Many factors influence the risk of death in patients with tuberculosis. The most significant factors are a clinical form of the disease, combinations, comorbidity, age, and the duration of death. The risk of death averaged 4.2% in patients with new-onset tuberculosis, 30.4% in those with recurrent tuberculosis, and 6.4% in the registered. In patients with new-onset tuberculosis, the highest risk of death was established in tuberculous meningitis, miliary tuberculosis, fibrocavernous tuberculosis, and complications of tuberculosis (such as hemorrhage, spontaneous pneumothorax) increased the risk of death by almost 10 times (40.2%) and progression of HIV infection to AIDS by 7 times. The risk of death was increased up to 9.2% in primary multidrug-resistant pulmonary tuberculosis and by 12.7% in acquired one.
In the Sverdlovsk Region, the main reason of death from tuberculosis is a fibrocavernous pulmonary process (51.8%) that is most commonly detected in the postportem diagnosis of tuberculosis (61.9%). Before death, patients with fibrocavernous tuberculosis do not ask for medical aid frequently (73.4%). In the first-year follow-up, most deceased persons come to health care facilities 3 months or more after the occurrence of significant clinical symptoms (60.8%). The refusals of patients to receive in- and outpatient therapy, multiple discharges from hospital due to their incompliance, following by long-term therapy discontinuance, which led to secondary multidrug resistance, were responsible for progressive tuberculosis that was the main cause of death from a fibrocavernous process.
Before the disease was registered, the first detected patients who died from tuberculosis had not generally turned for medical aid or had turned 3 months or more after the occurrence of significant clinical signs. Before their death from tuberculosis, the contingents of tuberculosis-controlling services of municipal entities were discharged from hospital many times for violation of the inpatient routine; subsequently they did not come to a tuberculosis dispensary and refused to be treated in the outpatient setting. Primary drug resistance, allergic reactions, and intolerability of antituberculous drugs did not play a significant role in the occurrence of death. The patients are themselves guilty in the development of secondary resistance to some drugs.
Tuberculosis (TB) remains a serious threat to public health in Russia and other former Soviet Union Countries. The purpose of this paper is to describe the current trends of TB and MDR-TB in Russia and identify the characteristics of the traditional Russian TB control model inherited from the Soviet Union. We discuss current challenges to TB control in the country.
WHO tuberculosis notification data were analysed for Russia and 14 other former Soviet Union countries. To investigate the characteristics of TB control in Russia, we performed a systematic literature review using MEDLINE/EMBASE databases. 136 articles were initially identified of which 66 fulfilled the inclusion criteria. Full texts were reviewed. Additionally, we reviewed non-systematically Russian state reports, guidelines and legislations.
In 2006, nearly 125 000 TB cases and 28 000 TB deaths were notified in the Russian Federation. The TB notification rate was 13 times higher than in Germany. The characteristics of the traditional Russian TB control model include: a centralised disease-specific inpatient network for diagnosis and treatment of TB, countrywide population screenings using fluorography, a strong focus on X-ray for diagnosis and disease classification, individualised and lengthy inpatient care, high rates of drug resistance, and inefficient financing systems.
Current challenges to TB control in Russia are: the implementation of a quality-assured laboratory network for sputum-smear microscopy, culture and drug susceptibility testing, ensuring MDR-TB treatment and control, prevention and management of TB/HIV, and reform of health care financing systems. For TB control to be successful in the Russian Federation, the characteristics of the traditional TB control model need to be taken into account.
In the Sverdlovsk Region, multidrug resistance was observed in greater than 8% of patients isolating bacteria mainly in the residents of cities, former prisoners, those having fibrocavernous tuberculosis complicated by chronic nonspecific lung disease (CNLD). Primary resistance was determined in 4.7%, secondary resistance developing in 57.4% of cases 3 years or longer after the initiation of treatment. The most common cause of multiresistant tuberculosis is irregular treatment, patients' discontinuation of some antituberculous agents, as well as scarce financing of a tuberculosis control service, which prevents the standard treatment regimens from using in tuberculosis. Death due to tuberculosis was largely occurred irregularly treated dwellers of cities, tuberculosis-induced disabled individuals, alcohol abusers, patients with CNLD, or having fibrocavernous tuberculosis resistant to 4-5 antituberculous agents.
Among new cases of fibrocavernous pulmonary tuberculosis and those who have died from it, the proportion of females and subjects with postmortem diagnosis increases and that of prisoners and the accused decreases. The institutions of confinement do not greatly affect the general regional morbidity and mortality due to fibrocavernous pulmonary tuberculosis. The new cases of fibrocavernous pulmonaary tuberculosis and those had died from it were mainly males aged 45 years or older who had a very low social status, lived in large towns and died outside a hospital, which substantiated forensic medical autopsy. Most of them had not consulted a doctor or long followed up for tuberculosis. This led to the fact that postmortem diagnosis was made in 62.6% of the cases.
Some areas in the charge of the Central Research Institute of Tuberculosis, Russian Academy of Medical Sciences, is marked by an increase in the morbidity rate among the residents from 1% in the Republic of Mordovia to 10.7% in the Ulyanovsk Region and by a decrease in the territorial rate. In 6 of 15 areas, tuberculosis mortality tends to increase, which is indicative of the strained tuberculosis epidemic situation in these areas. The rates of the proportion of patients who had died from active tuberculosis among those with new-onset tuberculosis, the deceased who had been followed up for as long as a year, and those who had not been followed up, which reflect the state-of-the-art of therapeutic and diagnostic work were studied.
Introduction of unwarranted shorter courses of chemotherapy, physicians' decreased attention to pathogenetic treatments, nonadherence to the standard of examination while transferring to a further follow-up of clinically cured patients have increased a risk for early tuberculosis recurrences. In the years ahead, there may be a further rise in the number of late recurrences in the general population of the Russian Federation as preventive measures have deteriorated amongst the tuberculosis-cured individuals after their referral for the general health care system. The persons who have experienced tuberculosis and stricken off the register in a tuberculosis dispensary more than 5 years ago make up a late recurrence risk group.
The paper provides the analysis of the prevalence rates of tuberculosis among children and adolescents in the Russian Federation, which has been made on the basis of the data available in official reporting forms Nos. 8, 33 (approved by the Resolution of the Russian Statistics Agency on November 11, 2005), and 47 (approved by Resolution No. 175 of the Russian Statistics Agency on September 10, 2002). Correlations between epidemiological indices have been calculated and assessed. The age-related features of the occurrence and course of tuberculosis have been studied among various age groups of children. It is concluded that in this situation in order to improve the epidemic situation among children and adolescents, emphasis should be primarily placed on the activation of intersectoral interaction of primary health care and tuberculosis service: to actively attract general practitioners, local pediatricians and therapists to prophylaxis in children.
[The results of work and experience of the Central Research Institute of Tuberculosis, Russian Academy of Medical Sciences, in the pilot areas in controlling, detecting, and treating tuberculosis (a cohort analysis)].
In the Russian Federation, the WHO program was launched in 1994 and it covered the whole country by 2005. Detection and therapeutic efficiency are suboptimal. The proportion of pulmonary tuberculosis averages 34.5% (21.0-61.0%). In terms of cessation of bacterial isolation, therapeutic efficiency averages 61.4% with a scatter of 37.4-75.0%. Social support has a considerable impact on the efficiency of treatment.