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Background: Despite the substantial global impact of influenza, there are limited economic data to guide influenza vaccination programs investments in middle-income countries. We measured the costs of influenza and the costs of an influenza vaccination program in Armenia, using a societal perspective., Methods: During December 2022 through March 2023, retrospective cost data were collected from case-patients and healthcare providers through structured questionnaires at 15 healthcare facilities selected through stratified sampling. Medical costs included medications, laboratory costs, laboratory and diagnostic tests, and routine health care service costs and direct and indirect societal costs were included. Vaccination program costs from the 2021-2022 influenza season were identified using accounting records and categorized as: planning, distribution, training, social mobilization and outreach, supervision and monitoring, procurement, and national- and facility-level administration and storage., Results: The mean costs per episode for SARI and ILI case-patients were $US 823.6 and $US 616.57, respectively. Healthcare service costs were the largest direct expenses for ILI and SARI case-patients. Total costs of the 2021-2022 influenza vaccination program to the government were $US 4,353,738, with the largest costs associated with national- and facility-level administration and storage (30% and 65% respectively). The total cost per dose administered was $US 25.61 ($US 7.73 per dose for procurement and $US 17.88 for the marginal administration cost per dose)., Conclusions: These data on the costs of seasonal influenza prevention programs and the societal costs of influenza illness in Armenia may inform national vaccine policy decisions in Armenia and may be useful for other middle-income countries. Influenza vaccines, like other vaccine programs, are recognized as substantially contributing to the reduction disease burden and associated mortality and further driving economic growth. However, a formal cost-effectiveness analysis should be performed once burden of disease data are available., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Introduction: Armenia's favorable geographical and climatic conditions support mosquitoes, sandflies, and ticks that can transmit various diseases. This study aimed to determine the prevalence of these vectors and circulating arboviruses in Armenia and assess healthcare workers` knowledge of arboviral diseases., Methodology: In 2021, we conducted fieldwork, combining morphological identification of vectors with polymerase chain reaction (PCR) analysis of pathogens to map the distribution of potential arbovirus vectors across Armenia., Results: Our entomological surveys identified four mosquito genera-Anopheles, Aedes, Culex, and Culiseta-comprising 20 species; and 11 species of Ixodidae ticks. Culex pipiens was found in all 11 regions, while Culiseta spp. was absent in Ararat Province. PCR testing of mosquito and tick samples revealed Crimean-Congo hemorrhagic fever virus (CCHFV) in 13 tick samples, but West Nile virus (WNV) was not detected in mosquitoes. Specifically, 13 out of 525 Ixodes tick pools tested positive for CCHFV; the positive samples originated from Hyalomma marginatum ticks in Syunik's Sisian region. None of the 11 pools that contained 473 Cx. pipiens mosquitoes tested positive for WNV. Analysis of questionnaires from 499 healthcare workers showed that epidemiologists, infectious disease specialists, and family doctors had greater awareness of arboviral diseases than other specialists. However, there was a low rate of sample submission for laboratory diagnosis and confirmation., Conclusions: The extensive presence of vectors combined with limited knowledge of arboviral diseases complicates disease understanding in Armenia. Strengthening the surveillance system through training and improved sample collection is essential for disease monitoring and public health interventions., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2024 Lilit Babayan, Arsen Manucharyan, Lusine Paronyan, Haykuhi Vardanyan, Ruben Danielyan, Gayane Melik-Andreasyan, Jenna E Achenbach.)

Background: The COVID-19 pandemic has imposed immense stress on global health care systems, especially in low- and middle-income countries (LMICs). Armenia, a middle-income country in the Caucasus region, contended with the pandemic and a concurrent war, resulting in significant demand on its already strained health care infrastructure. The COVID@home program was a multi-institution, international collaboration to address critical hospital bed shortages by implementing a home-based oxygen therapy and remote monitoring program., Objective: The objective of this study was to describe the program protocol and clinical outcomes of implementing an early discharge program in Armenia through a collaboration of partner institutions, which can inform the future implementation of COVID-19 remote home monitoring programs, particularly in LMICs or low-resource settings., Methods: Seven hospitals in Yerevan participated in the COVID@home program. A web app based on OpenMRS was developed to facilitate data capture and care coordination. Patients meeting eligibility criteria were enrolled during hospitalization and monitored daily while on oxygen at home. Program evaluation relied on data extraction from (1) eligibility and enrollment forms, (2) daily monitoring forms, and (3) discharge forms., Results: Over 11 months, 439 patients were screened, and 221 patients were managed and discharged. Around 94% (n=208) of participants safely discontinued oxygen therapy at home, with a median home monitoring duration of 26 (IQR 15-45 days; mean 32.33, SD 25.29) days. Women (median 28.5, mean 35.25 days) had similar length of stay to men (median 26, mean 32.21 days; P=.75). Despite challenges in data collection and entry, the program demonstrated feasibility and safety, with a mortality rate below 1% and low re-admission rate. Opportunities for operational and data quality improvements were identified., Conclusions: This study contributes practical evidence on the implementation and outcomes of a remote monitoring program in Armenia, offering insights into managing patients with COVID-19 in resource-constrained settings. The COVID@home program's success provides a model for remote patient care, potentially alleviating strain on health care resources in LMICs. Policymakers can draw from these findings to inform the development of adaptable health care solutions during public health crises, emphasizing the need for innovative approaches in resource-limited environments., (©Lusine Musheghyan, Nika M Harutyunyan, Abu Sikder, Mark W Reid, Daniel Zhao, Armine Lulejian, James W Dickhoner, Nicole T Andonian, Lusine Aslanyan, Varduhi Petrosyan, Zhanna Sargsyan, Shant Shekherdimian, Alina Dorian, Juan C Espinoza. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 30.09.2024.)

Hepatitis C virus (HCV) infection is among the leading causes of cirrhosis and hepatocellular carcinoma. Knowledge of its prevalence and risk factors can help to effectively fight the virus. This study was the first to investigate the seroprevalence of HCV, its genotypes, and factors associated with it among the general adult population of Armenia selected countrywide via cluster sampling. Anti-HCV antibodies were detected using third-generation immunoassay. Polymerase chain reaction and genotyping was performed among anti-HCV-positive individuals. Shortly after testing, the participants underwent a telephone survey. Logistic regression models were fitted to identify factors associated with anti-HCV antibody positivity and chronic HCV infection. The prevalence of anti-HCV antibodies among 3831 tested individuals was 2% (99% CI 1.4, 2.5), and chronic HCV infection was 0.7% (99% CI 0.4, 1.0), with genotypes 3 and 2 being the most common. The risk factors for chronic HCV infection included self-reported chronic liver disease (95% CI 1.47, 15.28), having tattoos (95% CI 1.34, 10.94), ever smoking (95% CI 1.16, 9.18), and testing positive for hepatitis B virus core antibody (95% CI 1.02, 7.17). These risk factors demonstrate that there could be room for strengthening infection control measures to prevent the transmission of HCV in Armenia.

Introduction: The success of health education programs heavily depends on the individuals' ability to comprehend information and apply it when making decisions regarding health. Low health literacy can lead to poor health in the context of both chronic and infectious diseases, as it influences a range of health-related behaviors. Little is known about infectious disease-related health literacy in Armenia and countries of similar socio-economic profiles. We aimed to quantify the levels of infectious disease-related health literacy and knowledge among the Armenian population and explore the underlying socio-economic factors., Materials and Methods: We conducted a nationwide phone survey among 3483 adults selected via stratified two-stage probability proportional to size sampling in 2021. Descriptive statistics, simple and multivariable regression were used for the analysis., Results: The average age of respondents was 49.5 years. The majority were female (71.0%) and had at least 12 years of schooling (70.5%). The mean literacy score was 5.64 out of 7 (SD:1.06). The mean infectious disease knowledge score was 2.48 out of 4 (SD:1.19). Younger age, female gender, higher level of education, city residence, being employed, and having higher monthly expenditures were associated with higher mean scores of infectious disease-related health literacy and knowledge. In multivariable linear regression analysis, all the socio-demographic characteristics remained significant for both dependent variables., Conclusions: The study results revealed population groups with a higher infectious disease-related health literacy and knowledge. Interventions should focus on groups lagging behind to engage them in proper prevention practices to protect themselves and improve health status of Armenian population., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Sargsyan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Removing legal barriers to HIV services is crucial for the global 2030 goal of ending the HIV and AIDS epidemic, particularly in eastern Europe, the Caucasus and central Asia. Despite state commitments to uphold human rights, gay, bisexual and other men who have sex with men (gbMSM), along with transgender people (TP) still face stigma and discrimination. This article presents an analysis of rights violations based on sexual orientation and gender identity (SOGI) and HIV reported in 2022 across six countries, highlighting features and their links to legislation and law enforcement practices., Methods: We examined documented cases of rights violations among gbMSM and TP in Armenia, Kazakhstan, Kyrgyzstan, Tajikistan, Uzbekistan and Ukraine in 2022 using the REAct system, a tool for documenting and responding to rights violations against key populations. Initially, we employed directed content analysis based on Yogyakarta Principles to analyse narratives of violations. A codebook was developed through contextual, manifest and latent coding, with themes, categories and codes converted into quantitative variables for statistical analysis. Descriptive statistics were used to identify the characteristics of violations., Results: A total of 456 cases of rights violations related to SOGI and HIV were documented, ranging from 22 cases in Tajikistan to 217 in Ukraine. Most violations concerned gbMSM (76.5%), with one-fifth involving TP, predominantly transgender women. Complex violations with multiple perpetrators or infringements were documented in Armenia and central Asia. Privacy rights were commonly violated, often through outing. Cases of violations of the right to the highest attainable standard of health (13.6%) and protection from medical abuses (2.6%) were also documented. Other rights violations were sporadic, with each country exhibiting distinct patterns of violated rights and types of violations. In Ukraine, the full-scale war in 2022 influenced the nature of documented cases, reflecting the challenges faced by gbMSM and TP., Conclusions: Monitoring rights violations proved effective for assessing the situation of gbMSM and TP, particularly in the insufficiently studied and diverse eastern Europe, Caucasus and central Asia regions. As rights violations are linked to both legislation and law enforcement practices, comprehensive interventions to minimize structural and interpersonal stigma are essential., (© 2024 The Author(s). Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.)

Introduction: Despite being highly preventable, cervical cancer (CC) is the eighth most prevalent form of female cancer in Armenia and the second most common malignancy among those aged 15 to 44. In Armenia, there is an age-standardized incidence of 7.8 per 100,000 females, and an age-standardized mortality of 4.6 per 100,000 females. Globally, the CC is the 4th most common cancer among women. Its incidence was 604,127 new cases and 341,831 deaths in 2020. We conducted a retrospective, observational cohort study using clinical data to verify the influence of HPV vaccine (Gardasil, Merck&CO) on fertility function in women, vaccinated in RA since 2017 year in the limits of anti-HPV vaccination Program (included in National Vaccination Calendar)., Materials and Methods: For the study, we analyzed data received from Armenian-American Wellness Center (Yerevan, Armenia). 98 female volunteers vaccinated with the 4vHPV who attended AAWC and were examined for reproductive function. The subjects were divided into 3 age groups - 1st group - 15 years -24 years 11 months, 2nd group - 25 years -34 years 11 months, 3rd group - 35 -40 years. Each control group was composed of randomly selected 30 healthy women in age identical to the main group who applied AAWC for regular checkup in the same time frame and have never been exposed to anti HPV vaccine., Results: The current research is aimed to reveal any negative impact of 4vHPV vaccine on fertility indicators in Armenian cohort. The performed comparative statistical analysis of the assessed indicators has revealed the ORs<1 for POI, late fertilization disorders of menstrual cycle and anovulation prevalence indicators. The chance of investigated disorders' development in 4vHPV vaccine exposed cohort did not exaggerate that in non-exposed sample cohort. The significant difference was not observed in Anti-Mullerian Hormone, FSH basal levels, as well as in mean ovarian volume and number of antral follicles indicators between clinical and respective control groups (p<.05)., Conclusion: The data obtained make us to conclude about absence of any negative impact of 4vHPV vaccine on fertility function indicators in 4vHPV vaccinated cohort in RA. The study results contribute to perception of the 4vHPV vaccine safety concept, what in its turn can trigger increase of vaccination coverage leading to CC control efficiency.

Purpose: This study assessed the prevalence of cataract blindness, cataract surgical coverage (CSC), effective CSC, visual outcome after cataract surgery, and barriers to cataract surgery in a population aged 50 years and older in Armenia using Rapid Assessment of Avoidable Blindness (RAAB) methodology., Methods: The study sample included 2258 individuals aged 50 years and older who were randomly selected from 11 provinces of Armenia in 2019 following the RAAB methodology. The study team randomly selected 50 clusters, 50 people in each. The RAAB survey form was used to collect information on cataract blindness, visual outcome after cataract surgery, and barriers to cataract surgery., Results: The mean age of the participants was 65.3 (SD = 9.9) ranging from 50 to 99. The majority of participants were women (65.6%). Age- and sex-adjusted prevalence of blindness due to all causes was 1.5%; of which 36.4% was bilaterally blind due to cataract. The CSC and effective CSC at a cataract surgical threshold of <6/12 were 55.1% and 24.4%, respectively. Good outcome was reported in 43.7% of eyes after cataract surgery, borderline in 37.2% of eyes, and poor outcome in 19.1%. The main barriers to cataract surgery included "cost," "need not felt," or "fear.", Conclusion: The prevalence of cataract blindness in our study was higher compared to high-income regions and lower than estimates from South/Southeast Asia. This study suggests the urgent need to update the National Strategic Plan to prevent blindness in Armenia with a focus on improving the quality and coverage of cataract surgery.

We aimed to investigate the role of pre-, peri- and neonatal risk factors in the development of autism spectrum disorder (ASD) among Armenian children with the goal of detecting and addressing modifiable risk factors to reduce ASD incidence. For this purpose a retrospective case-control study using a random proportional sample of Armenian children with ASD to assess associations between various factors and ASD was conducted. The study was approved by the local ethical committee, and parental written consent was obtained. A total of 168 children with ASD and 329 controls were included in the analysis. Multivariable logistic regression analysis revealed that male gender, maternal weight gain, use of MgB6, self-reported stress during the pregnancy, pregnancy with complications, as well as use of labor-inducing drugs were associated with a significant increase in the odds of ASD, whereas Duphaston use during pregnancy, the longer interpregnancy interval and birth height were associated with decreased odds of ASD. These findings are pertinent as many identified factors may be preventable or modifiable, underscoring the importance of timely and appropriate public health strategies aimed at disease prevention in pregnant women to reduce ASD incidence., (© 2024. The Author(s).)

Background: The COVID-19 pandemic has presented significant global healthcare challenges, particularly impacting the continuity of essential health services in low- and middle-income countries. This study investigates the impact of the COVID-19 pandemic on the utilization and provision of essential health services in Armenia., Methods: We employed a conventional qualitative study design, conducting semi-structured in-depth interviews (n = 17) within public and private primary healthcare (PHC) facilities in Armenia in 2021. Our study participants encompassed physicians providing specialty services in PHC facilities (e.g. endocrinologists, gynecologists/obstetricians, and pediatricians), regular visitors to PHC facilities (e.g. adults with chronic diseases, parents of children), and policymakers. Thematic analysis was conducted, yielding five emergent categories: mobilization and organization of PHC services during COVID-19; PHC visits during COVID-19; worsening of chronic conditions due to the decline in PHC visits; problems with routine childhood vaccinations; and patient-provider communication challenges., Results: The number of in-person visits to PHC facilities declined due to adaptations in service delivery, imposed lockdown measures, and the public's fear of visiting healthcare facilities. Maternal and child health services continued with no major disruptions. PHC providers deliberately limited the number of maternal and child visits to essential antenatal care, newborn screenings, and routine childhood immunizations. Still, children experienced some delays in vaccination administration. The pandemic resulted in a notable reduction in follow-up visits and monitoring of patients with chronic conditions, thereby exacerbating their chronic conditions. Phone calls were the primary method of patient-provider communication during the pandemic., Conclusions: The COVID-19 pandemic has had a profound impact on the delivery and utilization of essential healthcare services at PHC facilities, especially for those with chronic conditions who needed continuous care. Unified national-level guidance and technical capacity are needed to direct the provision of essential services at the PHC level, promote effective health communication, and implement digital platforms for the uninterrupted provision of essential care during public health emergencies., (© 2024. The Author(s).)

Purpose: This study aimed to assess the association between migraine headache and glaucoma among the adult population living in Armenia., Methods: This case-control study recruited 145 cases with glaucoma and 250 controls without glaucoma and other ocular disorders except refractive error from Optomed Canada Diagnostic Eye Center in Armenia. A structured questionnaire contained questions on socio-demographics, family history of glaucoma and stroke, ocular health, smoking, migraine, and obstructive sleep apnea. The Migraine Screening Questionnaire assessed possible migraine and the Berlin Questionnaire measured obstructive sleep apnea., Results: The mean ages of cases and controls were 63.3 (SD = 12.3) and 39.5 (SD = 13.5), respectively. Females comprised 62.8% of cases and 69.1% of controls. A total of 17.8% of cases and 19.0% of controls had possible migraine. In the adjusted analysis older age (OR 1.17; 95% CI 1.12; 1.23), average/lower than average socio-economic status (OR 5.27; 95% CI 1.30; 21.3), and family history of glaucoma (OR 4.25; 95% CI 1.51; 11.9) were associated with high-tension glaucoma., Conclusion: Timely case detection of glaucoma among those with average/low socio-economic status and those with family history of glaucoma could prevent further progression of the disease. Further studies to explore the relationship between migraine headache and specific types of glaucoma may be worthwhile., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Objectives: This study sought to determine the prevalence and associated factors of hepatitis B virus (HBV) infection ever in life and chronic HBV infection in Armenia., Design: A population-based cross-sectional seroprevalence study combined with a phone survey of tested individuals., Setting: All administrative units of Armenia including 10 provinces and capital city Yerevan., Participants: The study frame was the general adult population of Armenia aged ≥18 years., Primary and Secondary Outcome Measures: The participants were tested for anti-HBV core antibodies (anti-HBc) and HBV surface antigen (HBsAg) using third-generation enzyme immunoassays. In case of HBsAg positivity, HBV DNA and hepatitis D virus (HDV) RNA PCR tests were performed. Risk factors of HBV infection ever in life (anti-HBc positivity) and chronic HBV infection (HBsAg positivity) were identified through fitting logistic regression models., Results: The seroprevalence study included 3838 individuals 18 years and older. Of them, 90.7% (3476 individuals) responded to the phone survey. The prevalence of anti-HBc positivity was 14.1% (95% CI 13.1% to 15.2%) and HBsAg positivity 0.8% (95% CI 0.5% to 1.1%). The viral load was over 10 000 IU/mL for 7.9% of HBsAg-positive individuals. None of the participants was positive for HDV. Risk factors for HBsAg positivity included less than secondary education (aOR=6.44; 95% CI 2.2 to 19.1), current smoking (aOR=2.56; 95% CI 1.2 to 5.6), and chronic liver disease (aOR=8.44; 95% CI 3.0 to 23.7). In addition to these, risk factors for anti-HBc positivity included age (aOR=1.04; 95% CI 1.04 to 1.05), imprisonment ever in life (aOR=2.53; 95% CI 1.41 to 4.56), and poor knowledge on infectious diseases (aOR=1.32; 95% CI 1.05 to 1.67), while living in Yerevan (vs provinces) was protective (aOR=0.74; 95% CI 0.59 to 0.93)., Conclusion: This study provided robust estimates of HBV markers among general population of Armenia. Its findings delineated the need to revise HBV testing and treatment strategies considering higher risk population groups, and improve population knowledge on HBV prevention., Competing Interests: Competing interests: None declared., (© World Health Organization 2024. Licensee BMJ.)

Purpose: Central nervous system (CNS) tumors are the most common solid malignancies in children worldwide, including in Armenia. The current study aims to analyze epidemiological data, treatment, and outcomes of children and young adults (≤25 years) with CNS tumors in Armenia during the last 26 years., Methods: We collected data from pediatric and young adult patients treated in selected sites in Armenia from 1 st January 1995 to 31 st December 2020. Incidence by sex, age at diagnosis, time from first complaints to diagnosis, histopathology results, treatment strategies, complications, and overall survival (OS) rates were calculated., Results: The multicenter data analysis revealed 149 patients with diagnosed primary CNS tumors over 26 years. Among them, 84 (56.4%) were male. The median age at diagnosis was 7 years (range, 3 months to 25 years), and the median time from the first complaints to diagnosis was 2 months (range, 1 week to 70 months). Medulloblastomas and other embryonal tumors (47), low-grade gliomas (32), and high-grade gliomas (22) were the most commonly diagnosed malignancies. Ependymomas, craniopharyngiomas, germ cell tumors, and other malignancies were observed in 22 patients. For 26 patients, no histopathological or radiological diagnosis was available. Follow-up information was available for 98 (65.8%) patients. The 5-year OS rate for the whole study group was 67.7%., Conclusion: Consistent with international data, embryonal tumors, and gliomas were the most commonly diagnosed CNS malignancies in Armenia. Multimodal treatment was often not available in Armenia during the study period, especially for early cases., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: This study aimed to estimate the prevalence and main causes of blindness and visual impairment in population aged 50 years and older in Armenia using Rapid Assessment of Avoidable Blindness (RAAB) methodology., Methods: The study team randomly selected 50 clusters (each consisting of 50 people) from all 11 regions of Armenia. Data on participants' demographics, presenting visual acuity, pinhole visual acuity, principal cause of presenting visual acuity, spectacle coverage, uncorrected refractive error (URE), and presbyopia were collected using the RAAB survey form. Four teams of trained eye care professionals completed data collection in 2019., Results: Overall, 2,258 people of 50 years and older participated in the study. The age- and gender- adjusted prevalence of bilateral blindness, severe and moderate visual impairment were 1.5% (95% CI: 1.0-2.1), 1.6% (95% CI: 1.0-2.2) and 6.6% (95% CI: 5.5-7.7), respectively.The main causes of blindness were cataract (43.9%) and glaucoma (17.1%). About 54.6% and 35.3% of participants had URE and uncorrected presbyopia, respectively. The prevalence of bilateral blindness and functional low vision increased with age and was the highest in participants 80 years and older., Conclusion: The rate of bilateral blindness was comparable with findings from countries that share similar background and confirmed that untreated cataract was the main cause of blindness. Given that cataract blindness is avoidable, strategies should be developed aiming to further increase the volume and quality of cataract care in Armenia.

Background: The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems throughout the world. Many patients faced delays and cancellation of care due to scaled back services, mobility restrictions, and concerns related to the risk of infection. The present study aimed to assess the prevalence of and risk factors associated with the avoidance or delay of medical care due to COVID-19 in Armenia., Methods: We conducted a cross-sectional telephone survey of 3,483 adults across Armenia. We used stratified two-stage cluster sampling to select the participants from different age groups proportionate to their size in the population. Logistic regression analysis assessed the association of risk factors with avoidance/delay of routine, urgent/emergency, and any medical care., Results: The mean age of the sample was 49.5 (SD = 14.8), ranging from 18 to 90. About 9.9% of the respondents avoided/delayed any type of medical care; whereas 5.5% avoided/delayed urgent/emergency care and 6.6% routine care. In the adjusted analysis, female gender and higher monthly expenditures were associated with avoidance/delay of routine medical care. Factors associated with delay/avoidance of urgent/emergency care included female gender and higher perceived threat of COVID-19. Younger age, female gender, higher perceived threat and not being vaccinated against COVID-19 were associated with avoidance/delay of any medical care in the adjusted analysis., Conclusion: Since avoiding or delaying care might increase morbidity and mortality associated with conditions not related to COVID-19, identifying population groups that are more likely to avoid care is important. Targeting such groups with educational interventions focusing on the risks of using versus not using medical care in times of pandemic might be crucial. Ensuring the provision of in-home healthcare services for high-risk groups might help to address important medical care needs during the pandemic., (© 2023. The Author(s).)

Introduction: Armed conflict worldwide and across history has harmed the health of populations directly and indirectly, including generations beyond those immediately exposed to violence. The 2020 war between Armenia and Azerbaijan over Nagorno-Karabakh, inhabited by an ethnically Armenian population, provides an example of how conflict harmed health during COVID-19. We hypothesised that crises exposure would correspond to decreased healthcare utilisation rates and worse health outcomes for the maternal and infant population in Armenia, compounded during the pandemic., Methods: Following a mixed-methods approach, we used ecological data from 1980 to 2020 to evaluate health trends in conflict, measured as battle-related deaths (BRDs), COVID-19 cases, and maternal and infant health indicators during periods of conflict and peace in Armenia. We also interviewed 10 key informants about unmet needs, maternal health-seeking behaviours and priorities during the war, collecting recommendations to mitigate the effects of future crisis on maternal and infant health. We followed a deductive coding approach to analyse transcripts and harvest themes., Results: BRDs totalled more in the 2020 war compared with the previous Nagorno-Karabakh conflicts. Periods of active conflict between 1988-2020 were associated with increased rates of sick newborn mortality, neonatal mortality and pre-eclampsia or eclampsia. Weekly average COVID-19 cases increased sevenfold during the 2020 Nagorno-Karabakh war. Key informants expressed concerns about the effects of stress and grief on maternal health and pregnancy outcomes and recommended investing in healthcare system reform. Participants also stressed the synergistic effects of the war and COVID-19, noting healthcare capacity concerns and the importance of a strong primary care system., Conclusions: Maternal and infant health measures showed adverse trends during the 2020 Nagorno-Karabakh war, potentially amplified by the concurrent COVID-19 pandemic. To mitigate effects of future crises on population health in Armenia, informants recommended investments in healthcare system reform focused on primary care and health promotion., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Mortality from tuberculosis has decreased from 11.89 deaths per 100,000 population in 1990 to 4.18 deaths per 100,000 population in Kazakhstan in 2019. Thus, the deviation was (-)35.5%. If Kazakhstan showed the above result over the 29-year period, then how are things with other republics that were part of the Soviet Union and how have the countries' economies changed? Aim - determination of the difference in 15 republics using the mortality rate from tuberculosis per 100,000 population. The study included the following countries: Ukraine, Georgia, Kazakhstan, Kyrgyzstan, Uzbekistan, Russia, Estonia, Lithuania, Latvia, Turkmenistan, Tajikistan, Belarus, Moldova, Azerbaijan, Armenia. The analysis was carried out using the Global burden of diseases database. A relatively high reduction in TB mortality was found in Kazakhstan (-3.61%). In second place is Estonia (-3.25%), in third place is Azerbaijan (-2.39%), in fourth place is Latvia (-2.16%), and the top five is closed by Georgia (-1.98%). Despite the high level of GDP, countries such as Russia (6th place in the world ranking of GDP per capita) and Ukraine (42nd place in the world ranking of GDP per capita) are not in the leading positions in reducing the burden of TB. For example, Russia is in 10th place (-0.81%) in terms of the percentage reduction in mortality from TB, and Ukraine is in last place. According to the Global Burden of Disease, Ukraine has seen an increase in TB mortality (+1.62%). The leader among the former Soviet countries in terms of spending on the healthcare system is Armenia (12.24%). In general, current public spending on health care per capita is 11.6 times lower than in OECD (Organization for Economic Cooperation and Development) member countries: in 2020 in Kazakhstan this indicator was 341.5 USD, in the OECD - on average 3 959 USD. According to WHO recommendations for sustainable development, financing of the health care system should be up to 5% of GDP, while the share of private spending should not exceed 20% of current health care spending. As the experience of developed countries shows, the level of life expectancy directly depends on the financing of the healthcare system.

Canine dirofilariasis is a world-wide distributed mosquito-borne helminthiasis that has a potential zoonotic impact. This disease is a serious problem in Southern Caucasus region, including Armenia. Average extensity of Dirofilaria infection in canids in Armenia is 26.9%. At present, 77 mosquito species (Diptera: Culicidae) are presumed to have a role in the transmission of dirofilariasis. 80 species of Culicidae family mosquitoes are registered in Southern Caucasus Region, and 31 of them are described in Armenia. The following species of Culicidae can serve as vectors of Dirofilaria spp. in Armenia: Aedes vexans, Ae. caspius, Ae. albopictus, Ae. geniculatus, Culex pipiens, Cx. theileri, Cx. modestus, Anopheles maculipennis s.s., An. claviger, An. hyrcanus, An. superpictus, Coquillettidia richardi, Culiseta annulata and Uranotaenia unguiculta. We see a risk of transmission in active foci of dirofilariasis, as well as for human infection in Armenia. Comprehensive research should be conducted on detection of microfilariae in the target mosquito species and in target localities.

Medical aspects of the organization of replenishment of the Armed Forces with healthy and physically strong personnel are of great importance, and the deficit in the number of conscripts and their low-quality condition have become one of the main and important problems for the Armed Forces. The aim of the study was to improve the medical care of male conscripts aged 18-27 years by revealing the regularities and peculiarities of the expert assessment of surgical diseases among this category of young men on the basis of mathematical modeling. The object of the research was the study of the names of surgical profile articles, according to which these people were recognized as unfit or restricted fit for service, and the results of military medical expertise. Descriptive, social, and statistical methods were applied in the course of the study. The final stage was to conduct a systemic multifactor analysis in order to obtain a mathematical model of the process under study. The values of the influence coefficients of the mentioned indicators for 2013-2019 on the obtained mathematical models from the point of view of military-medical expertise of young men with surgical diseases both in the Republic of Armenia as a whole and in its separate regions are presented. Summarizing, it can be stated that from the point of view of military-medical expertise of young men with surgical diseases it is impossible to consider Yerevan city and the regions of RA as separate parts of the Republic of Armenia. Yerevan and the regions of the Republic of Armenia as separate parts, as they appear as a single whole according to the results of systemic multifactor analysis with mathematical modeling.

It is well known that there are many countries in the world where Urogynecology is not an existing subspecialty, and women are not receiving appropriate care for their pelvic floor disorders (PFD). One of these countries is the Republic of Armenia. Given the lack of expertise in the field of Urogynecology in Armenia, we conducted a study on the prevalence of PFDs and the degree of bother among women of all ages across the country, which was published in 2020. This led to the creation of the International Urogynecology Association for Armenia, comprising seven physicians from different countries: five from the USA, one urogynecologist from Lebanon, and one urologist from Russia. We implemented hybrid teaching based on Zoom lectures, case presentations, journal clubs, and live visits of mentors to Armenia on a regular basis to see patients and operate with our five fellows. We introduced our fellows to research and statistics by assigning research topics for different projects. Our fellows presented evidence-based presentations and extensive literature reviews on a regular basis. Our program will continue to grow the next 2-3 years. The success of this project holds significance for governmental, public, and healthcare entities in Armenia and across the world, where this subspecialty is non-existent, in preparing future female pelvic surgeons to care for the growing needs of women with these conditions. Replicating this program in other parts of the world will compound the benefits and successes of Urogynecology care across different societies, cultures, and people around the globe., (© 2023. The International Urogynecological Association.)

Protein tyrosine phosphatase, nonreceptor type 22 (PTPN22), is an archetypal non-HLA autoimmunity gene. It is one of the most prominent genetic contributors to type 1 diabetes mellitus outside the HLA region, and prevalence of its risk variants is subject to enormous geographic variability. Here, we address the genetic background of patients with type 1 diabetes mellitus of Armenian descent. Armenia has a population that has been genetically isolated for 3000 years. We hypothesized that two PTPN22 polymorphisms, rs2476601 and rs1310182, are associated with type 1 diabetes mellitus in persons of Armenian descent. In this association study, we genotyped the allelic frequencies of two risk-associated PTPN22 variants in 96 patients with type 1 diabetes mellitus and 100 controls of Armenian descent. We subsequently examined the associations of PTPN22 variants with the manifestation of type 1 diabetes mellitus and its clinical characteristics. We found that the rs2476601 minor allele (c.1858T) frequency in the control population was very low (q = 0.015), and the trend toward increased frequency of c.1858CT heterozygotes among patients with type 1 diabetes mellitus was not significant (OR 3.34, 95% CI 0.88-12.75; χ2 test p > 0.05). The control population had a high frequency of the minor allele of rs1310182 (q = 0.375). The frequency of c.2054-852TC heterozygotes was significantly higher among the patients with type 1 diabetes mellitus (OR 2.39, 95% CI 1.35-4.24; χ2 test p < 0.001), as was the frequency of the T allele (OR 4.82, 95% CI 2.38-9.76; χ2 test p < 0.001). The rs2476601 c.1858CT genotype and the T allele correlated negatively with the insulin dose needed three to six months after diagnosis. The rs1310182 c.2054-852CC genotype was positively associated with higher HbA1c at diagnosis and 12 months after diagnosis. We have provided the first information on diabetes-associated polymorphisms in PTPN22 in a genetically isolated Armenian population. We found only a limited contribution of the prototypic gain-of-function PTPN22 polymorphism rs2476601. In contrast, we found an unexpectedly close association of type 1 diabetes mellitus with rs1310182., Competing Interests: This study was supported by the Charles University projects COOPERATIO 39 and 260646/SVV/2023. The funders had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The authors declare no other competing financial interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Žak et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Estimating the size of hidden populations is essential to understand the magnitude of social and healthcare needs, risk behaviors, and disease burden. However, due to the hidden nature of these populations, they are difficult to survey, and there are no gold standard size estimation methods. Many different methods and variations exist, and diagnostic tools are needed to help researchers assess method-specific assumptions as well as compare between methods. Further, because many necessary mathematical assumptions are unrealistic for real survey implementation, assessment of how robust methods are to deviations from the stated assumptions is essential. We describe diagnostics and assess the performance of a new population size estimation method, capture-recapture with successive sampling population size estimation (CR-SS-PSE), which we apply to data from 3 years of studies from three cities and three hidden populations in Armenia. CR-SS-PSE relies on data from two sequential respondent-driven sampling surveys and extends the successive sampling population size estimation (SS-PSE) framework by using the number of individuals in the overlap between the two surveys and a model for the successive sampling process to estimate population size. We demonstrate that CR-SS-PSE is more robust to violations of successive sampling assumptions than SS-PSE. Further, we compare the CR-SS-PSE estimates to population size estimations using other common methods, including unique object and service multipliers, wisdom of the crowd, and two-source capture-recapture to illustrate volatility across estimation methods., (© 2023 Wiley-VCH GmbH.)

The research aimed to assess dietary exposure to developmental toxicants (Mo, Ni, Pb) among the Armenian adult female population of reproductive age (18-49 years). Commonly consumed foods with a daily intake of more than 1 g in Armenia have been selected to assess the occurrence of Mo, Ni, and Pb. Food consumption data among the adult population in Armenia were collected in the frame of the national survey via 24-h recall method. Estimated daily intakes (EDI) and associated potential health risks for both mean and high (95 percentile) consumers were assessed based on the health-based guidance values (HBGVs). None of the EDI values for the developmental toxicants via individual food consumption exceeded the HBGVs, however, the EDI of Pb in the case of aggregate consumption of all food products exceeded HBGV of 0.5 μg/kg b.w./day, indicating possible concerns for the neurodevelopmental effects. Noticeably, the intake of Pb through some individual food items (cheese curd, beef and veal, pelmeni and khinkali, black coffee, tap water) and the aggregate consumption of all the studied foods led to a Margin of Exposure lower than 10 compared to HBGV.This study is the first one carried out on dietary exposure to developmental toxicants among women of fertile age in a Caucasus country. The outcomes prompt the need to investigate sources of Pb pollution in foods consumed in Armenia (natural or human-derived environmental pollution, as well as food contact materials, etc.) and may pave the way for similar studies in the Caucasus region., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Davit Pipoyan reports financial support was provided by Science Committee MESCS RA. Davit Pipoyan reports a relationship with Science Committee MESCS RA that includes: funding grants., (Copyright © 2023. Published by Elsevier Inc.)

Background: The natural environment of southeastern Armenia, which includes the Syunik and Vayots Dzor regions, provides a high biodiversity of flora and fauna, including ectoparasites. Currently, the fauna and ecology of gamasid ticks and their role in the circulation of tularemia in this area are unclear and incomplete. To better understand the persistence of tularemia in Armenia, an assessment of specific hosts and their vectors is needed to evaluate their role in perpetuating tularemia. Materials and Methods: Utilizing data and samples collected from 1970 to 2020, we have evaluated the species composition of gamasid ticks found on the common vole and in their nests and burrows, and identified the presence of tularemia over time. We evaluated five different geographical landscapes: semidesert, dry mountain steppe, mountain steppe, mountain forest, and high mountain in the communities and open areas of Kapan, Goris, Sisian, Meghri, and Jermuk. Results: We determined the density of gamasid ticks in southeastern Armenia over the 50-year period and isolated 20 cultures of tularemia in 12 separate years. Conclusions: It is important to regularly monitor gamasid ticks in southeastern Armenia to clarify the risk factors for the occurrence of tularemia epizootics, among both carriers and vectors, to better understand the full epidemiological picture.

Adequate dietary iron (Fe) intake is crucial for preventing Fe-deficient anemia, a recognized global public health concern which is important in Armenia. This study aimed to analyze the intake of Fe, both heme (from animal tissues) and non-heme (more prevalent, but less efficiently absorbed), as well as the Fe dietary sources, among adults in a representative national sample in Armenia. The study was conducted on 1400 individuals aged 18-80 and above, who were enrolled from all regions of Armenia. The Fe intake was assessed through a 24 h dietary recall survey, while Fe occurrence was determined through atomic absorption spectrophotometry (AAS). The results showed a high proportion of adults with a Fe intake lower than the average requirements set by EFSA (65%, 80% and 85% of males, total females and females at fertile age, respectively). Main Fe sources were bread, fruits and vegetables; heme Fe accounted only for <5% of total Fe intake. Compared to males, females had a lower intake of all forms of Fe ( p < 0.05). Significant differences were observed in the intake of different forms of Fe between regions ( p < 0.05), while the age-group 36-55 years had higher intakes of total Fe. Our data call for comprehensive nutritional security strategies in order to reduce iron deficiency in Armenia, that represents a public health concern.

Background: There are an estimated 460,000 Armenians in the United States, and more than half live in California. Armenian-Americans are generally represented within the 'White' or 'Some Other Race' race categories in population-based research studies. While Armenians have been included in studies focused on Middle-Eastern populations, there are no studies focused exclusively on Armenians due to a lack of standardized collection of Armenian ethnicity in the United States or an Armenian surname list. To fill this research gap, we sought to construct and evaluate an Armenian Surname List (ASL) for use as an identification tool in public health and epidemiological research studies focused on Armenian populations., Methods: Data sources for the ASL included the California Public Use Death Files (CPUDF) and the Middle Eastern Surname List (MESL). For evaluation of the ASL, the California Cancer Registry (CCR) database was queried for surnames with birthplace in Armenia and identified by the MESL., Results: There are a total of 3,428 surnames in the ASL. Nearly half (1,678) of surnames in the ASL were not identified by the MESL. The ASL captured 310 additional Armenian surnames in the CCR than the MESL., Conclusions: The ASL is the first surname list for identifying Armenians in major databases for epidemiological research., (© 2023. The Author(s).)

Introduction: Childhood cancer (CC) is a leading cause of death among children aged 0-19 years worldwide. Each year, 400,000 new cases of CC are diagnosed globally. Given the between-country differences in CC incidence rates, types and trends, this study aimed to identify possible risk factors for CC in Armenia., Methods: We used a case-control study design and enrolled participants from the only specialized pediatric hematology and oncology center in Armenia. Cases included patients ≤ 14 years old diagnosed and treated with a malignant disease between 2017 and 2020 in the centre. Controls included patients diagnosed and treated in the center during the same period for a non-malignant disease. We conducted telephone interviews with mothers of cases and controls. Independent risk factors of cancer were identified using multivariable logistic regression analysis., Results: Overall, 234 participants (117 cases, 117 controls) were included in the study. Based on the fitted model, maternal usage of folic acid during pregnancy was protective against CC, almost twice decreasing its odds (OR = 0.54; 95% CI: 0.31-0.94). On the contrary, experiencing horrifying/terrifying event(s) during pregnancy (OR = 2.19; 95% CI: 1.18-4.07) and having induced abortions before getting pregnant with the given child (OR = 2.94; 95% CI: 1.45-5.96) were associated with higher odds for a child to develop cancer., Conclusion: Despite the limited sample size of the study, significant modifiable risk factors for CC in Armenia were identified, all of which were linked to the period of pregnancy. The data from this study adds to the limited information available from etiological CC research throughout the world, and it will increase understanding of CC risk factors in settings with small populations and low resources. Although these findings may be helpful for future research, they should be taken with caution unless validated from further larger-scale studies., (© 2023. The Author(s).)

Introduction: Emergency Medical Services (EMS) is a critical part of Disaster Medicine and has the ability to limit morbidity and mortality in a disaster event with sufficient training and experience. Emergency systems in Armenia are in an early stage of development and there is no Emergency Medicine residency training in the country. As a result, EMS physicians are trained in a variety of specialties.Armenia is also a country prone to disasters, and recently, the Armenian EMS system was challenged by two concurrent disasters when the 2020 Nagorno-Karabakh War broke out in the midst of the SARS-CoV-2/coronavirus disease 2019 (COVID-19) pandemic., Study Objective: This study aims to assess the current state of disaster preparedness of the Armenian EMS system and the effects of the simultaneous pandemic and war on EMS providers., Methods: This was a cross-sectional study conducted by anonymous survey distributed to physicians still working in the Yerevan EMS system who provided care to war casualties and COVID-19 patients., Results: Survey response rate was 70.6%. Most participants had been a physician (52.1%) or EMS physician (66.7%) for three or less years. The majority were still in residency (64.6%). Experience in battlefield medicine was limited prior to the war, with the majority reporting no experience in treating mass casualties (52.1%), wounds from explosives (52.1%), or performing surgical procedures (52.1%), and many reporting minimal to no experience in treating gunshot wounds (62.5%), severe burns (64.6%), and severe orthopedic injuries (64.6%). Participants had moderate experience in humanitarian medicine prior to war. Greater experience in battlefield medicine was found in participants with more than three years of experience as a physician (z-score -3.26; P value <.01) or as an EMS physician (z-score -2.76; P value <.01) as well as being at least 30 years old (z-score -2.11; P value = .03). Most participants felt they were personally in danger during the war at least sometimes (89.6%)., Conclusion: Prior to the COVID-19 pandemic and simultaneous 2020 Nagorno-Karabakh War, EMS physicians in Armenia had limited training and experience in Disaster Medicine. This system, and the frontline physicians on whom it relies, was strained by the dual disaster, highlighting the need for Disaster Medicine training in all prehospital medical providers.

Background: The aim of this study was to determine the dynamics and the structure of dental morbidity of the children population of the Republic of Armenia, in order to improve the system of methods of therapeutic and preventive measures., Methods: In recommended children's key age groups, 5879 WHO assessment forms (1997) were analyzed. Calculated prevalence and intensity of dental caries, the Significant Index of Caries (SiC) and European dental health indicators, and the condition of periodontal tissues were determined with the help of the community periodontal index (CPI) and oral hygiene by OHI-S. The statistical analysis was performed within the SPSS 19 (SPSS Inc., Chicago, IL, USA). The obtained data were statistically processed in the STATISTICA 6.0 (StataCorp LLC, College Station, TX, USA) for Excel program (Microsoft Corp., Redmond, WA, USA)., Results: The prevalence of caries of temporary teeth was 91.7% on the average. In 12-year-old schoolchildren the average prevalence of caries of permanent teeth rate was 87.5%. The prevalence of periodontal lesions in children was 47.8% on the average., Conclusions: In Armenia there was an increase in dental morbidity during the 2009-2019 period, which presumably would be continued unless the factors affecting the development of diseases will be changed. To improve dental health at the population level not only specialists but also health authorities should make efforts introducing appropriate prevention programs.

Introduction: The coronavirus disease (COVID-19) has led to millions of deaths around the world. The indirect effects of the pandemic, include disruption of routine immunization services., Methodology: We conducted a retrospective review to assess the impact of the pandemic on routine immunization in Yerevan and the vaccinations against COVID-19 in Armenia. We compared the number of administered doses of DPT/VHB/HIB/IPV1,2,3, Pneumococcal1,2,3, Rotarix1,2, and MMR1 vaccines in target groups in 2020 and 2021 and the total vaccination coverage in 2019, 2020, and 2021. We also analyzed the number of COVID-19 vaccines administered in Armenia from 17 May 2021 to 6 February 2022., Results: There was a decline in the number of administered doses of vaccines at the beginning of the pandemic due to restrictive quarantine measures: 16 ± 4.5 (95% CI, 11.8-20.2), p < 0.05, during the second wave 18 ± 2.6 (95% CI, 15.6-20.4), p < 0.05 and during the interruption due to COVID-19 vaccine delivery 16 ± 7.4 (95% CI, 9.1-22.9), p < 0.05. There was no significant decrease in the number of vaccinations during the first, third, and fourth pandemic waves (p > 0.05) Overall, the COVID-19 vaccination process was slow and only 30% of the population were vaccinated., Conclusions: The COVID-19 pandemic led to disruptions in the routine immunization process, but there was no significant decrease in the total vaccine coverage due to rapid scaling up of the vaccination services and catch-up vaccinations. Thus, the restrictions imposed during the pandemic did not affect the overall progress of vaccination., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2022 Naira Melkonyan, Arman Badalyan, Hasmik Hovhannisyan, Karine Poghosyan.)

Objective: Leukemia represents a serious public health concern as the incidence is increasing worldwide. In this study we aimed to describe the epidemiological profile of acute lymphoblastic (ALL) and myeloid (AML) leukemia, identify disease clusters and find association with possible risk factors., Methods: Data on leukemia cases were provided by the National Institute of Health of the Republic of Armenia for the period of 2012-2018. Age-standardized incidence rate was calculated using Segi World Population. SaTScan purely spatial analysis was applied to find leukemia clusters. To find association between leukemia and agricultural and mining activities and demographic data Poisson regression model was used., Results: During the studied period 259 new cases of ALL and 478 AML were recorded. The age-standardized incidence rate was 1.5 and 1.9 per 100,000 inhabitants with male to female ratio of 0.97 and 1.1 for ALL and AML, respectively. No significant changes in ALL or AML incidence trends were found. For ALL significant cluster encompassing Shirak, Lori, Tavush and Armavir provinces of Armenia was identified, while Kotayk and Ararat was provinces with the highest incidence of AML. We found significant positive association of ALL with crop density, while no elevated risk estimates were found between AML and exposure variables., Conclusion: Altogether, our results suggested that acute leukemias incidence in Armenia follows the pattern described for developing countries.

The increased antiretroviral therapy (ART) coverage of patients in the absence of routine genotyping tests and in the context of active labor migration highlight the importance of HIV-1 drug resistance (DR) surveillance in Armenia. We conducted a two-phase pretreatment DR (PDR) study in 2017-2018 (phase I; 120 patients) and 2020-2021 (phase II; 133 patients) according to the WHO-approved protocol. The analysis of HIV-1 genetic variants showed high degrees of viral diversity, with the predominance of A6. The prevalence of any PDR was 9.2% in phase I and 7.5% in phase II. PDR to protease inhibitors was found only in 0.8% in phase II. PDR to efavirenz and nevirapine was found among 5.0% and 6.7% of patients in phase I, and 6.0% and 6.8% of patients in phase II, respectively. The prevalence of PDR to nucleoside reverse-transcriptase inhibitors decreased from 5.0% in phase I to 0.8% in phase II. In addition, we identified risk factors associated with the emergence of DR-male, MSM, subtype B, and residence in or around the capital of Armenia-and showed the active spread of HIV-1 among MSM in transmission clusters, i.e., harboring DR, which requires the immediate attention of public health policymakers for the prevention of HIV-1 DR spread in the country.

The objective of the article is to consider the social and medical factors which contribute to the number of suicides in the Republic of Armenia. The study covers the suicide data for the period of 2011-2020. The article provides statistical data on gender and age aspects of suicide. The paper overviews the works of contemporary authors on the social aspects of the problem. The results of the study will contribute to the further development of the effective methods to prevent suicide. ; Objective - the objective of the study was to investigate and assess the socio-medical aspects of suicide in the RA.; The subject of the study was the data on suicides in the Republic of Armenia in 2011-2020. Standard statistical methods of data analysis were used to compare the data obtained, to assess their reliability, to determine the standard statistical and mean error, reliable difference between absolute and relative values. ; The study revealed 1858 suicide cases, registered in the Republic of Armenia over 10 years. The structure analysis of the suicides by gender in the Republic of Armenia from 2011 to 2020 has shown that males predominated in the structure of suicides over the whole period. Among the motivations of suicide, the ones that deserve attention are diseases, social problems, and bereavement.; The results obtained will contribute to suicide prevention.

In this work, we analysed human isolates of nontyphoidal Salmonella enterica subsp. enterica (NTS), which were collected from salmonellosis cases in Armenia from 1996 to 2019. This disease became a leading food-borne bacterial infection in the region, with the younger age groups especially affected. The isolates were characterised by serotyping, Enterobacterial Repetitive Intergenic Consensus (ERIC-PCR) typing, and whole genome sequencing (WGS). The main serotypes were S . Typhimurium, S . Enteritidis, and S . Arizonae. ERIC-PCR indicated a high degree of clonality among S . Typhimurium strains, which were also multidrug-resistant and produced extended spectrum beta-lactamases. During the study period, the frequency of S . Typhimurium and S . Arizonae isolations decreased, but with the increase in S . Enteritidis and other NTS. A total of 42 NTS isolates were subjected to WGS and explored for virulence-related traits and the corresponding genetic elements. Some virulence and genetic factors were shared by all NTS serotypes, while the main differences were attributed to the serotype-specific diversity of virulence genes, SPIs, virulence plasmids, and phages. The results indicated the variability and dynamics in the epidemiology of salmonellosis and a high virulence potential of human NTS isolates circulating in the region.

There is a scarcity of long-term studies of depression after natural disasters. This prospective epidemiologic study evaluated the course of depression and factors associated with it among survivors 23-years post-earthquake. A geographically stratified subsample of 725 adults exposed to the Spitak earthquake was assessed for depression using DSM-III-R criteria in 1991 and 2012. Additionally, an adapted CES-D-16 scale was used to assess depressive symptoms in 2012. A fitted multi-nominal logistic regression model identified predictors of different trajectories of depression. For the whole group, the rate of clinical depression dropped from 51.5% in 1991 to 31.7% in 2012. Earthquake intensity and experiencing strong fear at baseline were strongly associated with chronic (depressed at both assessments, 18.1%) and recovered (depressed only in 1991, 33.5%) depression trajectories compared with the healthy group, with odds ratios (OR) over 4.0 and 3.0, respectively. Predictors distinguishing chronic depression included earthquake-related nuclear-family deaths (OR=3.79), chronic illnesses at baseline (OR=1.24), and social support (OR=0.91). Predictors of the late-onset trajectory (depressed only in 2012, 13.5% of the cohort) included post-earthquake trauma (OR=1.42), socioeconomic status (OR=0.45), and social support (OR=0.86). The factors associated with the different trajectories of depression provide guidance for planning more effective mental health interventions after disasters., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Bullying perpetration might be an alternative way of hierarchy formation among adolescents. It can potentially compensate for the negative health influences of low socioeconomic status (SES), rewarding this unwanted behavior. This study aimed to investigate the role of bullying perpetration in the relationship between SES and health among Armenian adolescents. A nationally representative sample of 3679 adolescents aged 11-15 years (mean = 13.1, standard deviation = 1.6) participated in the Health Behavior in School-aged Children 2013/14 survey in Armenia. Complex samples multiple logistic regression were used to estimate the associations between two SES measures (family socioeconomic position [SEP] and material well-being) and three health outcomes (perceived health status, psychosocial well-being, and psychosomatic symptoms). Bullying perpetration was not associated with less than good health or low psychosocial well-being (P > 0.05) but increased the odds of reporting high psychosomatic symptoms (P < 0.05). Perpetration did not change the SES-health gradient substantially. However, in stratified analyses, socioeconomic inequalities in health were consistently weaker among perpetrators. The largest observed difference was in the relationship between low family SEP and less than good health (OR = 3.60, 95% CI = 2.77-4.67 vs. OR = 1.80, 95% CI = 1.06-3.04), whereas the smallest difference was in the relationship between low family SEP and high psychosomatic symptoms (OR = 1.27, 95% CI = 1.03-1.56 vs. OR = 1.04, 95% CI = 0.61-1.77). Our findings suggest that bullying perpetration, as an alternative hierarchy, may be looked at as a compensatory but vicious strategy in the face of the negative health influences of low SES in Armenian adolescents. For high-SES adolescents, on the other hand, social, emotional, or psychological problems might contribute to bullying perpetration. Consequently, bullying prevention activities in Armenia should focus on both low and high-SES adolescents, considering SES-specific pathways and mechanisms., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Child malnutrition is a major issue in conflict zones. Evidence-based interventions and their thorough evaluation could help to eliminate malnutrition. We aimed to assess the causal effect of a community-based multidisciplinary nutrition program for children in a chronic conflict zone near the northeastern border of Armenia on two main outcomes: stunting and anemia. We further compared the interpretations and public health relevance of the obtained effect estimates., Methods: In 2016, the study measured hemoglobin and anthropometric measures and collected data from the children's caregivers. We used propensity score matching analyses, inverse probability weighting, and overlap weighting methods to examine the average treatment effects among treated population (ATT), and among population with overlapping weights (ATO)., Results: The ATT for stunting among children who participated in the intervention program estimated by propensity score matching analyses (PSM-ATT) was (1.95; 95%CI 1.15-3.28). Nevertheless, children who took part in the program had a lower risk of anemia (0.28; 95%CI 0.19-0.42). The ATT, estimated by inverse probability weighting (IPTW-ATT), was slightly lower for stunting (1.82; 95%CI 1.16-2.86) while similar for anemia (0.33; 95%CI 0.23-0.46) compared to PSM-ATT. Compared to the IPTW-ATT and PSM-ATT the ATO was lower for stunting (1.75; 95%CI 1.14-2.68) and similar for anemia (0.31; 95%CI 0.22-0.43)., Discussion: Marginal models could be used in similar quasi-experimental settings to identify the causal effect of interventions in specific populations of interest. Nonetheless, these methods do not eliminate threats to internal validity. Thorough study design and accurate data collection are necessary to improve the efficiency of marginal models., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The sequencing of SARS-CoV-2 provides essential information on viral evolution, transmission, and epidemiology. In this paper, we performed the whole-genome sequencing of SARS-CoV-2 using nanopore and Illumina sequencing to describe the circulation of the virus lineages in Armenia. The analysis of 145 full genomes identified six clades (19A, 20A, 20B, 20I, 21J, and 21K) and considerable intra-clade PANGO lineage diversity. Phylodynamic and transmission analysis allowed to attribute specific clades as well as infer their importation routes. Thus, the first two waves of positive case increase were caused by the 20B clade, the third peak caused by the 20I (Alpha), while the last two peaks were caused by the 21J (Delta) and 21K (Omicron) variants. The functional analyses of mutations in sequences largely affected epitopes associated with protective HLA loci and did not cause the loss of the signal in PCR tests targeting ORF1ab and N genes as confirmed by RT-PCR. We also compared the performance of nanopore and Illumina short-read sequencing and showed the utility of nanopore sequencing as an efficient and affordable alternative for large-scale molecular epidemiology research. Thus, our paper describes new data on the genomic diversity of SARS-CoV-2 variants in Armenia in the global context of the virus molecular genomic surveillance.

Background: The aim of this study was to perform a retrospective analysis of the prevalence, etiologies, types of maxillofacial injuries (MFIs), sites of maxillofacial fractures (MFFs) and their management in Yerevan, Armenia., Methods: A retrospective cross-sectional study was conducted. The extracted data included age, sex, date of referral, mode of injury, etiology, radiology records and treatment methods. Study outcomes were measured using percentages, means, standard deviations and tests of proportions. P < .05 was considered significant., Results: A total of 204 patients had a mean age of 36.26 ± 1.08 years (156 males and 48 females), and a total of 259 MFIs were recorded between 2017 and 2020. Interpersonal violence was found to be the most common etiology of MFFs in this study (42.1%), followed by road traffic accidents (RTAs) (27.9%) and falls (18.6%). The nasal bone was the most common injury site (47.5%), followed by the mandible (31.4%) and zygomatic complex (11.7%). The most common fracture site was the mandibular angle (37.9%), followed by the symphysis/parasymphysis (28.1%) and body (12.6%). Isolated soft tissue injuries were reported in 5.9% of the cases. The majority of MFFs were treated by open reduction and internal fixation., Conclusion: Interpersonal violence, followed by RTAs and falls, was the most common cause of MFIs. Males in the 21-30 years age group had the highest MFI incidence rate. The nasal bone was the most common injury site, followed by the mandible and zygomatic complex. Social education with the objective of reducing aggression and interpersonal conflict should be improved, and appropriate RTA prevention strategies should be strengthened and implemented., (© 2022. The Author(s).)

Objective: This study aims to identify the prevalence of eye disorders and their causes among secondary schoolchildren aged 6-15 years old in Armenia, based on analysis of the Nationwide School Sight Sampling Survey., Methods and Analysis: A two-stage proportionate stratified cluster sample was designed for the survey. 22 600 students were screened for visual acuity in schools; 5944 of them were selected for analysis as a nationally representative sample. Those with 20/40 or worse vision were referred to photoscreening and rapid ophthalmic assessment in schools and then were provided with vouchers for free comprehensive eye examination in eye clinics. Data were collected through data collection forms and analysed using SPSS V.23., Results: While majority of the children (85%) had normal vision, 15% had a visual acuity ≤20/40. The prevalence of vision impairment (VI) in at least one eye was 9.7% and blindness in at least one eye was 0.05%. The prevalence of abnormal vision and VI was higher among girls and older children. VI was more prevalent in urban areas. The most common diagnoses were myopia (60%), astigmatism (33.7%), hyperopia (29.5%) and strabismus (3.8%)., Conclusion: Majority of the vision abnormalities and VI among schoolchildren are a result of refractive error and are treatable. Our results highlight the importance of regular eye examinations for schoolchildren to detect and prevent VI. Raising awareness among parents, school staff and children about eye health is vital., Competing Interests: Competing interests: JE is a paid consultant for AI Health. AI Health had no role in the design or execution of this work, the decision to publish or any editorial oversight., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Given high prevalence of smoking and secondhand smoke exposure in Armenia and Georgia and quicker implementation of tobacco legislation in Georgia versus Armenia, we examined correlates of having no/partial versus complete smoke-free home (SFH) restrictions across countries, particularly smoking characteristics, risk perceptions, social influences and public smoking restrictions., Design: Cross-sectional survey study design., Setting: 28 communities in Armenia and Georgia surveyed in 2018., Participants: 1456 adults ages 18-64 in Armenia (n=705) and Georgia (n=751)., Measurements: We used binary logistic regression to examine aforementioned correlates of no/partial versus complete SFH among non-smokers and smokers in Armenia and Georgia, respectively., Results: Participants were an average age of 43.35, 60.5% women and 27.3% smokers. In Armenia, among non-smokers, having no/partial SFHs correlated with being men (OR=2.63, p=0.001) and having more friend smokers (OR=1.23, p=0.002); among smokers, having no/partial SFHs correlated with being unmarried (OR=10.00, p=0.001), lower quitting importance (OR=0.82, p=0.010) and less favourable smoking attitudes among friends/family/public (OR=0.48, p=0.034). In Georgia, among non-smokers, having no/partial SFHs correlated with older age (OR=1.04, p=0.002), being men (OR=5.56, p<0.001), lower SHS risk perception (OR=0.43, p<0.001), more friend smokers (OR=1.49, p=0.002) and fewer workplace (indoor) restrictions (OR=0.51, p=0.026); among smokers, having no/partial SFHs correlated with being men (OR=50.00, p<0.001), without children (OR=5.88, p<0.001), daily smoking (OR=4.30, p=0.050), lower quitting confidence (OR=0.81, p=0.004), more friend smokers (OR=1.62, p=0.038) and fewer community restrictions (OR=0.68, p=0.026)., Conclusions: Private settings continue to lack smoking restrictions in Armenia and Georgia. Findings highlight the importance of social influences and comprehensive tobacco legislation, particularly smoke-free policies, in changing household smoking restrictions and behaviours., Trial Registration Number: NCT03447912., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Vitamin D plays a critical role in skeletal development and maintenance, thus sufficiency is an important goal for public health programs. Given the absence of foods fortified in vitamin D in Armenia, we hypothesized that vitamin D insufficiency would be widespread., Methods: We conducted a random modified cluster model survey of vitamin D status of women in the country. We measured 25-hydroxyvitamin D [25(OH)D] by liquid chromatography mass spectrometry in dried blood spot samples and utilized a questionnaire to assess lifestyle factors., Results: In summer, we sampled 1206 participants from 40 communities in Armenia. Mean 25-OH D level among women aged 18-24 was 20 ± 8 ng/mL; aged 25-64 was 21 ± 7 ng/mL; and >65 was 18 ± 8 ng/mL. The country-wide mean of the entire female population was 20 ± 8 ng/mL. A majority (>54%) had 25-OH D levels <20 ng/mL with nearly 13% having 25-OH D levels <12 ng/mL. Participants who reported calcium, vitamin D, or multivitamin supplementation had higher levels of 25-OH D (p values 0.004, 0.0002, and 0.03 respectively) as did pre- vs. postmenopausal women (p = 0.01), pregnant vs. nonpregnant women (p = <0.0001), and women who had experienced a sunburn in the past year (p = 0.004)., Conclusion: In Armenia, there is a high prevalence of vitamin D insufficiency. This information provides data that can be used to inform public health directives to address this pervasive threat to optimal health., (© 2021. The Author(s).)

Background: Eastern Europe and Central Asia (EECA) is one of the regions where the HIV epidemic continues to grow at a concerning rate. Antiretroviral therapy (ART) coverage in EECA countries has significantly increased during the last decade, which can lead to an increase in the risk of emergence, transmission, and spread of HIV variants with drug resistance (DR) that cannot be controlled. Because HIV genotyping cannot be performed in these countries, data about HIV DR are limited or unavailable., Objectives: To monitor circulating HIV-1 genetic variants, assess the prevalence of HIV DR among patients starting antiretroviral therapy, and reveal potential transmission clusters among patients in six EECA countries: Armenia, Azerbaijan, Belarus, Russia, Tajikistan, and Uzbekistan., Materials and Methods: We analyzed 1071 HIV-1 pol-gene fragment sequences (2253-3369 bp) from patients who were initiating or reinitiating first-line ART in six EECA counties, i.e., Armenia (n = 120), Azerbaijan (n = 96), Belarus (n = 158), Russia (n = 465), Tajikistan (n = 54), and Uzbekistan (n = 178), between 2017 and 2019. HIV Pretreatment DR (PDR) and drug resistance mutation (DRM) prevalence was estimated using the Stanford HIV Resistance Database. The PDR level was interpreted according to the WHO standard PDR survey protocols. HIV-1 subtypes were determined using the Stanford HIV Resistance Database and subsequently confirmed by phylogenetic analysis. Transmission clusters were determined using Cluster Picker., Results: Analyses of HIV subtypes showed that EECA, in general, has the same HIV genetic variants of sub-subtype A6, CRF63&#95;02A1, and subtype B, with different frequencies and representation for each country. The prevalence of PDR to any drug class was 2.8% in Uzbekistan, 4.2% in Azerbaijan, 4.5% in Russia, 9.2% in Armenia, 13.9% in Belarus, and 16.7% in Tajikistan. PDR to protease inhibitors (PIs) was not detected in any country. PDR to nucleoside reverse-transcriptase inhibitors (NRTIs) was not detected among patients in Azerbaijan, and was relatively low in other countries, with the highest prevalence in Tajikistan (5.6%). The prevalence of PDR to nonnucleoside reverse-transcriptase inhibitors (NNRTIs) was the lowest in Uzbekistan (2.8%) and reached 11.1% and 11.4% in Tajikistan and Belarus, respectively. Genetic transmission network analyses identified 226/1071 (21.1%) linked individuals, forming 93 transmission clusters mainly containing two or three sequences. We found that the time since HIV diagnosis in clustered patients was significantly shorter than that in unclustered patients (1.26 years vs 2.74 years). Additionally, the K103N/S mutation was mainly observed in clustered sequences (6.2% vs 2.8%)., Conclusions: Our study demonstrated different PDR prevalence rates and DR dynamics in six EECA countries, with worrying levels of PDR in Tajikistan and Belarus, where prevalence exceeded the 10% threshold recommended by the WHO for immediate public health action. Because DR testing for clinical purposes is not common in EECA, it is currently extremely important to conduct surveillance of HIV DR in EECA due to the increased ART coverage in this region., Competing Interests: The authors have declared that no competing interests exist.

Background: Visual impairment (VI) and blindness remain serious public health problems among patients with diabetes. This study assessed the prevalence of VI and its associated risk factors in individuals with diabetes mellitus (DM) in Armenia., Methods: This cross-sectional study recruited 1287 people with DM. All participants underwent comprehensive ophthalmic examination and responded to a structured questionnaire on sociodemographic and health characteristics, health-seeking behavior, and ocular health. The presence of eye diseases and VI was defined based on the International Classification of Diseases-11. Descriptive statistics and logistic regression were used to address the study objectives., Results: The mean age of participants was 61.5 (SD = 9.6) ranging from 19.4 to 99.8 years. The mean duration of diabetes was 7.4 years. The majority of participants (70.5%) were women. The prevalence of VI and blindness was 12.1% and 0.9%, respectively. Overall, 22.4% of participants had diabetic retinopathy. In the adjusted analysis, advanced age (OR = 1.08; 95%CI: 1.06-1.11), higher education (OR = 0.37; 95%CI: 0.19-0.74), diabetes duration (OR = 1.05; 95%CI: 1.02-1.08), the presence of diabetic retinopathy (OR = 3.61; 95%CI: 2.38-5.46), age-related macular degeneration (OR = 1.88; 95%CI: 1.15-3.05), cataract (OR = 2.45; 95%CI: 1.66-3.63), and glaucoma (OR = 2.32; 95%CI: 1.25-4.30) were associated with VI., Conclusion: The findings highlight the importance and need for regular eye screening and diabetes prevention programs in the country. Continuous educational programs on diabetes self-management among patients with DM can reduce complications of diabetes including vision loss due to diabetes., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

It is not so easy to understand the essence of the definition of physical health, although this phrase consists of two words that have an important semantic meaning, that is, "health" is a generalized characteristic, and "physical" is related to the physical capabilities of a person. The purpose of this study was to study the relationship between some physiological indicators of the physical health of the Armenian population. A cross - sectional study of 2000 residents aged 11 to 79 years (men n=429, average age - 33.7±13.2 and women n=1171, average age-34.6±12.1) of the Republic of Armenia was conducted. Physiological indicators (wellness and its component indicators-body composition, endothelium and stress resistance (stress scores) and) were measured using the Mutiscan BC-OXi PLUS Version 2.9 RU monitoring system to study indicators with acceptable reproducibility and a significant difference in values. Studies of the general sample showed that among the population of Armenia, the indicators of endothelium and wellness are within the normal range, the indicator of body composition is slightly below the norm, and the indicator of stress resistance is on the border between the norm and the violation. The average indicators of stress resistance, endothelium and wellness are significantly higher in women compared to men and a reliable direct proportional relationship of average strength between the indicators of stress resistance-wellness, endothelium-wellness and body composition-wellness in both groups are revealed. It was found that the correlation infrastructure (according to Spearman and Pearson) of the above indicators is subject to significant changes depending on gender, while the level of these indicators (in points) in the studied samples is significantly less susceptible to changes.