olony 33 in Mariinsk (initiated 1996; fully implemented 1997) has resulted in TB cure rates increasing from a low of 36% to 62% and a treatment failure rate decreasing from 56% to 23% (18).  The rate of TB cases that are resistant to isoniazid, rifampin, and streptomycin has remained relatively stable (22.6% in 1997 to 18.9% more recently) (18).  To treat MDR-TB, second line agents must be used , there treatments  are more expensive, less effective, and a lot more toxic than the first line agents   In Tomsk, and there is some evidence that there is misuse of second line agents.  The misuse of second line agents can lead to the development of resistance strands of TB, resulting in incurable disease.  The increasing rate of MDR-TB among the Russian civilian population is very likely related to MDR-TB in the prisons system.  The MDR rate among civilians was only 6% in 1997, and increased to 10% by 1998.  There are likely dual epidemics of MDR-TB in the civilian and prisons sectors, with both epidemics contributing to one another.  In the Colony 33 detention center, 90% of prison detainees are from the local area.  In the Tomsk prison, 63% of the MDR cohort is from the local area (18).



         In 1994, nearly 23 Million refugees had to flee their homes, and an additional 26 Million persons were displaced worldwide.  Refugees are also highly at risk to get Tuberculosis with an estimated  Half of  the world’s refugees  infected with TB (26).  Conditions in refugee camps are ideal for the spread of TB ,untreated TB can spread quickly in crowded living arrangements, .  In addition, since they are on the move, it is difficult to treat them fully because of the lengthy treatment regimen required by existing drugs.  Each year, over 17,000 refugees get sick with the disease.  People who have been displaced for other reasons-such that as of homeless people are also a very great risk.


            Reference for this section:


6.) http://www.lungusa.org/occupational/tuberculosis _workers.html

7.) http://www.osha-slc.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=13717

8.) http://www.cdc.gov/nchstp/tb/pubs/corrections/introduction.htm

9.) http://www.tbalert.org/news/tb_aids.htm

10.) http://www.avert.org/tuberc.htm

16.) http://www.worldpaper.com/2000/sept00/pumpyansky.html

18.) http://www.hopkins-id.edu/ats_2000/ats_4.html#1

19.) http://www.canadafirst.net/immi-kill/russian_tb_threatens_the_world.html

26.) http://www2.provlab.ab.ca/bugs/hlthprom/tbschnee.htm

27.) http://www.stoptb.4t.com/whystopTB.html

29. http://www.hendrickhealth.org/healthy/001409.htm


            The World Health Organization recommended treatment strategy for detection and cure of TB is DOTS or Directly Observed Treatment, Short-course (4).  DOTS is a combination of five different elements: drug supplies, political commitment, microscopy services, surveillance and monitoring systems and use of highly efficient regimes with direct observation of treatment (4).  In directly observed therapy, a trained health care worker monitors the patient taking each dose of anti-tuberculosis medication.  When TB patients receive all medications as prescribed under a program of DOTS, both patients and community benefit by response to therapy is closely monitored, Patients complete therapy, Survival may improve in patients infected with the human immunodeficiency virus (HIV), because DOTS ensures treatment for TB, (15).  DOTS is so important because it helps to deter the spread and development of Drug Resistant TB This is important the course of treatment for drug-resistant TB is USD250, 000 and that of normal TB is about USD 2000 (25).

            Although the DOT the strategy promoted by the World Health Organization to control and treat tuberculosis (TB) - has been widely accepted, many developing countries have been unable to expand coverage as rapidly as needed and have failed to achieve the global targets of detecting 70% of infectious cases and curing 85% of those detected by the year 2000 (14) The major obstacles to expanding the TB control are political, managerial, and financial, rather than technical (14).

            According to WHO the estimated costs of the 22 high-burden countries range of US$ 700–900 million per year, this is excluding investment in new interventions that are specifically designed to raise case detection and cure rates.  It is also estimated that the existing resource gap for TB control in the 22 most burdened countries is probably between US$100-300 million a year; this is provided that current loans and aid are sustained (14)

            Now patients with infectious TB have been identified using microscopy services, health, community workers, and trained volunteers observe and record the patients swallowing the full course of the correct dosage of anti-TB medicines in which Treatment lasts six to eight months (4).  The most common of the anti-TB drugs are isoniazid, rifampicin, pyrazinamide, streptomycin and ethambutol.  After two months, spectrum smear testing is repeated.  It is repeated to check the progress and again it is repeated at the end of treatment.  The patient’s progress is recorded and documented thought out the treatment and the outcome of the treatment is recorded (4).

            One a six-month supply of drugs for DOTS treatments costs as little as US $11 per patient per year in some parts of the world.  The World Bank has ranked DOTS as the “most cost-effective of all health interventions” (4).  DOTS have a cure rate of up to 95 percent this is even in the poorest of the poor countries (4).  DOTS helps to prevent new infections by curing the patients that are infectious.  It at the same time helps to prevent the development of MDR-TB by ensuring the full course of treatment is followed; it ensures this though directly observing the patients.      Since DOTS has been introduced on a global scale, millions of people have received effective cost affective treatment.  For instance, in half of China the cure rates among new cases are 96 percent (4).  Another example is that in Peru the widespread use of DOTS for more than five years has led to the successful treatment of 91 percent of cases.

            All 22 of the high TB burdened countries, which bear 80 percent of the estimated incident rates by the end of 1998, have adopted DOTS.  This brings the total of 43 percent of the world’s population that have access to DOTS, which is double what it was in 1995 (4).  In addition, at the same time in 1998 21 percent of the TB patients received treatment under DOTS, which is also double of what it, was in 1995 (4).  With only 21 percent receiving treatment under DOTS, it really needs to be greatly expanded.

            An example of a DOTS program in the west is the NYC Department of Health & Mental Hygiene Tuberculosis Control Program.  Because of how TB treatment is difficult and requires taking two or more medicines for at least 6 months.  Most people have trouble remembering to take their medicines, or they stop taking their medicines when they start to feel better.  When this happens, a person with TB could get sick again, and the TB germs could become resistant to the medicines.  Because of this DOTS was envisioned and this is why New York uses it to control the TB problem (15).  Some benefits that patients get thou using the DOT program in New York are Free TB medication, free tokens, food, and gift certificates to fast food restaurants, free social services, frequent medical checkups, and Help with transportation to and from clinics.  In addition, this is provided free of charge to all residents of New York (15).  The New York City program sets an example for the rest of the Developed and for the developing world on how to set up a TB treatment plan, which is effective and patient friendly.

            An example for a program of TB treatment in the Developing world is the TB Clubs in Ethiopia.  In Ethiopia, a strategy to combat TB was to set up though using peers as a support group to help others go though the TB treatment (23).  In exploring ways to increase the TB treatment adherence and outcomes they created, these so called TB clubs.  These Clubs were established by people who have TB and who live in the same geological area (23).  The people meet each other while attending outpatient appointments.  Medical officers and the Community support these groups.  Each of these groups have between three and ten members, they elect a leader of the club who ensures that the members attend the TB Clinic.  The leader also arranges the weekly meetings and checks up on their progress.  Members of these clubs support each other, share progress, and problems and send members that are not progressing correctly onto the Clinic.  The clubs with help from the community help to identify persons in the community who are suspected to have TB and they encourage these community members to be tested and to be treated.

            What have these TB clubs achieved?  During the first six months of the clubs in 1997, the clubs referred 181 people with suspected tuberculosis for investigation, of which two-thirds were diagnosed as TB cases (23).  They also identified 69% of all TB patients and 76% of new sputum smear-positive pulmonary TB patients with smear-positive sputum diagnosed in the district during the same six-month period (23).  TB clubs have helped to increase community awareness of the symptoms of TB and the need for treatment, Attendance at TB clinics has also improved significantly and treatment success rates are higher than in other parts of the country (23).

            This TB club approach shows what can be achieved - even in remote rural areas with limited resources and using a long course of treatment - if TB patients are at the centre of TB control efforts and if there is effective community involvement.  This shows how important community support is in a TB treatment program.        

         It is possible to control the spread of MDR-TB, but according to Atiel Pablo-Mendez who is from the Rockefeller Foundation presented arguments that DOTS alone may be sufficient to control TB globally.  This has been effective in a country like Peru (which has one of the best DOTS programs in the world and is relatively small), would be equally successful in a larger country such as India, where DOTS is not as widely used (18).  Although recent reports have noted so-called MDR-TB hotspots, the median prevalence of MDR-TB globally is 1%, with eight countries reporting no MDR-TB.  Rates of MDR-TB range from 14% in Estonia to 0% in France in the United States, the rate of MDR-TB has decreased from 1.6% to 1.2%.  It was stated that MDR-TB outbreaks are often due to poor infection controls for instance in New York City, Russian prisons) and that therefore improvement will occur when infection control is improved, not just the institution of DOTS-Plus.

TB in New York City

            New TB     Cases MDR-TB

1992        3,811       441

1997        1,730        53

Change -55%       -88%

Thus, there was a greater decrease in MDR-TB rates than overall TB rates.  There is a high correlation between incomplete therapy and MDR-TB, as well as the treatment failure rates (18).  Thus, for the programs that have low treatment success rates less then 60%), the preference would then be to provide a better implementation of DOTS prior to implementing DOTS-Plus program.  For programs that have a greater then 80% treatment success rate, use of DOTS-Plus could be considered.

            Controlling MDR-TB through DOTS-Plus: In settings where the prevalence of Multi- Drug Resistant -TB is low, cure rates with DOTS can exceed 90%; thus DOTS alone will suffice in many settings (18).  However, in settings with high rates of MDR-TB, cure rates of DOTS decreases to 40-60%.  For instance, in Baku, Azerbaijan, the cure rate using DOTS is 54% (18).  In areas with documented MDR-TB, cure rates have been found in a range from 6% (Ivanovo, Russia) to 59% (Peru) (18).  The common objections to DOTS-Plus include the argument that DOTS alone was responsible for the decrease in rates of TB and MDR-TB in New York City in the early 1990s, the expense of DOTS-Plus, the lack of cost-effectiveness, and the difficulty in implementing such treatment regimens (18).

            MDR-TB in the United States: The proportion of MDR-TB patients who died during therapy decreased from 41% in 1993 to 29% in 1996 (18).  Patients with MDR-TB were a lot more likely to die than those with non-MDR-TB.  Among AIDS patients with MDR-TB, 69% died during therapy, compared to the 27% of AIDS patients with non-MDR-TB.  Among patients who did not die during therapy, completion of therapy was less common in persons with MDR compared to non-MDR-TB.  This is leading to ways that we need to improve treatment so that we do not have to worry about increasing the rate of MDR-TB growth.  Implementing a strong cost-effective Tuberculosis treatment programs such as DOTS, will help stop the Spread of MDR-TB

References for this section:


4.) http://sprojects.mmi.mcgill.ca/tropmed/disease/tb/dots.htm

14.) http://www.who.int/gtb/policyrd/Dots_expansion/index.htm

15.) http://www.ci.nyc.ny.us/html/doh/html/tb/tb.html

18.) http://www.hopkins-id.edu/ats_2000/ats_4.html#1

20.) http://www.who.int/gtb/dots/index.htm

23.) http://www.who.int/gtb/policyra/commcae.htm

25.) http://www.stoptb.org/tuberculosis/poorly.managed.tb.prg.html


References for the whole chapter.

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5.) World TB Day 2002 Questionnaire . Stop TB. <http://www.stoptb.org/world.tb.day/WTBD_2002/default.asp>.

6.) Tuberculosis and Health Care Workers. American Lung Association. <http://www.lungusa.org/occupational/tuberculosis%20_workers.html>.

7.) Occupational Exposure to Tuberculosis; Proposed Rule - 62:54159-54309 . 17 Oct. 1997. Occupational Safety & Health Administration. <http://www.osha-slc.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=13717>.

8.) Controlling TB In Correctional Institutions 1995. 7 Sept. 2002. Centers for Disease Control & Prevention National Center for HIV, STD, and TB Prevention Division of Tuberculosis Elimination. <http://www.cdc.gov/nchstp/tb/pubs/corrections/introduction.htm>.

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10.) AIDS, HIV & Tuberculosis. AVERT. <http://www.avert.org/tuberc.htm>.

11.) Celebration of World TB Day 2003. 16 Apr. 2003. World Health Organization. <http://www.who.int/gtb/>.

12.) The TB & Sustainable Development 2000 Report. Stop TB. <http://www.stoptb.org/conference/tb.2000.html>.

13.) The Global Burden of Tuberculosis (TB) . USAID. <http://www.usaid.gov/pop_health/id/tuberculosis/burden.html>.

14.) GLOBAL DOTS EXPANSION PLAN. 6 Oct. 2002. World Health Organization . <http://www.who.int/gtb/policyrd/Dots_expansion/index.htm>.

15.) Tuberculosis (TB) Control. Nov. 2002. Bureau of Tuberculosis Control New York City Department of Health & Mental Hygiene . <http://www.ci.nyc.ny.us/html/doh/html/tb/tb.html>.

16.) Pumpyansky , Alexander. Russian prisoners incubate the worst TB is double sentence for at-risk inmates. Sept. 2002. The WorldPaper (US). . <http://www.worldpaper.com/2000/sept00/pumpyansky.html>.

17.) <http://www.river.org/~chuck/byline/1990/04/angela041.html>

18.) Multidrug Resistant TB. 10 Mar. 2000. The Johns Hopkins University . <http://www.hopkins-id.edu/ats_2000/ats_4.html>.

19.) Schweimler , Daniel . World: Europe Russian TB threatens the world. British Broadcating Corporation. <http://www.canadafirst.net/immi-kill/russian_tb_threatens_the_world.html>.

20.) An expanded DOTS framework for effective tuberculosis control. 12 July 2002. World Health Organization. <http://www.who.int/gtb/dots/index.htm>.

21.) <http://www.aegis.com/newa/ads/2000/AD001853.html>

22.) Pokrovsky, Vladimir. INCURABLE TB IS MAKING A COMEBACK New form of TB travels quickly in Russia. 12 Aug. 1997. Obschaya Gazeta. <http://www.amber.ucsf.edu/~ross/russia_/tb.txt>.

23.) Community Care for Tuberculosis . Mar. 2003. World Health Organization. <http://www.who.int/gtb/policyra/commcae.htm>.

24.) DOTS-Plus for multidrug-resistant tuberculosis (MDT-TB). Mar. 2003. World Health Organization. <http://www.who.int/gtb/policyrd/DOTSplus.htm>.

25.) Poorly managed TB programmes are threatening to make TB incurable . Stop TB. <http://www.stoptb.org/tuberculosis/poorly.managed.tb.prg.html>.

26.) Schnee, Paul. TB IS BACK--WITH A VENGEANCE! HEALTH CARE WORKERS BEWARE!! 24 Mar. 1996. Northern Alberta U. <http://www2.provlab.ab.ca/bugs/hlthprom/tbschnee.htm>.

27.) Problem Statement. Stop TB. <http://www.stoptb.4t.com/whystopTB.html>.

28.) History of TB. UK Coalition of People Living with HIV and AIDS . <http://www.ukcoalition.org/HIV___TB/History_of_TB/history_of_tb.html>.

29. Tuberculosis. 2002. The Thomson Corporation. <http://www.hendrickhealth.org/healthy/001409.htm >.***