Tuberculosis (TB) is a disease of immunouncompetent patients (see fig. 1-7). In the 21th century immunodeficiency is primarily associated with the human immunodeficiency virus and condition defined as AIDS (acquired immunodeficiency syndrome). Predisposing conditions of tuberculosis are well-described in medical literature and include starvation and malnutrition, imprisonment, general bad conditions of hygiene and habitation, diabetes, the high levels of stress of warfare and immigration, chronic viral and multietiological infections. All these factors and triggers are interconnected in their pathogenesis nature. Genetic versatility and variability of tuberculosis mycobacteria pose a challenge of multiresistance, which is a difficult task to solve in the real practical conditions lacking expensive drugs and microbiology sensitivity tests.
The Republic of Belarus is a country in Eastern Europe which gained independence after the breakdown of the Soviet Union in 1991. The total population is 9.7 million, 71.5% lives in towns. The Gross National Income is USD (United States dollars) 4,220 per capita. Tuberculosis is an important public health problem and one of the eight priority programs of the Ministry of Health. The WHO (world health organization) case notification rate (new cases and relapses) was 61 per 100,000 populations in 2007. Belarus also suffered from the Chernobyl disaster and 24% of the territory was polluted. Although there is no direct link between the radiation and TB infection, the territories significantly poisoned by Chernobyl are also seriously affected by TB. This fact is explained by migration of people, poverty level and staff drain of public healthcare professionals.
In 2009 we have registered 4441 new cases of tuberculosis, what constituted 47.9 per 100 000 of population and of 11.8% less than in the year 2005. During the recent 5 year period we have estimated double decrease in pediatric tuberculosis morbidity (from 156 to 72). Mortality from tuberculosis in comparison to the year 2005 has decreased, showing the reduction value of 33.1%. In particular, in the last year the rate of this decrease was 5.8%.
Tuberculosis is more often occurs in prisoners subjected to a severe jail conditions. The population of female and teenage criminals shows a less degree of tuberculosis incidence than in the respective adult male cohort.
Starting from the year 1991, we estimated a deterioration of the tuberculosis epidemiology rates. Thus, in 2005 MDR (multi drug resistant) TB rate represented 9.9 % of all newly detected cases, and in 2007, this parameter was 15.9%. During the decade 1991-2000, general tuberculosis morbidity increased by 62.0%. During the interval 2002-2005 tuberculosis morbidity rate (according to the data of all statistical departments) had grown from 51.7 in 2002 to 54.3 per 100 000 population in the year 2005. In 2007 the share of MDR TB cases among all smear positive cases was 40.6%. MDR TB situation in the penitentiary system of Belarus is aggravating and since 2003 the share of MDR TB cases grew from 17.6% up to 38.2% in 2007.The MDR TB Problem is relatively new to Belarus, and thus the country does not possess the experience necessary for successful MDR TB treatment. The first attempt to cure this complicated form of tuberculosis in a small cohort of patients was only made in 2006. There are many problems these activities encounter, including the difficulties the laboratory network has in MDR TB diagnosis, the scarcity of drugs for MDR TB treatment, and inpatient departments for MDR TB treatment that does not meet international requirements in respect to safe ventilation and conditions of hospitalization terms. A wide range of activities is needed aimed at training medical professionals and increasing medical knowledge, as well as the development and publication of MDR TB treatment protocols that would comply with international standards
The elevation in occurrence of the primary drug resistance and the multiresistance of tuberculosis microbe to antituberculosis medications and the increase in cases of HIV (human immunodeficiency)-associated tuberculosis represent negative trends in tuberculosis epidemiology in our country. In the year 2002 we estimated 65 patients suffering these two serious diseases, and in the beginning of 2010 this number was as high as 1262.
The estimated rate of multiresistant tuberculosis incidence was 16.1% in 2007 and 22.4% in 2009. The respective numbers for patients who had received antituberculosis treatment were 36.6 and 47.9 percents. According to these data, Belarus has a third leading place having the highest multiresistant tuberculosis incidence rates and a tenth place in the amount of patients who had been subjected to treatment before the diagnosis of multiresistant tuberculosis.
DOTS (directly observed therapy strategy) is the official strategy for TB control in Belarus. Its introduction started in late 2001 and has expanded to cover the entire country by the beginning of 2005, including the penitentiary sector. The Ministry of Health has the overall responsibility for TB control in the country. It undertakes this function through the health departments of the Regional Executive Committees and the State Institution “National Research Institute of Pulmonology and Phthisiology”, and involves the Ministry of Interior and other governmental entities. These institutions collaborate with international partners in the planning, implementation, monitoring and evaluation of activities. TB control interventions are delivered through a network of specialized TB service institutions and PHC (Primary Health Care) services. PHC providers have been involved in TB control activities according to DOTS strategy since 2003.
At the present time, antituberculosis activities are performed in the framework of the current “Tuberculosis” governmental program designed and established for the 2010-2014 interval. The principal objective of this activity is to provide the embodiment of civilian rights for the health security through the ways of decrease and prevention of tuberculosis infection expansion and via the other actions for the improvement of epidemiological situation.
The task to decrease the mortality and morbidity due to the multiresistant tuberculosis is among the major goals of this program. The proposed budget of this governmental grant is 280.1 000 000 000 Br (Belarusian rubles).
The list of accomplished activities performed for the aims of antituberculosis war include the establishment, implementation and an application of diagnostic and treatment guidelines and protocols designed in accordance with the WHO recommendations and the results of the local scientific research, the reconstruction of hospital resources with the increase in capacities for patients having multiresistant tuberculosis and for those epidemiologically hazardous patients forced to involuntary isolation and treatment after the decision of the court.
It is felt that substantial progress has been achieved in TB control in Belarus over a short period of time since DOTS introduction, in particular, in terms of:
- Improved TB case detection;
- Uninterrupted supply of 1st line anti-TB drugs;
- Strengthened and regionalized TB laboratory network;
- Reliable system of recording and reporting, effective program monitoring and evaluation under development;
- Successful implementation of the Global Fund support and effective collaboration and coordination between the partners.
The improvement of tuberculosis epidemiological situation was done thanks to the increase of attention to this problem from the side of society and government.