Global Audiology/Europe/Russia

The Russian Federation is the largest country in the world by area, covering more than one-eighth of the Earth’s inhabited land area (17,125,200 km2 or 6,612,100 sq miles), and the ninth most populous, with over 146 million people. The western European part of the country is much more populated and urbanized than the eastern part; about 77% of the population lives in European Russia.

Russia is a transcontinental country that extends across the entirety of Northern Asia (the eastern part) and much of Eastern Europe (the western part). Russia spans eleven time zones and incorporates a wide range of environments and landforms. From the northwest to the southeast, Russia shares land borders with Norway, Finland, Estonia, Latvia, Lithuania, and Poland (both in Kaliningrad Oblast), Belarus, Ukraine, Georgia, Azerbaijan, Kazakhstan, China, Mongolia, and North Korea. It shares maritime borders with Japan by the Sea of Okhotsk and with the U.S. state of Alaska across the Bering Strait. According to the Constitution, the country comprises 85 federal subjects. Federal subjects are grouped into eight federal districts.

The Russian Federation is a nation of many diverse cultures, languages, and religions. Russian is considered to be the primary language, but many other languages from around the world are actively spoken throughout the nation. Christianity is the most commonly practiced religion in the Russian Federation; however, Islam, Judaism, Buddhism, and other faiths are also represented (Russian Federation, 2020).

The prevalence of congenital and prelingual hearing loss among newborns and first-year-of-life babies is about 2.5-3.0 per 1000 live births (Tavartkiladze et al., 2016; Chibisova et al., 2018). The early identification of congenital hearing loss has dramatically improved with the implementation of the program of universal newborn hearing screening at a national level.

According to statistical data from the Ministry of Health of the Russian Federation, the prevalence of hearing loss >25 dB (average PTA thresholds 0, 5, 1, 2, 4 kHz) is about 4 per 1,000 in children 0-18 years old, 6.5 per 1,000 in the adult population, and 14 per 1,000 in people aged 60 years and older. It is estimated that 75% is bilateral sensorineural hearing loss (Prevalence, 2020)

According to the Global Burden of Disease 2017 study, the prevalence of socially significant hearing loss (i.e., >35 dB in the better hearing ear with average PTA thresholds of 0, 5, 1, 2, 4 kHz) in the Russian Federation is about 5.7 per 1,000 (Global Burden of Disease, 2020).

History
The system of audiological services was set up in the Soviet Union in 1952 with the issue of a legislative act by the Ministry of Public Health Care. At that time, audiological units were organized within the municipal and regional hospitals.

Up until 1979, the audiological and hearing aid fitting services were separate and supervised correspondingly by the Ministry of Public Health Care and the Ministry of Social Defense. It made providing proper assistance to patients with hearing problems difficult. In 1979, according to the legislative act of the Ministry of Public Health Care, both services were unified. This fact promoted the development of a well-functioning audiological system in the country.

In November of 1988, the All-Union Research Center for Audiology and Hearing Rehabilitation was founded according to the decision of the Soviet government. It was appointed the top national institution responsible for the fundamental and applied research in audiology as well as the supervision of the activities of all regional audiological centers. After the well-known geopolitical changes in 1991, the words “All-Union” were changed to “National” (History, 2020).

One of the most efficient approaches to solving the problem of early detection of hearing loss is the development and wide introduction of audiological screening programs on the national level. This system, considering all the peculiarities of the country's health care conditions, has been developed in Russia and is now being implemented all over the country. In March 1996, the Russian Ministry of Health issued regulations on the hearing screening of newborns and one-year-old children. It aimed for TEOAE registration of babies both high-risk and had not passed behavioral testing, with confirmation of referrals through ABR registration. This document had the status of legislative act and determined all steps and time of screening stages and follow-up.

In 2008, the universal newborn hearing screening program based on TEOAE registration was implemented nationally. The coverage of newborns has achieved 97% by the year of 2015. About 5,000 newborns and first-year-of-life babies with hearing loss are identified yearly (Tavartkiladze et al, 2016).

Education
Traditionally, otorhinolaryngologists were responsible for hearing evaluations in Russia. Since 1996, audiology has been included in the list of medical specialties in Russia.

Primary audiological training for specialists in general medicine lasts 2 years, and professional retraining for ENT specialists lasts 4 months. There is a requirement for continuous training of certified audiology specialists, which includes 1-month courses with accreditation every 5 years, 3-to14-day thematic courses, 1-2-hour distant educational modules, and participation in audiological conferences. Hearing aid dispensers currently do not need any special education.

The Audiology Department of Russian Medical Academy of Continuous Professional Training offers all forms of audiology education. There are a total of 9 educational facilities in Russia which perform 4-months of professional retraining:


 * Kuban State Medical University
 * Omsk State Medical University
 * North-Western State Medical University
 * Novokuznetsk State Institute of Postgraduate Medical Training
 * Penza State Medical University
 * Pirogov Russian National Research Medical University
 * Russian Medical Academy of Continuous Professional Training
 * Stavropol State Medical University
 * Ural State Medical University

The Audiology Department of Russian Medical Academy of Continuous Professional Training also offers courses on audiometry for nurses and professional training for educational specialists in audiology.

Audiology Practice: Public and Private
In Russia, the state guarantees audiological services through its program of free medical care for all citizens. These services include neonatal hearing screenings, audiological diagnostics, and medical treatment of hearing disorders. These services are paid for by the mandatory medical insurance.

Currently, there are 267 state regional specialized audiological centers: 84 serve only adults, 108 only serve children, and 75 serve both adults and children. Audiological centers could be included in otorhinolaryngological departments or could be separate departments of regional inpatient or outpatient hospitals.

The number of private audiological facilities is estimated at 400. They are mainly managed by chain clinics. The audiological services could be paid for by patients themselves or by voluntary medical insurance programs. Recently, the model of private-state partnership has been established, meaning private audiological services could be paid for from local mandatory medical insurance funds.

Hearing aids are distributed in Russia through state and private audiological units and centers as well as by individual representatives of various foreign hearing aid manufacturers. Once every 4 years, the cost of hearing aids from Russian manufacturers is covered from the fund of social insurance for disabled children under 18 and adults with bilateral severe or profound hearing loss. The costs of more expensive hearing aids could be partly reimbursed. The annual demand for hearing aids is 500,000 units. People with hearing loss could also be provided with individual earmolds, other hearing-assistive devices such as, mobile phones, TVs with capture technology, and services of a sign-language interpreter by the fund of social insurance if these needs are fixed in the individual program of rehabilitation or habilitation.

Qualifying with a hearing disability is very complicated. For this reason, many individuals with hearing impairments purchase hearing aids from their own funds. Some charities help people in need to obtain hearing aids.

The cochlear implant program was established in the Soviet Union in 1991, and the National Research Centre for Audiology and Hearing Rehabilitation was the first institution where all pre-operative testing, surgery, and postoperative rehabilitation were carried out. Currently about 1,000 cochlear implants per year are performed in four federal centers and financed from the federal budget. Since 2016, the speech processor upgrade program is financed by the mandatory medical insurance (once every 5 years).

Professionals
There is exact data on specialists employed in the public health sector (Resources, 2020); the ratios are estimates calculated based on the population of 146,745,098 (Russian Federation, 2020). Non-medical specialists like physicists, physiologists, specialists in acoustics, microelectronics, etc. are involved in audiological research and services. It is suggested that there are about 500 speech-language pathologists throughout the country. The number of audiologists employed in the private sector could be estimated at 700.

Audiological Services
Audiological services include:


 * Prevention of deafness and hearing loss (provided widely by immunization programs; yearly observation of employees with high risk of hearing loss due to occupational noise; recreational noise awareness activities);
 * Audiological ascertainment of newborn hearing screening referrals (available in regional audiological centers though not timely due to the lack of public specialists; also performed in private sector);
 * Diagnostics of hearing impairment (pure tone audiometry, acoustic impedance measurement available widely; registration of OAE, ABR and other classes of acoustic evoked responses are provided mainly in regional audiological centers);
 * Medical treatment of hearing impairments excluding ear surgery;
 * Tinnitus management;
 * Hearing aid fitting (widely for urban population);
 * Intraoperative monitoring of cochlear implant (only in clinics performing cochlear implantation)
 * Fitting of speech processors of cochlear implants and implantable middle ear hearing devices (available mainly in federal centers performing cochlear implantation or by some special trained audiologists in remote regions).

Services Offered by Otolaryngologists, Otologists and Otoneurologists
Otorhinolaryngologists are responsible for the primary diagnosis and treatment of acute or chronic ear diseases, congenital ear malformations, injuries, and balance impairments. It is the responsibility of the otorhinolaryngologist to refer patients with hearing impairments to an audiologist. Patients with sudden sensorineural hearing loss are hospitalized for medical treatment in otorhinolaryngological departments.

Otologists, or micro-ear surgeons are otorhinolaryngologists experienced in any type of ear surgery. Several specialists in Russia are trained to perform cochlear implantation and middle ear hearing devices implantation.

Otoneurologists are responsible for assessment of vestibular system and management of patients with peripheral vestibular disorders.

Neurosurgeons are invited to perform brainstem implantation, brain interventions in case of brain and intracranial nerves tumors affecting hearing and vestibular functions.

General practitioners, physicians and pediatricians could provide otoscopy and primary management of acute otitis media.

Professional and Regulatory Bodies
In 2001, the Russian Society of Audiology was officially registered by the Ministry of Justice of Russian Federation as a juridical body. The Russian Society of Audiology was established to promote cooperation among all specialists involved in the fields of audiology, hearing and speech rehabilitation, and the development of diagnostic equipment, hearing aids, and assistive devices.

In 2017, the authority was transferred to the National Medical Association of Audiologists. The regulatory bodies for audiological service are the Ministry of Health for Russian Federation and regional public health departments.

Scope of Practice and Licensing
The public medical facilities, as well as private clinics and individual professionals, should obtain a medical activity license in audiology from the federal health surveillance service to perform diagnostics, treatment, and hearing aid and speech processor fittings. Audiology standard on staff educational level and equipment has to be met. The dispensing of hearing aids does not require a special license.

Currently, audiology research in Russia is conducted in different fields. Fundamental studies are dedicated to the primary auditory perception, the micromechanics of the organ of Corti, mechanisms of coding and processing of speech information in the auditory system, and objective electrophysiology methods including cortical auditory evoked responses.

Special interest is paid to auditory neuropathy spectrum disorders and central auditory processing disorders. Long-lasting research has been held on the genetic and clinical heterogeneity of hereditary hearing loss as well as noise-induced hearing loss, ototoxicity, and epidemiological issues. After implementation of the newborn hearing screening program, the need for pre-school and adult hearing screening has been realized.

The results of Russian audiological research are published in peer-reviewed international scientific journals and presented at scientific conferences and meetings annually.

The largest and oldest public organization for the deaf and hard-of-hearing in Russia is the Russian Deaf Society, which was founded in 1926 and has over ninety thousand members. Recently, several charities were founded to assist families and individuals with hearing loss. Some of them are:


 * The Melody of Life Foundation
 * The Internet community - DeafWorld

=== Challenges ===
 * No national audiological committee to coordinate ear and hearing care;
 * Speech-language pathology therapists are not included in the public health service delivery;
 * The outcomes of hearing rehabilitation are not specified and standardized.


 * Chibisova, S.S., Markova, T.G., Alekseeva, N.N., Yasinskaya, A.A., Tsygankova, E.R., Bliznetz, E.A., Polyakov, A.V., & Tavartkiladze G.A. (2018). [Epidemiology of hearing loss in children of the first year of life]. Vestnik Otorinolaringologii, 83(4), 37-42.
 * Global Burden of Disease 2017 study. (2020).
 * History of the National Center for Audiology and Hearing Rehabilitation. (2020).
 * Prevalence of disorders in Russian population. (2020). Ministry of Health of the Russian Federation.