Letters Section Editor: Robert M. Golub,
MD, Senior Editor.
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).
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.
Thim S, Sath S, Sina M, Tsai EY, Delgado JC, Shapiro AE, Barry III CE, Glaziou P, Goldfeld AE. A Community-Based Tuberculosis Program in Cambodia. JAMA. 2004;292(5):566-568. doi:10.1001/jama.292.5.566-c