An approach to estimating tuberculosis incidence and case detection rate from routine notification data.

OBJECTIVE: To estimate tuberculosis (TB) incidence and case detection rate (CDR) using routine TB surveillance data only. METHODS: A mathematical model of the case detection process, representing competition between disease progression and case finding, is proposed. The model describes disease progression as a two-stage process (bacillary and non-bacillary TB), and so relates the proportion of bacillary TB cases on detection to the effectiveness of detection. Thus, given the annual numbers of newly detected TB cases stratified by bacillary status, the model estimates detection rates, incidence and CDR. Routine notification data from eight provinces in Russia, 2000-2011, were used for the study. RESULTS: Subnational level estimates of incidence and CDR were obtained. Incidence estimates varied by two-fold among the provinces; corrected CDR estimates varied by 1.5 times. The trend in the incidence estimates was similar to that in the World Health Organization estimates for the whole of Russia. The change in the trend in WHO CDR estimates in 2008-2009 was not supported by our estimates. CONCLUSION: The general approach that uses multistage models of disease progression and accordingly stratified notification data can be applied in various settings for the routine estimation of incidence and CDR.

[The ocular tuberculosis epidemic situation in the Sverdlovsk Region].

In the Sverdlovsk Region the proportion of extrapulmonary tuberculosis reduced from 9.7 +/- 0.2% in the 1990s to 3.8 +/- 0.2% in 2001-2007. The notified cases of extrapulmonary tuberculosis do not reflect the real situation. Ocular tuberculosis (9.6 +/- 0.49%) ranked fourth in the pattern of extrapulmonary tuberculosis, next to tuberculosis of the urinary tract (48.9 +/- 0.83%), peripheral lymph nodes (20.3 +/- 0.67%), and bones and joints (15.8 +/- 0.6). In 2001-2007, there was a rise in ocular tuberculosis morbidity and proportions in the pattern of extrapulmonary tuberculosis, the highest morbidity (0.75 per 100,000 population) being registered in the large towns of the Sverdlovsk Region. Uveitis amounted to 90.9 +/- 1.47% among all the clinical forms of ocular tuberculosis, posterior ocular vascular tunic lesion being most common (56.97 +/- 5.97 to 71.8 +/- 7.2%). In 2001-2007, there was an increase in the common forms of tuberculous uveitis up to 10.6 +/- 2.89%.

[To the program on state guarantees to deliver free medical aid to Russia's citizens in tuberculosis facilities].

The program on state guarantees for free medical aid to Russia's citizens in tuberculosis facilities shows too high standards for round-the-clock adult tuberculosis inpatient beds. Tuberculosis sanatorium beds that are also round-the-clock stay beds and should be a part of the federal standard are disregarded. Hospital-replacing technologies have been inadequately developed in the antituberculosis service. There is an excess of pediatric tuberculosis sanatorium beds that serve mainly for social, rather than clinical indications.

[Monitoring of tuberculosis recurrences: their causes and precipitating factors].

Introduction of unwarranted shorter courses of chemotherapy, physicians' decreased attention to pathogenetic treatments, nonadherence to the standard of examination while transferring to a further follow-up of clinically cured patients have increased a risk for early tuberculosis recurrences. In the years ahead, there may be a further rise in the number of late recurrences in the general population of the Russian Federation as preventive measures have deteriorated amongst the tuberculosis-cured individuals after their referral for the general health care system. The persons who have experienced tuberculosis and stricken off the register in a tuberculosis dispensary more than 5 years ago make up a late recurrence risk group.

[Female tuberculosis morbidity and mortality in the Sverdlovsk Region].

In 2000 to 2006, the female proportion increased in the structure of tuberculosis morbidity from 21.4 to 30.1% and in that tuberculosis mortality from 13.1 to 21.4% in the Sverdlovsk Region. Female tuberculosis morbidity increased mainly at the age of 25-34 years (by 50.9%) and 35-44 years (by 66.0%) and tuberculosis mortality by 2.7 times and 42.1%, respectively. The increase was due to the proportion of socially poor unemployed women. Pregnancy and lactation worsened the course of tuberculosis resulting in death in 1.3% of young women. Of the greatest importance was a patient's poor social status: only 6% of the women with tuberculosis leading to death were employed; 2.8% were dying. A portion of those who died from tuberculosis were drug addicts (5.4%) and HIV infected (12.3%).

[Hospital-replacing technologies in the treatment and rehabilitation of patients with pulmonary tuberculosis].

The paper presents data on bed reductions at tuberculosis care facilities in the Sverdlovsk Region. These data are compared with those in the neighboring regions. The main topic of the paper is the advantages of a day hospital over those of a day-and-night one. Indications for admission to a day hospital are presented. The 2004 statistical data on the work of a day hospital are given. The paper shows that hospital-replacing technologies are promising in the treatment and rehabilitation of patients with tuberculosis in the Sverdlovsk Region.

[Mortality due to recurrent tuberculosis in the Sverdlovsk Region].

In 2004 to 2005, recurrent tuberculosis in the structure of tuberculosis mortality averaged 21.6% in the Sverdlovsk Region. Predominantly males (84.0%) aged 45 years or more (62.0%) living in small towns and rural areas (56.9%), mainly the unemployed (97.7%), and ex-prisoners (30.3%) die from recurrent tuberculosis. The bulk of the patients (64.7%) survived less than 1 year after notification of recurrent tuberculosis or a recurrence was revealed only after death. Those who died from recurrent tuberculosis had not asked for a medical aid before its detection (23.1%) or had asked three months or more after the occurrence of significant clinical signs of the disease (34.0%). Refusals to be admitted (16.2%) and treated in the outpatient setting (28.7%) and multiple hospital discharges due to incompliance (20.7%) should be regarded as the main causes of progressive tuberculosis among the contingents of a tuberculosis-controlling service contingents dying from recurrent tuberculosis.

[Recurrent tuberculosis in the Sverdlovsk Region].

In 2000 to 2005, there was a 1.8-fold increase in the rate of early recurrences and a 1.6-fold decrease in late recurrences in the Sverdlovsk Region. In the prisoners, early recurrences were 21 times more frequently observed than in the general population, which make up a significant majority of all the recurrences of tuberculosis. In conclusion, during preventive examinations, recurrences are mainly detected with earlier forms of tuberculosis as compared with the recurrences recorded in the municipal entities of the region. In adult males, the rates of primary morbidity were 3.2 times higher in adult males than in females; those of early and late recurrences were 8.1 and 5 times higher, respectively. In adults aged 18-44 years, the rates of primary morbidity and early recurrences of tuberculosis were 1.7 times higher than those in the persons aged 45 years or more; those of late recurrences were 1.6 times less.

[Causes of death from fibrocavernous pulmonary tuberculosis in the Sverdlovsk Region].

In the Sverdlovsk Region, the main reason of death from tuberculosis is a fibrocavernous pulmonary process (51.8%) that is most commonly detected in the postportem diagnosis of tuberculosis (61.9%). Before death, patients with fibrocavernous tuberculosis do not ask for medical aid frequently (73.4%). In the first-year follow-up, most deceased persons come to health care facilities 3 months or more after the occurrence of significant clinical symptoms (60.8%). The refusals of patients to receive in- and outpatient therapy, multiple discharges from hospital due to their incompliance, following by long-term therapy discontinuance, which led to secondary multidrug resistance, were responsible for progressive tuberculosis that was the main cause of death from a fibrocavernous process.

[Tuberculosis and HIV infection in the Sverdlovsk Region].

In 2003, there were 6.9-, 4.6-, and 5.5-fold increases in the prevalence, incidence of, and mortality due to tuberculosis, respectively among the HIV-infected as compared with the HIV-uninfected population (adults and children) of the Sverdlovsk Region. As HIV infection progresses from its preclinical stages to AIDS, the tuberculosis epidemic situation in the Sverdlovsk Region begins to drastically deteriorate with a predominant rise in tuberculosis mortality rates. The large number of tuberculosis-unvaccinated babies born to HIV-infected mothers cause an increase in primary infection with tuberculosis and in its incidence in young childhood.

[Causes of death from tuberculosis in municipal entities of the Sverdlovsk Region].

Before the disease was registered, the first detected patients who died from tuberculosis had not generally turned for medical aid or had turned 3 months or more after the occurrence of significant clinical signs. Before their death from tuberculosis, the contingents of tuberculosis-controlling services of municipal entities were discharged from hospital many times for violation of the inpatient routine; subsequently they did not come to a tuberculosis dispensary and refused to be treated in the outpatient setting. Primary drug resistance, allergic reactions, and intolerability of antituberculous drugs did not play a significant role in the occurrence of death. The patients are themselves guilty in the development of secondary resistance to some drugs.

[Tuberculosis in the prisons of the Sverdlovsk Region].

In 1997 to 2002, the Sverdlovsk Region showed a reduction in the proportion of the accused and prisoners among adults and adolescents from 37.2 to 17.3% in the structure of tuberculosis morbidity and from 18.2 to 3.2% in that of its mortality. In 2003, prophylactic examinations revealed tuberculosis in 95% of the accused and prisoners. As compared with the general population, in adult and adolescent prisoners, morbidity due to tuberculosis was 8 times higher, its relapses were 9 times greater (early and late relapses being 28 and 3 times greater, respectively), its incidence was 9-fold and mortality, 1.3-fold.

[Tuberculosis in children from the Sverdlovsk Region].

The tuberculosis morbidity rate in BGC-unvaccinated infants is 18 times greater than that in BCG-vaccinated infants and 6 times higher than the rate of complications due to BCG vaccination. If a scar due to BCG vaccination is absent or 1-2 mm, the tuberculosis morbidity in children of 3 years of life is 7 times higher than when a 3-mm or more scar has formed after vaccination. The technological failures are main causes of complications due to BCG vaccination. The type of a vaccine (BCG-1 or BCG-M) does not play a substantial role in the development of complications.

[Fibrocavernous pulmonary tuberculosis in the Sverdlovsk Region]. / Fibrozno-kavernoznyi tuberkulez legkikh v Sverdlovskoi oblasti.

Among new cases of fibrocavernous pulmonary tuberculosis and those who have died from it, the proportion of females and subjects with postmortem diagnosis increases and that of prisoners and the accused decreases. The institutions of confinement do not greatly affect the general regional morbidity and mortality due to fibrocavernous pulmonary tuberculosis. The new cases of fibrocavernous pulmonaary tuberculosis and those had died from it were mainly males aged 45 years or older who had a very low social status, lived in large towns and died outside a hospital, which substantiated forensic medical autopsy. Most of them had not consulted a doctor or long followed up for tuberculosis. This led to the fact that postmortem diagnosis was made in 62.6% of the cases.

[Causes and factors of development of drug resistance in pulmonary tuberculosis]. / Prichiny i faktory formirovaniia lekarstvennoi ustoichivosti pri tuberkuleze legkikh.

To prevent secondary multidrug resistance and polyresistance of Mycobacterium tuberculosis (MBT), it is necessary to strictly observe the tested chemotherapy regimens during intensive care by using at least four essential antituberculous drugs (ATD) mainly in combination. The rehabilitative phase should be monitored at outpatient units of a day hospital. To prevent cross MBT infection with drug resistance to essential ATD and to efficiently use expensive reserve drugs, it is necessary to set up specialized inpatient units (wards) for treatment and rooms for outpatient receipt of patients who isolate drug-resistant MBT strains.

[Drug resistance of Mycobacterium tuberculosis in the Sverdlovsk Region]. / Lekarstvennaia ustoichivost' mikobakterii tuberkuleza v Sverdlovskoi oblasti.

In the Sverdlovsk Region, multidrug resistance was observed in greater than 8% of patients isolating bacteria mainly in the residents of cities, former prisoners, those having fibrocavernous tuberculosis complicated by chronic nonspecific lung disease (CNLD). Primary resistance was determined in 4.7%, secondary resistance developing in 57.4% of cases 3 years or longer after the initiation of treatment. The most common cause of multiresistant tuberculosis is irregular treatment, patients' discontinuation of some antituberculous agents, as well as scarce financing of a tuberculosis control service, which prevents the standard treatment regimens from using in tuberculosis. Death due to tuberculosis was largely occurred irregularly treated dwellers of cities, tuberculosis-induced disabled individuals, alcohol abusers, patients with CNLD, or having fibrocavernous tuberculosis resistant to 4-5 antituberculous agents.

[Dispensary registration groups and follow-up periods of patients with silicotuberculosis]. / O gruppakh dispansernogo ucheta i srokakh nabliudeniia bol'nykh silikotuberkulezom.

Silicosis is the most common and most frequently tuberculosis-complicated pneumoconiosis with poor prognosis. So a procedure for following up patients with silicotuberculosis requires revision and elaboration. Long-term follow-ups have made it possible to define early signs of this disease and to propose a number of techniques for its early diagnosis, such as chest computed tomography and polarization serum crystal microscopy. Specific recommendations on follow-ups of patients with silicosis and silicotuberculosis by a phthisiologist are laid down.

[Effectiveness of tuberculosis vaccines]. / Effektivnost' privivok protiv tuberkuleza.

BCG revaccination in the Sverdlovsk Region is performed thrice: at the age of 5, 10 and 15 years. The percent of children covered by tuberculin diagnosis and BCG vaccination is growing. Complications of BCG vaccination remain at the same level. Tuberculosis morbidity in children rises due to minor forms of tuberculosis. However, it is 2 times less than mean tuberculosis incidence in Russia. Primary infection is registered 4.5 times less frequently.

[Tuberculosis morbidity in the Sverdlovsk region]. / Zabolevaemost' tuberkulezom v Sverdlovskoi oblasti.

Childhood and adolescence tuberculosis morbidity rates are higher in girls than in boys. Adult males fall ill 5.3 times more frequently than adult females. Males fall ill with destructive (6.1 times), bacillary (4.1 times), pulmonary tuberculosis (5.3 times) more frequent than females. Females experience extrapulmonary tuberculosis 1.6 times as high as males. Convicts and those under investigation are ascertained to have earlier forms of respiratory tuberculosis than in the general population. At the same time, the facilities of the RF Ministry of Justice do not record extrapulmonary tuberculosis. Goal-oriented work with these facilities has caused a reduction in tuberculosis morbidity in the whole Sverdlovsk region.

[Concept of rendering antituberculosis care to the population of Sverdlovsk Region under present socioeconomic conditions]. / Kontseptsiia okazaniia protivotuberkuleznoi pomoshchi naseleniiu Sverdlovskoi oblasti v sovremennykh sotsial'no-ékonomichskikh usloviiakh.

The regional concept of rendering antituberculosis care to the population includes: the creation of a legal basis by passing a law on tuberculosis, special planning of tuberculosis control measures by adopting a special programme, an interdepartmental approach to rendering antituberculosis care to the population by setting up interdepartmental commission on tuberculosis control, computer-aided tuberculosis monitoring, activities in the prevention and detection of tuberculosis mainly in high-risk groups, the activities of phthisiological facilities by the developed standards and regulations, and the centralization of the antituberculosis drug supply system.