The Journal of Infection in Developing Countries <p>A peer-reviewed open access journal, focusing on global health.</p> en-US <p>Authors who publish with this journal agree to the following terms:</p> <ol type="a"> <li>Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a <a title="Creative Commons Attribution License" href="" target="_new">Creative Commons Attribution License</a> that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.</li> <li>Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.</li> <li>Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See <a title="The Effect of Open Access" href="" target="_new">The Effect of Open Access</a>).</li> </ol> (JIDC Central Office) (JIDC Tech Support) Thu, 16 May 2019 13:04:07 -0700 OJS 60 Why a special issue of JIDC on the Structured Operational Research and Training Initiative in Armenia Karapet Davtyan, Zhanna Davtyan, Gevorg Yaghjyan, Rony Zachariah ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Shifting from an inpatient to outpatient centered model through transforming the TB financing in ex-Soviet countries <p>Introduction: In former Soviet Union countries, tuberculosis (TB) financing largely relies on a hospital-centered model. The World Health Organization favors transformation to ambulatory treatment since it is cheaper and patient-centered. We explored policy and decision maker’s perspectives on: a) enabling factors for transformation in Armenia and b) challenges and ways forward in doing so in Ukraine and Tajikistan.</p> <p>Methodology: Qualitative study of key informants from government, donors and the national TB program.</p> <p>Results: 52 informants with a mean service record of 20 years were involved. Key enablers in Armenia included collaborative partnership and political will, carefully selecting an adapted financing scheme that avoided financial penalization of hospitals and health workers, and use of operational research. The operational challenges in Ukraine and Tajikistan hovered around the lack of technical capacity and guidance on “how to implement” alternative financing. Shortcomings in strategic planning, uncertainty/fear that existing hospital funding would be cut and reluctance to change were highlighted. Suggested ways forwards to change the current paradigm included country-level technical assistance, capacity building, regional exchanges and operational research.</p> <p>Conclusions: the perspectives of “those who decide” on transforming TB financing have been highlighted. Taking these perspectives on-board is vital for achieving the end-TB goals.</p> Karapet Davtyan, Olga Denisiuk, Azamdzhon Mirzoev, Hayk Davtyan, Seda Aghabekyan, Maryna Piskorska, Anna Tyshkevych, Joshua Jayaraj, Armen Hayrapetyan, Rony Zachariah ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Mind the gap: Improving the performance of the reference laboratory to end-tuberculosis in Armenia <p>Introduction: A one of the step towards achieving TB related targets is to ensure early and quality diagnosis of TB in national laboratories. WHO recommends that all national reference laboratories in TB burden countries strive to reach accreditation by 2025, based on ISO15189:2012 quality management system standard. To identify gaps, progress and evaluated the evolution in implementation QMS we performed a formal assessment of the national TB reference laboratory of Armenia, as well as estimates the specific quality indicators of NRL activity.</p> <p>Methodology: This is retrospective study cross-sectional study using laboratory data from the National TB Reference Laboratory in Armenia. Quality Management System assessments was conducted twice a year, using TB SLMTA assessment checklist. The sputum rejection and culture rates for quality indicators are calculated and assessed monthly.</p> <p>Results: Compared to the baseline in 2016, there was a quality improvement reflecting the progress from zero to a “one star” in 2018. Areas that reached half of the target score included document and records, management review and responsibilities, evaluation and audits. Sections as “client management and customer service” and “evaluation and audits” stagnated in terms of progress. In terms of NRL performace, all indicators improved except for culture positivity in smear negative tuberculosis.</p> <p>Conclusion: Although a quality management system was introduced in the NRL there is now an urgent need to develop and implement an adapted roadmap for Armenia. This will be vital to hasten the much-needed pace towards accreditation.</p> Viktorya Cholakyans, Eduard Kabasakalyan, Olga Denisiuk, Kristina Akopyan, Karapet Davtyan, Maka Akhalaia, Alvard Mirzoyan, Armen Hayrapetyan, Rony Zachariah ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Tuberculosis care services in Armenia: What has changed since the 2014 reform? <p>Introduction: In efforts to reach the 2020 Tuberculosis targets, the WHO advocates for an outpatient, people-centered model of TB care. To this end, the TB care system in Armenia underwent structural and financing reforms in 2014. Financing mechanism for inpatient TB facilities was changed from a fee per bed/day to a mixed type of financing that includes fixed and variable costs eliminating incentives for unnecessary and extended hospitalizations. Unfortunately, outpatient facilities continue to be financed through per-capita mechanism, resulting in high number of referrals and draining resources. This study aimed to assess the implementation of these reforms within the Armenian TB care system.</p> <p>Methodology: This was a retrospective cross-sectional study using nationwide programme data and survey data collected from healthcare facilities.</p> <p>Results: In 2017 a total of 901 TB patients were registered in outpatient facilities. Only 7.6% of total TB cases were diagnosed in outpatient facilities and 30.9% of the presumptive TB cases were referred to inpatient facilities. The number of hospitalizations was reduced by 76% from 2013 to 2017. The average duration of stay reduced as well from 55+ days to 37 days. However, the proportion of smear negative TB patients remains high among all hospitalized patients (63.8%).</p> <p>Conclusions: Overall, the reform has been successful, however unnecessary hospitalizations persist. Our results indicate there a need to go upstream for a structural and financial reform of the outpatient sector to complete Armenia’s TB healthcare reform and improve both patient outcomes and efficient use of system resources.</p> Hratchia Lylozian, Hayk Davtyan, Garry Aslanyan, Karapet Davtyan, Lisle S Hites ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Change in TB diagnostic profile after introduction of GeneXpert MTB/RIF assay in National TB Program of Armenia, 2013-2017 <p>Introduction: In 2013, the National Tuberculosis (TB) Program of Armenia introduced GeneXpert MTB/RIF (Xpert) assay to address World Health Organization (WHO) target of 80% (2020) of notified new and relapse TB cases to be tested with WHO recommended rapid diagnostic methods. This study aimed to assess the change in laboratory diagnostic profile of Mycobacterium tuberculosis after introduction of the Xpert assay from 2013 to 2017.</p> <p>Methodology: Retrospective cohort analysis of all presumptive TB patients’ records retrieved from the National Reference Laboratory database was performed.</p> <p>Results: This study showed increased trend of Xpert coverage for suspected TB cases from 25% in 2013 to 86% in 2017 which is in line with WHO TB global strategy’s target of 80% in 2020. In 4.7% cases, Xpert tested positive while microscopy showed negative results. There was also an improved detection of Rifampicin resistance with increased concordance from 99.1% to 99.4% and decreased discordance from 6.7% to 1.4% between culture and Xpert results.</p> <p>Conclusion: Armenia has achieved the 2020 target; in terms of utilizing the GeneXpert it is on track to achieve the End TB strategy target of 100% by 2025. The next step of this research will be assessment of the impact of GeneXpert and other TB tests utilization on the treatment outcomes in Armenia.</p> Eduard Kabasakalyan, Karapet Davtyan, Viktorya Cholakyans, Alvard Mirzoyan, Karine Kentenyants, Diana Petrosyan, Armen Hayrapetyan, Himanshu A Gupte ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Quality of care provided to tuberculosis patients in Armenia: How satisfied are the patients? <p>Introduction: Adherence to tuberculosis (TB) treatment as an important determinant for the successful cure of patients can be increased by focusing on patient satisfaction. The objective of this study was to evaluate patient satisfaction with TB services, different aspects of patient satisfaction, and demographic, health and treatment characteristics associated with satisfaction.</p> <p>Methodology: Overall 505 randomly selected TB patients that received treatment during 2014-2015 in Armenia underwent a cross-sectional telephone survey. Patient satisfaction items were selected from the Patient Satisfaction Questionnaire (PSQ-18). The Consultation and Relational Empathy (CARE) and Patient Enablement Instrument (PEI) were also used. Treatment adherence was assessed using the Morisky Adherence Scale.</p> <p>Results: The respondents comprised 386 (76.4%) men and 119 (23.6%) women with a mean age of 45.5 ± 0.7 years. Nearly 99% (n = 500) of them were treatment-adherent. However, 45 (8.9%) mentioned the side effects as a reason for not following the treatment, revealing the non-adherence level of approximately 9%. About 93% of the patients were generally satisfied with the TB services, about 46% were satisfied with consultation and relational empathy and about 95% were satisfied with patient enablement. Being unsatisfied with TB services was associated with treatment non-adherence, inpatient treatment, drug-resistant TB, higher education, being unmarried, having a family income of below 50,000AMD (~120 USD) on average, being unsatisfied with consultation and empathy and place of residence.</p> <p>Conclusions: This study reports that TB patients are highly satisfied with TB care in Armenia. However, addressing specific characteristics associated with satisfaction may improve the TB program.</p> Karapet Davtyan, Seda Aghabekyan, Hayk Davtyan, Armen Hayrapetyan, Garry Aslanyan ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 A country-wide evaluation of infection control for tuberculosis in health-care facilities in Armenia <p>Introduction: Infection control at health facilities is an important part of TB control programmes. To assess the implementation of tuberculosis infection control (TB IC) measures and barriers hindering their implementation in TB health care facilities (HCFs) in Armenia; to report the feasibility of using the WHO recommended checklist.</p> <p>Methodology: A cross-sectional survey using WHO TB-IC checklist and direct observations was conducted between January and May 2018.</p> <p>Results: The survey included all 62 TB institutions in Armenia. TB HCFs in Armenia had implemented some recommended TB IC measures: offering IC training to staff (48%), shortening time to diagnosing TB to less than one day (29%) and ensuring good ventilation (60%). N95 respirators were available in all HCFs. However, barriers that hindered implementation of TB IC measures were: lack of training, a different incentive model for primary care doctors versus TB doctors and lack of space and poor conditions of the building.</p> <p>Conclusion: The use of the standardized WHO checklist in this first evaluation of TB IC measures in Armenia was found to be useful and feasible in identifying areas of weak IC implementation and barriers to achieving good infection control. Other TB programs may benefit from the use of this model of assessment, based on the WHO checklist.</p> Joshua Chadwick Jayaraj, Karapet Davtyan, Hayk Davatyan, Anush Khachatryan, Armen Hayrepetyan, Lilit Khachatryan, Seda Abgaryan, Anthony Reid, Chinmay Laxmeshwar, Veerle Hermans, Maite Guardiola, Timothy Grieve, Rony Zachariah ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Acute and chronic brucellosis eleven-year audit from a tertiary hospital in Armenia <p>Introduction: The incidence of brucellosis in Armenia in 2010 was twice as high as in other countries of the Caucasian region and has almost doubled over the last three decades. This study aimed to investigate factors associated with acute or chronic forms of presentation of human brucellosis.</p> <p>Methodology: Retrospective study using data from medical records of 455 patients hospitalized for the first time at the Nork Republican Infectious Disease Referral Hospital in Yerevan, Armenia between the years 2006 and 2016. We undertook descriptive analysis of cases, compared acute and chronic cases, and identified factors associated with acute and chronic cases using regression.</p> <p>Results: The majority of brucellosis cases had acute case presentation (73.0%), were males (70.3%), between the ages of 20-60 years (66.2%) and unemployed (89.9%). About two-thirds of cases reported a history of consumption of raw unpasteurized milk. The multivariate analysis revealed that factors associated with the form of brucellosis were age, symptom duration preadmission, fever, antibody titer, and hospitalization outcomes.</p> <p>Conclusion: This study revealed that brucellosis is unevenly distributed across different age groups, as well as regions of Armenia. Affected individuals did not seek medical attention after the onset of the symptoms for about 2 months. Therefore, the targeted educational campaigns could be of crucial importance to prevent the disease in humans, contribute to its early diagnosis and treatment.</p> Lilit Sargsyan, Karapet Davtyan, Katrina Hann, Samvel Gasparyan, Vladimir Davidyants, Vladimir Shekoyan, Gayane Poghosyan, Diana Petrosyan ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Free hospitalization for acute respiratory infections in children: what effect and how much does it cost for Armenia? <p>Introduction: The “Child Certificate” program, launched in Armenia in 2011, made hospitalization for children less than seven years free in order to improve access to hospitalization, reduce out-of-pocket expenses and ensure Universal Health Coverage. We aimed to estimate trends in the number of outpatient and hospitalized acute respiratory infection (ARI) cases and related under-five mortality.</p> <p>Methodology: Cross-sectional study using data from national databases before (2008-2011) and after (2012-2017) Program implementation. The diagnosis of ARI was based on the International Classification of Disease (ICD-10).</p> <p>Results: The average hospitalization per 1000 children under 14 and infants increased by 85% and 75% respectively, compared with the period before the introduction of the Program, while the frequency of outpatient visits remained unchanged. The ARI-related mortality in children less than five years and in infants decreased by 11% and 19%, respectively. Financial allocations for ARI-associated hospitalizations amounted to 2.1 billion Armenian drams in 2011 and increased to 3.3 billion drams in 2016 (an increase of 57%). For pneumonia, this increase was 108% (from 0.35 to 0.72 billion).</p> <p>Conclusions: The introduction of free hospitalization for ARI led to an increase in the hospitalization rates. There was a favorable decline in under-five mortality and an exponential increase in financial allocations. The reasons for hospitalization should be investigated to ensure rational hospitalization with parallel improvement of primary care to reduce delayed presentations. It is necessary to find ways addressing the growing financial allocations for ARI-associated hospitalization.</p> Sergey Sargsyan, Diana Andreasyan, Samvel Kharazyan, Olga Denisiuk, Karapet Davtyan, Roni Zachariah ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 When will the coughing stop? Characteristics of children with pertussis (whooping cough) in Armenia (2014-2018) <p>Introduction: Despite the reported cases of whooping cough in Armenia, there has been no formal evaluation of “who these cases are and their load on hospital wards”. In a tertiary reference hospital, we determined the trend in hospitalized pertussis cases stratified by vaccination status and risk factors associated with apnea and hospital stay.</p> <p>Methodology: Retrospective cohort study of children (&lt; 18 years) with confirmed pertussis hospitalized at the Republican Infectious Diseases Hospital between 2014 and 2018. Multivariate logistic regression was used to identify risk factors.</p> <p>Results: The majority (62%) of 116 children (44% female, mean age 21 months) were from regions outside the capital city of Yerevan. Standardized pertussis admissions increased by almost fivefold, from 2.2/1,000 in 2014 to 10.6/1,000 in 2018. The cumulative average percentage (2014-2018) of children not vaccinated against pertussis was 33%, while 29% were completely vaccinated. Twenty-five children (21%) had apnea, two of whom died. Younger age (Odds Ratio (OR) = 1.04; P = 0.05), not having been vaccinated (OR = 3.57; P = 0.01) and having comorbidities (OR = 4.1; P = 0.09) were associated with apnea. After adjusting for age, the longer hospital stay (&gt;8 days) was significantly associated with non-vaccination (OR = 5.0, P = 0.002).</p> <p>Conclusions: There is a progressive increase in rate of hospital admissions for pertussis meriting closer vigilance on a national scale. Unvaccinated children of younger age are predisposed to apnea and longer hospitalization and would benefit from early referral to specialized infectious units. This may improve clinical outcomes and reduce hospital burden.</p> Sose Margaryan, Markus Wells, Hripsime Apresyan, Tatevik Grigoryan, Kristina Akopyan, Olga Denisiuk, Rony Zachariah, Karapet Davtyan ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Liver involvement in the process of acute respiratory infections in pediatric patients <p>Introduction: We aimed to investigate the prevalence of liver involvement in pediatric patients with ARI using both routine tests of hepatic panel, and ornithine carbamoyltransferase (OCT) to identify the most sensitive indicators of early hepatic injury.</p> <p>Methodology: A prospective cohort study of 84 armenian children with ARI was conducted to evaluate the associated liver involvement. The diagnostic variables of interest were the signs of clinical disease severity, and enzymatic profile of the patients.</p> <p>Results: Serum levels of OCT were increased in 94% of patients versus routine tests of hepatic panel (AST in 41.7%, ALT in 15.5%, etc). Variance analysis by severity groups showed the serum levels of OCT (p &lt; 0.001), ammonia (p &lt; 0.001), phospholipides (p = 0.05), glucose (p = 0.01), TNF-α (p = 0.01), IL-8 (p &lt; 0.001), AST (p &lt; 0.001), and ALP (p &lt; 0.001) were associated with the severity of underlying disease. Moreover, regression analysis revealed the serum activity of OCT (p value &lt; 0.001, OR = 1.27) and ammonia (p value 0.002, OR = 1.1) significantly predict the severity of the disease.</p> <p>Conclusions: Using more sensitive marker of liver damage can detect more cases of ARI with hepatic manifestations. For evaluation of the liver involvement we are suggesting the testing of serum OCT levels as a more sensitive and specific marker. Pediatric patients with ARI and with higher serum OCT levels have 27% more chance to experience increased disease severity, which can affect on liver state and prolong hospitalization time and cost.</p> Nune Baghdasaryan, Gohar Ayvazyan, Murad Grigoryan, Lilit Avetisyan, Olya Asatryan, Nane Mnatsakanyan, Anush Perikhanyan ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Evaluation of IL-2, IL-10, IL-4 and ɤ-interferon levels in the oral fluids of patients with hepatitis C, B and HIV <p>Introduction: Oral fluid cytokine levels can vary considerably during the onset of Inflammatory Periodontitis (IP) especially in people with hepatitis C virus (HCV), hepatitis B virus (HBV) and human immunodeficiency virus (HIV). Aim of our study was to evaluate levels of oral cytokines during the onset of IP among HCV, HBV and HIV negative and positive individuals in order to evaluate local immunity state during these infections.</p> <p>Methodology: This was a case control study with 3 groups of virally infected individuals and control group. All had IP including control group.</p> <p>Results: 45 patients (51.7%) had HCV, 18 (20.7%) HBV and 24 (27.6%) HIV. For IL-2 we received significant difference for all groups compared with control -2.83; HBV-31.1 (p &lt; 0.001), HCV-25.99 (p &lt; 0.001) and HIV-24.57 (p &lt; 0.001). For IL-10 significant difference was observed between control -0.94 and HCV-3.63 (p = 0.027), HBV-8.38 (15.51) groups (p &lt; 0.001). IL-4 was significantly higher in control group 14.29 compared to HCV 0.2 (p &lt; 0.001) and HIV 0.21 (p = 0.037) group. The adjusted analysis where we consider age as possible confounder revealed that only IL-2 significantly differs for all groups compared with control group: control vs HCV (p = 0.001); control vs HBV (p = 0.024); control vs HIV (p = 0.004).</p> <p>Conclusions: Evidence for significant differences when comparing oral fluid cytokines of individuals with HCV, HBV and HIV with non-viral individuals was more obvious for IL-2. IL-2 levels were significantly higher in all 3 groups vs non-viral group even when age is confounder.</p> Vahe Azatyan, Lazar Yessayan, Melanya Shmavonyan, Gayane Melik-Andreasyan, Anush Perikhanyan, Kristina Porkshenyan ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700 Respiratory syncytial and influenza virus detecting rapid tests in children younger than 5 years of age in Armenia <p>Introduction: Acute respiratory infections (ARIs) are major causes of morbidity in early childhood. They are mainly caused by viruses, including influenza (INF) and respiratory syncytial viruses (RSV). We aimed to investigate the role of RSV and INF in children hospitalized for ARIs and to show the impact of RSV/INF rapid testing on management of patients.</p> <p>Methodology: Cross-sectional study using data of inpatient care of children younger than five years hospitalized in Arabkir Medical Center due to ARI from November 1, 2013 to April 1, 2014. Nasopharyngeal swabs were tested for RSV and INF types A and B by direct antigen detection tests.</p> <p>Results: A total of 915 patients, 583 (63.7%) boys and 332 (36.3%) girls were included in the study with the mean age of 18.8 ± 16.3 months. Among them, 390 (42.6%) were tested positive, 3 (0.3%) subjects tested positive both for RSV and INF: 269 (29.4%) for RSV and 124 (13.6%) for INF (A – 121, B – 3). Out of 915 children, 209 (23%) were pretreated with antibiotics, most often with oral amoxicillin/clavulanic acid (n = 54, 25.8%), sulfamethoxazole/trimethoprim (n = 46, 22%), and amoxicillin (n = 38, 18.2%), followed by intramuscular ceftriaxone (n = 37, 17.7%).</p> <p>Conclusions: The usage of antigen tests for detection of respiratory viruses allowed to document high rates of RSV and INF in children admitted to the hospital. In settings where polymerase chain reaction method is not readily available, implementation of rapid tests for detection of respiratory viruses is important in the management of pediatric patients including cohorting and more targeted use of antibiotics.</p> Hrachuhi Ghazaryan, Ara Babloyan, Ashot Sarkissian, Karapet Davtyan, Christoph Berger ##submission.copyrightStatement## Thu, 16 May 2019 00:00:00 -0700