Following a considerable rise in the TB burden in the Russian Federation during the 1990s, a peak was reached in 2000 when some 132 000 cases of TB were notified. Since then, a progressive reduction in the number of reported cases has occurred, mainly because of a decline in the number of cases registered in the prison sector. However, the number of cases in the general population has increased, particularly among children. The DOTS strategy is not widely used in the Russian Federation. In oblasts where it is being applied, both case detection and treatment outcomes are still low. However, government commitment to TB control is strong, and a recent World Bank loan will allow accelerated expansion of both TB and HIV/AIDS programmes. In addition, the Russian Federation made a successful application to the GFATM in 2004, opening up additional opportunities to extend and improve these programmes. The increasing public health importance of TB/HIV coinfection is being addressed through a national TB/HIV coordinating body, which has developed a national strategy for TB/HIV control. Also receiving special attention is the growing MDR-TB epidemic in the Russian Federation; links between the MDR-TB and TB/HIV epidemics are being investigated. A major challenge is to improve the laboratory network to meet international standards and provide reliable diagnostic services for the TB control programme.
System of TB control
The Russian Federal Target Programme “Prevention and Control of Social Diseases (2002–2006)”, with the subprogramme “Urgent Measures of TB Control in Russia” was approved in 2001. The Programme aims to stabilize the epidemiological situation of social diseases through improvement of current organizations and newly established services. The plan covers strengthening the capacities of health facilities, research institutes and centres that carry out prevention, timely detection, diagnosis and treatment.
Several federal laws and regulations were developed to strengthen the foundation of the TB control programme. The national five-year plan, “Provision of guaranteed diagnostic and treatment procedures for TB patients and the development of TB services in Russia (2003–2006)”, was developed as the main framework for activities and cooperation with international partners. Reduction of TB incidence, disability and mortality is currently one of the priorities of state policy in the Russian Federation.
Within the federal TB control programme, five research institutes are responsible for organizing and supervising research, training and implementation of TB control in a wide network of more than 500 TB control facilities in 88 regions of the Russian Federation. These are the Research Institute of Phthisiopulmonology of Sechenov Moscow Medical Academy (RIPP MMA), the Central TB Research Institute of the Russian Academy of Medical Sciences (CTRI RAMS), St Petersburg Institute of Phthisiopulmonology, Ural Research Institute of Phthisiopulmonology and the Novosibirsk TB Research Institute. The TB dispensaries in turn supervise and monitor regional TB hospitals, sanatoria and TB units at district polyclinics. Under the Ministry of Justice, 37 hospitals and 57 treatment facilities provide treatment for TB patients within the penitentiary system.
The five federal TB research institute laboratories and 377 TB dispensary laboratories perform culture and drug susceptibility testing. In the territories, 348 centres with hospitals and sanatoria perform culture, and more than 11 000 centres perform smear microscopy.
Surveillance and monitoring
The increase in the number of annual TB case notifications after 1990 reached a peak of around 141 000 cases in 2000, and the number of reported cases has fallen each successive year since then. Similar trends have also been observed in other countries of the former Soviet Union that have also reported fewer cases, or at least a slowing in the rate of increase in the number of patients. This stabilization in notification rates in the Russian Federation could be the result of improved TB control or of general improvements in peoples’ health, but is most likely because of the decline in notified cases over the past few years observed in the prison sector. Since 2001, a decline of notified cases in the prison sector has occurred from more than 24 000 cases to around 16 000 in 2003. TB mortality rates remain increasingly high at around 20 per 100 000 population.
In 2003, DOTS coverage was low, with only 8.8% of cases detected under DOTS. It is therefore unlikely that the DOTS strategy had a major impact on incidence. In 2004, DOTS was implemented in 37 regions of the Russian Federation, with increased coverage to around 45% of the population; however, detection and treatment outcomes remain suboptimal. Moreover, treatment success in the 2002 cohort was low even in DOTS areas (67%) because many patients died (13%), failed treatment (9%) or were lost to follow-up (11%). The treatment outcomes for new smear-positive patients under DOTS have not improved in eight successive cohorts (1995–2002). Among the 962 DOTS relapse cases in 2002, fewer than half were successfully treated (46%), mainly because 26% failed re-treatment.
Treatment outcomes are not available for re-treatment after default or failure. Given the high prevalence of MDR-TB in the Russian Federation, it is important that these data be collated and analysed in future. Although sputum smear microscopy is increasingly used for diagnosis, the proportion of new pulmonary TB patients with a positive sputum smear was still only 33% in 2003 in DOTS regions and did not exceed 24% in non-DOTS regions, with an overall average for the Russian Federation of 25.3%. Nevertheless, the Russian Federation is different from many other HBCs in having a fairly comprehensive system for recording and reporting the total numbers of TB cases and deaths. This system of routine surveillance (rather than population-based surveys) should, with some refinements, be adequate for monitoring epidemiological trends and the future impact of TB control.
Improving programme performance
The current state policy aims to stabilize and improve the epidemiological situation, which is evidenced by an increase in federal budget allocations for TB control. The commitment of the federal government to TB control continues to grow, with sustained activities of the high-level working group (HLWG), one of the mechanisms of international cooperation in the field of medicine. The HLWG comprises representatives of the Ministry of Health and Social Development of the Russian Federation, the Ministry of Justice, RIPP MMA, CTRI RAMS, WHO and the Council of Europe. The federal government has adopted a number of regulations for TB control including: the Executive Order No. 109 of 21 March 2003 “On Improvement of TB Control in the Russian Federation” that focuses on laboratory diagnosis, chemotherapy standards, organization of treatment, prevention of TB transmission, system of centralized control and management of main TB interventions at the level of TB facilities in regions of the Russian Federation, and the introduction of the new reporting and dispensary follow-up system; the Executive Order No. 50 of 13 February 2004 “On Implementation of Registration and Reporting Documentation for Tuberculosis Monitoring” that includes cohort analysis and assessment of detection and treatment effectiveness in line with international standards; a recording form “Individual Card of TB/HIV Patient”; and recommendations on decreasing TB burden among high HIV prevalence populations.
Registers for recording and reporting TB based on cohort analysis were introduced by the Russian MoH in February 2004. From April 2004, new reporting forms were being introduced in 37 territories in both the civil and penitentiary sectors, and will be used country-wide from January 2005.
The activities of the federal TB control programme and expansion of the revised strategy are constrained by the shortage of staff and age of the existing medical staff working in TB services, many of whom are retiring. A detailed assessment of HR needs is under way and several activities are in progress to address HR capacity, including a staff development plan, as part of the overall TB plan for 2003–2007, and further training of TB service personnel supported by the World Bank-funded TB/AIDS project. New national guidelines and recommendations have been developed, published and distributed on case detection, TB treatment, laboratory services and TB/HIV control.
MDR-TB is a major challenge for TB control in the Russian Federation. MDR-TB patients outside the DOTS-Plus projects are treated on an individual basis and according to the availability of second-line drugs. Data on the prevalence of drug resistance are reported routinely from Ivanovo, Orel and Tomsk oblasts where the prevalence of MDR-TB among new cases ranges from 2.6% in Orel to 13.7% in Tomsk. Data from a few additional oblasts will be available shortly, and a plan to survey oblasts systematically is being developed. GLC-approved DOTS-Plus projects are being implemented in Archangelsk, Ivanovo, Orel and Tomsk. The GLC has approved the treatment of 2830 MDR-TB patients. The project in Tomsk, which was the first of these projects to start, has been successful in treating MDR-TB patients and has recently been expanded with financial support from the GFATM.
Diagnostic and laboratory services
The physical infrastructure of many diagnostic facilities in the Russian Federation does not meet Russian and international standards for laboratory design and safety. In addition, in many instances, laboratory equipment is outdated. Updating infrastructure of existing facilities and ensuring availability of quality equipment and supplies is an enormous challenge facing the national TB control programme.
Quality assurance is being addressed by the introduction of a federal system of EQA for smear microscopy approved by the MoH. However, given the financial constraints, the system has not yet been introduced in all diagnostic centres, nor have internal quality control procedures. The TB laboratory network faces a serious shortage of staff; HR capacity building through training and development of a model for effective laboratory services at the central level should lead to improvements in laboratory diagnosis at all levels.
HIV/AIDS is becoming a significant public health problem in the Russian Federation. A thematic working group, “TB in HIV-infected people”, has been established within the HLWG on TB and has developed recommendations on decreasing the TB burden among PLWHA. The group comprises leading national TB and HIV experts from research institutes, health facilities, WHO and international partners. Its basic objective is to develop a framework for establishment of the national system of TB care among HIV-infected people. The first stage resulted in the preparation of the “Recommendations on decreasing TB burden in high HIV prevalence populations” based on national and international practices.
Regional TB/HIV coordinators have been appointed in many regions of the Russian Federation. A number of federal-level seminars were held in 2004 where these coordinators were trained in principles of the newly developed TB/HIV strategy.
Links with other health-care providers
Collaboration between all relevant public sector health-care providers and related institutions is being strengthened, including general hospitals, TB hospitals, medical colleges, prison health services and the health services of the armed forces and of the police. The Ministry of Railway Communication, the Federal Security Service and a number of other ministries and departments have their own TB control services, and links with them need to be strengthened. The private sector plays a minor role in TB diagnosis and treatment.
Links with the community
Several community groups contribute to the provision of TB control activities in the Russian Federation, including an NGO of TB patients (NABAT), the Russian Red Cross, Russian TB Society and other regional foundations and societies. These groups participate in annual World TB Day campaigns and provide health education and social support for TB patients.
The HLWG, established in 1999, continues to play an important role in the development of TB control. It is responsible for coordinating TB activities between the national and international partners, and it works on recommendations for executive policy documents (prikaz) that regulate implementation of national TB control. Many national and international NGOs and technical agencies are partners in TB control within the 88 territories of the Russian Federation. Major donors include USAID, the Swedish International Development Agency, the EU, the Government of Finland and DFID. The Russian Federation successfully applied to the GFATM in round 4; funds for TB control activities should be available in 2005. A loan agreement between the Russian Federation and the World Bank to fund the project on “AIDS and TB Control” was signed in September 2003 and became effective in December 2003.
Budgets and expenditures
Financial data were prepared by WHO staff (Moscow office) using data available in the public domain, and are therefore estimates rather than official figures. Sources of data included the Ministry of Health and Social Development and the Federal Agency for Health Care and Social Development of the Russian Federation.
The total budget for TB control in both 2004 and 2005 is estimated at US$ 316 million (almost US$ 3000 per new TB patient). About US$ 250–260 million is available from the government in both 2004 and 2005 (including funds from a World Bank loan), a substantial increase compared with 2003. In 2005, the GFATM is expected to provide a further US$ 30 million, but grants from other sources are limited. While the available funding of about US$ 270 million in 2004 and 2005 is substantial by the standards of other HBCs, a funding gap of about US$ 40–50 million has been estimated for both years, primarily for the purchase of second-line drugs (US$ 18 million) and for investment in buildings and equipment (US$ 24 million). The Russian Federation accounts for almost one third of the total funding gap reported by the 22 HBCs.
The largest budget line items are for staff working exclusively on TB control (US$ 113 million in both years), initiatives to increase case detection and cure rates (US$ 84 million in both years), investment in buildings and equipment (US$ 60 million in both years) and second-line drugs (about US$ 45 million in both years). The budgets for staff, investment in buildings and equipment and second-line drugs are relatively large compared with those in other HBCs, and reflect the country’s extensive network of dedicated TB control facilities and the large number of patients with MDR-TB. When costs beyond those reflected in the reported budgets are included (i.e. the operating costs of a network of 81 425 dedicated TB beds and the cost of mass screening using fluorography), the total cost of TB control is estimated to be about US$ 400 million in both 2004 and 2005 (about US$ 3500 per patient treated), up from an estimated US$ 245 million in 2003.