Increased Risk of Tuberculosis Among Health Care Workers in Samara Oblast, Russia: Analysis of Notiﬁcation Data

Increased risk of tuberculosis among health care workers in Samara Oblast, Russia: analysis of notiﬁcation data

B. Dimitrova,* A. Hutchings,* R. Atun,† F. Drobniewski,‡ G. Marchenko,§ S. Zakharova,§ I. Fedorin,§ R. J. Coker* * Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, † The Business School, Imperial College, London, ‡ Department of Infectious Diseases, Guy’s, King’s and St Thomas’ Medical School, London, United Kingdom; § Samara Oblast Health Department, Samara, Russian Federation

SUMMARY

SETTING: Samara Oblast, Russia. ing at in-patient TB facilities were found to be at highest OBJECTIVE: To compare the rates of tuberculosis (TB) risk, with an incidence rate ratio of 17.7 (95%CI 11.6– in health care workers (HCWs) working in TB services, 27.0) compared to HCWs at the GHS. general health services (GHS) and the general popula- CONCLUSIONS: HCWs at TB services in the Russian tion in a region of the Russian Federation. Federation are at substantially increased risk for TB, DESIGN: Analysis of notification rates of TB among suggesting significant risks from nosocomial transmis- HCWs, GHS workers and the general population during sion. Control of institutional spread of TB in the Rus- the 9-year period from 1994 to 2002. sian Federation is an area that requires urgent attention, RESULTS: During 1994–2002, TB incidence among especially given the epidemic of human immunodefi- staff employed at the TB services in Samara Oblast was ciency virus that Russia is currently witnessing. ten times higher than among the general population, KEY WORDS: tuberculosis; health care workers; Russia reaching 741.6/100 000 person years at risk. Staff work-

INCREASED RISKS of tuberculosis (TB) have been Oblast reached its lowest ever level of 30.7 per reported in health care workers (HCWs) and sub- 100 000 population in 1991. Over the last decade, the groups of HCWs (medical laboratory workers, hospi- annual number of newly notiﬁed cases has been in- tal employees, pathologists and general health ser- creasing, and in 2002 the TB incidence was 54.4/ vices [GHS] staff) compared to rates in the general 100 000 among permanent residents and 74.9/100 000 population.1–6 In regions where specialised TB hospi- in all population groups (including prisoners, migrants, tals remain, the risk for TB among staff can reach army recruits and other special groups). Individuals di- 7.5–60 times that of the general population.7,8 agnosed with TB are routinely admitted to in-patient The Russian Federation has witnessed a marked facilities, usually for a period of 3 months, and subse- increase in rates of TB during the last decade.9 TB ser- quently followed up in out-patient facilities.11 vices in the Russian Federation are provided through The aim of this study was to estimate the incidence an extensive network of specialised TB facilities, and of TB in HCWs in Samara Oblast since 1994 and to treatment is associated with lengthy periods of hospi- compare incidence rates for different types of health talisation. According to ofﬁcial statistics of the Rus- care facility. sian Ministry of Health, rates of TB are six to eight times higher among HCWs employed in TB services STUDY POPULATION AND METHODS than among the general population.10 Samara Oblast is located about 750 km south-east We conducted a review of data on the number of of Moscow. It has a population of approximately 3.3 newly diagnosed TB cases per calendar year among million people. About 1.3 million people live in Samara health care staff from 1994 to 2002. We used as a (the regional capital), with a further 700 000 living in source the electronic database at Samara Oblast TB Togliatti, a nearby conurbation. Following a period Dispensary (OTBD), which contains individualised of steady decline, the incidence of TB in Samara demographic, clinical and epidemiological data on all

Correspondence to: Dr Richard Coker, Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK. Tel: (ϩ44) 207 9272926. Fax: (ϩ44) 207 6127812. e-mail: richard.coker@ lshtm.ac.uk Article submitted 3 March 2004. Final version accepted 25 May 2004. 44 The International Journal of Tuberculosis and Lung Disease

TB cases notified in Samara Oblast since 1994. Noti- RESULTS fication data are collected prospectively and, since Forty-nine separate TB facilities provide diagnostic 1994, have been entered into an electronic database. and curative services for adults with TB: four in- Diagnoses in all cases are based on clinical signs of ac- patient only facilities, 38 out-patient only facilities tive TB and radiological, clinical and bacteriological and seven facilities providing both in-patient and out- investigations. All TB cases are reviewed by the Cen- patient care (Table 1). The in-patient and out-patient tral Physician Commission, a central collegial body facilities at Samara OTBD were categorised separately that verifies the diagnosis of TB and registers all cases. because they were on different sites. The annual aver- Screening of staff by fluorography is performed every age number of TB HCWs was 1999 during the study 6 months, with further follow-up if abnormalities are period, with most working in the TB dispensaries. detected, as is routine throughout Russia. The GHS had an average of 63 656 HCWs during the We obtained data on the total number of TB cases same period. among HCWs in each calendar year for Samara There were 80 cases of TB notified during the Oblast and for each facility where TB patients were study period among HCWs working in TB facilities treated. Data on the annual TB incidence rates for the and 394 cases notified for workers in the GHS (Table 2). general population were obtained from official statis- With a mean age of 39.5 years, cases among workers tics of the Samara OTBD. For each TB facility we ob- at TB facilities were, on average, older than cases tained data on the average number of persons em- in the GHS by 2.9 years (95%CI 0.1–5.8). A higher ployed in each calendar year from the OTBD. Health proportion of cases in TB HCWs were female care staff studied included physicians, nurses, auxilia- (88.8%) than among cases in the GHS (74%). Most ries, laboratory technicians and other non-medical cases in TB HCWs were in nurses (38.8%) and aux- support staff. These data were derived from the Dis- iliaries (27.5%), although the distribution was simi- pensary database. lar to cases in the GHS (P ϭ 0.76). There was no ev- Each TB facility was categorised as providing in- idence of a difference in the proportion of pulmonary patient or out-patient services. Where a facility pro- TB cases or the proportion of these with bacterio- vided both, and it was possible to separately identify logical verification. A higher proportion of cases the number of cases and staff between in-patient and (91.3%) was detected through screening in TB out-patient services, the in-patient and out-patient HCWs compared with 67.5% among the GHS (P Ͻ services were categorised separately. A third cate- 0.001). gory was created for facilities where it was not The crude incidence rate of TB in HCWs working possible to separately identify cases and staff num- in TB facilities was 741.6/100 000 py (95%CI 413.3– bers between in-patient and out-patient services, or 1330.8) (Table 3). There was no evidence that the rate where individual staff worked across both types of changed during the study period 1994–2002 (inci- service. dence rate ratio 1.027/year, 95%CI 0.95–1.11). In Crude incidence rates per 100 000 person years comparison, the crude incidence rate among HCWs (py) at risk were calculated for staff working in TB fa- in the GHS was 68.8/100 000 py at risk (95%CI cilities and staff working in the GHS. The average an- 55.4–85.4), giving an incidence rate ratio of 10.8 nual number of staff employed in each facility was (95%CI 6.0–19.4) for HCWs in the TB services com- used as an estimate of person years at risk. The rates pared with those in the GHS. The rate in HCWs in the for staff working in the GHS were calculated after GHS was closer to the rates in the civil population subtracting staff working in TB facilities from the overall numbers for Samara Oblast. Differences in age, sex, occupation, TB site and detection by screening were assessed for cases from TB facilities and the Table 1 TB facilities in Samara Oblast, 1994–2002 ␹2 GHS using t-tests for continuous variables and Average tests for categorical variables. number of We used a Poisson regression model to estimate the Facilities Cases health care incidence of TB and the incidence rate ratios for each Type of facility n n workers category of TB facility compared with staff working in Hospitals (in-patients) 3 19 173.2 Oblast TB Dispensary (in-patients) 1 13 119.0 other health care facilities. Confidence intervals (CI) TB dispensaries in major towns 7 36 485.8 were calculated using robust standard errors to allow (in-patients and out-patients) for over-dispersion in the data.12 A test for trend was Samara City TB Dispensaries, Samara City TB physicians’ offices used to assess whether there was a trend in the inci- and Oblast TB Dispensary dence of TB associated with increasing in-patient (out-patients) 9 11 348.0 provision in the three categories of TB facilities. We Rural TB physicians’ offices 29 1 72.6 also tested for a trend in the annual incidence of TB (out-patients) among staff working in TB facilities by including year Total 49 80 1198.6 of notification in the model. TB ϭ tuberculosis. Tuberculosis control in health care workers 45

Table 2 TB cases among health care workers in Samara Oblast, 1994–2002

Other health TB facilities care facilities (n ϭ 80) (n ϭ 394) P value Age, years: mean (SD) 39.5 (13.0) 36.6 (11.6) 0.04 Female sex, n (%) 71 (88.8) 292 (74.1) 0.005 Occupation Doctor 13 (16.3) 77 (19.5) Nurse 31 (38.8) 164 (41.6) 0.76 Laboratory technician 5 (6.3) ] Auxiliary and other 31 (38.8) 153 (38.8) Site, n (%) Pulmonary 70 (87.5) 342 (86.8) 0.87 Extra-pulmonary 10 (12.5) 52 (13.2) Pulmonary cases with bacteriological verification,* n (%) 21 (30.0) 133 (38.9) 0.16 Detection by screening, n (%) 73 (91.3) 266 (67.5) Ͻ0.001 Figure TB incidence rates among staff of the TB services compared to the general health services and the general population, * Culture-positive and/or smear-positive. Samara Oblast, Russian Federation. GHS ϭ general health ser- ϭ ϭ TB tuberculosis; SD standard deviation. vices; TB ϭ tuberculosis.

(permanent residents only) of 56.3/100 000 and the a 300-bed facility situated on the outskirts of Samara general population (including prisoners and other spe- city. During the study period it had an average of cial groups reported separately) of 74.1/100 000 dur- 1404 admissions for TB every year, the highest admis- ing 1994–2002 (Figure). sion rate of all the region’s TB facilities. The hospital After categorising TB facilities according to their provides care for the poorest and most disadvantaged in-patient and out-patient services, we found strong TB patients. Although there is no consistent definition evidence of a trend of increasing incidence associated of a ‘chronic’ case in the Russian literature, in practice with greater provision of in-patient TB facilities (test TB cases are usually considered ‘chronic’ when they for trend P ϭ 0.001). The rate was highest for staff have several years’ history of TB, radiological changes working in in-patient facilities, with an incidence rate on X-ray showing cavitary and fibrotic lesions, and ratio of 17.7 (95%CI 11.6–27.0) compared to workers positive smear microscopy or culture results. The hos- in the GHS (Table 3). pital also serves as a hospice for terminally ill prisoners The two main TB facilities contributed the most with TB. In 2000, 35% of all patients admitted to the cases among HCWs, with 18 at Samara City TB Hos- hospital were ‘chronic’ infectious cases.13 Many of pital No. 1 and 13 at the OTBD. The crude TB inci- these ‘chronic’ cases probably had multidrug-resistant dence rate in HCWs at Samara City TB Hospital No. TB (MDR-TB, defined as resistance to at least iso- 1 was 1460/100 000 py at risk. During 1994–2002, niazid and rifampicin), with poor treatment outcomes. on average 137 persons were employed at TB Hospi- The second major site for cases in HCWs was the tal No. 1 at any time, including 16 physicians, 49 in-patient department of the OTBD, a tertiary referral medium-level health staff (nurses, laboratory techni- facility for TB patients from Samara Oblast, provid- cians and pharmacists), 40 junior health staff (auxil- ing consultative diagnostic services and conservative iaries) and 32 other support personnel. The hospital is and surgical treatment. During the study period the average number of staff employed at the OTBD in- patient department annually was 119. Thirteen cases Table 3 Incidence of TB among HCWs by setting in of TB were diagnosed among staff, corresponding to Samara Oblast, Russian Federation an incidence rate of 1210/100 000 py at risk. Seven of Incidence of TB per Incidence these had worked for more than 12 years at that fa- 100 000 person years rate ratio cility before being diagnosed with TB, and only three Setting (95%CI) (95%CI) had worked there for fewer than 5 years. The dispen- HCWs in GHS 68.8 (55.4–85.4) reference sary has 180 beds and on average 886 admissions per TB HCWs 741.6 (413.3–1330.8) 10.8 (6.0–19.4) year; approximately 500 surgical operations are per- By category of TB facility formed annually in the treatment of TB. Other invasive TB out-patient 317.0 (162.6–618.0) 4.6 (2.3–9.3) treatment procedures are also widely used, including TB out-patient and in-patient 823.4 (570.2–1188.9) 12.0 (7.8–17.7) bronchoscopy for direct intrabronchial infusion of TB in-patient 1216.7 (845.7–1750.5) 17.7 (11.6–27.0) anti-tuberculosis drugs.14 No TB cases among staff at

TB ϭ tuberculosis; HCWs ϭ health care workers; CI ϭ conﬁdence interval; the out-patient department were registered during the GHS ϭ general health services. study period. 46 The International Journal of Tuberculosis and Lung Disease

DISCUSSION curred through better case detection among staff in TB facilities compared to the general population. This The findings presented in this paper show that staff may result from the regular screening for TB and raised working in TB facilities in one region of the Russian levels of awareness of the risks of disease amongst Federation are at substantially increased risk of ac- medical staff. Because of the retrospective nature of quiring TB compared with their colleagues working the study, data were not available on the demographic in the GHS and the general population. It seems likely characteristics of HCWs across the different TB facil- that these high rates are a consequence of occupational ities or GHS, so we could not examine the extent to exposure, as higher rates were seen in in-patient than which differences in these characteristics may explain out-patient TB facilities; patients treated in out-patient the observed age and sex differences. Moreover, the facilities have traditionally completed several months retrospective nature of the study also meant that of treatment and are likely to be less infectious, and sputum status and drug sensitivity patterns of isolates therefore expose HCWs to less risk than in TB in- were unavailable, information on exposures to TB patient facilities.11 other than occupation was lacking, and follow-up data The rates reported here in employees in TB services on identified cases were also lacking. are higher than those reported previously from other The federal government, recognising the increased regions of the Russian Federation.15,16 risk for staff working in some areas, supports control ef- Few young professionals seek employment at the forts through regulatory guidance administered through TB services because of low salaries, occupational haz- the network of sanitary epidemiological stations and ards and limited career development opportunities, TB dispensaries.18–20 For example, under article 34 of which could explain the older mean age of cases and the General Sanitary Epidemiological Law, certain the higher proportion of female cases among workers professions are obliged to undergo screening for TB at TB facilities. Other reports have shown that certain prior to entering employment and periodically there- professional groups working within the TB services after.18 Health care workers, those working in educa- are at especially high risk including, in declining order tional institutions, and workers in the food industries, of relative risk, those working within microbiology public transport and other service branches, are obliged laboratories, specialised TB hospitals, out-patient TB to be screened for TB once a year, while those working facilities, and pathology departments.17 Staff of inter- in health and educational facilities with young children nal disease wards in large general hospitals, emer- and adolescents are screened every 6 months.19 gency health services and those working in pharma- The occupational hazards experienced by health cies seem to be at relatively low risk.17 In Samara, 31 workers and other personnel working with TB ser- cases were notified from the pathology department of vices have recently been recognised in the Federal the forensic medicine services, services outside the TB Law on TB Control, which ensures the provision of services. certain benefits including extended annual leave, re- Our research has a number of limitations. Notifi- duced working hours, additional remuneration and cation bias may have resulted from HCWs with newly early retirement.21 diagnosed TB being transferred from other health ser- It has been suggested that effective TB infection vices to the TB services. Similarly, staff who acquire control programmes need to focus on the use of ad- TB working in some disciplines, for example paediat- ministrative measures to reduce the risk of exposure rics, are prohibited from working in this discipline from those who have infectious TB, the use of engi- again and may seek employment in the TB service. neering controls to prevent the spread and reduce the These potential sources of bias would tend to increase concentration of infectious droplets, and the use of the relative rates of TB in HCWs working in TB ser- personal protective respiratory equipment.22 vices if HCWs are incorrectly categorised as working In the Russian Federation, resource limitations and a in TB services for notification purposes. However, traditional emphasis on radiological diagnosis rather we consider that these potential sources of bias are than microbiological determination means that diag- unlikely to substantially alter our findings, for four nostic approaches have probably not effectively pri- reasons. First, formal procedures mean that TB cases oritised infectious patients, and the separation of in- are registered at their original place of work rather fectious from non-infectious patients has not been than in subsequent work settings. Second, we have at- institutionalised in practice. Moreover, limited re- tempted to avoid bias by reviewing the cases with dis- sources and the maintenance of substantial hospital pensary chiefs. Third, over 90% of cases in TB facili- infrastructures have probably resulted in under-funding ties were detected by screening at those facilities. and inappropriate or inadequate engineering controls. Fourth, data from Samara OTBD showed that only Whilst the use of ultraviolet (UV) light is widespread, three of the 13 cases had been working at the Dispen- the effectiveness of old lamps and their positioning sary for fewer than 5 years before they were diag- may, anecdotally, limit the benefits gained. Effective nosed with TB. air filtration and airflow engineering in hospital set- A further potential source of bias may have oc- tings are prohibitively expensive to install and main- Tuberculosis control in health care workers 47 tain. Likewise, the cost of personal protective equip- 7 Kruuner A, Danilovitsh M, Pehme L, Laisaar T, Hoffner S E, ment is prohibitive in most Russian institutions and it Katila M L. Tuberculosis as an occupational hazard for health is only very rarely available to staff. care workers in Estonia. Int J Tuberc Lung Dis 2001; 5: 170– 176. Institutional spread of TB is a phenomenon recog- 8 Skodric V, Savic B, Jovanovic M, et al. Occupational risk of tu- nised worldwide. The recognition of the potential berculosis among health care workers at the Institute for Pul- magnitude of this problem arose in part when disease monary Diseases of Serbia. Int J Tuberc Lung Dis 2000; 4: from strains that were resistant to several first-line 827–831. anti-tuberculosis drugs was observed in patients who 9 World Health Organization. Global TB Control. Geneva, Swit- zerland: WHO, 2002. had been cared for in the same hospital or institution. 10 Ministry of Health. On the improvement of the provision of The epidemic of the human immunodeficiency virus antituberculosis services to the population of the Russian Fed- (HIV) helped bring this spread to attention because of eration. Order No. 324. Moscow, Russian Federation: Minis- the rapidity with which co-infected cases developed try of Health, 1995. TB. Russia is now witnessing an epidemic of HIV and 11 Coker R, Dimitrova B, Drobniewski F, et al. Tuberculosis control in Samara Oblast, Russia: institutional and regulatory en- has high rates of TB (and MDR-TB). The tradition of vironment. Int J Tuberc Lung Dis 2003; 10: 920–932. lengthy hospitalisation in the treatment of TB appears 12 Stata Corporation. Stata statistical software: release 7.0. Col- to put at risk HCWs working within those institutions lege Station, TX: Stata Corporation, 2001. and also, presumably, the patients residing there. Mea- 13 Annual Report of City Hospital 1. Samara City, Samara sures to reduce institutional spread have been intro- Oblast, Russia, 2000. 14 Ministry of Health. On approval of standards (model proto- duced over the past 2 years, including safer sputum cols) for management of tuberculosis. Order No. 33 from 2 collection practices and measures to separate infec- February 1998 of the Ministry of Health of the Russian Feder- tious from non-infectious patients. In addition, sub- ation, 1998. stantial investment since 2002 has improved microbi- 15 Priimak A A, Plotnikova L M. Zabolevaemost’ tuberkulezom ology laboratory capacity and quality. Institutional meditsinskikh rabotnikov i mery ikh sotsial’noi zashchity. spread of TB in Russian hospitals represents a sub- Probl Tuberk 1992; 11–12: 24–26. 16 Nechaeva O B, Shorikova L I, Vatolina V A, Mordovskoi G G, stantial public health threat and challenge, a chal- Kondrashin A G. Vliianie grupp riska na zabolevaemost’ tu- lenge that is likely to grow in magnitude with an ex- berkulezom i profilakticheskai rabota s nimi. Probl Tuberk panding HIV epidemic, and one that requires urgent 1997; 5: 17–19. attention. 17 Kosarev V. Occupational diseases of health care workers. Sa- mara, Russian Federation: Samara State Medical University, 1998. References 18 Ministry of Health. About the sanitary-epidemiological well- being of the population. Federal Law No 52 of 12 March 1999. 1 Menzies D, Fanning A, Yuan L, Fitzgerald M. Tuberculosis Moscow, Russian Federation: Ministry of Health, 1999. among health care workers. N Engl J Med 1995; 332: 92–98. 19 Ministry of Health. About conducting obligatory medical 2 Sugita M, Tsutsumi Y, Suchi M, Kasuga H, Ishiko T. Pulmonary screening for TB and regulations for permission to work in cer- tuberculosis. An occupational hazard for pathologists and pathol- tain professions for persons suffering from TB. Instruction of ogy technicians in Japan. Acta Pathol Jpn 1990; 40: 116–127. the MoH of the USSR from 27.12.73. Moscow, Russian Fed- 3 Harrington J M, Shannon H S. Mortality study of pathologists eration: Ministry of Health, 1973. and medical laboratory technicians. BMJ 1975; 4: 329–332. 20 Ministry of Health. Sanitary rules by work in tuberculosis fa- 4 Meredith S, Watson J M, Citron K M, Cockcroft A, Darbyshire cilities in the system of the Ministry of Health of USSR, 1959. J H. Are healthcare workers in England and Wales at increased Moscow, Russian Federation: Ministry of Health, 1959. risk of tuberculosis? BMJ 1996; 313: 522–525. 21 Ministry of Health. On prevention of the spread of tuberculo- 5 Cuhadaroglu C, Erelel M, Tabak L, Kilicaslan Z. Increased risk of sis. Federal Law N 77-FZ of 18.06.2001. Moscow, Russian tuberculosis in health care workers: a retrospective survey at a Federation: Ministry of Health, 2001. teaching hospital in Istanbul, Turkey. BMC Infect Dis 2002; 2: 14. 22 Centers for Disease Control and Prevention. Guidelines for 6 Kilinc O, Ucan E S, Cakan M D, et al. Risk of tuberculosis preventing the transmission of Mycobacterium tuberculosis in among healthcare workers: can tuberculosis be considered as health-care facilities, 1994. MMWR 1994; 43(RR-13). an occupational disease? Respir Med 2002; 96: 506–510.

RÉSUMÉ

CONTEXTE : Oblast de Samara, Russie. RÉSULTATS : Pendant la période 1994–2002, l’incidence OBJECTIF : Comparer les taux de tuberculose (TB) chez de la TB parmi le personnel employé dans les services de les travailleurs de soins de santé (HCW) travaillant dans TB dans l’Oblast de Samara est 10 fois supérieure à l’in- les services TB, dans les services généraux de santé cidence de la TB dans la population générale et atteint (GHS) et dans la population générale dans une région de 741,6/100.000 personnes/année de risque. Le personnel la Fédération de Russie. travaillant dans les services d’hospitalisation TB a le ris- SCHÉMA: Analyse des taux de déclaration de TB parmi que le plus élevé, avec un ratio d’incidence de 17,7 (in- les HCW, les travailleurs GHS et la population générale tervalle de conﬁance à 95% 11,6–27,1) par comparai- au cours d’une période de 9 ans entre 1994 et 2002. son avec les HCW du GHS. 48 The International Journal of Tuberculosis and Lung Disease

CONCLUSIONS : Les HCW dans les services TB de la Fédération de Russie constitue un secteur exigeant une Fédération de Russie encourent un risque substantielle- attention urgente, particulièrement vu l’épidémie du ment accru de TB, ce qui suggère des risques signiﬁca- virus de l’immunodéﬁcience humaine (VIH) que connaît tifs provenant de la transmission nosocomiale. La lutte la Russie. contre la dispersion institutionnelle de la TB dans la

RESUMEN

MARCO DE REFERENCIA : Samara Oblast, Federación de por 100.000 personas-año. El personal de los estable- Rusia. cimientos hospitalarios para TB presentó el riesgo más OBJETIVO : Comparar las tasas de tuberculosis en los alto con respecto a la de los trabajadores de los servicios trabajadores de atención en salud de los servicios de TB, de medicina general, con una razón de tasas de inciden- en los servicios de medicina general y en la población cia de 17,7 (intervalo de conﬁanza 95% 11,6–27,0). general en una región de la Federación de Rusia. CONCLUSIONES : Los trabajadores de atención en salud METODO : Análisis de las tasas de declaración de TB en- en los servicios de TB de la Federación de Rusia presen- tre los trabajadores de la salud, los empleados de los ser- tan un riesgo considerablemente aumentado de TB, lo vicios de medicina general y la población general du- cual indica un gran riesgo de transmisión nosocomial. rante un periodo de 9 años entre 1994 y 2002. La lucha contra la diseminación institucional de la tu- RESULTADOS : Entre 1994 y 2002 la incidencia de TB berculosis en la Federación de Rusia es un asunto que re- entre el personal empleado en los servicios de TB de Sa- quiere atención urgente, y aún más teniendo en cuenta la mara Oblast fue 10 veces más alta que la incidencia de epidemia de infección por el virus de la inmunodeﬁcien- TB en la población general y alcanzó un riesgo de 741,6 cia humana (VIH) que se presencia en este país.