Results of a tuberculosis trial, published in this week’s issue of THE LANCET, suggest that a WHO strategy could make a valuable contribution to tuberculosis control in Russia.
There has been a resurgence of tuberculosis in Russia in the past decade, mainly due to the collapse of the health-care infrastructure in the 1980s and early 1990s. Traditional Russian services for treatment of tuberculosis are very different from those in the West. Patients suspected of having the disease are referred to specialist tuberculosis hospitals or sanatoria. Treatment methods combine chemotherapy with a range of additional treatments, some of which predate the chemotherapy era (10% of patients undergo surgery); long periods of hospitalisation are common. Nicholas Banatvala and colleagues from Merlin (a UK-based international health-care agency) compared the effects of WHO short-course chemotherapy with standard Russian antituberculous treatment.
New adult tuberculosis patients were included in a trial and allocated to receive either traditional Russian tuberculosis treatments or WHO short-course chemotherapy in the two largest tuberculosis diagnostic and treatment centres of Tomsk Oblast, western Siberia. Standard WHO tuberculosis outcomes and rates of sputum conversion were used as primary outcomes.
646 patients took part in the trial; 356 patients were given Russian tuberculosis treatment (155 smear positive) and 290 were given WHO short-course chemotherapy (155 smear positive). There was no statistical difference between the proportion cured or completing treatment (63% for both groups), or in the proportion of patients who died (8% WHO, 11% Russian treatment).
In an accompanying Commentary (p 434), Richard Coker from the London School of Hygiene and Tropical Medicine, UK, states that the benefits of the WHO strategy (such as reduced health-care costs from decreased hospitalisation) has not so far resulted in a transformation of tuberculosis care in western Siberia, even though the trial was completed five years ago. He comments on the profound cultural differences between western and Russian approaches to health care: “many patients in Russia continue to undergo long periods of hospital admission (especially for the early stages of treatment), and although the number of beds dedicated to long-term treatment of patients with tuberculosis has fallen by about a fifth since 1994, staff numbers in hospital facilities have hardly altered. Why has there been such a resistance to change? Because changing health structures requires more than evidence from clinical trials and cost-effectiveness analyses. Structural impediments are commonly extremely difficult to overcome. Funding of tuberculosis services in Russia is linked to bed numbers, and those people responsible are understandably reluctant to shrink their budgets voluntarily. Likewise, professional authority is intimately allied to hospital capacity. Insecure, vulnerable clinicians are, not surprisingly, wary of change and generally reluctant to embrace modifications to work patterns that potentially threaten them professionally and financially. A complex web of perverse incentives means organisational changes are difficult to initiate and sustain.”
Contact: Dr Nicholas Banatvala, Department of Public Health, Suffolk Health PO Box 55, Foxhall Road, Ipswich, Suffolk IP3 8NN, UK; T) 44-1473-323-373; M 07887 855216 F) 44-1473-323420; E) nick.banatvala@hq.suffolk-ha.anglox.nhs.uk
Dr Richard Coker, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; T) 44-20-7927-2926; F) 44-20-7612-7812; E) richard.coker@lshtm.ac.uk
Journal
The Lancet