Of these 25, 13 are former CIS and Baltic States.
More than half (50.9%) of the 58,620 patients in 2007 needing treatment for MDR-TB, were in the CIS and Baltic countries, of which, 27.9% of the total were estimated in Russia alone. In 2008, the total number needing treatment is projected to be 100,068 for all 25 countries (with a large proportion of the increase to be found in India), while Russia will increase by slightly over 3,000 additional cases up to 19,675 persons needing treatment for MDR-TB. In addition, XDR-TB in Russia is projected to increase from 1,915 in 2007 to 2,306 in 2008.
When and if the latter types of tuberculosis in Russia combine with the weakened immune system of HIV-positive individuals, the danger of dual epidemics will be even greater, especially if the programs to mitigate or significantly reduce the problems fail. In addition to the growth of drug-resistant TB, the number of HIV-positive persons is projected by Onishchenko (as well as Vadim Pokrovskiy, head of the Federal AIDS Center) to increase in 2008 by 10,000; the total number of registered HIV-positive persons grew in December of 2007 by about 3,500 yielding an official (total) prevalence of 408,535 HIV cases. If one appliesWHO’s low (adjusted) estimate of about 800,000, the prevalence number represents more than 1 percent of the population 15 to 49 years of age used by WHO, the defining tipping point in the spread of HIV. TB/HIV co-infections in the country have grown between 4,506 in 2004 and 7,500 in 2005, according to various WHO estimates by Jakubowiak and the Global Tuberulosis Control 2007 report. (In the United States, the comparable number is 1,000.)
The mutation rate from MDR-TB to XDR-TB is estimated by WHO based on the pattern in Latvia to be about 15%. If this conversion rate holds, then the 24,000 MDR-TB cases reported for 2006 and 34,055 in 2007, would lead to an additional 3,600 and 5,100 cases of XDR-TB, respectively. However, given the imprecision of laboratory work in Russia in the past, described by Jakubowiak and now Onishchenko, the correct number might be an even higher base (of MDR-TB) and the resultant number of XDR new cases.
Much work is going on to upgrade laboratories. According to Jakubowiak at the 38th Union World Conference on Lung Health, held in November of 2007, $60 million has been assigned to upgrade laboratory microscopy culture capabilities at federal and regional levels in Russia. The Stop TB office, with the cooperation of Swedish, German and English Supra-National Laboratories and their counterparts in other countries are involved in upgrading the quality of work, especially in central reference labs. Hopefully, as a result of this work, proper and more rapid diagnoses can be obtained before advanced, more serious forms of tuberculosis develop. Stop TB’s latest program for proper medication protocols and treatment of drug-resistant patients to prevent mortal outcomes is reflected in the Onishchenko directive.
Progress is being made but it is slow. It is costly and requires staff retraining, as well as capital investments in upgrading these other facilities as described by Onishchenko. Much more money is being spent, but the outcome is not yet certain. In the interim, the lack of clean water alone could seriously affect the efficiency of treatment and the possibility of excerbating the condition of patients. At the least, the attention to the range of needed correctives is noteworthy, but until recently the highest medical and political authorities basically neglected the tuberculosis issue just as they neglected the growth of human immunodeficiency virus (HIV). The picture described here shows that the situation is perilous. The work of many people and institutions is to be commended, but as with much of Russian affairs, attempts to remedy the immediate situation are implemented very late.
APPENDIX A: LIST OF 22 HIGH-BURDEN COUNTRIES, ALL TUBERCULOSIS CASES AS DETERMINED BY WHO, 2005
(RANKED BY ABSOLUTE NUMBER, IN THOUSANDS)
1. INDIA—1852
2. CHINA—1319
3. INDONESIA—533
4. NIGERIA—372
5. BANGLADESH—322
6. PAKISTAN—286
7. SOUTH AFRICA—285
8. ETHIOPIA—266
9. PHILLIPINES—242
10. KENYA—220
11. DR CONGO—205
12. RUSSIAN FEDERATION—170
13. VIET NAM—148
14. UR TANZANIA—131
15. BRAZIL—111
16. UGANDA—106
17. THAILAND—91
18. MOZAMBIQUE—89
19. MYANMAR—86
20. ZIMBABWE—78
21. CAMBODIA—71
22. AFGHANISTAN—50
Source: WHO, Global TB Control Report 2007 (www.who.int/tb/publications/global_report)
APPENDIX B: 25 PRIORITY MDR-TB AND XDR-TB COUNTRIES
NUMBER ON TREATMENT, ESTIMATED AND PROJECTED FOR 2007 AND 2008 (IN ABSOLUTE NUMBERS), AS LISTED IN ORIGINAL SOURCE:
2007 2008
COUNTRY MDR-TB XDR-TB MDR-TB XDR-TB
DR CONGO 268 27 523 48
ETHIOPIA 343 34 669 61
NIGERIA 173 17 337 21
SOUTH AFRICA 719 71 1,401 129
AZERBAIJAN 614 72 737 86
BELARUS 579 68 695 81
ESTONIA 60 7 72 7
GEORGIA 363 42 435 51
KAZAKHSTAN 2,212 258 2,655 311
KYRGYZSTAN 627 73 752 88
LATVIA 155 18 186 22
LITHUANIA 336 39 425 50
REP. OF MOLDOVA 567 66 680 80
RUSSIAN FED’N 16,393 1,915 19,675 2,306
TAJIKISTAN 1,123 131 1,348 158
UKRAINE 4,306 503 5,169 606
UZBEKISTAN 3,032 354 3,640 427
PAKISTAN 1,224 104 2,397 182
BANGLADESH 1,741 150 3,116 260
INDIA 9,873 853 27.176 2,266
INDONESIA 2,937 254 8,084 674
MYANMAR 461 40 1,269 106
CHINA 8,142 669 14,423 1,120
PHILIPPINES 1,473 121 2,610 203
VIET NAM 899 74 1,593 124
TOTAL: 58,620 5,960 100,068 9,477
SOURCE: WHO, The Global MDR-TB & XDR-TB Response Plan, 2007-2008:, Geneva, Stop TB Parnership, 2007, Annex III.