Совершенствование организации противотуберкулезной помощи с учетом распространенности лекарственно-устойчивых форм туберкулеза в регионе Приаралья

Аннотация

Topicality and demand of the subject of dissertation. In 2012, there were 8.8 million ТВ cases in the world and 1.5 million cases ended in death1. The number of patients with MDR-TB is approximately 450 thousand, they often live several years before dying of tuberculosis. Therefore, the prevalence of MDR-TB can be three times as high as its frequency which supposedly allows estimating the number of MDR-TB patients’ more than 1 million people2. In many countries MDR-TB has become a serious public health problem that impedes effective ТВ control in the world. The level of drug resistance is as high as in the countries of the former Soviet Union. In the Republic of Uzbekistan in the field of prevention, early detection and effective treatment of tuberculosis, programs recommended by the World Health Organization are implemented. As a result of these organized actions, conditions for the early detection of tuberculosis, profiling of drug resistance in the short terms with the help of molecular genetic rapid tests and effective treatment of patients were created. In the past 10-12 years, in the Republic of Uzbekistan, including, Karakalpakstan, thanks to carried out complex large-scale ТВ control activities, morbidity rates have been reduced. Currently, particular attention is drawn to the high mortality rates from the consequences of the prevalence of tuberculosis and its resistant forms in the Republic of Karakalpakstan. Improving rapid methods for detection of resistant forms of tuberculosis, and measures for the prevention of nosocomial transmission, improving the effectiveness of treatment of resistant forms, the use of less toxic and more effective new anti-ТВ drugs in the treatment of patients with multi and extensive drug-resistant tuberculosis, conducting clinical trials for approbation of shortened treatment regimes are the pressing problems of public health. High rates of drug-resistant tuberculosis in Karakalpakstan, as well as advanced diagnostic and treatment requires a revision of the organizational principles of ТВ care to the population, improvement of anti-epidemic control measures for the prevention of nosocomial spread of the infection. Furthermore, the need for improving the scientific basis of ТВ care, taking into account the prevalence of drug-resistant forms of tuberculosis on the basis of medical and organizational aspects and targets are the most important tasks. In this direction, justificating recommendations on using molecular genetic techniques to identify drug-resistant tuberculosis in Karakalpakstan from an organizational point of view and the development of locally adapted approaches to the process of organization of medical patients on an outpatient basis and justification of recommendations for the revision of the organizational principles are considered to be the most important scientific problems. In the structure of scientific and organizational activities, which is advisable to conduct, justifying the possibility of a successful organization of the process of effective treatment of patients with drug-resistant and drug-sensitive tuberculosis in outpatient settings, identifying the main factors affecting the long-term preservation of family foci of tuberculosis, such as drug resistancy of the source of infection in the outbreak, poor hygiene of living conditions and compliance of therapeutic and preventive measures in these centers from an organizational point of view to the current situation, and the reasons for the network optimization and capacity of ТВ facilities play an important role. Researches aimed at the early detection of drug-resistant forms of tuberculosis and improving the organizational principles of ТВ services were identified as one of the priorities of the State program on combatting tuberculosis in the Republic of Uzbekistan, with Decree of the Cabinet of Ministers №62 «On additional measures to reduce the incidence of tuberculosis in the Republic of Uzbekistan for 2011-2015 "dated March 5, 2011. Demand for this thesis is characterized by the development of scientific substantiation of organizational approaches to provide effective ТВ care and to improve the quality of care provided by skilled population in the region unfavorable epidemiological situation of ТВ, including the Republic of Karakalpakstan, on the basis of evidence-based recommendations for the improvement of methods of detection and treatment of drug-resistant forms of ТВ taking into account the highest levels of prevalence. Purpose of research is the approaches to improve ТВ control improving detection and treatment account its prevalence in the region.. development of new organizational in the Republic of Karakalpakstan, of drug-resistant ТВ taking into Scientific novelty of dissertational research: Conditionality of adverse epidemiological situation of tuberculosis in the region with its prevalence of resistant forms is proven; The efficiency of molecular genetic methods for determining drug sensitivity in comparison with the "gold standard", the possibility and feasibility of its application from an organizational point of view in terms of Karakalpakstan is shown; Increasing levels of drug resistance and nosocomial spread by genetic analysis of Mycobacterium tuberculosis DNA strains are proven in patients with drug-resistant tuberculosis who are cured in patient treatment, risk factors for health personnel of drug-resistant strains are identified; Locally adapted organizational approaches to the treatment of patients with tuberculosis in the outpatient setting from the first day of treatment are developed; The possibility of successful treatment of patients with drug-sensitive and drug-resistant tuberculosis in an outpatient setting is proven; Revealed that the main factors in maintaining homes and families of tuberculosis for a long period are drug resistance of the source of infection, poor hygiene living conditions and inadequately conducted therapeutic and preventive measures from organizational point of view; The discrepancy of the number of ТВ beds with the real need for them is revealed; the need for network optimization and beds of ТВ services is proven; Recommendations for the revision and improvement of the organizational principles of ТВ care to the population are developed. CONCLUSION 1. The complex epidemiological situation of tuberculosis in the Republic of Karakalpakstan is due to the high prevalence of resistant forms and growth of its dynamics. This requires a review of organizational bases of ТВ care. 2. The main factors contributing to long-term preservation of family foci of tuberculosis in the Republic of Karakalpakstan (5 years or more) are high levels of drug-resistant strains of the МВТ (72%), low levels of sanitary living conditions of persons living in these centers, the inadequacy of ongoing treatment -preventive maintenance work on their recovery, which is carried out as standard, without considering negative factors. Therefore, the organization of rehabilitation of homes and families of tuberculosis should be carried out taking into account the drug sensitivity of the source of infection, measures aimed at improving sanitation and socio-economic conditions in the centers 3.Identification of 57 new cases of active tuberculosis among the contact persons residing in family outbreaks of tuberculosis, including 19 cases from the previously recorded shows insufficiency of amount of health and anti-epidemic measures in these centers. These points to the need to revise the nonnative acts regulating the measures on improving family outbreaks of tuberculosis and classification of these outbreaks based on drug susceptibility source of infection 4.The high specificity (100%) and sensitivity (98,6%) of Hain-test for rapid diagnosis of drug susceptibility of Mycobacterium tuberculosis to the major anti-first-linc drugs (isoniazid and rifampicin), is fully justified by its ability of quickly identifying the profile resistance of the patient, which allows to start the treatment in a timely manner and take infection control measures. Therefore it is recommended to include one of the fastest molecular genetic test (Hain-test or expert Gene) in the diagnostic algorithm of ТВ. 5. In the Republic of Karakalpakstan in conditions of intense epidemiological situation of tuberculosis, which is due to high prevalence of its resistant forms (60%), the degree of increase of drug resistance in hospital care (22%) in ТВ facilities and nosocomial spread of tuberculosis among patients and staff is high. To reduce the risk of nosocomial transmission of ТВ in health facilities the practice of hospitalizing all patients in the intensive phase of treatment should be abandoned and must be used outpatient treatment extensively. In addition, in all health care settings a plan for infection control must be developed, a staff specialist on infection control should be included in the staffing of large institutions, a committee, holding the authority to infection control, must be established 6. In the Republic of Karakalpakstan satisfactory results of treatment of drug-resistant tuberculosis (62.7%) have been achieved compared with other projects in the country and abroad. To further enhance the effectiveness of the treatment process, introducing the practice of short regimens of treatment, the acceleration of the use of new drugs in cases of extensive drug-resistant is necessary 7. Early detection and coverage of effective treatment of MDR-TB in this program in Karakalpakstan has improved the success of treatment, and also contributed to the decrease in the dynamics of the proportion of patients with a poor outcome (from 20% to 6.5%) and deaths (from 24% to 7%). 8. The main reasons for the lack of effectiveness of treatmentresistant forms of tuberculosis is the development or presence of XDR-TB patients, unmotivated refusal of treatment (56) by patients and the availability of social (12%) and family (8%) problems. Therefore, to implement measures of psychosocial support to patients, aimed at improving adherence to treatment, more in-depth study of the causes of failure of patients to continue treatment are necessary. 9. The effectiveness of DS and DR tuberculosis treatment (83% and 58%) are satisfactory and not inferior to the results of treatment in hospital (82% and 57%) conditions. Further research on medical, social and economic efficiency of treatment of patients in the outpatient setting, careful examination of the risks for patients and others, the transition of the system of financing of ТВ services to more advanced and cost-effective methods is needed. 10. Mightiness of ТВ beds in ТВ institutions of the Republic of Karakalpakstan and the number of beds in them 1.8 times higher than the actual need. Therefore, it is necessary to optimize the network of ТВ facilities and beds with the real needs.