By Sarah Schafer
Special to The Washington Post
Monday, August 24, 2009
MOSCOW -- Russia's severe tuberculosis problem is about to get much worse, increasing the risk that the dangerous drug-resistant strains that are common here will spread, causing outbreaks elsewhere, local health officials and other experts warn.
Preliminary surveys have recorded an uptick in infections, which experts say could be the start of a surge fueled by declining living standards and deteriorating medical care resulting from the country's worst economic slowdown in a decade.
But Russian officials and health specialists also blame the government's failure to order supplies of key medicines last year, a blunder that could strengthen antibiotic-resistant forms of TB and threaten wealthier countries that have all but eradicated the disease.
Russia already has one of the highest rates of TB in the world. In parts of its Far East, the infection rate is three times what the World Health Organization considers epidemic levels. The government has made progress in recent years, with infection rates falling from a peak in 2000, but health officials are worried that those gains are now in jeopardy.
Preliminary state statistics show the rate of infection growing from 83.2 cases per 100,000 people in 2007 to 85.2 in 100,000 last year, and anecdotal evidence from hospitals and clinics around the country suggests that the numbers are still climbing.
By comparison, the infection rate in the United States is about 8 in 100,000, with about 0.2 percent of American TB cases ending in death. In Russia, about 18 percent of TB patients die of the disease, according to WHO figures.
"Because people are poorer and life is worse, the disease is progressing much faster now," said Veronika Agapova, a tuberculosis specialist with the Russian Red Cross. "The Ministry of Health didn't pay a lot of attention to this problem last year," she added.
Although the increase reported was small, officials are worried because the number of TB cases soared the last time Russia suffered a severe economic downturn, rising from 74 cases per 100,000 people before the 1998 financial crisis to 90.4 two years later.
"What was bad in 2008 will continue to be seen in 2009 and 2010," said Mikhail Perelman, Russia's most prominent TB specialist. "I am pessimistic. . . . The WHO set a goal to eradicate tuberculosis, but this task seems quite fantastic to us at this point."
A spike in infections in Russia could have consequences well beyond its borders because about a fifth of all TB patients here suffer from drug-resistant strains -- more than almost anywhere else in the world.
In 2006, a Russian-born man infected with a strain of drug-resistant TB was jailed after moving to Arizona and ignoring a judge's order to wear a mask outdoors. A year later, an American lawyer with drug-resistant TB set off an international panic and was quarantined after traveling across Europe and returning to the United States.
"Like air pollution, it doesn't see a border," said Murray Feshbach, an expert on Russian public health at the Woodrow Wilson International Center for Scholars who argues that Russia understates its TB rate by as much as 50 percent.
Tuberculosis is a bacterial infection that primarily affects the lungs and is about as contagious as the flu. It spreads especially quickly among people living in crowded conditions and those with AIDS or weak immune systems.
Drug-resistant strains are common in Russia because the government has struggled to provide a steady supply of drugs and make sure that patients complete their treatment. The disease is also rampant in the prison system, and prisoners rarely continue taking antibiotics after they are released.
Treatment for TB is free, but Russia's chief epidemiologist, Gennady Onishchenko, warned in a 2007 report that only 9 percent of the country's TB hospitals met basic hygiene standards, nearly a fifth suffered shortages of required drugs and more than 40 percent lacked adequate medical equipment. Some didn't have sewage systems or running water, he said.
Valentina Kravchenko, deputy health minister in the hard-hit far-eastern province of Amur, said she waited anxiously last year for federal authorities to deliver critical anti-TB drugs. But help never came because the Health Ministry did not buy them for more than a year.
Kravchenko and several others involved in treating TB patients said ministry officials told them the government shut down the agency responsible for buying the medicine as part of a reorganization and failed to reassign the task.
"About 70 percent of those who needed treatment were not provided with proper medication," Kravchenko said. "As a result, many of them got drug-resistant forms or had complications. And of course, more people caught tuberculosis, and the number of cases grew in our region."
In response to a reporter's queries, the Health Ministry issued a statement that suggested a basic misunderstanding about how its procurement system works. "The problem is the long delivery process for products from the WHO," it said.
Dmitry Pashkevich, coordinator for WHO's TB Control Program in Moscow, said the explanation made no sense because the government buys the antibiotics on its own from drug companies, in part with funds from a 2003 World Bank loan.
"We are not involved in procurement," he said.
The failure to deliver the medicine last year is worrisome because pausing or stopping treatment gives the bacterium time to mutate into a drug-resistant form. Nearly 11 percent of new cases here last year were drug-resistant, compared with less than 1 percent in the United States, officials said.
Patients with drug-resistant strains require treatment for as long as two years with more costly antibiotics, and sometimes need surgery. The most virulent strains cannot be cured.
Olga Demikhova, deputy director of Russia's Central Tuberculosis Research Institute, which specializes in treating drug-resistant TB, said many Russians are afraid to seek treatment. Some are worried about losing their jobs or, if they are immigrants, of being deported, and those fears have been amplified by the recession.
But she added that the disease is no longer limited to the poor in Russia. "Now we have ordinary people, not marginalized people, but socially well-adapted people," she said.
Agapova, the Red Cross official, said more children have been getting infected, too. "Today, tuberculosis has no limits or borders," she said. "When young people get sick, it means there's a real problem."