Cablegate: Russia: Tuberculosis Cases Stabilizing, but Drug Resistance

DE RUEHMO #4543/01 2600331
R 170331Z SEP 07





E.O. 12958: N/A

REF: Moscow 2487

MOSCOW 00004543 001.2 OF 003


1. (SBU) SUMMARY: Increased Russian Government attention to TB
control and treatment in recent years, and regional pilot programs
involving international donors and experts, are helping to turn the
tide in Russia's battle with TB. Tuberculosis (TB) cases in Russia
have recently stabilized within the general population, albeit at a
high level, and are dramatically declining within prisons. However,
multi-drug resistant TB (MDR-TB) cases have been gradually
increasing, while the prevalence of extensively drug resistant TB
(XDR-TB) is still unclear. Cases of TB/HIV co-infections are
steadily rising, suggesting that Russia's HIV epidemic is also
beginning to drive the TB epidemic. The Russian Government and
international donor community should next focus on targeted programs
aimed at studying, controlling and effectively treating
drug-resistant forms of TB and TB/HIV co-infections. END SUMMARY.

2. (U) The World Health Organization (WHO) ranks Russia twelfth on
the list of the world's 22 high burden TB countries. According to
statistics published by the Ministry of Health and Social
Development (MOHSD), Russia registered 117,646 new cases of TB in
2006 (a rate of 82.4 cases per 100,000 people), a decline of 1.3
percent compared to 2005. Among the general population, there were
96,867 new cases recorded (67.9 cases per 100,000 population). TB
mortality has modestly declined in recent years from 21.9 deaths
recorded per 100,000 population in 2002 to 19.5 deaths per 100,000
in 2006.

TB Situation Most Acute East of the Urals

3. (U) TB incidence and mortality are most acute east of the Urals.
In 2006, newly registered TB cases in Siberia stood at 131.6 cases
per 100,000 population, and there were 37.3 deaths from TB per
100,000 population -- the highest rates in Russia. New TB cases in
the Russian Far East (RFE) stood at 127.8 cases per 100,000
population, while there were 33 deaths from TB per 100,000 (the
second highest rates in Russia). The incidence of TB among children
aged 0-14 years is also highest in Siberia and the RFE with 29.2
cases per 100,000 reported in Siberia in 2006, and 26.5 cases per
100,000 in the RFE. (NOTE: Russia-wide TB incidence rates among
children have been flat over the past five years, and stood at 16.1
newly registered TB cases per 100,000 children in 2006.)

4. (SBU) As many as 10-15 percent of patients refuse to begin taking
medication when they are initially diagnosed with TB, according to
doctors at the Federal TB Center in Novosibirsk, which treats the
most difficult TB cases from Siberia and the RFE. TB clinics and
doctors could in theory resort to the Russian court system to
quarantine patients and compel them to undergo treatment, but in
practice it is virtually unheard of for a local prosecutor to take
on a public health enforcement action.

5. (SBU) Thanks to increased government funding and financial
support from the World Bank and Global Fund, many of Russia's
federal TB centers and regional clinics are now well-equipped with
modern diagnostics, testing and treatment equipment. However, it is
often difficult to attract doctors, nurses and lab technicians to
specialize in TB and other pulmonary ailments. The salaries for TB
specialists are not particularly attractive, even with the extra
hazard pay they receive for working with infectious patients.

Behind Bars, TB Situation Has Improved

6. (U) Despite the fact that the TB situation in prisons has
dramatically improved over the last seven years, a Russian prisoner
today is still nearly five times more likely to have active TB than
a civilian. There were 47,431 active TB cases in Russia's prison
system in 2006, and 14,823 new TB cases were recorded within the
penitentiary system in 2006 (1,387 cases per 100,000 inmates).
(Note: The total number of prison and civilian cases does not quite
equal the overall number of TB cases, because Russia tracks
additional categories of registered cases, including TB among the
police, military, and foreign citizens.) The prevalence of prison
cases has steadily declined every year since 1999, when there were
4,347 TB cases for every 100,000 inmates. TB mortality has also
dramatically declined, from 238 deaths per 100,000 inmates in 1999

MOSCOW 00004543 002.2 OF 003

to 79.1 deaths per 100,000 in 2006. The USG provides financial
support to the International Federation of the Red Cross to fund TB
programs in Russia's prison system operated by the Russian Red
Cross, one of the few organizations (along with the WHO and the U.S.
NGO Partners in Health) that is permitted to work with Russian
prison populations. TB control programs have been successful in
reducing the share of TB cases within the penitentiary system from
29.l percent of all TB cases in 1999 to 12.1 percent in 2006.

--------------------------------------------- ------
MDR-TB Gradually Increasing, XDR-TB Picture Unclear
--------------------------------------------- ------

7. (SBU) Multi-drug resistant TB (MDR-TB) cases have gradually
increased over the past seven years from 6.7 percent of all new TB
cases in 1999 to 8.1 percent in 2004, and to 9.4 percent in 2006.
The official statistics are only approximations of the actual share
of MDR-TB cases in Russia, because some regional labs do not have
the capacity to perform sensitivity tests to distinguish MDR-TB from
normal TB, quality control issues at other labs call into question
the accuracy of their results, and not all patients are tested for
the presence of drug resistant strains of TB.

8. (SBU) The gradual increase in MDR-TB cases is partly attributable
to patients' failure to adhere to the full course of TB antibiotic
treatment. Many TB patients are from socially marginalized groups
such as alcoholics, ex-prisoners, and the homeless, who generally do
not access the health care system and find it difficult to adhere to
a full course of TB treatment. Another major difficulty is ensuring
that released prisoners continue treatment. Prisoners with active
TB are segregated from the regular prison population and rigorously
take their medicines (otherwise, according to some of our health
contacts, they would likely be punished by guards or prison
administrators). However, experts estimate that about 40 percent of
paroled inmates never show up at a civilian TB clinic after their
release to continue taking medication and for follow-on treatment.

9. (SBU) There is no comprehensive data on the prevalence of
extensively drug resistant TB (XDR-TB) in Russia, though there is a
limited amount of data available from regional studies. Data from a
2006 USG-funded WHO study of 102 long-term TB patients in Orel
Oblast found that 56.7 percent of those cases were diagnosed with
MDR-TB, and 18.9 percent of the MDR-TB cases also met the WHO
definition of XDR-TB. A similar 2006 WHO study in Vladimir Oblast
found no evidence of XDR-TB among 35 newly registered TB patients,
but XDR-TB was detected in nine out of 132 chronic TB patients.
Studies in Tomsk Oblast found that 5.1 percent of 611 patients
enrolled in a cohort study between September 2000 and September 2004
had XDR-TB at the start of treatment. The USG is currently
considering supporting a nationally representative drug resistance
survey in FY08 and FY09 to identify the magnitude of the drug
resistant TB problem nationwide.

Rising Tide of TB/HIV Co-Infections

10. (U) Russia's fast-growing HIV epidemic may be starting to fuel
TB infections. TB is the leading cause of death among people with
HIV/AIDS, accounting for 59 percent of all deaths among this group
in 2006. The number of TB/HIV co-infections has risen from 2,524
cases registered in 2002 (0.6 percent of all TB cases), to 9,102
cases in 2006 (3.1 percent of all TB cases). Likewise, the 3,907
new TB/HIV co-infections detected in 2006 represent 3.3 percent of
the 117,646 new TB cases detected in 2006. Within prisons, TB/HIV
co-infections have risen from four percent of all TB cases in 2002
to six percent of all cases in 2006.

--------------------------------------------- ---------
Government Spending Up, International Programs Working
--------------------------------------------- ---------

11. (U) Russian Government spending on infectious diseases,
including TB, has increased significantly in recent years. Under a
federal program targeting socially significant diseases, the Russian
federal and regional governments together spent $220 million on TB
control and treatment in 2006, according to the WHO, and will spend
a similar amount in 2007. As the WHO noted in its March 2007 TB
assessment for Russia, Russian budgets for TB control are "much
higher" than in other high burden TB countries.

12. (SBU) World Bank and Global Fund financial support, and regional
pilot programs involving international donors and experts, are also

MOSCOW 00004543 003.2 OF 003

helping to turn the tide in Russia's battle with TB. As the WHO
noted in its March 2007 TB Assessment for Russia, "The current
positive momentum in TB control in the Russian Federation is partly
due to the successful implementation of a number of pilot projects
carried out in selected oblasts, supported by international
technical partners." Through 2006, the WHO revised TB control
strategy of Directly Observed Therapy Short Course (DOTS) has been
officially adopted in 85 out of 88 Russian regions with the support
of World Bank and Global Fund grants, but implementing a
comprehensive DOTS system will remain challenging in many regions.
New TB treatment standards and new TB reporting requirements have
been implemented in 68 Russian regions which cover 83 percent of
Russia's population.

13. (U) The American NGO Partners in Health has introduced
aggressive case management systems to improve treatment for MDR-TB
patients and non-adherent TB patients in Tomsk Oblast (Siberia),
which have led to improved cure rates. Partners in Health's TB
training center in Tomsk has trained over 215 Russian doctors in the
best methods of treating MDR-TB. The center also completed two
clinical studies of MDR-TB patients that led to the release of new
MDR-TB treatment guidelines in May 2006, backed by both the WHO and
the Centers for Disease Control and Prevention (CDC) in Atlanta.
Innovative USG-supported TB programs have helped Orel Oblast halve
the total number of TB cases between 2003 and 2006, and achieve an
81.2 percent treatment success rate (significantly higher than the
national average of 57.2 percent). Eli Lilly's MDR-TB Partnership
in Russia has helped to strengthen domestic TB drug production
capacity by transferring the know-how to produce MDR-TB drugs to SIA
International, one of Russia's leading pharmaceutical companies

14. (SBU) COMMENT: As the WHO noted last March, "Major efforts are
still needed" in Russia "to address the threat of MDR-TB and
extensively drug-resistant TB and of TB/HIV, as well as to start
involving the community in TB control." In the wake of recent
incidents where international travelers with drug resistant TB
entered the United States, TB control and treatment efforts should
remain a key part of USG and other international partners'
collaboration with Russia on infectious diseases.


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