Factors associated with unfavourable treatment outcomes among people with rifampicin-resistant tuberculosis in Armenia, 2014-2017


Rifampicin-Resistant/Multidrug-Resistant Tuberculosis (RR/MDR-TB) is recognized as a major public health concern globally. In Armenia, the proportion of RR/MDR-TB is increasing among all people affected with TB. We conducted a nationwide cohort study involving analysis of programmatic data to investigate the rates of and factors associated with unfavourable treatment outcomes among patients with RR/MDR-TB registered by the national TB programme from 2014 to 2017 in Armenia. We used Cox regression to identify factors associated with the outcome. Among 451 RR/MDR-TB patients, 80% were men and median age was 46 years. Of them, 53 (11.8%) had Extensively Drug-Resistant Tuberculosis (XDR-TB) and 132 (29.3%) had pre-XDR-TB. Almost half (224, 49.7%) of the patients had unfavourable treatment outcome, which included 26.8% Loss To Follow-Up (LTFU), 13.3% failures and 9.5% deaths. In multivariable analysis, people with pre-XDR-TB [adjusted Hazard Ratio [aHR] 3.13, 95% confidence intervals [CI] 2.16-4.55] and XDR-TB (aHR 4.08, 95% CI 2.45-6.79) had a higher risk of unfavourable outcomes. Patients receiving home-based treatment (71/451, 15.7%) and treatment with new drugs (172/451, 38.1%) had significantly lower risk (aHR 0.45, 95% CI 0.28-0.72 and aHR 0.26, 95% CI 0.18-0.39) of unfavourable treatment outcome.  The proportion of MDR-TB patients reaching favourable treatment outcome in Armenia was substantially lower than the recommended level (75%). The most common treatment outcome was LTFU indicating the need for further assessment of underlying determinants. Home-based treatment looks promising and future studies are required to see if expanding it to all RR/MDR-TB patients is feasible and cost-effective.



PlumX Metrics


Download data is not yet available.

Author Biographies

Ajay M.V. Kumar, International Union Against Tuberculosis and Lung Disease, Paris

International Union Against Tuberculosis and Lung Disease, South-East Asia Office, New Delhi;
Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru, India

Kristina Akopyan, Tuberculosis Research and Prevention Center, Yerevan

World Health Organization,  Regional Office for Europe, Copenhagen, Denmark


WHO. Global tuberculosis report 2019. Geneva: World Health Organization; 2019. Accessed on: 2019 Nov 22. Available from: https://www.who.int/tb/publications/global_report/en/

Acosta CD, Dadu A, Ramsay A, et al. Drug-resistant tuberculosis in Eastern Europe: challenges and ways forward. Public Heal Action 2014;4:S3-12.

WHO. Armenia country review report 2019. Geneva: World Health Organization; 2019.

WHO Regional Office for Europe. Tuberculosis surveillance and monitoring report in Europe 2019. Accessed 2020 Jul 1. Available from: https://www.euro.who.int/en/health-topics/communicable-diseases/tuberculosis/publications/2019/tuberculosis-surveillance-and-monitoring-report-in-europe-2019

WHO. Armenia TB profile 2018. Geneva: World Health Organization; 2019.

Migliori GB, Tiberi S, Zumla A, et al. MDR/XDR-TB management of patients and contacts: challenges facing the new decade. The 2020 clinical update by the global tuberculosis network. Int J Infect Dis 2020;92:S15–25.

Woldeyohannes D, Assefa T, Aman R, et al. Predictors of time to unfavorable treatment outcomes among patients with multidrug resistant tuberculosis in Oromia region, Ethiopia. PLoS One 2019;14:e0224025.

Alffenaar JWC, Akkerman OW, Kim HY, et al. Precision and personalized medicine and anti-tb treatment: is tdm feasible for programmatic use? Int J Infect Dis 2020;92:S5–9.

Sanchez-Padilla E, Marquer C, Kalon S, et al. Reasons for defaulting from drug-resistant tuberculosis treatment in armenia: a quantitative and qualitative study. Int J Tuberc Lung Dis 2014;18:160–7.

Chem ED, Van Hout MC, Hope V. Treatment outcomes and antiretroviral uptake in multidrug-resistant tuberculosis and HIV co-infected patients in sub-Saharan Africa: a systematic review and meta-analysis. BMC Infect Dis 2019;19:723.

Verdecchia M, Keus K, Blankley S, et al. Model of care and risk factors for poor outcomes in patients on multi-drug resistant tuberculosis treatment at two facilities in Eswatini (formerly Swaziland), 2011-2013. PLoS One 2018;13:e0205601.

Huangfu P, Ugarte-Gil C, Golub J, et al. The effects of diabetes on tuberculosis treatment outcomes: an updated systematic review and meta-analysis. Int J Tuberc Lung Dis 2019;23:783-96.

Choi H, Lee M, Chen RY, et al. Predictors of pulmonary tuberculosis treatment outcomes in South Korea: a prospective cohort study, 2005-2012. BMC Infect Dis 2014;14:360.

Parmar MM, Sachdeva KS, Dewan PK, et al. Unacceptable treatment outcomes and associated factors among India’s initial cohorts of multidrug-resistant tuberculosis (MDR-TB) patients under the revised national TB control programme (2007–2011): evidence leading to policy enhancement. PLoS One 2018;13:e0193903.

Htun YM, Khaing TMM, Aung NM, et al. Delay in treatment initiation and treatment outcomes among adult patients with multidrug-resistant tuberculosis at Yangon regional tuberculosis centre, Myanmar: a retrospective study. PLoS One 2018;13: e0209932.

Phuong NTM, Nhung NV, Hoa NB, et al. Management and treatment outcomes of patients enrolled in mdr-tb treatment in viet nam. Public Heal Action 2016;6:25-31.

Alegria-Flores K, Weiner BJ, Wiesen CA, et al. Innovative approach to the design and evaluation of treatment adherence interventions for drug-resistant TB. Int J Tuberc Lung Dis 2017;21:1160-1.

Bastard M, Sanchez-Padilla E, Hewison C, et al. Effects of treatment interruption patterns on treatment success among patients with multidrug-resistant tuberculosis in Armenia and Abkhazia. J Infect Dis 2015;211:1607–15.

Bastard M, Sanchez-Padilla E, Du Cros P, et al. Outcomes of HIV-infected versus HIV-non-infected patients treated for drug-resistance tuberculosis: multicenter cohort study. PLoS One 2018;13: e0193491.

Ministry of Health of the Republic of Armenia. National tuberculosis strategy 2016-20. Accessed on: 2020 Aug 5. Available from: http://www.irtek.am/views/act.aspx?aid=84463

WHO. Review of financial sustainability of tuberculosis activities in Armenia. Accessed on: 2020 Jul 1. Available from: https://www.euro.who.int/__data/assets/pdf_file/0006/376998/armenia-fin-sust-tb-eng.pdf

WHO. Rapid communication: key changes to the treatment of drug-resistant tuberculosis. 2019. Accessed on: 2020 Jul 1. Available from: https://www.who.int/tb/publications/2019/WHO_RapidCommunicationMDR_TB2019.pdf?ua=1

WHO. Introduction of bedaquiline for the treatment of multidrug-resistant tuberculosis at country level. Accessed on: 2020 Jul 1. Available from: https://www.who.int/tb/publications/2015/Bedaquiline_implementation_plan.pdf?ua=1

WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. 2016. Accessed on: 2020 Jul 1. Available from: https://apps.who.int/iris/bitstream/handle/10665/208825/9789241549684_eng.pdf;jsessionid=CFDC692E793B2858A95868810F57808A?sequence=1

Avaliani Z, Gozalov O, Kuchukhidze G, et al. What is behind programmatic treatment outcome definitions for tuberculosis? Eur Res J 2020;56 2001751.

International Labour Organization (ILO). Migration and development Armenia country study, 2009. Accessed on: 2020 Jun 29. Available from: http://www.un.am/up/library/Migr_Dev_Study_eng.pdf

Muñnoz-Torrico M, Luna JC, Migliori GB, et al. Comparison of bacteriological conversion and treatment outcomes among mdr-tb patients with and without diabetes in mexico: preliminary data. Rev Port Pneumol 2017;23:27-30.

Atif M, Bashir A, Ahmad N, et al. Predictors of unsuccessful interim treatment outcomes of multidrug resistant tuberculosis patients. BMC Infect Dis 2017;17:655.

Leveri TH, Lekule I, Mollel E, et al. Predictors of treatment outcomes among multidrug resistant tuberculosis patients in Tanzania. Tuberc Res Treat 2019;2019:3569018.

Makhmudova M, Maxsumova Z, Rajabzoda A, et al. Risk factors for unfavourable treatment outcomes among rifampicin-resistant tuberculosis patients in Tajikistan. Int J Tuberc Lung Dis 2019;23:331-6.

Tola HH, Shojaeizadeh D, Garmaroudi G, et al. Psychological distress and its effect on tuberculosis treatment outcomes in Ethiopia. Glob Health Action 2015;8:29019.

Merid MW, Gezie LD, Kassa GM, et al. Incidence and predictors of major adverse drug events among drug-resistant tuberculosis patients on second-line anti-tuberculosis treatment in Amhara regional state public hospitals; Ethiopia: a retrospective cohort study. BMC Infect Dis 2019;19:286.

Zhang Y, Wu S, Xia Y, et al. Adverse events associated with treatment of multidrug-resistant tuberculosis in china: an ambispective cohort study. Med Sci Monit 2017;23:2348-56.

Alene KA, Yi H, Viney K, et al. Treatment outcomes of patients with multidrug-resistant and extensively drug resistant tuberculosis in Hunan Province, China. BMC Infect Dis 2017;17:573.

Migliori GB, Nardell E, Yedilbayev A, et al. Reducing tuberculosis transmission: a consensus document from the World Health Organization Regional Office for Europe. Eur Respir J 2019;53:1900391.

Khachadourian V, Truzyan N, Harutyunyan A, et al. People-centered tuberculosis care versus standard directly observed therapy: study protocol for a cluster randomized controlled trial. Trials 2015;16:281.

Ravenscroft L, Kettle S, Persian R, et al. Video-observed therapy and medication adherence for tuberculosis patients: randomised controlled trial in Moldova. Eur Respir J 2020;56:2000493.

Sinkou H, Hurevich H, Rusovich V, et al. Video-observed treatment for tuberculosis patients in Belarus: findings from the first programmatic experience. Eur Res J 2017;49: 1602049.

Wade VA, Karnon J, Eliott JA, et al. Home videophones improve direct observation in tuberculosis treatment: a mixed methods evaluation. PLoS One 2012;7:e50155.

Horter S, Stringer B, Reynolds L, et al. “Home is where the patient is”: a qualitative analysis of a patient-centred model of care for multi-drug resistant tuberculosis. BMC Health Serv Res 2014;14:81.

Mhimbira F, Hella J, Maroa T, et al. Home-based and facility-based directly observed therapy of tuberculosis treatment under programmatic conditions in urban Tanzania. PLoS One 2016;11:e0161171.

Bastard M, Guglielmetti L, Huerga H, et al. Bedaquiline and repurposed drugs for fluoroquinolone-resistant multidrug-resistant tuberculosis: how much better are they? Am J Res Care 2018;198:1228-31.

Hewison C, Bastard M, Khachatryan N, et al. Is 6 months of bedaquiline enough? Results from the compassionate use of bedaquiline in Armenia and Georgia. Int J Tuberc Lung Dis 2018;22:766–72.

Mbuagbaw L, Guglielmetti L, Hewison C, et al. Outcomes of bedaquiline treatment in patients with multidrug-resistant tuberculosis. Emerg Infect Dis 2019;25:936–43.

Bonnet M, Bastard M, Du Cros P, et al. Identification of patients who could benefit from bedaquiline or delamanid: a multisite MDR-TB cohort study. Int J Tuberc Lung Dis 2016;20:177–86.

Skripconoka V, Danilovits M, Pehme L, et al. Delamanid improves outcomes and reduces mortality in multidrug-resistant tuberculosis. Eur Respir J 2013;41:1393–400.

Kuksa L, Barkane L, Hittel N, et al. Final treatment outcomes of multidrugand extensively drug-resistant tuberculosis patients in Latvia receiving delamanid-containing regimens. Eur Res J 2017;50.

List of essential medicines of ra [Internet]. Accessed on: 2020 Jul 1. Available from: http://digicollection.org/hss/documents/s17079e/s17079e.pdf

Truzyan N, Crape B, Grigoryan R, et al. Increased risk for multidrug-resistant tuberculosis in migratory workers, Armenia. Emerg Infect Dis 2015;21:474–6.

Thematic Articles
Default, case fatality, treatment failure, home-based treatment, directly observed treatment (DOT), family DOT
  • Abstract views: 126

  • PDF: 65
How to Cite
Khachatryan, L., Grigoryan, R., Dadu, A., Kumar, A. M., Akopyan, K., Dumchev, K., Harutyunyan, H., & Matteelli, A. (2021). Factors associated with unfavourable treatment outcomes among people with rifampicin-resistant tuberculosis in Armenia, 2014-2017 . Monaldi Archives for Chest Disease, 91(1). https://doi.org/10.4081/monaldi.2021.1677

Most read articles by the same author(s)