Diagnostic algorithms of TB case finding and their effect on TB epidemiology in Russian Regions Andrey Maryandyshev, Elena Nikishova Northern State Medical University Arkhangelsk, Russia

Arkhangelsk region of the Russian Federation Area: 578,000 square km Population: 1, 117, 096 people 24 municipal districts in penal system

TB service of the area Arkhangelsk Clinical Antituberculosis Dispensary reference laboratory and 3 in-patient departments for 100 patients: Sensitive TB SS+ 35 MDR/XDR TB SS+ 35 Sensitive, MDR TB SS- 30 Out-patients department 27 municipal tuberculosis ambulatory TB Colony for continuation treatment Regional hospital of penitentiary system - bacteriological laboratory and 2 in-patient departments for 140 patients (sensitive and MDR)

TB Incidence including penitentiary system (new cases and relapses ) and mortality in Arkhangelsk Region (per population)

MDR TB burden among new cases and relapses consist 35,4% in 2013

Rapid Drug Susceptibility Tests implemented BacTAlert– LPA (Hain Test) in 2009 – DST for 1 and 2 line drugs Bactec MGIT - DST for first line drugs DST for second line drugs Gene Xpert

Algorithm in Arkhangelsk region

TB registration in the civil sector of Arkhangelsk region, 2007 – 2013

DST results of new TB cases Sensitive H MDR R H R H R Km Am Cm H R Fq XDR MDR clinical cases No DST results (SS- Culture– and DST not done)

DST results of patients with relapse of TB Sensitive H MDR R 621 H R H R Km Am Cm H R Fq XDR MDR-TB clinically No DST results (SS- Culture – and DST not done)

DST results of patients with category “treatment after loss to follow-up” Sensitive H MDR R H R H R Km Am Cm 113 H R Fq XDR No DST results

DST results of patients with category “treatment after failure” Sensitive H MDR R H R H R Km Am Cm H R Fq XDR MDR-TB clinically No DST results 111

Standard regimens for treated all TB patients depending of the DST Group of patients (new case, relapse, treatment after loss follow up, treatment after failure) Intensive Phase Continuation phase Sensitive TB, SM and Culture negative 2 HREZ4 HR Isoniazid resistance TB, including combinations with other TB drugs except for rifampicin 3 R Z E Km Lfx6 R Z E Lfx Multidrug-resistant TB8 Z Km Lfx Pto Cs 12 Z Lfx Pto Cs

Treatment outcomes of patients with sensitive TB Regist ered 100% Cured % Failur e% Died from TB% Died not from TB% Loss to follow up% Refus ed from treat ment % Transf erred out% TB not confir med% MDR- TB develo ped% ,7 9,71,516,41,54, ,71,47,43,75,63,75, ,51,48,21,96,32,45, ,71,64,4 2,7 0,5 1, ,10,56,21,93,3 0,5 1, ,51,87,13,64,8 0,6

Treatment outcomes of patients with H resistance. Regist ered Curedfailur e Died from TB Died not from TB Loss to follow up Refus ed from treat ment Trans ferred out TB not confir med MDR- TB develo ped ,82,110,66,410,6 4,3 19, ,56,811,44,5 6,8 2,3 18, ,9 4,4 17,84, ,7 12,85,17,7 2,5 5, ,62,112,82,14,3 2, ,33,36,73,3

MDR-TB treatment outcomes Regis tered Still on treat ment Cure d failur e Died from TB Died not from TB Loss to follow up Refus ed from treat ment Trans ferre d out TB not confir med XDR- TB devel oped ,73,221,78,320,41,3 0,0 1, ,33,413,06,823,32,1 0,02, ,32,811,97,722,41,43,50, ,93,511,76,412,92,3 0,02, ,660,13,210,85,113,91,91,30,02, ,027,35,2 10,48,43,9 0,6

Results of treatment of TB with resistance to R / H R Regis tered Still on treat ment Cure d Failu re Died from TB Died not from TB Loss to follow up Refus ed from treat ment Trans ferre d out TB not confir med XDR- TB devel oped ,72,222,69,720,6 1, ,64,015,87,923,82, ,02,913,76,921,61,0 2, ,04,611,57,013,10,8 2,30, ,860,22,311,36,015,01,52,3 0, ,119,66,2 12,48,22,17,2

Treatment outcomes of clinical cases of MDR-TB. Regist ered Still on treat ment Treat ment compl eted Failur e Died from TB Died not from TB Loss to follow up Refus ed from treat ment Transf erred out TB diag nosis remo ved MDR/ XDR devel oped ,8 11,15, ,9 4,317,44, ,0 10,015,0 10, ,0 6,3 18, ,4 28, ,044,43,711,13,7

Treatment results of patients without MTB confirmation (Radiology confirmation) Regist ered Treat ment compl eted Failur e Died from TB Other reason s of death Loss to follow up Refus ed from treat ment Transf erred out TB diagn osis was remov ed Devel opme nt of MDR/ XDR ,8 4,74,2 2,13,42, ,6 7,21,92,9 0,5 1, ,3 2,94,42,5 1, ,7 1,02,5 3,54,5 1, ,10,72,1 4,20,73,5 0, ,62,21,52,26,51,5

Treatment outcomes of Sm (+) patients with no DST data. Regist ered CuredFailur e Died from TB Other reason s of death Loss to follow up Refuse d from treatm ent Transf erred out TB diagno sis was remov ed Develo pment of MDR/ XDR ,5 25,06,84,52,315, ,2 34,97,04,5 2,3 11, ,5 25,64,7 2, ,8 24,113,86,9 3, ,811, ,035,010,05,0

Results of treatment all registered (508) TB cases in civil sector in 2012 Treatment success (preliminary data) New cases– 67,4% (279/414), 11,1% (46/414) – treatment continue Relapses ––52,4% (43/82), 13,4% (11/82) – treatment continue «treatment loss follow up» –– 57,1% (4/7) «failure treatment» –60,0% (3/5) Among all registered cases in 2012 – treatment success 64,8% (329/508), 13,8%- (57/414) – treatment continue

Conclusion Everyone tuberculosis patient before of treatment should have the Rapid Drug Susceptible Test WHO Standards of treatment according DST cured more than 80 % tuberculosis patients

Thank you for attention!