Tuberculosis in Russian Prisons
Introduction
Authored by: Christopher Murphy
Mycobacterium tuberculosis, better known as tuberculosis, is considered one of the most deadly infectious diseases. It spreads person to person, its only reservoir, through aerosol transmission when an infected person sneezes, coughs or talks. Over the course a year a person infected with tuberculosis can infect 10-15 people. The bacteria can last in the air for days and travel far distances. The bacteria (at least 10 cells) needs to reach the lungs' alveoli in order to infect. The lungs are a desirable location because of the high oxygen levels.
As a result, humans have suffered heavily from this disease which mainly attacks the lungs. More specifically, the 17th and 18th centuries experienced the "White Plague" in which about everyone had been infected and 25% of adult deaths could be attributed to tuberculosis. Roughly 33% percent of the world has latent tuberculosis, as long as the immune system is not compromised there will be no issues. There are several levels of tuberculosis, that very on their severity. A latent infection means that the bacteria exists in the body but the immune system has suppressed it, then there are the different levels of active/susceptible which include multi-drug resistant (MDR) and extensively drug resistant(XDR).
In recent years, starting after the fall of the Soviet Union, there has been a reemergence of tuberculosis in Russia. This is in part due to the rise in the amount of people susceptible, especially those with AIDS, and the rise of multi-drug resistant TB. In 1993, the World Health Organization announced that tuberculosis had become a global emergency. One of the most conducive breeding grounds for tuberculosis has been prisons. However, prisoners are not the only ones that need to be concerned, the tuberculosis is likely to spread to the rest of society through released prisoners and prison and hospital workers.
Why Tuberculosis is so prevalent in Russia
Tuberculosis is an opportunistic infection, relying on the exploitation of compromised immune systems, thrives in stressful and impoverished regions. Sizable populations, inadequate nutrition, continual stress, tight and squalid living areas, the use of intravenous drugs, alcoholism and co-infections(HIV/AIDS) all contribute to compromised immune systems. All of these risk factors can be found abundantly in Russia, particularly in Russian prisons. These prisons are overcrowded and in sordid conditions, consequences of severe penal codes and lack of funds. An example of the severity of penal codes is the prison sentence that resulted from the theft of a cell phone. As previously mentioned before approximately 33% of the world has latent tuberculosis. Therefore it is very likely that when prison populations increased in the 1990s, many of the inmates were carrying tuberculosis. All of a sudden in the 1990s a large amount of people were crowded together in extremely sordid conditions resulting in uniquely high stress levels. In addition, due to the stigma towards prisoners, little has been done to improve their conditions. The isolation of prisoners is less than ideal, all the infected prisoners are sometimes housed together causing re-infection, though occasionally those making a recovery will be separated.
Moreover, prisoners are 58 times likelier to contract tuberculosis than the average Russian citizen and are 28 times likelier to die from the disease than the average Russian citizen. The number of TB cases has reached an epidemic level. As of 1999 the Russian prison population neared 1.1 million prisoners, of those prisoners 1 in 11 have tuberculosis. In addition, treatment is sporadic at best and consequently MDR strains have arisen affecting 20,000 prisoners. The prison population surged above over a million and the movement of people being incarcerated and being released also numbered in the millions. The strict penal codes in addition to the dire economic state of Russia only added to this number. As a result prisoners with latent infections could no longer had the immune strength to suppress the TB and other prisoners became infected by being in such close proximity with sick prisoners.
The recent spike in cases is attributed to the combined affect of the fall of the Soviet Union and prisoners who are inadequately treated for TB being released back into society. As a result of the collapse of Russian infrastructure, alcoholism, unemployment, crime rate, incarceration rate and the movement in and out of prison all increased significantly. In addition, health and social services ceased to exist only exacerbating the problem at hand. Diagnostic tests could not be afforded any more as well microscopes for sputum examination. Consequently, much of the treatment was stop-and-go leading to TB rates that topped the charts as the world's highest and MDR strains of Tuberculosis.
To highlight the consequences of the effects of crime, prisons were deemed "epidemiological pumps" for the rest of Russian society. After being in cramped quarters inside prisons, released prisoners would return home to equally small apartment blocs. During the winters, these unventilated apartments served as breeding grounds for TB. Additionally, there is also the risk of workers at prisons and hospitals will become infected and transmit the disease to people outside of the prisons and hospitals. Russia had previously its satellites to produce antibiotics but with the collapse drugs and funding were both in short supply. The newly independent satellite republics no longer continued the barter trade with Russia for antibiotics.
Another factor perpetuating was the Health ministry's resistance to adopting the DOTS strategy. They were adamant about keeping the status quo. Surgery, removing a partial lung is the approved method in Russia despite the controversy this procedure warrants from the outside world. Doctors are also skeptical about DOTS and passionate about their own version. Mikhail I. Perelman encapsulates this idea with his quote, "DOTS-this system was developed for the poorest countries of Africa. These places are not like Russia." Roughly 10 to 15% of patients undergo this operation. On the contrary, many of the local doctors were fine with participating in the DOTS strategy, however, many of the pharmacies ran out of supplies-even first-line drugs where in short supply.
Attempts of Fighting off Tuberculosis
Russia continued to struggle with Tuberculosis until recent outside help, starting in the late 1990s George Soros has been a principle financial contributor. In addition, the work of Medical Emergency Relief International and Partners in Health in the area, as they experiment to develop a new TB program, has lead to success. Russia has also heavily relied on the Eli Lilly and Company Foundation and the Global Fund to Fight AIDS, TB and Malaria. The creation of the Green Light Committee, a drug procurement consortium, has been crucial to the fight against Tuberculosis. Green Light Committee is compromised of WHO, U.S. CDC, ngos and pharmaceutical firms. The effectiveness of this program is highlighted by the drop in cost of patient care. Previously, treatment cost $10,000 to $15,000 and currently runs around $3,000 to $4,000. Through this committee countries such as Russia could afford medication, including the more expensive second line drugs to treat MDR-TB. This was the direct consequence of purchase contracts and subsidies. The general condition of hospitals has improved with increased funding from organizations such as Global Fund. Improvements include new lab equipment such as airtight closets to house sputum and technology for culturing. The handling of cases has also changed for the better, those with TB are sent back to the barracks while MDR-TB prisoners are isolated in the hospitals, 6 to 8 prisoners to a room. The goal of the international organizations is to counsel, help develop an infrastructure and empower Russia to be self-reliant.
The DOTS program has been implemented and is usually the strategy of choice. It is an daily procedure in which 4 antibiotics are taken orally for 6 to 9 months under the care of a health official.cumbersome and requires a significant amount of work by the health workers. It was first believed in the 1940s that the drug streptomycin was the cure all until it was discovered that tuberculosis mutates and that multiple drugs were necessary. The logic is based on statistics and probability, the drugs attack the tuberculosis in several different places simultaneously. Tuberculosis is slow growing, only reproducing once a day, resulting in a lengthy therapy session. One new idea of treatment is the pursue the strategy of directing more attention to MDR-TB than susceptible TB. This strategy has been adopted by Russia and many over former satellite republics that collectively form the Commonwealth of Independent States. It is hoped that this method begins to be adopted by other countries around the world as well as helping reach the 2015 goal of cutting the TB's global prevalence and mortality in half. Partners in Health developed this technique called DOTS Plus, in which all MDR-TB cases are treated, this has lead to more extensive and intensive treatment. It is considered a bolder and more costly procedure. Local doctors were encouraged first in the prison system and then all throughout the region. This program takes up to two years and requires 6 to 8 drugs. MDR-TB and TB are similar in their capability to be lethal, the main difference is that MDR-TB is much harder to treat than TB. There is more and more agreement that MDR-TB should be the form of TB to be concentrated on because in treating MDR-TB then TB will also be treated.
As patients are being treated for tuberculosis the most important things is to make sure the patients takes all of the medicine. What tends to happen is that during the beginning months the majority of the tuberculosis bacteria is killed and the symptoms go away, the treatment lasts much longer (6 to 9 months) than symptoms do. When this happens many patients will stop taking the medications falsely believing that they are cured. Unbeknown to them some tuberculosis survives and makes a waxy coat and buries away in the lung. Among the remaining tuberculosis are extremely resistant bacteria and with the stopping of treatment the more resistant strains take over. Another reason patients may object to continuing therapy is that the DOTS drugs have adverse side effects such as hallucinations, nightmares and vomiting. It is hard to tell who will react adversely to the drugs and to what extent.
Tuberculosis Studies
Case Study 1
Some of the most convincing evidence of the general risk factors of Tuberculosis and varying importance in Russia comes from the study "Risk factors for pulmonary tuberculosis in Russia: case-control". The study was a case-control study in which existing cases of a medical condition are compared with a control group of the same number and similar composition. The goal of the study was to find and rank the risk factors for pulmonary tuberculosis. The leading risk factors were low accumulated wealth, financial insecurity, consumption of unpasteurized milk, diabetes, living with a relative with tuberculosis, unemployment, overcrowded living conditions, illicit drug use and incarceration. Of these leading risk factors when considering the amount of exposure, consumption of unpasteurized milk and unemployment.
Case Study 2
In the study "Rates of latent tuberculosis in health care staff in Russia" the goal was to find individuals with latent tuberculosis infections and the rates of infection to treat through chemo prophylaxis and cross-infection strategies. In a cross sectional study, risk of tb was compared between unexposed students, medical students, primary health care providers and TB hospital health providers. Results showed that the amount of exposure could be linked to the likelihood of having LTBI. Primary health care providers were more likely to have TB(39.1% or 90/230) than students (8.7% or 32/368) and TB hospital health providers (46.9% or 45/96) were more likely to have TB than the primary health care providers (29.3% or 34/115). In addition, TB laboratory workers also had high levels of tuberculosis (61.1% or 11/18). From the results it can be concluded that TB Health Care Workers are have the highest risk and precautionary measures need to be taken.
Case Study 3
A major concern for using second line drugs to treat MDR Tuberculosis is that many of them cause adverse reactions because of their toxicity. Through a retrospective case series "Adverse Reactions among patients being treated for MDR-TB in Tomsk, Russia" explored this question. Of the 244 cases 76% were cured, 6.6 % failed, 4.9 % died and 11.5 % defaulted. 73.3% of all cases showed adverse reactions, 74.8% in patients that adhered (at minimum took 80% of prescribed doses) and 59.1% of those that did not adhere. It was found that these adverse reactions varied on the amount of drugs taken but had no effect on the outcome.
Conclusion
Overall paper length should be approximately 2,000 to 2,500 words.
Include at least two data figures.
Use professional sources, including at least two research studies.
References
Edited by student of Joan Slonczewski for BIOL 191 Microbiology, 2009, Kenyon College.
