Examining the quality of childhood tuberculosis diagnosis in Cambodia: a cross-sectional study.

BACKGROUND: Cambodia is one of the 22 countries with the highest TB burden. While childhood TB is estimated to make up 10-20% of total TB cases in high-burden settings, this proportion ranges from 1.3 to 39.4% throughout Cambodia's provinces, suggesting potential under- and over-diagnosis of childhood TB, subnationally. The proportion of case notifications classified as extrapulmonary TB out of total TB case notifications in children is 87%, greatly exceeding the expected global range of 20-30%. There is a gap in the literature on how childhood TB is diagnosed in resource-poor settings, and the quality of diagnoses. The study's aim is to quantitatively assess the quality of clinician performance and availability of diagnostic tools, for diagnosing childhood TB in high-burden Operational Districts in Cambodia. METHODS: Between August and September of 2015, a cross-sectional study was conducted at referral hospitals and villages in 24 high-burden Operational Districts. 40 clinicians, and 104 parents whose child was recently diagnosed with TB were interviewed. Questionnaires assessed availability of diagnostic tools, and clinician knowledge and practice during a clinical examination. Descriptive statistics were calculated to provide cross-sectional data. RESULTS: Availability of advanced diagnostic tools was low. Only 27.5% of clinicians had Xpert machines available at their facility, and 5% had equipment to perform gastric aspiration. 77.5% of clinicians reported that they had a chest X-ray at their facility, but only 34.6% of parents reported that the clinician conducted a chest X-ray. 72.5% of clinicians could name 5 out of 7 main TB screening criteria; however, parent data suggests that clinicians may not be applying knowledge to practice. The mean number of examinations/tests the clinician conducted during the clinical assessment of the child was 1.64. Of the parents whose child had an enlarged lymph node, 60.22% described lymph node characteristics that were not suggestive of TB. CONCLUSION: Limited availability of diagnostic tools and suboptimal clinician performance highlight where resources should be allocated to improve quality of diagnoses. Further research needs to be done in low burden Operational Districts to determine the capacity of clinicians and health facilities for diagnosing childhood TB, where cases are likely being missed.

A systematic review: effectiveness of mass media campaigns for reducing alcohol-impaired driving and alcohol-related crashes.

BACKGROUND: Mass media campaigns have long been used as a tool for promoting public health. In the past decade, the growth of social media has allowed more diverse options for mass media campaigns. This systematic review was conducted to assess newer evidence from quantitative studies on the effectiveness of mass media campaigns for reducing alcohol-impaired driving (AID) and alcohol-related crashes, particularly after the paper that Elder et al. published in 2004. METHODS: This review focused on English language studies that evaluated the effect of mass media campaigns for reducing AID and alcohol-related crashes, with or without enforcement efforts. A systematic search was conducted for studies published between January 1, 2002 and December 31, 2013. Studies from the review by Elder et al. were added as well. RESULTS: A total of 19 studies met the inclusion criteria for the systematic review, including three studies from the review by Elder et al. Nine of them had concomitant enforcement measures and did not evaluate the impact of media campaigns independently. Studies that evaluated the impact of mass media independently showed reduction more consistently (median -15.1%, range -28.8 to 0%), whereas results of studies that had concomitant enforcement activities were more variable (median -8.6%, range -36.4 to +14.6%). Summary effects calculated from seven studies showed no evidence of media campaigns reducing the risk of alcohol-related injuries or fatalities (RR 1.00, 95% CI = 0.94 to 1.06). CONCLUSIONS: Despite additional decade of evidence, reviewed studies were heterogeneous in their approaches; therefore, we could not conclude that media campaigns reduced the risk of alcohol-related injuries or crashes. More studies are needed, including studies evaluating newly emerging media and cost-effectiveness of media campaigns.

Results from early programmatic implementation of Xpert MTB/RIF testing in nine countries.

BACKGROUND: The Xpert MTB/RIF assay has garnered significant interest as a sensitive and rapid diagnostic tool to improve detection of sensitive and drug resistant tuberculosis. However, most existing literature has described the performance of MTB/RIF testing only in study conditions; little information is available on its use in routine case finding. TB REACH is a multi-country initiative focusing on innovative ways to improve case notification. METHODS: We selected a convenience sample of nine TB REACH projects for inclusion to cover a range of implementers, regions and approaches. Standard quarterly reports and machine data from the first 12 months of MTB/RIF implementation in each project were utilized to analyze patient yields, rifampicin resistance, and failed tests. Data was collected from September 2011 to March 2013. A questionnaire was implemented and semi-structured interviews with project staff were conducted to gather information on user experiences and challenges. RESULTS: All projects used MTB/RIF testing for people with suspected TB, as opposed to testing for drug resistance among already diagnosed patients. The projects placed 65 machines (196 modules) in a variety of facilities and employed numerous case-finding strategies and testing algorithms. The projects consumed 47,973 MTB/RIF tests. Of valid tests, 7,195 (16.8%) were positive for MTB. A total of 982 rifampicin resistant results were found (13.6% of positive tests). Of all tests conducted, 10.6% failed. The need for continuous power supply was noted by all projects and most used locally procured solutions. There was considerable heterogeneity in how results were reported and recorded, reflecting the lack of standardized guidance in some countries. CONCLUSIONS: The findings of this study begin to fill the gaps among guidelines, research findings, and real-world implementation of MTB/RIF testing. Testing with Xpert MTB/RIF detected a large number of people with TB that routine services failed to detect. The study demonstrates the versatility and impact of the technology, but also outlines various surmountable barriers to implementation. The study is not representative of all early implementer experiences with MTB/RIF testing but rather provides an overview of the shared issues as well as the many different approaches to programmatic MTB/RIF implementation.

Changing epidemic of tuberculosis amidst the COVID-19 pandemic in the Western Pacific Region: analysis of tuberculosis case notifications and treatment outcomes from 2015 to 2022.

Background: Coronavirus disease-2019 (COVID-19) pandemic has deeply impacted tuberculosis (TB) services globally. This study aims to assess the COVID-19 pandemic's impact on TB diagnosis and care and explore associated factors in the Western Pacific Region. Methods: We analysed TB case notifications and treatment outcomes for the Region and 14 selected countries and areas from 2015 to 2022. We further explored differences in reported cases from predicted cases by the UHC service coverage index and Human Development Index (HDI), and the relationship between the Stringency Index and TB case notifications during the pandemic. Findings: TB case notifications declined in 2020 (21%) and 2021 (23%) compared to predicted cases and partly recovered in 2022 (18%). The shortfalls in 2020 and 2021 were more prominent in priority countries with high TB burden, where the decrease in clinically diagnosed pulmonary cases and paediatric cases was particularly pronounced. In priority countries, TB case notifications have a positive relationship with UHC service coverage index and HDI in 2021 and an inverse relationship with Stringency Index during the pandemic. In contrast, treatment outcomes have not changed significantly due to the pandemic across countries in the Region. Interpretation: The COVID-19 pandemic has adversely impacted TB diagnosis and care in the Western Pacific Region, especially TB case detection. Stringent government policies against the pandemic, coupled with weak health systems and suboptimal socio-economic development, may have brought a more profound and prolonged impact in priority countries. Funding: The Korea Disease Control and Prevention Agency and the Japan Ministry of Health, Labour and Welfare.

Correction: Expansion of social protection is necessary towards zero catastrophic costs due to TB: The first national TB patient cost survey in the Philippines.

[This corrects the article DOI: 10.1371/journal.pone.0264689.].

Clinician perspectives of drug-resistant tuberculosis care services in the Philippines.

BACKGROUND/OBJECTIVES: In the Philippines, treatment success rates for drug-resistant tuberculosis (DR-TB) remains low and little is known about the quality of DR-TB services. This study aimed to explore clinician's perspectives of DR-TB care services. METHODS: We conducted semi-structured in-depth interviews from January-March 2018 with 11 providers selected purposively to explore the barriers associated with DR-TB care service delivery, best practices, and recommendations for enhancing patient care. Emerging themes were organized according to the socio-ecological framework. RESULTS: Five major themes were identified: (1) nurses do not feel empowered; (2) particular patients are left behind and more vulnerable than others; (3) infection control practices, fear, and limited capacity in rural health centers; (4) financial insecurity due to program reimbursement mechanisms; and (5) local government support is limited and requires more involvement in support of DR-TB elimination activities. Best practices focused on tailored approaches that eliminated structural, economic, and motivational barriers for patients. Participants recommended financial support from local government units, nutritional assistance for patients, and refresher training for healthcare workers. CONCLUSION: The findings provide additional understanding regarding the barriers that limit successful DR-TB care delivery and provide critical information to improve clinical practice and develop public health interventions for frontline staff including nurses in the Philippines. These strategies could ultimately reduce disparities associated with access to care and treatment adherence, if implemented.

Epidemiology of dengue reported in the World Health Organization's Western Pacific Region, 2013-2019.

The global burden of dengue, an emerging and re-emerging mosquito-borne disease, increased during the 20-year period ending in 2019, with approximately 70% of cases estimated to have been in Asia. This report describes the epidemiology of dengue in the World Health Organization's Western Pacific Region during 2013-2019 using regional surveillance data reported from indicator-based surveillance systems from countries and areas in the Region, supplemented by publicly available dengue outbreak situation reports. The total reported annual number of dengue cases in the Region increased from 430 023 in 2013 to 1 050 285 in 2019, surpassing 1 million cases for the first time in 2019. The reported case-fatality ratio ranged from 0.19% (724/376 972 in 2014 and 2030/1 050 285 in 2019) to 0.30% (1380/458 843 in 2016). The introduction or reintroduction of serotypes to specific areas caused several outbreaks and rare occurrences of local transmission in places where dengue was not previously reported. This report reinforces the increased importance of dengue surveillance systems in monitoring dengue across the Region.

Early detection of tuberculosis through community-based active case finding in Cambodia.

BACKGROUND: Since 2005, Cambodia's national tuberculosis programme has been conducting active case finding (ACF) with mobile radiography units, targeting household contacts of TB patients in poor and vulnerable communities in addition to routine passive case finding (PCF). This paper examines the differences in the demographic characteristics, smear grades, and treatment outcomes of pulmonary TB cases detected through both active and passive case finding to determine if ACF could contribute to early case finding, considering associated project costs for ACF. METHODS: Demographic characteristics, smear grades, and treatment outcomes were compared between actively (n = 405) and passively (n = 602) detected patients by reviewing the existing programme records (including TB registers) of 2009 and 2010. Additional analyses were performed for PCF cases detected after the ACF sessions (n = 91). RESULTS: The overall cost per case detected through ACF was US$ 108. The ACF approach detected patients from older populations (median age of 55 years) compared to PCF (median age of 48 years; p < 0.001). The percentage of smear-negative TB cases detected through ACF was significantly higher (71.4%) than that of PCF (40.5%). Among smear-positive patients, lower smear grades were observed in the ACF group compared to the PCF group (p = 0.002). A fairly low initial defaulter rate (21 patients, 5.2%) was observed in the ACF group. Once treatment was initiated, high treatment success rates were achieved with 96.4% in ACF and with 95.2% in PCF. After the ACF session, the smear grade of TB patients detected through routine PCF continued to be low, suggesting increased awareness and early case detection. CONCLUSIONS: The community-based ACF in Cambodia was found to be a cost-effective activity that is likely to have additional benefits such as contribution to early case finding and detection of patients from a vulnerable age group, possibly with an extended benefit for reducing secondary cases in the community. Further investigations are required to clarify the primary benefits of ACF in early and increased case detection and to assess its secondary impact on reducing on-going transmission.

Patient- and Health-System-Related Barriers to Treatment Adherence for Patients with Drug-Resistant Tuberculosis in the Philippines: A Mixed-Methods Study.

Purpose: In the Philippines, drug-resistant tuberculosis (DRTB) is a growing concern. Healthcare workers face challenges in retaining patients with DRTB in care. This study intends to understand their perspectives on the factors that influence patient treatment outcomes and to propose potential programmatic solutions for strengthening care services for the patients. Methods: A mixed-methods study was conducted in the Philippines between December 2017 and March 2018 to understand the major barriers for healthcare workers to provide quality care to DRTB patients across the care continuum. In the quantitative phase, healthcare workers participated in an online survey; in the qualitative phase, in-depth interviews were conducted with a select number of the survey respondents to better understand their survey responses. Results: 272 healthcare workers participated in the survey, and of those, 11 were interviewed. Survey results identified economic constraints, patient perceptions of care, family-related concerns, and limited accessibility to healthcare services as the major patient-related barriers across the care continuum. Major health-system-related barriers were insufficient human resources, lack of financial and political support, and limited knowledge about DRTB by healthcare providers. Interviews revealed more elaborate, contextualized, and nuanced aspects of each of the major challenges. The elaborated patient-related barriers included expenses needed during treatment (e.g., transportation); fear of being stigmatized by family, community, or healthcare staff; worries about adverse drug reactions from medication; a lack of family support; and the location of patients' homes. The health-system-related barriers revealed through interviews included the limited capacities of facility staff to provide DRTB care due to insufficient human resources; the shortage of funds to support treatment completion (e.g., transportation allowance and food package for patients, service vehicles and mobile phone costs for outreach actions at the facility level); and discrimination by healthcare staff against patients with DRTB attributed to the staff's limited knowledge and experiences of treating the patients. Conclusion: This study identified the main barriers for DRTB facility staff in the Philippines from the perspectives of providers. Further exploration of the barriers and best practices in facilities may be useful for improving DRTB care in the Philippines.

Expansion of social protection is necessary towards zero catastrophic costs due to TB: The first national TB patient cost survey in the Philippines.

BACKGROUND: Tuberculosis (TB) is a disease associated with poverty. Moreover, a significant proportion of TB patients face a substantial financial burden before and during TB care. One of the top targets in the End TB strategy was to achieve zero catastrophic costs due to TB by 2020. To assess patient costs related to TB care and the proportion of TB-affected households that faced catastrophic costs, the Philippines National TB Programme (NTP) conducted a national TB patient cost survey in 2016-2017. METHODS: A cross-sectional survey of 1,912 TB patients taking treatment in health facilities engaged with the NTP. The sample consists of 786 drug-sensitive TB (DS-TB) patients in urban facilities, 806 DS-TB patients in rural facilities, and 320 drug-resistant TB (DR-TB) patients. Catastrophic cost due to TB is defined as total costs, consisting of direct medical and non-medical costs and indirect costs net of social assistance, exceeding 20% of annual household income. RESULTS: The overall mean total cost including pre- and post-diagnostic costs was US$601. The mean total cost was five times higher among DR-TB patients than DS-TB patients. Direct non-medical costs and income loss accounted for 42.7% and 40.4% of the total cost of TB, respectively. More than 40% of households had to rely on dissaving, taking loans, or selling their assets to cope with the costs. Overall, 42.4% (95% confidence interval (95% CI): 40.2-44.6) of TB-affected households faced catastrophic costs due to TB, and it was significantly higher among DR-TB patients (89.7%, 95%CI: 86.3-93.0). A TB enabler package, which 70% of DR-TB patients received, reduced catastrophic costs by 13.1 percentage points (89.7% to 76.6%) among DR-TB patients, but only by 0.4 percentage points (42.4% to 42.0%), overall. CONCLUSIONS: TB patients in the Philippines face a substantial financial burden due to TB despite free TB services provided by the National TB Programme. The TB enabler package mitigated catastrophic costs to some extent, but only for DR-TB patients. Enhancing the current social and welfare support through multisectoral collaboration is urgently required to achieve zero catastrophic costs due to TB.

Variation in Grain Zinc and Iron Concentrations, Grain Yield and Associated Traits of Biofortified Bread Wheat Genotypes in Nepal.

Wheat (Triticum aestivum L.) is one of the major staples in Nepal providing the bulk of food calories and at least 30% of Fe and Zn intake and 20% of dietary energy and protein consumption; thus, it is essential to improve its nutritional quality. To select high-yielding genotypes with elevated grain zinc and iron concentration, the sixth, seventh, eighth, and ninth HarvestPlus Yield Trials (HPYTs) were conducted across diverse locations in Nepal for four consecutive years: 2015-16, 2016-17, 2017-18, and 2018-19, using 47 biofortified and 3 non-biofortified CIMMYT-bred, bread wheat genotypes: Baj#1, Kachu#1, and WK1204 (local check). Genotypic and spatial variations were found in agro-morphological traits; grain yield and its components; and the grain zinc and iron concentration of tested genotypes. Grain zinc concentration was highest in Khumaltar and lowest in Kabre. Likewise, grain iron concentration was highest in Doti and lowest in Surkhet. Most of the biofortified genotypes were superior for grain yield and for grain zinc and iron concentration to the non-biofortified checks. Combined analyses across environments showed moderate to high heritability for both Zn (0.48-0.81) and Fe (0.46-0.79) except a low heritability for Fe observed for 7th HPYT (0.15). Grain yield was positively correlated with the number of tillers per m2, while negatively correlated with days to heading and maturity, grain iron, grain weight per spike, and thousand grain weight. The grain zinc and iron concentration were positively correlated, suggesting that the simultaneous improvement of both micronutrients is possible through wheat breeding. Extensive testing of CIMMYT derived high Zn wheat lines in Nepal led to the release of five biofortified wheat varieties in 2020 with superior yield, better disease resistance, and 30-40% increased grain Zn and adaptable to a range of wheat growing regions in the country - from the hotter lowland, or Terai, regions to the dry mid- and high-elevation areas.

Perceptions of the Private Sector for Creating Effective Public-Private Partnerships against Tuberculosis in Metro Manila, Philippines.

This article's goal is to assess the perspectives of private providers on current and future public-private engagement in Metro Manila, a city of 13 million using semistructured interviews with a convenience sample of 18 private physicians. Our study found that private providers perceived their clientele as loyal and their services as distinct from public services, with unique attractions of convenience and quality of service. They saw value in engaging with the public sector for knowledge exchange, access to public-sector commodities, and access to public sector assistance with public health tasks related to tuberculosis (TB). However, their proposed ways of engaging were more centered on the private sector role, in ways that are not currently being pursued by the public sector. It is of the utmost importance to recognize that private provider perspectives are essential to build effective engagement models and, thus, to reach all clients with quality TB care.

Bringing state-of-the-art diagnostics to vulnerable populations: The use of a mobile screening unit in active case finding for tuberculosis in Palawan, the Philippines.

BACKGROUND: Globally, case detection of tuberculosis (TB) has stabilized in recent years. Active case finding (ACF) has regained an increased attention as a complementary strategy to fill the case detection gap. In the Philippines, the DetecTB project implemented an innovative ACF strategy that offered a one-stop diagnostic service with a mobile unit equipped with enhanced diagnostic tools including chest X-ray (CXR) and Xpert®MTB/RIF (Xpert). The project targeted the rural poor, the urban poor, prison inmates, indigenous population and high school students. METHODS: This is a retrospective review of TB screening data from 25,103 individuals. A descriptive analysis was carried out to compare screening and treatment outcomes across target populations. Univariate and multivariate analyses were performed to identify predictors of TB for each population. The composition of bacteriologically-confirmed cases by smear and symptom status was further investigated. RESULTS: The highest yield with lowest number needed to screen (NNS) was found in prison (6.2%, NNS: 16), followed by indigenous population (2.9%, NNS: 34), the rural poor (2.2%, NNS: 45), the urban poor (2.1%, NNS: 48), and high school (0.2%, NNS: 495). The treatment success rate for all populations was high with 89.5% in rifampicin-susceptible patients and 83.3% in rifampicin-resistant patients. A relatively higher loss to follow-up rate was observed in indigenous population (7.5%) and the rural poor (6.4%). Only cough more than two weeks showed a significant association with TB diagnosis in all target populations (Adjusted Odds Ratio ranging from 1.71 to 6.73) while other symptoms and demographic factors varied in their strength of association. The urban poor had the highest proportion of smear-positive patients with cough more than two weeks (72.0%). The proportion of smear-negative (Xpert-positive) patients without cough more than two weeks was the highest in indigenous population (39.3%), followed by prison inmates (27.7%), and the rural poor (22.8%). CONCLUSIONS: The innovative ACF strategy using mobile unit yielded a substantial number of TB patients and achieved successful treatment outcomes. TB screening in prison, indigenous population, and urban and rural poor communities was found to be effective. The combined use of CXR and Xpert largely contributed to increased case detection.

Increased Case Notification through Active Case Finding of Tuberculosis among Household and Neighbourhood Contacts in Cambodia.

BACKGROUND: Globally, there has been growing evidence that suggests the effectiveness of active case finding (ACF) for tuberculosis (TB) in high-risk populations. However, the evidence is still insufficient as to whether ACF increases case notification beyond what is reported in the routine passive case finding (PCF). In Cambodia, National TB Control Programme has conducted nationwide ACF with Xpert MTB/RIF that retrospectively targeted household and neighbourhood contacts alongside routine PCF. This study aims to investigate the impact of ACF on case notifications during and after the intervention period. METHODS: Using a quasi-experimental cluster randomized design with intervention and control arms, we compared TB case notification during the one-year intervention period with historical baseline cases and trend-adjusted expected cases, and estimated additional cases notified during the intervention period (separately for Year 1 and Year 2 implementation). The proportion of change in case notification was compared between intervention and control districts for Year 1. The quarterly case notification data from all intervention districts were consolidated, aligning different implementation quarters, and separately analysed to explore the additionality. The effect of the intervention on the subsequent case notification during the post-intervention period was also assessed. RESULTS: In Year 1, as compared to expected cases, 1467 cases of all forms (18.5%) and 330 bacteriologically-confirmed cases (9.6%) were additionally notified in intervention districts, whereas case notification in control districts decreased by 2.4% and 2.3%, respectively. In Year 2, 2737 cases of all forms (44.3%) and 793 bacteriologically-confirmed cases (38%) were additionally notified as compared to expected cases. The proportions of increase in case notifications from baseline cases and expected cases to intervention period cases were consistently higher in intervention group than in control group. The consolidated quarterly data showed sharp rises in all forms and bacteriologically-confirmed cases notified during the intervention quarter, with 64.6% and 68.4% increases (compared to baseline cases), and 46% and 52.9% increases (compared to expected cases), respectively. A cumulative reduction of case notification for five quarters after ACF reached more than -200% of additional cases. CONCLUSIONS: The Cambodia's ACF with Xpert MTB/RIF that retrospectively targeted household and neighbourhood contacts resulted in the substantial increase in case notification during the intervention period and reduced subsequent case notification during the post-intervention period. The applicability of retrospective contact investigation in other high-burden settings should be explored.

Mitigating Financial Burden of Tuberculosis through Active Case Finding Targeting Household and Neighbourhood Contacts in Cambodia.

BACKGROUND: Despite free TB services available in public health facilities, TB patients often face severe financial burden due to TB. WHO set a new global target that no TB-affected families experience catastrophic costs due to TB. To monitor the progress and strategize the optimal approach to achieve the target, there is a great need to assess baseline cost data, explore potential proxy indicators for catastrophic costs, and understand what intervention mitigates financial burden. In Cambodia, nationwide active case finding (ACF) targeting household and neighbourhood contacts was implemented alongside routine passive case finding (PCF). We analyzed household cost data from ACF and PCF to determine the financial benefit of ACF, update the baseline cost data, and explore whether any dissaving patterns can be a proxy for catastrophic costs in Cambodia. METHODS: In this cross-sectional comparative study, structured interviews were carried out with 108 ACF patients and 100 PCF patients. Direct and indirect costs, costs before and during treatment, costs as percentage of annual household income and dissaving patterns were compared between the two groups. RESULTS: The median total costs were lower by 17% in ACF than in PCF ($240.7 [IQR 65.5-594.6] vs $290.5 [IQR 113.6-813.4], p = 0.104). The median costs before treatment were significantly lower in ACF than in PCF ($5.1 [IQR 1.5-25.8] vs $22.4 [IQR 4.4-70.8], p<0.001). Indirect costs constituted the largest portion of total costs (72.3% in ACF and 61.5% in PCF). Total costs were equivalent to 11.3% and 18.6% of annual household income in ACF and PCF, respectively. ACF patients were less likely to dissave to afford TB-related expenses. Costs as percentage of annual household income were significantly associated with an occurrence of selling property (p = 0.02 for ACF, p = 0.005 for PCF). CONCLUSIONS: TB-affected households face severe financial hardship in Cambodia. ACF has the great potential to mitigate the costs incurred particularly before treatment. Social protection schemes that can replace lost income are critically needed to compensate for the most devastating costs in TB. An occurrence of selling household property can be a useful proxy for catastrophic cost in Cambodia.

Tuberculosis case-finding in Cambodia: analysis of case notification data, 2000 to 2013.

The routine tuberculosis (TB) surveillance system in Cambodia has been strengthened under the National TB Programme (NTP). This paper provides an overview of the TB surveillance data for Cambodia at the national level for the period 2000 to 2013 and at the subnational level for 2013. The proportion of the total population that were screened for TB rose from 0.4% in 2001 to 1.1% in 2013, while the smear-positivity rate decreased from 28.9% to 8.1% in the same period. The total number of notified TB cases increased steadily from 2000; this has stabilized in recent years with 39 055 cases notified in 2013. The proportion of all TB cases that were smear-positive decreased from 78% in 2000 to 36% in 2013. Case notification rates (CNRs) for all forms of TB and new smear-positive TB in 2013 were 261 and 94 per 100 000 population, respectively. Higher CNRs were found in the north-western and south-eastern parts of the country and were higher for males especially in older age groups. The increase in TB screening, decline in the smear-positive rate and decline in notified smear-positive TB cases likely reflect a long-term positive impact of the NTP. A negative correlation between the proportion of the population screened and the smear-positivity rate at the subnational level helped identify where to find undiagnosed cases. Subnational differences in case notification of the elderly and in children provide more specific targets for case-finding and further encourage strategic resource allocation.

The association between household poverty rates and tuberculosis case notification rates in Cambodia, 2010.

INTRODUCTION: Poverty is a risk factor for tuberculosis (TB); it increases the risk of infection and active disease but limits diagnostic opportunities. The role of poverty in the stagnant case detection in Cambodia is unclear. This study aims to assess the relationship between district household poverty rates and sputum-positive TB case notification rates (CNRs) in Cambodia in 2010. METHODS: Poisson regression models were used to calculate the relative risk of new sputum-positive TB CNR for Operational Districts (ODs) with different poverty rates using data from the National Centre for Tuberculosis and Leprosy Control and the National Committee for SubNational Democratic Development. Models were adjusted for other major covariates and a geographical information system was used to examine the spatial distribution of these covariates in the country. RESULTS: The univariate model showed a positive association between household poverty rates and sputum-positive TB CNRs. However, in multivariate models, after adjusting for major covariates, household poverty rates showed a significantly negative association with sputum-positive TB CNRs (relative risk [RR] = 0.95 per 5% increase in poverty rate). The negative association was stronger among males than females (RR = 0.93 versus 0.96 per 5% increase in poverty rate). Similar spatial patterns were observed between household poverty rates and other covariates, particularly OD population density. CONCLUSION: Household poverty rate is associated with a decrease in sputum-positive TB CNR in Cambodia, particularly in men. The potential of combining surveillance data and socioeconomic variables should be explored further to provide more insights for TB control programme planning.

The association between household poverty rates and tuberculosis case notification rates in Cambodia, 2010

Introduction: Poverty is a risk factor for tuberculosis (TB); it increases the risk of infection and active disease but limits diagnostic opportunities. The role of poverty in the stagnant case detection in Cambodia is unclear. This study aims to assess the relationship between district household poverty rates and sputum-positive TB case notification rates (CNRs) in Cambodia in 2010. Methods: Poisson regression models were used to calculate the relative risk of new sputum-positive TB CNR for Operational Districts (ODs) with different poverty rates using data from the National Centre for Tuberculosis and Leprosy Control and the National Committee for SubNational Democratic Development. Models were adjusted for other major covariates and a geographical information system was used to examine the spatial distribution of these covariates in the country. Results: The univariate model showed a positive association between household poverty rates and sputum-positive TB CNRs. However, in multivariate models, after adjusting for major covariates, household poverty rates showed a significantly negative association with sputum-positive TB CNRs (relative risk [RR] = 0.95 per 5% increase in poverty rate). The negative association was stronger among males than females (RR = 0.93 versus 0.96 per 5% increase in poverty rate). Similar spatial patterns were observed between household poverty rates and other covariates, particularly OD population density. Conclusion: Household poverty rate is associated with a decrease in sputum-positive TB CNR in Cambodia, particularly in men. The potential of combining surveillance data and socioeconomic variables should be explored further to provide more insights for TB control programme planning.