E.B. Tsybikova
Federal Research Institute for Health Organization and Informatics of Ministry of Health and Social Development of the Russian Federation, Moscow

Summary. The very foundations of combating tuberculosis in every existing system of public health imply that a patient himself bears responsibility for genuine and completed treatment, once a course of chemotherapy has been started. The specific trait of TB course treatment is that drug resistance developed will always be considered as a result of poorly organized treatment of a patient with TB. The best way to avoid development of drug resistance will be a chemotherapy-based combined treatment at such anti-TB medical establishments that would possess the facilities that could be easily adjusted to the clinical form of the disease.

Aim: to identify organization-wise reasons for cases of failure in population-based treatment for primary identified pulmonary tuberculosis in various regions of Russia.

Methods and Materials: The structure of TB morbidity in the studied regions of Russia was juxtaposed to the structure of the pool of anti-TB medical establishments differentiated for their intrinsic medical facilities. Registry and account forms of medical documentation envisaged by Order No. 50 of the Ministry of Public Health and Social Development of the Russian Federation from Feb.13, 2004 were used for calculation and estimation of physical indicators under this survey. For the estimation of the structure of the community of patients with primary identified pulmonary tuberculosis at the destructive phase and failed chemotherapy, a questionnaire poll concerning the results of cohort trials of 2008 was staged in 66 regions of the Russian Federation.

Results: In Russia in 2008-2009, the structure of the pool of patients with primary identified pulmonary tuberculosis that had been registered for treatment had a prominent feature of evident unbalanced polarization between the patients - when half of them presented absence of specific bacterial expression and destruction of pulmonary tissues, while 27% of them were presenting just these features identified at routine microscopy of the sputum. In 65 regions of the Russian Federation, the proportion of patients with primary identified destructive pulmonary tuberculosis in whom chemotherapy proved ineffective had a multifold surpass of the normal standards of treatment: in 40 regions it was surpassed 2-3 times, and in 25 regions - 5 times or more.

The results of questionnaire poll staged in 66 regions of in the Russian Federation demonstrated that in the structure of the pool of patients with primary identified destructive pulmonary tuberculosis, in whom chemotherapy proved ineffective, more than one fourth of them (26.4%) developed drug resistance.

Discussion: The real decline in population-based efficiency of pulmonary TB management emerged recently in the Russian Federation was associated with structural crisis in the system of anti-TB dispensaries where a large-scale demolition of the 2^nd line anti-TB dispensaries had occurred as a consequence of which the remaining clinics turned out to be totally unprepared to fulfill comprehensive treatment of patients with primary identified destructive pulmonary tuberculosis.

Patients with primary identified destructive pulmonary tuberculosis, in whom chemotherapy proved ineffective, tended to enter the sub-pool of patients with acquired tuberculosis in whom developed the most notorious feature – namely, the drug resistance, and this sub-pool was to form a reservoir of infection for the rest of the population. A tendency to provide wide hospital admission to patients with primary identified destructive pulmonary tuberculosis with confirmed absence of specific bacterial expression and no destruction of pulmonary tissues still persisted in recent years, when actually these patients should have had admittance only to dispensaries and mainly treated there on outpatient basis or - in the last resort – in hospital department of ordinary anti-TB dispensaries. A dramatic rise in the need for creation of 3^rd-4^th line anti-TB establishments (practically, a hospice) proved quite obvious – mainly due to widespread of drug resistant pulmonary tuberculosis.

Conclusion: The main reason for organizationally-caused overall failure in treatment of patients with primary identified pulmonary tuberculosis in Russia was the structural crisis among anti-TB medical establishments which has made itself quite expressed in the first decade of the 21^st century, when 2^nd line anti-TB dispensaries has declined in half of territories of the RF, while 1^st line anti-TB dispensaries has declined in one third of territories, and that meant a rise in a widespread of TB in Russia.

Keywords. Cohort study, Structure of patients with primary identified TB, Pulmonary tuberculosis, Drug resistance, Infrastructure of anti-TB establishments, Outcomes of treatment, Surgical treatment

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