The article describes the anti-tuberculosis system in Moscow, formed as a result of the reorganization of tuberculosis institutions of the Moscow Governmental Health Department. Emphasis is placed on the features of a large metropolis after the new territories inclusion, these were the starting point for the organization of an advanced, unparalleled system. It effectively combines elements of traditional urban and rural models of TB care with the development of the original directions, allowing to centralize significant proportion of services and to improve the quality of care for children’s population, individuals with immunodeficiency, social risk groups. The activity of the largest anti-tuberculosis institution of the Russian Federation is provided by the Moscow Research and Clinical Center for Tuberculosis Control. It plays a leading role in TB care in the capital and has an excellent scientific, therapeutic and organizational capacities which is described in details. The Center has got 1,424 hospital beds and 148 beds in the Department of Day Care, it is able to receive 5,536 outpatient visits a day.

The programme of tuberculosis control, implemented in Belgorod region (Russia), is based on cooperation between local authorities, public health administration, TB- and primary medical care facilities, Regional State Center of sanitary and epidemiological supervision,
penitentiary medicine, Regional Department of Ministry of internal affairs, regional Department of Federal migration service, regional Red Cross department, mass media and community. The required legal base was worked up (regional low, regional government regulation, programmes, orders), the integrated regional TB monitoring system and personal data-base for screening by fluorography examination and so on. Primary care medical facilities are involved in TB diagnostic and treatment, especially in nidus of infection. The effectiveness of the programme confirmed by improving of the basic epidemiological indicators in 2001-2012 (all – per 100 thousands of population): the incidence decrease from 75,2 to 39,1, the prevalence – from 166,1 to 52,2, the death rate – from с 9,4 to 1,8.

In article results of application of a cartographical method of supervision in work with the centers of a tubercular infection during the period from 2005 to 2011 are analysed. The cartographical method allowed to visualize an epidemiological situation on tuberculosis in the territory of city policlinics of one administrative district of Moscow. Besides cases of family tuberculosis, the territorial centers where near a source the neighbor in a landing fell ill are revealed. Thus, use of a cartographical method of supervision over the centers of a tubercular infection allows to prove need of expansion of the contingent of surveyed contact persons. Introduction will allow to carry out epidemiological monitoring to practical work of the district doctor of the phthisiatrician of the computer program «Site Card» in the service territory at identification of the patient by tuberculosis, to define the contingent of surveyed contact persons in each case, for the purpose of detection of the hidden centers of a tubercular infection.

The algorithm of patients’ examination in Central Moscow TB bacteriological laboratory in Moscow Research and Clinical TB Center include etiological diagnosis and drug susceptibility of mycobacteria testing. As basic equipment ВАСТЕС 960, ВАСТЕС 2050 and, реже,
VersaTREK are routinely used. The non-tuberculosis mycobacteria identification performed by molecular genetic methods with «GenoType CM» и «GenoType AS». The drug susceptibility testing based on cultivation on liquid media Middlebrook 7H9 by applying the BACTECTM MGITTM960 system, Sensititre MycoTB in combination with molecular genetic techniques: for first-line drugs – «TB-BIOCHIP», «GeneXpert MBT/RIF», or second-line (include fluoroquinolones and aminoglycosides) – «TB-BIOCHIP-2», «GenoType MTBDRsl». The Moscow Research and Clinical TB Center experience demonstrate, that the use of molecular genetic methods along with current bacteriological assays considerably accelerates and makes more effective the laboratory diagnosis of tuberculosis and mycobacterioses and the assessment of drug susceptibility of mycobacteria.

In Moscow in 2012, 521 children and adolescents were identified with tuberculosis (58,2% – Moscow citizens, 41.8% – migrants). We studied the way and details of the TB detection, the ratio of positive and negative Mantoux test and with recombinant tuberculosis allergen (ATP) of the patients, assessed the possible causes of adverse reactions.
Most of children, including the migrants, who were detected by mass tuberculin testing followed by skin test with the ATP. However, the number immigrants with TB, who were identified this way, more than permanent Moscow citizens (79.4 and 65.7%, respectively, p<0.001). Among adolescents, unlike children, a great number of patient with TB were identified while seeking for medical help (mostly as in-patients): 20.7% vs 1.7%. The high sensitivity of the skin test with ATP in children and adolescents (96.5% overall, 95%CI 94.5%, 97.8%), corresponds to the sensitivity of the Mantoux test. The negative results of tests with the ATP marked by a massive infection in infants, in immunocompromised persons and also in cases where the processes already identified in the phase of an involution (calcification) and during complications of the BCG vaccination.

Phthisiatrists and infectionists providing treatment of patients with co-infection (HIV and tuberculosis) are faced with several problems: how long the treatment should be, what kind of indications must be considered for beginning of the treatment and selection of effective and safe anti-tubercular and ARVT schemes. Today nobody is in doubt about that treatment of patients with active tuberculosis should be started with anti-tuberculosis treatment first. Still under discussion is the question of ARVT prescription for patients with co-infection HIV/tuberculosis still remains, when initial CD4+ lymphocytes count is > 350 cells/mkl (and especially >500 cells/mkl. The choice of ARVT starting scheme depends on initial number of CD4+ lymphocytes during development of tuberculosis and need of inclusion of rifampicin in the scheme anti-tuberculosis treatment, keeping in mind that use of it substantially narrow choice of ARV drugs. The replacement of rifampicin for rifabutin makes easier taking the decision about what scheme of ARVT should be. In this situation it is possible to prescribe the ARV drugs from the group of reverse-transcriptase inhibitors and from the groups of protease inhibitors or integrase inhibitor.

The analysis of the main features of TB as a medical specialty, which is closely related to the organization of TB care and development of the TB science was taken. The basic position of the system of postgraduate education Phthisiatricians, also there are innovations in a complex of relevant training programs, including educational programs and continuous system of education. There are also mentioned the major issues and specific suggestions for further improvement and optimization of the Reformation in the country’s health.

The combined chemotherapy remains the main strategy of antituberculosis treatment. Current therapeutic regimens are associated to a high rate of adverse effects that can lead to therapeutic failure and worse prognosis. The review contains the recent data about classification, pathogenesis and clinical features of adverse reactions to anti-tuberculosis drugs. The universal strategy to prevent adverse reactions is presented. It based on individual risk assessment with subsequent choose of antituberculosis regimen, monitoring scheme and preventing drug prescriptions. The main problems in management of developed adverse reactions are reviewed, included methods of causality assessment, indications to withdrawal of antituberculosis drugs and symptomatic treatment.

We discussed about the experience of providing psychosocial care for tuberculosis patients. The characteristic of tuberculosis patient’s state is an affective stress which is provoking opposite interaction with other people often leads to social exclusion and poor quality of life or poor adherence to treatment.
The most progressive trend in the rehabilitation of patients with tuberculosis is a psychosomatic approach. For its reanalysis it is necessary to conduct trainings in specialized medical institutions and to gather multifunctional teams of TB specialists, psychologists, social work specialists and lawyers. This assumes the maximum involvement of the patient in all phases of the solution of his or her problems.

The target of the new approach to hepatitis C treatment – so called triple therapy (protease inhibitors additional to peginterferon and ribavirin) – are the viral proteins. The sustained virologic response achieved in 70% patients with genotype 1, however the increasing
of adverse treatment events (in comparison with interferon therapy) was obtained. Therefore, more effective regimens, including the second generation of protease inhibitors (Simeprevir, Daclatasvir, Asunaprevir, Faldaprevir and others), viral proteins NS5A (Daclatasvir,
Ledipasvir) inhibitors and inhibitors of RNA-polymerase NS5B (nucleoside – Sofosbuvir, Mericitabine, and non-nucleoside – in particular, TMC-647055, VX-222, ANA598, IDX-375 and others, that are on different phases of clinical trials). The regimens of the triple therapy, including new drugs of direct antiviral action, and regimens excluded interferon may be implemented in patients with hepatocirrhosis and serious concomitant diseases. Moreover, some new drugs of direct antiviral action are strong inhibitors, irrespective of viral hepatitis C genotype. For patients with poor virologic response by standard regimens, four-component treatment is required. In future, individual-tailored treatment, depend on patients’ peculiarities and/ or viral hepatitis C genotype.