ORIGINAL RESEARCH
A cross-sectional study of the turnaround time of Armenia’s national tuberculosis programme laboratory services in 2017–2018
Eduard Kabasakalyan1, Karapet Davtyan2, Alvard Mirzoyan1, Viktorya Cholakyans1, Ruzanna Grigoryan5 Ramona Groenheit3, Katrina Hann4,Soudeh Ehsani2, Lusine Kocharyan1
1 National Tuberculosis Control Centre, Abovyan, Armenia
2 WHO Regional Office for Europe, Copenhagen, Denmark
3 WHO Supranational Reference Laboratory for Tuberculosis, Public Health Agency of Sweden, Stockholm, Sweden
4 Sustainable Health Systems, Freetown, Sierra Leone
5 Tuberculosis Research and Prevention Centre NGO, Yerevan, Armenia
Corresponding author: Eduard Y. Kabasakalyan (email: eduard.kabasakalyan@gmail.com)
ABSTRACT
Context: The rapid diagnosis of presumptive tuberculosis (TB) in patients is vital in the fight against the disease. The overall turnaround time (TAT) of the laboratory investigation as well as its individual components can serve as crucial indicators of the standard of TB diagnostic services.
Objectives: To evaluate the overall TAT of the Armenian TB diagnostic service in 2017–2018, to assess factors associated with delays within the diagnostic process and to compare TATs before and after the introduction of the rapid diagnostics tool GeneXpert MTB/Rif Ultra.
Methodology: A cross-sectional study based on 7307 samples from the National Reference Laboratory electronic database and paper-based registers from regional laboratories from September 2017 to December 2018.
Results: The mean overall TAT was 2.5 days, with microscopy, GeneXpert testing and reporting TATs at 0.2, 1.3 and 1.1 days, respectively. Following the introduction of GeneXpert Ultra in September 2018, the testing TAT decreased by 23%. Despite this reduction, the overall TAT actually increased from 2.5 to 3.1 days in this period as a result of increases in reporting TATs, which are heavily dependant on a vehicle transportation system.
Conclusion: The introduction of rapid TB diagnostic tools in Armenia, should be accompanied by the introduction of equally efficient systems for the reporting of results to clinicians, such as an electronic TB database, in order to substantially reduce the time to initiate appropriate treatment and improve the overall TB situation.
Keywords: TUBERCULOSIS, DIAGNOSTICS, GENEXPERT ULTRA, DELAY, TURNAROUND TIME, ARMENIA
BACKGROUND
Tuberculosis (TB) is the leading infectious cause of mortality worldwide, causing 1.5 million deaths in 2018, with a third of these attributable to multidrug resistant (MDR) TB cases (1).
In Armenia, despite the significant success of the National TB Programme (NTP), as of 2018 the rate of TB (31 per 100 000 population) and MDR-TB (8.2 per 100 000 population) remain high and need to be further controlled (2).
A comparison of treatment initiation times in MDR-TB patients showed that a rapid diagnosis can be essential in successfully fighting TB; directly reducing morbidity and
mortality of patients as well as decreasing overall transmission within communities (3).
Rapid molecular diagnostic methods allow for accurate diagnosis of TB and drug resistance and provide results within a few hours, compared to the gold-standard culture method, which can take anywhere between two and eight weeks.
Therefore, they substantially reduce the time taken to initiate suitable treatment (4). In 2011 WHO endorsed Cepheid’s GeneXpert technology with a GeneXpert MTB/Rif cartridge (Xpert) (5) for the rapid molecular based diagnosis of TB.
Armenia had already introduced the Genotype MTBDRplus in 2010 for the rapid diagnosis of TB and the introduction of
Xpert, which additionally allows for the detection of rifampicin resistance, followed in 2013 (6, 7). Following the introduction of Xpert in Armenia, the NTP indicated positive trends in timely TB diagnosis and treatment initiation (8).
Cepheid then introduced a second generation of GeneXpert- based TB diagnosis technology in 2017 – the GeneXpert MTB/Rif Ultra cartridge (Xpert Ultra) (9–11), which has a 5% increased sensitivity compared to the older version, allowing for the identification of additional TB cases, despite a 3% loss of specificity. The turnaround time (TAT) for Xpert Ultra is 67–80 minutes, making it almost twice as fast as its predecessor (6, 9, 12, 13). Since September 2018 the Armenian NTP has successfully managed to incorporate one Xpert Ultra system into routine TB diagnostics at the National Reference Laboratory (NRL) to improve TB case detection, which, due to diagnostic algorithms, is particularly effective in the diagnosis of extrapulmonary TB cases, children and people living with HIV (14).
While the improvement in testing TAT with Xpert Ultra is clear, there is no data on how the incorporation of Xpert Ultra into the Armenia NTP has affected program performance (6, 10).
Potential bottlenecks affecting overall TAT (the time from a sample analysis request to communication of results back to the clinician), include factors not only associated with testing TAT, but also with sample collection, transportation and result communication (15–18). The overall TAT of the diagnostic processes in Armenia has not been previously assessed, neither in the context of Xpert or Xpert Ultra. Therefore, this study aims to evaluate the overall TAT of the Armenian TB diagnostic service in 2017–2018, assess factors associated with TAT delays within the diagnostic process and compare TATs before and after the introduction of Xpert Ultra to the NRL.
METHODS
STUDY DESIGN
This was a cross-sectional study using routinely collected electronic and paper-based data available from the TB NRL and peripheral TB laboratories.
STUDY SETTING
General settings: Armenia is a mountainous upper-middle income country, which is divided into 11 administrative regions. The population of Armenia is about 3 million, with approximately 30% of people living below the poverty line (19–21). In 2006, following WHO recommendations, the Armenian NTP expanded the basic package of services
to provide countrywide, free of charge TB diagnostic and treatment services (8–14). The NTP is run by the Ministry of Health of the Republic of Armenia through the National Tuberculosis Control Centre (NTCC).
TB diagnostic algorithm and laboratory network: TB diagnosis in Armenia is based on the National TB diagnostic algorithm approved by the Ministry of Health, which is in compliance with WHO recommendations (4, 22). Briefly, TB diagnosis is performed through smear microscopy, followed by Xpert (or Xpert Ultra). In addition, as required by the algorithm, cultures on liquid and solid media are carried out on samples as are Line Probe Assay tests if samples are smear-positive or positive based on the Xpert (or Xpert Ultra) report(9).
These tests are carried out in a network of laboratories comprising the NRL, 14 TB peripheral microscopy laboratories, and 10 regional microscopy laboratories that are also equipped with Xpert machines. These microscopy laboratories are distributed throughout the country including in the penitentiary system.
The NRL is currently the only facility with Xpert Ultra.
Culture-based and molecular based (with the exception of the Xpert technique) diagnosis of first- and second-line drug resistance of TB strains are centralized in the NRL.
TB SAMPLE TRANSPORTATION SYSTEM
Samples are collected either directly at the laboratory location or at designated sputum collection points (SCPs) in outpatient centres. A transportation system using vehicles is used to transport sputum samples from these SCPs to peripheral laboratories, regional laboratories or directly to the NRL in regions that lack laboratory capacity. The same system also transports samples between peripheral laboratories and the NRL for Xpert testing. The laboratories and SCPs based in Yerevan, the capital city, can request a transportation vehicle three times per week, while laboratories and collection points based in the other 10 regions of Armenia can only request a transportation vehicle twice per week to transfer samples to the NRL. The same vehicles are used to distribute the paper-based results across the sample collection network, and, therefore result delivery occurs at the same frequency (see Box 1).
Testing that occurs in regional laboratories does not require the use of the transport system if the SCP is located within the facility and therefore the overall TAT for samples processed at these locations equal less than one day.
DATA COLLECTION AND ANALYSIS
Data from all presumptive TB patients between September 2017 and December 2018 were extracted from the NRL
internal electronic database and paper-based laboratory result distribution registers. Data included sociodemographic and clinical characteristics as well as the dates of sample request, sample delivery to Xpert laboratory, sample testing and result reporting to the clinician (Table 1). Overall TAT was defined as the duration between the sample analysis request from the clinician and the clinician receiving back the result.
This time period was then subdivided into microscopy TAT (sample request to a microscopy test result) and GeneXpert TAT (microscopy test result to GeneXpert test result), which together comprised the testing TAT, as well as the reporting TAT (GeneXpert test result to the clinician receiving the Gene Xpert result) (see Box 1). For the purpose of this study, samples with an overall TAT of more than three days were defined as delayed samples whereas those with an overall TAT equal to or less than three days were considered non-delayed.
The statistical analysis was conducted using the EasyStat online statistical platform https://easystat.app/ (23). Chi- squared tests and t-tests were used to test the differences in proportions and means in different groups, respectively. The level of significance was set at 5%. In order to compare the above defined TATs before and after the introduction of Xpert Ultra in September 2018, samples processed at the NRL and the peripheral/regional laboratories of Armenia in the periods of September 2017 – August 2018 and September – December 2018 were compared, with the process, systems, procedures and guidelines otherwise unchanged. It should be noted that the TATs for laboratories outside of the NRL were effectively equal to zero days, so any changes observed are primarily related to those of the NRL.
ETHICAL APPROVAL
The study protocol was approved locally by the Institutional Review Board of the Center of Medical Genetics and Primary Health Care of Armenia. An ethical exemption was also obtained from the WHO Research Ethics Review Committee.
The need for informed consent was waived.
RESULTS
Overall 7307 samples of presumptive TB cases were analysed from September 2017 to December 2018 and comprised the study population. Overall, the male to female gender ratio was 4.4:1, the average age was 46.8 and the overall pulmonary to extrapulmonary TB ratio was 7.9:1. The detailed sample characteristics are presented in Table 1.
The mean overall TAT for all samples between September 2017 and December 2018 was 1.8 (SD ±2.2) days, with the mean microscopy TAT at 0.2 (SD ±0.6) days, GeneXpert TAT at 0.9 (SD ±1.2) days and reporting TAT at 0.7 (SD ±1.6) days.
Overall, 82% of samples were processed within 3 days and therefore classified as non-delayed. Of the remaining 18%, the delays ranged anywhere between the minimal 4 days up to 22 days, but almost all delays (98.3%) were at seven days or less (Fig. 1). There was no difference in the gender distribution of patients whose samples were delayed compared to those whose were not, however, patients whose samples were delayed were found to be significantly, albeit marginally, older than their non-delayed counterparts (46.3 (SD ±18.6) years and 48.9 (SD ±18.7) years, respectively).
The percentage of TAT delays differed depending on the region the sample originated from, ranging from 9.7% in the Lori region to 23.4% in the capital and reference region, Yerevan.
Yerevan had statistically significantly longer overall TAT than five other regions (Fig. 2).
The likelihood of a delayed overall TAT was 17 times higher if the sample was processed at the NRL than if it was tested in regional laboratories from September 2017 – December 2018 (CI=13.5-22.5, P<0.01). Additionally, the odds of a delayed overall TAT was 2.6 times higher in pulmonary cases than in extrapulmonary cases (CI=2.0-3.3, P<0.01) and 40% higher among the samples with TB negative results compared to those with positive results (OR=1.4, CI=1.1-1.8, P<0.01).
In order to compare TATs before and after the introduction of Xpert Ultra in September 2018, the TATs of samples processed in TB laboratories and in the NRL in the periods of September 2017 – August 2018 and September – December 2018 were extracted for additional analysis. Despite the introduction of the Xpert Ultra with its reduced running time, overall TAT delays increased from 2.5 days in 2017 to 3.1 days in this period in 2018 (P<0.01) (Table 2). This increase was associated with delays in reporting TAT, which increased from 1.1 (SD±1.58) to 2.0 (SD±2.92) days (P <0.01)). As expected, the GeneXpert TAT did decrease (1.3 (SD±1.26) to 1.0 (SD±1.01) day (p<0.01) and there was no change in the microscopy TAT with the introduction of Xpert Ultra.
DISCUSSION
We undertook the first evaluation of overall TAT of the TB diagnostic services of the Armenian NTP. Recommended laboratory testing TAT benchmarks are set by WHO, but
these focus solely on testing TAT. We were able to assess the overall TAT, which included both testing and reporting times as well as their components, and studied them separately. This allowed for the operational aspects of the TB diagnosis system to be more widely captured.
We found that the largest number of delays, accounting for almost a quarter of all cases, was found for samples originating from the capital city, Yerevan. This is likely to be due to the overwhelming number of samples received by the NRL for analysis. Outside of the capital, the diagnostic burden is shared by the 10 regional laboratories equipped with Xpert machines, but in Yerevan five out of seven laboratories do not have an Xpert system so samples are being sent to the NRL, which is also receiving samples from SCPs and other peripheral laboratories.
This is in line with our findings that overall TAT delays were dramatically longer in the NRL compared to regional laboratories. In order to cater for the higher diagnostic needs in Yerevan the vehicle transporting both the samples and results generally operates three times a week compared to the twice a week frequency in the regions. However, this frequency was temporarily decreased following the new assignment of NTCC management staff in 2018. Our results here highlight that any interventions to improve the turnaround times of TB diagnostic services, should initially prioritize the capital city region.
The Xpert Ultra was introduced into the NRL in September 2018 to increase the precision of the laboratory services, with the Xpert method introduced in some regional laboratories to decrease the time-to-detection of TB. As expected, in comparing testing TATs before and after the introduction of Xpert Ultra we observed a reduction of around a quarter.
However, this reduction was insufficient to decrease overall TAT and in fact observed a reversing trend, with the overall TAT for the NRL increasing from 2.5 days in 2017 to 3.1 days in the final 3 months of 2018. This increase was shown to be the result of growing delays in reporting TAT, which increased to 2 days from 1.1 days over this period, which are likely to be due the reductions in transportation frequency. Supporting this, we observed a lower overall TAT for extrapulmonary TB cases compared to their pulmonary equivalents. Extrapulmonary TB patients are primarily cared for at the National TB Control Centre, which is adjacent to the NRL and therefore no additional time is required for transporting samples to the NRL and results back to the clinicians.
In addition, we also observed a higher overall TAT for TB negative cases than those that were positive. This could be attributed to the fact that clinicians receive scanned copies of the paper-based results via email for positive cases in addition
to receiving the originals through the transport delivery system, but this is time-demanding for laboratory staff and therefore negative results are only sent out via the vehicle transport system. This is not ideal as despite the priority of treating TB in positive cases in order to reduce the spread of TB in society, presumptive TB patients are sometimes started on first-line TB treatment prior to a laboratory-based diagnosis, therefore, the sooner that negative sample results are reported to the physician, the sooner appropriate action can be taken and a differential diagnosis process can begin. However, in any case, this again highlights the sample transportation system as the limiting factor in clinicians receiving results.
There are important policy and practice implications stemming from the study findings. Although the recently implemented Xpert Ultra allows for a reduced testing TAT for TB, the reporting TAT remains a primary concern in the rapid receipt of diagnostic results by clinicians. The vehicle- based transportation system of results, which is not capable of operating in line with the high TB diagnostic needs of the country needs modernizing, especially in Yerevan, so that the investment in the modern diagnostic systems is worthwhile.
There are indeed plans to introduce two more Xpert Ultra systems into the TB laboratory network in 2020, but our results indicate that patients might not benefit from these additions unless improvements to the result delivery system are also made. We believe that an electronic-based laboratory or health information system could easily and effectively connects all TB clinicians to a united information network and make the immediate reporting of all results possible. The implementation of such an electronic system would substantially reduce reporting and overall TAT and the number of delays as a result of a reliance on the physical transportation of paper-based results throughout Armenia.
This study adhered to the STROBE guidelines for the reporting of observational studies (24), and the data were collected from a routine setting, meaning that the study is likely to reflect operational reality, although some data were not validated with double entry, which could increase the level of error. This study is also limited by the information within the database and could therefore be expanded with the addition of more variables that also may contribute to TAT delays, such as the drug sensitivity level of each TB case and the collection frequency of each specific laboratory. Furthermore the three- day cut-off for a sample being referred to as delayed was chosen based on our own expectations of how the system should function. More work should be done to ascertain how and at what point the delay of a sample becomes detrimental to both the patient and society.
In conclusion, the introduction of rapid TB diagnostic tools in Armenia, need to be accompanied by the introduction of equally efficient systems in the reporting of results to clinicians in order to substantially reduce the time to initiate appropriate treatment and improve the TB situation in Armenia.
Acknowledgements: The authors thank the National TB Control Centre of Armenia for defining the research questions and providing data for this study and the secretariat of the European TB Research Initiative (ERI-TB) at the WHO Regional Office for organizing the Structured Operational Research Training (SORT-TB) for six eastern European countries supported by the United States Agency for International Development (USAID)-WHO regional partnership project to End TB in eastern Europe (RP). The SORT-TB curriculum was an adaptation of the SORT IT course of the Special Programme for Research and Training in Tropical Diseases made for the eastern European context.
We would also like to express thanks to the staff of the National TB Control Centre and National TB reference
laboratory, especially to microbiologist N. Petrosyan, laboratory technicians A. Gasparyan, A. Martirosyan and M.
Gulbandyan, and registrars A. Melkonyan, S Gharibyan and H. Hovhannisyan, to the support staff at the NRL for their uninterruptable and quality work during the time of data collection, and all staff that facilitated organization: European TB research Secretariat WHO Regional Office for Europe, led by Dr. Masoud Dara and supported by Dr. Andrei Dadu.
Sources of funding: This study was funded by United States Agency for International Development. The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
Conflicts of interest: None declared.
Disclaimer: The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization.
BOX 1. DETAILED DESCRIPTION OF ACTIVITIES PERFORMED DURING EACH SPECIFIC TURNAROUND TIME OF THE ARMENIAN TUBERCULOSIS LABORATORY SERVICE, SEPTEMBER 2017 – DECEMBER 2018
Turnaround time* Activities performed during the specified TAT period Additional notes
Overall TAT Testing TAT Microscopy TAT
Sample request by clinician Requests are made by filling out the laboratory request form TB-05
Sample collection from patient Samples are taken in TB care facilities or in laboratories Pick up of sample from the clinician and delivery to the
microscopy laboratories (peripheral, regional or NRL)
Delivery is performed by the transportation system or directly by patients, with a delivery time of <72 hours in cold chain storage
Microscopy testing, and registration of result and
analysis date Results are registered in the paper-based TB-06 form
GeneXpert TAT
Delivery of sample for GeneXpert analysis to a regional
TB laboratory or NRL If the microscopy laboratory is equipped with GeneXpert,
the GeneXpert TAT is assumed to be 0.
Results are registered in paper-based TB-06 form GeneXpert testing and registration of result and analysis
date
Reporting TAT Pick up request for paper-based microscopy and
GeneXpert results (TB-06 form) Vehicle transfer of results Delivery of results to TB doctors
Delivery is performed by the sample transportation system
If the TB outpatient centre includes a TB microscopy and GeneXpert laboratory the reporting TAT is assumed to be 0.
* We defined overall TAT in days
TAT – overall turnaround time (time of test request to communication of results to the clinician) TB – Tuberculosis
TABLE 1. FACTORS ASSOCIATED WITH OVERALL TURNAROUND TIMES AND ITS COMPONENTS OF THE ARMENIAN TUBERCULOSIS LABORATORY SERVICES, SEPTEMBER 2017–DECEMBER 2018
Characteristics Total
n=7307 ≤ 3 days
n=5954 More than 3
days n=1353 OR/Mean
Difference 95% CI P value*
Gender (n,%) Female Male
1350 (18.5) 1087 (18.3) 263 (19.4) 1.1 [0.9, 1.3] 0.31
5957 (81.5) 4867 (81.7) 1090 (80.6) 1
Age (mean (±SD)) 46.8 (±18.6) 46.3 (±18.6) 48.9 (±18.7) 2.6 (±0.6) [1.1, 3.7] <0.01
Type of TB (n,%) Pulmonary Extrapulmonary
6485 (88.8) 5204 (87.4) 1281 (94.7) 2.6 [2.0, 3.3] <0.01
822 (11.2) 750 (12.6) 72 (5.3) 1
Year (n,%) 2017 2018
3573 (48.9) 2870 (48.2) 703 (52.0) 1.2 [1.0, 1.3] 0.01
3734 (51.1) 3084 (51.8) 650 (48.0) 1
Detection of TB GeneXpert (n, %) MTB detected
MTB not detected Trace
552 (7.6) 474 (8.0) 78 (5.8) 1 - -
6733 (92.1) 5461 (91.7) 1272 (94.0) 1.4 [1.1, 1.8] <0.01
22 (0.3) 19 (0.3) 3 (0.2) 1 [0.3, 5.6] 1
GeneXpert (n, %) NRL
Regional
4480 (61.3) 3191 (53.6) 1289 (95.3) 17 [13.5, 22.5] <0.01
2827 (38.7) 2763 (46.4) 64 (4.7) 1
TAT of microscopy (mean (±SD)) 0.2 (±0.6) 0.1 (±0.4) 0.4 (±1.1) 0.3 (±0.03) [0.2, 0.4] <0.01
TAT of GeneXpert (mean (±SD)) 0.9 (±1.2) 0.6 (±0.8) 2.2 (±1.6) 1.7 (±0.1) [1.6, 1.7] <0.01
TAT of reporting (mean (±SD)) 0.7 (±1.6) 0.3 (±0.6) 2.8 (±2.6) 2.5 (±0.1) [2.4, 2.6] <0.01
Overall TAT (mean (±SD)) 1.8 (±2.2) 1 (±1.0) 5.4 (±2.1) 4.5 (±0.1) [4.4, 4.6] <0.01
Overall TAT – overall turnaround time (time of test request to communication of results to the clinician), SD – standard deviation, OR – odds ratio, CI – confidence interval, TB – tuberculosis, MTBC – mycobacterium tuberculosis complex, NRL – National Reference Laboratory, Testing TAT – (comprised of both microscopy and Xpert components) time from sample request by clinician to documentation of Xpert and microscopy results
Testing TAT, microscopy – time from sample request by clinician to documentation of the microscopy test results; Testing TAT, GeneXpert – time from pick up of the samples for GeneXpert analysis to documentation of the GeneXpert test results; Reporting TAT – time from notification of pick up required for paper-based laboratory results of microscopy and GeneXpert (TB-06 form) to clinicians receiving results * Refers to comparisons between the ≤ 3 days group and the > 3 days group.
TABLE 2. COMPARISON OF THE OVERALL TURNAROUND TIMES AND ITS COMPONENTS OF THE ARMENIAN TUBERCULOSIS NATIONAL REFERENCE LABORATORY SERVICES BEFORE AND AFTER THE IMPLEMENTATION OF GENEXPERT ULTRA, SEPTEMBER 2017 – DECEMBER 2018
Variables Total
N=4480 Xpert
N=3874 XpertUltra
N=606 Mean
Difference 95% CI P value
mean (±SD)
Microscopy TAT 0.2 (±0.6) 0.2 (±0.53) 0.2 (±0.73) 0.0 (± 0.03) [0.0, 0.1] 0.66
GeneXpert TAT 1.2 (±1.2) 1.3 (±1.26) 1.0 (±1.01) 0.3 (±0.05) [0.2, 0.3] <0.01
Reporting TAT 1.2 (±1.8) 1.1 (±1.58) 2.0 (±2.92) 0.9 (±0.12) [0.6,1.1] <0.01
Overall TAT 2.6 (±2.3) 2.5 (±2.12) 3.1 (±3.11) 0.6 (±0.13) [0.4,0.9] <0.01
SD – standard deviation, OR – odds ratio, CI – confidence interval, Overall TAT – overall turnaround time (time of test request to communication of results to the clinician), Microscopy TAT– time from sample request by clinician to documentation of the microscopy test results; GeneXpert TAT, – time from pick up of the samples for GeneXpert analysis to documentation of the GeneXpert test results; Reporting TAT – time from notification of pick up required for paper-based laboratory results of microscopy and GeneXpert (TB-06 form) to clinicians receiving results
FIG. 1. THE DISTRIBUTION OF THE OVERALL TURNAROUND TIME OF THE TUBERCULOSIS
LABORATORY SERVICES IN ARMENIA FROM SEPTEMBER 2017 TO DECEMBER 2018
FIG. 2. PERCENTAGE OF DELAYED AND NON-DELAYED OVERALL TURNAROUND TIMES OF THE ARMENIAN TUBERCULOSIS LABORATORY SERVICES 2017–2018 BY REGION OF SAMPLE ORIGIN
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40 35 30 25 20 15 10 5
0 1 2
36
24
13
9 7
4 4
1 2
3 4 5 6 7 8–22
-
Overall TAT distribution, %
Overall TAT, days
Regions
Percentage of delayed samples Yerevan*
Artsakh Armavir Gegarkunik Aragatsotn Syunik**
Shirak**
Tavush**
Vayots dzor Kotayk**
Ararat Lori**
0% 10%
Non-delayed TAT n=5954
20% 30% 40% 50% 60% 70% 80% 90% 100%
Delayed TAT n=1353
90.3% 9.7%
88.9% 11.1%
87.7% 12.3%
84.1% 15.9%
83.9% 16.1%
82.3% 17.7%
81.9% 18.1%
79.6% 20.4%
79.1% 20.9%
77.4% 22.6%
76.9% 23.1%
76.6% 23.4%
Overall TAT (turnaround time) is the time from sample analysis request to the
communication of results back to the clinician) * Reference group
** Significantly different from the reference group, p<0.05.
TAT – overall turnaround time (time of test request to communication of results to the clinician)
Non-delayed TAT – 3 days or less, Delayed TAT – more than 3 days
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