1. TB in Northwest Russia based on Filha´s experience Kristiina Salovaara Rauni Ruohonen Filha

2. Strategy development IUATLD Standardisation of recording and reporting EURO TB Strategy development WHO (Geneva, Copenhagen, Moscow) FILHA Russia Project Region

3. General objectives of the FILHA TB projects Improved control strategies Improved TB laboratory services Improved knowledge and skills of the staff Improved infection control in TB

4. 1997 1996 1998 1997 1999 1997 FILHA´s TB control program cooperation: Murmansk Karelian Republic Leningrad St. Petersburg Estonia No-TB Baltic

5. UIN related TB activities in Northwest Russia Murmansk prison project 1999 - 2001, funded by the MoHSA of Norway Combined civilian and prison TB project in Murmansk 2002 - 2007 Technical co-operation with the MoJ Finland TB project in Karelian Republic 1998 - 2005 Assistance to the MoJ Finland TB project in St.Petersburg and Leningrad Region GUFSIN 2001- (ongoing)

6. TB training courses co-organised by FILHA International –TB management training course for physicians annually in Estonia since 1996 –TB training courses for nurses annually in Estonia since 2001 –TB infection control course in Murmansk since 2008 Russian –Course for TB nurses in Murmansk since 2006

7. Main problems in TB control in Northwest Russia Adherence to treatment –Integration of TB services with general health care –Outreach of socially marginalised population groups –Lack of NGO´s Drug resistance Poor laboratory services especially in penitentiary care Lack of proper infection control Inadequate cooperation between civilian and penitentiary care Increasing HIV epidemic

8. Treatment interrupters in Murmansk 2005

9. Activities to improve adherence to TB treatment Treatment close to patients residence Social support Individual approach to each patient Psychological support by staff Juridical support Trained and skilled empathetic staff

10. TB incidence in Northwest Russia

11. Primary TB drug resistance in 2005 and 2006 (%) in North-West Russia MDR 20052006 Arkhangelsk region 27,123,1 Vologda region 11,318,7 Kaliningrad region 21,528,5 Karelian R Komi22,8 Leningrad region 10,416,8 Murmansk region 29,821,0 Novgorod region 17,519,3 Pskov region 6,315,3 St. Petersburg 12,220,1 Northwest Russia 16,820,8 A. Shalygin, St.Petersburg RIPP 2007

12. Abigail Wright, WHO 2007

14. Total population Infected with M. tuberculosis Infected with HIV Determinants for the Frequency of HIV-Associated Tuberculosis in a Community Prevalence and incidence of infection with M. tuberculosis Prevalence and incidence of HIV infection Overlap of the two respective population segments H.Rieder

15. HIV + TB HIV is the major risk factor for developing TB HIV + TB infection : annual risk 5-15 % for developing active TB TB is harder to diagnose; progression faster, Easily fatal if undiagnosed TB is the leading cause of death among people who are HIV positive

16. Adverse effects of HIV on TB control programmes Increased TB case notifications ”Hot spots” of TB transmission ( prisons, refugee camps, health facilities etc. ) Creation of stigma Illness and death in health care workers A.D. Harries 2008

17. Adverse effects of HIV on TB control – on patient management More difficult diagnosis Increased morbidity and mortality Increase rates of recurrent TB Facilitation of the spread of drug-resistant TB TB burden goes up, case detection down Mortality rises, TB treatment success decreases A.D. Harries 2008

18. Sickness 1987-921993-71998-92000-012002 tuberculosis8,019,032,129,043,8 generalized bacterial infections20,06,83,600 bact.pneumonia06,8000 cytomegalovirus infection 24,031,035,738,721,9 sarkoma Kaposy32,027,614,812,99,4 lymfoma01,73,63,26,3 Opportunistic infections and other diseases (%) among HIV-positive patients in Russia in autopsy material

19. Increased rates of recurrent TB Rates of relapses are higher in HIV-infected Burden of TB increases Management of relapses is more complicated and expensive

20. Impact: HIV favouring TB drug resistance Documented evidence:  Nosocomial transmission (HIV facilities, prisons, etc.)  Poor adherence to TB treatment by HIV-positive patients  Malabsorption of TB drugs (advanced immunosuppression, chronic diarrhea)  Acquired rifampicin resistance (diarrhea, antifungal treatment, antiretroviral treatment)  Poor TB programme performance (overload of TB cases due to HIV epidemic, unknown association of HIV) Need of more studies Pierpaolo de Colombani, WHO-EURO

21. HIV + TB treatments Treatment is difficult ( side-effects, drug interactions ) Treatment is expensive Treatment results are pure Risk of MDR-epidemics among HIV- patients

22. WHO Collaborative TB/HIV activities A. Establish the mechanisms for collaboration A.1 Set up a coordinating body for TB/HIV activities effective at all levels A.2 Conduct surveillance of HIV prevalence among tuberculosis patients A.3 Carry out joint TB/HIV planning A.4 Conduct monitoring and evaluation B. Decrease the burden of tuberculosis in people living with HIV/AIDS B.1 Establish intensified TB case-finding B.2 Introduce isoniazid preventive therapy B.3 Ensure TB infection control in health care and congregate settings C. Decrease the burden of HIV in tuberculosis patients C.1 Provide HIV testing and counselling C.2 Introduce HIV prevention methods C.3 Introduce co-trimoxazole preventive therapy C.4 Ensure HIV/AIDS care and support C.5 Introduce antiretroviral therapy

23. HIV testing and treatment in TB patients, by WHO regions, 2006 WHO report 2008

24. Prisons increasing TB burden; Samara (Russia), 2002. Data from Samara (Russian Fed.), 2002. In Drobniewski FA et al. Tuberculosis, HIV seroprevalence and intravenous drugs abuse in prisoners. Eur Respir J 2005; 26:298-304. Main indicator TB patients among prisoners TB patients among civilians Multiplier TB incidence (per 100,000)2,2007530 TB mortality (per 100,000)60125 MDR-TB prev. in new cases37%4%9 HIV prevalence164/1,344 (12%)33/1,935 (2%)6 Drug use650/1,341 (45%)61/1,512 (0.4%)112 History of past TB treatment1,214/1,339 (91%) History of previous detention 1 time 1.5% 2 times19.2% 3 times37.5% 4 times25.1% Any time83.3%

25. 0 20 40 60 80 100 120 -95-96-97-98-99-00-02-03 /1000 inmates TB HIV TB and HIV in Russian prisons Moscow Centre for prison reform

26. Registrated TB + HIV –patients in the penitentiary care of St.Petersburg and Leningrad region in 2001 –05 (per 100 000 inmates) I.Tamatorin St.Petersburg and Leningrad region GUFSIN 2005

27. Reasons for TB epidemic in penitentiary care – Key control components Delayed diagnosis and treatment –Screening at entry, by symptoms and contacts –Identify persons already diagnosed/ on therapy –Adequate laboratory services Problems of infection control –Separation of infectious cases from general prison population –Improve engineering and ventilation controls –Personal respiratory protection of staff

28. Thank you for your attention !