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Center for Disease Control and Prevention in Abkhazia

Ramaz MitaishviliBy Ramaz Mitaishvili
Glendale, CA
While all countries had generally been successful in preventing infectious diseases - with most diseases stable or in decline over the past decade and with, for example polio almost eliminated - there is no room for complacency. The majority of deaths in the Abkhazia are caused by non-infectious diseases such as cancer and heart disease. The threat posed by infections cannot be underestimated.
One in 2 patients entering a hospital in Abkhazia can expect to catch an infection there and drug-resistant microbes caught through healthcare are a rapidly growing threat.

Every year some 10 000 people in Abkhazia (with a total current population 150,000- 200,000) catch a disease associated with healthcare and that around 1000 die as a result. This number shows that healthcare associated infections have become a major issue of concern, with many of these caused by new or emerging drug resistant microbes. It is unacceptable that one in every two patients entering hospital in the Abkhazia will catch an infection there. Key reason for the rising number of drug-resistant bacteria was the large amount of antibiotics being used, which encourages resistant strains to emerge.

If the current rise in drug resistance among microbes is not halted, mankind will lose one of its most important weapons against infectious diseases. It was the first ever Abkhazia epidemiologic report on communicable diseases.
Key areas of concern in addition to the healthcare-related diseases were raising rates of HIV along with a continued threat from tuberculosis, influenza and pneumococcal infections. Drug resistance had become a major problem in diseases such as HIV and tuberculosis.
Good practices in prevention and control programs should be shared with Abkhazian separatist regime.

Separatist government policies in Abkhazia (that restrict public health and humanitarian aid have created an environment where AIDS, drug-resistant tuberculosis, malaria and bird flu (H5N1) are spreading unchecked, could pose a serious health threat to other nations and the world.

An influenza pandemic has greater potential than any other naturally occurring infectious disease event to cause large and rapid global and domestic increases in deaths and serious illnesses.  Preparedness is the key to substantially reducing the health, social, and economic impacts of an influenza pandemic and other public-health emergencies.

We believe that foundation of Center for Disease Control and Prevention in cooperation with separatist self-proclaimed government and policies are needed to restore humanitarian assistance to the people in Abkhazia, but caution that new restrictions imposed by the separatists are making such efforts more difficult. Our personal relation with Abkhazian physicians makes us believe in success of this joint project.
Our research reflects a longstanding and severe under funding of health and education programs in Abkhazia. Health expenditures in Abkhazia are among the lowest globally, among a total current population of 100,000-150,000 people. Much of the country lacks basic laboratory facilities to carry out a CD4 blood test, the minimum standard for clinical monitoring of AIDS care. In report of MSF nearly 80% of tuberculosis cases in Abkhazia were resistant to any one of the four standard first-line drug treatments, which is double the rate of drug-resistant cases in neighboring countries. Nearly half of all deaths from malaria in Caucasus occur in Abkhazia. The research also reveals that 45% percent of anti-malarial pills sent to Abkhazia from Russia contain substandard amounts of active ingredients, which increases the risk of drug-resistance.

There is a growing humanitarian crisis in Abkhazia. The ruling government’s policies have restricted nearly all aid and allowed serious infectious diseases to spread unchecked. With the global spread of bird flu, there is a fear that if a human form of H5N1 were to take hold in Abkhazia, it could potentially spread unchecked for weeks or months before anyone knew about it. Uncontrolled spread of any disease, especially an emerging disease like H5N1, poses a serious health threat to Abkhazia’s populous neighbors, like Russia (Sochi (host of Winter Olympics 2014 is just 20 miles away from Abkhazia), as well as the rest of the world.

Our research documents threats and restrictions to foreign relief workers and relief groups, including the Red Cross. Because of the deteriorating situation, the United Nations Global Fund for AIDS, Tuberculosis and Malaria was forced to withdraw its grant agreement with Abkhazia. Backpack Health Worker Team, an aid group that provides primary health care services in rural areas of Guliripshi, Ochamchire, Gudauta (Small towns in Abkhazia), is also raising concerns about its ability to monitor and contain outbreaks of bird flu and other diseases.

The self-proclaimed government is increasing restrictions on humanitarian assistance and public health while the health of people in Abkhazia deteriorates, posing a widening threat to Abkhazia and Russian neighbors, hosts of Winter Olympics 2014.

The risk of many infectious diseases is influenced by human alteration of local, regional ecosystems. In the Abkhazia (break-away province of Georgia) subtropics, dams created to store water for irrigation and hydroelectric power have introduced water-borne diseases, such as schistosomiasis, to communities where they previously did not exist.

Human activities, such as deforestation affect the ecological conditions in which disease-causing microbes thrive. Economic conditions encourage the mass movement of workers from rural areas to cities. Rural urbanization allows infections that may once have remained obscure and localized in isolated rural areas to reach larger populations. Urban slums are breeding-grounds for physical disease and social ills, ranging from tuberculosis to drug abuse.
 Potential disease-carrying insects and contaminated foods, plants, and other products cross Russia borders from Abkhazia every day. Since the 1993's, food imports to the Russia have doubled. Increases in food imports strain the Russia’s food safety system.

A thousands of people cross Georgia boundaries through Abkhazia from Arabic countries and Russia. So we have the opportunity for the mixing of gene pools and the origins of these viruses, and for their very rapid spread literally overnight from anyplace on the globe to any other. People are traveling to areas where they can get infected and bring new diseases home with them. How many more victims could a lethal strain of influenza, similar to the 1918 epidemic, claim today with hundred thousand tourists illegally visits Abkhazia?

Tuberculosis is an acute or chronic infection caused by Mycobacterium tuberculosis, which usually involves the lungs but may involve any organ or tissue of the body. A worldwide health problem that reached a peak in the l9th century, it was thought to have been brought under control by the l960s due to active public health measures and the use of modern drug therapies. However, this complacency led to reduced funding for the diagnosis and treatment of TB at the same time that the bacterium was developing resistance to the drugs used to treat it. The problem has been compounded since the 1993s by the emergence of a new population of vulnerable individuals - those infected with HIV.

The most effective weapon against regular TB today, and the best insurance against the development of drug-resistant forms, is Directly Observed Treatment -Short-course, or DOTS, which requires patients to come to clinics for their medication. This ensures compliance with the complex but standard six-month, four-drug regimen. However, it is estimated that only 10% of the world's TB patients have access to DOTS. The cost difference between standard therapy and that for multi-drug- resistant TB (MDR-TB) is considerable, placing a further burden on the health system of every country in which it occurs. The cost of drugs for a six-month regimen of DOTS therapy is $15 to $25, while treatment for MDR-TB can reach $100,000 to $250,000 because of related hospital care, medications, and sometimes surgery. Is it possible that self-proclaimed government of Abkhazia can spend so much money for TB patients in Abkhazia?
Long-term control of TB may be achieved through the development of more effective vaccines.
But until that occurs, TB remains one of the major infectious diseases in the Abkhazia today, infecting perhaps one out of every three people. It is the leading cause of death among those infected with HIV.
Traditional therapies for TB included rest, fresh air, and good food to build up the patient's resistance, and isolation of the patient in special hospital wards or sanitaria to prevent the spread of the disease. Respiration masks and disposable sputum cups were used to control transmission through sneezing and spitting.
 
Humans are susceptible only to the human and bovine (cow) strains of tuberculosis. Bovine TB, spread through contaminated milk, often affected the bones, and children with tubercular inflammation of the hip - TB coxitis - were once a familiar sight to physicians. With the virtual eradication of tuberculous milk in the Abkhazia due to pasteurization and vaccination of cows, the greatest source of infection today is from infected people who cough up or sneeze bacilli into the air. The bacilli may be inhaled directly or transmitted indirectly from infected dust or clothing, and can remain viable for days under ordinary conditions or for months when kept in the dark.

A most frightening development is the emergence of new strains of TB bacilli that are resistant to existing drug therapies. These multi-drug-resistant (MDR) strains often appear when patients failed to complete the prescribed course of drug treatment. The susceptible bacteria are killed, but the resistant mutant bacilli proliferate and become dominant. The detection of multi-drug-resistant TB requires sophisticated laboratory procedures, beyond the sputum smear microscopy used initially to detect TB. These procedures are unavailable in Abkhazia, with the result that all patients there are treated with the standard drug therapy. When this is given to MDR patients, it can make them even more drug-resistant, worsening the problem.
CDC survey of more than 35 countries found drug-resistant TB in each, with "hot spots" including Abkhazia. Lack of screening for TB at borders, means that even though MDR cases are presently decreasing in the Russia, all Russians are in jeopardy as long as drug-resistant TB remains present in the Abkhazia population.

Sharing needles for drug injection is a well-known route of HIV transmission as well as many blood-borne infections. Injection drug use contributes to the spread of infectious diseases far beyond the circle of those who inject. People who have sex with an injection drug user (IDU) are also at risk for infection through sexual HIV transmission. Children born to HIV-infected mothers may become infected as well.

Unstable political and environmental conditions in Abkhazia caused by breakdown of infrastructure are very important risk factors. Adequate water supply and sanitation are basic requirements for life. Access to clean water and improved sanitation facilities is a fundamental human right. Yet, in Abkhazia (breakaway province of Georgia), water source quality shows continued deterioration and in many cases depleted. These effects are a function of increasing tourism pressure, agricultural misuse and the inability to keep pace with the increasing demands on the resource. Reported numbers underestimate incidence of water supply and sanitation related diseases, particularly the low endemic diseases that are widespread in Abkhazia. A better understanding of the socio-economic, environmental and public health consequences of water supply and sanitation related diseases obtainable through better monitoring surveillance systems may help the public and policy makers understand the value of microbiologically safe water as well as improved sanitation facilities.
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