A. Hayrapetyan1, N. Mezhlumyan1, H. Davtyan1, M. Sevoyan2
1 National Tuberculosis Control Office, Ministry of Health, Republic of Armenia
2 Health Project Implementation Unit, State Agency, Ministry of Health, Republic of Armenia
Citation: Hayrapetyan A, Mezhlumyan N, Davtyan H, Sevoyan M. Tuberculosis Trends in Armenia. EpiNorth 2012;13:13-17.
Tuberculosis (TB) re-emerged after independence in 1991 and disease burden is currently high in Armenia. Some improvements have been observed since 2005, such as TB incidence and mortality are stabilizing and the number of patients with interrupted treatment is decreasing. The National Tuberculosis Control Programme is strengthening essential elements of the DOTS (directly observed treatment short course) strategy to prevent drug resistant TB, scaling up capacity for the management of drug resistance, increasing the TB case detection rate, providing comprehensive social and psychological support to patients, providing diagnostic and “through care” services to seasonal migrants, increasing the capacity for providing home treatment for eligible cases and involving the primary health care system.
Tuberculosis (TB) is a serious public health problem in Armenia. Following the collapse of the Soviet Union in 1991 conditions enabling the re-emergence of TB with an increase in morbidity and mortality have prevailed. Increasing poverty, unemployment, migration, limited resources available for the health care system, inappropriate TB control services, inadequate disease management practices, the development of multidrug resistant TB (MDR-TB), a low TB detection rate among risk groups and low level of public awareness have all fueled the TB epidemic in Armenia. HIV/AIDS has further increased TB morbidity and mortality. Of the 242 deaths registered among HIV/AIDS patients in 1990-2011, 109 were co-infected with TB.
TB control activities are conducted within the framework of the National TB Control Programme (1). The goal of the National TB Control Programme in 2007-2015 is to reduce TB morbidity and mortality, and to curb the development of MDR-TB in Armenia. The DOTS strategy has been implemented to control TB in Armenia (1, 2).
TB diagnostic and treatment services are provided by a network of 85 specialized facilities, including a) eight in-patient TB departments within general hospitals (one in the hospital of detainees), b) two specialized hospitals, including the Republican TB Dispensary with a 75-bed specialized department for MDR-TB patients, c) 73 TB cabinets in out-patient clinics and d) one TB sanatorium for children under 17 years of age. Primary health care providers are increasingly involved in TB control. Twice a year TB screening using mobile digital fluorography is provided in the penitentiary system and military service.
According to the national immunization schedule, infants receive BCG vaccine within first 48 hours after birth. It is recommended that infants who are not BCG-vaccinated within 48 hours receive the vaccine by 1 year of age. Children more than 2 months old are tested with TST (tuberculin skin test). The objectives of this paper are to describe trends of TB morbidity and mortality over the time in Armenia.
Epidemiological surveillance data for TB were obtained from the National Tuberculosis Control Programme register. The surveillance system registers all confirmed laboratory and clinical cases. The generally acknowledged TB treatment case definitions (new case, relapse, treatment failure and return after default) were used. TB diagnosis was based on the results of direct sputum microscopy supported by chest X-ray. The network of TB laboratories consists of 34 first level microscopy laboratories and the national reference laboratory, which performs microscopy, culture and drug susceptibility testing in addition to laboratory quality assurance. Laboratories report findings of acid fast bacilli, positive cultures and drug susceptibility. Clinicians report confirmed and suspected cases of TB and individual treatment outcome.
The number and incidence rate of new TB cases have been increasing sin¬ce 1990 (p< 0.001) and peaked in 2005. A slow decrease has been observed after 2005. In 2010 the incidence of new TB cases was 41.3 per 100,000 population, a 9.2% reduction (p< 0.05) compared to the incidence in 2009 (Figure 1).
Of all registered TB cases 75% were new cases and 25% re-treatment cases. In 2010, 1329 new TB cases were notified of which 339 were new sputum smear-positive TB cases. The proportion of new sputum smear-positive cases among new pulmonary cases was 35%. The incidence of sputum smear-positive pulmonary TB cases in 2010 was 10.4 per 100,000 population. Nearly all (97%) of the sputum smear-positive cases were hospitalized during the intensive phase of treatment.
Among notified new cases 6% were children (0-17 years of age) and 33.3% of the children were diagnosed with pulmonary TB. In 2010 the incidence of new TB cases among children was 10.7 per 100,000 population compared to 12.2 per 100,000 in 2009.
The majority (66.7%) of all notified new cases were from urban populations (incidence 43.4 per 100,000 urban population) while 33.3% were from rural population (incidence 37.5 per 100,000 rural population). The notification rate among men was approximately 2.5 times higher (58.7 per 100,000) than among women (23.7 per 100,000). Seventy four percent of new TB cases were among the age group 15-54 years. Imported cases accounted for 9% of notified new cases.
The diagnosed TB cases had a total of 3432 close contact family members. In 2010, 2977 family contacts were examined for TB and 61 new cases were diagnosed. Twenty four were less than 18 years of age.
Primary health care providers are responsible for detecting TB suspects. A total of 3990 suspected cases were referred to TB services and 656 (16.4% of the referred cases) new TB cases were diagnosed in 2010.
All detainees are screened twice a year for TB. Forty five TB cases were notified in prisons in 2010 including 26 new pulmonary TB cases of which 38% were sputum smear-positive cases.
The TB mortality trend is presented in Figure 2. In 2010 the TB mortality rate was 2.9 per 100,000 population, 25% less than in 2009. Among primary TB cases, 57% died in 2010 and for 18% diagnosis was established after autopsy.
TB treatment outcome
TB treatment outcome results in 2004-2009 are shown in Table 1. The treatment success rate for new smear-positive cases has been stable and the proportion of defaults has decreased since 2004 (p < 0.05). Between 30-40% of the patients including MDR-TB cases moved abroad as labour migrants and thus defaulted.
Adherence to the lengthy TB treatment course is particularly challenging. Patients prefer to be cared for by their families and often leave the treatment institutions or ambulatory facilities. Most of treatment failures are due to MDR-TB and are enrolled in the second-line treatment course.
The 4th WHO/IUATLD (The International Union against Tuberculosis and Lung Disease) Drug Resistance Global Survey reported that among never treated patients and previously treated patients 9.4% and 43.2%, respectively, were MDR-TB cases. Out of these, 4% were XDR-TB cases.
In 2010, 281 drug susceptibility tests were performed on samples selected from a total of 339 notified new sputum smear-positive cases of which 10.6% were MDR-TB cases. In the same year 74 drug susceptibility tests were performed out of notified 107 re-treatment cases and 22.9% were MDR-TB cases.
The TB burden remains high in Armenia. The country is currently one of the 18 high priority countries for TB control in the WHO European Region, and among the 27 MDR-TB burden countries in the world (3).
The high TB and MDR-TB incidence rates are consequences of the failing health system during the 1990s and disintegration of the TB control programme. This led to shortages of anti-TB drugs and incomplete treatment, inadequate infection control in hospitals resulting in nosocomial infection, and poor adherence to TB treatment. Lack of standardization in case management, sub-optimal treatment regimens prescribed by many providers, and the inappropriate use of second-line drugs has further impeded TB control.
Treatment for MDR-TB was not available in Armenia until September 2005 when it was started by an initiative of Médecins Sans Frontières in two regions of the capital city. In the beginning of 2010, after approval by the Green Light Committee, treatment of MDR-TB cases was included in the National TB Control Programme. Currently, all MDR-TB patients are enrolled in treatment.
The National TB Control Programme of Armenia is strengthening the essential components of the DOTS strategy to prevent drug resistant TB. In addition, emphasis is being placed on scaling up the capacity required to manage MDR-TB cases, increasing the TB case detection rate, providing social and psychological support to TB patients, improving diagnostics and “through care” for seasonal migrants, increasing the capacity for providing home treatment for eligible cases, involving more primary health care providers and improving social mobilization interventions to support TB control.
1. National Tuberculosis Control Programme for years 2007-2015. National Tuberculosis Control Office. 2006. [In Armenian, accessed 10 August 2011]. Available online: http://www.ntp.am/arm/publications/prog.pdf
2. Vink K, Colombani P, Mosneaga A et al. Tuberculosis Assessment Mission to Armenia. WHO, 2005. Available online: http://www.euro.who.int/__data/assets/pdf_file/0019/123166/TubArmAss.pdf
3. Towards Universal Access to Diagnosis and Treatment of Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis by 2015. WHO, WHO Progress Report 2011. Available online: http://www.who.int/tb/publications/2011/mdr_report_2011/en/index.html