2 Aug 2013

The rising spectre of tuberculosis across Russia

In a village, 30km outside the Siberian city Tomsk, 59-year-Nadezdha takes her daily dose of 20 tablets and is given an injection.

Surrounded by her barking dog and numerous cats, in what amounts to little more than a shack, she is being treated for drug resistant tuberculosis.

She tells us later that she thinks she caught it while working as a nurse in the local TB hospital.

It will take as long as two years before Nadezdha can be pronounced cured. This is a virulent form of an ancient disease.

And it is a disease that is sweeping the Russian Federation. As the former Soviet Union collapsed, so too did its healthcare system. Poverty and alcoholism increased bringing with it TB.

In recent years, the rates of the most common form of tuberculosis have started to come down.

But to the alarm of the World Health Organisation (WHO) and other international bodies, the rates of multi-drug resistance (MDR) and extremely drug resistance (XDR) are climbing. They are now the highest in Europe and the third highest in the world.

It is a result of patients not completing their course of drugs.

But the pattern is now changing. The WHO now estimates that 20 per cent of new TB cases in Russia are MDR. That is, they are contracting the disease without having been treated before. And it is emerging in increasing numbers amongst children.

Yet in the midst of this desperate situation – the Russian government has taken a decision that has astounded international observers.

With little notice, it has banished one of the biggest funders of TB programmes – USAID – because it is American, and it is now refusing help from the Global Fund for Aids/TB and malaria.

Russia is, the government says, a donor country and it would be inappropriate to take the fund’s money.

Dozens of TB projects have now had to close their doors or are under threat, including many run by the Boston-based Partners in Health (PiH) who were funded by USAID.

Oksana Ponomarenko, director of Partners in Health, Russia, said numerous international organisations and Russian non-governmental organisations were funded by USAID.

The reason for kicking them out, she said, was political because they provided support for political organisations and mass media.

Yet by taking this decision, PiH has bee forced to scale back or close down some of its projects.

‘The Russian Red Cross had to return US funding for 11 projects across some of the country’s worst-hit areas. Five of the projects had to close down.

In Tomsk, they have a highly-acclaimed TB project, which is largely as a result of international funding from the UK, the Global Fund and USAID.

The twice daily treatment Nadezhda receives is part of this – they call it the Sputnik programme.

Nurses and a driver go to the villages to treat those who are too ill or old to come into the town.

They also track down TB patients who do not want to be treated or have such severe alcohol problems they forget to come for their tablets. And in a rundown building in the middle of the city, they have a diagnostic centre, counselling and a dispensary.

Here, they also give out food parcels as an incentive to patients to take those drugs: tinned beef, instant potatoes and jam.

Dr Sergei Mishustin, the chief TB officer of Tomsk Region, is optimistic that the project with continue, even without the international funding. He said money was being provided by the federal government, although they have not yet had a budget from the local government.

Yet the USAID money has already gone and the Global Fund cash finishes in November.

“If we were to start the TB programme today, we could have managed it without international funding, but unfortunately during the course of the past 19 years there was not the necessary funding available from the Federal or Tomsk regional budget,” Dr Mishustin said. In other worse, this internationally-acclaimed project would not have happened.

MDR-TB is caused by a bacteria that is resistant to the most effective anti-TB drugs, isoniazid and rifampicin. XDR is resistant to those two drugs as well as a number of second-line TB drugs. There are now cases emerging of TDR – total drug resistance, which doctors does not mean there is no effective medication, it is just they have not yet found it.

Crucial to the Tomsk project is the local prison.

Drug resistant rates of TB are proportionately higher in Russia’s prisons than in the civilian population. Nearly 100 per cent of prisoners have a positive skin test which shows they have or have had the disease.

And while conditions have improved enormously over the past few years, concerns remain about the failure to reduce MDR/XDR amongst prisoners.

So in Tomsk, all prisoners with TB from around the region are placed into one tuberculosis prison.

When we were shown around, there were 700 prisoners – 500 of them with TB – or recently cured. The remaining 200 are there for health and safety reasons. They are the only ones allowed to work in the kitchens and canteens.

The focus here is on containment and cure – ensuring the prisoners do not go back into the community only to reinfect others or become reinfected themselves.

They have testing facilities, laboratories and isolation wards for the most contagious. Their success rate for MDR treatment is as high as 80 per cent.

Crucially, when the prisoners are released because they have finished their time, but have not finished their course of drugs, they are taken straight to hospital so they do not disappear and either fall ill again themselves or infect others.

Dr Alexander Leshchev, deputy head of the Tomsk TB prison, said their approach was that people needed to be cured of TB no matter whether they were in prison or out in society.

“We are also protecting society,” Dr Leshchev said. “If he is not cured he will come out into society sooner or later and will infect masses of people, including children.”

And certainly the two prisoners we were introduced to both agreed that they wanted to finish their gruelling courses of anti-TB medication because they did not want to infect their wives, children and mothers.

Ivan, a 28-year-old, who was in prison for theft, appeared to have contracted is MDR-TB from the prison. “For three years I had x-rays and they did not detect anything. But when it showed up they sent me here to Tomsk,” he said.

“I spent three months in the hospital and I have been taking the pills for 20 months.”

Ivan told us he felt fine, although there were occasions during the interview when he appeared to be in a pain.

Now the funding for the Tomsk project is to be taken over by the federal government but they do not have confirmation yet that the regional Government will also step in.

Partners in Health say they have found another funding source and will be able to continue with their support in Tomsk but they have had to withdraw from similar projects in other cities.

The impact of the funding cuts is only just being felt. In the south-west of Siberia – a city called Omsk (not to be confused with Tomsk) we went to the Sibalt project which had been funded by USAID and administered through the Russian Healthcare Foundation.

Based loosely on the Tomsk programme, they were providing social and psychological help to nearly 300 patients. They would ensure they had food in return for taking their medication, help them with housing or financial issues, and given them counselling.

Of the 286 clients, 44 had MDR-TB. But in March this year that money was withdrawn as USAID was thrown out of the country.

We found Valentina, 32, a former client, in a local hospital. She was being treated for a thigh fracture which is not healing properly, partly because of the TB.

She was enthusiastic about the support she had received. “We were given food supplies, which helped because the state did not give us any compensation or anything like the project gave us.

“I could come with any questions. It helped because when we were given food parcels its was an incentive to take the medication.”

The conditions in the hospital were grim. Men with broken legs were being treated in the dark corridors. The beds were rusty with lumpy mattresses. Damp climbed the walls and the paint was peeling.

And that is part of the frustration felt by the international community.

The United Nations special envoy for HIV/AIDS in Eastern Europe and Central Asia, Dr Michel Kazatchkine, said healthcare sites were dangerous because of the risk of cross-infection.

Dr Kazatchkine said he had not been able to hold talks with the Russian health ministry but he said he was now concerned because the work of NGOs on TB has been remarkable and now that money is being removed.

What is increasingly worrying observers too is the rising rate of TB and particularly drug resistant TB in children. The World Health Organisation, with classic understatement, describes it as the ‘unfavourable trend of MDR-TB rates.

The trend, too, seems to be that children are developing first-line MDR-TB, so they are being infected with this more virulent form from others who have failed to take their medication.

Dr Irina Vasileva, Russia’s chief TB doctor, said: “If there is someone in the family with this strand, everyone will become infected, first of all the children because their immune systems are weak.”

In Moscow, a TB hospital in the suburbs has 400 beds – nearly a quarter of them for children aged between three and 18.

They are sent from all over the Russian Federation. For the past three years the numbers of children developing all forms of TB has risen, according to WHO figures.

But this is not just a Russia problem, experts warn. TB does not stay within the confines of hospital wards or prisons. Nor does it recognise borders.

This is a disease that is spreading far beyond the Russian Federation.

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