International Medical Corps in the Russian FederationInternational Medical Corps in the Russian Federation

Tuberculosis in the North Caucasus: an expected epidemic

Moscow, Russia

IMC in the Russian Federation: key program areas

IMC in the Russian Federation: key program areas

IMC has been working in Russia since 2000 in the following areas:

• Public Health and infectious disease prevention

• Small business development• Youth programs• GBV prevention and

management

IMC TB assessment in the North CaucasusIMC TB assessment in the North Caucasus

In December 2009 – January 2010 IMC conducted an assessment of TB epidemiological situation, available services and needs in order to address the epidemic in the North Caucasus with the focus on Chechnya and Ingushetia, as areas with highest burden of disease in the region

TB Survey MethodsTB Survey Methods• Assessment was based on data collected by the

Republican TB control service, with statistics on all suspected and registered cases identified by the primary care facilities using the methodology of Decree # 892, including following diagnostic methods:

• X-ray (digital and film)• Bacteriological• TST

Survey limitationsSurvey limitations

• IMC used secondary data collected by badly trained republican MoH staff

• Randomized sampling was not used during data collection

• Varying sampling protocols within the different areas, due to local inefficiencies in many areas also invalidates drawing definitive comparative conclusions of the population

Survey limitationsSurvey limitations• The data only represents the factual confirmed TB

cases in the population and findings cannot be generalized to the population beyond the actual caseload identified

• TB is a highly stigmatized and TB control service estimates that 40 to 50% of cases go undetected

• Interpretation of this data should be treated with caution, as factual number of TB cases may be significantly higher

Survey findings: TB control in Chechnya and IngushetiaSurvey findings: TB control in Chechnya and Ingushetia• Health facilities are overcrowded –

not accredited by and not in compliance standards with Federal standards: no separation of patients with MDR TB, no separation of patients by sex, HIV status, TB localization

• Over 40% of patients are not hospitalized due to lack of facilities

TB Control service - serious gapsTB Control service - serious gaps

• Understaffing of TB control service (0.25 staff per 100,000 persons compared to 0.6 in Russian Federation)

• Inadequate TB testing facilities – only 44 staff are employed by the TB control service (with 75 vacancies)

TB control in Chechnya and IngushetiaTB control in Chechnya and Ingushetia• Inadequate

preparedness of local primary level clinics for TB screening

• Inadequate patient care due to lack of hospital facilities

• According to Chechen and Ingush MOH data, at least 40 to 50% cases go undetected

TB control service in Chechnya: findingsTB control service in Chechnya: findings• Laboratory diagnostics in

Chechnya - microscopy sputum Ziehl - Neelsen method in 3 labs (level 1)

• Due to lack of trained staff there is no functioning bacteriological laboratory (level 2) in Chechnya

• Screenings (профосмотр) detected only 123 TB patients (0,026/10 000 persons screened)

в 2009 г. он равен 12,8%, а в 2008 г. – 10,8% (по РФ этот показатель в 2007 г. равнялся 56%).

TB control service in ChechnyaTB control service in Chechnya

Ruins of TB hospital in Grozny: the area is still

mined

• In 2010 Chechen TB control service requires 98 full time phtysiatrists, 7 X-Ray specialists, 5 laboratory specialists - there are less than 50% available

• TB control staffing rate is only at 0,27/10,000, with Russian Federal average at 0,65

TB control service vs. primary careTB control service vs. primary care

• Over 60% of new cases registered are at diagnostic stage I with major parenchymal damage, demonstrating failure of primary care level of early detection

• Proportion of TB cases detected by the primary care level screening in 2009 was at 12,8%, and 2008 at 10,8%, while proportion was at 56% in mainland Russia

Primary care issuesPrimary care issues

• Key primary care level diagnostic issues: low TST rates

• No consultations with phtysiatrists were provided

• Due to lack of phtysiatrists a large proportion of X-Ray positive (TB suspects) were never seen by phtysiatrists

TB Prevalence rates in the Caucasus vs. “mainland” Russia*

TB Prevalence rates in the Caucasus vs. “mainland” Russia*

TB Prevalence0

50

100

150

200

250

300

350

400

190.5

77.8

107.3

162.5171.9

206.5222.5

240.9262.3

318.2325

335377 Russian Federation

Moscow

St. Petersburg

Adygea

Dagestan

Stavropol

North Ossetia

Ingushetia

Irkutsk

Tomsk

Altai Krai

Chechnya

Kemerovo

IMC TB program activitiesIMC TB program activities• IMC staff trainers coach MoH

primary care staff at district and republican clinical facilities on early detection of TB, screening and prevention

• IMC provides primary care and district TB and PHC clinics with small grants to increase their ability to respond to the epidemic, acquire necessary equipment and supplies, and IEC materials

IMC TB program activitiesIMC TB program activities• IMC improved quality of the referral

system for TB suspected cases by training primary care health facility staff in TB screening, detection and follow up

• IMC trained primary health staff in case management and international standard follow up strategies

• IMC improved DOT TB patient treatment adherence through 20 community health activist groups in Chechnya and Ingushetia

IMC TB program activitiesIMC TB program activities• Currently, there are over 851

chronic TB patients registered at the IMC service area

• IMC assisted MOH clinics managed 51 successful TB case referrals in 2008 - 2009, and 60 in 2009 - 2010

• IMC in collaboration with the Ministries of Health of Chechnya and Ingushetia works to increase local capacity for prevention of tuberculosis and care for TB patients

IMC TB program activities IMC TB program activities

IMC conducts TB prevention campaign in Ingushetia and Chechnya including:

IEC materials: Brochures Posters Educational videos

TB program activitiesTB program activities• Training of trainers at

community level, including health activists, teachers and students

IMC health staff conducts educational sessions for students, families and communities on TB

IMC Community Mobilization Program for TB ActivitiesIMC Community Mobilization Program for TB ActivitiesThrough its Community Mobilization Program, IMC facilitated creation of effective and instrumental Community Based Groups – Community Action Groups - 59 in Chechnya and 45 in Ingushetia who help facilitate all IMC activities in the region

IMC Community Mobilization program in the North CaucasusIMC Community Mobilization program in the North CaucasusDuring its health improvement program IMC also created 40 Community Health Activists Groups in Chechnya, Ingushetia and Dagestan, including elders and key community stakeholders

Specifics of TB epidemic in Chechnya and IngushetiaSpecifics of TB epidemic in Chechnya and Ingushetia• Low detection rate (actual

rates may be up to 50% higher according to local MOH estimates• TST – (Tuberculin Skin Test)

covered less than 50% in 2009• Advanced stage pulmonary TB

(cavitary TB and lung necrosis) detected among 60% of new cases (Chechnya 2009 - 56,17%)• Higher morbidity among

women (in Ingushetia 47% compared to 30-35% in Russia)

Probable causative factors of the epidemicProbable causative factors of the epidemic

• Extreme poverty and appalling living conditions

• Unemployment (69% in Chechnya and 58% in Ingushetia)

• High youth unemployment (93% in Ingushetia and 85% in Chechnya)

• Behavioral factors• State of the health care

system

IMC TB control strategies for the regionIMC TB control strategies for the region

• Strengthening the TB control service of the region and primary care delivery system by creating a North Caucasus Center of Excellence for TB Control in Stavropol

• Creating community groups of activists living with TB to raise awareness and improve early detection

QUESTIONS?

Thank you!

Simon Rasin MD, MPHsimon.rasin@imcworldwide.org

Statistical information provided by: 1. Republican ministries of health2. Ресурсный центр по изучению политики в сфере туберкулеза