2. Measures to Decrease TB Prevalence in the Barents Region Andrey O. Maryandyshev Elena I. Nikishova Dmitry V. Perkhin

3. Tuberculosis incidence in the civil sector (per 100,000 and in absolute figures) 200720082009 Arkhangelsk Region 45,7 (578) 46,0 (584) 45,2 (570) Murmansk Region 45,9 (423) 43,0 (364) 46,6 (391) Komi Republic 68,7 (698) 67,4 (674) 60,1 (611) Republic of Karelia 62,5 (433) 49,1 (341) 51,9 (358)

4. Mortality from tuberculosis in the civil sector (per 100,000 and in absolute figures) 200720082009 Arkhangelsk Region 12,0 (154) 9,7 (123) 7,8 (99) Murmansk Region 11,8 (101) 9,0 (76) 7,4 (62) Komi Republic 14,1 (137) 16,2 (151) 15,7 (157) Republic of Karelia 13,8 (150) 18,6 (129) 16,8 (116)

5. Total number of MDR TB patients in the civil sector (in absolute figures) 200720082009 Arkhangelsk Region 434436439 Murmansk Region 260263244 Komi Republic 263287309 Republic of Karelia 185206213

6. The number of TB/HIV co-infection cases, detected in the civil sector (in absolute figures) 200720082009 Arkhangelsk Region 3511 Murmansk Region 121814 Komi Republic 11206 Republic of Karelia 358

7. Targets of the TB Control Program in the Barents Region To cure at least 85% of new sputum smear-positive TB cases, including drug resistant cases To detect at least 70% of the sputum smear-positive TB cases, and rapidly detect drug resistant cases To prevent transborder transmission of the infection

8. Major activities Provide treatment for TB patients Treatment strategies for susceptible and drug resistant TB complies with international guidelines and recommendations TB drugs to treat drug susceptible tuberculosis cases are procured from the Regional budgets Arkhangelsk Oblast, Republic of Karelia and Komi Republic have been approved by the GLC – reserve line drugs (for the majority of MDR TB patients) were procured by GFATM

9. Detection of smear-positive and drug resistant TB cases At the primary health care level from 55 to 70% cases are detected with sputum smear microscopy. Automated BACTEC system (liquid media) for rapid detection of drug resistant TB strains is used.

10. Main challenges and possible solutions (1) 1.In 2010 the Global Fund ceases to support the Russian Federation, therefore there is a risk of a drug supply insufficient to cover all TB patients. Suggestions (solutions): Purchase the drugs from the Federal and Regional budgets (through target-oriented programs) Apply to the GFATM for continued support for reserve line drug procurement 2. A high default rate among MDR TB patients is reported in all territories Suggestion: Patient social support should be an integral part of treatment

11. Main challenges and possible solutions (2) 3. Amplification of drug resistance, including XDR TB development, during treatment Suggestion: in order to prevent nosocomial infection, in-patient TB departments should have separated wards for: - Susceptible TB cases; - MDR TB cases; -XDR TB and failure cases 4. MDR among new cases varies from 20 to 30 %; time needed to detect drug resistance – 1 month (automated systems with liquid media) Suggestion: introduce molecular-genetic diagnostic methods and detect drug resistance in 7 days (TB-BIOCHIP test system, Russia; GenoType® MTBDRplus and GenoType® MTBDRsl, Hain Lifescience GmbH, Germany)

12. Main challenges and possible solutions (3) 5. High risk of infection with M. Tuberculosis strains, incl. MDR TB strains, for TB/HIV patients, hospitalized in the inpatient departments Suggestions: Open specialized isolated boxes for such patients in the infectious diseases hospitals (infectious departments) Develop together with the Center for Infectious Diseases and HIV/AIDS Prevention joint patient management programs

13. Suggestions To coordinate joint efforts it is recommended to regularly summon the working group, which includes the head doctors of the TB facilities and heads of Phthisiopulmonology chairs in the Barents Region To exchange experience in treatment and management of MDR TB and XDR TB patients To exchange experience in the methods, allowing rapid detection of drug resistant forms of tuberculosis To strengthen coordination between the civil and penal sectors in order to reduce TB prevalence, including TB/HIV co-infection To establish an information system for MDR TB monitoring, allowing for the analysis of the dynamic changes within this patient group

14. Immediate Plans Training on Infection Control (Murmansk) LFA Seminar on the challenges of TB and HIV (Saint Petersburg) Conference for the head doctors of TB facilities, MDR and XDR TB clinicians, heads of bacteriological laboratories and TB registers of the Barents Region (Arkhangelsk, second half of 2010)

15. Thank you for attention!