Anti-TB Program in Siberia, Russia
The Penal System in Russia
There are now eight million men, women and children in prisons around the world. Half of them are in three countries: China, the USA, and the Russian Federation. In Russia, there are over one million prisoners (around 1,080,000). With 685 of every 100,000 Russians currently in penal custody, the country has the highest per capita prison population in the world.
Known as GUIN (the Department of Corrections), the Russian penal system is comprised of prison "colonies" (corrective labor facilities best translated as "labor camps") and SIZOs (pre-trial detention centers). Under Yeltsin, the prison system was transferred from the Interior Ministry to the Justice Ministry.
Due to the deplorable living conditions (massive overcrowding and malnutrition) in Russian prisons, these have become a breeding ground for tuberculosis. Penal detention often carries with it an extra-judicial sentence of ill health. The airborne bacteria thrives in the prisons, then is spread to the wider population when prisoners are released.
The Kemerovo Region of Siberia
The Kemerovo "Oblast" or region is located in the heart of Siberia. It is one of several regions in Russia with a high concentration of prisoners. There are about three million inhabitants in Keremovo and 32,000 of them are incarcerated in 27 colonies and three SIZOs.
Colony 33 in Mariinsk is the primary referral hospital for all prisoners from the region sick with TB. In 1995, Natalia Vezhnina - a Russian Doctor and army colonel, who at the time was the Medical Head of Colony 33 - requested aid from the international community to tackle the alarming spread of TB she was witnessing. MSF responded by proposing to implement the World Health Organization's DOTS (Directly Observed Short-Course) strategy in the prison colonies of Kemerovo. DOTS is an effective TB control strategy used in more than 50 countries world-wide.
After six months of negotiations with the Russian penitenciary authorities, a five-year protocol of agreement was signed and, in the summer of 1996, MSF began its anti-tuberculosis program. Over the past five years the program has expanded and now covers the entire penal system of Kemerovo, meaning that all prisoners with active (contagious) TB currently have access to DOTS treatment and to high quality anti-TB drugs.
Break the chain of transmission
Breaking the chain of transmission of TB and decreasing mortality and morbidity rates are the two main goals of the program. The first step is the correct and rapid detection of the bacteria among prisoners. The main method of diagnosis used is the analysis of sputum by microscopy. The second step involves isolating infected prisoners and curing them with DOTS treatment. Priority is given to the treatment of patients who are smear-positive, that is, who have active TB and are thus infectious. MSF aims to develop a model for TB control that is replicable nation-wide.
Address the problem of resistance
Some patients have received incomplete or erratic treatments in the past, and have acquired a resistance to common TB medication. The rise of "multi-drug resistant TB" (MDR TB) is linked to the post-perestroika breakdown of the health care system in Russia, and to the decrease in access to TB drugs. Treatment for MDR TB, known as DOTS , can be 100 to 250 times more expensive than DOTS, while the cure rate is substantially inferior.
MSF is currently addressing the problem of resistance by conducting research; ensuring the early detection and isolation of MDR TB patients; lobbying to reduce the exorbitant costs of medication; and preparing to launch DOTS pilot projects. Nonetheless, MSF operates on the belief that prevention of MDR surpasses treatment: fully curing patients with common TB and controlling a treatable epidemic will halt the development of an untreatable epidemic.
Treatment in Colonies
Treatment is offered in the following colonies:
- Colony 33, the primary prison-hospital of the region, in Mariinsk (since 1996)
- Colony 35, a female colony in Mariinsk (since 1998)
- Colony 16, the 2nd prison-hospital of the region, in Novokuznietsk (since 1999).
In addition, Colony 21, located in Taiga, was opened in 1999. This dispensary colony offers post-treatment follow-up to smear-negative (no longer infectious) patients.
Treatment in Pre-Detention Centers
In February 2000, MSF began screening and treating patients in the pre-trial detention centers, where conditions are even worse than in the colonies. Working in SIZOs raised medical and ethical questions that had to be resolved. The first issue was whether detainees in SIZOs would be able to follow a full, six-month DOTS treatment, or whether their release might put them at risk of becoming defaulters (given the current absence of DOTS in the civil sector).
MSF conducted a survey among the general SIZO population, and found that, on average, 30% of the detainees were released before six months. With such a high default rate, a medical intervention was unjustified. But MSF then learned that many of the detainees with TB were recidivists. A new study narrowed the targeted group to TB-infected detainees. The results showed that, under usual circumstances, more than 90% of these detainees were recidivists and thus very likely to be convicted. In other words, MSF could predict a default rate inferior to 10%.
The second question was whether treatment would be interrupted due to the displacements of detainees during the investigation and court trial procedures. The GUIN's suggestion was to keep those with active TB inside the SIZOs to ensure proper treatment. But such restrictions on their movement could potentially delay the trial procedures. MSF thus requested that the investigators be brought to the SIZOs and that detainees be allowed to travel for a maximum period of three days. This protocol was accepted and signed in mid February, and MSF now covers the three SIZOs of the region (Mariinsk, Kemerovo, and Novokuznietsk).
Region-wide Screening System
In addition to the central laboratories in the TB colonies, peripheral laboratories have been installed under the supervision of MSF in 9 colonies where a high prevalence of TB was suspected. This decentralized approach allows for the early detection of TB-infected prisoners by trained staff. Patients with active cases are rapidly transferred to TB hospitals and put on treatment. A mobile team from Colony 33 collects sputum samples and covers screening in the other colonies. This service is decreasing as the peripheral labs build their capacity, and it will cease as soon as the network is fully autonomous.
- MSF supplies laboratory equipment, materials, and quality drugs to detect and treat TB.
- Over 100 medical professionals (doctors, nurses, and lab technicians) have been trained in the implementation of DOTS.
- MSF assists national staff in the collection and processing of TB data,
- Teams provide supplementary food and hygiene items to TB patients and continue to sensitize penitenciary authorities to the nutritional and hygienic needs of prisoners.
Current MSF staff
There are currently seven international MSF volunteers in Kemerovo: two physicians, two nurses and three lab technicians. They work hand in hand with a dozen national staff and are supported by a medical coordination team in Moscow.
CHALLENGES TO THE PROGRAM
- Although the cure rate has risen significantly, it now hovers around 70%. Further improvement is hindered by external factors, including:
- the high prevalence of multi-drug resistance among DOTS patients, who received incomplete or erratic treatments in the past. A survey completed by MSF in mid-1999, conducted on a cohort of 300 patients over a year, revealed an initial MDR rate of 18.9%.
- the release of prisoners by amnesties before they have completed DOTS treatment. This has a measurable negative impact on the cure rate. The amnesties in 1998, for example, contributed to creating defaulters (the ensuing decrease in the cure rate is visible in Graph 1 below, after the peak in the second quarter of 1998).
- Not only are infected prisoners released, but also infected civilians regularly enter the penal system. The constant flow of individuals in and out of prisons (the turnover of prisoners is around 25% per year ) poses an on-going challenge to controlling the TB epidemic.
- Although the DOTS strategy is now widely accepted and implemented in Kemerovo, skepticism among the Russian medical community still lingers, and traditional, less effective methods of diagnosis by fluorography (chest X-rays) have not been discontinued.
- There has been no improvement of living conditions in the prisons.
ACHIEVEMENTS AND RESULTS
- When MSF began working in Kemerovo, TB patients were dying at a rate of 2-3 per day. By the end of 1998, this figure was reduced to 2-3 per month.
- To date, MSF has treated more than 5,000 TB patients: 4,350 in Colony 33 between June 1996 and March 2000 (see table below); and 837 in Colony 16 between January 1999 and March 2000. There are currently 1,500 prisoners under treatment.
- The delay between diagnosis and treatment of TB cases has been reduced from 6 months prior to 1995 to currently less than 2 weeks.
- Overall, MSF has quadrupled the total number of smear-positive patients who receive DOTS treatment and good-quality anti-TB drugs. This is reflected in the figures for Colony 33 (table below), showing an increase from 57 to 235 patients.
- MSF has established a system of isolating different TB cases by degrees of severity and other criteria, and most importantly, a system of isolating those with MDR TB.
- More than 70% of the patients MSF includes on DOTS treatment are now smear-positive cases (see table). This percentage matches WHO's recommendations.
- MSF has decreased the number of patients who receive erratic treatments (see decline of "cases previously treated" in Graph 2). This was achieved mainly by limiting the use of anti-TB drugs in peripheral colonies. Russian staff working in these colonies used to offer available anti-TB drugs to patients before they were transferred to the TB hospitals. The non-intended but harmful effect was an increase in multi-drug resistance.
- Many of the above-mentioned achievements are due, in chronological order, to the expansion of DOTS treatment to a total of three colonies; to the establishment of the laboratory network; and to the inclusion of SIZOs in the program.
- It is worth noting that it may take over a year for the positive effects of recent measures to come to light in a quantifiable form.
MSF plans to:
- Continue the DOTS program covering the complete penitenciary system of the region.
- Expand the DOTS strategy to the civil society. If the Russian counterparts are committed to MSF's regional approach, pilot projects targeting the civilian population could begin by autumn of this year.
- Participate in the treatment of multi-drug resistant TB in the penitenciary system using a DOTS program and second-line drugs as soon as an efficient, reliable DOTS program is in place in the civil society. At present, the absence of a DOTS program in the civilian population means that individuals released from prisons either receive no follow-up treatment or receive erratic treatment, which contributes to the development of resistance.
Number of Cases Enrolled in Treatment in Colony 33
- "BK " indicates smear-positive cases
- "BK ret." indicates smear-positive cases that had to be retreated
(due to relapse or defaulting)
- "BK-" indicates smear-negative cases