58557 Battle Against Tuberculosis: Some Gains in Russia Patricio V. Marquez, Wieslaw Jakubowiak, Dmitry 1 D.Pashkevich and Vladimir A. Grechukha Across Russia, the deep socio-economic crisis of the 1990s and early 2000s provided fertile ground for the spread of Key Messages TB. Indeed, as noted, "People who were already living very precariously saw their real incomes drop by 25% to 30% at About 1.1 million people, or almost 0.6- a time when government spending was also falling."2 As a 0.7% of the population in Russia, developed result, social and health conditions deteriorated, and TB TB between 1995 and 2004. spread rapidly. Russia also had one of the highest rates of imprisonment in the world that, coupled with adverse Russian TB control practices were highly conditions in prisons, increased the risk of TB, HIV and centralized, relied heavily on mass X-ray other infectious diseases among prisoners.3 screenings and were not effective in This situation contributed to Russia having one of the controlling the increasing numbers of TB highest rates of TB in the world. The annual number of new cases. cases and relapses tripled after 1990, reaching 92 per 100,000 population in 2001; Russian prisons reported more From 2003-2008, the World Bank, in than 50,000 TB patients annually during this period. More coordination with the World Health than 50% of all new TB cases in the country were among Organization (WHO) and other the unemployed, pensioners, homeless and alcoholics.4 international partners, supported the implementation of the TB/AIDS Control Project in Russia. The Project covered 79 of Expanding the Directly Observed Treatment the 83 regions across Russia, strengthening Strategy (DOTS) for TB Control both the civilian and prison health systems. Project activities supported the Russian TB control practices were highly centralized and implementation of the WHO-recommended relied heavily on mass X-ray screenings. Treatment "Directly Observed Treatment Strategy" included lengthy hospitalizations in specialized centers and (DOTS) for TB control. allowed for variations in drug regimens for patients. This approach, coupled with a deteriorated health system, was Since 2004, notifications of new TB cases in not effective in addressing the increasing numbers of TB Russia have stabilized. TB mortality in the cases: 1.1 million people, or almost 0.6-0.7% of the general population has decreased by 25% population, developed TB between 1995 and 2004. and among prisoners by 35%. From 2003-2008, the World Bank supported the implementation of the TB/AIDS Control Project (total cost The Challenge US$ 244 million), in partnership with the WHO Stop TB Program. The Project was complemented by support from Tuberculosis (TB), a disease that infects the lungs, is spread the Global Fund to Fight AIDS, TB and Malaria, of the US from person to person through the air. It tends to manifest Agency for International Development (USAID), as well as itself in situations of high social stress, poor nutrition, and low levels of immunity. If not treated, TB can be fatal. 2 John Litwack, World Bank Lead Economist in Russia, as quoted in "A Turning Point in the Fight Against Tuberculosis in Russia" (de Preneuf. F., 2006). World Bank web site: http://go.worldbank.org/XDVC6X0JM0 1 This Knowledge Brief takes into account the results of the Implementation Completion Report for the Russia 3 Bobrik, A., K. Danishevski, K. Eroshina, and M. McKee. 2005. "Prison Health in Russia: The Larger TB/AIDS Control Project prepared by Betty Hanan and Asel Sargaldakova in December 2009, WHO Picture." Journal of Public Health Policy 26:30-59. assessments, and data from the Russian MOHSD. 4 Coker, R., M.McKee, R.Atun, and others. 2006. "Risk Factors for Pulmonary Tuberculosis in Samara, Russia: A Case-Control Study." British Medical Journal 332:85-7. ECA Knowledge Brief Russia's own federal and regional efforts. The Russian health system, where it was the weakest. The reference Health Care Foundation managed project implementation laboratories at the federal research institutes were also on behalf of the Federal Ministry of Health and Social strengthened. More than 42,000 units of modern laboratory Development (MOHSD) and the Ministry of Justice's equipment and 200 X-ray/fluorography machines were Federal Corrections Center in charge of prisons. procured for six reference laboratories at federal TB research institutes, 49 bacteriological laboratories and 2,371 The Project was designed in accordance with the Federal clinical diagnostic laboratories in primary care facilities. Targeted Social Disease Prevention and Control Program Routine drug resistance surveillance is now in place; in (2002-2006). About 80% of Project funds were allocated for 2009, over 90% of culture-positive cases were tested for TB control with the goal of contributing to a leveling-off or resistance to first line anti-TB drugs. The supply of reduction in morbidity, mortality and transmission of TB. biosafety cabinets increased the capacity of laboratories for The Project covered 79 of the 83 regions across the vast infection control. More than 24,000 medical personnel Russian territory - from the Baltic Sea to the Pacific Ocean, working in civilian and prison health facilities were trained strengthening both the civilian and prison health systems. on the role of primary care physicians, organization of TB To achieve its objective, Project investments and activities control at the municipal level, and TB detection using supported the full-scale implementation of the WHO microscopy and culture methods. recommended DOTS strategy for TB control as follows: 3. Standardized short-course chemotherapy for all cases 1. Sustained political commitment to TB control. The of TB, including direct observation of treatment. By MOHSD-led High Level Working Group (HLWG) on TB 2007, all 83 regions in the Russian Federation, up from 14 and Thematic Working Groups, made up of representatives in 2003, adopted the WHO recommended DOTS strategy of leading national agencies and specialists, revised the for TB control. Training of specialists in accordance with national TB strategy according to international standards new MOHSD TB treatment protocols was provided. and developed new policies and guidelines for TB control. These groups also facilitated consultation among Russian In routine TB cases, standard first-line treatment regimens and international experts and the coordination of all TB are prescribed. The majority of infectious TB patients are programs in the country. A Strategic Five Year Plan for TB hospitalized during the intensive phase of treatment to (2003-2007) was launched by the MOHSD, along with prevent person-to-person contagion; during out-patient Ministerial Orders 109, 50, and 690 to guide the treatment, drug dispensing and follow-up of patients are implementation of activities. Needs assessments and performed at primary care facilities. Management of investment plans financed under the Project in each of the TB/HIV co-infection is carried out jointly by TB and participating regions were prepared by teams from HIV/AIDS services. Six to nine months of therapy is specialized institutes: Research Institute of required, using a combination of several drugs, to cure TB. Phthisiopulmonology of the Sechenov Medical Academy, The Project supplied 142 civilian and prison health facilities Central TB Research Institute of the Russian Academy of in 80 regions with anti-TB first-line drugs (Isoniazid, Medical Sciences, St. Petersburg Research Institute of Rifampicin, Pirazinamid, Ethambutol) worth US$ 19.3 Phthisiopulmonology, Ural Research Institute of million, which ensured uninterrupted treatment using Phthisiopulmonology, and Novosibirsk TB Research strengthened centralized drug procurement systems. Institute. The Ministry of Justice's Federal Corrections Center conducted similar work in the prison health system. Some regional governments, such as in Vladimir, have Technical assistance was provided by WHO. implemented social support programs for TB patients to prevent treatment interruptions and defaults during 2. Access to quality sputum microscopy for case detection ambulatory treatment, particularly targeting the among persons with TB symptoms (for example, unemployed, homeless, alcoholics, and former prisoners. prolonged cough). The most common diagnostic test to Support provided includes food supplements, free detect TB is microscopic examination of sputum smeared transportation or reimbursement of transport costs, and on a glass slide. It detects the most infectious cases and is psychological and legal counseling. Incentives for service highly specific in high-prevalence settings. This test, providers are also included to support timely detection and supported by X-rays when necessary and confirmed by treatment. bacteriological culture, is considered the diagnostic gold standard as it can identify over 80% of TB cases and allows Compliance with the standard treatment regimen among for drug susceptibility testing. newly detected TB cases has increased from 44% in 2004 to about 75% in 2008 - close to the 85% target set for the end Project investments modernized the public health laboratory of the project. Assessment of treatment success is done network, particularly at the municipal level and in the prison using cohort data. ECA Knowledge Brief 4. Confronting multiple-drug resistant TB. While Project Since 2003, TB notifications have stabilized (Figure laboratory improvements contributed to better diagnosing 1). The notification of new TB cases was 82.6 per drug-resistant TB cases, parallel funding from national 100,000 population in 2009, down from 90.7 at the programs, the Global Fund and USAID supported treatment beginning of the decade. In 2009, the registered TB with second-line TB drugs following WHO guidelines. prevalence rate was 185.1 per 100,000, significantly 5. Improved recording and reporting system, enabling down from 218.2 per 100,000 in 2004. assessment of patient outcomes. New forms of TB recording and reporting were introduced in all civilian and Figure 1: New TB Cases in the Russian Federation prison health facilities for cohort method analysis of TB (all health facilities), 1992-2009 detection and treatment outcomes. Specialists from federal TB research institutes monitored TB control activities in every region covered by the project. Training workshops 100.0 were conducted to improve monitoring and evaluation 85.2 90.7 88.5 86.3 85.1 90.0 82.7 83.3 84.0 82.6 83.3 82.6 capacity. 80.0 73.9 76.0 67.4 6. Addressing HIV/TB co-infection. With Project support, 70.0 57.8 a comprehensive set of 52 standards and protocols for 60.0 Per 100K 48.0 HIV/AIDS prevention, diagnosis, care and treatment were 50.0 42.9 developed by the MOHSD and adopted for nationwide use. 40.0 35.8 In addition, the laboratory network in 82 regional AIDS 30.0 TB notification rate centers, 16 regional STI centers, 35 regional prison 20.0 laboratories, and federal research institutes, was 10.0 strengthened with new equipment and supplies for the 0.0 detection, diagnosis and case management of HIV and other 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 sexually transmitted diseases using PCR (polymerase chain reaction), CD4, Viral Load and CD8 tests. This investment contributed greatly towards confronting the spread of the Source: Data from MOHSD's routine TB recording and reporting system. HIV/AIDS epidemic; timely access to quality PCR testing, which helps detect and diagnose infectious diseases such as By 2008, 75% of new TB patients were receiving HIV, and the measurement of the number of CD4 and CD8 the standardized treatment regimen, up from 44% in cells in the blood and viral load concentrations, that assess 2004. The treatment success rate among TB cases the status of the immune system in persons diagnosed with registered for treatment was about 60%, still below HIV, are critical procedures that support the scaling-up of the 85% recommended by WHO, due in large treatment with anti-retroviral drugs, help reduce the measure to the increase in the number of multiple- infectivity level of patients, slow the rate of new infections, drug resistant TB cases. However, improved and help increase the life expectancy and quality of life of diagnosis and care hold the promise for better people infected with HIV The safety of blood services was treatment success rates. also improved, reducing the risk of HIV transmission via blood transfusions. TB mortality in the general population decreased by 25% between 2003 and 2009 (Figure 2). In prisons, Results TB deaths dropped by 35% over this period. Timely detection and diagnosis are yielding higher numbers of notified TB cases among previously Diagnosis of HIV infected people improved unscreened or misdiagnosed patients, including significantly and the percentage of HIV patients those in the late phase of TB who are harder to cure. receiving treatment with anti retroviral drugs more than doubled between 2005 and 2008, reaching Between 2003 and 2008, case detection among 60% of those in need of treatment as determined by persons with TB symptoms using sputum smear CD4 count (a measure of the state of the immune microscopy increased by more than 24%, reaching a system) and viral load tests (a measure of the 73% level in 2008.5 severity of the viral infection). Expanded access to treatment contributed to the decrease in HIV- positive infants born to HIV-infected mothers, from 5 WHO. 2009. Global TB Control Report. Geneva. 13.2% in 2003 to 10.6% in 2008. ECA Knowledge Brief The spread of drug-resistant TB (about 15% of new Figure 2: TB Mortality Rate in the Russian cases in 2009) and HIV/AIDS are a serious Federation challenge to effective TB control in Russia. The provision of social support services (for example, free transportation between the home of the patient 140.0 130 National TB mortality rate and the health center, food supplementation, etc.) 118 TB mortality rate, penitentiary system 120.0 and compliance by patients to the treatment regime 103 is needed to prevent treatment interruptions and 100.0 defaults during ambulatory treatment, particularly 85 79.1 81.3 80.1 among the unemployed, homeless, alcoholics, and Per 100K 80.0 former prisoners. TB/HIV co-infection is also a 60.0 growing problem among vulnerable population groups (for example, injecting drug users), 40.0 22.0 21.4 22.6 demanding improved prevention and treatment 20.0 18.4 17.9 20.0 16.5 efforts. 0.0 The strengthening of case registration and reporting 2003 2004 2005 2006 2007 2008 2009 systems, and improved technical capacity at different levels of the health system to monitor and evaluate TB detection and treatment outcomes Lessons Learned using cohort data, are key institutional building blocks for improving program management and The establishment of high level and thematic policy formulation. working groups for policy setting and coordination and the participation of key stakeholders in the implementation of project activities were crucial to securing ownership of new approaches and sustaining activities and gains. A clear division of responsibilities among international agencies helped harmonize cooperation and maximize their impact in supporting the implementation of the national program. About the Authors Patricio V. Marquez, Lead Health Specialist, Human Modernization of the public health laboratory Development Sector Unit of the Europe and Central Asia network and improved knowledge and skills of Region of the World Bank. Wieslaw Jakubowiak, Former health personnel were essential to facilitate Coordinator, WHO Stop TB Program in Russia. Dmitry adoption of new guidelines for TB and HIV control, D.Pashkevich, Acting Coordinator, WHO Stop TB Program and scale up treatment. in Russia. Vladimir A. Grechukha, Former Project Director, Russian Health Care Foundation. "ECA Knowledge Brief" is a regular series of notes highlighting recent analyses, good practices and lessons learned from the development work program of the World Bank's Europe and Central Asia Region http://www.worldbank.org/eca