8 The Role of Nurses in Preventing Tuberculosis in Russia’s Remote Northern Territories of Residence
Nikolai Diachkovskii and Aleksandra Obutova
Tuberculosis (TB) continues to be a global healthcare problem and is the leading cause of death among infectious diseases. In 2014, a Global Report by the World Health Organization (WHO) declared its intention to eliminate TB worldwide by the year 2035. The Russian Federation is one of the countries with a high TB burden, with the worst incidence of TB observed in the regions of the Extreme North of Russia. Control measures against TB are influenced in complex ways by living conditions and lifestyle characteristics, which stem from extreme weather and climate conditions. For instance, residents of the Extreme North were observed to develop ‘polar stress syndrome’, leading to increased vulnerability to environmental factors. Simultaneously, traditional ways of life and interpersonal relations are changing due to an influx of migration and the extensive industrial land use of the traditional territories of Indigenous peoples. All of these factors have left a deep imprint on the lives of the Indigenous population. The only available medical care in Russia’s Extreme North, with its sparse population and absence of all-season roads, is often provided solely by nurses, especially in remote villages, located far from administrative centers. Therefore, nurses are required to take on a more important role, as an autonomous actor within the rural TB control service. In this context, it is becoming increasingly important to explore social and health-related aspects of TB and its prevention in Indigenous populations, and which take into consideration the conditions of the Extreme North when determining strategies to achieve the WHO’s goal of eliminating TB.
Key Terms: Tuberculosis, Extreme North of Russia, Northern Nursing, Infectious Diseases.
Introduction
For the past few decades, global tuberculosis (TB) incidence and mortality trends have been in decline. Nevertheless, as per testimony from the World Health Organization (WHO), TB is still the top cause of death from infectious diseases. The WHO Strategy to end TB between 2016 to 2035, approved by the World Health Assembly (WHA), urges a reduction by 950% in the number of deaths from TB by 2030, and by 980% in the incidence of TB, as compared to 2015 statistics (World Health Organization, 2014). According to the WHO (2014) strategy, for these tasks goals to be achieved, all health workers within the community must be ready to assume leadership and perform these duties. Too often, there is a single health worker tasked to work on improving the quality of care for TB patients in rural areas.
In conventional practice, a mid-level health personnel professional, such as a nurse or rural feldsher, would be assigned the role of physician’s assistant and carry out the physician’s prescriptions and recommendations. But, in remote sparsely populated areas, which are located at a considerable distance from central district hospitals and may entail the absence of year-round road transportation, physicians are often not on site to participate directly in anti-epidemic activities and deliver medical care to the rural population. In light of this reality, an increasingly important role in managing anti-epidemic measures against TB infection would be assigned to the nurse, as an autonomous health worker within the rural TB service.
Considering the stressful situation caused by the high TB incidence and high mortality rates, the problem of strengthening efforts to better prevent this infectious disease is one requiring an urgent response. During recent years, M.tuberculosis (MTB), the causative agent of TB, has been acquiring the features of a nosocomial infection, i.e. one acquired in a hospital, that is highly virulent and transmissible, and possessing multidrug resistance and resistance to disinfectants. The emergence of TB hotspots with HIV and hepatitis co-infection has been observed as well (Skachkova & Nechaeva, 2006).
We found few works in the current literature which address the role of mid-level personnel in organizing TB control measures (Obutova, 2017; Oshchepkova, 2013). To date, both draft and officially issued legal regulations do not provide any implementation mechanisms or guidelines for mid-level personnel on how to manage anti-TB measures (including targeted measures) in the settings of a feldsher-midwife station. The feldsher-midwife station is a structural division within a healthcare system, which delivers pre-hospital primary care in rural areas and is led by a mid-level health worker. In the situation of a feldsher-midwife, anti-TB measures are performed under the guidance of a district physician (or district TB physician), and it is quite often performed under distance supervision, especially when it comes to remote and isolated settlements.
In response to this reality, there has been a need to develop a unified algorithm of preventive and anti-epidemic measures against TB, to be used by health workers at feldsher-midwife stations and targeted primarily at reducing the infection pool and reducing TB disease incidence in northern and remote populations of the administrative territories. This chapter underscores a pilot project, “Village Free from TB”, in the territory of Khomustakh village, Ust-Aldan district of the Sakha Republic (Yakutia), that undertook the development and implementation of this algorithm. We begin with a review of the literature. Next, we describe the Village Free from TB pilot project. Following, we describe the outcomes of that project on TB incidence, TB contact rates, and the rates of preventative behavior within the Khomustakh village, and conclude with some thoughts on the project.
Literature Review
During the years 2009 to 2014, a total of 360 patients with TB (at various periods and phases of chemotherapy) have been observed at feldsher-midwife stations of the Ministry of Health system of the Sakha Republic (Yakutia). Of those patients, 80% did not have permanent employment; 59.2% were newly diagnosed with TB; 5.8% had a relapse; 35% had chronic TB; and 50.3% were sputum and/or culture positive for TB. Smoking and alcohol abuse were adverse factors which had an aggravating effect on treatment and rehabilitation in rural settings.
A rural TB hotspot comprises the patient’s place of residence, and public and administrative facilities visited by patient; therefore, if at least one active TB case has been detected, the entire village is considered a TB hotspot. In our study, TB hotspots were present in 23.1+1.7% feldsher-midwife stations. On average, 7.1+0.9% of all patients with TB resided in the serviced territory. On average, each household hotspot had at least 1 adult patient with TB and less than 1 normal child. The number of children residing per one household hotspot was less (p <0.001) than the number of adult TB patients (p <0.001). 40.2% of household hotspots were designated as class 1 hotspots, indicating the co-existence of the most unfavorable factors in those hotspots, and requiring special attention. A link was established between the presence of TB household-hotspots in an area serviced by feldsher-midwife station, and the probability of new hotspot emergence (r = 0.84, p <0.001).
To assess the effectiveness of preventive and anti-epidemic measures against TB performed by a rural feldsher-midwife station under scientific and methodical guidance from the Phthisiatry Research-Practice Center, we developed and implemented the project Village Free from TB.
Village Free From TB Project
Upon mutual agreement with the local administration and after receiving approval from the active villagers, a pilot project was implemented from 2009 to 2014, in the territory of Khomustakh village, Ust-Aldan district of the Sakha Republic (Yakutia). The project included systematic annual preventive house-to-house examination of the total population. Specifically, adults underwent x-ray examination and children were tested with the 2TU Mantoux test. Patients with TB became subject to regular medical check-ups and were referred for treatment to a district-level or republic-level TB Clinic. Individuals with prolonged cough (i.e. more than 2 weeks) were referred to sputum microscopy for AFB (acid fast bacilli). All individuals who skipped their obligatory x-ray examination were tested with Diaskintest, an intra-dermal test based on recombinant protein CFP10-ESAT6. Program efficiency was assessed based on occurrence of new cases of TB, skin test conversions1 in children, and population coverage percentage with preventive examinations.
The algorithm of procedures on anti-TB and anti-epidemic measures for a nurse working in feldsher-midwife station included 4 stages:
Stage I: Comprehensive plan of anti-TB measures:
– Compile comprehensive plan of TB control work in a village (prepared by a feldsher at a feldsher-midwife station; based on the district-level plan and cleared through the village administration).
Stage II: Organize preventive medical examinations for the population:
2.1. Perform census of households.
2.2. Perform immunological diagnosis in pediatric population.
2.3. Perform x-ray examination of adolescent and adult population.
2.4. Perform Diaskintest for those who failed to undergo x-ray examination in time.
2.5. Arrange collection of sputum samples for AFB test and transport to TB Clinic.
If positive results were obtained:
2.6. Consult with therapist.
2.7. Consult with TB physician.
Stage III: Conduct anti-TB activities at hotspots:
3.1. Arrange hospitalization of patients to in-patient facility.
3.2. Manage patient treatment:
· Manage directly observed administration of anti-TB drugs in treatment continuation phase.
· Refer to TB Clinic for planned (periodic) examination.
3.3. Conduct anti-epidemic measures at household-hotspots:
· Trace contacts;
· Train people to perform current disinfection;
· Organize terminal disinfection at household-hotspots;
· Have the veterinary service check the hotspots.
3.4. Work with contacts exposed to TB:
· Perform preventive medical check-up;
· Isolate children from household-hotspots;
· Manage specific preventive chemotherapy (after consultation with TB physician);
· Perform activities at patient’s workplace.
3.5. Conduct anti-epidemic measures covering an entire village:
· Notify Village Administration on emergence of new infected households;
· Cooperate with active villagers to perform terminal disinfection depending on data of drug sensitivity of mycobacteria circulating in a village to disinfectants.
3.6. Manage out-patient observation of clinically cured patients:
· Timely refer patients to planned medical examination, prescribe and monitor anti-relapse therapy (by a TB physician, twice a year).
Stage IV: Monitor for TB, analyse the work done.
Discussion
At the beginning of the implementation of the project, Village Free from TB annually identified from 2 to 5 foci of tuberculosis infection. Sources of tuberculosis were persons released from penitentiary places. The number of contact persons of the adult population varied from 2 to 4 people, and the children’s contingent of the population was up to 14 years old from 1 to 6 children (Table 1).
| Year | Amount of adults | Amount children under 14 years | Amount foci of tuberculosis | Amount contact persons | Amount contact children under 14 years old |
| 2007 | 175 | 77 | 2 | 2 | 1 |
| 2008 | 191 | 76 | 5 | 4 | 6 |
| 2009 | 184 | 76 | 5 | 3 | 4 |
| 2010 | 176 | 69 | 5 | 2 | 3 |
| 2011 | 181 | 73 | 3 | 2 | 1 |
| 2012 | 195 | 78 | 0 | 0 | 0 |
| 2013 | 182 | 84 | 0 | 0 | 0 |
| 2014 | 179 | 81 | 0 | 0 | 0 |
At the same time, it should be noted that since 2011, the second year of the project, there has been a clear decrease in the number of foci of tuberculosis and contact persons of adults and children in the population of the village Khomustakh. Specifically, during the study period, the baseline pediatric infection level in Khomustakh village has declined from 5 cases (6.5%) to 1 (1.2%) case within the entire pediatric population (χ2= 3.99; p < 0.05); after 2013, no new cases of TB were registered. The pool of adult patients with TB reduced from 5 (2.7%) to 0 (r=0.95; p<0.001). The population coverage with preventive x-ray exams increased substantially, from 66.3% in 2007 to 91.3% in 2014 (r=0.81; p<0.05), due to examining the so-called unreached sector. Meanwhile, every third case of TB among detected ones originated from the unreached sector (Please see Table 2).
Table 2. Trends in preventive medical check-ups and tuberculosis disease occurrence in Khomustakh village, years 2007 to 2014.
| 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | Total | |
| Mantoux skin test conversion | 5 | 6 | 2 | 0 | 1 | 0 | 2 | 1 | 2.12+0.78* |
| Proportion of pediatric population infected with TB (%) | 6.5 | 7.9 | 2.6 | 0 | 1.4 | 0 | 2.4 | 1.2 | 2.75+1.03 |
| Number of patients with TB at feldsher-midwife station | 2 | 4 | 5 | 5 | 4 | 1 | 1 | 0 | 2.75+0.70* |
| Proportion of adult population (%) | 1.1 | 2.1 | 2.7 | 2.8 | 2.2 | 0.5 | 0.5 | 0 | 1.48+0.38 |
| Number of cases among adults | 2 | 2 | 2 | 1 | 1 | 1 | 0 | 0 | 1.12+0.29** |
| Number of cases among children | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| X-ray examination (%) | 66.3* | 71.6 | 71.8 | 86.6 | 87.5 | 89.5 | 89 | 91.3* | 81.7+3.5** |
Notes: *- p<0.05 (χ2=3.99)**-p<0.05 (r=0.950)*- p<0.05 (r=0.805).
Conclusion
Thus, in the remote settlements of the Far North, the nurse is the main organizer and direct implementer of antituberculous preventive and antiepidemic measures, whose quality correlates to the quality of TB care for the rural population. As demonstrated by the Village Free from TB pilot project, conducting continuous annual preventive examinations of the population are more effective in detecting tuberculosis in unorganized population groups. The algorithm of the feldsher-midwife station nurse’s work on anti-tuberculosis and antiepidemic measures consisting of 4 stages is a simple, inexpensive and at the same time most effective method of preventing tuberculosis infection.
Notes
- Tuberculin skin test conversion – change from negative to positive of a response to intradermal introduction of tuberculin, not associated with vaccination against TB, or else, 6 mm or more enlargement of reaction on top of postvaccinal allergy during 1.
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