Medicine/12. Infectious diseases.
Volgograd State Medical University, Russia
Pressing problems of tuberculosis management
Morbidity rate of the population in the Volgograd region was 70.3 per 100000 in 2012 which is considerably less than in 2000 (82.6). The reduction in tuberculosis mortality rate has been insignificant for the last few years. Tuberculosis transmission depends on socioeconomic factors more than on medical ones. Migration is one of the risk factors. Human migration has a negative impact on the spread of disease in the region. The shift in migration from the regio with elevated TB prevalence has combined to affect markedly the epidemiology of the disease in our region.
One of the most effective means in up-to-date cure of TB is a diagnostic evaluation of population including fluorography, bacterioscopy and tuberculinazation. Such measures are used to assess the work of health care facilities under the “Health” state project. The portion of persons with tuberculosis revealed on examination has been increasing gradually compared with the period when “Health” state project started. In 2004 it accounted for 50.7%, but in 2012 the value was 65.4%.
Bacterioscopy is a pressing issue in case detection among patients presenting with symptoms of TB in health care facilities. The number of individuals with tuberculosis revealed by means of bacterioscopy increased from 1.0% in 2004 and to 7.6% in 2011 correspondingly. The state of TB detection by direct bacterioscopy is too low which indicates that primary health care specialists are not interested in early TB detection.
Thus, in the Volgograd region fluorography is a major diagnostic procedure in tuberculosis. The number of patients who had undergone fluorography turned out to be 2 times greater in 2012(90.0%) compared with 2004. Mobile photofluorography units are used not only to monitor populations but to enhance the availability of this procedure to remote districts in Volgograd region.
Thus, in Russia, most TB cases are revealed by fluorography.
Morbidity, mortality and transmission are epidemiological indexes in tuberculosis at the regional level. Patients aged 25 -50 are more susceptible to TB. Male patients who have been exposed to TB primary constitute 67%. Socioeconomic damages due to tuberculosis are essential. High morbidity rate at the age of 25-50 is a prognostic sign for progression TB in future.
Analysis of age dependence showed that patients’ age structure had changed for the last three years. Young patients have become more susceptible to TB. Infiltrative –pneumonic lung tuberculosis is more common among clinical forms.
Mortality rate is the most informative index used to define an epidemiological level. Tuberculosis mortality rates in the Volgograd region were 15.0% per 100 000 inhabitants in 2006 and 10.8%% per 100 000 inhabitants in 2012, correspondingly. Tuberculosis mortality rate is the highest among able-bodied population (72%). It should be emphasized that tuberculosis is not only a medical and social issue, but also an economical one. Children’s mortality is not registered in our region.
The data on tuberculosis transmission are under discussion. The trend towards a decline is observed but the value is still high compared with the Russian Federation. Tuberculosis transmission was 346.6 per100 000 inhabitants in 2000 and 264.1 per 100 000 inhabitants in the Russian Federation correspondingly. This value was reduced to 224.3 per100 000 inhabitants by 2012.
Although the value is higher on average compared with the Russian Federation, it shows that TB specialists do not easily declare the patient healthy or refer him to district doctor care and sophisticated epidemiological situation at the regional level.
Social maladjustment was marked in 54% of patients with recurrent tuberculosis. Infiltrative –pneumonic lung tuberculosis is prevalent in patients with recurrent tuberculosis, and 10% of patients show disseminated and fibrocavitary tuberculosis.
Disease recurrence is characterized by an extensive lung involvement causing atropholysis of pulmonary tissues and bacterioexcretion. Treatment of patients with recurrent tuberculosis requires higher costs. Patients discharged to out-patient care have to be seen at regular intervals by phthisiatricians. Patients with mycobacterium tuberculosis are hospitalized in the first term. Thus, 91.9% of patients with mycobacterium tuberculosis were hospitalized in 2012 and only 83.3 % of patients with primary tuberculosis.
An urgent and pressing issue is to manage patients avoiding treatment. Cooperation of antituberculous services with law institutions plays an important role here. The number of patients brought an action against turned out to be three times more compared with 2005 and accounts for 237. Involuntary commitment submitted by a court increased by 2.5 times compared with 2005 and now it is 159. The number of patients who was forced to involuntary commitment turned out to be three times greater.
Involuntary commitment is a legal process established and practiced by courts but involuntary treatment is not legitimated, so imperfect national law leads to negative results.
The issue of managing patients avoiding treatment and compliance should be tackled to achieve greater results in antituberculous measures.
Thus, tuberculosis transmission is not only increasing the number of TB cases in people this process also reflects the socioeconomic situation which is an overall index of social development. Both efficacy of antituberculous measures and some changes in social standard of living and environment have an impact on the disease.