Russian health policies and inaction risk 'super-resistant' TB warn MSF

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Inaction by Russian health authorities could mean that super-resistant strains of tuberculosis (TB) emerge in the country, according to a letter from Medecins sans Frontiieres (MSF) published in the January 17th edition of The Lancet.

MSF is calling on international bodies such as the World Health Organisation (WHO) and the World Bank to ensure that Russian TB control comes up to internationally agreed standards, warning that unless such action is taken any donations to fight TB in Russia could do more harm than good.

From 1996 to September 2003 MSF worked in Siberian prisons, with the agreement of the penal authorities, to provide WHO-led directly observed (DOTS) TB therapy. Approximately 22% of new TB, and 40% of re-treatment cases treated by MSF doctors involved multi-drug resistant tuberculosis (MDR-TB). Expensive treatment options involving costly second-line TB drugs for up to two years were not available to the MSF physicians.

Glossary

multidrug-resistant tuberculosis (MDR-TB)

A specific form of drug-resistant TB, due to bacilli resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs. MDR-TB usually occurs when treatment is interrupted, thus allowing organisms in which mutations for drug resistance have occurred to proliferate.

second-line treatment

The second preferred therapy for a particular condition, used after first-line treatment fails or if a person cannot tolerate first-line drugs.

drug interaction

A risky combination of drugs, when drug A interferes with the functioning of drug B. Blood levels of the drug may be lowered or raised, potentially interfering with effectiveness or making side-effects worse. Also known as a drug-drug interaction.

strain

A variant characterised by a specific genotype.

 

cure

To eliminate a disease or a condition in an individual, or to fully restore health. A cure for HIV infection is one of the ultimate long-term goals of research today. It refers to a strategy or strategies that would eliminate HIV from a person’s body, or permanently control the virus and render it unable to cause disease. A ‘sterilising’ cure would completely eliminate the virus. A ‘functional’ cure would suppress HIV viral load, keeping it below the level of detection without the use of ART. The virus would not be eliminated from the body but would be effectively controlled and prevented from causing any illness. 

In order to obtain quality therapy capable of achieving a cure, MSF and the regional Russian authorities submitted an application to the Green Light Committee, which was accepted and would have enabled the aid agency to provide recognised MDR-TB treatment to 150 Siberian prisoners.

The Russian Health Ministry rejected MSF’s application to use the drugs, however, even though the treatment regimens met internationally agreed standards, stating that the proposed treatments contradicted the guidelines of the Russian Pharmaceutical Committee. What’s more, the Russian health authorities classified the treatment regimen as “experimental” and therefore forbidden under penal law.

Russian drug legislation forbids the use of some second-line TB drugs. This legislation is completely out of step with recognised international treatment principles on the drugs to be used for MDR-TB and the duration of therapy.

MSF say that “to comply with the existing drug legislation, we were effectively being asked to implement a treatment strategy for MDR-TB that contradicts the basic treatment principles outlined by WHO.” Therefore, MSF pulled out of Siberia in September 2003.

The difficulties encountered by MSF in Siberia do not, however, appear to be a one-off. In 2003 Russian health authorities published protocols for Russian doctors for standard and MDR-TB therapy. These protocols, approved by WHO, should have meant that Russian TB control incorporated international treatment standards, an essential requirement for a substantial World Bank loan for TB control.

”We now know”, say MSF, “that, at least for MDR-TB these standards are not being met.” This means that for about a year some Russian regions have been using second-line TB drugs without “clear guidelines, appropriate infrastructure, trained personnel, and with non-existent follow-up for released patients under treatment.” MSF warns that this means “an increased risk of creating super resistant TB” and calls on WHO and the World Bank to take action.

”Future control of TB in Russia is in the balance” conclude MSF, adding “the donor community runs the risk of doing more harm than good.”

Further information on this website

Tuberculosis - overview

Tuberculosis, public health and the need for ARVs - news story

AIDS Treatment Update, January 2003 - includes information on the interaction between TB and HIV in Russian prisons

References

Lafontaine D et al. Treatment for multidrug-resistant tuberculosis in Russian prisons. The Lancet 363, 246 – 247, 2004.