The multi-step process of building TB/HIV collaboration in Cambodia.

Tuberculosis and HIV/AIDS have synergistic health impacts in terms of disease development and progression. Therefore, collaborative TB and HIV/AIDS activities are a logical health systems response. However, the establishment of these activities presents a challenge for countries that have strong vertical disease programs that differ in their implementation philosophies. Here, we review the process by which TB/HIV collaboration was established in Cambodia. A cycle of overlapping and mutually reinforcing initiatives - local research; piloted implementation with multiple options; and several rounds of policy formulation guided by a cross-functional Technical Working Group - was used to drive nationwide introduction of a full set of TB/HIV collaborative activities. Senior Ministry of Health officials and partner organizations brought early attention to TB/HIV. Both national programs implemented initial screening and testing interventions, even in the absence of a detailed, overarching framework. The use of multiple options for HIV testing identified which programmatic options worked best, and early implementation and pilots determined what unanswered questions required further research. Local conduct of this research - on co-treatment timing and TB symptom screening - speeded adoption of the results into policy guidance, and clarified the relative roles of the two programs. Roll-out is continuing, and results for a variety of key indicators, including screening PLHIV for TB, and testing TB patients for HIV, are at 70-80% and climbing. This experience in Cambodia illustrates the influence of health research on policy, and demonstrates that clear policy guidance, the pursuit of incremental advances, and the use of different approaches to generate evidence can overcome structural barriers to change and bring direct benefits to patients.

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.

Fighting the tuberculosis epidemic in the Western Pacific region: current situation and challenges ahead.

INTRODUCTION: Tuberculosis (TB) remains a major public health problem in the Western Pacific Region. More than 20% of the global burden of TB is found in the Region. In 2007, the latest year for which data is available, there were an estimated 1.9 million incident cases (109 per 100,000 population). Four countries (Cambodia, China, the Philippines and Vietnam) account for 93% of the total estimated incident cases in the Region. Every year an estimated 300 thousand persons die due to TB. The Region is host to an estimated 135,000 multi-drug resistant TB cases, most of which can be found in China. TB PREVALENCE AND TB MORTALITY: The Regional Stop TB strategy aims to halve the prevalence and mortality rates of 2000 by 2010. Based on current estimates, the TB prevalence declined with 24% between 2000 and 2007, while TB mortality declined with 19% in the same period. Given the current annual decrease in TB prevalence and mortality, it is unlikely that the Region will achieve the 50% reduction by 2010. CASE FINDING: Approximately 1.4 million new TB cases were notified in the Region in 2007, of which close to 0.7 million smear-positive cases. Cases from China accounted for 70% of the total notified smear-positive cases. The Regional case detection rate was sustained at 78%. Case detection rates in China, the Lao People's Democratic Republic, Mongolia, the Philippines and Vietnam exceeded the 70% target. TREATMENT OUTCOMES: A total of 92% of the 0.7 million new pulmonary smear-positive cases registered for treatment in 2006 were successfully treated. The treatment success rates exceed the 85% target in all countries with a high burden of TB, except Papua New Guinea where it was reported at 73%. MULTIDRUG-RESISTANT TB: In 2007, the proportion of MDR-TB in new TB cases was estimated to be 4%. A total of 135,411 MDR-TB cases was estimated to have occurred in 2007. Based on the overall case management data, 10,231 new patients and 1,596 re-treatment patients were reported with available drug susceptibility testing (DST) results in the Region. Of these, 1% (89/10,231) and 29% (468/1,596) had MDR-TB, respectively. Capacity to detect and treat MDR-TB cases is still very limited in most countries in the Region. Eighteen countries and areas in the Region have conducted drug resistance surveillance (DRS) since 2000, according to the Global Project on Anti-tuberculosis Drug Resistance Surveillance. Among new TB cases, the prevalence of multidrug-resistant TB (MDR-TB) ranged from 0% in Cambodia to 11.1% in the Commonwealth of the Northern Mariana Islands. MDR-TB prevalence among re-treatment cases ranged from 3.1% in Cambodia to 27.5% in Mongolia. In the five countries with a high burden of TB with available data from surveys (Cambodia, China, Mongolia, the Philippines, and Vietnam), MDR-TB prevalence in new cases and re-treatment cases ranged from 0% in Cambodia to 4.9% in China and from 3.1% in Cambodia to 27.5% in Mongolia, respectively. Notably, there were alarming rates of MDR-TB in several provinces in China among both new and retreatment cases. Increasing numbers of MDR-TB cases are reported from Papua New Guinea. TB-HIV CO-INFECTION: The overall estimated prevalence of HIV in new TB cases in 2007 was 2.7%. With 8.0% in 2008 compared to 11.8% in 2003, Cambodia shows a declining prevalence of HIV in new TB cases. There was a significant increase in the use of anti-retroviral therapy (ART) in the Region. However, detailed and complete data as well as strong collaboration in HIV and TB management are needed to be able to closely monitor the use of ART and its impact on TB-HIV co-infection in the Region. CONCLUSION: In spite of the substantial progress made in most countries with a high burden of TB, substantial challenges remain in the Region. The rate of decline in TB prevalence and mortality is too low to reach the 50% reduction goal in 2010. It will be necessary to further increase TB case detection and address the emerging spread of drug-resistant TB. The slow response in the most affected countries in the Region is a cause for concern. Strong commitment by national governments and their partners is needed to sustain and further strengthen the current TB control efforts.

Reaching the global tuberculosis control targets in the Western Pacific Region.

PROBLEM: In 1999, a tuberculosis (TB) crisis was declared in the Western Pacific Region. APPROACH: In response, WHO established the Stop TB Special Project, which sought to halve 2000 levels of TB prevalence and mortality by 2010 through first reaching the global 2005 TB targets. LOCAL SETTING: Particular issues in the region were low political commitment, inadequate numbers of staff (particularly of adequately trained staff) and a wide variation in TB burden between countries. RELEVANT CHANGES: WHOs leadership (especially the commitment of its Regional Director) and building of regional and national partnerships strengthened political and donor commitment. This accelerated the implementation of regional and national TB control plans, allowing the region to reach the 2005 targets for TB control. LESSONS LEARNED: The experience in the Western Pacific Region demonstrated that WHOs leadership was pivotal in generating the political commitment necessary to accelerate actions on the ground. The regions investment in building partnerships and a motivated workforce was an important contribution towards achieving the 2005 global TB targets.