Tackling Drug-Resistant Tuberculosis in Conflict-ridden Donbass, Ukraine

The authors of this article placed first at the 3rd annual Toronto Thinks Global Health Case Competition. Toronto Thinks is a nation-wide case competition that simulates real-life global health issues and challenges delegates to work in a multidisciplinary team. The 2015 Challenge and case guide can be found here. 

Context

Tuberculosis (TB), an airborne infectious disease caused by Mycobacterium tuberculosis (M. tuberculosis), has plagued mankind for centuries. Although TB is no longer an immediate threat to the developed world, it disproportionately affects low-income countries and regions of conflict because its root causes stem from social inequity.

One of the most recent outbreaks is in the Donbass region of Ukraine, which is currently in a state of civil war. Following the Russian annexation of Crimea, pro-separatist sentiments gave  rise to a violent conflict in Eastern Ukraine, displacing many citizens and creating a humanitarian crisis. Many of these citizens have become internally displaced persons (IDPs) relying on government assistance for relocation and healthcare. Unfortunately, the fear of persecution has prevented many unregistered IDPs from utilizing government resources, including healthcare services. Consequently, TB has flourished in Ukraine, indiscriminately targeting those affected by  the conflict.

Challenge

Diagnosing and treating TB patients has been further complicated by multidrug resistant TB (MDR-TB), extensively drug resistant TB (XDR-TB), and HIV/TB comorbidities. Patients with these strains of TB have higher mortality rates, higher rates of relapse and require more expensive and dangerous second-line therapies. As a result, more screening and diagnostic tests are necessary to distinguish between latent (asymptomatic), active, and drug resistant TB.

Monitoring TB in the Donbass region is paramount to creating a robust public health protocol that can control this epidemic. Unique measures must be taken to handle the sociopolitical climate delicately in order to track TB on a national scale and provide a comprehensive solution.

Phase I: Building Capacity

Prior to implementing a surveillance strategy, it is imperative to build capacity by creating an environment with the political framework and community participation necessary to successfully implement healthcare interventions in the Donbass region. Establishing trust with Russian and Ukrainian authorities as well as rebel groups, community leaders, and medical personnel would allow for better access to their respective populations and infrastructure. Facilitating communication through regional spokespersons would promote patient compliance with TB interventions in the Donbass region. By engaging all stakeholders, the intervening strategy would be able to encompass the various needs of the affected parties and also remain neutral, a necessary step due to the withdrawal of Medecine sans Frontieres from the region as a result of allegations of partial medical care.

Phase II: Implementing Surveillance Systems

Upon building capacity, surveillance data can be collected through passive, sentinel, and active surveillance to provide an evidence-based approach for healthcare provision. These methods of surveillance use different levels of contact to monitor health challenges, with passive and active methods using healthcare providers to report case incidence, differentiating only in the provision of incentives. Rather than receiving data from a range of sources, sentinel surveillance utilizes selective locations to signal trends and identify the burden of disease in communities. The partnerships established with regional health professionals would allow for access to health records from local clinics and drug sale reports from pharmacies. This form of passive surveillance could track influxes of patients reporting TB-related symptoms and purchasing TB medication, and signal a potential TB outbreak. Concurrently, sentinel surveillance systems would gather data regarding TB incidence and prevalence using the relationships formed with regional spokespeople. Community leaders, such as priests, would provide local insight to direct the setup of mobile clinics in vulnerable locations of the Donbass region. The bulk of the monitoring data would be gathered from active surveillance from mobile clinics, polyclinics, and other existing healthcare infrastructure.

Mobile clinics would serve as the point of contact for migratory populations to provide active sputum TB testing and self-administered HIV tests, and direct those in need of further assistance to specialized polyclinics. Polyclinics are multi-purpose healthcare centres that would provide screening for both regular and antibiotic-resistant TB. They would be stationed near IDP internment camps to allow easy access to the particularly vulnerable population of registered and unregistered IDPs. They would receive thorough medical attention and basic emergency supplies in one location, effectively replacing the need for IDPs to access multiple service centers. Active surveillance data can be collected as a byproduct of emergency and primary care delivered in these clinics. These polyclinics can also be implemented within the separatist-controlled infrastructure in the eastern Donbass region, such as schools and churches to treat the remaining at-risk populations.

Phase III: Data Centralization

The purpose of the surveillance systems is to create a national databank for tracking all TB incidence and their treatments. For this purpose, QR-code cards would be distributed to patients during their first point of contact with a clinic, whether it be a mobile clinic or a polyclinic. These cards would contain the patient’s health status, which would be updated after every subsequent visit to a healthcare center. This QR system would enable the centralization of data to promote efficient data transfers between health-care centers while also protecting patient confidentiality and security in high conflict areas. The data on the QR code would ultimately be synchronized with Ukraine’s current healthcare database. The benefit of QR codes compared to other medical tracking technologies is that it is cheap and secure, only readable by our QR code readers. By not asking for identification and issuing our own, impartial health card, it would garner the trust of people who are afraid of revealing their identity.

What’s special about our proposal?

This solution is unique because it caters to each stakeholder in a manner that prioritizes their protection and needs by implementing customized interventions. An initial sputum test result would allow healthcare workers to order the appropriate tests, for either drug resistant TB if positive or latent TB if negative. The polyclinics would screen for a multitude of health indicators and co-morbidities which would allow for customized interventions. Building capacity enables the utilization of existing infrastructure, allowing for a smooth transition of the surveillance system to the local healthcare authorities and making this solution sustainable. The proposal involves collaboration on a national and local level by recruiting local and international nurses, social workers, physicians, allied health professionals, and community healthcare workers in addition to government officials. The innovative use of information communication technology in healthcare surveillance adds an element of novelty to our idea without adding challenges often associated with technology.