Cardiovascular Diseases in Central and Eastern Europe: A Call for More Surveillance and Evidence-Based Health Promotion.

Objectives: The paper aims to identify the priorities for cardiovascular health promotion research in Central and Eastern Europe (CEE), the region with the highest cardiovascular diseases (CVD) burden in the world. Methods: This narrative review covered peer-reviewed publications and online databases using a nonsystematic purposive approach. Results: In despite of a steady decrease in CVD burden in the region, the East-West disparities are still significant. There is minimal continuity in the past and current CVD prevention efforts in the region. Many challenges still exist, including an opportunity gap in research funding, surveillance and population-based preventive interventions. A comprehensive approach focusing on multisectoral cooperation, quality and accessibility of healthcare and equity-oriented public policies and supported by well-designed epidemiologic studies is needed to overcome these challenges. Conclusion: The current level of effort is not adequate to address the magnitude of the CVD epidemic in CEE. It is imperative to strengthen the epidemiological base concerning cardiovascular health in the region, to foster surveillance and progress in implementation of CVD preventive strategies in the most affected populations of Europe.

Consensus on management of hepatitis C virus infection in resource-limited Ukraine and Commonwealth of Independent States regions.

Globally, 69.6 million individuals were infected with hepatitis C virus (HCV) infection in 2016. Of the six major HCV genotypes (GT), the most predominant one is GT1, worldwide. The prevalence of HCV in Central Asia, which includes most of the Commonwealth of Independent States (CIS), has been estimated to be 5.8% of the total global burden. The predominant genotype in the CIS and Ukraine regions has been reported to be GT1, followed by GT3. Inadequate HCV epidemiological data, multiple socio-economic barriers, and the lack of region-specific guidelines have impeded the optimal management of HCV infection in this region. In this regard, a panel of regional experts in the field of hepatology convened to discuss and provide recommendations on the diagnosis, treatment, and pre-, on-, and posttreatment assessment of chronic HCV infection and to ensure the optimal use of cost-effective antiviral regimens in the region. A comprehensive evaluation of the literature along with expert recommendations for the management of GT1-GT6 HCV infection with the antiviral agents available in the region has been provided in this review. This consensus document will help guide clinical decision-making during the management of HCV infection, further optimizing treatment outcomes in these regions.

[Analysis of HIV-1 (Human immunodeficiency virus-1, Lentivirus, Orthoretrovirinae, Retroviridae) Nef protein polymorphism of variants circulating in the former USSR countries.]

INTRODUCTION: The human immunodeficiency virus (HIV) Nef protein is one of the key factors determining the infectivity and replicative properties of HIV. With the ability to interact with numerous proteins of the host cell, this protein provides the maximum level of virus production and protects it from the immune system. The main activities of Nef are associated with a decrease in the expression of the CD4 receptor and major histocompatibility complex class I molecules (MHC-I), as well as the rearrangement of the cytoskeleton. These properties of the protein are determined by the structure of several motifs in the structure of the nef gene encoding it, which is quite variable. OBJECTIVES: The main goal of the work was to analyze the characteristics of Nef protein of HIV-1 variant A6, which dominates in the countries of the former USSR. The objective of the work was a comparative analysis of natural polymorphisms in the nef gene of HIV-1 sub-subtypes A6 and A1 and subtype B. MATERIAL AND METHODS: The sequences of the HIV-1 genome obtained during the previous work of the laboratory were used, as well as the reference sequence from GenBank. In this work, Sanger sequencing and new generation sequencing methods, as well as bioinformation analysis methods were used. RESULTS AND DISCUSSION: The existence of noticeable differences in the prevalence of Nef natural polymorphisms (A32P, E38D, I43V, A54D, Q104K, H116N, Y120F, Y143F, V168M, H192T, V194R, R35Q, D108E, Y135F, E155K, E182M, R184K and F191L), some of which are characteristic mutations for variant A6, was shown. CONCLUSION: Characteristic substitutions were found in the Nef structure, potentially capable of weakening the replicative properties of HIV-1 variant A6.

Patient Access, Unmet Medical Need, Expected Benefits, and Concerns Related to the Utilisation of Biosimilars in Eastern European Countries: A Survey of Experts.

This policy research aims to map patient access barriers to biologic treatments, to explore how increased uptake of biosimilars may lower these hurdles and to identify factors limiting the increased utilisation of biosimilars. A policy survey was developed to review these questions in 10 Central and Eastern European (CEE) and Commonwealth of Independent States (CIS) countries. Two experts (one public and one private sector representative) from each country completed the survey. Questions were related to patient access, purchasing, clinical practice, and real-world data collection on both original biologics and biosimilars. Restrictions on the number of patients that can be treated and related waiting lists were reported as key patient access barriers. According to respondents, for both clinicians and payers the primary benefit of switching patients to biosimilars would be to treat more patients. However, concerns with therapeutic equivalence and fear of immunogenicity may reduce utilisation of biosimilars. Similar limitations in patient access to both original biologics and biosimilars raise concerns about the appropriateness and success of current biosimilar policies in CEE and CIS countries. The conceptual framework for additional real-world data collection exists in all countries which may provide a basis for future risk-management activities including vigorous pharmacovigilance data collection.

Molecular epidemiology of HIV-1 subtype A in former Soviet Union countries.

While in other parts of the world it is on decline, incidence of HIV infection continues to rise in the former Soviet Union (FSU) countries. The present study was conducted to investigate the patterns and modes of HIV transmission in FSU countries. We performed phylogenetic analysis of publicly available 2705 HIV-1 subtype A pol sequences from thirteen FSU countries: Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Russia, Ukraine and Uzbekistan. Our analysis showed that the clusters from FSU countries were intermixed, indicating a possible role of transmigration in HIV transmission. Injection drug use was found to be the most frequent mode of transmission, while the clusters from PWID and heterosexual transmission were intermixed, indicating bridging of HIV infection across populations. To control the expanding HIV epidemic in this region, harm reduction strategies should be focused on three modes of transmission, namely, cross-border migration, injection drug use and heterosexual.

[Rapid spread of the HIV-1 circular recombinant CRF02-AG in Russia and neighboring countries].

The spread of the HIV-1circular recombinant CRF02-AG in countries of the former Soviet union (Commonwealth of Independent States, CIS) was studies using partial and full genome sequences. The full-genome sequence of the CRF02-AG recombinant circulating in Russia was obtained for the first time. A Global phylogenetic tree of CRF02-AG full-genome sequences was constructed. Three distinct groups of the sequences were detected as clustered by the geographical location (CIS, South Korea, and France), which is indicative of the single-virus introduction in each of the regions mentioned above. The CIS cluster exhibiting minimum genetic diversity was, therefore, relatively young. The phylogenetic analysis of the env gene sequences within the CIS cluster made it possible to clearly discriminate three branches: two of Russian and one of Uzbek origin. The low genetic diversity within the two Russian subclusters provides evidence of at least two recent independent introductions of the CRF02-AG recombinant from Central Asia into Russia. This work was performed within the framework of the 7th Federal Research Program (FP&), Project EURIPRED (European Research Infrastructures for Poverty Related Diseases), grant agreement No.312661.

The effect of health on labour supply in nine former Soviet Union countries.

This paper examines for the first time the consequences of ill health on labour supply for a sample of nine countries from the former Soviet Union (FSU), using a unique multicountry household survey specifically designed for this region. We control for a wide range of individual, household, and community factors, using both standard regression techniques and instrumental variable estimation to address potential endogeneity. Specifically, we find in our baseline ordinary least squares specification that poor health is associated with a decrease in the probability of working of about 13 %. Controlling for community-level unobserved variables slightly increases the magnitude of this effect, to about 14 %. Controlling for endogeneity with the instrumental variable approach further supports this finding, with the magnitude of the effect ranging from 12 to 35 %. Taken together, our findings confirm the cost that the still considerable adult health burden in the FSU is imposing on its population, not only in terms of the disease burden itself, but also in terms of individuals' labour market participation, as well as potentially in terms of increased poverty risk. Other things being equal, this would increase the expected "return on investment" to be had from interventions aimed at improving health in this region.

[The current malaria situation in the CIS countries (2011-2012)].

In the last 3 years, the malaria situation has considerably improved in the CIS countries: Three CIS countries, such as Turkmenistan, Armenia, and Kazakhstan, received the malaria-free status (in 2010, 2011, and 2012, respectively) confirmed by the WHO certificate; Azerbaijan, Kyrgyz Republic, Uzbekistan, and Tajikistan are in the elimination period. Despite the continuing intensive migration of CIS citizens to Russia, its malaria situation has been favorable, which is associated with the significant reduction of imported infection cases among migrants.

Screening and rapid molecular diagnosis of tuberculosis in prisons in Russia and Eastern Europe: a cost-effectiveness analysis.

BACKGROUND: Prisons of the former Soviet Union (FSU) have high rates of multidrug-resistant tuberculosis (MDR-TB) and are thought to drive general population tuberculosis (TB) epidemics. Effective prison case detection, though employing more expensive technologies, may reduce long-term treatment costs and slow MDR-TB transmission. METHODS AND FINDINGS: We developed a dynamic transmission model of TB and drug resistance matched to the epidemiology and costs in FSU prisons. We evaluated eight strategies for TB screening and diagnosis involving, alone or in combination, self-referral, symptom screening, mass miniature radiography (MMR), and sputum PCR with probes for rifampin resistance (Xpert MTB/RIF). Over a 10-y horizon, we projected costs, quality-adjusted life years (QALYs), and TB and MDR-TB prevalence. Using sputum PCR as an annual primary screening tool among the general prison population most effectively reduced overall TB prevalence (from 2.78% to 2.31%) and MDR-TB prevalence (from 0.74% to 0.63%), and cost US$543/QALY for additional QALYs gained compared to MMR screening with sputum PCR reserved for rapid detection of MDR-TB. Adding sputum PCR to the currently used strategy of annual MMR screening was cost-saving over 10 y compared to MMR screening alone, but produced only a modest reduction in MDR-TB prevalence (from 0.74% to 0.69%) and had minimal effect on overall TB prevalence (from 2.78% to 2.74%). Strategies based on symptom screening alone were less effective and more expensive than MMR-based strategies. Study limitations included scarce primary TB time-series data in FSU prisons and uncertainties regarding screening test characteristics. CONCLUSIONS: In prisons of the FSU, annual screening of the general inmate population with sputum PCR most effectively reduces TB and MDR-TB prevalence, doing so cost-effectively. If this approach is not feasible, the current strategy of annual MMR is both more effective and less expensive than strategies using self-referral or symptom screening alone, and the addition of sputum PCR for rapid MDR-TB detection may be cost-saving over time.

Individual and community level socioeconomic inequalities in contraceptive use in 10 Newly Independent States: a multilevel cross-sectional analysis.

INTRODUCTION: Little is known regarding the association between socioeconomic factors and contraceptive use in the Newly Independent States (NIS), countries that have experienced profound changes in reproductive health services during the transition from socialism to a market economy. METHODS: Using 2005-2006 data from Demographic Health Surveys (Armenia, Azerbaijan, and Moldova) and Multiple Indicator Cluster Surveys (Belarus, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine, and Uzbekistan), we examined associations between individual and community socioeconomic status with current modern contraceptive use (MCU) among N = 55,204 women aged 15-49 married or in a union. Individual socioeconomic status was measured using quintiles of wealth index and education level (higher than secondary school, secondary school or less). Community socioeconomic status was measured as the percentage of households in the poorest quintile of the nationals household wealth index (0%, 0-25%, or greater than 25%). We used multilevel logistic regression to estimate associations adjusted for age, number of children, urban/rural, and socioeconomic variables. RESULTS: MCU varied by country from 14% (in Azerbaijan) to 62% (in Belarus). Overall, women living in the poorest communities were less likely than those in the richest to use modern contraceptives (adjusted odds ratio (aOR) = 0.82, 95% Confidence Interval = 0.76, 0.89). Similarly, there was an increasing odds of MCU with increasing individual-level wealth. Women with a lower level of education also had lower odds of MCU than those with a higher level of education (aOR = .75, 95%CI = 0.71, 0.79). In country-specific analyses, community-level socioeconomic inequalities were apparent in 4 of 10 countries; in contrast, inequalities by individual-level wealth were apparent in 7 countries and by education in 8 countries. All countries in which community-level socioeconomic status was associated with MCU were in Central Asia, whereas at the individual-level inequalities of the largest magnitude were found in the Caucasus. There were no distinct patterns found in Eastern European countries. CONCLUSIONS: Community-level socioeconomic inequalities in MCU were most pronounced in Central Asian countries, whereas individual-level socioeconomic inequalities in MCU were most pronounced in the Caucasus. It is important to consider multilevel contextual determinants of modern contraceptive use in the development of reproductive health and family planning programs.

The Soviet legacy in diagnosis and treatment: Implications for population health.

This article reviews diagnosis and treatment in the Commonwealth of Independent States in three clinical areas: tuberculosis, substance misuse, and neurological disorders in children. While the specific problems in each of these areas differ greatly, commonalities emerge, pointing to the continued influence of the Soviet past. Although progress in developing evidence-based medicine is being made, the isolation of Soviet science from Western developments has resulted in the widespread use of outdated diagnostic procedures and treatment protocols, while finance mechanisms still encourage unnecessary hospitalizations and treatments. A hierarchical medical system, as well as underdeveloped patient rights and medical ethics, mean that patients have little information and ability to participate in decision-making. The continued use of outdated approaches to diagnosis and treatment contributes to poor population health outcomes in the region.

Universal salt iodization in the Central and Eastern Europe, Commonwealth of Independent States (CEE/CIS) Region during the decade 2000-09: experiences, achievements, and lessons learned.

BACKGROUND: By 2000, the global track record on universal salt iodization (USI) indicated 26% access to adequately iodized salt in the Central and Eastern Europe, Commonwealth of Independent States (CEE/ CIS) Region. OBJECTIVE: Aimed at extracting lessons learned, this study examined experiences, achievements, and outcomes of USI strategies in CEE/CIS countries during the subsequent decade. METHODS: Information from the design, timing, execution, outputs, multi-sector management and results of actions by national stakeholders yielded 20 country summaries. Analysis across countries used a LogFrame Analysis typical for public nutrition development. RESULTS: By 2009, USI strategies had reached the target and population iodine nutrition shown adequate levels in 9 countries, while in 6 others, USI was close and/or population iodine status showed only minor imperfection. True USI, i.e., iodization of salt destined both for the food industry and the household, had been made mandatory in 13 of these 15 countries. In the Balkan area, USI and iodine nutrition advanced more than in CIS. Of the 20 sample countries, 17 (85%) had exceeded the mark of 50% adequate access, while the overall regional score reached 55% by 2010. CONCLUSIONS: Experience from this region suggests that strong partnership collaboration, a new concept in post-Soviet societies, was a major success factor. Voluntary iodization or focusing on household salt alone was less likely conducive for success. Achieving optimum iodine nutrition required the setting of proper iodine standard Weak political leadership insistence in the Russian Federation and Ukraine to embrace USI is the main factor why the region remains behind in the global progress.

Epidemiology chapter.

This chapter outlines the epidemiology of brucellosis in the Russian Federation and in five countries bordering Russia. Since the Soviet Union's dissolution, Russia and the newly formed independent republics have failed to maintain policies to control brucellosis and other zoonotic diseases. Many of these republics, due to weak animal control and prevention systems and dangerous food preparation practices, are still burdened with the human cost of brucellosis. The final summary of this section provides an example of the successful transboundary cooperative efforts between Arizona and Mexico, which could be applied to the situation between Russia and the bordering independent republics.

[Microbial risk assessment to establish water quality-enteric infection morbidity relationships].

The authors have constructed a mathematical model for the cause-and-effect relationship between acute enteric infection (AEI) morbidity and the levels of water bacterial contamination and the properties of microorganisms. New procedures were proposed to calculate a risk for water-borne AEI depending on the sanitary-and hygienic conditions of water use and the degree of water contamination in the direct isolation of the causative agents of pathogenic and opportunistic infections, which allow the calculation and prediction of the occurrence of AEI at the individual and population levels.

Alcohol and other drug related deaths among young people in CIS countries: proximal and distal causes and implications for policy.

BACKGROUND: Although the mortality crisis that followed the break-up of the Soviet Union in 1992 has been well researched, most attention has been paid to mortality among middle-aged men. There has been relatively little analysis of death rates among young people, many of which appear related to alcohol and other drug (AOD) use. Death rates ranged from exceedingly high in some countries (e.g. Russia) to very low in others (e.g. Armenia). This divergence among Commonwealth of Independent States (CIS) countries increased considerably over the 1990s. What caused this divergence in youth deaths and what policy response is needed? METHOD: An ecological study of country-level data was used to explore the relationships between risk factors, AOD use and youth deaths across time and between countries. Qualitative research literature was used to supplement the statistical data. RESULTS: AOD abuse risk factors were divided into 'proximal causes' (e.g. AOD availability) and 'distal causes' (e.g. social cohesion, welfare, culture). Proximal risk factors appeared to explain some of the AOD use and death data, but they did not explain all of the country differences. Analysis of distal risk factors suggested that family and community strength are important factors in the trends in AOD abuse and youth mortality. CONCLUSIONS: The policy response to AOD abuse and mortality among young people needs to attend to both proximal and distal factors. An exclusive focus on proximal risk factors is unlikely to provide a satisfactory solution. Rather, the social determinants of child and youth development need to be considered. More research is needed on the relationship between AOD abuse and youth mortality, and on the influence of family and community strength on both these outcomes in the region. Useful lessons may be learned from countries such as Armenia, where both AOD abuse and youth mortality have remained low.

Demographic features and trends in tuberculosis cases in the European Region, 1995-2005.

In 2005, 426,457 tuberculosis (TB) cases were notified in the World Health Organization (WHO) European Region, with a wide variation and an incremental west-to-east gradient in notification rates also reflected in TB mortality rates. In the enlarged European Union ('EU-27') and other western countries--where 19% of cases were of foreign origin in 2005 (>50% in 13 countries)--overall TB notification rates decreased by 2.4% yearly between 2000 and 2005, compared to 1.6% in 1995-2000, reflecting a declining incidence in all age groups and in most countries. Half the cases notified by the 12 ex-republics of the former Soviet Union in the East in 2005 were reported by the Russian Federation. In the East, the mean annual increase in 1995-2000 (10.0%) was higher than in 2000-2005 (3.9%), and in recent years the number of new cases stabilised while previously treated cases have increased. Efforts are still needed to improve and standardise TB surveillance across the Region. The collection of additional data on risk factors of TB may be useful for surveillance and control.

Diphtheria.

Diphtheria is a contagious upper respiratory illness that was a major cause of childhood mortality in the prevaccine era. In the early twentieth century, an effective toxoid vaccine was developed. Implementation of childhood vaccination virtually eliminated diphtheria from developed countries after the Second World War and implementation of the Expanded Program on Immunization in developing countries led to rapid declines in diphtheria globally in the 1980s. However, in the 1990s, a massive epidemic of diphtheria spread throughout the countries of the former Soviet Union. Unlike the prevaccine era, most cases of severe disease and deaths were reported among adults. Multiple factors contributed to the epidemic, including increased susceptibility among both adults and children; suboptimal socioeconomic conditions; high population movement; and delay in implementing appropriate control measures. Mass immunization was the key element in the epidemic control strategy developed and implemented in a well-coordinated response by an international public health coalition. This strategy focused on rapidly raising population immunity of both adults and children; the immunization of more than 140,000,000 adults and adolescents and millions of children successfully controlled the epidemic. While improved coverage of children in developing countries with diphtheria toxoid has led to progressive decreases in diphtheria; eradication is unlikely in the foreseeable future and gaps in immunity among adult population exist or are developing in many other countries. Routine childhood immunization with diphtheria toxoid is the key to controlling diphtheria while the role of routine adult reimmunization is less established; mass immunization will remain an important control measure for widespread diphtheria outbreaks.

[Visceral leishmaniasis in the Commonwealth of Independent States (CIS): results and basic lines of further study].

The results of studies of visceral leishmaniasis (VL) made in the 20th century in the Commonwealth of Independent States that are VL-endemic, such as Azerbaijan, Armenia, Georgia, Kazakhstan, Kyrghyzstan, Tadjikistan, Turkmenistan, and Uzbekistan are summed up. The magnitude of studies of VL in different regions is different. The authors analyze the epidemiological and epizootological situation and define the basic lines of further studies of VL, which include the present view of the prevalence of VL in Central Asia and Transcaucasia; identification of strains of the pathogen by molecular genetic methods; study of its vectors; detection of natural reservoirs of the pathogen, improvement of methods for VL diagnosis; and their introduction into laboratories' work.

Drinking in the Commonwealth of Independent States--evidence from eight countries.

AIMS: To describe the frequency of alcohol consumption and beverage preferences in eight countries of the Commonwealth of Independent States (CIS). DESIGN: Cross-sectional. SETTING: Populations of Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation and Ukraine. PARTICIPANTS: Representative samples of the adult population of each country (overall sample size 18,428; response rates: 71-88%). MEASUREMENTS: A standardised questionnaire was administered by trained interviewers to examine alcohol consumption frequency and usual intakes of beer, wine and strong spirits. FINDINGS: Between 11 and 34% of males and 26-71% of females reported never drinking alcohol. Abstention was lowest in the Russian Federation and Belarus, two traditional spirits-drinking countries. It was particularly high in Kyrgyzstan and Georgia, two countries with a relatively low frequency of alcohol consumption but large amounts consumed per occasion (particularly Georgia). On the contrary, Moldovan respondents drank frequently, but consumed smaller amounts per occasion. As expected, spirits were consumed in largest amounts in traditional spirits-drinking countries, as well as Armenia and wine in traditional wine-drinking countries. Beer consumption was relatively high in Russia, Belarus, Ukraine and Kazakhstan (males), particularly in young respondents. CONCLUSIONS: Although cross-country comparisons of alcohol intake should be interpreted cautiously, this study suggested that drinking patterns in the countries examined are not entirely typical of usual dry/wet drinking cultures, and confirms that the CIS is very diverse in terms of drinking patterns and beverage preferences. The study provides an important baseline for future comparisons as markets open to new products, as has been the case elsewhere in Europe.