TB in Russia’s prisons is now mostly resistant

DOTS may be making things worse, not better

Most TB cases in prisons in countries throughout the former Soviet Union, including Russia, are now resistant to at least one drug, with about a fourth of all cases among prisoners resistant to at least two frontline drugs, says Michael Kimerling, MD, MPH, medical director for the Russian TB program of the New York City-based Public Health Research Institute (PHRI). He also is a consultant to the Belgian arm of Medicins Sans Frontieres, which is working to fight TB in Russian prisons, as well.

"The epidemiology of MDR-TB is enormous, and DOTS [directly observed therapy, short-course] as it now exists is inadequate," he says. "What you’ve got in the prisons is actually a dual epidemic: one of drug-sensitive TB and another of drug-resistant disease. But it’s resistant disease that’s taking over."

The more epidemiologists look, the more they are finding the same rates of resistant and multidrug-resistant (MDR) disease are starting to turn up in other countries that make up the former Soviet Union, he adds. "What we are seeing are the same patterns and the same problems in Russia as in Azerbaijan and Kazakhstan."

Resistant forms of TB continue to spread beyond the prisons, he adds. At present, only the Siberian oblast, or province, of Tomsk is providing consistent follow-up to prisoners once they have been released into the community. Outside the prisons, the rate of multidrug-resistant TB is about 5% to 7%, according to available data, Kimerling says. (That compares to about 1.4% MDR among all cases in the United States, according to the most recent available figure.)

Inside Russian prisons, the situation is much worse. "About 20% to 30% of cases that are culture-proven are MDR-TB," says Kimerling. "And in another proportion of cases, we’re seeing intermediate resistance patterns. The result is that in Tomsk, only about 30% of all TB cases in the prisons are pan-sensitive" — that is, responsive to all frontline drugs.

In Kemerovo, a region adjacent to Tomsk where Kimerling also has been gathering data, rates of pan-sensitive TB inside prisons appear to be closer to 40%, with resistant strains accounting for the remainder. The irony is that under such circumstances, DOTS is actually worse than useless, since its application is creating more resistance, he says. It has taken nongovernmental organizations (NGOs), such as PHRI or the Massachusetts-based Partners in Health, to point that out, he adds.

"The World Health Organization can’t afford to take that kind of position. It takes an NGO or a private donor like [George] Soros to take that kind of risk and to be willing to think outside the box, and that’s critical to making the necessary adjustments to any program," he says.

Being able to envision unconventional solutions such as DOTS-Plus, which the new paradigm developed by Partners in Health has been dubbed, doesn’t solve the problem, Kimerling adds. "In Russia, you don’t have a national program; it’s difficult to build a DOTS-Plus program where you don’t even have DOTS. So you have to develop the infrastructure and build a DOTS-Plus program all at the same time. That makes it all a lot more complicated and prevents you from moving as quickly as you’d like to be."