Incurable forms of TB challenge Armenia – and the world

Public health specialists and international organizations in Armenia speak out

by Maria Titizian

Published: Friday December 12, 2008

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Yerevan - In a jarring article datelined Yerevan, December 7, New York Times columnist Nicholas D. Kristof sounded the alarm about a potential worldwide public-health disaster, the quick spread of extensively drug-resistant tuberculosis (XDR TB).

The article, "A Killer without Borders," focuses on a young man with the disease, and notes that by riding crowded public transportation, he exposes dozens of people to XDR TB every day. The man happens to live in Armenia. Mr. Kristof's point is that he could be anywhere.

Only a fraction of people exposed to TB actually develop the disease. People with weak immune systems are especially vulnerable.

How the healthcare system and public-health officials of any country handle tuberculosis affects the situation in the country and beyond.

Armenian public-health authorities have been grappling with TB for a long time. Indeed, children have been given a mandatory vaccine against TB, the BCG vaccine,  since Soviet times. There are signs that the authorities are now stepping up their efforts, with the support of Médecins Sans Frontières France (MSF), the Global Fund, the International Committee of the Red Cross, and others.

Infection and treatment

The World Health Organization estimates that one-third of the world's population is infected with latent TB bacteria. TB is spread through the air when a person with active TB disease of the lungs or throat coughs or sneezes. The sun quickly kills the bacteria, but in confined spaces, people nearby may breathe in live bacteria and become infected.

According to the U.S. Centers for Disease Control and Prevention, in most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop them from growing. The bacteria become inactive. The person has no symptoms and cannot spread TB to others.

But the bacteria remain alive in the body and can become active later - if the body's immune system cannot stop them. People with HIV, the virus that causes AIDS, and others with weak immune systems are at particular risk of developing tuberculosis.

If active TB disease is detected early and fully treated with a course of four standard, or first-line, anti-TB drugs, most people with the disease quickly become noninfectious and are eventually cured.

But if they are infected with a multiple-drug-resistant strain of TB (MDR TB), treatment becomes much more difficult. If they are infected with XDR TB, which is resistant to first-line and second-line drugs, they are left with treatment options that are much less effective.

Patients with active TB disease whose treatment is mismanaged can develop MDR TB.

A public-health challenge

The public-health challenge is to contain MDR TB and XDR TB, and to make sure that regular TB cases are managed properly.

Gayane Ghougasyan, program coordinator for communicable diseases at the World Health Organization's office in Armenia, told the Armenian Reporter that several government initiatives seek to tackle this public-health challenge.

Primary healthcare providers are familiar with the symptoms of tuberculosis and are able to refer patients to free treatment centers. A national TB dispensary has been established in the city of Abovian, not far from the capital. Another dispensary has been established in Yerevan. Regional hospitals have TB units.

Patients receive in-patient treatment until they test negative for active TB infection, which usually takes two months. They must then continue to take anti-TB drugs for another four months.

Because a failure to complete the course of treatment can lead to drug resistance, physicians are responsible for administering the drugs to outpatients every day, which can be a formidable challenge.

But Christian Ferrier, head of mission of Médecins Sans Frontières France (MSF), the medical charity, told the Armenian Reporter in an interview that primary healthcare providers do not always know what steps to take when faced with a TB case. Patients may get incomplete treatment, or may be treated with second-line drugs, increasing the danger that they will develop a drug-resistant infection. He said the Ministry of Health has to tackle this problem with greater energy.

Treating drug-resistant cases

MDR TB cases are referred to MSF, which is implementing a pilot project in two districts of Yerevan, Malatia-Sebastia and Shengavit. Mr. Ferrier said MSF has a contract with the government to expand the project, but implementation awaits the resolution of practical issues like who is going to pay for hospital furniture.

Mr. Ferrier said MSF has been treating 170 MDR TB patients. According to Ms. Ghougasyan, the patients under MSF's care account for about 15 percent of people with active MDR TB in Armenia.

Varduhi Petrosyan, associate dean of the College of Health Sciences and director of the Center for Health Services Research and Development at the American University of Armenia (AUA), told the Armenian Reporter in an interview that prisoners account for a significant portion of the population with active TB disease. With the assistance of several international organizations, a program has been implemented to control the spread of the disease among the prison population. "We had amazingly positive results," Dr. Petrosyan said. "This shows that we can make changes."

Treatment of MDR TB involves an extended period of inpatient care - often six months - followed by two years of continued daily drug treatment. Ms. Petrosyan said the treatment costs over $50,000 per person.