Tuula Toljamo in TB seminar 18-19.9.2017 St Petersburg - Nordic Russian Health Programme

1. Utsjoki
Inari
Sodankylä
Savukoski
Kittilä
Enontekiö
Muonio
Kolari
Pello
Ranua
Posio
Salla
Pelkosen-
niemi
Kemi-
järvi
Rovaniemi
Tuula Toljamo
MD, PhD, Docent
Chief of the Pulmonary Department,
Lapland Central Hospital
Lapland Hospital District, Finland
E-mail: tuula.toljamo@lshp.fi

2. The Main Principles of Finnish Social and Health Care
• Everyone has the right to adequate social and health services
regardless of place of domicile and wealth (constitution)
• Services are predominantly public and funded through taxation
• The state is responsible for providing direction and for monitoring
• Municipalities/local governmental joint service areas are responsible
for organization
• Public-sector service providers
• Private sector service providers
• The non-governmental patient organizations supply patient
education The Organisation for Respiratory Health in Finland, The Allergy, Skin and Asthma Federation etc.

3. TB Control today in Finland
• Strong legislative support
• The updated Communicable Diseases Law
• Defines TB screening practices for workers in certain fields of work (food industry etc)
• Allows for registration of TB contacts
• Mandates the isolation of infectious TB patients
• A national infectious diseases register with integrated laboratory data run by the
National Institute for Health and Welfare (THL)
• National advisory expert groups for TB control and TB care
• The updated national TB programme
• The National Tuberculosis Control Programme 2013. Ministry of Social Affairs and Health
• Web-based training courses and information for health professionals and population
www.filha.fi
Rajalahti,I. SLL. 2017

4. Responsibilities of Primary Health Care and Occupational Health Care in TB Control
Implementation of control actions of communicable diseases
… In TB
1. Prevention
• spread information on tuberculosis for the citizens, vaccinations, health
counseling and check-ups
• education of health care personnel
• regional monitoring of tuberculosis control
• acts addressed for the risk groups
• fast diagnostics and referrals
2. Monitoring of treatment together with specialized health care
• Provision of DOT
3. Prevention of spreading of tuberculosis
• contact tracing and examinations of contacts
• health counseling
4

5. Responsibilities of hospital districts in TB Control
• Co-operation with primary health care is essential
- Monitoring of TB infection regionally
- Help communities to investigate local epidemias
- Maintenance of regional register of TB
- Education and information
• Treatment of patients as a whole
- diagnostics
- prevent hospital transmissions
- start of treatment,end of treatment
- written instructions for follow-up
- consultations
5

6. What about TB history in Finland ?…

7. Tuberculosis Act 1948
• The decree of the 1927 tuberculosis act was repealed
• Strong administrative structure to prevention and treatment
• Responsibility for the arranging of the care to municipilaties
• Role of tuberculosis district
• Every municipality must belong to some TB district
• Sanatorium
• Outpatient clinic has responsibility for TB prevention
• The chief doctor has much power and responsibility
• Contagious TB patients can be forced to the care
• Vaccinating voluntary
• Free-of-charge care to poor
1.11.2017 7According to Keistinen T, 2017

8. Fighting TB during 1930 – 1960/1970 in Finland
• Improving socio-economic conditions (slow)
• Sanatoria first to the privileged, then for all
• Anti-TB non-governmental organizations
• Diet and rest
• Major role of surgery: pneumothorax and thoracoplastia
• Vaccination
• Drugs
According to Keistinen T,2017

9. New Tuberculosis Act 1960
• To municipalities strong duty to arrange the care
• To municipalities be belonged to the tuberculosis district
• Tuberculosis district must offer TB patients care
• Compulsory group inspections
• Contagious TB patients can be forced to the care
• Rehabilitation is also part of care
• Care and examinations are free-of-charge to patients
According to Keistinen T, 2017
9

10. Into and during the 1980´s
• Mass X-ray, vaccination
• Standard anti TB regimens shorter duration (6 – 9 months)
• Legislation changed starting 1987
• Communicable Diseases Act 1986 and Act on Specialized Medical Care 1989
• The special position for tb disappears
• Doctor responsible into the Primary health centers for the infectious diseases
• Notification still compulsory
• Dipensaries/sanatoria converted into pulmonary departments at central
hospitals
• Tb treatment and prevention as an ordinary sector of somatic health care
• Clinical research
According to Keistinen T, 2017

11. What was the big change ?
….Why was the new legislation needed?
… reasons and consequences…

12. 1.11.2017 12
The number of the new tuberculosis cases
during years 1975 - 2012 in Finland

13. The age groups of TB patients in Finland during 1998 - 2015

14. Major changes during 1990 ´s
• The majority of the tuberculosis sanatoriums were connected administratively as
part of central hospitals
• TB diminished - other pulmonary diseases asthma, COPD, Obstructive sleep
apnea ,pulmonary cancer gave time to the change
• The increase in the out-patient care reduced the need for the beds
• The hospitals to be found new use. Some of the hospitals remained empty
• Of the nursing staff and doctors there was a shortage and they were placed in
other tasks of the care
• More attention to the roles of primary health care and occupational health care
in TB control
1.11.2017 14

15. What is TB patient´s chain of care today in Finland ?

16. Symptoms No
follow-up
Patient is
discharged
:No further
examination
Indications of
contact
tracing
Treatment
completed
Patient
monitoring/
information
Patient
monitoring and
follow-up
Home monitoring/ follow-up
visits
Suspicion of
tuberculosis
Find out all risk
factors
Basic
examinations
A referral to the Central Hospital/ Pulmonary Clinic
DOT is organized –who is respnsible
of treatment,what to do in case of
problems,organization of follow-up
visits
Further
examinations and
differential
diagnostics
The
medication is
started
Medication and
length of stay in
hospital
Most important
side-effects
DOT arrangements
and written
personal guidelines
Monitoring of
treatment
success
Duration of
the whole
treatment
Notification of tb for the National Infectious
Diseases Register
Classification of treatment
success –follow-up
notification
Following facts are written to the
patient chart
Diagnosis of
pulmonary
TBi
NO
Yes
Patient
Primary Health
Care
Center or
Occupational
Health Care
Central
Hospital/
Pulmonary
Clinic
The National
Institute for
Health and
Welfare (THL)
More
Information
The chain of care of a tuberculosis patient
Hospital admission and
the safety
AIRBORNE INFECTION
ISOLATION ROOM
in the Pulmonary ward
The
medication is
started
Outpatient follow-up
visits

17. Isolation in airborne infection isolation room
• single room, wc, shower
• separate ventilation system, 12
ach/h
• negative air pressure
• (anteroom, window in interior
door, basin)
- All TB patients and suspicions of TB
are taken care in airborne isolation
rooms
- New sputum samples are collected
when a patients arrives to the ward
- If sputum smears positive, the
patients are treated in isolation for at
least 2 weeks
- After 2 weeks new samples are
collected and the isolation treatment
will continue until the smears are
negative
Picture: Duodecim web TB-course
17

18. Patient monitoring and follow-up visits
Normal 6-months first line drug treatment (INH+RM+EMB+PZA) –drug susceptible TB
18
Examination Before 2weeks 1month 2months 3months 4months 5months 6months (at the end)
Symptoms, clinical
examination
x x x x x x
Weight x x x x x x x
Blood tests
Alat, Afos,Bil, Krea,
PVK,La CRP,HIV-ab
x
Alat,Bil PVK (CRP,La
if needed)
x x x x x x
sputum-
tbx3,(TbNho)
x x x x x x x x
THX X-RAY x x (x) x
Test of vision (EMB) x x x x
National Tuberculosis Control programme,2013 Ministry of Social Affairs and Health, Finland

19. The first line TB drugs, drug susceptible TB :
TB-patient Intensive care Follow-up care Total treatment
time
Basic drug care
New TB-case INH,RIF,PZA,EMB
2 months
INH, RIF 4 months
(in extensive
disease
INH,RIF,EMB ad 12
months)
6 months
Intensive drug care
TB resistance
possible
(foreign, earlier
tb)
INH,RIF,PZA,EMB,SM
2 months
along with TB
resistance
along with TB
resistance
Relapsed TB INH,RIF,PZA,EMB,SM
2 months
and
INH,RIF,PZA,EMB
1 month
INH,RIF,EMB 5
months
8 months
Drug not used Intesive care follow-up care Total time of used
drug
PZA INH,RIF,EMB
2months
INH,RIF 7 months 9 months
RIF INH,
EMB,Mfx/Lfx,PZA
2-3months
INH,EMB,Mfx/Lfx,
10-16 months
12-18 months
INH RIF,EMB,PZA 2
months
RIF,EMB,PZA 10
months
12 months
If side-effects to some TB drug :
National Tuberculosis Control programme,2013 Ministry of Social Affairs and Health, Finland

20. Before TB medicine During TB –care
Patient has had known contact with MDR TB-
patient
Sputum smear or culture positive after taken over
3months TB drugs
Patient has lived >6month as a tourist or has
visited own country > 3months period (Baltic
countries, East- Europe, Middle-Asia, China, India,
Somalia, conflict areas: Syria, Irak)
TB progression during therapy clinically or
radiologically and/or sputum smear become
positive again
Patient has been at hospital care or in prison in
some over-mentioned country or has in Finnish
prison contacted a citizen from those countries
Treatment unsuccessful, drugs taken irregularly
Earlier interrupted TB treatment
When MDR-TB/ XDR –TB is suspected in Finland ?
National Tuberculosis Control programme,2013 Ministry of Social Affairs and Health, Finland

21. Classification of TB treatment success
• Healed
• full treatment and sputum culture conversion
• Treatment completed
• full treatment but bacterial confirmation missing
• Unsuccessful treatment
• cultures stay positive or become positive after 5 month
treatment
• Dead
• Interrupted treatment
• at least for 2 mo or patient has moved, no treatment
reports available
• Continued treatment
• Not available
21
National Tuberculosis Control programme,2013 Ministry of Social Affairs and Health, Finland

22. Exclude active TB – symptoms, contact
exposure-questionnaires, THX X-ray, blood
tests, induced sputumx3
High risk to have
active TB
-anamnesis or
THX X-RAY
All other cases
No active TB
B-LyTbIFNg
or
B-TbIFNg
Positive Negative
Cure of LTBI No cure of LTBI
Screening and treatment of LTBI
in case of using TNF-alfa-inhibitors in case of having other drugs
adalimumab, etanersept, golimumab, abatasept, tosilitsumab,ustekinumab,chemotherapy, glucocorticoids
sertolitsumabipegol ja infliksimab
Exclude active tb- symptoms, TB
exposure -questionnaires, THX X-
RAY,other examinations
No active TB
High or very high
probability of TB
Anamnesis, THX X RAY
No riskfactors of TB
IGRA
Positive Negative
No cure of LTBICure of LTBI
ADULT: INH 300mgx1 + B6 20mgx1 for 6(-9)months or RIF 600mg x1 (weight>50kg) + INH 300mgx1 +B620mgx1 3months
Blood tests(TVK, ALAT,Afos, Bil, Krea) at baseline, 2weeks, then x1/month
Follow-up afterwards: THX 2months + 6months http://reumatologinenyhdistys.fi/files/LTBI-reumatologinen-yhdistys-lopullinen.pdf

23. Rapidly changing challenges in TB work in Finland
… a forgotten rare disease ?
• Cases becoming rare
• Problem to maintain the knowledge and
• Continuous effort and action needed
• Cost-effective use of resources
• To determine the most important
subgroups within the main risk groups
• Foreign- born persons
• Mean age of TB patients has declined –
increasing proportion of immigrant cases
• Alcohol and subtance abusers
• The homeless
• Children
• Adolescents- students
• Close contacts
Rajalahti,I.
SLL. 2017

24. The Russian collegues visited
Lapland Central Hospital 1.5 – 5.5. 06
COPD co-work
Panychev Dmitry,
Pääterapeutti, Sosiaali -ja terveydenhuoltokomitea,
Murmanskin aluehallinto
Mechkovskaya Olga,
Keuhkosairauksien ylilääkäri, Murmanskin aluesairaala
Lyalyushkin Sergey,
Lääkäri , Montsegorskin kaupunginsairaala
Rocheva Irina,
Ylilääkäri, Kirovskin kaupunginsairaala
Rushechnikova Liudmila
Ylihoitaja, Murmanskin aluesairaala

25. Environmental exposure as an independent risk factor of
chronic bronchitis in northwest Russia
Pentti Nieminen1*, Dmitry Panychev2, Sergei Lyalyushkin3,
German Komarov4, Alexander Nikanov5, Mark Borisenko2,
Vuokko L. Kinnula6 and Tuula Toljamo7
1Medical Informatics and Statistics Research Group, University of Oulu, Oulu, Finland; 2Ministry of Health and
Social Development, Murmansk Region, Murmansk, Russia; 3Monchegorsk City Hospital, Murmansk,
Russia; 4Department of Pulmonary, Murmansk Regional Hospital, Murmansk, Russia; 5NordWest Science
Centre of Public Health Care, Murmansk, Russia; 6Department of Medicine, Pulmonary Division, University of
Helsinki, Helsinki, Finland; 7Department of Pulmonary Medicine, Lapland Central Hospital, Rovaniemi,
Finland
Background. In some parts of the northwest Russia, Murmansk region, high exposures to heavy mining and
refining industrial air pollution, especially sulphur dioxide, have been documented.
Objective. Our aim was to evaluate whether living in the mining area would be an independent risk factor of
the respiratory symptoms.
Design. A cross-sectional survey of 200 Murmansk region adult citizens was performed. The main outcome
variable was prolonged cough with sputum production that fulfilled the criteria of chronic bronchitis.
Results. Of the 200 participants, 53 (26.5%) stated that they had experienced chronic cough with phlegm
during the last 2 years. The prevalence was higher among those subjects living in the mining area with its high
pollution compared to those living outside this region (35% vs. 18%). Multivariable regression model
confirmed that the risk for the chronic cough with sputum production was elevated in a statistical significant
manner in the mining and refining area (adjusted OR 2.16, 95% CI 1.074.35) after adjustment for smoking
status, age and sex.
Conclusions. The increased level of sulphur dioxide emitted during nickel mining and refining may explain
these adverse health effects. This information is important for medical authorities when they make
recommendations and issue guidelines regarding the relationship between environmental pollution and
health outcomes.
Keywords: sulphur dioxide; pollution; respiratory symptoms; Murmansk; mining
Int J Circumpolar Health. 2013;72. doi: 10.3402/ijch.v72i0.19742. Epub 2013 Feb 22.