Tomsk Oblast, Russian Federation

Patient-Centered TB Control Approach Leads to Significant Declines

Following the dissolution of the Soviet Union in 1991 and the termination of many Soviet-era social services, there was a dramatic increase in rates of TB across the newly established Russian Federation. As the new millennium approached, both TB and multidrug-resistant TB (MDR-TB) rates had doubled compared to rates at the end of Soviet governance, and the rates in Tomsk Oblast were even higher than the average across the rest of the Russian Federation. Partners in Health (PIH) began working with Tomsk Oblast TB Services in 1998, initiating declines in incidence and mortality rates that continued throughout the 2000s.

In 1998, the TB case notification rate in Tomsk was 90.3 per 100,000 people in the civilian sector, with a mortality rate of 21.2 per 100,000 people. The percentage of MDR-TB among new cases and retreatment cases was 8.5 percent and 32.2 percent, respectively. In the prison sector, the TB case notification rate was 3,357 people per 100,000, with a mortality rate of 129.9 per 100,000. The percentage of MDR-TB among new cases and retreatment cases was 13.1 percent and 34.9 percent, respectively.

Tomsk Oblast TB services initiated one of the world’s first MDR-TB programs. In 2000, the World Health Organization Green Light Committee approved the project to treat 630 MDR-TB patients with high-quality second-line TB drugs. Starting with the most disadvantaged cohort — prisoners with MDR-TB — the project expanded to the civilian sector of Tomsk Oblast.

Teams of nurses and mobile clinic drivers set out every day to ensure people suffering from TB — especially MDR-TB — fully complied with treatment regimens.

Between 2004 and 2009, with support from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the Tomsk project focused on expanding treatment through the introduction of a comprehensive and integrated program to treat 950 MDR-TB patients. The project addressed many issues, including the strengthening of drug resistant TB laboratory diagnoses, improving infection controls and developing sub-programs focused on social and psychological issues related to TB treatment, such as reduction of alcohol use, treatment adherence and early case detection.

In 2006, PIH implemented the Sputnik project. The Sputnik program mobilized around a patient-centered approach to TB care, especially to individuals most at-risk of not completing TB therapy. Teams of nurses and mobile clinic drivers set out every day to find the patients enrolled in the program, many of whom were indigent or suffering from substance abuse disorders. These healthcare workers not only ensured that people with TB fully complied with treatment regimens — especially those with MDR-TB — but they also delivered food and provided other forms of social support to mitigate the socioeconomic constraints that patients faced in their daily lives. As part of the Sputnik project, PIH successfully collaborated with the Tomsk Regional AIDS Center, which resulted in the implementation of a TB prevention program among people living with HIV. Later, in 2009, the Global Fund extended its funding to the Tomsk project, enabling Tomsk TB Services to expand MDR-TB treatment activities and improve its efficiency.

The programs in Tomsk make clear that a comprehensive, patient-centered approach to managing TB is vital to an inclusive and successful TB program. The MDR-TB project implemented in Tomsk addressed both programmatic and socioeconomic factors associated with unfavorable outcomes. The result has been a strengthening of the overall TB control program in the region and improved case management for the most vulnerable patients. The model of MDR-TB care in Tomsk can be applied to other resource-poor settings facing challenges to TB and MDR-TB control.

Keeping Up the Fight

• Russia continues to have a high burden of MDR-TB, constituting nine percent of new MDR-TB cases globally in 2018. As funding was removed from these programs in Tomsk, the incidence and mortality from TB and MDR-TB immediately started to rise, suggesting that sustained investment in comprehensive TB programs is vital for driving down TB rates in a substantial way.
• The procurement of new TB drugs and repurposed drugs required for an adequate treatment regimen for XDR-TB remains a challenge in Russia.
• Russia has also seen an increase in HIV/AIDS incidence rates, which have been growing at a rate of around 10 percent per year. Co-infections with HIV makes TB more difficult to treat successfully.
• Chronic hepatitis C infections have been on the rise in the Russian Federation as well, nearly tripling since the turn of the century.