Tuberculosis in Moldova

The Republic of Moldova is a small country in eastern Europe with a population of about 4 million that gained independence from the Soviet Union in 1991. Moldova is high burden TB and MDR-TB country. WHO estimate the TB incidence in country on 153/100,000 population, which is the highest TB incidence in the European Region in 2014(D.1). Reasons for the high TB and MDR-TB burden in the country include poverty, lack of rapid diagnostic capacities and inconsistent availability of anti-TB drugs, especially for the treatment of MDR-TB. Patients with TB, especially MDR-TB, are long-term hospitalized and hospitals are inadequately equipped with infection control measures to prevent nosocomial infection.

As was the case of most countries of the former Soviet Union, following independence the tuberculosis (TB) situation substantially worsened, with an increase in TB incidence from 39/100,000 in 1990 to 133/100,000 in 2005, and decrease up to 88/100,000 in 2015. Similarly, TB mortality increased from 4/100,000 to 18/100,000 during the same period, and decrease up to 8/100,000 in 2015 (D.2).

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The prevalence of MDR-TB in the Republic of Moldova was 23% in new cases and 63% re-treatment cases in 2014. The country has high burden of drug resistance and high burden of TB/HIV co-infection. An extremely high burden of drug resistance and its delayed diagnosis represents the key problem for TB control in Moldova (D.3). In 2014, 98% of TB patients were tested for HIV infection, and 6.2% were co-infected. The high prevalence of MDRTB patients was detected in big cities and the territories around municipalities.   In total most of 58% of MDRTB patients were notification in only 10 territories, from 42 districts and 4 municipality of Moldova (D.4).

 

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Moldova undertook reforms in tuberculosis control and health care consistent with international recommendations and advanced towards the global target for case detection. The National TB Program (NTP) ensures universal access to diagnosis of TB and DR-TB, with high coverage by rapid methods and drug-susceptibility testing (DST). Passive case finding is the main method of TB case detection and is carried out through investigation of symptomatic individuals (TB suspects) seeking medical assistance. Diagnosis of TB is established in the specialized TB cabinets, located within the outpatient consultative departments in each peripheral district of the country. Diagnosis is established by direct sputum smear microscopy and Gene Xpert MTB/RIF, complemented by culture methods investigations and additional clinical and X-ray examinations. Universal access is ensured to treatment of MDR-TB and ARV treatment.
The laboratory network has been substantially strengthened over the last years. The TB laboratory service in Moldova is well developed into three diagnostic levels (D.5). The first level consists of 59 microscopy centers (MC), situated at TB outpatient facilities (in average one laboratory per 77,000 population). In addition, 70 sputum collection points, attached to TB cabinets are also included in this level. The microscopy laboratories participate in proficiency testing (LQAS) organized by the National Reference Laboratory (NRL) which is performed as an “on site evaluation” during the monitoring visits. The main activities in the MC are the sputum investigation by smear microscopy and Xpert MTB/RIF. The average number of samples are 2000 sputum per year. There are a total 59 Xpert MTB/RIF instruments functional in the country (including AIDS Centers and the penitentiary system). The machines and cartridges have been provided with TB REACH project support.

The second level is represented by three Regional Reference Laboratories (RRLs), which perform culture and drug susceptibility testing (DST), and report the data to the NRL and are responsible for quality control of microscopy centers in respective areas.

The third level is represented by the NRL, situated at the Institute of Phthisiopneumology (IPP) in Chisinau. This laboratory carries out the leading role in organizing TB laboratory services in the country, development of protocols for laboratory diagnosis, training and supervision.
The routine courier sputum transportation system is functional and covers transportation of sputum specimens from peripheral microscopy centers to RRLs and NRL for culturing and DST. Each of these laboratories serves a defined region in the country.

The rapid methods of TB diagnostic are well developed and processes the full range of investigations (D.6). The automated MGIT technique for rapid culturing and DST is implemented in the country since 2005. Molecular methods (MDRTB Plus, LPA Hain method) are implemented since 2009.

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The external quality assurance (EQA) for Moldova is undertaken by the Supranational Reference Laboratory in Borstel, Germany, starting 2005. The laboratories have achieved over 95% level of coincidence in results starting from 2007.
Electronic surveillance of all TB data, including notification, treatment outcomes and microbiological investigations on national level online.

In spite of achievements, many challenges remain for Moldova. During a period of increasing case detection, the treatment success rate did not increase. MDR-TB) are threats to Moldova’s strive to reach global targets. An ongoing study is estimating the extent of drug-resistant TB in Moldova. As a result, drug resistance increased step-wise with the eventual emergence and transmission of multi-drug resistant strains, which today pose a problem in the implementation and success of the National TB Program.