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Stubborn TB taxes patients, world experts

Special Feature: Health Watch on Ukraine

By Melanie Zipperer
Reporting from Donetsk, Ukraine

The man in the green training suit slowly shuffles down the empty hospital hallway toward his room. The odor of harsh cleaning products and leftover food pervades the air. The only sound is that of his own steps, echoing between the walls of the corridor. He is tired, and it is difficult for him to walk. He chest hurts. He enters his small room and, relieved of the effort, sits down on his narrow bed. The only piece of furniture in the room is an old fridge, with the door ajar. It serves as a shelf and holds a couple of rusty pots. A dusty light bulb on a long cable hangs down from the ceiling. The old windows, unpainted for years, never had curtains.


Nikolai Vlasenko is a MDR-TB patient at the Donetsk hospital, in residence now for two months.
The man, Nikolai, looks out of the window, into a brownish sky. It is March, and the skinny trees in the courtyard have no leaves yet. Nikolai is a patient at the tuberculosis treatment center in Donetsk, a one-hour flight east from Kiev. In Soviet times the main center for steel production and coal dismantling, Donetsk has steadily declined since the breakdown of the Soviet Union, partly because of the loss of traditional Soviet customers but also because of the industry’s overall aging and deteriorating technology. Today, the situation is gloomy: Poverty levels are constantly rising, and many people have lost their jobs and with it their hope for a better life. They are malnourished, and many suffer from severe alcohol problems.

Before getting TB, a deadly lung disease if left untreated, Nikolai worked in one of Donetsk’s coal mines. He has been hospitalized for two months now. But he is likely to stay for a long time because he got infected with a specific kind of TB that is resistant to most of the currently available anti-TB drugs. Treating this so called multi-drug resistant TB (MDR-TB) is much more difficult and a hundred times more expensive than curing “normal” TB, which costs about $10 for a six-month course of medication. Even then, a cure for MDR-TB and Nikolai’s survival are not guaranteed. There is no effective vaccine. Everyone is vulnerable to infection simply by breathing in a droplet carrying a virulent drug-resistant strain.

MDR-TB develops when public-health programs fail to deliver regular and reliable treatment to patients. The fall of the Soviet state and with it the collapse of a centralized public health system left the population in the newly independent states in Eastern Europe and the Russian Federation without proper replacement access to health care. These transition problems have affected TB, and, according to a recently launched World Health Organization (WHO) report on the deadly, infectious disease, patients in parts of Eastern Europe and Central Asia are now 10 times more likely to have MDR-TB than elsewhere in the world.

“We have some second-line drugs for our MDR patients, but we don’t know which of them work. There is little data on MDR in Ukraine,” says Dr. Swetlana Lebschiva, Assistant Professor for TB and Pneumology at the University of Donetsk, who works at the TB hospital. Another problem is the patients themselves. According to Dr. Lebschiva, many are socially handicapped, particularly former prisoners and drug users. Some of them quit the hospital before the end of their treatment, without the doctor’s permission, and come back later in even poorer conditions, and resistant to drugs.

Until the year 2000, because of the worsening economic and social situation in Ukraine, TB prevalence grew by 15 to 20 percent annually. This year, for the first time, the trend was reversed. “The main reason for this success lies in the introduction of an internationally recommended TB treatment strategy called DOTS,” says Dr. Oleg Karatajev, Chief Health Administrator for Donetsk and the surrounding region. DOTS was launched by WHO. It promotes its application throughout the world as a pragmatic and effective strategy to fight the disease. In Ukraine, it was implemented as a pilot project in Donetsk at the end of 2001, with funding from the US Agency for International Development.

The DOTS strategy is composed of five elements which, if administered accurately, can treat TB at a success rate of nearly 99 percent and help to avoid the development of MDR-TB. First and most importantly, sound political commitment is an imperative for supporting DOTS. Then, regular drug supplies must be ensured, and diagnostic microscopy services need to be established. Other key elements include the creation of individual patient-monitoring systems, and use of highly effective regimes with direct observation of treatment. Once patients with infectious TB have been identified using microscopy services, health and community workers and trained volunteers observe and record patients taking the full course of the correct dosage of anti-TB medicines. The treatment must be followed for six to eight months.

For Ukraine, implementing DOTS means radically changing from a centralized and very costly system to a new, more cost-effective and decentralized scheme of patient treatment and follow-up. “Before using DOTS, only TB specialists were allowed to detect cases, with expensive X-rays. But there are not many TB specialists in the Donetsk region, which is home to more than 5 million people. Therefore, only a few cases could be detected and treated, and the patients had to stay at the hospital for at least one year,” says Dr. Maja Goroschko, Deputy Director of the Donetsk hospital. Through the DOTS program, general practitioners are trained to do a simple sputum test to detect TB under a microscope. If a patient is infected, the doctor transfers him to the next TB dispensary. “This is a huge difference,” Dr. Goroschko says. “Now everybody who developed infectious TB can be detected and treated.”

The major challenge for implementing DOTS in Ukraine is that it is conceived in two phases. During the first phase, when patients are still contagious, they stay at the hospital for, on average, about two months. After that, when they no longer can transmit the disease, they continue with their treatment from home. Trained workers or volunteers in local clinics provide them with medicines.

“To make sure the TB patients continue to take their drugs from home, we use a little trick,” says Dr. Irina Dubrovina, WHO Training Coordinator in Donetsk. Over the past years, she has given more than 50 courses to train health workers how to follow-up TB treatment with outpatients. “Each time they come to get their medicine we provide them with a small package of food. Most of the people are very poor and their families take care that they don’t miss their appointment.” Funding for this enticing incentive, however, is only secured for another six months.

Although the change of mentality that is needed to apply DOTS correctly is a long process, it is already having a positive impact. “Since we have used the DOTS method, our success rate in treating TB has risen from 57 to 81 percent. This is a major step up that, in the long run, will also help to get the development of MDR under control,” Dr. Goroschko says.

Tuberculosis is not only a major public health problem in Eastern Europe but across the globe. There are an estimated 8.8 million new cases of TB each year, of which 3.9 million are infectious. Two million people die from the TB bacillus annually. The good news is that the number of TB patients diagnosed and treated under DOTS is now rising much faster than at any time since its expansion began in 1995, according to a WHO report released on 24 March 2004, World TB Day. Indeed, the past two years have witnessed accelerated growth in the implementation of DOTS programs worldwide.

DOTS programs are now treating three million TB patients every year, an increase of more than one million patients compared to just two years ago. That increase is nearly double the average annual increment of 270,000 patients during the previous six-year period, and the trend is still upward. India is leading the surge with more than a quarter of all additional DOTS cases being treated, followed by smaller but significant increases in five other key countries with high rates of TB: South Africa, Indonesia, Pakistan, Bangladesh and the Philippines.

Yet, these international facts do not really convince Dr. Yuri Feshcenko, Chief Pulmonologist and top TB specialist at the Ministry of Health in Ukraine. Although he welcomes the work of international agencies to fight TB in Ukraine, he believes the old strategies are more effective. “If donors want to do something good for this country they should give us more funding to equip our laboratories and hospitals with up-to-date technology. We don’t need technical guidance. We know what works and what not.”

Dr. Kestutis Miskinis, Medical Officer at the WHO TB Control Office in Ukraine, understands these arguments. “However, in order to control TB and MDR-TB in the long term we need to move forward with DOTS systematically. In regions where DOTS is not implemented, doctors do not have to follow any protocol with regard to the use of first and second line drugs. Drugs that are prescribed to MDR-TB patients often have not even been tested before and there are no regulations for a recommended dosage. If we don’t expand DOTS, all these factors will contribute to even quicker mounting levels of drug resistance in the country.”

An additional enormous public health challenge is presented by the rapidly expanding combined HIV/AIDS epidemic. Ukraine and other countries in Eastern Europe and Central Asia where prevalence of MDR-TB is highest also experience the world’s fastest growing HIV infection rates. Recently the UN Development Program reported more than 1.5 million people living with HIV in the region, compared to just 30,000 in 1995. People living with HIV/AIDS are many times more susceptible to contracting all forms of TB. “With people’s immune systems compromised, MDR-TB has a perfect opportunity to spread rapidly and kill,” explains WHO Assistant Director-General of HIV/AIDS, TB and Malaria, Dr. Jack Chow, “As a priority to prevent the spread of TB, we need more investment in resources, programs and health workers.”

To share knowledge and expertise and to explore ways how to ensure an effective joint HIV/TB response, WHO and the Ukrainian Ministry of Health will hold a workshop in Donetsk at the beginning of April. “We cannot control one without controlling the other, and must begin quickly to scale up TB/HIV collaborative activities to provide a synergy of prevention, treatment and care for co-infected patients,” says Dr. Chow.

The gathering is the latest in a line of crafted WHO initiatives aimed at ensuring the country’s TB control program has political resonance that will see innovation translated into action. Already preparations for the formation of a high-level working group, made up of international and national TB specialists, is gaining pace. The investment could pay off. Ukraine could be the test bed that sees innovative and modern TB control practices being put in place that will rapidly accelerate the country toward reaching global targets set for 2005.

“Ukraine remains a top priority for WHO,” says Dr. Mario Raviglione, WHO’s Director of the Stop TB Department. “Regionally, it is second only to Russia as the country with the highest TB burden. Yet, importantly, from my visit to Ukraine, it’s a fact that the country has the valuable capacity to rapidly scale up and modernize TB control. If it can do this, we will see the threat from the TB/HIV co-infection and MDR-TB reduce. But for this to happen, the political will must be in place.”

Melanie Zipperer is a Geneva-based spokesperson for the World Health Organization.