From: Secretary of Health, Russia

Hannah Lofgren

Tuberculosis in Russia

From: Secretary of Health, Russia

To: Minister of Finance, Russia

Introduction:

Russia is on the brink of a serious TB epidemic. Since the collapse of the health system after the breakup of the Soviet Union, we have been unable to sustain our TB treatment programs, resulting in increased TB incidence rates, as well as drug-resistant TB cases. We have the world’s third largest number of MDR-TB cases at 43,000[i] and one of the highest rates of XDR-TB. HIV/AIDS is also on the rise and seriously exacerbates existing TB treatment and detection problems. Socially vulnerable groups, including the unemployed, substance abusers, and the prison population are high-risk TB groups. Russia’s first priority is to arrest the increase of drug-resistant TB cases through improved DOTS implementation and treatment oversight. HIV/AIDS awareness and information campaigns are also crucial to tackling both disease epidemics.

Nature and Magnitude of the Problem:

TB is an increasingly severe public health problem in Russia. It ranks eleventh out of twenty-two on the WHO’s list of high-burden TB countries.[ii] Among our approximately 141 million people, the TB prevalence rate is 132 cases per 100,000, with an incidence rate of 106 new cases per 100,000.[iii] In addition, an estimated 80 percent of Russians have latent TB.[iv] Currently, about 16 percent of all new TB cases and 42 percent of retreatment cases are MDR-TB.2 Even worse, 14 percent of all TB positive cases in Russia are XDR-TB.[v] Although DOTS coverage has reached 100 percent, case detection for new smear-positive cases remains low at 49 percent, as does treatment success at 58 percent,2 both of which are well below the WHO’s guidelines of 70 and 85 percent, respectively.

Affected Populations:

In Russia, TB largely afflicts young males and poor, socially marginalized groups, especially prisoners, migrants, substance abusers, the unemployed, and the homeless.6 Nearly 70 percent of new TB cases occur in individuals aged 25-54 years.[vi] The incidence of TB in men is also 2.7 times higher than in women.5 Poor, socially vulnerable groups have less access to continual treatment and are also more likely to engage in behaviors that elevate the risk of contracting TB, including alcohol and drug use, smoking, unsafe sex, and crime. Rates of TB incidence vary by region as well, with the highest rates occurring in the poorest regions of Siberia and the Far East. The Republic of Tyva has an incidence rate nearly twice the national average at 206.5 cases per 100,000. 5

Risk Factors:

The greatest risk factors for acquiring all strains of TB in Russia include unemployment and/or homelessness, substance abuse, incarceration, inadequate treatment and/or failure to complete it and being HIV positive. Among Russia’s unemployed population, TB incidence is a startling 750 cases per 100,000, as opposed to only 45 among the working population.5 Unemployment is often connected to homelessness, and both factors have a strong correlation with substance abuse. Alcoholism and smoking, both of which are rampant in our society, contribute to a weakened immune system, making the individual more susceptible to contracting TB. These addictions may also affect the patient’s adherence to treatment, increasing the spread of drug-resistant TB.

An estimated 12 percent of the total Russian prison population is TB positive,5 due to confined and overcrowded conditions where TB can spread rapidly. This is nearly 17 times higher than TB prevalence among the civilian population.5 Incarcerated individuals are also much more likely to have been involved in other risk behaviors prior to entering prison, which may in turn affect their ability to complete treatment. Russia’s quickly growing HIV/AIDS incidence, largely driven by injection drug users, also has serious implications for TB rates, as HIV raises TB susceptibility and complicates TB treatment. Out of all current TB cases, 16 percent are HIV positive.2 Furthermore, TB has recently become the leading cause of death for HIV positive people in Russia.5

Economic and Social Consequences:

Increasingly high rates of TB, often coexisting with or resulting from similarly high rates of substance abuse and HIV/AIDS, will only further weaken our stagnant economy and fragile society. The interconnectedness of TB, HIV/AIDS and substance abuse in Russia creates a continuous cycle of disease and addiction. The alarmingly high rates of drug-resistant TB are also of urgent and paramount importance. Russia’s low case detection and treatment success rates are quickly breeding a sick population without any hope of treatment. Not only does this create a new epidemic, it is costly. Six months of first-line TB drugs cost $60-$100, whereas second-line drugs used to treat MDR-TB must be taken for 18-24 months at a cost of up to $30,000.5

Priority Action Steps:

In order to combat the rising TB epidemic, Russia must prioritize halting the spread of drug-resistant TB. This requires identifying drug-resistant cases and ensuring that they receive quality drugs for the entire course of treatment. In addition, while better case detection in general is necessary, we must first improve the poor treatment success rate under our DOTS program to prevent new drug-resistant TB cases. Additional healthcare personnel and an improved national database to track patients undergoing treatment are therefore vital for the success of treating and preventing all strains of TB. There is also a significant lack of coordination among the hospitals and the penal and primary care health systems, which must be corrected to improve treatment outcomes and reduce transmission. This collaboration is particularly salient in managing increasing TB/HIV co-infections. Similarly, HIV/AIDS awareness and prevention is crucial, especially since it remains quite a stigmatized and taboo subject in Russia.

[i] “Tuberculosis: Russia.” USAID. 2009. http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/eande/russia_profile.html

[ii] “Tuberculosis: Russia.” USAID. 2009. http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/eande/russia_profile.html

[iii] “Russian Federation Tuberculosis Profile.” WHO. 2009. http://www.who.int/countries/rus/en/

[iv]

“Tuberculosis Policy Framework and Implementation in Russia.” Global Business Coalition on HIV/AIDS, TB, and Malaria. www.hivpolicy.ru/LeadersForum/en/.../TBRussiaPolicyFramework_eng.pdf

[v]

“Drug-Resistant TB in Russia.” Global Health Initiative and Woodrow Wilson Center. 2007. http://www.wilsoncenter.org/index.cfm?topic_id=116811&fuseaction=topics.event_summary&event_id=239772

[vi]

“Tuberculosis Policy Framework and Implementation in Russia.” Global Business Coalition on HIV/AIDS, TB, and Malaria. www.gbcimpact.ru/files/upload/publications/3578.pdf.