MDR TB treatment success rates for 7 years of program implementation in civilian sector of Tomsk, Russia.

D Taran1; S Mishustin2; G Yanova3; P Golubchikov2, A Barnashov2, A Yedilbayev4, S Keshavjee4, 5, 6, A Golubkov4, 5, 6

1 Partners In Health, Russia; 2 Tomsk Oblast TB Services, Russia; 3 Tomsk Oblast TB Hospital, Russia; 4 Partners In Health, Boston, MA, USA; 5 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA; 6 Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA

Background:

The MDR-TB project in Tomsk, Siberia was the first DOTS Plus project piloted in Russia. The Tomsk project was launched in September 2000 in the prison sector and extended to the civilian sector in January 2001.

The initial treatment success rate of the first cohort of patients was relatively good, >70% (1). However, as the project expanded to cover more DR-TB patients, especially in rural areas, the treatment success rate began decreasing (to 54.3% in 2004), and default and failure rates rose.

Conclusions:1.For the last two years, the Tomsk program has shown a higher treatment success rate than the average for MDR-TB programs (2,3).2.High success rates were achieved as a result of interventions that address known gaps and issues related to patients’ adherence (4).3.The key adherence-related interventions that have facilitated success in Tomsk have been: • Free side effects medications for patients, • Valuable social support such as daily food sets, especially for patients treated in rural areas (worth at least $1/day), • Home-based treatment in the city through accompaniment and “Sputnik”, with emphasis on target high risk TB patients. 4.The authors believe that the MDR-TB treatment model piloted in Tomsk could be implemented throughout the Russian Federation with MoH and Social Security funds and that compulsory TB treatment for high risk TB patients can therefore be avoided.

Population ~ 1.04 mln.½ in the capital – Tomsk.½ in the remote villages.Size ~ Poland.T: from - 40 C up to + 45 C

• Home-based care was organized for limited number of patients: those who were unable to attend outpatient clinics.

• Home-based care was organized for limited number of patients: those who were unable to attend outpatient clinics.

Literature cited: 1. Shin S, Pasechnikov A, Gelmanova I, Peremitin G, Strelis A, Andreev Y, Golubchikova V, Tonkel T, Yanova G, Nikiforov M, Yedilbayev A, Mukherjee J, Furin J, Barry D, Farmer P, Rich M, Keshavkee S. Treatment outcomes in an integrated civilian and prison multidrug-resistant tuberculosis treatment program in Russia. International Journal of Tuberculosis and Lung Disease. 2006; 10(4): 402-8. 2. Johnston JC, Shahidi NC, Sadatsafavi M, Fitzgerald JM (2009) Treatment Outcomes of Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-Analysis. PLoS ONE 4(9): e6914. doi:10.1371/journal.pone.00069143. Evan W Orenstein, Sanjay Basu, N Sarita Shah, Jason R Andrews, Gerald H Friedland, Anthony P Moll, Neel R Gandhi, Alison P Galvani. Treatment outcomes among patients with multidrug-resistant tuberculosis: systematic review and meta- analysisLancet Infect Dis 2009;9: 153–614. Adherence to long-term therapies: evidence for action. World Health Organization 2003

Acknowledgments: Natasha Morozova, Irina Gelmanova, Vera Golubchikova, Sergei Yanov, Alexandra Solovyova, Natasha Zemlyanaya, Oksana Ponomarenko. MDR-TB program support has been received from: Eli Lilly Foundation, Bill & Melinda Gates Foundation, Open Society Institute, Partners In Health Boston, Global Fund Against AIDS, TB and Malaria.

• Program provided daily food sets, monthly hygiene sets, transportation tickets to those in need and clothing. Hired social workers helped patients to solve social issues like passport recovery, disability benefits, etc.

• Program provided daily food sets, monthly hygiene sets, transportation tickets to those in need and clothing. Hired social workers helped patients to solve social issues like passport recovery, disability benefits, etc.

• Regional “Adherence committee” in the civilian sector was formed and meetings were organized weekly to discuss and plan necessary actions to prevent default among non-adherent patients.

• Monitoring and supervision of TB personnel at the DOT and treatment locations was improved. Necessary assistance was provided.

• Regional “Adherence committee” in the civilian sector was formed and meetings were organized weekly to discuss and plan necessary actions to prevent default among non-adherent patients.

• Monitoring and supervision of TB personnel at the DOT and treatment locations was improved. Necessary assistance was provided.

• TB-HIV program was launched to timely detect TB and LTBI and provide Isoniazid prophylaxis to PLWHA.

• TB-HIV program was launched to timely detect TB and LTBI and provide Isoniazid prophylaxis to PLWHA.

• Staff became more experienced in management of MDR-TB.

• Regional Clinical Committee was empowered.

• Staff became more experienced in management of MDR-TB.

• Regional Clinical Committee was empowered.

2001-2004: 2001-2004: PIH cohorts - PIH cohorts - 430430 patientspatients

2001-2004: 2001-2004: PIH cohorts - PIH cohorts - 430430 patientspatients

Tomsk region

•PIH launched the “Sputnik” Project - a patient-oriented program for patients at high risk of default.

Adherence rate among enrolled patients increased from 51% to 83%. •Home-based treatment was expanded to 2 teams; up to 50 patients received

medications under the direct supervision at their homes or workplaces every day. •Anti-alcohol subprogram was incorporated into standard TB care approach:

AUDIT test for all new TB patients performed and consultations by addiction specialists and psychologist launched.

•PIH launched the “Sputnik” Project - a patient-oriented program for patients at high risk of default.

Adherence rate among enrolled patients increased from 51% to 83%. •Home-based treatment was expanded to 2 teams; up to 50 patients received

medications under the direct supervision at their homes or workplaces every day. •Anti-alcohol subprogram was incorporated into standard TB care approach:

AUDIT test for all new TB patients performed and consultations by addiction specialists and psychologist launched.

• Monthly food packages were given to increase adherence during the treatment on ambulatory stage by the Tomsk Red Cross personnel.

• Transportation tickets were reimbursed by local government for a limited number of patients.

• Monthly food packages were given to increase adherence during the treatment on ambulatory stage by the Tomsk Red Cross personnel.

• Transportation tickets were reimbursed by local government for a limited number of patients.

• Medical management was performed according to international protocols: individualized MDR-TB regimens were designed based on the resistance profile of each individual’s isolate. Whenever possible, regimens consisted of at least five drugs to which the patient’s isolate was susceptible and lasted at least 18 months.

• Adverse reactions were managed aggressively and TB drugs and side effect medications were free of charge for patients.

• Medical management was performed according to international protocols: individualized MDR-TB regimens were designed based on the resistance profile of each individual’s isolate. Whenever possible, regimens consisted of at least five drugs to which the patient’s isolate was susceptible and lasted at least 18 months.

• Adverse reactions were managed aggressively and TB drugs and side effect medications were free of charge for patients.

• Several electronic databases were developed in order to monitor patient’s medical status while on MDR-TB treatment and to perform statistical analyses of the treatment cohorts, including the prison sector.

• Several electronic databases were developed in order to monitor patient’s medical status while on MDR-TB treatment and to perform statistical analyses of the treatment cohorts, including the prison sector.

• DOT was provided in civilian sector at one inpatient and several

outpatient facilities. All doses were directly observed. • The Red Cross was instrumental in establishing and

monitoring strong DOT programs in rural settings.

• DOT was provided in civilian sector at one inpatient and several

outpatient facilities. All doses were directly observed. • The Red Cross was instrumental in establishing and

monitoring strong DOT programs in rural settings.