Press release of the V Annual Conference of Moscow TB doctors
of the V Annual Conference of Moscow TB doctors
«Preventive anti-tuberculosis activity in a megapolis: volume, costs, efficiency»,
Moscow, September 14-15, 2017
Anti-tuberculosis activity organization in Moscow is based on 90-years old experience of Russian phthisiology in view of the main provisions of the WHO Stop TB Strategy, 2016-2035.
On the eve of the First Global Ministerial Conference of the WHO, the V Annual Conference of Moscow phthisiatricians «Preventive anti-tuberculosis activity in a megapolis: volume, costs, efficiency» with the participation of leading specialists of almost 50 subjects of the Russian Federation was held. It demonstrated achievements of a new model of anti-tuberculosis care organization for the capital population.
The steady decline of the morbidity rate in the capital resident population together with increasing migration processes and the maintenance of the imported tuberculosis risk predetermined the necessity to change traditional approaches to anti-tuberculosis activity. In 2012 the new organizational model creation based on the five components started:
1. Integration of medical organizations.
2. Decrease in the number and reorientation of hospital beds.
3. Centralization of basic services management: dispensary, hospitalization, personnel, laboratory, pharmacy, pathoanatomical ones.
4. Strengthening of the administrative personnel with highly qualified specialists and creating of a continuous system of the knowledge and skills improvement for anti-tuberculosis institutions’ specialists together with the involvement of leading scientists from higher education institutions, non-profit public organizations, as well as registration of an own scientific periodical.
5. Monitoring of the epidemiological situation, control of all the activities by the chief TB of the Moscow City Department of Health.
Within five years the new model has allowed to change five directions in the anti-tuberculosis care organization:
1. The emphasis is shifted from inpatient to outpatient care providing phthisiatricians control over the mostly endangered TB risk groups in the capital - homeless people, HIV-infected persons, migrants. The TB doctor’s rooms were organized on the basis of the AIDS Center, the Center for Social Adaptation «Lublino», the Migration Center.
2. The method of identifying TB patients among adults has been changed. A broad screening using digital X-ray and sputum smear microscopy in coughing and low-mobile residents have been complemented by risk group examination for latent TB infection using immunological analysis and subsequent computed tomography of the chest. Sputum microscopy has been replaced by molecular-genetic methods to detect bacterial excretion. In addition, in order to find the source of the infection, method of fluorography examination of the environment of children with latent TB infection has been started to use.
3. A new methodology for work in the TB infection nidus locations is applied with the use of cartography method, by examination of the first, second and third circles of contact persons in co-operation with city polyclinics for children and adult population. A detailed epidemiological investigation is conducted with the search for all possible contact persons. The average number of examined people from the environment of a patient with bacterial excretion increased from 4 to 38 persons. Final disinfection in medical organizations in cases of identified TB infection is carried out under direct monitoring of the Moscow City Department of Health. In domestic nidus location, the area of the final disinfection has been expanded to an apartment building entrance. The TB incidence rate in such nidii decreased 41-fold and became 2.6 times lower than the territorial level.
4. Chemoprophylaxis of the disease to the persons with latent infection and from contact with TB patients reduced the probability of active TB forms development in the most vulnerable group of risk - those with latent TB infection. During 2016 it allowed to reduce the TB incidence among permanent residents by 11.7%, among children - by 23.8%. The increase by 1.4 times in the chemoprophylaxis coverage of adults reduced the need for chemoprophylaxis of children by 1.8 times.
5. The approaches to etiotropic treatment of severe, previously incurable patients with MDR and XDR TB have been improved: new chemotherapy regimens with Bedaquiline and Linezolid were developed and implemented, surpassing in 1.4 times the standards accepted in the world practice (according to the WHO data) and allowing to stop bacterial excretion in 88% of previously practically incurable patients. The Department for Patients’ Social, Psychological and Legal Assistance has been created, including those who evade treatment; it allowed to reduce the number of patients who voluntarily interrupted chemotherapy to the minimum figures (2 people for the eight months in 2017, at the same period in 2016 - 6 people).
Results: Expansion of preventive work with risk groups, strengthening of work in nidus locations, chemoprophylaxis in persons with latent TB infection and persons from risk groups led to a 11.7% decrease of TB incidence rate in Moscow resident population during 2016. The intensification of preventive work with the migratory population in the territory of the city made it possible, during the same period, to reveal additionally only among foreign citizens 1,605 TB patients who were not given a permission for work or residence.
As a result, the prevalence of tuberculosis with bacterial excretion (infection «reservoir») decreased from 18.1 to 10.2 per 100 000 population and is minimal in the country. Over the past five years, the number of registered patients with MDR TB has decreased by 44% (to 3.4 per 100 000 of the population), also reaching the lowest level in the country.
Reduction and re-profiling of hospital beds along with increased staffing of specialists led to an increase in surgical activity, the introduction of high-tech methods of surgical interventions, a decrease of lethality, including postoperative one. The organization of a unified Consultative and Diagnostic Center and a Central Medical Commission made it possible to streamline the diagnostic process, to reduce in times the number of registered patients with extrapulmonary TB.
Reduction of the infection reservoir in the city and effective epidemiological control contributed to a significant decrease of the TB incidence rate in children (by 23.8%) and HIV-infected (by 10%) in 2016. The TB prevalence in children in Moscow was 4.5 per 100 000 of the population, which equates to the prevalence of orphan diseases. The prevalence of HIV/TB co-infection has decreased by 32% since 2012, the death rate from HIV-infection in combination with mycobacterial infection - by 14.3%.
The incidence of the resident population in Moscow (12.8) has decreased to the TB incidence in a number of developed countries, such as France (10), Spain (12) and Japan (17) [WHO, 2015].
In 2016, the TB death rate was 2.5 per 100 000 of the population. Since 2012, the number of TB deaths in the capital has decreased by 22%.
The main epidemiological TB indicators in Moscow according to 2016 are significantly lower than in the Russian Federation: mortality – in 3.7 times, incidence – in 1.8 times, prevalence – in 3.9 times, which contrasts with the reverse situation in European cities (London, Paris, Milan, Barcelona, Berlin, etc.) and confirms the effectiveness of the selected model of anti-tuberculosis activity in Moscow.