Tuberculosis epidemic is a real national problem of Ukraine. Only in Kyiv TB dispensaries there are16 thousand registered patients, 1675 of whom have active TB infection. Moreover, according to doctors, the disease rate keeps rising since 2010.
After the adoption of amendments to the law "On fighting against tuberculosis" the Cabinet decreed to hospitalize tuberculosis patients forcefully in case they refuse treatment or violate the treatment regime.
Some history
The bacillus causing tuberculosis, Mycobacterium tuberculosis, was identified and described on 24 March 1882 by Robert Koch. Koch announced a glycerine extract of the tubercle bacilli as a "remedy" for tuberculosis in 1890, calling it 'tuberculin'. While it was not effective, it was later successfully adapted as a screening test for the presence of presymptomatic tuberculosis. In 1946, the development of the antibiotic streptomycin made effective treatment and cure of TB a reality.
Prior to the introduction of this drug, the only treatment (except sanatoria) was surgical intervention, including the "pneumothorax technique", which involved collapsing an infected lung to "rest" it and allow tuberculous lesions to heal. The emergence of MDR-TB has again introduced surgery as an option within the generally accepted standard of care in treating TB infections.
Current surgical interventions involve removal of pathological chest cavities ("bullae") in the lungs to reduce the number of bacteria and to increase the exposure of the remaining bacteria to drugs in the bloodstream, thereby simultaneously reducing the total bacterial load and increasing the effectiveness of systemic antibiotic therapy. Hopes of completely eliminating TB from the population were dashed after the rise of drug-resistant strains in the 1980s. The subsequent resurgence of tuberculosis resulted in the declaration of a global health emergency by the World Health Organization in 1993.
Tuberculosis typically attacks the lungs, but can also affect other parts of the body. It is spread through the air when people who have an active TB infection cough, sneeze, or otherwise transmit their saliva through the air. The bacteria are not afraid of cold or a short-time exposure to high temperatures.
The only way to fight the disease is to regular medical examination and hospitalization of sick. However, since 1995 it has become impossible to force tuberculosis patients to hospitalization without violating their rights. Interesting that, the same year Ukraine was hit by tuberculosis epidemic.
Helpful law
The 11th article of the new version of the law on fighting against tuberculosis provides for compulsory hospitalization of patients with active TB infection in order to prevent the disease spread among the population. To force a patient into hospitalization, a TB dispensary must appeal to court. The application must include grounds for urgent hospitalization. If court decides that the hospitalization is necessary, the patient gets hospitalized for the term of up to three months. If hospitalization must be prolonged, but the patient refuses to stay, the TB dispensary can again appeal to court.
In case of complications, law enforcement bodies may assist with compulsory hospitalization within the limits of their authorities. Non-compliance with the court decision on compulsory hospitalization involves criminal responsibility in accordance with the legislation.
Opinion of a specialist
To learn the opinion of doctors on the innovation, ForUm went to the Kyiv central TB dispensary #1. Deputy Chief Doctor on treatment quality and disability examination Myroslava Serheyeva kindly agreed to answer our question and hold a tour around.
Myroslava Serhiyeva is an experienced specialist and a member of the medical council and medical consultative board of the dispensary. She also works with complicated cases and difficult patients.
"All patients have the same reaction to the diagnosis 'tuberculosis'. These patients simply do not hear what doctors say. At the beginning, patients do not understand that the disease is curable, that they will be protected socially and financially, that their employers have no right to fire them. For the first month patients are in shock. The only thing they care about is the reaction of their dears and others."
According to Myroslava Serhiyeva, treatment results often depend on support of relatives. "If a patient knows he has all support of his family the treatment goes smoothly," the doctor explains.
However, what ForUm is interested in is the procedure of compulsory hospitalization.
"Compulsory hospitalization is now possible. If a patient avoids hospitalization he may face criminal charges. We had two patients against who we filed suits. The next day they personally came to the dispensary and stayed. Now we have another difficult case. It looks like we have to appeal to court again. Well, it is a chance to learn about the innovation."
According to the doctor, there are patients who just do not want to undergo treatment, but the majority of patients do not want to stay because of the poor conditions of the institutions.
"I cannot blame them, the conditions are really poor. I believe that if TB dispensaries have hotel-like conditions, people will have no problems with staying there. Dispensaries also need special rooms for incurable cases and special intensive care departments for complicated cases (two infectious diseases at the same time). It is in development now. Moreover, if doctors have better working conditions, young specialists will stay longer."
Myroslava Serhiyeva also informed that in case of compulsory hospitalization, TB dispensaries may use ambulances, not police cars, to transport patients, however the procedure is not properly regulated.
"For the moment we hospitalize patients in ordinary way. We do not have special cars, so we use ambulances. Afterwards, the cars undergo thorough disinfection process."
Speaking about foreign practice, the specialist told ForUm that in Europe and America patients with active TB infection can be treated at home. "Such patients have special devices which control allowed walking perimeter, and in case of crossing the border the alarm goes off. Moreover, every TB patient has a laptop and must communicate with his doctor at a given time."
"There are many various methods of treatment, but they are not available in Ukraine for now. In case of active form of tuberculosis, a patient must be hospitalized, and if he refuses, a doctor or dispensary commission has a right to appeal to court to obtain decision on compulsory hospitalization. Anyway, our primary task is to reveal the disease in time and to inform about it."
Lifesaving rooms
Kyiv central TB dispensary is located on Vasylkovska street. It has been working for over 50 years and provides such services as medical consultation, examination, tests. It also has patient department for patients with active TB infection. All services are free of charge if there is a referral letter from a physician.
Entrances for patients are divided - children and workers have a separate entrance. At every entrance, there is a warning to always wear a mask.
The building is old, but tidy, some rooms are under repair. On the first floor there are offices of infectiologist, ultrasonographer, pediatrician, urologist and gynecologist. The dispensary also expects a psychologist in the near future.
Room for medical procedures.
Room for test administration.
On the second floor there is a research lab, the best in Kyiv. The lab examines biological materials from five districts of Kyiv, children's hospital "Ohmadit", psychoneurological hospital of Glevakha, in-patient hospital #6, central hospital of Interior Ministry, Gromashevski institute of epidemiology and infectious diseases and Lukyanivske detention facility.
The walls of the building are covered with warnings about biohazard. In this respect, we asked laboratory assistant about the salary considering the risks. It turned out that the salary is average, 4000 hryvnias. 60% increase - 6000 hryvnias - can be gained only after ten-year term of service. The major part of workers are pensioners, 60 years old and older. Due to high risks and hard working conditions, young specialists do not hurry to come here.
In day patient department nurses sort out medicines. TB patients have to take many drugs - 15-20 pills simultaneously.
In-patient department has 55 places. Now it is empty, but Myroslava Serhiyeva assured us that last year the department was 92.8% full.
In the diner, patients can eat packed lunch. The doctors says that the dispensary spend 15-20 hryvnias per patient daily. However, it is not enough to provide proper nutrition for patients.
In 2012, Kyiv TB dispensary saw 1143 patients, excluding non-residents, and 195 out of them were homeless. 1052 patients were diagnosed with tuberculosis, and 657 out of them had active TB infection.
How to protect yourself from infection
What came as a surprise was that homeless people are not in the risk group. "Homeless people are not as sick as believed. They live in the street and are better weathered than us, hothouse people."
The statistics says that the risk group includes people of 20-45 years old, who suffer stress and poor nutrition. People under stress have weaker immune system.
The risk group also includes HIV positive people, diabetics, peptic ulcer patients, oncology patients. However, healthy people also risk getting sick if they do not eat meat and dairy products or follow low-protein diets. Staying in closed institutions, like boarding schools or foster houses, also increase the risk.
"There is no 100-percent-efficient recipe of protection against tuberculosis. But I'll give you a piece of advice: eat protein products, avoid stress, take vitamins, walk in fresh air and undergo regular medical examination," Myroslava Serhiyeva says. Tuberculosis is an insidious disease: symptoms of the first stages are not visible, while strong cough and bleeding of the last stage may lead to lethal outcome.
Tuberculosis has been present in humans since antiquity at the latest. Skeletal remains show prehistoric humans (4000 BC) had TB, and researchers have found tubercular decay in the spines of Egyptian mummies dating from 3000–2400 BC. It means that the bacillus always has been and will be living next to us. The only thing we can do is to create all necessary conditions to stop the epidemic in the country. Let's hope the new version of the law on fighting tuberculosis will help us with the task.
Anastasia Pika, photos by Maxim Trebukhov
After the adoption of amendments to the law "On fighting against tuberculosis" the Cabinet decreed to hospitalize tuberculosis patients forcefully in case they refuse treatment or violate the treatment regime.
Some history
The bacillus causing tuberculosis, Mycobacterium tuberculosis, was identified and described on 24 March 1882 by Robert Koch. Koch announced a glycerine extract of the tubercle bacilli as a "remedy" for tuberculosis in 1890, calling it 'tuberculin'. While it was not effective, it was later successfully adapted as a screening test for the presence of presymptomatic tuberculosis. In 1946, the development of the antibiotic streptomycin made effective treatment and cure of TB a reality.
Prior to the introduction of this drug, the only treatment (except sanatoria) was surgical intervention, including the "pneumothorax technique", which involved collapsing an infected lung to "rest" it and allow tuberculous lesions to heal. The emergence of MDR-TB has again introduced surgery as an option within the generally accepted standard of care in treating TB infections.
Current surgical interventions involve removal of pathological chest cavities ("bullae") in the lungs to reduce the number of bacteria and to increase the exposure of the remaining bacteria to drugs in the bloodstream, thereby simultaneously reducing the total bacterial load and increasing the effectiveness of systemic antibiotic therapy. Hopes of completely eliminating TB from the population were dashed after the rise of drug-resistant strains in the 1980s. The subsequent resurgence of tuberculosis resulted in the declaration of a global health emergency by the World Health Organization in 1993.
Tuberculosis typically attacks the lungs, but can also affect other parts of the body. It is spread through the air when people who have an active TB infection cough, sneeze, or otherwise transmit their saliva through the air. The bacteria are not afraid of cold or a short-time exposure to high temperatures.
The only way to fight the disease is to regular medical examination and hospitalization of sick. However, since 1995 it has become impossible to force tuberculosis patients to hospitalization without violating their rights. Interesting that, the same year Ukraine was hit by tuberculosis epidemic.
Helpful law
The 11th article of the new version of the law on fighting against tuberculosis provides for compulsory hospitalization of patients with active TB infection in order to prevent the disease spread among the population. To force a patient into hospitalization, a TB dispensary must appeal to court. The application must include grounds for urgent hospitalization. If court decides that the hospitalization is necessary, the patient gets hospitalized for the term of up to three months. If hospitalization must be prolonged, but the patient refuses to stay, the TB dispensary can again appeal to court.
In case of complications, law enforcement bodies may assist with compulsory hospitalization within the limits of their authorities. Non-compliance with the court decision on compulsory hospitalization involves criminal responsibility in accordance with the legislation.
Opinion of a specialist
To learn the opinion of doctors on the innovation, ForUm went to the Kyiv central TB dispensary #1. Deputy Chief Doctor on treatment quality and disability examination Myroslava Serheyeva kindly agreed to answer our question and hold a tour around.
Myroslava Serhiyeva is an experienced specialist and a member of the medical council and medical consultative board of the dispensary. She also works with complicated cases and difficult patients.
"All patients have the same reaction to the diagnosis 'tuberculosis'. These patients simply do not hear what doctors say. At the beginning, patients do not understand that the disease is curable, that they will be protected socially and financially, that their employers have no right to fire them. For the first month patients are in shock. The only thing they care about is the reaction of their dears and others."
According to Myroslava Serhiyeva, treatment results often depend on support of relatives. "If a patient knows he has all support of his family the treatment goes smoothly," the doctor explains.
However, what ForUm is interested in is the procedure of compulsory hospitalization.
"Compulsory hospitalization is now possible. If a patient avoids hospitalization he may face criminal charges. We had two patients against who we filed suits. The next day they personally came to the dispensary and stayed. Now we have another difficult case. It looks like we have to appeal to court again. Well, it is a chance to learn about the innovation."
According to the doctor, there are patients who just do not want to undergo treatment, but the majority of patients do not want to stay because of the poor conditions of the institutions.
"I cannot blame them, the conditions are really poor. I believe that if TB dispensaries have hotel-like conditions, people will have no problems with staying there. Dispensaries also need special rooms for incurable cases and special intensive care departments for complicated cases (two infectious diseases at the same time). It is in development now. Moreover, if doctors have better working conditions, young specialists will stay longer."
Myroslava Serhiyeva also informed that in case of compulsory hospitalization, TB dispensaries may use ambulances, not police cars, to transport patients, however the procedure is not properly regulated.
"For the moment we hospitalize patients in ordinary way. We do not have special cars, so we use ambulances. Afterwards, the cars undergo thorough disinfection process."
Speaking about foreign practice, the specialist told ForUm that in Europe and America patients with active TB infection can be treated at home. "Such patients have special devices which control allowed walking perimeter, and in case of crossing the border the alarm goes off. Moreover, every TB patient has a laptop and must communicate with his doctor at a given time."
"There are many various methods of treatment, but they are not available in Ukraine for now. In case of active form of tuberculosis, a patient must be hospitalized, and if he refuses, a doctor or dispensary commission has a right to appeal to court to obtain decision on compulsory hospitalization. Anyway, our primary task is to reveal the disease in time and to inform about it."
Lifesaving rooms
Kyiv central TB dispensary is located on Vasylkovska street. It has been working for over 50 years and provides such services as medical consultation, examination, tests. It also has patient department for patients with active TB infection. All services are free of charge if there is a referral letter from a physician.
Entrances for patients are divided - children and workers have a separate entrance. At every entrance, there is a warning to always wear a mask.
The building is old, but tidy, some rooms are under repair. On the first floor there are offices of infectiologist, ultrasonographer, pediatrician, urologist and gynecologist. The dispensary also expects a psychologist in the near future.
Room for medical procedures.
Room for test administration.
On the second floor there is a research lab, the best in Kyiv. The lab examines biological materials from five districts of Kyiv, children's hospital "Ohmadit", psychoneurological hospital of Glevakha, in-patient hospital #6, central hospital of Interior Ministry, Gromashevski institute of epidemiology and infectious diseases and Lukyanivske detention facility.
The walls of the building are covered with warnings about biohazard. In this respect, we asked laboratory assistant about the salary considering the risks. It turned out that the salary is average, 4000 hryvnias. 60% increase - 6000 hryvnias - can be gained only after ten-year term of service. The major part of workers are pensioners, 60 years old and older. Due to high risks and hard working conditions, young specialists do not hurry to come here.
In day patient department nurses sort out medicines. TB patients have to take many drugs - 15-20 pills simultaneously.
In-patient department has 55 places. Now it is empty, but Myroslava Serhiyeva assured us that last year the department was 92.8% full.
In the diner, patients can eat packed lunch. The doctors says that the dispensary spend 15-20 hryvnias per patient daily. However, it is not enough to provide proper nutrition for patients.
In 2012, Kyiv TB dispensary saw 1143 patients, excluding non-residents, and 195 out of them were homeless. 1052 patients were diagnosed with tuberculosis, and 657 out of them had active TB infection.
How to protect yourself from infection
What came as a surprise was that homeless people are not in the risk group. "Homeless people are not as sick as believed. They live in the street and are better weathered than us, hothouse people."
The statistics says that the risk group includes people of 20-45 years old, who suffer stress and poor nutrition. People under stress have weaker immune system.
The risk group also includes HIV positive people, diabetics, peptic ulcer patients, oncology patients. However, healthy people also risk getting sick if they do not eat meat and dairy products or follow low-protein diets. Staying in closed institutions, like boarding schools or foster houses, also increase the risk.
"There is no 100-percent-efficient recipe of protection against tuberculosis. But I'll give you a piece of advice: eat protein products, avoid stress, take vitamins, walk in fresh air and undergo regular medical examination," Myroslava Serhiyeva says. Tuberculosis is an insidious disease: symptoms of the first stages are not visible, while strong cough and bleeding of the last stage may lead to lethal outcome.
Tuberculosis has been present in humans since antiquity at the latest. Skeletal remains show prehistoric humans (4000 BC) had TB, and researchers have found tubercular decay in the spines of Egyptian mummies dating from 3000–2400 BC. It means that the bacillus always has been and will be living next to us. The only thing we can do is to create all necessary conditions to stop the epidemic in the country. Let's hope the new version of the law on fighting tuberculosis will help us with the task.
Anastasia Pika, photos by Maxim Trebukhov
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