Tuberculosis epidemic. Tuberculosis - first signs, symptoms, causes, treatment and prevention of tuberculosis. Where do drug-resistant forms of mycobacteria come from?

Consumption, scrofula – tuberculosis used to have many names. Just half a century ago, tuberculosis in Russia was one of the most dangerous fatal diseases.

Statistics from ten years ago showed that almost 90 people died from tuberculosis every day in our country. Think about it: daily!

Back in 1993, WHO (World Health Organization) declared tuberculosis a global problem. The statistics on the incidence of tuberculosis, cited by WHO, are frightening: every year 9 million people in the world fall ill with a dangerous disease, and 2 million die.

The problem is no less large-scale in our country: before, tuberculosis was a death sentence, now the situation has changed somewhat, however, at the present stage, compare mortality from tuberculosis (often in combination with HIV infection) with deaths from other causes: road accidents, suicides, murders and alcohol intoxication.

Yes, these are terrible numbers, although earlier, and now tuberculosis remains a disease that is not customary to talk about out loud: in the classic works of Russian literature, poor students and degenerates died of consumption; in Soviet times, it was believed that only prisoners and Homeless people.

Alas, no one is safe. Moreover, medical sources indicate that every third inhabitant of the Earth is infected with tuberculosis, although in a “sleeping”, dormant form. In Russia, this figure is even more frightening - from 70 to 99% of the population are carriers of the main tuberculosis pathogen - Koch bacillus.

Will we all die from tuberculosis?

In the 60s of the last century, an active and consistent fight against a deadly disease was launched in Russia. This mandatory fluorography is not the whims of doctors, but an attempt to identify the disease at the earliest stages. The mandatory annual procedure bore fruit in the first decades: by the 1980s, our country was able to get closer to the world average, but not for long.

The political and socio-economic situation in the country has led to the fact that the incidence of tuberculosis in Russia has tripled in just one decade and reached alarming proportions. Today Russia is among the leading countries in the incidence of tuberculosis, and this is a modern developed state!

Yes, today few people in the world die from tuberculosis, and these are mostly representatives of the “risk group”: prisoners - current or former, people leading a certain lifestyle. However, a quarter of those infected become disabled for the rest of their lives, and curing tuberculosis is very, very difficult.

Who is at risk for the disease?

Considering that almost every one of us is a carrier of Koch's bacillus, everyone is at risk.

However, this does not mean that each of us should get sick a priori: the danger is posed by the active stage of bacterial activity. They awaken when the body is weakened, when immunity drops sharply. In other cases, a person is healthy, even if he is a carrier of pathogenic bacteria.

That's why it includes:

• marginalized;
• persons who were previously imprisoned, penal colonies;
• patients of psychiatric and drug treatment institutions;
• shelter residents.

This is a social risk group. In addition to it, there are outpatient groups for people with weakened immune systems:

1. women in the postpartum period;
2. AIDS patients and infected people;
3. patients with diabetes mellitus, stomach and intestinal ulcers;
4. chronic alcoholics, drug addicts, patients with mental illness;
5. patients with liver pathologies.

The outpatient risk group is the largest, since any nonspecific lung diseases, frequent headaches, long-term arthritis, diseases of the genitourinary system and other body systems can cause the awakening of pathogenic bacteria.

The danger of the disease also applies to persons who have direct contact with tuberculosis patients (family members, medical staff of clinics).

The disease they don't talk about

Tuberculosis is dangerous, but this does not mean that a person who contracts it is doomed. The disease becomes mortally dangerous only in its final stages, when the person is not treated. If the disease is detected in a timely manner, it is almost always curable.

There is no need to think that everyone who leads a healthy lifestyle, is young and cheerful, will be spared the disease.

Tuberculosis statistics show that young people and middle-aged people most often get sick: from 18 to 45 years old, the peak of diseases occurs:

• for men - for 35-45 years;
• for women - for 25-35 years.

Pathological changes in the body are not easy to notice in the early stages, and in people’s minds it is associated with consumptive people coughing blood and leading an illegal lifestyle. However, many say that at first they simply noticed fatigue and weakness.

Who pays attention to such symptoms?

This is not a disease of alcoholics and drug addicts, it can affect any of us, and the symptoms of tuberculosis may initially be minor:

1. rapid fatigue, fatigue;
2. nervousness, irritability;
3. excessive sweating;
4. slight increase in body temperature: no higher than 37.2-37.5 degrees.

At the same time, there is not even an ordinary cough, let alone a bloody, painful one with phlegm. The man just felt tired. I just want to sleep more and my productivity decreases. All this is usually attributed to the frantic pace of modern life: “I’ll go on vacation and everything will pass.” But I should go for fluorography.

And again the figures cited by Rospotrebnadzor: in 2014, 78,000 new cases of the disease were registered, in 2015 – 77,000. And these are only the first diagnoses. In terms of the prevalence of the disease by region, the most tense situation is in the Urals, Siberia and the Far East.

If we compare the data with statistics from the beginning of the 21st century, then up to 120,000 cases of the disease were registered annually; now this figure has been significantly reduced, but it is too early to clap your hands.

The main reason why pathogenic bacteria become active in the human body is weakened immunity.

The reasons for this could be many factors:

• stress associated with problems in the family, at work, even simply moving to another city or entering an educational institution;
• poor nutrition and unhealthy diets;
• chronic lack of sleep;
• frequent processing;
• addiction to alcohol.

That is why we can say that each of us is at risk. However, the main factor in which the human immune system is in a critical condition is HIV infection.

According to the World Health Organization, the risk of developing tuberculosis in HIV-infected people increases by 20-30 times compared to other people. Hence the high incidence of tuberculosis in the whole world, where more than 7.5 thousand new cases of HIV infection are registered every day.

Tuberculosis is curable. And this is the main point

Medicine does not stand still. Today, to make an accurate diagnosis, special tests are used that make it possible to determine the form of tuberculosis and its sensitivity to drugs within two hours. This allows you to quickly select a treatment package.

Non-advanced forms of tuberculosis are treated with antibiotics and chemotherapy. The process is long, but you need to endure the whole range of procedures: a strict rhythm - two months of antibiotics, four - a maintenance course. You can’t skip it, otherwise your body will develop resistance to antibiotics.

Much more difficult is the form of tuberculosis, when treatment with conventional pills is ineffective: the body does not accept them. This stage of “multidrug resistance” requires a different treatment: more expensive and toxic to the body. If courses of antibiotics are ineffective, surgery is prescribed. It guarantees a complete cure.

In the Russian Federation, tuberculosis is considered a socially significant disease. The state controls treatment, which is compulsory and free. Throughout the entire time from the moment of diagnosis, the patient is registered at the tuberculosis dispensary and regularly undergoes courses of treatment.

Is tuberculosis contagious?

The epidemiological danger of tuberculosis (otherwise the risk of infection) depends on the form of the disease. In case of active release of pathogenic bacteria, treatment is carried out exclusively in anti-tuberculosis dispensaries; in closed forms, contact of a person with stable immunity with the patient is not dangerous.

A special risk group is HIV-infected people. In 2016, when the UN recognized Russia as the epicenter of the global HIV epidemic, funding for regions to purchase drugs for HIV-infected people was reduced in our country, which immediately affected the level of recorded cases of tuberculosis. And its therapy without suppressing HIV infection is impossible.

The second factor that caused the increase in the number of patients is the lack of information and preventive work among the population.

And again - dry statistics of tuberculosis in Russia:

1. in 2015, mortality in Russia from tuberculosis reached 9 people per 100,000;
2. in 2016 – 7.5 people per 100,000.

On the one hand, progress is visible, a decrease in the number of deaths, on the other hand, these figures do not contain data on how many HIV-infected people died, the cause of death of which was tuberculosis. People do not die from AIDS or HIV; the cause is diseases that develop against the background of reduced immunity, primarily tuberculosis.

Therefore, other figures will be closer to the truth: in 2015 in Russia it was he who caused the death of 13.5 to 20.9 thousand people. These data are comparable to losses from suicide and road accidents.

The disease of the century - tuberculosis - depends on the level of social well-being in the country, and the fact that in Russia in the 21st century the incidence rate is not decreasing, but is only increasing, indicates that with this indicator of the standard of living in our country everything is far from good.

Vaccinations for children are not effective enough, and the low level of literacy of modern parents leads to the fact that they refuse this protection of the child’s body. All this leads to the fact that victory over tuberculosis is still very far away.

XX century was characterized by the most rapid dynamics of tuberculosis prevalence. This is due to the fact that it was at the turn of the 19th-20th centuries. For the first time, humanity had “tools” for actively influencing tuberculosis. R. Koch's discovery of Mycobacterium tuberculosis made it possible to study the characteristics of the causative agent of the disease, which was initially used to develop bacteriological diagnostic methods and tuberculin diagnostics, and then to create a specific vaccine. Using the discovery of V.K. X-rays and the mass introduction of radiation research methods into practice were the second revolutionary contribution to the development of phthisiology. Thanks to the X-ray method, clinicians have significantly expanded their understanding of the nature and characteristics of the course of the tuberculosis process and, most importantly, for the first time have the opportunity to diagnose the disease before the onset of its clinical manifestations.

The progressive development of medicine, biological sciences and a number of related specialties, the integration of specialties and the use of scientific and technological progress have made it inevitable to solve a problem that seemed insoluble to many generations of doctors and patients - the development and introduction of specific anti-tuberculosis drugs. The contribution of surgical treatment methods, the development and application of which in the 20th century, cannot be underestimated. saved the lives of hundreds of thousands of tuberculosis patients. Epidemiology, the development and implementation of a system of organizational measures, the creation of accounting methods, statistics, and then tuberculosis monitoring also made their contribution to the fight against tuberculosis.

The presence of sufficiently reliable factual data allows us to conduct a retrospective analysis of the patterns and dynamics of the tuberculosis epidemic in the 20th century.

By the beginning of the 20th century. Tuberculosis remained a widespread disease. In 1900, in Paris, for example, 473 people died per 100 thousand inhabitants, in Vienna - 379, in Stockholm - 311, etc. Against the background of economic growth before the First World War, some countries observed a decrease in mortality from tuberculosis (England, Germany, Denmark, the Netherlands, the USA) or a stabilization of this indicator (Austria, Norway, Finland, France).

The economic and social upheavals associated with the First World War caused a significant increase in mortality from tuberculosis in all European countries. Its rise was noted already by the end of the first year of the war, and subsequently this figure had a clear upward trend in England, Austria, Germany, Italy and Czechoslovakia. In Austria in 1918, the mortality rate from tuberculosis exceeded the pre-war level by 56%. and in Germany - by 62% (Fig. 10-1). The mortality rate among the population of large cities (London, Berlin, Vienna) increased at a faster pace. In Warsaw, by 1916, mortality increased almost 3 times.

During the First World War, some features of the course of tuberculosis were noted among various age groups of the population. Young children suffered the least, while older children and the young population (from 15 to 30 years old) suffered the most. In most countries, the typical peacetime differences in mortality rates between men and women have remained. Thus, higher numbers among men in England were observed throughout the war. The reverse relationship that occurred in Switzerland and the Netherlands in peacetime did not change in 1915-1917. After the end of the First World War, against the backdrop of economic recovery and stabilization of the social sphere, mortality from tuberculosis decreased to one degree or another in most European countries and in Australia. New Zealand and USA.

During the Second World War, mortality rates increased again in countries occupied by the German army, in Germany itself and Japan. Mortality from tuberculosis in many countries and large cities increased steadily as hostilities continued. In 1941-1945 it exceeded the pre-war level among the residents of Amsterdam. Brussels, Vienna. Rome, Budapest by 2-2.5 times, and in Berlin and Warsaw by 3-4 times (Fig. 10-2).

It should be noted that the data provided concerned only the civilian population; they did not include the huge number of deaths from tuberculosis in the army, captivity and concentration camps. Meanwhile, among prisoners of war released from concentration camps and sent to Sweden, there were from 40 to 50% patients with tuberculosis. At the same time, in most countries that did not take part in World War II (for example, Sweden and Switzerland), the mortality rate continued to decline. This figure was stable in Canada and the United States, which did not actively participate in hostilities. Thus, the sanitary consequences of the Second World War regarding tuberculosis were not the same in different countries. To a large extent, this depended on the degree of destruction of the material and technical base and economic ties, overcrowding of the majority of the population, high intensity and partial uncontrollability of migration processes, massive violations of sanitary standards, disorganization of the health service and anti-tuberculosis care to the population.

At all times, it was very difficult to talk about the true prevalence of tuberculosis due to the inequality of statistical information coming from different countries. However, at the end of the 20th century. The work carried out by WHO and health authorities in various countries has made it possible to get a general idea of ​​the main epidemiological indicators for tuberculosis in different regions of our planet. Since 1997, WHO has published an annual report on the situation with tuberculosis in the world. In 2003, the report covered 210 countries.

Currently, it should be recognized that tuberculosis is widespread in all countries of the world. The highest incidence of tuberculosis is found in Africa, especially in countries with a high prevalence of HIV infection. It accounts for about 1/4 of all newly diagnosed tuberculosis patients. Half of all newly diagnosed patients in the world occur in 6 Asian countries: India, China, Bangladesh, Indonesia, Pakistan, and the Philippines.

It should be said that if in 1970 the incidence rate of tuberculosis in the world was about 70 per 100 thousand, then at the beginning of the 21st century. it reaches the level of 130 per 100 thousand.

According to WHO, the current rise in the incidence rate is primarily due to the rapid spread of undetected HIV infection on the African continent, which has led to a sharp increase in the incidence of tuberculosis.

In the 90s of the XX century. The highest death rate from tuberculosis in the world was recorded. In 1995, according to WHO, 3 million patients died annually from tuberculosis. In 2003, 1.7 million people died. For the period 2002-2003. The mortality rate among all tuberculosis patients decreased by 2.3%, and among HIV-negative tuberculosis patients by 3.5%, however, approximately 5,000 patients die every day worldwide. About 98% of deaths occur in the young, working population. In Africa, tuberculosis is the leading cause of death among young women.

In 2003, 8.8 million patients with tuberculosis were identified in the world, of which 3.9 million had bacterial excretion determined by sputum microscopy. In total, there were 15.4 million patients with tuberculosis, of which 6.9 million were bacteria-excreting according to sputum smear microscopy. According to WHO, the global incidence rate is currently increasing by 1% annually, mainly due to an increase in incidence in Africa. Among the African population with a high prevalence of HIV infection, the incidence of tuberculosis reaches 400 per 100 thousand.

The World Health Organization considers the Mantoux test to be the most effective way to detect tuberculosis.

However, in our country it is increasingly being replaced by Diaskintest. And not because the newfangled method gives an unmistakable result - billions of dollars in revenue for the drug’s manufacturers are at stake.

In mid-November, the World Conference on Tuberculosis was held in Moscow. Welcoming its participants, the President Vladimir Putin called the diagnosis and treatment of this serious disease an important national task. Head of the Ministry of Health Veronica Skvortsova in turn, she assured: Russia will take an active part in the WHO anti-tuberculosis campaign.

Against this background, the decision of the department headed by Veronika Igorevna to replace the proven method of diagnosing tuberculosis - the Mantoux test - with the newfangled Diaskintest looks strange. According to scientists, this will lead to the fact that 5-8 percent of active tuberculosis cases will remain undetected.

Andersen's truth

Diaskintest, produced by Generium, a leader in the field of biotechnological development and production, entered the Russian market in 2009 and was used in 37 regions of the country the following year. At the end of 2014, the Ministry of Health issued guidelines on replacing the Mantoux test with Diaskintest during mass examinations of children from 7 to 17 years old. The decision was made despite scandals and fierce discussions in the medical community on this topic. Sensible scientists referred to world experience: leading clinics are in no hurry to introduce into clinical practice drugs whose effectiveness and safety have not been fully studied. The creator of the new method is a Danish professor Peter L. Andersen(now executive vice president of the Center for Vaccine Research at the SSI Serum Institute in Copenhagen) also emphasizes: research on the test is still underway. And he himself concludes: the new skin test cannot replace the Mantoux test due to insufficient sensitivity.

Mycobacteria - pathogens

Diagnostics means nothing

In Russia, the untested technique was adopted without delay. And already frightening results. Chief Researcher of the Department of Organization of Anti-Tuberculosis Care of the Research Institute of Phthisiopulmonology PMGMU named after. THEM. Sechenova, professor Margarita Shilova found: the use of Diaskintest led to an increase in the incidence of children and adolescents in 64 of 85 regions of Russia. In particular, in the Yaroslavl region, acute forms of tuberculosis began to be detected three times less often than when using the Mantoux test.

Diaskintest has positive properties, but this drug is not suitable for mass screening, experts warn. However, this point of view is not supported by officials from the Ministry of Health. Phthisiatrician, professor Konstantin Puchkov, who stated that the new method does not allow timely detection of the disease in children and adolescents, was dismissed from his post as deputy chief physician for pediatrics at the Moscow Scientific and Practical Center for the Fight against Tuberculosis. Now a well-known scientist, the author of more than 100 scientific papers, holds the post of chief physician of the regional tuberculosis hospital of Vyborg, Leningrad region.

Meanwhile, scientists’ fears are also confirmed by other sources. Head of the Laboratory of Immunoprophylaxis, Central Research Institute of Epidemiology, Rospotrebnadzor Irina Mikheeva proved that when switching to screening using Diaxyntest, up to 300 cases per year of active tuberculosis in children can be missed. In addition, adverse reactions to Diaskintest occur much more often than to the Mantoux test. Head of the Department of Phthisiology, St. Petersburg State Pediatric Medical University, Professor V Ladimir Krivokhizh described nonspecific reactions that occur during the procedure: a sharp increase in temperature to 39°C, swelling of the arm into which the drug was injected, redness and pain.

For selfish sake

And one more important detail. The triumph of Diaskintest began after former subordinates of the ex-Minister of Industry and Energy Viktor Khristenko - Andrey Dementyev And Andrey Reus received 12.5 percent of shares in Generium, a leading company in the field of biotechnological development and production. All three, by the way, are good neighbors and golf partners. Firms associated with Dementiev and Reus receive government orders as a priority, including from the Ministry of Health, which was headed by Khristenko’s wife Tatiana Golikova. And the Lecco company is engaged in the production of diaskintest. It is part of the Pharmstandard group, the main owner of which is a businessman close to the Khristenko family Victor Kharitonin.

After Golikova left the Ministry of Health, the campaign to introduce Diaskintest was supported by the chief children's phthisiatrician Valentina Aksenova. And although today she denies her role in promoting the method, on the website of Perm State Medical University named after. I.M. Sechenov retained a message that in 2014, “Valentina Aksenova, as part of a group of researchers commissioned by the Generium company, took part in the development of the biotechnological product Diaskintest.”

Based on the above, it becomes clear: lobbying for a new method can lead to a man-made tuberculosis epidemic in Russia, which will require billions to combat.

THINK!

• According to market experts, the production of Diaskintest will bring Generium from 1.5 to 2 billion rubles per year. The money will mainly come from the Russian budget, since the procedure is performed free of charge for patients.

REFERENCE

• The Mantoux test has been used in our country since 1952. Tuberculin is injected intradermally - a mixture of filtrates of killed cultures of Mycobacterium tuberculosis.
• Diaskintest is carried out like the usual Mantoux, but contains synthetic antigens. The result can be false negative at the beginning of the disease, when the pathogen has entered the body but has not yet begun to actively multiply, and in severe forms of tuberculosis, when the body is so weakened that it does not fight the pathogen.

Text: Nina Nazarova

Getting sick in Russia is not only scary, but sometimes it’s shameful - a number of diagnoses are surrounded by such a strong stigma that it evokes a mixture of horror and contempt among others, including some doctors. And if one of these diseases - HIV - is gradually starting to be talked about more humanely and less unscientifically, then it seems that they don’t talk about tuberculosis at all. Deadly consumption from the classics of Russian literature, the disease of homeless people and prisoners - that’s about all that is usually known about him. Few people suspect that in 2016 this could literally happen to anyone: every third person in the world is infected with a dormant form of the disease, and in Russia almost every first person is infected. Nina Nazarova talked with people who had the disease and doctors about how tuberculosis is treated in Russia, and also understood the scale and causes of the problem.

Fatigue

From her third year, Ksenia Shchenina mainly remembers the feeling of endless fatigue and constant guilt for it: “Fatigue, fatigue, fatigue, it’s hard to get up in the morning, the feeling that I can’t cope with anything and everything is falling out of my hands.” It was 2008, Ksyusha was twenty years old. She came to Moscow from Khabarovsk, studied at the Institute of Journalism and Literary Creativity and led student life in its classically romantic version: concerts of the White Guard, love, meetings with online friends, first publications in Time Out and on Zvukah.ru .

I didn’t go to the doctors - there were no other symptoms, so Ksyusha attributed her condition to her own character and scolded herself all the time: “I’m lazy.” I only got to the doctors when I arrived home for the summer holidays and, closer to departure, decided to get examined at my native district clinic for the year ahead. The therapist gave me a referral for tests, sent me to a cardiologist and for fluorography.

But when the time came to receive the results of fluorography at the reception, for some reason Ksyusha was not given them and was sent to the doctor. The following dialogue took place in the office:

What's your last name? Ah, so it's you!

I mean, me?

Have you finally arrived? And where have you been for two years?

It quickly became clear that when Ksyusha came home for the summer after her first year in 2006 and, as part of an on-duty visit to doctors, had a fluorography done, and then flew back to study without taking the results, the changes characteristic of tuberculosis were already obvious in the picture. To a reasonable question why they didn’t report this, the doctor replied that it seemed like they were calling home. Indeed, my mother recalled, a couple of months before they called from the clinic and said: “Your daughter has something wrong with her lungs, let her come in when she’s in Khabarovsk.” Mom conveyed exactly the message to Ksyusha: “There’s something wrong with the lungs, if you come home during the holidays, come in.”

It was the end of August, return tickets to Moscow were purchased, and the fourth year began in a week. The therapist announced: “If you’re lucky, make it within a year. Tomorrow morning with a voucher to see the pulmonologist.” - “I have things to do in the morning, can I come later?” - “Your lungs are decomposing, what’s going on?!” Here Ksyusha quietly said “Aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaatime period of 2020-2008-2015-03-08-2013 12:38:00” Ksyusha quietly said “Aaaaaaaaaah” and left. “No brochures, no explanations, whether it can be treated or not, what should I prepare for, what kind of disease is this of the great Russian writers.”

According to WHO, a third of the world’s population is infected with the “dormant” tuberculosis bacterium. Russian doctors call the figure much more impressive - from 70% to 99% of the country's residents are carriers of Koch's bacillus. But, despite the striking contrast in the numbers, the difference is small for the time being: a person gets sick only if the bacteria enters the active stage - this can happen when immunity drops sharply. As long as the immune system is in order, a person, even if he is a carrier of bacteria, is healthy and is not able to infect others.

They die from tuberculosis. But they die if the disease is advanced or the person is not treated for some reason - tuberculosis detected in time is almost 100% curable. The bad news is that while oncology and HIV are at least partly well-known and both activists and the media remind about the need for prevention and regular tests, tuberculosis is practically absent in the current information field, which means it is not so easy to notice it in the early stages. that's simple. In addition to the “great Russian writers”, the disease is associated with “consumptive young ladies”, as well as with marginal and declassed elements - for example, the homeless or prisoners.

“My mother was shocked when she heard my diagnosis - after all, there is a stereotype that this is a disease of alcoholics, drug addicts and dysfunctional families”

Few people know that people aged 18–44 years most often get sick, and the peak occurs at 25–34 years among women and 35–44 years among men. When Masha, at the age of eighteen, after a long treatment for pneumonia, was diagnosed with tuberculosis, her family found it so difficult to believe that she and her mother went to Moscow to the Central Research Institute of Tuberculosis on the Yauza River for confirmation. The name "Masha" is not real. The VKontakte and Skype accounts through which we communicate are also registered under a fictitious name. The conversation takes place without video or any personal details - the girl does not even name her hometown. The onset of Masha’s illness is similar to Ksenia’s story: “For about four months I felt weaker than usual, but I chalked it up to the fact that it was winter, that I went back to work six months ago, and that I was tired out of habit. I had a long cold and thought about taking some vitamins in the spring. I was talking to my friends, and they responded: “Oh, I’m tired too.”

Masha has been healthy for a long time, she went to university and got married, but no one in her current circle knows about the several years she spent in the tuberculosis clinic, with the exception of her parents and husband - the social stigma of tuberculosis is such that it’s scary and embarrassing to talk about. “My mother was shocked when she heard my diagnosis - after all, there is a stereotype that this is a disease of alcoholics, drug addicts and dysfunctional families. And we have a prosperous, intelligent home, our own business. Where?" Only when Masha got sick, she didn’t make a secret of this, but after talking with people in the hospital, she was very scared: “Even my brother turned away from one girl: don’t call, don’t write to me anymore - to that extent.”

And most importantly, the idea of ​​the symptoms of the disease remained the same, at the level of the novels of Turgenev, Dostoevsky and Lydia Charskaya. But symptoms familiar from classical literature, such as bloody sputum, appear in the later stages. In fact, the symptoms of tuberculosis are as follows. Chronic fatigue, irritability, sweating, the temperature rises slightly - up to 37.2–37.5, and is easy to bear on your feet: there is no chills. And no bloody cough. And often even the most ordinary cough. In most cases, people with the initial stage of tuberculosis simply do not think that something abnormal is happening to them: the desire to sleep, decreased performance, conversations “I should go on vacation”, “I’m tired” are attributed to the tension of modern life. There is a joke among patients at tuberculosis dispensaries: “If it seemed to you that a loved one suddenly began to behave like the last m...<плохой человек>, send him for fluorography, perhaps he has tuberculosis.”

"Silent and tough"

In Russia, tuberculosis is officially recognized as a “socially significant” disease - this means that it is treated without fail and free of charge. Everything takes place in specialized institutions - tuberculosis dispensaries: doctors prescribe tests and treatment and assign you to a hospital.

The tuberculosis dispensary in Khabarovsk, where Ksyusha ended up, looked exactly like demotivators about the state of Russian medicine: a ward with seven beds, rusty pipes and headboards, linoleum worn to concrete. Cockroaches crawled across the books and literally fell on my head.

But what Ksyusha remembered much more than her living conditions was the feeling of confusion in the first weeks. There were an endless number of questions: what does this or that analysis say, how does her diagnosis differ from that of her roommate, why is this procedure needed, how is the treatment structured, and what will happen. At the same time, the medical staff answered all questions something like this:

Do the pills have side effects?

Did you think you were in a fairy tale? We don't have candy here.

The atmosphere was depressing, the neighbors in the ward recounted passions and horrors and frightened each other with operations: “There was a story that after an operation everyone would definitely die, no one lives longer than five years.”

Tuberculosis is treated with chemotherapy - antibiotics. The best you can hope for is six months. Two months of intensive antibiotic regimen, four months of maintenance. This is if the disease was caught at the very beginning of its development. Treatment most often takes place in a hospital - a queue lines up for hours at a time to see the nurse, and everyone takes pills under supervision: “You won’t see such a parade anywhere else: twenty people stand in a row, drink and drink, drink and drink.” An impressive pile of pills is collected: depending on the form of the disease, they are taken from 12 to 22 per day - in four months, Ksyusha has drunk 1,320 “wheels”. The worst thing a person suffering from tuberculosis can do is to skip even the minimum treatment: resistance to antibiotics develops very quickly and tuberculosis from a drug-sensitive form easily mutates into the stage of “multidrug resistance”. This type of tuberculosis can also be treated, but the drugs required to cure it are less accessible and more toxic to the body. By order of the Ministry of Health, the treatment of drug-resistant forms of tuberculosis is strictly controlled, to the point that the nurse has the right to ask the patient to open his mouth and extend his tongue to confirm that he actually swallowed the pills. This severity is due to the fact that with this type of tuberculosis, bacteria that are already resistant to antibiotics can be transmitted to other people.

The infectiousness, or, in medical terms, the epidemiological danger of tuberculosis, is in no way connected with drug resistance, but depends on the volume of damage to the lung tissue and the access of these damaged masses to the bronchi. In everyday life this is called an open or closed form, among doctors - bacterial excretion; it can be scanty, moderate and abundant. Patients with active bacterial excretion are subject to mandatory isolation in dispensaries, but everyone else is not, and there is no reason to shy away from them: contact with a person with a closed form of tuberculosis, provided that the immune system is stable, is not dangerous.

If someone tried to run home, the attending physician called the person to her
into the office and took out a heavy folder
with records of recently deceased patients

If the tuberculosis process does not completely resolve, residual changes are removed by surgery. This happens in approximately half of the cases and serves as a guarantee of complete cure - a person after surgery is no different from people who have never encountered tuberculosis.

For most patients, the most difficult thing psychologically is to come to terms with the fact that treatment can be very slow and complicated by relapses. “I was discharged after six months,” says Masha. - I was in love then, I wanted to forget the dispensary like a bad dream. And I was very nervous - the experiences of a young girl in love - and in September I began to feel bad again, and a relapse occurred. I have such a fear: I have to stay in the hospital again, again painful procedures, in general, I won’t go anywhere. I began to look for alternative methods of treatment: massage, qigong gymnastics - I was ready to believe in anything. As a result, three months later, I, green in color, was taken to the hospital, and the doctors said that the process had begun on the second lung, and now I needed surgery. They were very angry with me for taking too long.”

Explanatory work and convincing patients of the need to continue treatment actually falls on the shoulders of doctors. The attending physician in the department of the Khabarovsk dispensary where Ksyusha was hospitalized acted “silently and harshly” in such cases: if someone tried to run home or skipped taking medications, she called the person to her office and took out a heavy folder with records of recently deceased patients - Young women under thirty years of age were collected separately. The tactics, as a rule, worked, but only increased the fear and confusion that reigned in the department.

What do people do in the 21st century when they feel a lack of information? They look for it on the Internet. There were no articles that were clear or understandable to a non-specialist, but on the whole Ksenia had some idea of ​​what was happening to her. Therefore, when, after two months of treatment, the doctor suddenly announced that it was necessary to undergo surgery, she protested - it seemed to her that the doctors, out of indifference, simply wanted to get rid of her: “I read on the Internet that since some pills do not help, they prescribe others. Well, that's what it says! You don't understand the subtleties. I thought she would prescribe some other pills that should help. They don’t explain anything.” In addition, eerie rumors circulated around the department that surgeons were paid extra for each person operated on. I told my dad: they’re hurting me. Dad came to investigate. The doctor shrugged her shoulders and extended the course of antibiotics for two months. Ksenia now remembers mistrusting the doctor as the most fatal mistake in her life. In two months, the decay in her lungs tripled. Not one operation was required, but two. At that moment, Ksyusha became truly scared.

Ksyusha speaks about operations in an embarrassed patter: “Five-rib thoracoplasty and resection,” looking at my reaction - won’t I be scared?

This means: fragments of five ribs were removed and part of the lung was cut off.

2016

In absolute numbers, according to Rospotrebnadzor, 77 thousand new cases of the disease were registered in Russia in 2015, and 78 thousand in 2014. It is the newly identified cases that are counted: if a person was diagnosed in the previous year, he is no longer included in the statistics, even if he continues to get sick, so in reality there are several times more people fighting tuberculosis. The highest incidence is in the Far East, Siberia and the Urals. But these statistics are encouraging: now in Russia the situation with tuberculosis is much better than in the mid-2000s, when up to 120 thousand new diagnoses were made per year. Over the past five years, a test has been introduced that allows you to find out in two hours what form of tuberculosis a person has, sensitive to drugs or resistant to them, which means that the necessary treatment can be selected much faster. New chemotherapy regimens have significantly increased the effectiveness of recovery of the drug-resistant population. In short, the situation was slowly but improving. Until the beginning of 2016.

The main factor in the development of tuberculosis (if we are not talking about contact with a patient with an open form) is weakened immunity. Immunity can decline for a variety of reasons: due to severe stress (divorce, moving, being fired from work or entering university), due to diets or poor nutrition, due to chronic lack of sleep, overwork, alcohol. But there is at least one condition when the immune system is guaranteed to decline - HIV. According to WHO, people with HIV are 20–30 times more likely to develop tuberculosis than uninfected people.

According to WHO, people with HIV are 20–30 times more likely to develop tuberculosis than uninfected people.

In July 2016, the UN recognized Russia as the epicenter of the global HIV epidemic. At the same time, Russian regions have had their funding for drugs for HIV-infected people cut by up to 30%. Marina M., deputy medical director of one of the tuberculosis dispensaries in the Kemerovo region (last name not indicated for reasons explained below), says that over the past six months there has been an exceptionally sharp increase in the incidence of tuberculosis among HIV-positive people.

The problem was primarily provoked by a shortage of antiretroviral therapy at the beginning of 2016 - the connection is clearly visible. In the regions there is not enough money to purchase drugs, plus, as part of import substitution, they began to give drugs made in Russia: “Patients with a severe stage of HIV infection, who previously took therapy normally, now have such toxic reactions to Russian drugs that they have to cancel anti-tuberculosis therapy - people find themselves unable to take any kind of pill.” Without suppressing HIV infection, it is almost impossible to cure tuberculosis, but neither Marina nor her colleagues can do anything - the problem is not being solved at the level of anti-tuberculosis services: “Apparently, there is a shortage of drugs in AIDS centers, and this is a big problem, which we cannot influence. So we're just in trouble." Other experts in the field of coinfection of HIV and tuberculosis also speak about problems in communication “patient - AIDS center - tuberculosis hospital”.

Specialized clinics and departments are needed for people with HIV-associated tuberculosis, but despite orders from the Ministry of Health, there are practically none outside of Moscow and St. Petersburg. Ideally, all HIV-infected people should take prophylactic medications at some point to prevent the development of tuberculosis. But not everyone takes prophylaxis, not everyone is registered, not everyone actually knows about it - there is no information.

Stories of people

Ksenia remembers the preparation for surgery, the operations themselves and rehabilitation, which lasted for a year and a half, as if in a fog: “I was twenty, and then I became twenty-three.” During the operation, a nerve in my right hand was damaged. Wild pains that prevented me from sleeping for two months, a temporary degree of disability. She dates her return to the ordinary world from a trip to Altai to a sanatorium: “It’s as if I came from exile to life: I rode a train across the steppe for five days and read Game of Thrones.”

Very early, just after getting to the tuberculosis dispensary, Ksyusha realized with amazement that she was not only the only student from Moscow there, but also the only resident of Khabarovsk - her neighbors gathered from all over the region, and at the same time from the Amur and Jewish Autonomous Regions: “People reasoned about matters completely alien to me: that food for cows has become more expensive and how best to sharpen scythes.” My bedmate in the surgical department was a woman from the Amur people of the Ulchi - there are less than three thousand of them left in the world: “Very quiet, calm, calm. She was from the taiga, where you can only get there during one season and for a lot of money, and therefore she lived for a whole year in a ward for ten people. We had conversations like in Japanese movies. One day, a painkiller had a strange effect on me, and I had a bad trip - muscle hypertonicity, terrible panic, through tears I asked how she agreed to the second operation. “I have something to endure for.” And I thought: how different people are. And I wanted to preserve her story.”

Ksenia began writing down other people’s stories, albeit fragmentarily, almost immediately. She had problems accepting her own emotions during illness: “A person who is sick turns into an asshole. Completely. People just don't know how to talk to you. I couldn’t stand it when they felt sorry for me - anger immediately came in response. Then one of my friends decided to pretend that nothing was happening, that nothing had changed in our relationship. And in response I was furious again - how has nothing changed?! I'm dying! And, as if by contrast, the more insistently she became interested in the emotions and stories of others. Someday later, she dreamed, she would write a book a la Svetlana Alexievich and call it “Tuberculosis. Stories of people."

And then Ksenia completely recovered and again became a funny, curly-haired girl - perhaps with the firm intention of changing the world for the better. She returned to Moscow in 2011 and re-entered the journalism department. Wrote a thesis “Is Tuberculosis a Social Disease?” about how the disease is portrayed in the media. I started one blog, then a second. At the same time, I wrote to all organizations that were in one way or another connected with tuberculosis: “Hello, I really want to do something, use me somehow.” In 2013, Ksyusha was offered to become the administrator of a half-abandoned thematic group on VKontakte. First of all, she changed the old name, which sounded like “Microkiller Tuberculosis,” to “Tuberculosis: Support and Answers” ​​(https://vk.com/hopetb) and added the slogan “It’s a shame to be sick!”

Ksyusha is twenty-eight. In three years, she has created a supportive community for people with a diagnosis that does not seem to exist in the average person’s mind.

Now the group is advised by two TB doctors, a children's TB doctor, a lawyer (answers questions from people who are forced to go to work with untreated tuberculosis or are trying to fire them after recovery) and even a psychologist who also suffered from tuberculosis. There is a brochure with popular questions and answers. Ksenia checks the group daily, if the questions are standard, she answers herself, if something is serious or urgent, she writes an SMS to the doctors asking for a prompt response.

This is an amazing world where a good half of the participants are anonymous. Even phthisiatrician Marina M. consults under a fictitious name - in her words, in order to give an objective assessment of the work of her colleagues: “It happens that I criticize incorrect prescriptions or ignoring the problems of patients and I don’t want someone with I called with complaints." Marina, like Ksenia, suffered from tuberculosis herself and spends her time voluntarily and for free: “Someone needs to hear a second opinion, someone needs to be sent to a research institute, someone needs to be dissuaded from unconventional methods of treatment. Some even write from villages where there is only one paramedic for hundreds of kilometers and it is impossible to get qualified help.”

The group has only a thousand participants, but more than twenty thousand people from Russia, Ukraine and Turkmenistan read it every month. All these people are afraid not only to write to the group under their own name, but also to simply add the page to their favorites: they are afraid that their friends and relatives will panic at the very word “tuberculosis”.

And at some point, everything came together in Ksenia’s head: she needed to create a separate beautiful website where both real people’s stories and comprehensive medical information would be collected. So that each section would be represented by a living person: “Hello, my name is Misha/Sasha/Pasha, by profession I am so-and-so, I suffered from such and such a form of tuberculosis and I know everything about it,” and one could read his story of recovery. So that next comes the medical section, which the hero represents. So that the information is verified and presented in accessible language. So that you can ask a question and receive a qualified answer. There is only one problem - in order to make such a site, you need money, time and effort. Or at least money. But in general, there are none.

Ksyusha is twenty-eight. In three years, in parallel with her master’s degree, work and private life, she created a full-fledged supportive community for people with a diagnosis that does not seem to exist in the minds of the average person. Ksyusha is enthusiastic and open (among other things, she makes a living transcribing interviews for various publications - and the first question she asked during our acquaintance was: “I’ve heard your voice so many times that you seem like family to me, may I Shall I hug?"). She gets embarrassed easily. She is painfully demanding of herself. She calls herself an emotional junkie: “I can do a lot if I get feedback.” Ksyusha really wants to make sure that everyone in Russia knows about tuberculosis, no one is afraid of it, and everyone receives qualified help and support. And she’s very upset that it hasn’t worked out yet: “Sometimes I think: what if the whole point is that I’m just lazy?”

Since the 1990s, the number of cases of tuberculosis in Russia has increased significantly. Perhaps today this is the most mythologized disease. Olga NOSKOVA, head of the tuberculosis diagnostics department at Children's Infectious Diseases Hospital No. 3 in St. Petersburg, told the Mercy portal about the reasons for the current situation.

— Is it true that by the time they reach adulthood, 70% of the population is already infected?

- Alas, not 70% but more. By age 40, 100% of the population is infected.

- How so? After all, Russia has a long tradition of fighting tuberculosis. Why has the problem now become so urgent that people are increasingly talking about an epidemic?

— According to official statistics, there is no epidemic in Russia, but the incidence is high. Moreover, in the regions of the Far East and the Far North it is much higher than, say, in Moscow and St. Petersburg.

As for the change in the situation after the collapse of the USSR, epidemic problems have a number of reasons that arose in the 90s. This includes the reorganization of the entire medical service, including children's TB. These are migration processes that are characteristic not only of Russia, but of the whole world. The geographic direction of the flow of migrants has changed over the years: first Azerbaijan prevailed, then Ukraine, Moldova, and Armenia. Now migrants are represented mainly by Central Asia: mainly Uzbekistan and Kyrgyzstan, Tajikistan. There is also internal migration in the Russian Federation. Moreover, migration is not only the movement of people, among whom there may be sick people, it is also stress that causes illness in previously healthy people.

A phenomenon common among migrants is foci of familial tuberculosis - when both parents or several relatives are sick with open forms. We recently treated a girl from such a family. Her parents, brother and aunt, migrants from Central Asia, were sick with an open form of tuberculosis. She fell ill with a complicated form of primary tuberculosis. Fortunately, the girl was vaccinated with BCG, which is generally uncommon for people from the former southern Soviet republics, so she did not develop tuberculous meningitis, which is fatal for the child.

However, foci of familial tuberculosis occur not only among migrants.

- Where else?

- As a rule, in asocial families. Of course, among the factors influencing the epidemic situation are a decline in the material standard of living, the spread of diseases such as HIV infection and AIDS associated with drug addiction, which is also growing. The characteristics of Mycobacterium tuberculosis (formerly called “Koch bacillus”) have also changed - it has become resistant. In the last 3-5 years, resistance has very often been observed in foci of familial tuberculosis.

— What myths about tuberculosis are present in the mass consciousness? Is this really “the disease of hungry times”?

Photo by Maxim Dondyuk on the page http://prophotos-ru.livejournal.com/

— Tuberculosis is usually written with an equal sign with “consumption,” that is, rapidly progressing tuberculosis, a disease when the lung tissue is massively affected. This course of the disease occurs against the background of altered immunity. Alcoholism, drug addiction, HIV infection, as well as diabetes mellitus, treatment with hormones and cytostatics play a significant role here. This disease can have a lightning-fast course. It is worth talking about diabetes mellitus, a disease to which tuberculosis especially likes to “stick” and in which tuberculosis is very difficult to treat. Recently, a boy was treated at our department, almost a youth, one might say. He had type 1 diabetes, meaning he was on insulin. He didn’t have a fluorography done for a year, because his mother didn’t pay attention to the doctors’ recommendations, and he didn’t even care. Upon entering the school, he was diagnosed with complicated tuberculosis during the next preventive examination. Despite all efforts, conservative treatment did not bring lasting improvement. He was faced with the prospect of becoming a “chronic patient,” and then the phthisiosurgeons decided to perform an operation - removing part of the lung. Fortunately, the operation was successful, the boy recovered from tuberculosis, and is now a tall and handsome young man, studying to become a veterinarian.

— What about patients with other forms?

— And patients with other forms of tuberculosis have a good prognosis and live long. As for socially adapted people, they did not immediately become so; their past is full of emotional and physical stress, stress and other predisposing factors. They get sick just like everyone else. There is also a reluctance to take care of one’s health, and there is also a hidden fear of identifying tuberculosis, non-recognition of an already identified disease, the so-called anosognosia.

- For example?

— For example, in a family where the “coming dad” was sick with an open form of tuberculosis, the child had a high Mantoux reaction. The mother swore that the child had no contact with sick people, was indignant at the examination ordered, and did not believe when the doctor told her that the child was sick. However, later, after several months of treatment in the hospital, having seen how her baby’s well-being and mood were improving, she spoke about the contact and naively added: “I didn’t tell you on purpose so that the child wouldn’t be given tuberculosis!”

— What do they mean when they say that tuberculosis is a social disease?

— The fact that tuberculosis is a social disease was noted back in the 18th century by the discoverer of percussion, the Austrian physician Leopold Auenbrugger, although this was known even in the time of Hippocrates. Auenbrugger said that people experiencing various kinds of hardships, separated from loved ones, are more likely to develop consumption.

Photo by Maxim Dondyuk on the page http://prophotos-ru.livejournal.com/

“But among the sick people there are also quite wealthy people. One privately practicing pediatrician told me that he has recently had many clients with tuberculosis from Rublyovka...

— Old Russian phthisiatricians said that tuberculosis spares neither huts nor palaces. Even in the royal family there were cases of tuberculosis.

— What then are the preventive measures?

— Prevention is, first of all, such a simple thing as a healthy lifestyle. Eat regularly and variedly, go to bed on time, walk in the fresh air, exercise, do not abuse alcohol, and do not smoke. It is also necessary to pay attention to your body during a period of decreased immunity - with frequent, recurring colds. In addition, of course, it is necessary to undergo a preventive fluorographic examination, and for children - an annual Mantoux test.

— How can one suspect tuberculosis? What should you do if a loved one gets sick in order to help him and not get infected yourself?

— You can suspect it if a person has a series of acute respiratory infections with recurring symptoms, a cough that does not stop, fever, and increased sweating at night. But tuberculosis in the early stages has few symptoms. It is detected by fluorography in the early stages. Symptoms appear as the disease progresses. In addition, tuberculosis puts on the “masks” of other diseases. The phthisiatrician must be able to recognize them. There are cases about which they say “it’s as if the child has been replaced”: he becomes hyperactive, he can’t get into bed, he won’t wake up in the morning, he’s sweating. He is referred to a neurologist, although this is one of the masks for early tuberculosis intoxication.

— How informative is Mantoux’s reaction? In recent years, many children have papule much larger than normal - are they all really infected?

— It should be said right away that there are no norms in assessing the Mantoux reaction.

The fact is that the Mantoux reaction reflects the state of immunity, moreover, that part of it that plays a decisive role for the development of tuberculosis infection in the body - cellular immunity. The state of immunity is not constant, and the state of health of children, starting from the neonatal period and further, changes from year to year - since there are factors that negatively affect it. Various concomitant pathologies, allergies, nutritional disorders, diseases of the central nervous system, endocrine pathology, infections, for example, ENT organs, kidneys, childhood infections (chickenpox, measles), antibacterial and hormonal therapy, chemotherapy for cancer change the response to administration tuberculin.

Let me explain that tuberculin is a low-molecular-weight specific protein, a hapten, which causes a response in individuals who have either been vaccinated with BCG, or have had an infection or are infected with Mycobacterium tuberculosis. Based on the Mantoux reaction, children are “screened” and should come under the close attention of a TB doctor.

In hospitals, after this, in-depth tuberculin diagnostics are carried out, in which they use not two tuberculin units, as in the standard Mantoux reaction, but one hundredth, one thousandth, one ten-thousandth of a tuberculin unit, as well as a skin prick test with different percentages of tuberculin dilution. This makes it possible to identify different levels of tension of anti-tuberculosis immunity, since the reaction to a small amount of tuberculin indicates a high degree of antigenic irritation, which means that the mycobacteria that have entered the body are active. These tests, like other immunological tests, are assessed by a phthisiatrician. The diagnostic significance of tuberculin diagnostics does not decrease, although the interpretation is quite complex due to the above reasons.

— Why is the population so little informed that tuberculosis treatment is free in our country?

— In our country there is a federal program to combat tuberculosis, which involves providing free assistance to the population. The population is informed, because there are anti-tuberculosis dispensaries in every district of the city, and upon initial visit to the clinic, the therapist will always require fluorography. But there is an internal fear of seeking TB help. Unfortunately, people generally have low literacy regarding tuberculosis infection.

— Tuberculosis is completely curable, but why has the effectiveness of many anti-tuberculosis drugs decreased? Or is this a myth?

- This is not a myth, this is due to drug resistance. It occurs as a result of interrupted courses of treatment in persons suffering from alcoholism, for example. They leave the hospital because there is no compulsory treatment for such persons. When the course is not completed, Mycobacterium tuberculosis adapts to the effects of the drugs. This microorganism is generally extremely stable in the external environment and has a powerful set of enzymes for “self-defense”, and if the course is not completed, a population of drug-resistant “Koch bacilli” is created.

— Why is phthisiology not popular among medical university students? Do future doctors not want to risk their health? Or because of the lack of job prospects in private clinics?

— The main reason is insufficient funding for healthcare. Of course, a tuberculosis hospital is not a private clinic; there is a threat to the doctor’s health. Phthisiatrists are a risk group; they undergo fluorographic examinations twice a year. In addition, TB doctors have almost no benefits: their pension and vacation are the same as other doctors. Yes, there is a 15% increase in salary, but this is practically not noticeable. In addition, becoming a phthisiatrician is not easy. Diagnosis and treatment of tuberculosis require a high professional level and long-term training. A young graduate of a medical university can become a competent specialist only after 5 or more years if he is engaged only in phthisiology.

— What is needed to stop the spread of tuberculosis in Russia?

“It is impossible to say that there is an epidemic in our country based on statistics, but the incidence is extremely high. First of all, it is necessary to solve social problems: improve the standard of living of the population, conduct examinations of migrants, medical examinations, treat drug addiction and alcoholism. Then tuberculosis will recede.