Key Determinants of MDR-TB in Tomsk, Russia

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