Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: non-adherence, default and the acquisition of multidrug resistance.

OBJECTIVE: To identify barriers to successful tuberculosis (TB) treatment in Tomsk, Siberia, by analysing individual and programmatic risk factors for non-adherence, default and the acquisition of multidrug resistance in a TB treatment cohort in the Russian Federation. METHODS: We conducted a retrospective cohort study of consecutively enrolled, newly detected, smear and/or culture-positive adult TB patients initiating therapy in a DOTS programme in Tomsk between 1 January and 31 December 2001. FINDINGS: Substance abuse was strongly associated with non-adherence [adjusted odds ratio (OR): 7.3; 95% confidence interval (CI): 2.89-18.46] and with default (adjusted OR: 11.2; 95% CI: 2.55-49.17). Although non-adherence was associated with poor treatment outcomes (OR: 2.4; 95% CI: 1.1-5.5), it was not associated with the acquisition of multi-drug resistance during the course of therapy. Patients who began treatment in the hospital setting or who were hospitalized later during their treatment course had a substantially higher risk of developing multidrug-resistant TB than those who were treated as outpatients (adjusted HRs: 6.34; 95% CI: 1.35-29.72 and 6.26; 95% CI: 1.02-38.35 respectively). CONCLUSION: In this cohort of Russian TB patients, substance abuse was a strong predictor of non-adherence and default. DOTS programmes may benefit from incorporating measures to diagnose and treat alcohol misuse within the medical management of patients undergoing TB therapy. Multidrug-resistant TB occurred among adherent patients who had been hospitalized in the course of their therapy. This raises the possibility that treatment for drug-sensitive disease unmasked a pre-existing population of drug-resistant organisms, or that these patients were reinfected with a drug-resistant strain of TB.

Adverse reactions among patients being treated for MDR-TB in Tomsk, Russia.

BACKGROUND AND SIGNIFICANCE: Treatment of multidrug-resistant tuberculosis (MDR-TB) is challenging because of the toxicity of second-line medications. Little is known about whether adverse events impact treatment outcome. METHODS: We conducted a retrospective case series of 244 MDR-TB patients enrolled in Tomsk between 10 September 2000 and 10 September 2002. Adverse reactions were determined by laboratory data and/or clinical criteria. A multiple logistic regression model was performed to determine whether the occurrence of adverse reactions was associated with poor treatment outcome. RESULTS: In this cohort, 76.0% were cured, 6.6% failed, 4.9% died and 11.5% defaulted. Adverse events were observed in 73.3% of patients, occurring in 74.8% of patients who were adherent (taking at least 80% of prescribed doses) and 59.1% of non-adherent individuals (P = 0.11). The impact of adverse events on outcome was modified by non-adherence; among adherent patients, the occurrence of any adverse reaction was associated with treatment cure (adjusted odds ratio 3.24, 95% confidence interval 1.56-6.70). CONCLUSION: Adverse reactions occurred frequently in MDR-TB patients in Tomsk, Russia, but did not negatively impact treatment outcome. The occurrence of adverse reactions among adherent patients was associated with treatment cure.

Treatment outcomes in an integrated civilian and prison MDR-TB treatment program in Russia.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) is a major problem in countries of the former Soviet Union in both the civilian and prison sectors. OBJECTIVE: To evaluate outcomes of the MDR-TB treatment program (DOTS-Plus) in Tomsk, Russia. DESIGN: Retrospective case series of all patients enrolled in this program between 10 September 2000 and 10 September 2002. The program involves both the civilian and penitentiary TB services in Tomsk. Poor treatment outcome was defined as death, default and treatment failure. RESULTS: Among the 244 patients who received treatment, 77% were cured, 5% died, 7% failed, and 12% defaulted. In a multivariable analysis, alcohol consumption during treatment and the presence of both cavitary and bilateral disease were found to be the strongest predictors of poor treatment outcome. CONCLUSIONS: The integration of civilian and penitentiary TB services in the Tomsk MDR-TB treatment program has resulted in high cure rates and low rates of default. However, alcohol use among patients with MDR-TB is associated with poor treatment outcomes. Better understanding and programmatic alcohol interventions are needed if large-scale treatment of MDR-TB is to be successful in areas with high rates of alcohol use disorders.

[Laboratory service optimization in the implementation of a complex programme for detection and treatment patients with tuberculosis].

The paper presents a model of laboratory service in implementing a complex program aimed at detecting and treating patients with tuberculosis in the Tomsk Region. Organizational, methodological, and managerial measures to set up bacteriological stations and a main (reference) laboratory for microbiological sputum study in Tomsk, intensification of this work at all clinical-and-diagnostic laboratories of general health care facilities have improved the quality of the whole system detecting bacterial isolators and ensured a close organizational and methodological interaction between the therapeutic-and-diagnostic institutions of the general medical system and tuberculosis-controlling service.

[New infrastructures in the system of organization of antituberculosis services]. / Novye infrastruktury v sisteme organizatsii protivotuberkuleznoi pomoshchi naseleniiu.

To provide regular supplies of antituberculous drugs into the Tomsk region, the new infrastructure the Central Fund of Antituberculous Drugs has been founded on the basis of a regional antituberculosis dispensary. The main objectives of the Fund are to plan needs for antituberculous drugs, to provide their regular supplies, to monitor the records of receipts and expenses. The structure of the Fund is simple and includes only one pharmacist, 23 facilities of different levels are provided by drug. Analyzing the activity of the Fund shows that it copies with its facing tasks well and suggests that it is necessary to set up such funds.

Developing nursing practice as part of the collaborative TB control programme, Tomsk, Siberia.

SETTING: Review of nursing practice, identification of training needs and implementation of training for nurses working in the Tomsk Oblast' Tuberculosis Services (TOTBS), Russia. OBJECTIVE: Preparation of TOTBS nurses for the implementation of a WHO-style TB control programme in January 1997. METHODS: Nursing services and training needs were assessed through observation visits to a number of institutions providing care for TB patients, semi-structured interviews, and discussions at staff meetings. Training sessions focused on the WHO DOTS strategy, patient education and default tracing. An evaluation visit focused on nurses' attitudes and levels of treatment completion. RESULTS: Out of a total of 165 TB cases notified in Tomsk Oblast' between January and March 1997, 53 were started on DOTS on an ambulatory basis. Five patients who defaulted returned to treatment within five days (range 2-5) and no patients were lost to follow up. Improved compliance was attributed to better patient education offered by nurses and a reliable supply of medication. Quarterly reports continue to show satisfactory levels of treatment completion. CONCLUSIONS: Obstacles to the development of nursing practice included resistance to change and low morale due to enormous workloads, no pay and staff shortages. Motivation improved through the setting of achievable targets.

[International concept of antituberculous care organization for the Tomsk region's population]. / Mezhdunarodnaia kontseptsiia organizatsii protivotuberkuleznoi pomoshchi naseleniiu Tomskoi oblasti.

The priorities of the international concept of organization of antituberculous care to the population of the Tomsk Region are as follows: detection of bacillar patients and their short-term intensive chemotherapy by the WHO categories; formation of a 6-month reserve of tuberculostatics and complete control over patients' drug use; diagnosis of diseases by the general medical network for patients' referrals by introducing indications for clinical examinations for tuberculosis and sputum tests for Mycobacterium tuberculosis, fluorographic studies of only risk group populations; tuberculin diagnosis among children aged 1-14 years from risk groups; BCG vaccination of the newborn and revaccination at the age of 6-7 years. Resource mobilization is essential. This includes: strengthening of basic service institutions and centralization of its structures; fund saving by reasonably reducing the beds in sanatoria and hospitals; extension of therapeutical and diagnostic services at the outpatient stage of a follow-up; decrease in the length of patients' medical examinations and in the number of groups registered at a tuberculous dispensary; intensification the work of a phtx11p4trist and a nurse with their salary increases.