can zero deaths become a reality? lessons from tomsk, russian

CAN ZERO DEATHS
BECOME A REALITY?
LESSONS FROM TOMSK,
RUSSIAN FEDERATION
SALMAAN KESHAVJEE, MD, PHD, SCM
HARVARD MEDICAL SCHOOL
BRIGHAM AND WOMEN’S HOSPITAL
PARTNERS IN HEALTH
CASCADES – IMPROVING TB CARE
PARIS, FRANCE
NOVEMBER 1, 2013
BACKGROUND
Source: Russian Ministry of Health and Social Development 2012
Photo: Open Society Institute/Sergei Gitman
Source: Russian Ministry of Health and Social Development 2012
“
MDR-TB is too expensive
to treat in poor countries;
it detracts attention and
resources from treating
drug-susceptible disease.
- World Health Organization
Groups At Risk, 1996
ADVISED BY THE WHO TO
FOCUS ON
DRUG-SENSITIVE
TB ONLY
Photo: Open Society Institute/Pep Bonet
”
Tomsk Oblast Population:
1,073,600
Area = 317,000 km2
TB Incidence per 100,000 – Tomsk Prison Sector
8000
7171
6000
4052
4314
4042
4523
3388
4000
2000
0
987
403
1993
3565
1292
879
583
1994
1995
941
1996
Prison
Source: Tomsk Oblast Tuberculosis Services
3081
3357
1371
1997
1998
1999
Jails
2000
3416
3009
2001
3812
2810
2002
TB Incidence per 100,000 – Tomsk Civilian Sector
140
120
98.8
100
117.6
108.7
107.7
115.9
112.8
108.2
103
80
60
40
42.4
66.2
39.5
20
0
1987 1990 1994 1995 1996 1997 1998 1999 2000 2001 2002
Source: Tomsk Oblast Tuberculosis Services
TB Incidence, Prevalence, and Mortality in
Tomsk, Russian Federation
Penal Sector, 1998
Holding Section TB case notification/100,000
3,565
Holding Section TB Prevalence/100,000
3,743
Prison TB case notification/100,000
4,042
Prison TB Prevalence/100,000
TB Mortality/100,000
21,581
353
Percentage of MDR-TB among new cases
28
Percentage of MDR-TB among re-treatment cases
54
Source: Tomsk Oblast Penitentiary Tuberculosis Services, Tomsk, Russian Federation, July 2005.
MDR-TB prevalence among all smear-positive new and re-treatment
cases 2001, Tomsk Oblast (n=1303)
530 (40.6 %)
773
MDR
Source: Tomsk Oblast Tuberculosis Services
Non-MDR
Resistance patterns of Tomsk Cohort (244)
First-line drugs
Second-line drugs
100% 100%
99%
Percent
77%
66%
54%
49%
10%
INH
RIF
EMB
PZA
SM
Drug
Source: Tomsk Oblast Tuberculosis Services, Tomsk, Russian Federation, 2005.
KM
CM
2%
6%
CS
FQ
Ethio
Selected characteristics of first cohort of patients in
Tomsk, Russian Federation (N=244)
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
Age (mean)
Male
Prison
Civilian
Employed
Married
Disability
Homeless
Previous treatments:
Yrs with TB before
MDR Rx
Source: Shin et al., IJTLD 2006
32
86%
45%
55%
17%
38%
42%
3.3%
2 (1-6)
• 
• 
• 
• 
• 
3.3 (0.1-28.3)
• 
• 
TB contact
HCW
Previous prison
Low BMI
Co-morbidity
–  Abnormal LFTs
–  Substance abuse
•  Alcohol hx
•  Alcohol during Rx
•  IVDU
Tobacco use
Cavitary and bilateral
disease
67%
2.5%
64%
42%
18%
50%
35%
32%
18%
88%
66%
If the patient has the right to care (as is
legally the case in the Russian
Federation), what needs to be done in
order to ensure that they receive care?
Find programmatic solutions for all
barriers to care.
DIAGNOSIS & MEDICINES
TREATMENT
SOLUTIONS
•  Improvement of facilities
•  Transportation assistance for patients and health workers
•  Choice of treatment site
•  Food assistance for patients
•  Aggressive management of adverse events
•  Treatment at home for patients who are unable to ambulate or
who live too far
•  The use of enablers and incentives
•  Social assistance for patients
Case detection and management of TB and MDR-TB in Tomsk Oblast
PRISON
General polyclinics:
Active and passive
General hospitals:
Passive
TB dispensary,
rural TB offices
Rural clinics,
Hospitals
Among TB contacts
Active and passive
TB Committee in Tomsk TB dispensary (OKEK)
Ambulatory treatment
PRISON
TB Hospital
Sites where
patients can
receive care
and food
and care
TB Hospital
Day Care
Hospital:
TB dispensary
Rural TB offices,
Rural feldsher
or doctor clinics
Home visits
Collaboration
with Red Cross
Collaboration
with Red Cross
OUTCOMES
MDR-TB Patient Treatment Outcomes
Tomsk Oblast Prison Sector (2000 – 2004)
N=110
80.8%
3%
Cured
Source: Tomsk Oblast TB Services
Default
3.50%
Failure
12.70%
Died
TB mortality in the Tomsk Penitentiary System
(1999 – 2006; per 100,000 population)
450
384
400
350
300
250
238
181
200
135
150
112
130
118
130
100
108
50
0
11.85
12.1
103
46.3
11.1
0
1999
2000
2001
2002
Prison System Tomsk
Source: Tomsk Oblast TB Services
2003
2004
2005
Prison System Russia
2006
TREATMENT OUTCOMES OF FIRST COHORT (N=244)
TOMSK, RUSSIA
Default
11.5%
Death
4.9%
Failure
6.6%
Cure
77.0%
Source: Shin et al., IJTLD 2006
Source: Keshavjee et al., Lancet, 2008
Photo: PIH Kazakhstan
KNOW YOUR EPIDEMIC
Treatment Outcomes, Civilian Sector
Tomsk Oblast, Russian Federation
Treatment
Failure
Death
Treatment
Default
Cured
Source: Tomsk Oblast TB Services, Analysis by Dr. D Taran, PIH Moscow
“Sputnik” program
•  Some patients require assistance to finish treatment
•  Need a system of accompaniment to help overcome barriers to
treatment (this is different from simple DOT)
–  Social supports
–  Nutritional supports
–  Family support
•  One Sputnik will look after five to seven patients
•  Changes the onus of responsibility for adherence from the
patient (“non-compliant”) to the program (programmatic failure)
“SPUTNIK” Program
53 non-adherent patients were enrolled on
Sputnik program from December 17, 2006
to November 30, 2008
2 patients refused to
participate
51 patients stayed on Sputnik program
5 patients restarted new
treatment course with
83% adherence
[baseline adherence 0%]
46 patients continued previous
treatment. Adherence increased from
52% before enrolment on the program
to 81% while on Sputnik, p<0.0001
Note: No deaths were due to TB; most were due to violent crimes
“Default” includes the 2 patients who refused to participate in the program
Source: Gelmanova et al., IJTLD 2011
Photo: PIH Russia
Treatment Outcomes, Civilian Sector
Tomsk Oblast, Russian Federation
2001-2007
Transferred out
Treatment
Failure
Death
Treatment
Default
Cured
Source: Tomsk Oblast TB Services, Analysis by Dr. D Taran, PIH Moscow
Interrupting transmission: treatment of all patients
Ambulatory care and community based approaches provide a way to
treat large numbers of patients rapidly, and safely
Source: WHO 2010
Dynamics of Tuberculosis notification rate in Tomsk Oblast,
Siberia, and Russian Federation (per 100,000 population)
160
140
120
126.4
113
117.6
100.9
100
80
131.4
126.7 127.8 124.7 126.1
76
85.2
116.7
113.8
109.3
90.4 88.8
86.1
133.6 131.9
105.6
107.2
105.5
83.2
83.1
84
2003
2004
2005
128.1
132.9
129.1
121.4
107.9 102.4
101.3
91.2
82.6
83.3
85.1
82.6
60
80.4
75.5
77.4
MDR-TB
treatment
began
40
20
0
1998
1999
2000
2001
2002
Tomsk region
Source: Tomsk Oblast TB Services
Siberia
2006
2007
2008
Russia
2009
2010
2011
Dynamics of Tuberculosis mortality in Tomsk Oblast, Siberia, and
Russian Federation (per 100,000 population)
40
33.8 35
30
26 25
20
15
28.6 30.5 29.9 22.6 21.9 20 20.6 16.9 15.4 19.8 18.3 35.6 37.3 32.3 33.3 29.1 29.3 21.8 21.9 21.4 22.6 17.9 17.7 17.8 20 18.4 27.5 16.8 15.4 16.2 12.7 10
MDR-TB
treatment
began
5
17.9 27.9 11.9 9.4 10.3 8.6 5.6 0
1998
1999
2000
2001
Russia
Source: Tomsk Oblast TB Services
2002
2003
2004
Siberia
2005
2006
2007
2008
Tomsk Oblast
2009
2010
2011
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