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August 4, 2004

A Community-Based Tuberculosis Program in Cambodia

Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2004;292(5):566-568. doi:10.1001/jama.292.5.566-c

To the Editor: Cambodia has one of the highest global burdens of tuberculosis (TB).1 In 1994, the Cambodian Health Committee (CHC), a nongovernmental organization, developed a community-based approach to the treatment of TB using microfinance and food supplementation in Svay Rieng, one of Cambodia's poorest provinces.


The program comprised 2 components: a health center–based component (hospital/health care center [HHC]) and a home-based component (Home Directly Observed Therapy Short Course [Home DOTS]). The mean annual target population was 149 577 for the HHC component and 11 557 for the Home DOTS component. Between 1994 and 2001, 2780 patients with TB were treated in the HHC protocol involving DOTS (with 2 months of forced hospitalization during the period 1994-1999, per the national protocol), followed by 6 months of outpatient therapy with monthly drug pick-up at the HHC. After 1999, daily health center visits were offered as an alternative to hospitalization during the intensive phase. From 1999 to 2001, a separate Home DOTS protocol used mobile health teams to actively detect patients in 2 districts not served by HHC and to provide TB therapy to 219 patients in their homes. Compliance strategies in both components expanded on those pioneered in refugee camps at the Thai-Cambodian border2 and included: pretreatment patient education, patient supporters to supervise treatment, a treatment contract, nutritional supplementation, and surprise home visits. Beginning in 1994, a novel linked microfinance project established a network of village banks.3


Mean notification rates of all new TB cases (ie, both smear-positive and -negative) per year were 1.5 (HHC) and 4.2 (Home DOTS) times higher than the reported 2001 national rate of 144 per 100 000 (Table 1).4 In addition, mean cure rates of 94% and 99% of new patients with TB were achieved in the HHC (1994-2001) and Home DOTS (1999-2001) components, respectively (Table 2). Among category 2 patients (ie, those previously treated for TB for more than 4 weeks), cure rates were similarly high (93% in HHC and 91% in Home DOTS) (data not shown). Upon diagnosis of TB, an increased proportion of extrapulmonary TB cases were identified in Home DOTS compared with HHC (13% vs 4%, respectively; P<.001), presumably due to active case-finding as opposed to self-presentation by patients with TB. There was a significantly shorter delay between onset of symptoms and diagnosis of TB in Home DOTS compared with HHC (6 months vs 30 months, respectively; P = .006).

Table 1. Cambodian Health Committee Program Clinical Outcomes by Year: TB Case Notification in HHC and Home DOTS
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Table 2. Cambodian Health Committee Clinical Program Outcomes by Year: New Smear-Positive (Category 1) Patients With TB
Image description not available.

Loan repayment and TB cure rates approached 100% among 590 families benefiting from participation in village banks. Interest charged on funds provided through village banks established a Village Health Fund and enabled the training of 96 Village Health Agents, who conducted community education and assisted in patient detection and follow-up (Sok et al, unpublished data). Food supplementation, in collaboration with the World Food Program, was initiated at HHCs as an incentive for all HHC patients to pick up their monthly supply of medicines during the continuation phase and was delivered on a monthly basis to all Home DOTS patients. Consisting of a supplement of 15 kg of rice, 700 mL of cooking oil, and 2 cans of fish, it is now a nationwide component of the Cambodian National TB Program.


The CHC program achieved case detection rates among the highest in the world.5 CHC strategies to improve treatment compliance, case detection, and cure overcame numerous barriers presented by previous methods, including restricted access to health care facilities in rural areas, the economic burdens of hospitalization and travel to HHC, and low visibility of health workers in the community. To our knowledge, this program is unique in using poverty reduction as a component of community-based tuberculosis treatment. The village banks reduced poverty in the community at large and simultaneously increased the visibility of health workers and the CHC program, thus presumably increasing awareness of TB symptoms within the community, reducing disease-associated stigma, and improving case detection and treatment adherence in conjunction with patient supporters.

Active case-finding by the CHC resulted in a marked increase in case detection, suggesting that in extremely high-prevalence areas such as Cambodia this approach can be a productive component of TB programs, particularly in the initial stages of a program's expansion into a previously unserved area. The decreased time to diagnosis seen in Home DOTS is notable since earlier detection and treatment of TB leads to reduced disease transmission, improved pulmonary fitness, increased ability to work, and to other, unquantifiable, benefits. These results were achieved using transferable methods in one of the world's most resource-poor rural environments.

Dr Glaziou is currently affiliated with the Western Pacific Regional Office, World Health Organization, Manila, Philippines.

Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC.WHO Global Surveillance and Monitoring Project.  Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country.  JAMA.1999;282:677-686.PubMed
Miles SH, Maat RB. A successful supervised outpatient short-course tuberculosis treatment program in an open refugee camp on the Thai-Cambodian border.  Am Rev Respir Dis.1984;130:827-830.PubMed
Khandker SR, Khaliliy B, Khan Z. Is Grameen Bank Sustainable? Washington, DC: Human Resources Development and Operations Policy Division, World Bank; 1994.
 Tuberculosis Control in the WHO Western Pacific Region . Manila, Philippines: World Health Organization, Office for the Western Pacific Region; 2003.
 WHO Report: Global Tuberculosis Control—Surveillance, Planning, Financing . Geneva, Switzerland: World Health Organization; 2002.