Comparison of the effectiveness of WHO short-course chemotherapy and standard Russian antituberculous regimens in Tomsk, western Siberia

Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients: Design and Implementation

BACKGROUND

While the integration of alcohol screening, treatment, and referral in primary care and other medical settings in the U.S. and worldwide has been recognized as a key health care priority, it is not routinely done. In spite of the high co-occurrence and excess mortality associated with alcohol use disorders (AUDs) among individuals with tuberculosis (TB), there are no studies evaluating effectiveness of integrating alcohol care into routine treatment for this disorder.

METHODS

We designed and implemented a randomized controlled trial (RCT) to determine the effectiveness of integrating pharmacotherapy and behavioral treatments for AUDs into routine medical care for TB in the Tomsk Oblast Tuberculosis Service (TOTBS) in Tomsk, Russia. Eligible patients are diagnosed with alcohol abuse or dependence, are newly diagnosed with TB, and initiating treatment in the TOTBS with Directly Observed Therapy-Short Course (DOTS) for TB. Utilizing a factorial design, the Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients (IMPACT) study randomizes eligible patients who sign informed consent into 1 of 4 study arms: (1) Oral Naltrexone + Brief Behavioral Compliance Enhancement Therapy (BBCET) + treatment as usual (TAU), (2) Brief Counseling Intervention (BCI) + TAU, (3) Naltrexone + BBCET + BCI + TAU, or (4) TAU alone.

RESULTS

Utilizing an iterative, collaborative approach, a multi-disciplinary U.S. and Russian team has implemented a model of alcohol management that is culturally appropriate to the patient and TB physician community in Russia. Implementation to date has achieved the integration of routine alcohol screening into TB care in Tomsk; an ethnographic assessment of knowledge, attitudes, and practices of AUD management among TB physicians in Tomsk; translation and cultural adaptation of the BCI to Russia and the TB setting; and training and certification of TB physicians to deliver oral naltrexone and brief counseling interventions for alcohol abuse and dependence as part of routine TB care. The study is successfully enrolling eligible subjects in the RCT to evaluate the relationship of integrating effective pharmacotherapy and brief behavioral intervention on TB and alcohol outcomes, as well as reduction in HIV risk behaviors.

CONCLUSIONS

The IMPACT study utilizes an innovative approach to adapt 2 effective therapies for treatment of alcohol use disorders to the TB clinical services setting in the Tomsk Oblast, Siberia, Russia, and to train TB physicians to deliver state of the art alcohol pharmacotherapy and behavioral treatments as an integrated part of routine TB care. The proposed treatment strategy could be applied elsewhere in Russia and in other settings where TB control is jeopardized by AUDs. If demonstrated to be effective, this model of integrating alcohol interventions into routine TB care has the potential for expanded applicability to other chronic co-occurring infectious and other medical conditions seen in medical care settings.

Knowledge, attitudes, and practices of physicians in Tomsk Oblast tuberculosis services regarding alcohol use among tuberculosis patients in Tomsk, Russia

In recent years, the Russian Federation has seen a dramatic rise in morbidity and mortality from tuberculosis (TB), attributed in part to an increase in alcohol use disorders (AUDs), which are associated with worse TB treatment outcomes. This study describes the knowledge, attitudes and practices of physicians who treat TB patients in Tomsk, Russia. We conducted semistructured interviews with 16 TB physicians and 1 addiction specialist. Interviews were audiorecorded, transcribed, translated and systematically analyzed. We identified four key domains: definitions of alcohol use and abuse and physicians' knowledge, attitudes and practices regarding these problems. Physicians described patients as largely precontemplative and reluctant to seek treatment. Physicians recognized their limited knowledge in diagnosing and treating AUDs but expressed interest in acquiring these skills. Few options are currently available for treatment of AUDs in TB patients in Tomsk. These findings suggest that Tomsk physicians are aware of the need to engage AUDs in TB patients but identify a knowledge gap that restricts their ability to do so. Training TB physicians to use simple screening instruments and deliver evidence-based alcohol interventions improves TB outcomes among patients with co-occurring AUDs.

Treatment of extensively drug-resistant tuberculosis in Tomsk, Russia: a retrospective cohort study

BACKGROUND

Mycobacterium tuberculosis strains that cause untreatable drug-resistant disease are a threat worldwide. We describe the treatment, management, and outcomes of patients with extensively drug-resistant tuberculosis in Tomsk, Russia.

METHODS

We undertook a retrospective cohort study of 608 patients with multidrug resistant tuberculosis who had treatment in civilian or prison services, between Sept 10, 2000, and Nov 1, 2004, according to the treatment strategy recommended by WHO. Clinical characteristics, management practices, and treatment outcomes of patients with extensively drug-resistant (XDR) tuberculosis and non-extensively drug-resistant (non-XDR) tuberculosis are described. The main outcome was the frequency of poor and favourable outcomes at the end of treatment.

FINDINGS

Of 608 patients with multidrug resistant tuberculosis, 29 (4.8%) patients had baseline XDR tuberculosis. Treatment failure was more common in patients with XDR tuberculosis than in those with non-XDR tuberculosis (31%vs 8.5%, p=0.0008). 48.3% of patients with XDR tuberculosis and 66.7% of patients with non-XDR tuberculosis had treatment cure or completion (p=0.04). The frequency and management of adverse events did not differ between patients with XDR and non-XDR tuberculosis.

INTERPRETATION

The chronic features of tuberculosis in these patients suggest that extensively drug-resistant tuberculosis may be acquired through previous treatments that include second-line drugs. Aggressive management of this infectious disease is feasible and can prevent high mortality rates and further transmission of drug-resistant strains of Mycobacterium tuberculosis.

[Hospitalizations for pulmonary tuberculosis in the State of São Paulo in 2004]

Tuberculosis (TB) continues as one of the main challenges for public health and primary health care.

OBJECTIVE

To analyze hospitalizations for pulmonary TB that occurred in the State of São Paulo in 2004.

METHODOLOGY

Data were collected related to: number of hospitalizations for pulmonary tuberculosis according to gender and age range; average hospitalization time; deaths during hospitalizations and hospitalization costs for the Unified Health System (SUS), using DATASUS, the SUS database.

RESULTS

In 2004, 4,859 hospitalizations for pulmonary tuberculosis occurred in the State of São Paulo. Hospitalizations were more frequent among men, with 4079 (84%) cases; average hospitalization time was 26.2 days; 202 (4.53%) patients died, 155 of whom were men; higher costs were found for patients under 14.

CONCLUSION

Early diagnosis is essential in the identification of TB, with a view to reducing the number of TB hospitalizations, however there is a need for a primary health care service that is capable of accomplishing these actions.

Reform of tuberculosis control and DOTS within Russian public health systems: an ecological study

OBJECTIVES

To investigate the association between clinical need and hospital bed supply and utilization in Russia; and, to investigate these associations in areas where traditional Russian tuberculosis health care systems exist and where the directly observed therapy-short course (DOTS) strategy has been implemented.

DESIGN

Ecological study using 2002 routine data.

MAIN OUTCOME MEASURES

Hospital bed utilization and hospital admissions for patients with tuberculosis in regions that adhere to the traditional Russian method of managing tuberculosis and those where the DOTS strategy has been implemented.

RESULTS

The ratio of beds per newly notified case was 0.86. The mean duration of hospital stay per admission was 86 days for non-DOTS regions and 90 days for regions where the DOTS strategy had been implemented. The number of admissions in each region correlated closely with the number of newly registered cases and hospital beds were, on average, occupied for 325 days. In the regions where the DOTS strategy had been implemented bed occupancy was 324 days.

CONCLUSIONS

Under the Russian tuberculosis control system, hospital utilization is predominantly determined by supply-side factors, namely the number of tuberculosis dedicated hospital beds, and this system extends across all regions. Implementation of the DOTS strategy in Russia has not led to fundamental structural changes in tuberculosis control systems.

Implementing WHO DOTS strategy in the Russian Federation: stakeholder attitudes

Russia has the ninth highest tuberculosis burden in the world. After a period of decline starting in the 1960s, the case notification rate tripled during the 1990s. Historically, case-finding, treatment and reporting practices in Russia have differed from those advocated by WHO and the international community: Directly Observed Therapy--short course (DOTS). By 2003, approximately 26% of the population in Russia was covered by the DOTS strategy. By contrast, the average coverage in the 22 high-burden countries is 61%. The reasons for this low rate in Russia have not been systematically examined. Using qualitative research methods we explored, in depth, the attitudes of key stakeholders involved in tuberculosis control to introduction of DOTS in a region of Russia. Six focus groups and 128 in depth interviews were held with clinicians, managers, policy-makers and patients. The results show negative attitude to change due to inadequate understanding of DOTS; perceived 'directiveness' of the 'externally developed' DOTS strategy and the standardized nature of the treatment regimen. The doctors, managers and patients saw that prolonged periods of hospitalisation (the traditional way of managing TB in Russia) was advantageous because treatment routines could be ensured, medical expertise was readily available, and other needs such as shelter and food were provided. Respondents felt that the patients were unlikely to adhere to treatment in the community. Cultural issues and capacity constraints, especially in laboratory equipment and personnel, would impede introduction and sustainability of the DOTS strategy.

Health system frailties in tuberculosis service provision in Russia: an analysis through the lens of formal nutritional support

OBJECTIVE

The aim of this study was to describe health system challenges faced by tuberculosis (TB) treatment facilities in Russia through an analysis of formal institutional dietary provisions to patients in an inpatient facility that provides care for poor patients.

METHODS

Analysis of formal dietary provisions by institutions and financing data from TB hospitals in Samara Oblast, Russia.

RESULTS

Formal dietary provision for inpatients with TB has fallen substantially in recent years. In a hospital providing inpatient care for the poorest patients with fewest social support networks, this has been very pronounced. The likely reason for this is that financial support for other budget lines, principally salaries, has required protection.

CONCLUSION

Formal institutional nutritional support in institutions providing care for the poorest patients with TB is unlikely to be enhancing the speed of recovery, or reducing the duration of infectiousness. Furthermore, the role that hospital may have played in the past in enabling patients to regain weight lost before admission may have been limited by reductions in formal financing. Reductions in state provision of food for patients may serve as an important illustration of wider TB control system frailties in the Russian Federation.

Seasonal variation and hospital utilization for tuberculosis in Russia: hospitals as social care institutions

BACKGROUND

Clinical management of tuberculosis in Russia involves lengthy hospitalizations, in contrast to the recommended strategy advocated by the World Health Organization.

METHODS

We used Fourier transform, spectral analysis and Student's t-test to analyse periodic and seasonal variations in admission and discharge rates for tuberculosis hospitalizations in 1999-2002, using routinely captured data from the Samara Region, Russia.

RESULTS

Hospital admissions in colder months were significantly higher than in warmer months. The mean monthly adjusted number of admissions in colder and warmer months for all adults was 413 and 372 (P < 0.01), for unemployed adults 218 and 198 (P < 0.02) and for pensioners 104 and 82 (P < 0.05). Hospital discharges varied seasonally. Maximum differences between admissions and discharges occurred in colder months and minimum differences were observed in warmer months.

CONCLUSIONS

As hospitalizations of tuberculosis patients in colder months fulfil an important social need, shifts to ambulatory care must be carefully managed.

The Effect of Initial Drug Resistance on Treatment Response and Acquired Drug Resistance during Standardized Short-Course Chemotherapy for Tuberculosis

BACKGROUND

In Tomsk Oblast, Russian Federation, during the period of 1996-2000, most previously untreated patients with tuberculosis received standardized short-course chemotherapy, irrespective of drug-susceptibility testing results. A retrospective analysis was done to determine the effect of initial drug resistance on treatment outcome and acquired drug resistance in new patients receiving standardized short-course chemotherapy.

METHODS

During the period of 1 November 1996 through 31 December 2000, a total of 2194 patients received a category 1 treatment regimen. Drug susceptibility test results for 1681 patients were available for analysis. Drug resistance patterns before and during treatment were compared for 73 patients whose culture results were persistently positive during treatment. Acquired resistance was defined as new drug resistance (during or at the end of treatment) that was not present at the beginning of treatment.

RESULTS

Pretreatment drug resistance was strongly associated with treatment failure. In patients who had strains with pretreatment resistance patterns that included isoniazid or rifampin resistance, but not resistance to both, 17 (70.8%) of 24 cases involving treatment failures acquired new multidrug resistance. In patients with pretreatment pan-susceptible or streptomycin-monoresistant strains, 13 (41.9%) of 31 cases involving treatment failures acquired new multidrug resistance.

CONCLUSIONS

Early diagnosis of drug-resistant tuberculosis and judicious use of second-line drugs is recommended to decrease transmission of drug-resistant strains and to prevent the creation of multidrug-resistant strains. Finally, if drug susceptibility tests are not available or results are delayed, physicians should recognize that patients who do not respond to directly observed empirical short-course chemotherapy are at high risk of having multidrug-resistant tuberculosis and should be treated accordingly.

Understanding health care in the south Caucasus: examples from Armenia

Along with sociopolitical and economic problems, the medical poverty trap in the south Caucasus region exacerbates its health problems

Regimens of less than six months for treating tuberculosis

BACKGROUND

WHO recommends 6 months of treatment in TB programmes.

OBJECTIVES

The purpose of this review is to assess the effects of regimens lasting less than 6 months compared with longer regimens in the treatment of active TB.

SEARCH STRATEGY

Search strategy: MEDLINE 1955-, Cochrane Infectious Diseases Trials Register, existing reviews, and researchers in the field. Date of the most recent search: January 1999.

SELECTION CRITERIA

Randomized trials comparing two or more TB drug regimens, in which at least one regimen was <6 months and it was compared with at least one regimen that lasted longer, in any patients with active TB.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data and assessed trial quality.

MAIN RESULTS

Seven trials with a total of 9 comparisons of <6 months (range: 2-5 months) versus longer treatment were included. About 2200 patients were in the shorter regimens and about 1900 in the longer regimens (the same comparison groups were used for more than one shorter regimen, in two studies). Relapse rates were consistently higher after shorter duration treatment regimens, regardless of the comparison made, though they were all relatively low. Results were significantly better in the longer groups in the meta-analyses of 2, 3, and 4 months of treatment vs longer treatment (Peto OR = 6.1 [95%CI 2.19,17.01], 3.67 [2.42,5.58], 3.64 [1.71,7. 75] but not in the single trial of 5 vs. 7 months (Peto OR = 2.24 [0. 90,5.59]. Relapse rates after longer (comparison) regimens ranged from 0-7% at one year (or more), and in the shorter treatment arms, they ranged from 1-9% in 8 trials, and18% relapsed in the one remaining. There was little or no difference in the rates of adverse reactions or toxicity requiring a change of regimen or discontinuation of treatment. The "sterilizing efficacy" at the end of treatment varied little among treatments, providing no predictive value for relapse rates. Few or no deaths were reported in the individual trials, and in no case did enough deaths occur for a comparison of short vs. long regimens.

REVIEWER'S CONCLUSIONS

Longer periods of treatment (at least up to 6 months) result in higher success rates in patients with active TB, but the differences are small. Under field conditions, where adherence to treatment is a big problem, and shorter regimens might improve adherence, these differences may not be evident. A comparison of <6 months vs. 6 months of treatment under programme conditions would be needed to determine this.