Eurosurveillance

ECDC

Tuberculosis in Murmansk region

 Rediger
 1 Published: 27.07.04 Updated: 27.07.2004 14:22:02
A.V. Chernev, E.A. Matsievskaya, T.M. Liseeva, L.A. Boiko, Murmansk region State Sanitary and Epidemiological Centre, Murmansk region Tuberculosis Dispensary
Tuberculosis has been increasing medical-social problem in Murmansk region of Russian Federation. Since 1993 the incidence of TB has risen three-fold and reached 46,4 per 100 000 population (5,8 for children population) in 2002. TB incidence in the penitentiary institutions in Murmansk region was 1476,0 per 100 000 prisoners. Increasing TB mortality rate is observed in the region – in last ten years it increased ten-fold and reached 11,5 per 100 000 population in 2002. 15 TB cases among health care workers were notified in 2002. M. tuberculosis drug-resistance has become a serious problem – the prevalence of primary resistant forms was 43,7% and secondary resistant forms 83,7% in 2002. Four TB and HIV-infection co-infection cases were notified in 2002.

Introduction

Being a social disease, tuberculosis became a medico-social problem of the most concern. Taking into account asocial status of the majority of tuberculosis patients, absence of place for living, means of subsistence for most of them; early detection of communicable cases of the disease, treatment of patients, development and implementation of social support methods are of the most importance. Taking into account an on-going epidemiological situation on tuberculosis, measures, implementing only by tuberculosis institutions, health-care network and State Sanitary and Epidemiological Surveillance Centres cannot be sufficient enough without social support of the municipal authorities.

Methods

Main methods of early detection of tuberculosis are fluorography and tuberculin test. On introduction of DOTS strategy since 1997 on the territory of the region for tuberculosis revelation when people ask for medical assistance health-care institutions perform smear microscopy of the patients, who have symptoms suspected for tuberculosis. In the incidence analysis, as indicated below, statistical data of the Regional State Sanitary and Epidemiological Surveillance Centre and Regional Tuberculosis Dispensary, information from epidemiological investigation forms.

Results

Incidence rate for tuberculosis per 100 000 population in Murmansk region has fallen twice since 1970 (61,1) every ten years (1980 - 31,5; 1990 - 16,0) and reached the lowest level in 1992 (14,2). During the last ten years of the 20th century the incidence has risen three-fold and came to 46,4 per 100 000 population in 2002 (Fig 1).

Figure 1. Incidence per 100 000 population for active forms of tuberculosis in Murmansk region and Russian Federation in 1992-2002

High rate of increasing of disease incidence in comparison with the previous year was registered in 2002 – 30%.  Incidence rate as a total accounting prisoners contingent was 62,6 in 2002 (in 2001 – 59,5). Incidence rate inside the penitentiary system institutions in Murmansk region was 1476,0 per 100 000 prisoners, that is almost twice more than in early 1990s (1991 – 718,2; 1992 – 867,3). However, the positive dynamics of decreasing of tuberculosis incidence in penitentiary system institutions is observed. During the last three years its level fell twice owing to the organization of regular medicine supply, full-bodied feeding, improvement of hospital conditions after the penitentiary tuberculosis hospital reconstruction, timely photofluorography examination of patients and case detection.
Along with the tuberculosis incidence of adults incidence of tuberculosis among children increases: the rate was 5,8 per 100 000 of children population in 2002 (1992 – 0,3) (Fig 2). 

Figure 2. Incidence per 100 000 population for children tuberculosis in Murmansk region and Russian Federation in 1992-2002

Fatal outcome of tuberculosis was notified for the first time in recent decades for the child of two years old from family focus of infection. Unfavorable tendency of increasing of mortality rate is observed in the region.

Figure 3. Mortality rate dynamics for tuberculosis in Murmansk region in 1992-2002 (per 100 000 population)

For the period of ten years mortality rate increased ten-fold and came to 11,5 per 100 000 population. The structure of mortality causes continues to change and the share of the deceased during up to one year of observation was 34,1% in 2002 and 14,1% - in 1992 (Fig 3).
Along with the increase of incidence of all active forms of tuberculosis three-fold since 1992, the incidence of bacillus forms increased almost two-fold and was 18,8 in 2002 against 10,3 in 1992. The disease incidence increase is followed by increase in severity of clinical outcome of tuberculosis. There are more patients with severe, extensive, acute clinical processes among cases. During the last decade the number of newly diagnosed cases with caseous pneumonia increased three-fold (1992 – 7; 2002 – 21), and the share of fatal cases among such patients is higher than the similar value among the patients with other clinical forms of the disease (7,5-fold). The increase of absolute numbers by the end of the year of the most epidemically dangerous categories of patients is registered during the decade: it is five-fold for fibrotic-cavernous tuberculosis (1992 – 17; 2002 – 87) and 2,4-fold for eliminators of bacilli (270 and 656, respectively).
As a whole, tuberculosis incidence in the region increased twice during the last decade. Moreover, during the proceeding decades, starting from 1970s, the incidence reduced two-fold every ten years up to the beginning of 1990s (Table 1).

Table 1. Tuberculosis incidence among Murmansk region population (per 100 000)

Years

 

 

1970

1980

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Incidence

335,7

160,9

96,8

97,3

90,7

95,8

99,6

109,5

123,4

138,7

161,9

170,0

178,1

179,3

189,0

Figure 4. Age structure of respiratory system tuberculosis incidence among Murmansk region population in 1992 and 1997 (share, per cent)
 
Figure 5. Age structure of respiratory system tuberculosis incidence among Murmansk region population in 1998 and 2002 (share, per cent)

Incidence peak falls on the most able-bodied age groups from 20 to 40 years; the increase of share of persons older than 45 is also observed during the last five years (Fig 4, Fig 5).

Table 2. Social structure of newly diagnosed cases

 

   Total

Invalids, pensioners

Non-employed

Pre-school institutions and school staff

Food industry staff

Housing depart-ments staff

Medical institu-tions staff

   Sailors

Homeless persons

Refugees

1992

share

116

 

21

21

1

3

2

4

8

1

-

100 %

18,1 %

18,1 %

0,9 %

2,6 %

1,7 %

3,4 %

6,9 %

0,9 %

-

2002

share

442

 

54

182

6

5

6

15

12

26

4

100 %

12,2 %

41,2 %

1,4 %

1,1 %

1,4 %

3,4 %

2,7 %

5,9 %

0,9 %


Tuberculosis was and continues to be a social disease. The significant reservoir of infection sources is concentrated mainly among groups of population with low socio-economic conditions. About 60% of newly diagnosed persons in the region are unemployed; the number of homeless persons increases every year. The last category is the most difficult task for diagnosis and treatment (Table 2).
The problem of tuberculosis drug-resistance has become one of the most important in recent years. 

Figure 6. Drug-resistance in 1992 – 2002 (per cent of examined during the year under review) / Лекарственная резистентность за 1992-2002 годы (% среди обследованных в течение отчетного года)

The share of primary resistant forms increased in 2002 three-fold in comparison to 1992 and came to 43,7%, secondary resistant forms – 1,5-fold and was 83,7%. The number of patients with multiresistant tuberculosis grows up steadily in recent years (Fig 6, Table 3). 

Table 3. Dynamics of patients share with multiresistant forms of tuberculosis

Year

From newly diagnosed cases

By the end of the year

Absolute number

Share, %

Absolute number

Share, %

1999

10

6,5

55

11,3

2000

11

6,5

75

14,6

2001

13

7,3

99

17,6

2002

25

10,5

176

26,8


The data given in the table affirm that by the end of the year the number of cases of multiresistance acquired in consequence of insufficient treatment is twice more than that of newly diagnosed cases. Federal supplies of anti-tuberculosis drugs for the patients with multiresistant forms are absolutely insufficient. Only 15% of requirements in reserve medicines were satisfied in 2002. Effectiveness of treatment is still low. For example the share of patients of primary revealed patients, which discontinued to excrete bacilli in 12 months of treatment in 2002 was 59,8% (1992 – 77,2%).

Discussion

Tuberculosis incidence increase in the region followed the social changes at the beginning of 90s after the political and economical shifting in the post-Soviet society.
Epidemic situation with tuberculosis is complicated by the increase of HIV-cases notification linked to drug abuse epidemic. Cumulative incidence rate was 97,9 per 100 000 population in 2002. Four cases of tuberculosis and HIV co-infection were registered in 2002.

Main procedures for early tuberculosis revilement are photofluorography and tuberculin test. However, 10% decrease of regional population fluorographic examination coverage was registered during ten years. Only less than half of Murmansk region population is annually examined by fluorography (2002 – 41%), at the same time the share of cases revealed on regular examinations continues to be high – near 40%. Coverage of determined groups, in which situation could be influenced by the administrative measures, is being more than 98%. There were no unfavorable for tuberculosis stockbreeding farms registered on the region’s territory. All the stockbreeders have their photofluorography made every year (in 2002 – 98,9%).

Tuberculin test coverage of children was improved for 10 years and reached 98,8% in 2002 (71,6% in 1992), for adolescents – 89,3% (1992 – 70,6%). Vaccination coverage of newborns and revaccination coverage of those who are subject to at the age from 7 to 14 years was more then 98% (1992 – V=95,3%, RV=91,4% at the age of seven and 91,0% at the age of 14).

15 cases of tuberculosis among health care workers were registered in 2002, four of them – among the employees of the Regional Tuberculosis Dispensary. There are no conditions at the dispensary to separate patients with BK+ and BK-, with susceptible and resistant forms of tuberculosis.

The law “The framework for organization of tuberculosis prevention in Murmansk region” was developed in the region in 1997; the corresponding alterations and additions were inserted in 2001 in accordance with the legislation of the Russian Federation. In course of “Programme for protection of Murmansk region population from tuberculosis in 1998 – 2002” implementation the reconstruction of outpatient department, bacteriological laboratory of the Regional Tuberculosis Dispensary and canteen of in-patient department were carried out.
Russian-Finnish international programme “Anti-tuberculosis project to enhance the effectiveness of prevention and treatment of tuberculosis in Murmansk region” is being implemented in the region. The basis of the project is to adopt DOTS strategy for detection (microscopy of sputum smears when appealing for medical aid) and treatment of tuberculosis (short-term treatment courses with direct control).
Joint programme together with the regional branch of Red Cross “Russian Red Cross against tuberculosis and AIDS in Russia” is being implemented, according to which socially unadapted patients receive food and hygiene sets, get meal at the canteen in order to attract them to treatment. Russian Red Cross purchased microscopes to provide smear microscopy at the outpatient clinics’ laboratories.

Because of sharp incidence increase in 2002 the decision of the Regional Sanitary-Epidemic Commission “Measures for prevention of tuberculosis spread in Murmansk region” was adopted in April 2003, which stated main directions of the activity of different interested services and institutions. One of the most important steps in the fight against tuberculosis was that the Government of the region and Regional Duma adopted local programme “Protection of the population of the Murmansk region against tuberculosis” for the years 2004-2008 with financial support of nearly 360 millions rubles (21% - from federal budget, 30% - from the budgets of the cities and districts and 49% - from the regional budget). Programme was developed on the basis of epidemic situation analysis and effectiveness of measure to struggle against tuberculosis. Purchase of tuberculosis drugs for resistant forms of tuberculosis (which need huge financial investments), reconstruction of therapeutic department of the Regional Tuberculosis Dispensary (including creation of separate wards for patients with resistant tuberculosis, enlargement of space in the wards up to 7 m2, which is prescribed by sanitary norms and will allow to isolate the most infectious patients).

Conclusions

Tuberculosis in the 21st century continues to be a social disease, implementation of only preventive measures cannot be effective enough without social support from the local authorities. In the modern conditions main tasks to implement epidemic surveillance of this infection are the following:

  • development and implementation of special tuberculosis programmes;
  • preservation of high vaccination coverage in the determined groups of children and adolescents, timely and full implementation of tuberculin testing;
  • implementation of sanitary and epidemic measures in the foci of the infection in order to improve them;
  • improvement of safety measures in tuberculosis institutions, purchase of reliable airways protection equipment for health-care workers;
  • conduction of preventive fluorographic investigations of population in accordance with the legislation of the Russian Federation in order to reveal tuberculosis on early stages;
  • further development of joint work with mass media to promote population-based and individual-based prevention of tuberculosis;
  • development of international collaboration, implementation of international strategies to fight against tuberculosis.

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