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Public Health Assessment -- Russian Federation, 1992
On December 25, 1991, the Russian Federation became an independent republic, and on January 2, 1992, restrictions on retail prices of most commodities were removed. From January 16 through February 6, a multidisciplinary team from the U.S. Food and Humanitarian Assistance Bureau (FHA) conducted an assessment of the needs for humanitarian and technical assistance, focusing on three regions in the southern Ural Mountains--Yekaterinburg, Perm, and Cheliabinsk--and three regions in south-central Siberia--Kusbas, Tomsk, and Novosibirsk. The FHA assessment included observations of health facilities, vaccine- and drug-storage centers, and disease-control programs; review of health data at central, regional, and district epidemiology stations; and collection of food-price and income data through interviews with administrative authorities and surveys of markets and private homes. This report summarizes findings from the assessment.
Summary Information. The Russian Federation (population: 150 million) has a reported birth rate of 13.5 per 1000 population, crude death rate of 11.2 per 1000 population, infant mortality rate of 17.5 per 1000 live births, and maternal mortality rate of 54.7 per 100,000 live births. Approximately 75% of all deaths are caused by cardiovascular diseases, cancer, and trauma; 3% of deaths are caused by infectious diseases.
Infectious diseases. During 1991, the incidence of certain infectious diseases increased, reversing previous trends. For example, the national annual incidence rates of reported cases of diphtheria, pertussis, and measles increased by 54.7%, 25.1%, and 12.2%, respectively, over those in 1990. Moreover, measles vaccine has not been produced in Russia since August 1991, and vaccine reserves were depleted in December. Current vaccination coverage rates for children 1-3 years of age vary by region for measles (65%-80%) and for diphtheria and tetanus toxoids and pertussis vaccine (DTP) (45%-60%). Although only 16 cases of poliomyelitis were reported in Russia in 1991, oral poliomyelitis vaccine (OPV) production has declined, while the cost of OPV has increased 10-fold.
During 1991, national incidence rates for bacterial dysentery and certain other enterically transmitted diseases increased substantially. In the Tom River Basin in Siberia, problems with maintenance of water-purification systems and organic pollution of drinking water supplies were associated with incidence rates of gastroenteritis, hepatitis A, and bacterial dysentery that were up to 82%, 47%, and 22% higher, respectively, than the national incidence rates.
Noninfectious diseases. Severe shortages of essential medical supplies and drugs have restricted the capacity of hospitals and clinics to care for newborn infants and to manage patients with chronic diseases and acute surgical and traumatic problems. However, the public health impact of these shortages has not yet been quantified.
Nutrition. Protein-energy malnutrition has not been reported; however, clinic physicians reported an increase in the number of children and women with anemia and micronutrient deficiencies. Price and income data indicate that persons at risk for decreases in dietary intake include the elderly, the unemployed, single-parent families, the homeless, and the displaced. For example, in mid-January, in the Siberian regions (where 25% of all persons receive a pension for the elderly), the average pension was 342 rubles per month; however, the average monthly cost per capita for basic food items was 700-750 rubles--an income-to-food cost ratio of 1:2. Some regional governments are attempting to target assistance toward groups at risk for malnutrition by providing subsidized meals and free food coupons, as well as free milk daily to preschool-aged children.
Assistance priorities. The FHA team provided recommendations for assistance, including the need to support existing targeted food programs; provide measles vaccine and essential drugs and medical supplies; and develop an emergency public health surveillance system.
Reported by: AA Monisov, Vice-Chairman, State Committee on Sanitary and Epidemiologic Surveillance under the President of Russia, Moscow, Russia. Commonwealth of Independent States Working Group, US Food and Humanitarian Assistance Bur, Moscow, Russia. International Health Program Office, CDC.
Editorial Note: In the Russian Federation, evolving public health problems are related to three factors: the gradual erosion of hard currency income; the sudden separation of Russia from traditional sources of supplies in the other republics of the former Soviet Union; and inflation associated with the removal of restrictions on retail prices of basic commodities. Vaccine production plants and water-purification systems have not been adequately maintained, and there have been acute shortages of basic hospital supplies (e.g., disposable syringes and needles, intravenous catheters, blood transfusion sets, rubber gloves, glass ampoules, bandages, and suture material) and essential drugs (e.g., cephalosporins, quinolones, insulin, analgesics, anaesthetic agents, disinfectant agents, bronchodilators, and oral contraceptives). Finally, since late 1991, prices have increased threefold for basic foodstuffs (e.g., bread, eggs, meat, and milk).
The FHA assessment indicated three priorities for public health assistance to the Russian Federation. First, efforts should focus on the prevention of vaccine-preventable childhood diseases, including measles, pertussis, diphtheria, and poliomyelitis. The assessment indicated that approximately 3 million children aged 1-3 years may be at risk for measles and serious sequelae. In addition to providing measles vaccine, efforts are needed to increase the production of other childhood vaccines. Second, support should be provided to water-purification plants, particularly in regions where organic pollution of public water supplies is severe. Third, medical supplies should include essential and life-saving drugs and other basic supplies.
As food-related emergencies evolve, evidence of malnutrition may be delayed (1). However, one important early indicator of malnutrition is a change in the ratio of income-to-market food prices, such as that identified in Siberia (2). Although the FHA assessment did not identify reports of protein-energy malnutrition, efforts to prevent and monitor this potential problem must be maintained. International food assistance should target the elderly and the young, who are at increased risk for problems associated with diminished nutrition.
The impact of commodity shortages on the health status of the population should be monitored through an emergency public health surveillance system that can be adapted from the existing national health information system. An additional approach may be to employ sentinel surveillance in a representative sample of regions. Potential indicators include age-specific death rates for persons aged greater than or equal to 65 years; incidence rates for measles, diphtheria, and pertussis; incidence rates for bacterial dysentery; incidence rates for anemia in pregnant women; diabetes-specific hospital-admission and death rates; death rates for selected surgical conditions; perinatal mortality rates in maternity hospitals; asthma death rates; and emergency room-based death rates for selected injuries. A surveillance system also could include prices of selected food items, income data, and stocks of essential medical supplies in sentinel hospitals.
To maximize the impact and cost-effectiveness of humanitarian assistance efforts to Russia and the other republics of the former Soviet Union, such efforts should continue to be based on initial field assessments and, subsequently, on ongoing surveillance information. Because baseline health indicators in the central Asian republics suggested more serious problems than those in Russia before the dissolution of the Soviet Union, assessments in these republics (i.e., Kazakhstan, Kyrgyztan, Tadzhikistan, Uzbekistan, and Turkmenistan) should be expedited.
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