A man in a green training suit shuffles down an empty hallway. The smell of cleaning products and food leftovers hangs in the air. He is tired. Walking is difficult. He has pain in his chest. He turns into his small hospital room and, relieved of the effort, sits down on his narrow bed.
The man, Nikolai, is a patient at the tuberculosis (TB) treatment centre in Donetsk, Ukraine. Formerly a Soviet centre for steel production and coal dismantling, life in Donetsk has steadily become more difficult over the last fifteen years. Today, poverty levels are rising and many people have lost their jobs.
Nikolai has been hospitalized for two months now. He is likely to stay in hospital for a long time because he is infected with a strain of TB that is resistant to most of the available first line anti-TB drugs. Treating this so called multidrug-resistant TB (MDR-TB) is much more difficult and expensive than curing ‘normal’ TB. Even then, a cure of MDR-TB, and Nikolai’s survival, is not guaranteed.
Multidrug-resistant tuberculosis (MDR-TB)
Multidrug-resistant TB (MDR-TB) is the disease caused by TB bacilli that are resistant to at least isoniazid and rifampicin – the two most powerful anti-TB drugs. It results from inconsistent or partial treatment of TB, and develops when public health programmes fail to deliver regular and reliable treatment to TB patients. The end of the Soviet state left the people in the newly independent states in Eastern Europe and the Russian Federation with uneven access to health care. According to a recent WHO report TB patients in parts of Eastern Europe and Central Asia are now ten times more likely to have MDR-TB than those in the rest of the world.
“We have some second line drugs for our MDR-TB patients, but we don’t know which of them work. There are few data on MDR-TB in Ukraine,” says Dr Swetlana Lebschiva, Assistant Professor for TB and Pneumology at the University of Donetsk, who works at the TB hospital. She adds that some of the TB patients leave the hospital before the end of their treatment, only to return in poor condition and resistant to drugs.
Tuberculosis control: DOTS
Until the year 2000, TB prevalence in Ukraine grew annually by 15% to 20% as a result of the more and more difficult economic and social situation. This year, for the first time, the trend was reversed. “The main reason of 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 is the internationally recommended TB control strategy. It is composed of five elements:
Patients with infectious TB are identified using microscopy services. Then health workers, community workers and trained volunteers observe and record patients taking the full course of the correct dosage of anti-TB medicines. The treatment has to be followed for six to eight months. If administered accurately, DOTS can treat TB with a success rate of nearly 99% and can help to avoid the development of MDR-TB.
- political commitment to sustained TB control
- a regular supply of anti-TB drugs
- sputum smear diagnostic microscopy services
- individual patient monitoring systems
- standardized treatment regimes with direct observation of therapy (DOT).
More on DOTS
In Ukraine, DOTS was implemented as a pilot project in Donetsk at the end of 2001. “Before DOTS, only TB specialists were able to detect cases, by using expensive x-rays. Only a few cases could be detected and treated, and the patients had to stay at the hospital for at least one year,” explains Dr Maja Goroschko, Deputy Director of the Donetsk hospital. “With DOTS, general practitioners are trained to detect TB using a simple sputum test. If a patient is infected, he is transferred to a TB dispensary. This is a huge difference: now everyone who develops infectious TB can be detected and treated.”
The major challenge for implementing DOTS widely across Ukraine is the fact that DOTS has two phases. During the first phase, when patients are still contagious, they stay at the hospital. On average, this period lasts two months. After that, when they can no longer transmit the disease, they continue with their treatment from home. Trained workers or volunteers in local clinics provide them with medicines.
Although the changes needed to apply DOTS across Ukraine will be a long process, DOTS is already having a positive impact in the country. “Since we started DOTS our success rate in treating TB has risen from 57% to 81%. This is a major step up that will also help to get the development of MDR-TB under control,” says Dr Goroschko.
Dr Kestutis Miskinis, Medical Officer at the WHO TB Control Office in Ukraine, agrees. “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 do not expand DOTS, these factors will contribute to mounting levels of drug resistance in the country.”
HIV and TB
Ukraine and other countries in Eastern Europe and Central Asia where MDR-TB prevalence is high, also experience the world’s fastest growing HIV infection rates. This rapidly expanding combined epidemic presents an enormous public health challenge. People living with HIV/AIDS are many times more susceptible to developing 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, “We cannot control one without controlling the other, and we must begin to scale up TB/HIV collaborative activities to provide a synergy of prevention, treatment and care for co-infected patients.”
At the beginning of April, WHO and the Ukrainian Ministry of Health held a workshop in Donetsk to explore ways of ensuring an effective joint HIV/TB response. The gathering is the latest in a line of WHO initiatives aimed at assisting countries scale-up TB control programmes. Already, preparations for the formation of a high level working group, made up of international and national TB specialists, are gaining pace. Ukraine could be the test bed that sees innovative and modern TB control practices put in place.
"Ukraine has the capacity to rapidly scale up and modernize TB control," says Dr Mario Raviglione, Director of WHO's Stop TB Department. "If Ukraine 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."
Nikolai, at the Donetsk TB dispensary, might not be aware of the complex public health issues behind the seven pills he takes three times each week. The pain in his chest is still there. It is simply a matter of living, or dying.