TB prevention and treatment in Ukraine: Keeping momentum through conflict

March 24, 2023 by Gunta Dravniece, Valentyna Polunya, and Jessica Farley

PATH implements innovative tuberculosis (TB) prevention, diagnosis, and care while responding to the pressing needs of humanitarian response.

Biosamples are transported by a mobile unit to ensure timely diagnostics. Photo credit: Galyna Gorenko.

Biosamples are transported by a mobile unit to ensure timely diagnostics. Photo credit: Galyna Gorenko.

PATH’s USAID-funded Support TB Control Efforts in Ukraine (STBCEU) project began in 2019, with the goal of reducing the tuberculosis (TB) epidemic in Ukraine through prevention, early detection, and appropriate care for people living with TB, drug-resistant TB, and TB/HIV. The project works across the TB continuum, including building capacity for health care workers; improving early TB detection, diagnosis, treatment, and management; and supporting civil society, TB advocacy, and stigma reduction efforts. Throughout its work, STBCEU aims to strengthen the delivery of TB care at the primary health care (PHC) level to make it possible for those affected by TB to receive person-centered care wherever they live.

The project’s numerous achievements to date were seriously threatened by Russia’s military invasion of Ukraine in February 2022, which affected all areas of life in Ukraine, including its health system, and endangered and displaced millions of Ukrainians. Many STBCEU project regions were at the center of military conflicts, though patients in all regions of Ukraine were impacted. People affected by TB were forced to urgently seek care in new facilities or regions, interrupting their existing treatment plans, and increasing the likelihood of TB spreading and higher rates of infection.

Humanitarian response and project expansion to meet needs

At the beginning of the war, STBCEU quickly added emergency response to its TB activities in all 12 regions where the project was active. The project streamlined its efforts to address the emerging needs and urgent requests of TB patients and partners in war-affected areas, including evacuation to safer regions. STBCEU procured food supplies for inpatient medical wards, as well as furniture, warm clothes, mattresses and warm blankets, and heaters for medical ward bomb shelters. The team also organized transportation of drugs and biosamples, restoration of lost medical records, accommodation and reemployment of displaced TB specialists, and clinical backstopping to patients who had lost access to specialized TB services.

“Project support is geared toward addressing the new challenges of TB control in Ukraine resulting from the many negative impacts of Russia's large-scale war against Ukraine… such as limited access to diagnostic and treatment services for TB patients, increased risk of TB infection and progression to active TB, new risk groups (IDPs [internally displaced persons], migrants, etc.), need for re-profiling hospitals and specialists, staff shortages, [and] logistics problems with drugs and commodities,” said Gunta Dravniece, MD, STBCEU Project Director.

Beyond contributing to humanitarian response and ensuring treatment continuity for TB patients, these interventions allowed STBCEU to maintain collaboration with project partners in all project sites except in occupied territories, sustain the pace of interventions, and continue to lay the groundwork for further project scale-up.

Due to the demand for increased technical and practical assistance on health system recovery, STBCEU, in consultation with USAID, the Ukrainian Ministry of Health, and the National TB Program, decided to expand the project’s geographic scope from the original 12 oblasts to the entire territory of Ukraine. The first wave of expansion reached five additional regions by the end of 2022.

Expansion to additional regions of Ukraine was vital, and it is now enabling the project to implement TB care in regions with influxes of internally displaced persons (IDPs) while continuing its ongoing work and response efforts in areas that have experienced considerable infrastructure damage and health care worker migration. Throughout Ukraine, STBCEU continues to respond to the high risk of growing TB incidence as a result of war and disruptions across the TB care continuum.

Expanding services to provide person-centered TB care in Ukraine

STBCEU introduced several innovations in TB diagnosis and treatment and launched initiatives to improve care and support for people living with TB and increase public TB awareness. Building upon earlier investments in the TB laboratory network, PHC capacity-building, new TB treatment regimens piloting, nongovernmental organization mobilization for TB care and support, confronting TB stigma and discrimination, and others, STBCEU progressed advancements including molecular-genetic stool testing for TB detection in children, community-based active TB case finding through mobile x-ray screening, updated regimens for preventive treatment, adoption of a framework policy on stigma-free health care facilities, and development of tools for age-appropriate TB education in school and preschool settings.

While adapting to the war and resulting humanitarian emergency, STBCEU has concurrently kept the pace and sustained project work throughout the last year, introducing, expanding, and scaling TB interventions to build health system resiliency for screening, diagnosis, treatment, and prevention throughout Ukraine and strengthening PHC systems that deliver TB care.

Examples include the following:

Mobile x-ray capabilities and remote image reviews. X-ray technology is a key component of TB screening and diagnosis, but getting to a health facility with an x-ray machine poses a barrier to many people in Ukraine, especially in rural and conflict-affected areas and for IDPs.

STBCEU has brought x-ray access to the PHC and community levels through portable digital x-ray units, mobile x-ray examinations, and off-site x-ray image review. STBCEU procured four portable digital x-ray units, weighing 3.5 kilograms each, making them easy to use in any building or outside and functional for examinations in small areas such as patient wards or in remote locations far from a health care facility.

The project has also supported health care teams to travel to remote areas to provide comprehensive TB examinations and screenings using mobile x-ray and transport TB specimens and drugs. Finally, STBCEU has introduced a radiological information system to enhance the efficiency of x-ray examination.

Using this system, radiologists can review x-ray images remotely from more than one machine, enabling rapid TB detection and referrals.

An x-ray laboratory technician is trained on the use of a portable digital x-ray unit. Photo: Valentyna Polunya/PATH.

An x-ray laboratory technician is trained on the use of a portable digital x-ray unit. Photo: Valentyna Polunya/PATH.

Early identification of latent TB infection. People who have been exposed to someone with TB can develop active infection or latent TB infection (LTBI), which can be treated through TB preventive therapy before it becomes active TB. Early identification of LTBI is especially important in Ukraine, which ranks eighth among countries with a high multidrug-resistant TB burden, which requires longer and more difficult treatment.

To boost the diagnosis and treatment of LTBI, especially among children who have been in contact with a person with TB, STBCEU established partnerships with two private laboratories to test for LTBI using a powerful new test called QuantiFERON-TB Gold.

Between September 2021 and September 2022, 2,927 tests were performed, with 624 positive results, a 21 percent testing yield. The introduction of this test provides an important tool for TB/multidrug-resistant TB prevention.

Stool testing for TB in children. Another innovative, child-friendly TB diagnostic method that STBCEU introduced in Ukraine is stool testing for pediatric patients as an alternative biological specimen to test for TB. For children, who often cannot produce a sputum sample for testing without a painful additional procedure, stool testing is a painless alternative method to test and diagnose TB. STBCEU worked with Ukraine’s National Reference Laboratory to develop methodological recommendations and protocols, and led trainings and ongoing mentorship for clinical and laboratory staff who perform the test. As a result of STBCEU efforts, in August 2022, the stool testing method was recommended by the National TB Program for use throughout the country.

A Regional TB Dispensary laboratory specialist conducts stool testing to diagnose a pediatric TB patient during the war. Photo credit: Olesia Shuk.

A Regional TB Dispensary laboratory specialist conducts stool testing to diagnose a pediatric TB patient during the war. Photo credit: Olesia Shuk.

Digital adherence technologies. STBCEU introduced and supports digital adherence technologies (DATs)—like smart pill boxes and video-observed therapy on smartphones—that remind people to take medication and allow health care providers to monitor adherence and follow up when necessary. DATs were introduced before the war began, and they have become even more essential during wartime when travel is unsafe—significantly reducing the number of trips patients need to make to health facilities and enabling providers to monitor treatment from any secure point where internet is available, such as their homes or bomb shelters.

“It’s great to have a ‘magic’ box to adhere to treatment; after all, it always signals on time and reminds me to take medication,” said Valentyn, a patient who has been using a smart pill box for his treatment. Since April 2022, 604 TB patients have used DATs during their treatments, with an average adherence rate of 88.7 percent.

Improving TB care in Ukraine and globally

For PATH and our partners in Ukraine, adapting and strengthening TB service delivery that fits within local systems and contexts has been central to STBCEU’s ability to expand diagnostic and treatment options for TB.

Dr. Dravniece reflects: “Despite all the challenges and emerging needs, [STBCEU] continues to bring innovations to the country. I am proud of our team, who not just managed to continue support, but even scaled it up, covering additional regions and bringing even more innovations.”

Expanding services that bring exemplary TB prevention, screening, diagnostics, and treatment to all people who need it, through strengthening high-quality, person-centered PHC, is a key approach to ending TB by 2030.