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FM AMEMBASSY MOSCOW
TO RUEHC/SECSTATE WASHDC 3867
INFO RUEAUSA/DEPT OF HHS WASHDC
RUEHYG/AMCONSUL YEKATERINBURG 2696
RUEHVK/AMCONSUL VLADIVOSTOK 2402
RUEHZN/EST COLLECTIVE
RUEHPH/CDC ATLANTA GA

UNCLAS SECTION 01 OF 03 MOSCOW 004543 
 
SIPDIS 
 
SENSITIVE 
SIPDIS 
 
DEPARTMENT FOR OES/IHA AND EUR/RUS 
USAID FOR GH, E&E 
HHS FOR OGHA 
 
E.O. 12958: N/A 
TAGS: TBIO SCUL SOCI RS
SUBJECT: RUSSIA: TUBERCULOSIS CASES STABILIZING, BUT DRUG RESISTANCE 
GROWING 
 
REF: Moscow 2487 
 
MOSCOW 00004543  001.2 OF 003 
 
 
THIS CABLE IS SENSITIVE BUT UNCLASSIFIED.  NOT FOR INTERNET 
DISTRIBUTION. 
 
¶1. (SBU) SUMMARY:  Increased Russian Government attention to TB 
control and treatment in recent years, and regional pilot programs 
involving international donors and experts, are helping to turn the 
tide in Russia's battle with TB.  Tuberculosis (TB) cases in Russia 
have recently stabilized within the general population, albeit at a 
high level, and are dramatically declining within prisons.  However, 
multi-drug resistant TB (MDR-TB) cases have been gradually 
increasing, while the prevalence of extensively drug resistant TB 
(XDR-TB) is still unclear.  Cases of TB/HIV co-infections are 
steadily rising, suggesting that Russia's HIV epidemic is also 
beginning to drive the TB epidemic.  The Russian Government and 
international donor community should next focus on targeted programs 
aimed at studying, controlling and effectively treating 
drug-resistant forms of TB and TB/HIV co-infections.  END SUMMARY. 
 
¶2. (U) The World Health Organization (WHO) ranks Russia twelfth on 
the list of the world's 22 high burden TB countries.  According to 
statistics published by the Ministry of Health and Social 
Development (MOHSD), Russia registered 117,646 new cases of TB in 
2006 (a rate of 82.4 cases per 100,000 people), a decline of 1.3 
percent compared to 2005.  Among the general population, there were 
96,867 new cases recorded (67.9 cases per 100,000 population).  TB 
mortality has modestly declined in recent years from 21.9 deaths 
recorded per 100,000 population in 2002 to 19.5 deaths per 100,000 
in 2006. 
 
----------------------------------------- 
TB Situation Most Acute East of the Urals 
----------------------------------------- 
 
¶3. (U) TB incidence and mortality are most acute east of the Urals. 
In 2006, newly registered TB cases in Siberia stood at 131.6 cases 
per 100,000 population, and there were 37.3 deaths from TB per 
100,000 population -- the highest rates in Russia.  New TB cases in 
the Russian Far East (RFE) stood at 127.8 cases per 100,000 
population, while there were 33 deaths from TB per 100,000 (the 
second highest rates in Russia).  The incidence of TB among children 
aged 0-14 years is also highest in Siberia and the RFE with 29.2 
cases per 100,000 reported in Siberia in 2006, and 26.5 cases per 
100,000 in the RFE.  (NOTE: Russia-wide TB incidence rates among 
children have been flat over the past five years, and stood at 16.1 
newly registered TB cases per 100,000 children in 2006.) 
 
¶4. (SBU) As many as 10-15 percent of patients refuse to begin taking 
medication when they are initially diagnosed with TB, according to 
doctors at the Federal TB Center in Novosibirsk, which treats the 
most difficult TB cases from Siberia and the RFE.  TB clinics and 
doctors could in theory resort to the Russian court system to 
quarantine patients and compel them to undergo treatment, but in 
practice it is virtually unheard of for a local prosecutor to take 
on a public health enforcement action. 
 
¶5. (SBU) Thanks to increased government funding and financial 
support from the World Bank and Global Fund, many of Russia's 
federal TB centers and regional clinics are now well-equipped with 
modern diagnostics, testing and treatment equipment.  However, it is 
often difficult to attract doctors, nurses and lab technicians to 
specialize in TB and other pulmonary ailments.  The salaries for TB 
specialists are not particularly attractive, even with the extra 
hazard pay they receive for working with infectious patients. 
 
-------------------------------------- 
Behind Bars, TB Situation Has Improved 
-------------------------------------- 
 
¶6. (U) Despite the fact that the TB situation in prisons has 
dramatically improved over the last seven years, a Russian prisoner 
today is still nearly five times more likely to have active TB than 
a civilian.  There were 47,431 active TB cases in Russia's prison 
system in 2006, and 14,823 new TB cases were recorded within the 
penitentiary system in 2006 (1,387 cases per 100,000 inmates). 
(Note: The total number of prison and civilian cases does not quite 
equal the overall number of TB cases, because Russia tracks 
additional categories of registered cases, including TB among the 
police, military, and foreign citizens.)  The prevalence of prison 
cases has steadily declined every year since 1999, when there were 
4,347 TB cases for every 100,000 inmates.  TB mortality has also 
dramatically declined, from 238 deaths per 100,000 inmates in 1999 
 
MOSCOW 00004543  002.2 OF 003 
 
 
to 79.1 deaths per 100,000 in 2006.  The USG provides financial 
support to the International Federation of the Red Cross to fund TB 
programs in Russia's prison system operated by the Russian Red 
Cross, one of the few organizations (along with the WHO and the U.S. 
NGO Partners in Health) that is permitted to work with Russian 
prison populations.  TB control programs have been successful in 
reducing the share of TB cases within the penitentiary system from 
29.l percent of all TB cases in 1999 to 12.1 percent in 2006. 
 
--------------------------------------------- ------ 
MDR-TB Gradually Increasing, XDR-TB Picture Unclear 
--------------------------------------------- ------ 
 
¶7. (SBU) Multi-drug resistant TB (MDR-TB) cases have gradually 
increased over the past seven years from 6.7 percent of all new TB 
cases in 1999 to 8.1 percent in 2004, and to 9.4 percent in 2006. 
The official statistics are only approximations of the actual share 
of MDR-TB cases in Russia, because some regional labs do not have 
the capacity to perform sensitivity tests to distinguish MDR-TB from 
normal TB, quality control issues at other labs call into question 
the accuracy of their results, and not all patients are tested for 
the presence of drug resistant strains of TB. 
 
¶8. (SBU) The gradual increase in MDR-TB cases is partly attributable 
to patients' failure to adhere to the full course of TB antibiotic 
treatment.  Many TB patients are from socially marginalized groups 
such as alcoholics, ex-prisoners, and the homeless, who generally do 
not access the health care system and find it difficult to adhere to 
a full course of TB treatment.  Another major difficulty is ensuring 
that released prisoners continue treatment.  Prisoners with active 
TB are segregated from the regular prison population and rigorously 
take their medicines (otherwise, according to some of our health 
contacts, they would likely be punished by guards or prison 
administrators).  However, experts estimate that about 40 percent of 
paroled inmates never show up at a civilian TB clinic after their 
release to continue taking medication and for follow-on treatment. 
 
¶9. (SBU) There is no comprehensive data on the prevalence of 
extensively drug resistant TB (XDR-TB) in Russia, though there is a 
limited amount of data available from regional studies.  Data from a 
2006 USG-funded WHO study of 102 long-term TB patients in Orel 
Oblast found that 56.7 percent of those cases were diagnosed with 
MDR-TB, and 18.9 percent of the MDR-TB cases also met the WHO 
definition of XDR-TB.  A similar 2006 WHO study in Vladimir Oblast 
found no evidence of XDR-TB among 35 newly registered TB patients, 
but XDR-TB was detected in nine out of 132 chronic TB patients. 
Studies in Tomsk Oblast found that 5.1 percent of 611 patients 
enrolled in a cohort study between September 2000 and September 2004 
had XDR-TB at the start of treatment.  The USG is currently 
considering supporting a nationally representative drug resistance 
survey in FY08 and FY09 to identify the magnitude of the drug 
resistant TB problem nationwide. 
 
----------------------------------- 
Rising Tide of TB/HIV Co-Infections 
----------------------------------- 
 
¶10. (U) Russia's fast-growing HIV epidemic may be starting to fuel 
TB infections.  TB is the leading cause of death among people with 
HIV/AIDS, accounting for 59 percent of all deaths among this group 
in 2006.  The number of TB/HIV co-infections has risen from 2,524 
cases registered in 2002 (0.6 percent of all TB cases), to 9,102 
cases in 2006 (3.1 percent of all TB cases).  Likewise, the 3,907 
new TB/HIV co-infections detected in 2006 represent 3.3 percent of 
the 117,646 new TB cases detected in 2006.  Within prisons, TB/HIV 
co-infections have risen from four percent of all TB cases in 2002 
to six percent of all cases in 2006. 
 
--------------------------------------------- --------- 
Government Spending Up, International Programs Working 
--------------------------------------------- --------- 
 
¶11. (U) Russian Government spending on infectious diseases, 
including TB, has increased significantly in recent years.  Under a 
federal program targeting socially significant diseases, the Russian 
federal and regional governments together spent $220 million on TB 
control and treatment in 2006, according to the WHO, and will spend 
a similar amount in 2007.  As the WHO noted in its March 2007 TB 
assessment for Russia, Russian budgets for TB control are "much 
higher" than in other high burden TB countries. 
 
¶12. (SBU) World Bank and Global Fund financial support, and regional 
pilot programs involving international donors and experts, are also 
 
MOSCOW 00004543  003.2 OF 003 
 
 
helping to turn the tide in Russia's battle with TB.  As the WHO 
noted in its March 2007 TB Assessment for Russia, "The current 
positive momentum in TB control in the Russian Federation is partly 
due to the successful implementation of a number of pilot projects 
carried out in selected oblasts, supported by international 
technical partners."  Through 2006, the WHO revised TB control 
strategy of Directly Observed Therapy Short Course (DOTS) has been 
officially adopted in 85 out of 88 Russian regions with the support 
of World Bank and Global Fund grants, but implementing a 
comprehensive DOTS system will remain challenging in many regions. 
New TB treatment standards and new TB reporting requirements have 
been implemented in 68 Russian regions which cover 83 percent of 
Russia's population. 
 
¶13. (U) The American NGO Partners in Health has introduced 
aggressive case management systems to improve treatment for MDR-TB 
patients and non-adherent TB patients in Tomsk Oblast (Siberia), 
which have led to improved cure rates. Partners in Health's TB 
training center in Tomsk has trained over 215 Russian doctors in the 
best methods of treating MDR-TB.  The center also completed two 
clinical studies of MDR-TB patients that led to the release of new 
MDR-TB treatment guidelines in May 2006, backed by both the WHO and 
the Centers for Disease Control and Prevention (CDC) in Atlanta. 
Innovative USG-supported TB programs have helped Orel Oblast halve 
the total number of TB cases between 2003 and 2006, and achieve an 
81.2 percent treatment success rate (significantly higher than the 
national average of 57.2 percent).  Eli Lilly's MDR-TB Partnership 
in Russia has helped to strengthen domestic TB drug production 
capacity by transferring the know-how to produce MDR-TB drugs to SIA 
International, one of Russia's leading pharmaceutical companies 
(Reftel). 
 
¶14. (SBU) COMMENT: As the WHO noted last March, "Major efforts are 
still needed" in Russia "to address the threat of MDR-TB and 
extensively drug-resistant TB and of TB/HIV, as well as to start 
involving the community in TB control."  In the wake of recent 
incidents where international travelers with drug resistant TB 
entered the United States, TB control and treatment efforts should 
remain a key part of USG and other international partners' 
collaboration with Russia on infectious diseases. 
 
BURNS