1. Diagnostic algorithms of TB case finding and their effect on TB epidemiology in Russian Regions Andrey Maryandyshev, Elena Nikishova Northern State Medical University Arkhangelsk, Russia

2. Arkhangelsk region of the Russian Federation Area: 578,000 square km Population: 1, 117, 096 people 24 municipal districts 11282 in penal system

3. TB service of the area Arkhangelsk Clinical Antituberculosis Dispensary reference laboratory and 3 in-patient departments for 100 patients: Sensitive TB SS+ 35 MDR/XDR TB SS+ 35 Sensitive, MDR TB SS- 30 Out-patients department 27 municipal tuberculosis ambulatory TB Colony for continuation treatment Regional hospital of penitentiary system - bacteriological laboratory and 2 in-patient departments for 140 patients (sensitive and MDR)

4. TB Incidence including penitentiary system (new cases and relapses ) and mortality in Arkhangelsk Region 2001-2012 (per 100 000 population)

5. MDR TB burden among new cases and relapses consist 35,4% in 2013

6. Rapid Drug Susceptibility Tests implemented BacTAlert– 2004-2009 LPA (Hain Test) in 2009 – DST for 1 and 2 line drugs Bactec MGIT - DST for first line drugs -2010 DST for second line drugs - 2011 Gene Xpert - 2011

7. Algorithm in Arkhangelsk region

9. TB registration in the civil sector of Arkhangelsk region, 2007 – 2013

10. DST results of new TB cases 2007200820092010201120122013 Sensitive 172 178179169181152165 H 38 373934412322 MDR 103969912510411171 R 4522113 H R 55586792866747 H R Km Am Cm 22118145 13 H R Fq 4233554 XDR 3 21134 MDR clinical cases 152017136 2126 No DST results (SS- Culture– and DST not done) 24322821520513912894

11. DST results of patients with relapse of TB 2007200820092010201120122013 Sensitive 15232411251119 H 643444 MDR 15423944524225 R 621 H R 55303134442818 H R Km Am Cm 22744475 H R Fq 4 1231 XDR 3 212 MDR-TB clinically 153331 5 No DST results (SS- Culture – and DST not done) 36222824 122512

12. DST results of patients with category “treatment after loss to follow-up” 2007200820092010201120122013 Sensitive 815411 4 5 H 322 2 2 MDR 66411 R H R 55111 H R Km Am Cm 113 H R Fq XDR No DST results 11321 1

13. DST results of patients with category “treatment after failure” 2007200820092010201120122013 Sensitive 12211 H 111 11 MDR 1211121 R H R 11 111 H R Km Am Cm 11 11 H R Fq XDR MDR-TB clinically No DST results 111

14. Standard regimens for treated all TB patients depending of the DST Group of patients (new case, relapse, treatment after loss follow up, treatment after failure) Intensive Phase Continuation phase Sensitive TB, SM and Culture negative 2 HREZ4 HR Isoniazid resistance TB, including combinations with other TB drugs except for rifampicin 3 R Z E Km Lfx6 R Z E Lfx Multidrug-resistant TB8 Z Km Lfx Pto Cs 12 Z Lfx Pto Cs

15. Treatment outcomes of patients with sensitive TB Regist ered 100% Cured % Failur e% Died from TB% Died not from TB% Loss to follow up% Refus ed from treat ment % Transf erred out% TB not confir med% MDR- TB develo ped% 2007 19566,7 9,71,516,41,54,1 2008 21672,71,47,43,75,63,75,6 2009 20874,51,48,21,96,32,45,3 2010 18384,71,64,4 2,7 0,5 1,6 2011 209 86,10,56,21,93,3 0,5 1,4 2012 168 81,51,87,13,64,8 0,6

16. Treatment outcomes of patients with H resistance. Regist ered Curedfailur e Died from TB Died not from TB Loss to follow up Refus ed from treat ment Trans ferred out TB not confir med MDR- TB develo ped 2007 4746,82,110,66,410,6 4,3 19,1 2008 4445,56,811,44,5 6,8 2,3 18,2 2009 4568,9 4,4 17,84,4 2010 3966,7 12,85,17,7 2,5 5,1 2011 47 76,62,112,82,14,3 2,1 2012 30 83,33,36,73,3

17. MDR-TB treatment outcomes Regis tered Still on treat ment Cure d failur e Died from TB Died not from TB Loss to follow up Refus ed from treat ment Trans ferre d out TB not confir med XDR- TB devel oped 2007 15742,73,221,78,320,41,3 0,0 1,3 2008 146 47,33,413,06,823,32,1 0,02,1 2009 143 50,32,811,97,722,41,43,50,0 2010 171 57,93,511,76,412,92,3 0,02,9 2011 158 0,660,13,210,85,113,91,91,30,02,5 2012 154 37,027,35,2 10,48,43,9 0,6

18. Results of treatment of TB with resistance to R / H R Regis tered Still on treat ment Cure d Failu re Died from TB Died not from TB Loss to follow up Refus ed from treat ment Trans ferre d out TB not confir med XDR- TB devel oped 2007 9340,72,222,69,720,6 1,1 2008 101 42,64,015,87,923,82,0 2009 10252,02,913,76,921,61,0 2,0 2010 130 60,04,611,57,013,10,8 2,30,8 2011 1330,860,22,311,36,015,01,52,3 0,8 2012 9738,119,66,2 12,48,22,17,2

19. Treatment outcomes of clinical cases of MDR-TB. Regist ered Still on treat ment Treat ment compl eted Failur e Died from TB Died not from TB Loss to follow up Refus ed from treat ment Transf erred out TB diag nosis remo ved MDR/ XDR devel oped 2007 18 77,8 11,15,6 2008 23 73,9 4,317,44,3 2009 20 65,0 10,015,0 10,0 2010 16 50,0 6,3 18,8 2011 7 71,4 28,6 2012 26 37,044,43,711,13,7

20. Treatment results of patients without MTB confirmation (Radiology confirmation) Regist ered Treat ment compl eted Failur e Died from TB Other reason s of death Loss to follow up Refus ed from treat ment Transf erred out TB diagn osis was remov ed Devel opme nt of MDR/ XDR 2007 236 78,8 4,74,2 2,13,42,5 2008 208 85,6 7,21,92,9 0,5 1,9 2009204 87,3 2,94,42,5 1,0 2010 202 84,7 1,02,5 3,54,5 1,5 2011 143 88,10,72,1 4,20,73,5 0,7 2012 135 85,62,21,52,26,51,5

21. Treatment outcomes of Sm (+) patients with no DST data. Regist ered CuredFailur e Died from TB Other reason s of death Loss to follow up Refuse d from treatm ent Transf erred out TB diagno sis was remov ed Develo pment of MDR/ XDR 2007 44 45,5 25,06,84,52,315,9 200843 37,2 34,97,04,5 2,3 11,6 200943 60,5 25,64,7 2,3 2010 29 44,8 24,113,86,9 3,4 2011 9 77,811,1 2012 20 45,035,010,05,0

22. Results of treatment all registered (508) TB cases in civil sector in 2012 Treatment success (preliminary data) New cases– 67,4% (279/414), 11,1% (46/414) – treatment continue Relapses ––52,4% (43/82), 13,4% (11/82) – treatment continue «treatment loss follow up» –– 57,1% (4/7) «failure treatment» –60,0% (3/5) Among all registered cases in 2012 – treatment success 64,8% (329/508), 13,8%- (57/414) – treatment continue

23. Conclusion Everyone tuberculosis patient before of treatment should have the Rapid Drug Susceptible Test WHO Standards of treatment according DST cured more than 80 % tuberculosis patients

24. Thank you for attention!