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MDR TB treatment success rates for 7 years of program
implementation in civilian sector of Tomsk, Russia.
D Taran1; S Mishustin2; G Yanova3; P Golubchikov2, A Barnashov2, A Yedilbayev4, S Keshavjee4, 5, 6, A Golubkov4, 5, 6
1 Partners
In Health, Russia; 2 Tomsk Oblast TB Services, Russia; 3 Tomsk Oblast TB Hospital, Russia; 4 Partners In Health, Boston, MA, USA; 5 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA; 6 Department of
Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
Background:
The MDR-TB project in Tomsk, Siberia was the first DOTS Plus project
piloted in Russia. The Tomsk project was launched in September 2000 in the
prison sector and extended to the civilian sector in January 2001.
Population ~ 1.04 mln.
½ in the capital – Tomsk.
½ in the remote villages.
Size ~ Poland.
T: from - 40 C up to + 45 C
The initial treatment success rate of the first cohort of patients was relatively
good, >70% (1). However, as the project expanded to cover more DR-TB
patients, especially in rural areas, the treatment success rate began decreasing
(to 54.3% in 2004), and default and failure rates rose.
2001-2004: PIH cohorts - 430 patients
•
Home-based care was organized
for limited number of patients:
those who were unable to attend
outpatient clinics.
• PIH launched the “Sputnik” Project - a patient-oriented program for patients at high risk of default.
Adherence rate among enrolled patients increased from 51% to 83%.
• Home-based treatment was expanded to 2 teams; up to 50 patients received medications under the
direct supervision at their homes or workplaces every day.
• Anti-alcohol subprogram was incorporated into standard TB care approach: AUDIT test for all new
TB patients performed and consultations by addiction specialists and psychologist launched.
• Monthly food packages were given to increase
adherence during the treatment on ambulatory
stage by the Tomsk Red Cross personnel.
• Transportation tickets were reimbursed by local
government for a limited number of patients.
• Program provided daily food sets, monthly hygiene sets, transportation tickets to those in
need and clothing. Hired social workers helped patients to solve social issues like passport
recovery, disability benefits, etc.
• DOT was provided in civilian sector at one inpatient and several
outpatient facilities. All doses were directly observed.
• The Red Cross was instrumental in establishing and monitoring strong
DOT programs in rural settings.
• Regional “Adherence committee” in the civilian sector was formed and
meetings were organized weekly to discuss and plan necessary actions
to prevent default among non-adherent patients.
• Monitoring and supervision of TB personnel at the DOT and
treatment locations was improved. Necessary assistance was provided.
• Several electronic databases were developed in order to monitor patient’s medical status
while on MDR-TB treatment and to perform statistical analyses of the treatment cohorts,
including the prison sector.
• TB-HIV program was launched to timely detect TB
and LTBI and provide Isoniazid prophylaxis to
PLWHA.
• Medical management was performed according to international protocols: individualized MDR-TB regimens
were designed based on the resistance profile of each individual’s isolate. Whenever possible, regimens
consisted of at least five drugs to which the patient’s isolate was susceptible and lasted at least 18 months.
• Adverse reactions were managed aggressively and TB drugs and side effect medications were free of charge
for patients.
• Staff became more experienced
in management of MDR-TB.
• Regional Clinical Committee was
empowered.
Conclusions:
1. For the last two years, the Tomsk program has shown a higher
treatment success rate than the average for MDR-TB programs (2,3).
2. High success rates were achieved as a result of interventions that
address known gaps and issues related to patients’ adherence (4).
3. The key adherence-related interventions that have facilitated success
in Tomsk have been:
• Free side effects medications for patients,
• Valuable social support such as daily food sets, especially for
patients treated in rural areas (worth at least $1/day),
• Home-based treatment in the city through accompaniment and
“Sputnik”, with emphasis on target high risk TB patients.
4. The authors believe that the MDR-TB treatment model piloted in
Tomsk could be implemented throughout the Russian Federation
with MoH and Social Security funds and that compulsory TB
treatment for high risk TB patients can therefore be avoided.
Literature cited:
1. Shin S, Pasechnikov A, Gelmanova I, Peremitin G, Strelis A, Andreev Y, Golubchikova V, Tonkel T, Yanova G, Nikiforov M, Yedilbayev A, Mukherjee J, Furin J, Barry D, Farmer P, Rich M, Keshavkee S. Treatment outcomes in an integrated civilian and prison multidrug-resistant
tuberculosis treatment program in Russia. International Journal of Tuberculosis and Lung Disease. 2006; 10(4): 402-8.
2. Johnston JC, Shahidi NC, Sadatsafavi M, Fitzgerald JM (2009) Treatment Outcomes of Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-Analysis. PLoS ONE 4(9): e6914. doi:10.1371/journal.pone.0006914
3. Evan W Orenstein, Sanjay Basu, N Sarita Shah, Jason R Andrews, Gerald H Friedland, Anthony P Moll, Neel R Gandhi, Alison P Galvani. Treatment outcomes among patients with multidrug-resistant tuberculosis: systematic review and meta- analysis
Lancet Infect Dis 2009;9: 153–61
4. Adherence to long-term therapies: evidence for action. World Health Organization 2003
Acknowledgments: Natasha Morozova, Irina Gelmanova, Vera Golubchikova, Sergei Yanov, Alexandra Solovyova, Natasha Zemlyanaya, Oksana Ponomarenko.
MDR-TB program support has been received from: Eli Lilly Foundation, Bill & Melinda Gates Foundation, Open Society Institute, Partners In Health Boston, Global Fund Against AIDS, TB and Malaria.