Diagnostic algorithms of TB case finding and their effect on TB epidemiology in Russian Regions

Diagnostic algorithms of TB case finding and their effect on TB epidemiology in Russian

Regions

Andrey Maryandyshev, Elena Nikishova

Northern State Medical UniversityArkhangelsk, Russia

Arkhangelsk region of the Russian Federation

Area: 578,000 square km

Population: 1, 117, 096 people

24 municipal districts

11282 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+ 35Sensitive, MDR TB SS- 30Out-patients department

27 municipal tuberculosis ambulatory

TB Colony for continuation

treatment

Regional hospital of penitentiary system - bacteriological laboratory

and 2 in-patient departmentsfor 140 patients (sensitive and MDR)

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

Region 2001-2012 (per 100 000 population)

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

Rapid Drug Susceptibility Tests implemented

• BacTAlert– 2004-2009• LPA (Hain Test) in 2009 – DST for 1

and 2 line drugs • Bactec MGIT - DST for first line drugs -

2010 DST for second line drugs - 2011

• Gene Xpert - 2011

Algorithm in Arkhangelsk region

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

572 568 533 562476 431 409

104 91 94 85 93 82 5918 24 13 4 5 7 51 3 4 4 3 5 4

2007 2008 2009 2010 2011 2012 2013

new case relapse

treatment after loss follow up treatment after failure

434 436 439372 392

348281

208 182 196 183 165 155 127

27 28 16 9 15 7 18

2007 2008 2009 2010 2011 2012 2013

Total MDR TB new MDR TB

new XDR TB

DST results of new TB cases2007 2008 2009 2010 2011 2012 2013

Sensitive 172 178 179 169 181 152 165H 38 37 39 34 41 23 22MDR 103 96 99 125 104 111 71R 4 5 2 2 1 1 3H R 55 58 67 92 86 67 47H R Km Am Cm 22 11 8 14 5 14 13

H R Fq 4 2 3 3 5 5 4XDR 3   2 1 1 3 4MDR clinical cases 15 20 17 13 6  21 26

No DST results (SS- Culture– and DST not done)

243 228 215 205 139 128 94

DST results of patients with relapse of TB 2007 2008 2009 2010 2011 2012 2013

Sensitive 15 23 24 11 25 11 19H 6 4 3 4 4 4MDR 15 42 39 44 52 42 25R 6 2 1    H R 55 30 31 34 44 28 18H R Km Am Cm 22 7 4 4 4 7 5

H R Fq 4     1 2 3 1XDR 3     2 1 2MDR-TB clinically 15 3 3 3 1  5No DST results (SS- Culture – and DST not done)

36 22 28 24 12 25 12

DST results of patients with category “treatment after loss to follow-up”

2007 2008 2009 2010 2011 2012 2013Sensitive 8 15 4 1 1 4 5H 3 2 2   2 2

MDR 6 6 4 1 1R          H R 5 5 1 1 1H R Km Am Cm 1 1 3    

H R Fq          XDR          No DST results

1 1 3 2 1 1

DST results of patients with category “treatment after failure”

2007 2008 2009 2010 2011 2012 2013Sensitive   1 2 2 1 1

H 1 1 1   1 1

MDR 1 2 1 1 1 2 1

R          

H R 1 1   1 1 1

H R Km Am Cm

  1 1     1 1

H R Fq          

XDR          

MDR-TB clinically

No DST results

1 1 1

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 HREZ 4 HR

Isoniazid resistance TB, including combinations with other TB drugs except for rifampicin

3 R Z E Km Lfx 6 R Z E Lfx

Multidrug-resistant TB 8Z Km Lfx Pto Cs

12Z Lfx Pto Cs

Treatment outcomes of patients with sensitive TB

Registered 100%

Cured%

Failure%

Died from TB%

Died not from TB%

Loss to follow up%

Refused from treatment%

Transferred out%

TB not confirmed%

MDR-TB developed%

2007 195 66,7   9,7 1,5 16,4 1,5 4,1

2008 216 72,7 1,4 7,4 3,7 5,6 3,7 5,6

2009 208 74,5 1,4 8,2 1,9 6,3 2,4 5,3

2010 183 84,7 1,6 4,4 4,4 2,7 0,5 1,6

2011 209 86,1 0,5 6,2 1,9 3,3 0,5 1,4

2012 168 81,5 1,8 7,1 3,6 4,8 0,6 0,6

Treatment outcomes of patients with H resistance.

Registered

Cured failure Died from TB

Died not from TB

Loss to follow up

Refused from treatment

Transferred out

TB not confirmed

MDR-TB developed

2007 47 46,8 2,1 10,6 6,4 10,6 4,3 19,1

2008 44 45,5 6,8 11,4 4,5 4,5 6,8 2,3 18,2

2009 45 68,9   4,4 4,4 17,8 4,4

2010 39 66,7   12,8 5,1 7,7 2,5 5,1

2011 47 76,6 2,1 12,8 2,1 4,3 2,1

2012 30 83,3 3,3 6,7 3,3 3,3

MDR-TB treatment outcomesRegistered

Still on treatment

Cured failure Died from TB

Died not from TB

Loss to follow up

Refused from treatment

Transferred out

TB not confirmed

XDR-TB developed

2007157 42,7 3,2 21,7 8,3 20,4 1,3 1,3 0,0 1,3

2008 146 47,3 3,4 13,0 6,8 23,3 2,1 2,1 0,0 2,1

2009 143 50,3 2,8 11,9 7,7 22,4 1,4 3,5 0,0 0,0

2010 171   57,9 3,5 11,7 6,4 12,9 2,3 2,3 0,0 2,9

2011 158 0,6 60,1 3,2 10,8 5,1 13,9 1,9 1,3 0,0 2,5

2012 154 37,0 27,3 5,2 5,2 10,4 8,4 3,9 3,9 0,6

Results of treatment of TB with resistance to R / H R

Registered

Still on treatment

Cured

Failure

Died from TB

Died not from TB

Loss to follow up

Refused from treatment

Transferred out

TB not confirmed

XDR-TB developed

2007 93 40,7 2,2 22,6 9,7 20,6 1,1  1,1

2008 101 42,6 4,0 15,8 7,9 23,8 2,0 2,0 2,0

2009 102 52,0 2,9 13,7 6,9 21,6 1,0 2,0

2010 130   60,0 4,6 11,5 7,0 13,1 0,8 2,3 0,8

2011 133 0,8 60,2 2,3 11,3 6,0 15,0 1,5 2,3 0,8

2012 97 38,1 19,6 6,2 6,2 12,4 8,2 2,1 7,2

Treatment outcomes of clinical cases of MDR-TB. Registered

Still on treatment

Treatment completed

Failure

Died from TB

Died not from TB

Loss to follow up

Refused from treatment

Transferred out

TB diagnosis removed

MDR/XDR developed

2007 18   77,8       11,1 5,6 5,6

2008 23   73,9     4,3 17,4 4,3

2009 20   65,0     10,0 15,0 10,0

2010 16   50,0   6,3 6,3 18,8 18,8

2011 7 71,4       28,6

2012 26 37,0 44,4 3,7 11,1 3,7

Treatment results of patients without MTB confirmation (Radiology confirmation)

Registered

Treatment completed

Failure

Died from TB

Other reasons of death

Loss to follow up

Refused from treatment

Transferred out

TB diagnosis was removed

Development of MDR/XDR

2007 236 78,8   4,7 4,2 4,2 2,1 3,4 2,5

2008 208 85,6   7,2 1,9 2,9 0,5 1,9

2009 204 87,3   2,9 4,4 2,5 1,0 1,0 1,0

2010 202 84,7   1,0 2,5 2,5 3,5 4,5 1,5

2011 143 

 88,1 0,7 2,1 

4,2 0,7 3,5 0,7

2012 135 85,6 2,2 1,5 2,2 6,5 1,5 1,5

Treatment outcomes of Sm (+) patients with no DST data.

Registered

Cured Failure

Died from TB

Other reasons of death

Loss to follow up

Refused from treatment

Transferred out

TB diagnosis was removed

Development of MDR/XDR

2007 4445,5   25,0 6,8 4,5 2,3 15,9

2008 43 37,2   34,9 7,0 4,5 2,3 2,3 11,6

2009 43 60,5   25,6 4,7 4,7 2,3 2,3 2,3

2010 2944,8   24,1 13,8 6,9 6,9 3,4

2011 9 77,8 11,1 11,1

2012 2045,0 35,0 10,0 5,0 5,0

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!