Multidrug-resistant tuberculosis in Tomsk, Russia has several key determinants, some of which are surprising.
There are biological determinants including immune status (HIV status) and psychological disorders (depression). Co-infection of HIV and TB, along with the development of MDR-TB in HIV positive persons has been reported globally. In Russia, the dual epidemic of HIV and TB has already arrived; the risk of developing TB in HIV positive persons is 10% per year, leading to the threat of increased MDR-TB incidence. [1] Additionally, 85% of HIV positive persons are injection-drug users, indicating a behavior determinant that could also contribute. [1]
Psychological disorders, especially depression, are also a key determinants. The odds ratio for having depression and developing drug resistant TB is 3.3, indicating the necessity of metal health therapies. [2]
There are also social determinants that contribute to developing MDR-TB in Tomsk. Several organizations have pointed out that social stigma exists against tuberculosis patients in prisons or tuberculosis patients who are ex-prisoners; being in prison, or aving history of imprisonment has also been shown to be a determinant. Being an ex-prisoner has an OR of 1.4 for developing MDR-TB, and this population is a contributor to the population of those who don’t finish drug therapies (a risk for developing MDR-TB, as will be shown later) [2,3]. The social stigma can affect the resource pool for DOT staff.
Perhaps the biggest social determinant is poverty. Approximately 26% of the Tomsk population is below the poverty line. [4] Poverty provides the ideal condition for the acceleration of TB (unsanitary housing, overcrowding, etc), and also significantly contributes to the development of MDR-TB. Substandard treatment (interrupted treatments, insufficient medications leading to short treatment times, and poor adherence) along with MDR-TB transmission from previously infected persons (overcrowding) are cited as contributors [4].
Environmental determinants also exist. Hospital crowding contributes by creating reservoirs of MDR-TB. Even in populations adherent to drug therapies, hospitalization became a significant contributor to MDR-TB development, with a hazard ratio of 6. [5] Hospital-acquired MDR-TB may indicate pre-existing MDR-TB or re-infection with MDR-TB; infection-control actions may be needed.
Several behavior determinants have significant effect. With a 26% default rate, not adhering to TB treatment has an OR of 6.7 on MDR-TB development. [2] Substance abuse is strongly associated with nonadherence, having an OR of 7.3, indicating that substance abuse is also a major behavior determinant. [5] Indeed, alcohol abuse causes an eight-fold increase in drug resistance, and is a major predictor of MDR-TB. [6,7]
Inadequate labs (a political determinant) is still a contributor to increased MDR-TB and TB rates [8]. Several suggestions have been made as to how they can be improved [9], so we can extrapolate to say that inadequate training, technology and staffing have contributed to inadequate laboratory diagnosis services.
So in summary, the most important determinants that I can address:
Psychological disorders and alcohol abuse
Adherence to treatment
Poverty (substandard treatments and overcrowding)
Hospital-acquired MDR-TB
Inadequate labs
[1] Implications of the growing HIV-1 epidemic for tuberculosis control in Russia
[2] The risk of MDR-TB and polyresistant tuberculosis among the civilian population of Tomsk city, Siberia, 1999
[3] Alcohol and drug use disorders, HIV status and drug resistance in a sample of Russian TB patients
[4] Treating Multidrug-Resistant Tuberculosis in Tomsk, Russia: Developing Programs That Address the Linkage between Poverty and Disease
[5] Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: non-adherence, default and the acquisition of multidrug resistance
[6] Alcohol and drug use disorders, HIV status and drug resistance in a sample of Russian TB patients
[7] Treatment outcomes in an integrated civilian and prison MDR-TB treatment program in Russia.
[8] Reform of tuberculosis control and DOTS within Russian public health systems: an ecological study
[9] The state-of-the-art of Russia's Laboratory Tuberculosis Diagnosis Service: basic problems and ways of their overcoming
Sunday, November 28, 2010
Friday, November 19, 2010
The Magnitude of MDR-TB in Russia.
After much thought and research into several cities, I have decided to focus in on Tomsk, Russia. Preliminary research didn’t reveal much data about MDR-TB in HIV patients in Tomsk, but more data was available for MDR-TB in new and re-treatment tuberculosis patients in Tomsk. Therefore, I have revised my problem statement to:
High Incidence of MDR-TB in New and Re-treatment Tuberculosis Patients in Tomsk, Russia from 1990 to Present Day.
The role of surveillance of MDR-TB in Tomsk is given to the Tomsk City Tuberculosis Services (TCTS), which “oversees diagnosis, treatment and reporting of adult patients with TB,” following WHO guidelines [1]. Further research into the TCTS didn’t reveal much, other than the impression that there was a comprehensive network of tuberculosis facilities involved in surveillance [2], including tuberculosis laboratories that report all drug-susceptibility testing results accompanied by various other data (“new case” vs “previously treated case,” age, sex, HIV status, etc) [3]
The WHO has a project called the Global Project (on Anti-Tuberculosis Drug Resistance Surveillance), which collects and analyzes drug-resistance, mortality and budget data from population surveys and national surveillance systems around the world. It uses the data to help countries scale-up MDR-TB management, including standardized surveillance systems like patient surveys and drug susceptibility testing [3].
Interestingly, the WHO compiles country-specific data into country-specific “profiles.” These profiles outline various surveillance parameters, some of which are indicators such as mortality, incidence and prevalence, finances. Let’s just focus on a few of these indicators, and how they present the public health impact of the problem. Rates such as morality, incidence and prevalence are direct indicators.
In Russia, MDR-TB accounts for 13% of new TB cases and 49% of retreatment TB cases, as of 2007 [4]. In Tomsk, MDR-TB accounts for 11.2% of all new TB cases and 42.2% of all retreatment cases by 2003 estimates. [5] Together, the prevalence data show that Tomsk has a significant MDR-TB burden similar to Russia’s as a whole; strikingly, MDR-TB occurs a huge portion of previously-treated TB cases. With TB incidence rates increasing by 2.1% in Russia [4], I would predict that these numbers would increase without good public health measures.
Mortality data for MDR-TB is lacking; what I found was that in 2003, TB in general caused 17.6 deaths per 100,000 in Tomsk [5]; and since 2007, TB has caused 18 deaths per 100,000 per year in Russia as a whole [4]. Steady mortality rates may indicate that treatment protocols aren’t being largely beneficial across the board.
TB budget expenditures of Russia [4] are an indirect indicator of the MDR-TB problem in Russia. In 2009, the largest budget component (36%) was for staff dedicated to TB control, 28% for TB hospitals and 11% for MDR-TB, indicating that MDR-TB is recognized as a significant problem in Russia.
A systematic weakness in most of these data from Russia is that this is reported data from facilities such as labs and hospitals. For those in the rural areas or without access to such facilities, they may not be represented in these statistics. For example, this could be reflected in the statistics taken from source 5, since the data is reported to be collected by the Tomsk Oblast Tuberculosis Services or TCTS.
[1] http://www.who.int/bulletin/volumes/85/9/06-038331/en/
[2] http://eurpub.oxfordjournals.org/content/17/1/98.full
[3] “Guidelines for surveillance of drug resistance in tuberculosis” Fourth edition
[4] “Global Tuberculosis Control WHO Report 2009”
[5] “Treating Multidrug-Resistant Tuberculosis in Tomsk, Russia”
High Incidence of MDR-TB in New and Re-treatment Tuberculosis Patients in Tomsk, Russia from 1990 to Present Day.
The role of surveillance of MDR-TB in Tomsk is given to the Tomsk City Tuberculosis Services (TCTS), which “oversees diagnosis, treatment and reporting of adult patients with TB,” following WHO guidelines [1]. Further research into the TCTS didn’t reveal much, other than the impression that there was a comprehensive network of tuberculosis facilities involved in surveillance [2], including tuberculosis laboratories that report all drug-susceptibility testing results accompanied by various other data (“new case” vs “previously treated case,” age, sex, HIV status, etc) [3]
The WHO has a project called the Global Project (on Anti-Tuberculosis Drug Resistance Surveillance), which collects and analyzes drug-resistance, mortality and budget data from population surveys and national surveillance systems around the world. It uses the data to help countries scale-up MDR-TB management, including standardized surveillance systems like patient surveys and drug susceptibility testing [3].
Interestingly, the WHO compiles country-specific data into country-specific “profiles.” These profiles outline various surveillance parameters, some of which are indicators such as mortality, incidence and prevalence, finances. Let’s just focus on a few of these indicators, and how they present the public health impact of the problem. Rates such as morality, incidence and prevalence are direct indicators.
In Russia, MDR-TB accounts for 13% of new TB cases and 49% of retreatment TB cases, as of 2007 [4]. In Tomsk, MDR-TB accounts for 11.2% of all new TB cases and 42.2% of all retreatment cases by 2003 estimates. [5] Together, the prevalence data show that Tomsk has a significant MDR-TB burden similar to Russia’s as a whole; strikingly, MDR-TB occurs a huge portion of previously-treated TB cases. With TB incidence rates increasing by 2.1% in Russia [4], I would predict that these numbers would increase without good public health measures.
Mortality data for MDR-TB is lacking; what I found was that in 2003, TB in general caused 17.6 deaths per 100,000 in Tomsk [5]; and since 2007, TB has caused 18 deaths per 100,000 per year in Russia as a whole [4]. Steady mortality rates may indicate that treatment protocols aren’t being largely beneficial across the board.
TB budget expenditures of Russia [4] are an indirect indicator of the MDR-TB problem in Russia. In 2009, the largest budget component (36%) was for staff dedicated to TB control, 28% for TB hospitals and 11% for MDR-TB, indicating that MDR-TB is recognized as a significant problem in Russia.
A systematic weakness in most of these data from Russia is that this is reported data from facilities such as labs and hospitals. For those in the rural areas or without access to such facilities, they may not be represented in these statistics. For example, this could be reflected in the statistics taken from source 5, since the data is reported to be collected by the Tomsk Oblast Tuberculosis Services or TCTS.
[1] http://www.who.int/bulletin/volumes/85/9/06-038331/en/
[2] http://eurpub.oxfordjournals.org/content/17/1/98.full
[3] “Guidelines for surveillance of drug resistance in tuberculosis” Fourth edition
[4] “Global Tuberculosis Control WHO Report 2009”
[5] “Treating Multidrug-Resistant Tuberculosis in Tomsk, Russia”
Friday, November 12, 2010
Tuberculosis: A Resilient Killer
The tuberculosis bacterium is a nasty organism to deal with. It has all sorts of tricks, like having a very thick outer coating that enables it to survive inside the body for long periods of time. Tuberculosis has also developed the ability to resist drugs that are typically used against it.
The bacterium is causing an annual global burden of twelve billion [1] while infecting one third of the world’s population [2]. A population that is especially threatened by tuberculosis is HIV positive people; for them, developing tuberculosis is a much higher possibility than if they were HIV negative. In fact, research indicates that HIV and TB facilitate each other’s attack on our immune system. Interestingly, in HIV positive people, multi-drug-resistant tuberculosis (MDR-TB) is twice as common than in HIV negative people [3].
These observations indicate that HIV and TB must be addressed together, and that MDR-TB among HIV positive persons is a significant emerging issue. I would like to base my paper on the topic of MDR-TB in HIV positive persons.
I find this topic interesting because of so many factors that contribute to tuberculosis and the emergence of MDR-TB. Tuberculosis and poverty form a cycle of disaster. Because poverty correlates with hunger, lack of sanitation and poor housing conditions, poverty forms a friendly breeding ground for tuberculosis. Tuberculosis then worsens the situation by decreasing people’s capacity to work, makes them poorer due to expensive treatments, and generally exacerbates poverty.
It is also interesting that poverty correlates with high incidence of HIV in inner cities. So it would be possible that the topic can be focused on MDR-TB in HIV positive persons in inner cities.
I think this is an important topic to investigate because biomedical research still has to make major improvements in the realm of MDR-TB and effective tuberculosis vaccinations. MDR-TB is something that would only be exacerbated if treated with more drugs, so the most effective approach would be a public health approach. There are some novel ideas coming out from research, like using antimicrobial pigments from Antarctic bacteria to treat TB, but that could take years to develop and test.
I hypothesize that by focusing on MDR-TB in HIV positive persons, we can tailor MDR-TB or TB prevention programs specifically to HIV positive persons. By using models from various existing inner-city programs that work, MDR-TB/TB prevention programs for HIV positive persons can be targeted to HIV positive persons living in inner cities.
I am already eying Partners in Health and their community-based programs in Boston as a good source of information, and certainly a model to consider.
[1] http://www.who.int/trade/distance_learning/gpgh/gpgh3/en/index7.html
[2] http://www.who.int/mediacentre/factsheets/fs104/en/
[3] http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2008/20080227_MDR_rprt_for_UNAIDS.asp
The bacterium is causing an annual global burden of twelve billion [1] while infecting one third of the world’s population [2]. A population that is especially threatened by tuberculosis is HIV positive people; for them, developing tuberculosis is a much higher possibility than if they were HIV negative. In fact, research indicates that HIV and TB facilitate each other’s attack on our immune system. Interestingly, in HIV positive people, multi-drug-resistant tuberculosis (MDR-TB) is twice as common than in HIV negative people [3].
These observations indicate that HIV and TB must be addressed together, and that MDR-TB among HIV positive persons is a significant emerging issue. I would like to base my paper on the topic of MDR-TB in HIV positive persons.
I find this topic interesting because of so many factors that contribute to tuberculosis and the emergence of MDR-TB. Tuberculosis and poverty form a cycle of disaster. Because poverty correlates with hunger, lack of sanitation and poor housing conditions, poverty forms a friendly breeding ground for tuberculosis. Tuberculosis then worsens the situation by decreasing people’s capacity to work, makes them poorer due to expensive treatments, and generally exacerbates poverty.
It is also interesting that poverty correlates with high incidence of HIV in inner cities. So it would be possible that the topic can be focused on MDR-TB in HIV positive persons in inner cities.
I think this is an important topic to investigate because biomedical research still has to make major improvements in the realm of MDR-TB and effective tuberculosis vaccinations. MDR-TB is something that would only be exacerbated if treated with more drugs, so the most effective approach would be a public health approach. There are some novel ideas coming out from research, like using antimicrobial pigments from Antarctic bacteria to treat TB, but that could take years to develop and test.
I hypothesize that by focusing on MDR-TB in HIV positive persons, we can tailor MDR-TB or TB prevention programs specifically to HIV positive persons. By using models from various existing inner-city programs that work, MDR-TB/TB prevention programs for HIV positive persons can be targeted to HIV positive persons living in inner cities.
I am already eying Partners in Health and their community-based programs in Boston as a good source of information, and certainly a model to consider.
[1] http://www.who.int/trade/distance_learning/gpgh/gpgh3/en/index7.html
[2] http://www.who.int/mediacentre/factsheets/fs104/en/
[3] http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2008/20080227_MDR_rprt_for_UNAIDS.asp
Sunday, November 7, 2010
The Half-way Point
It’s astounding how much was covered in the first half of Intro to Public Health! We’ve covered the science, the economics, and even the environmental aspects behind public health (and that’s not even the full list.)
The design of the class makes it easy for us to understand this wide variety of topics. I enjoyed how there were different lectures each class, and each lecture used the textbook for background information. This combination helped to identify the most pertinent concepts being taught in each topic. The weekly blog posts are also contributing to my understanding of each topic. Because the posts require some reflection, concepts are reinforced and applied in sample scenarios. But of course, it also matters how much I enjoy the topics.
The topics in which I felt most engaged include epidemiology, infectious disease and history of public health. I enjoyed epidemiology not only because I had background in epi, but also because Dr. Alexander dissected into its definition; that epi is the study of distribution and determinants of disease frequencies was subtly taught to me previously, but not explicitly said. In the context of this definition, epi began to make more and more sense, and because the strongest/clearest part of public health for me.
Infectious disease was also interesting to me because of the many possibilities for intervention, and because of the recent vaccine-fear issues. Since vaccination is one method to break the chain of infection, fear about vaccines can undermine the goal of prevention. To me this was particularly interesting because whereas one might think that an intervention in the chain of infection would be foolproof, human qualities can cause an intervention to fail or be weaker than designed.
I don’t think I ever intended on taking interest in the history of public health, but the lecture surprised and convinced me otherwise. Public health was described as the “promise of control,” but sometimes public health falls short. This is where history of public health comes in and investigates to learn from public health’s successes and failures; and to determine how societal and governmental functions can affect public health programs. I especially enjoyed learning about cholera and how John Snow’s study shifted the paradigm from “treat to prevent.” In the context of the modern world, I feel that this is important because often we address issues with treatments rather than preventions (take food contamination and swine flu as examples).
My first post described how I wanted “this course [to] change all my preconceptions and inspire me to think cleverly about future public health.” I feel that so far, it has done so; I got exposed to areas I never even knew were involved in public health (e.g. health services research). And where I used to think of public health as unnecessarily involving too much politics and economics, I now know that these two areas have significant impact on public health. I would say that my interests in public health have broadened and now, I can see the relevance of several topics.
I am looking forward to learning more about some specific topics, and slowly narrowing down.
Eric
The design of the class makes it easy for us to understand this wide variety of topics. I enjoyed how there were different lectures each class, and each lecture used the textbook for background information. This combination helped to identify the most pertinent concepts being taught in each topic. The weekly blog posts are also contributing to my understanding of each topic. Because the posts require some reflection, concepts are reinforced and applied in sample scenarios. But of course, it also matters how much I enjoy the topics.
The topics in which I felt most engaged include epidemiology, infectious disease and history of public health. I enjoyed epidemiology not only because I had background in epi, but also because Dr. Alexander dissected into its definition; that epi is the study of distribution and determinants of disease frequencies was subtly taught to me previously, but not explicitly said. In the context of this definition, epi began to make more and more sense, and because the strongest/clearest part of public health for me.
Infectious disease was also interesting to me because of the many possibilities for intervention, and because of the recent vaccine-fear issues. Since vaccination is one method to break the chain of infection, fear about vaccines can undermine the goal of prevention. To me this was particularly interesting because whereas one might think that an intervention in the chain of infection would be foolproof, human qualities can cause an intervention to fail or be weaker than designed.
I don’t think I ever intended on taking interest in the history of public health, but the lecture surprised and convinced me otherwise. Public health was described as the “promise of control,” but sometimes public health falls short. This is where history of public health comes in and investigates to learn from public health’s successes and failures; and to determine how societal and governmental functions can affect public health programs. I especially enjoyed learning about cholera and how John Snow’s study shifted the paradigm from “treat to prevent.” In the context of the modern world, I feel that this is important because often we address issues with treatments rather than preventions (take food contamination and swine flu as examples).
My first post described how I wanted “this course [to] change all my preconceptions and inspire me to think cleverly about future public health.” I feel that so far, it has done so; I got exposed to areas I never even knew were involved in public health (e.g. health services research). And where I used to think of public health as unnecessarily involving too much politics and economics, I now know that these two areas have significant impact on public health. I would say that my interests in public health have broadened and now, I can see the relevance of several topics.
I am looking forward to learning more about some specific topics, and slowly narrowing down.
Eric
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