The present situation with tuberculosis in Russia is very serious. In 1999 Russian patients with TB constituted 2% of the total cases and 0.7% of all deaths from TB in the world. The morbidity rate has increased from 34/100 000 in 1991 up to 86/100 000 in 2000. The mortality rate in comparison with the period 1986-1991 has grown 2.5 times and is now 20 per 100 000 (1,2).
Fig 1. TB morbidity and mortality per 100 000 population in Russia.
General economic destruction, military conflicts, negative changes in the environment, intensive migration, increasing unemployment and homelessness all influence the TB situation in Russia.
A search of the databases MEDLINE and CAPLUS yielded 15 938 papers on TB in Russia since 1957. Of these 319 papers concerned TB in Russian prisons. This review summarizes the 26 most important ones since 1994.
TB in Russian prisons
Russia is the leading country in the world in number of the convicted persons (740/100 000) (3). A decrease in TB incidence in penal institutions was recorded in the period from 1987 to 1991 (from 643.7 to 321.7 per 100 000), but this has now changed to a new increase (4).
In the civilian population in Russia TB rates have been increasing steadily during the last 10 years. The infection rates in prisons are from 32 to 100 times higher than in civil society. It is estimated that about 75 000 new cases annually will be detected in the Russian civilian population (150 million) in the next years, while about 40 000 new cases for a population of 1 million will be found in prisons (5). In 1999 9.5% of Russian prisoners were reported to have active TB and the incidence of new cases was around 4 000/100 000 (6). Also the mortality among prisoners is much higher as compared to civilians. For instance, in 1997 it amounted to 16,8/100 000 in civilian population (7), while in prisons it was ca. 500/100 000 (8). These numbers vary in different parts of Russia.
Fig 2. Prisoners’ morbidity and mortality per 1000 in Russia, 1991-1997
Rates in Siberia have been 20% higher than for the Russian Federation on average. As an example, the Kemerovo region (West Siberia) has over 25 000 prisoners, housed in approximately 22 colonies and pre-trial detention facilities. Mariinsk is a city in the North of the region with 50 000 inhabitants. The city has five prisons. Colony number 33 holds the prisoners from the region who have TB (9). All prisoners are initially incarcerated in jails while their cases are investigated. Convicted persons are sent to regional prisons; those not convicted are released. The stay in such pre-trial detection centre lasts one year on average; people reside in overcrowded cells containing from 30 to 50 persons each. Legally, TB suspects in jails cannot be moved to the TB colony unless convicted, so they are kept together with healthy persons in cells. Convicted TB suspects may be transferred to Colony 33 from the other colonies only when a bed becomes available and only if they are not due for release during the next several months (10).
The incidence and causes of pulmonary tuberculosis relapses were studied in convicted persons from the corrective labour establishment of the Saratov region (11). There were a number of aggravating factors (being in prison, stress, refusal of food and treatment, hypovitaminosis, residual tuberculosis changes in the lungs) that influenced the occurrence of relapses. It was determined that morbidity and result of treatment vary strongly with conditions of detention (12). However, the TB situation in the Saratov region has stabilized in 1999 (13).
The Sverdlovsk region has a large number of convicts and pre-trial people. One in ten of them have active TB. Every prison and colony is overcrowded. The staff in the prisons has the high risk to be sick with TB (839.8 per 100 000 in 1996-1998 (14, 15)). This is 3.2 times higher than the morbidity rate among the workers of the civilian anti-tuberculosis service in the region. According to ref. 16, a third of the patients had fallen ill during the first 5 years of imprisonment. The disease was also detected in half of the former prisoners in the first 3 years after release. Extrapulmonary tuberculosis is almost never diagnosed due to the lack of diagnostic methods. The rates of relapse, incidence, and death due to tuberculosis in 1996 are, respectively, 72, 36, and 10 times higher, compared to the civilian population (17).
Clinical structure of newly diagnosed tuberculosis was studied (Sverdlovsk region) in convicts and civilians in 1996-1998. Infiltrative (82,3% and 60,2%, respectively) and focus (12.2% and 10.1%) forms are predominated, while fibrocavernosus (0.2% and 3.7%) and cirrhotic (0.03% and 0.3%) forms are nearly absent. More often people in prisons died from infiltrative tuberculosis (53.4% and 20.6%) (15).
A study of social characteristics of patients with TB in penitentiaries was made in the TB hospital in Arkhangelsk for convicted people (18). 345 convicted patients with tuberculosis underwent socio-hygienic examination. Among them, the disease was first detected in 74.2% in colony, in 25.8% in an investigating cell. The persons who fell ill with TB in places of confinement were from 20 to 39 years. Only every 4th patient with tuberculosis is condemned for the first time, more than half the patients have over 3 convictions and every 5th patient has over 5 convictions. 19.1% of all prisoners have duration of confinement (in total) 10-14 years, and every 4th patient has over 15 years. Low morbidity was detected among dangerous recidivists, this is probably due to the fact, that they were contained in separated cells and have small contact with other prisoners. Among examinees, 7.6% were homeless before conviction. The majority of the convicts had no social contacts: 52.2% were never married. 90.1% of prisoners with tuberculosis are smoking (80.1% of them are smoking for longer than 10 years). 85.6% of patients are alcohol-addicts.
Also in Voronezh region, after a big incidence among prisoners during the 1990`s, there now seems to be trend towards stabilization of tuberculosis morbidity (19).
Prisoners often receive little or no treatment, and sometimes treatment includes only one or two drugs. Courses of treatment are frequently incomplete because of a lack of drugs or prisoners being moved to other places or being released before treatment is completed. The result has been a rapid increase in the incidence of multi-drug resistant TB. The high MDR-TB rates (40% of patients in prisons and 10% in the community) explain the high level of treatment failures (20).
As example, the increase in the incidence of MDR-TB in Tomsk is of great concern. This has risen from 6.9% of the new cases in 1998 to 12.6% in the first nine months of 1999 and there are now at least 250 MDR-TB cases in the oblast (6). The increase is thought to be mostly due to cases in (or recently released from) prisons (where primary MDR rates exceed 25%) but may also have a component due to the “amplifier effect” of using a regimen of four first-line drugs in a situation of widespread multidrug-resistant TB (21).
HIV infection and tuberculosis
Another emerging problem in the Russia is the association of TB with human immunodeficiency virus infection. At the end of 1999, 17 888 individuals were identified as being infected with HIV. During the 3 first months of 2000, the number of newly infected individuals increased 4.6 times compared with the same time period in 1999. At the beginning of 2000, 515 cases of dual HIV/TB infection were reported, 90% of these in drug addicts (2). In the St. Petersburg’s prisons, there were at the same time 1360 patients with HIV infection, 45 patients with dual HIV/TB infection (most of them from pre-trial detection facilities).
According to one prognosis (1), with the current trend of socio-economic conditions and organization of anti-tuberculosis service, the TB morbidity in Russia will continue to increase and reach 132/100 000 in 2005 and 190/100 000 in 2010. This means that morbidity will more than double in the next 10 years.
The main reasons for the increasing TB problem in Russian prisoners are insufficient funding from the government and other sources, insufficient nutrition for prisoners, poor living conditions in prisons, incomplete treatment, high multidrug-resistance TB prevalence and unresolved social problems. Several criminogenic, personal and behavioural factors predispose to tuberculosis (18,22). There is a need to provide a standardized and adequate treatment for new patients before they are incarcerated in prison and for persons with MDR-TB (23).
In 1999, in Russian Federation started the programme “Emergency measures to fight TB in Russia for 1998-2004”, but this funds only 25-30% of the patients treatment (24). It is necessary to improve diagnosis and laboratory facilities in the prisons for the early detection of TB among the convicted (25, 26).
The trend analysis predicts that the TB situation in Russia will probably worsen even more in the near future due to the continuing amnesty actions. This results in the release of prisoners with active TB, incompletely treated, and carriers of multidrug-resistant M. tuberculosis strains from prisons without confirmed continuing treatment in civilian life. The success of the TB programme in Russia thus substantially depends on improved socio-economic conditions (2).
1. Schilova M. The organization and results of the treatment of people with tuberculosis in Russia. Vrach 2001; 2: 3-7.
2. Perelman M. Tuberculosis in Russia. Int J Tuberc Lung Dis 2000; 4(12): 1097-1103.
3. Sazhin V. The scientifical grounding for organization of the medical service for convicted. Thesis. St. Petersburg, 1997.
4. Bubochkin.B. Epidemiological situation in relation to tuberculosis in penalty institutions. Problemy Tuberkulosa 1995; 3: 7-9.
5. Coninx R. Tuberculosis in prisons in countries with high prevalence. British Medical Journal 2000; Feb 12.
6. Healing T, Peremetin G, Lyagoshina T et al. TB across the globe (3).Tuberculosis in Russia. Scot Med J 2000; 45(Supp 1): 14-15.
7. Punga V, Kapkov L. Tuberculosis in Russia. Problemy Tuberculosa 1999; 1: 14-16.
8. V.L.Sazhin V, Yuriev V. Health and diseases of convicted. 1999; St.-Petersburg.
9. Stern V. Sentenced to die? London, 1999.
10. Kimerling M, Kluge H, Vezhnina N et al. Inadequacy of the current WHO re-treatment regimen in a central Siberian prison: treatment failure and MDR-TB. INT J Tuberc Lung Dis 1999; 3(5): 451-453.
11. G.K.Kovalev, G.I.Gvozdilkin, T.G.Datsuk. Pattern of recurrence of pulmonary tuberculosis in corrections work camps (Saratov). Problemy Tuberkulosa 1994; 2: 56-57.
12. Kovalev G, Gvozdilkin G. Epidemiological foci of pulmonary tuberculosis among the convicts of reformatories. Problemy Tuberkulosa 1994; 5: 9-11.
13. Hudzik T, Vygodchikov Y, Salina T et al. Dynamic of tuberculosis epidemiological indexs in prisons in the Saratov region. 9-th National congress of Lung Diseases. Moscow, 1999,.419.
14. Nechaeva O. Co-operation between anti-tuberculosus service and head direction of prisons system. The session “Anti-tuberculosis work in Ural and Volgo-Viat region. Ekaterinburg, 2000, 16-17.
15. Nechaeva O. Tuberculosis in corrective labour institutions in Sverdlovsk region. Zdravoohranenie Rossiiskoi Federatsii. 2000; 4: 38-40.
16. Nechaeva O. Respiratory tuberculosis in prisoners. Problemy Tuberkulosa 1994; 1: 8-10.
17. Nechaeva O, Arenskii V, Naymenko Y et al. The influence of tuberculosis in penitentiaries on the epidemiological situation in the Sverdlovsk region. Problemy Tuberkulosa 1998; 4: 11-12.
18. Sannikov A, Kuznetsov A. Social characteristic of patients with tuberculosis in penitentiaries. Problemy Tuberculosa 1998; 5: 11-13.
19. Merculova L, Ershov C, Timoshenko O et al. The fundamental directions in organization anti-tuberculosis job in corrective labour institutions in Voronezh region. Bolschoi Tselevoi Zhurnal 2000; 10: 20-21.
20. Banatvala N. Deal struck for Russians with tuberculosis. The Lancet 1999; 354: 56.
21. Heifets L, Iseman M. Are we on the brink of a new white plague in Russia? Editorial. Int J Tuberc Lung Dis 2000; 4(12): 1095-1096.
22. Drobniewski F, Tayler E, Ignatenko N. Tuberculosis in Siberia: 1. An epidemiological and microbiological assessment. Tubercle and Lung Dis 1996; 77: 199-206.
23. WHO. Fourth Meeting of National Tuberculosis Programme Managers. Helsinki, Finland 8-10 June, 2000; 12.
24. Kononets A. The organization of treatment the people with tuberculosis in the penal executive system. Khimioterapia tuberkulosa 2000; p.39-40.
25. Rybkina T. Tuberculosis in convicts. 2-nd (12-th) Phthisiatrics Meeting. Abstracts. Saratov 1994, 35.
26. Starikov A. The system of organization of dispansery job in penitentiary-labour establishments in Russia. 2-nd (12-th) Phthisiatrics Meeting. Abstracts. Saratov 1994, 36.