Among the deceased in the Sverdlovsk Region in 1995 - 1996 there was a larger proportion of males and individuals aged over 40 years, unemployed, homeless persons, patients with infiltrative pulmonary tuberculosis, concomitant diseases and a smaller proportion of those with prolonged pulmonary tuberculosis, its fibrocavernous type, persons who died from secondary nonspecific changes and complications of the tuberculosis process. Today the most common causes of premature death due to tuberculosis are in patients' refusal of treatment, systemic incompliance, a severe concomitant disease, contraindications for surgical treatment, drug resistance to tuberculostatic agents, drug shortage, late referral for medical aid and long-term evasion of prophylactic surveys for tuberculosis.
To estimate tuberculosis (TB) incidence and case detection rate (CDR) using routine TB surveillance data only.
A mathematical model of the case detection process, representing competition between disease progression and case finding, is proposed. The model describes disease progression as a two-stage process (bacillary and non-bacillary TB), and so relates the proportion of bacillary TB cases on detection to the effectiveness of detection. Thus, given the annual numbers of newly detected TB cases stratified by bacillary status, the model estimates detection rates, incidence and CDR. Routine notification data from eight provinces in Russia, 2000-2011, were used for the study.
Subnational level estimates of incidence and CDR were obtained. Incidence estimates varied by two-fold among the provinces; corrected CDR estimates varied by 1.5 times. The trend in the incidence estimates was similar to that in the World Health Organization estimates for the whole of Russia. The change in the trend in WHO CDR estimates in 2008-2009 was not supported by our estimates.
The general approach that uses multistage models of disease progression and accordingly stratified notification data can be applied in various settings for the routine estimation of incidence and CDR.
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.
The course of consumption was studied in 374 residents of the Sverdlovsk Region who had been in prison for different periods of time. Among them, there were prevalent young males with lower educational and professional levels, who were single or divorced, and had a poor social status. A third of the patients had fallen ill mainly in the first 5 years of imprisonment. The disease was detected in the half of the remaining persons in the first 3 years after imprisonment. Despite frequent cases with severe tuberculosis, long-term multimodality therapy allowed the tuberculosis process to be adequately treated and the disease to be cured in most patients. The main cause that aggravates the course of tuberculosis is the patients' refusal to take a systematic treatment.
Studies of the clinical courses of lung cancer in 66 patients professionally engaged in dust-affected labour conditions in comparison with 219 diseased inhabitants of machine-producing industrial zones, revealed that the pneumoconiosis-related cases developed mostly peripheral forms of lung cancer. In pneumoconiosis-free patients occupationally engaged in labour conditions affected with dust, lung cancer, once it had appeared, was progressing very fast. This confirmed the necessity of annual preventive examinations of the workers who had been engaged in coniosohazardous labour conditions.
The regional concept of rendering antituberculosis care to the population includes: the creation of a legal basis by passing a law on tuberculosis, special planning of tuberculosis control measures by adopting a special programme, an interdepartmental approach to rendering antituberculosis care to the population by setting up interdepartmental commission on tuberculosis control, computer-aided tuberculosis monitoring, activities in the prevention and detection of tuberculosis mainly in high-risk groups, the activities of phthisiological facilities by the developed standards and regulations, and the centralization of the antituberculosis drug supply system.
Silicosis is the most common and most frequently tuberculosis-complicated pneumoconiosis with poor prognosis. So a procedure for following up patients with silicotuberculosis requires revision and elaboration. Long-term follow-ups have made it possible to define early signs of this disease and to propose a number of techniques for its early diagnosis, such as chest computed tomography and polarization serum crystal microscopy. Specific recommendations on follow-ups of patients with silicosis and silicotuberculosis by a phthisiologist are laid down.
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.