National, International, Armenia, and Community News and Opinion

The Armenian Reporter | December 13, 2008 15ArmeniaIncurable forms of TB are a global challengeby Maria TitizianYEREVAN – In a jarring articledatelined Yerevan, December 7,New York Times columnist NicholasD. Kristof sounded the alarmabout a potential worldwide publichealthdisaster, the quick spread ofextensively drug-resistant tuberculosis(XDR TB).The article, “A Killer without Borders,”focuses on a young man withthe disease, and notes that by ridingcrowded public transportation,he exposes dozens of people to XDRTB every day. The man happens tolive in Armenia. Mr. Kristof’s pointis that he could be anywhere.Only a fraction of people exposedto TB actually develop the disease.People with weak immune systemsare especially vulnerable.How the healthcare system andpublic-health officials of any countryhandle tuberculosis effects the situationin the country and beyond.Armenian public-health authoritieshave been grappling with TBfor a long time. Indeed, childrenhave been given a mandatory vaccineagainst TB, the BCG vaccine,since Soviet times. There are signsthat the authorities are now steppingup their efforts, with the supportof Médecins Sans FrontièresFrance (MSF), the Global Fund, theInternational Committee of theRed Cross, and others.Infection, treatmentThe World Health Organizationestimates that one-third of theworld’s population is infected withlatent TB bacteria. TB is spreadthrough the air when a personwith active TB disease of the lungsor throat coughs or sneezes. Thesun quickly kills the bacteria, butin confined spaces, people nearbymay breathe in live bacteria and becomeinfected.According to the U.S. Centers forDisease Control, in most peoplewho breathe in TB bacteria and becomeinfected, the body is able tofight the bacteria to stop them fromgrowing. The bacteria become inactive.The person has no symptomsand cannot spread TB to others.But the bacteria remain alive inthe body and can become activelater – if the body’s immune systemcannot stop them. People withHIV, the virus that causes AIDS, andothers with weak immune systemsare at particular risk of developingtuberculosis.If active TB disease is detectedearly and fully treated with a courseof four standard, or first-line, anti-TB drugs, most people with the diseasequickly become noninfectiousand are eventually cured.But if they are infected with amultiple-drug-resistant strain ofTB (MDR TB), treatment becomesmuch more difficult. If they areinfected with XDR TB, which is resistantto first-line and second-linedrugs, they are left with treatmentoptions that are much less effective.Patients with active TB diseasewhose treatment is mismanagedcan develop MDR TB.Public-health challengeThe public-health challenge is tocontain MDR TB and XDR TB, and tomake sure that regular TB cases aremanaged properly.Gayane Ghougasyan, programcoordinator for communicable diseasesat the World Health Organization’soffice in Armenia, told theArmenian Reporter that several governmentinitiatives seek to tacklethis public-health challenge.Primary healthcare providersare familiar with the symptoms oftuberculosis and are able to referpatients to free treatment centers.A national TB dispensary has beenestablished in the city of Abovian,not far from the capital. Anotherdispensary has been established inYerevan. Regional hospitals haveTB units.Patients receive in-patient treatmentuntil they test negative foractive TB infection, which usuallytakes two months. They must thencontinue to take anti-TB drugs foranother four months.Because a failure to complete thecourse of treatment can lead to drugresistance, physicians are responsiblefor administering the drugsto outpatients every day, which canbe a formidable challenge.But Christian Ferrier, head ofmission of Médecins Sans FrontièresFrance (MSF), the medicalcharity, told the Armenian Reporterin an interview that primaryhealthcare providers do not alwaysknow what steps to take whenfaced with a TB case. Patients mayget incomplete treatment, or maybe treated with second-line drugs,increasing the danger that they willdevelop a drug-resistant infection.He said the Ministry of Health hasto tackle this problem with greaterenergy.Drug-resistant casesMDR TB cases are referred to MSF,which is implementing a pilotproject in two districts of Yerevan,Malatia-Sebastia and Shengavit.Mr. Ferrier said MSF has a contractwith the government to expand theproject, but implementation awaitsthe resolution of practical issueslike who is going to pay for hospitalfurniture.Mr. Ferrier said MSF has beentreating 170 MDR TB patients. Accordingto Ms. Ghougasyan, thepatients under MSF’s care accountfor about 15 percent of people withactive MDR TB in Armenia.Varduhi Petrosyan, associatedean of the College of Health Sciencesand director of the Centerfor Health Services Research andDevelopment at the American Universityof Armenia (AUA) told theArmenian Reporter in an interviewthat prisoners account for a significantportion of the populationwith active TB disease. With the assistanceof several international organizations,a program was implementedto control the spread of thedisease among the prison population.“We had amazingly positiveCause for concernA recent WHO report, Anti-TuberculosisDrug Resistance in theWorld, which is based on informationcollected between 2002and 2006 on 90,000 TB patientsin 81 countries found that XDRTB has been recorded in 45 countries.Based on this survey, WHOestimates that there are nearlyhalf a million new cases of MDRTB, or about 5 percent of all newglobal TB cases (approximately 9million). The highest rate was recordedin Baku, Azerbaijan, wherenearly a quarter of all new TB cases(22.3 percent) were reported asMDR TB. The highest incidences ofMDR TB among new TB cases: 19.4percent in Moldova; 16 percent inDonetsk in Ukraine; 15 percent inTomsk Oblast in the Russian Federation;and 14.8 percent in Tashkentin Uzbekistan. These ratessurpass the highest levels of drugresistance published in the lastWHO report in 2004. The situationis also widespread in China. fresults,” Dr. Petrosyan said. “Thisshows that we can make changes.”Treatment of MDR TB involves anextended period of inpatient care– often six months – followed by twoyears of continued daily drug treatment.Ms. Petrosyan said the treatmentcosts over $50,000 per person.Based on the MSF pilot project,Mr. Ferrier said it is important toindividualize treatment, based onthe patient’s response to variousdrugs, side effects, other ailments,and similar considerations. He saidthe Ministry of Health needs todevelop firm yet flexible guidelines.“The attitude of healthcare providersin Armenia is that they can onlydo what is explicitly allowed,” hesaid. “Our attitude is that we cando whatever is not forbidden. Wecome across new challenges everyday, and physicians need to be creativein their solutions.”The National TB Program, underthe auspices of the Ministry ofHealth, declined repeated requestsfor an interview. However, the programis hosting a two-day conferencefor journalists on December13–14 as part of an effort to get theword out about TB.Indeed, Dr. Petrosyan said fearand stigma attached to TB areamong the factors that contributeto inadequate treatment. “TB inArmenian society carries a hugeMédecins Sans Frontières FranceMSF France has been working inArmenia since the earthquake 20years ago. Since 2004, it has focusedexclusively on tuberculosis.“We started our program in 2004with a pilot project,” head of missionChristian Ferrier said in aninterview. “This project had twocomponents – an institutionalcomponent to organize a goodsystem, a decentralized system toimprove the quality of the diagnosisand the detection of TB patients,all the TB patients, but wewere focusing on the treatment ofthe MDR TB patients.“The Ministry of Health and theauthorities were not able to treatTB patients at the beginning ofthe program. Therefore we treatedregular TB patients. From 2005,the Ministry of Health receivedstigma. Even health providers areafraid of patients with TB,” shesaid.An intensive effortAn important contribution mightbe a public awareness campaignto help people and health providersbetter understand the disease.“We need to understand that TB iscurable if managed properly,” Dr.Petrosyan added.In October, a conference broughttogether all the major stakeholdersin the fight against tuberculosis inArmenia. They included Armenia’sMinistry of Health, its NationalTB Program, the Global Fund, MSFFrance, the International Committeeof the Red Cross (ICRC), andothers.The conference considered astudy carried out by the AmericanUniversity of Armenia on behalf ofthe ICRC. The study will be releasedin January, Dr. Petrosyan said.A five-year grant from the GlobalFund supports TB treatment in Armenia.A second grant, under consideration,would build on that supportstarting in 2009. Mr. Ferrier saidthat the fund’s Green Light Committeehas set forth certain criteria; ifArmenia’s healthcare system meetsthose criteria, anti-TB drugs will becomeavailable to Armenia at about aquarter of the market cost. fsupport from the Global Fundand they also received supportfrom the ICRC and German bilateralcooperation. From 2005, theauthorities have had the means totreat regular TB patients. So fromthis point on we focused only onMDR TB patients,” he said.Today, MSF France is treating170 MDR TB patients in Armenia.Mr. Ferrier said 7.7 percentof their patients have been diagnosedwith XDR TB.MSF relies on volunteers, whotypically go on missions lastingan average of six months. Mr. Ferriersaid the organization does nottake money from governments; itwelcomes private contributions,however.fhttp://www.msf.org/Vic Darchinian visits Gyumri on 20thanniversary of earthquakeWBC, WBA, and IBF world boxingchampion Vic Darchinian tookpart in the 20th anniversary commemorationsof the 1988 SpitakEarthquake. While in Gyumri, Mr.Darchinian visited the Hope Children’sHouse where he passed outgifts he had brought for the children.According to Armenpress,the world famous boxer said, “AlthoughI have a big fight comingup, I felt I had to be here to honorthe memory of the victims of theearthquake. I am happy that I’mhere at the children’s house andcan communicate with the childrenmore closely.”The Hope Children’s Houseopened its doors in 2000 forhomeless orphans, beggars andabandoned children. The centernamed after Frederich Nansen ishome to 69 children. While thehouse struggles to keep operating,the director Rubik Markosian saidthat all these can be resolved.Vic Darchinian Photo: Photolure.“If you are not alone and thereare people by you, the difficultiesare possible to overcome.The only unsolved issue is theemployment of children of thehouse in future,” the directersaid.f