DOTS-Plus pilots take first flights in Russia
October 1, 1999 3 minutes read
DOTS-Plus pilots take first flights in Russia
Finding ways to treat through,’ no matter what
Over the coming months, fledgling DOTS-Plus programs across the former Soviet Union will began trying their wings. One such pilot DOTS-Plus program — founded, as the others are, on the belief that it’s possible to treat patients with multidrug-resistant TB in poor countries instead of letting them die — started this month in a crowded Siberian prison in the province of Tomsk. Other pilots are due to begin running soon in other Russian provinces and in the Eastern European nation of Latvia.
As the start of the projects drew near, American TB experts helping oversee the work were understandably anxious. "In the prisons, we don’t have the advantages of community and family supports," says Michael Kimerling, MD, MPH, assistant professor in the schools of medicine and public health at the University of Alabama in Birming ham and a consultant to Russian DOTS-Plus programs.
In other settings where DOTS-Plus has been tried — a Peruvian shantytown in northern Lima, most notably — clinicians have advantages not available in Russia, Kimerling explains. "In Peru, patients can be with their families; psychologically, they’re in a much better setting. In Siberia, you just have a roomful of people in prison vomiting."
Still, the pressure is on to perform. "These projects will undergo a lot of scrutiny," says Nancy Binkin, MD, MPH, associate director for international activities at the Division of TB Elimination at the Centers for Disease Control and Prevention. Binkin serves as a consultant to a project starting up in Ivanova. "If we come up with a poor success rate, then everyone will say, Hey, this isn’t worth doing.’"
The Russian physicians whom Kimerling and others have spent the summer training are nervous as well, worried about whether they’ll be able to manage the terrible side effects brought on by the harsh drugs required. American TB experts will be doing a lot of on-site handholding, especially for the first six months, says Kimerling. "I knew from the start that this project would take up a lot of my time," he says wearily. "I didn’t know it would be this much."
Is a standard regimen the answer?
Last month, after wrapping up a tour of DOTS-Plus sites in the United States and Peru, Kimerling sat down with the Russian physicians who will be working in Tomsk to devise a protocol that everyone hopes will work in Russia. Initially, it was decided, prisoners will be given the same standardized regimen. As test results come back, regimens will be modified according to five or six basic treatment schemes.
The question of how much to customize regimens is a tough one, says Binkin. One side argues for putting everyone on a standard regimen; after all, a big reason the Russians got into trouble in the first place was a nonstandardized approach to treatment.
Yet in the Ivanova community-based project where Binkin is working, 60% of patients are alcoholics, meaning they probably have severe liver damage and perhaps ulcers as well. In the course of unsuccessful treatments, the patients have suffered side effects of loss of hearing and balance. All that means that for many, a standard regimen simply won’t work, Binkin says.
One of Kimerling’s approaches to potential problems is to devise lots of algorithms for dealing with side effects as they crop up and then being there when things go badly anyway, as he knows they will. "We’ve got to treat through," he says. "No matter what happens, treating through has got to be our mantra."
Binkin, with a caseload of feisty patients walking around in the community, has decided she’s got to be selective. "With some candidates, I’ve decided I can reserve the right to be pessimistic about their chances of making it through treatment," she says. "And so many people will be watching."
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