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best practices in prevention,

control and care for drugresistant tuberculosis

A resource for the continued implementation of the Consolidated

Action Plan to Prevent and Combat Multidrug- and Extensively
Drug-Resistant Tuberculosis in the WHO European Region,

address the needs of special populations

best practices in m/xdr-tb prevention, control and care in the who european region |


Submitted by: Rafael Mekhdiyev, Fuzuli Huseynov Main Medical Department, Ministry of Justice; Nahmat Rahmanov Specialised Treatment
Institution, Ministry of Justice; Asker Ismayilov, Elmira Gurbanova, Rasim Tahirli Main Medical Department, Ministry of Justice; Elchin Mukhtarli
Saglamliga Khidmat, public union, NGO

TB control programme in the prison system

The Main Medical Department of the Ministry of Justice in
Azerbaijan provides TB services to 23 prisons with a population of about 17 000, 2% of which are women. At the end of
2012, the TB notification rate was 3565 per 100 000 people;
19% of notified TB cases were among people living with HIV.
Since approximately 1995, the TB control project has been
successfully developed in line with WHO recommendations,
by virtue of political commitment, standardized TB treatment with strict compliance, a standard registration and
reporting system, and a continuous supply of certified medicines. The most successful aspects of the programme are
highlighted below.
TB detection and diagnosis
TB case detection practice in the prison system is based on
screening at the entrance to pretrial isolators, mass screenings and responsive screenings. The use of a screening algorithm and the availability of new, on-the-spot diagnostic
tools and qualified staff are key to early detection of TB cases.
Identified TB cases are immediately isolated and transferred
to the Special Treatment Institution in Baku.
The Decentralized TB Laboratory Service is equipped with
modern diagnostic equipment for fluorescence microscopy,
culture and drug DST on liquid and solid media, and PCR.
Since 2006, the Special Treatment Institution laboratory has
been accredited by the Supranational Reference Laboratory
in Borstel, Germany.
TB treatment
At the Special Treatment Institution, treatment is provided
free of charge and on a voluntary basis for all TB patients,
regardless of gender, age or designated punishment. Infection control is applied with an emphasis on administrative
and engineering methods in tandem with regular monitoring of the treatment process. Contributing to the successful
treatment of TB has been the absence og waiting times for
treatment integration, vigilant quality control of anti-TB
drugs, timely HIV identification and antiretroviral therapy


| azerbaijan

(ART) initiation, treatment adherence promotion and psychological support for stresses associated with the disease, and
the general confinement approach.
Timely initiation of ART for HIV-positive TB patients is a priority for TB/HIV coinfection management in the prison system.
Continuum of care between prison and
civilian institutions
The TB control started within the prison system is maintained
after release, if treatment is not complete. The Main Medical Department has been working for several years with the
Scientific-Research Institute for Lung Diseases to ensure the
necessary legal framework and with NGOs that support former prisoners with TB.
The Special Treatment Institution operates a training centre
for medical and non-medical prison staff to provide education
on fighting TB infection. Training centre managers are working towards obtaining the WHO collaborating centre status.
Using the theoretical base of the training centre and practical framework of the programme, operational research and
studies of the latest developments and recommendations
from WHO are carried out. With the support of WHO, delegations from different countries are visiting the programme to
exchange experiences.

TB detection and diagnosis
All newcomers are tested for TB on admission to pretrial
isolators and more than 95% of inmates annually undergo a
mandatory TB mass screening (questionnaires, X-ray, sputum
examination) by means of mobile medical teams and digital
X-ray diagnostics.
As a result of early detection, the proportion of prisoners
identified with lung damage has decreased significantly.
The proportion of MDR-TB among inmates has decreased
by 22%, and the proportion of drug-susceptible TB has
increased by 18%.

TB treatment
Treatment success was only 55% for the cohort of new sputum smear-positive drug-susceptible TB patients in 2008.
This low figure was mostly due to nearly 25% of patients in the
cohort failing to continue treatment after release. Currently
(2011 cohort), the rate of loss to follow-up after release has
been reduced to almost zero and the treatment success rate
for new sputum smear-positive drug-susceptible TB patients
has increased to 88%.
Similarly, in 2008, 10% of the MDR-TB patient cohort was lost
to follow-up after release and the treatment success was less
than 65%. According to the latest data (2010 cohort) there
were no patients lost to follow-up after release and the treatment success rate was 83%.
In the last 6 months, the number of HIV-positive TB patients
enrolled in ART has increased to 17%.
Continuum of care between prison and
civilian institutions
Prior to 2009, support and maintenance for former inmates
with TB was not provided consistently. During 20092011,
the Main Medical Department in collaboration with the International Committee of the Red Cross and the Scientific-Research Institute for Lung Diseases conducted support and
maintenance for released prisoners with MDR-TB. Since 2011,
under the framework of WHOs Stop TB Strategy Empowering people with TB, and public organizations through partnerships, the project has expanded to provide full coverage of all
released prisoners with TB.
Every year, on average, 120 drug-susceptible TB patients and
20 MDR-TB patients under treatment are released. Prior to
the start of this programme, only about 10% continued TB
treatment after release, which had a negative effect on treatment outcomes. Nowadays, follow-up procedures are actively
applied and treatment adherence in the civilian setting has
increased to 98%.

TB case detection specifically in the use of mobile X-ray

machines and systematic sputum transportation to the laboratory network.
 nother example of a good practice has been screening at the
entrance to pretrial isolators, optimized by the introduction
of digital radiography and rapid methods of sputum investigation (GeneXpert).
 ombination phenotypic and genotypic methods for TB
diagnosis (Hain, MGIT, GeneXpert) are the most appropriate
for combating TB in prison settings, in order to ensure rapid
diagnosis and initiation of appropriate treatment regimens.
TB treatment
Experience suggests that a centralized TB treatment model
is optimal for the prison systems of former Soviet Union
countries. The best results can be achieved through timely
TB/HIV coinfection diagnosis and management, patient segregation according to infection and DST profiles, the use of
the latest TB laboratory tools, as well as appropriate treatment regimens according to DST.
 dditionally, regular treatment monitoring and adequate
side-effects management, provide high cure rates.
B/HIV coinfection demands a special attention. Early
detection and treatment of coinfection increases the chances
of successful completion of TB treatment.
 ontinuum of care between prison and civilian
A long with the traditional support methods for treatment
after release, namely the provision of transport costs and
incentive packages, intensive patient education plays an
important role in ensuring the continuity of TB therapy and
patients integration into civil society. These educational and
motivational initiatives should start in prison and continue
after release, during the remaining treatment period.

Lessons learnt
TB detection and diagnosis
Maximum coverage and rapid detection of TB cases in Azerbaijani prisons was achieved through capacity building in

azerbaijan |