Tuberculosis (TB) and Tobacco Control in Armenia Varduhi Petrosyan, MS, PhD Professor of Health Sciences and Dean, Gerald and Patricia Turpanjian School of Public Health Director, Zvart Avedisian Onanian Center for Health Services Research and Development January 20-29, 2017 Armenian Heritage Cruise Burden of Tuberculosis (TB) WHO 2015 Estimates  TB incidence: 41 per 100,000  TB mortality: 3 per 100,000  Estimated proportion of MDR-TB cases: o 11% - new o 47% - retreated (developed MDR-TB)  8 cases of XDR-TB  Treatment success rate TB Incidence&Mortality per 100,000 National TB Control Center National TB Control Center NTCC • NTCC organizes and coordinates both inpatient and outpatient TB services through TB prevention and treatment at 3 levels • Central level – responsible for direct coordination and professional assistance to all services • Hospital level – responsible for diagnosis and inpatient care during intensive phase of TB treatment for sputum smear positive (SS+) patients o Republican TB Dispensary in Abovian city with 300 TB hospital beds serving about 90% of all TB patients from Armenia: around 3,000 TB patients annually o TB Dispensary in Yerevan with 48 TB hospital beds o 4 regional departments in Gyumri, Vanadzor, Kapan, and Goris with 110 TB hospital beds  Primary health care level – 60 outpatient TB centers in polyclinics providing outpatient services Counseling for TB Patients and Their Family Members: a Pilot Project • Supported by Armenian Medical Fund • Literature review • Pre-intervention qualitative research • Intervention – Training of Trainers (TOT) – Counseling of TB patients and family • Regular TB patients from Shirak, Kotayk and Aragatsotn marzes who at the time of the counseling were receiving outpatient phase of TB treatment • All family members or some family members of TB patients • Friends, relatives, and neighbors if invited by the TB patient • Evaluation of intervention • Recommendations Main Findings • The overall mean cumulative knowledge score for TB patients and family members significantly improved from baseline to follow-up • Family members showed greater overall improvement in knowledge than TB patients • Stigmatizing social practices within the families reduced • Rates of TB treatment success significantly increased and lost to follow-up and failure and death rates significantly decreased among TB patients who participated in the household counseling sessions (Pilot Project) compared to those TB patients who were not involved Bold Innovation to Improve TB Care in Armenia and Globally: a Cluster Randomized Controlled Trial • Self-administered drug intake by empowered TB patients – supervised by a trained family member and supported by medical counseling and daily SMS reminders – to improve treatment success rates • Similar clinical effectiveness as the WHO standard treatment, improved knowledge about TB, patients’ depression status, stigma within family, and self- reported adherence to TB treatment • Close collaboration with Ministry of Health, National TB Control Center, national strategy and scale-up Study Rationale • No evidence that Directly Observed Therapy (DOT) compared to self-administered treatment leads to better treatment outcomes • Involving family members in TB treatment can improve patient adherence • DOT has been problematic in Armenia during the continuation treatment phase – Existing studies suggest: up to 1/3 of TB patients reported adhering to DOT during the continuation treatment phase Study Aim and Design To evaluate a multi-stage multi-component innovative strategy for recommending nationwide policy change Cluster randomized controlled trial • Clusters – 52 TB outpatient centers – 26 outpatient TB centers assigned to intervention arm – 26 outpatient TB centers assigned to control arm Target population Inclusion criteria • Having a diagnosis of drug sensitive pulmonary TB • Starting the continuation phase of TB treatment between March and December 2014 • Being at least 18 years old at the time of enrolment • Ability to communicate in Armenian Exclusion criteria • TB patients in the Home Based TB Treatment Program