Russia has one of the highest levels of tuberculosis (TB) in the world. The Directly Observed Therapy Short-Course (DOTS), recommended by the World Health Organization, is the most effective way of curing the disease. However, in Russia, TB is often drug-resistant.

DOTS is used internationally and follows a standard procedure over a six month period. The DOTS programme recommends lab tests on patients’ sputum to check for infection. However, the former Soviet Union has its own system and diagnosis is based on chest x-rays. Case detection remains low at 22 percent. London School of Hygiene and Tropical Medicine, St Bartholomew and Queen Mary School of Medicine, and Imperial College, London, UK, together with the Samara Tuberculosis Dispensary introduced a DOTS programme into the Samara Region of Russia.

DOTS should:

• cut costs by reducing long periods of hospitalisation
• improve cure rates
• reduce the development of drug-resistant TB.

More than 2,000 study participants were selected from the general population and from local prisons. The DOTS programme cured three-quarters of these patients, whilst six percent were not cured and four percent died - these were better rates than the previous system. These figures compare favourably to average rates from studies across Eastern Europe where nine percent of cases did not respond to treatment and seven percent of patients died during treatment.

The study found that:

• Patients most at risk from drug resistant TB were: prisoners; patients who had a relapse; patients infected with the Beijing strain of TB; and patients whose treatment was unsuccessful.
• A high proportion of new cases were drug resistant; 25 percent did not respond to the drug isoniazid; 20 percent resisted the drug rifampicin; and 17 percent of cases were multi-drug resistant.
• Half of all patients had Beijing strain TB.
• Twice as many relapse cases (34 percent) were multi-drug resistant compared to new cases.

Whilst the DOTS programme was successful in Samara, laboratories need to be improved to improve diagnosis.

Russian patients remain in hospital for long periods of time, particularly over winter months. While it may not seem cost effective, it makes sure patients receive the care they need. Many of them are poor, unemployed and substance abusers. Overall care for these patients is currently lacking and must be included in Russian DOTS programmes.

Although DOTS does not include specific methods for treating drug-resistant cases, the strategy does reduce the number of patients who acquire drug-resistant TB. A TB epidemic in Samara is just beginning. Drug-resistant TB will become an even greater problem as the epidemic develops. In order to prevent drug-resistant TB being spread in hospitals, prisons and other institutions, the study recommends:

• Patients with drug-resistant TB should be put into isolation.
• Good co-ordination between prison and civilian TB services.
• Improving infection control and treatment of the disease.
• Developing rapid methods to discover whether a case is drug-resistant.

Source(s):
‘The Directly Observed Therapy Short-Course (DOTS) strategy in Samara Oblast, Russian Federation’, BioMed Central, by Y Balabanova, F Drobniewski, I Fedorin, S Zakharova, V Nikolayevskyy, R Atun and R Coker, 2006 Full document.

Funded by: UK Department for International Development (DFID)

id21 Research Highlight: 6 October 2006

Further Information:
Richard Coker
Department of Public Health and Policy
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: +44 (0) 20 76368636
Fax: +44 (0) 20 74365389
Contact the contributor: Richard.Coker@lshtm.ac.uk

St Bartholomew and Queen Mary School of Medicine, London, UK

Other related links:
'The rise of tuberculosis in Russia: are hospitals to blame?'

'Systematic Review: Does watching patients take their TB drugs increase treatment success?'

'Improving health systems: TB control in the Russian Federation'

'A decade on: what is the impact of China’s TB programme?'

'Tuberculosis control needs strong national health services'

'DOT topic – expanding the debate on directly observed tuberculosis treatment'

Tuberculosis in Russia, European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, UK