Asian National Stop TB Partnership Forum"Community people’s roles in End TB
Strategy in Asia”
United Nation University, Tokyo, Japan
14 and 15 March, 2016
Dr. Khloeung Phally
Mr. Chry Monyrath

TB Burden in Cambodia• Cambodia is still one of the 22 HBC with TB in theworld• Incidence rate of TB all forms in 2014 is 390/100,000*.
• Prevalence rate of TB all forms in 2014 is668/100,000*.
• Prevalence rate of Sm+ for age 15 and over in 2011 is272/100,000.
• Death rate 58/100,000** Global report 2015

About CATA (1)1. Background:
Cambodia Anti-Tuberculosis Association(CATA), alocal NGO established in 2003, as a TB professional
association of individual and institution committed tocontribute to the fight against TB in Cambodia.
2. Vision:
Make Cambodia free from TB and Lung Disease.

About CATA (2)3. Mission
Coordinate and advocate for TB free Cambodia and ensuresocial and community enabling environment through: Promoting the institution and the individual to involve inStop/End TB strategy
 Information sharing, research and capacity building Promoting the quality of effective prevention, early detection
and treatment of Tuberculosis and Lung disease Strengthening the effective enforcement of relevant laws,policies and guidelines.

About CATA (3)4. GoalStrengthening the coverage and quality of TB services
by increasing commitment of the institution and theindividual and promoting the social and community
environment.

Current Projects
Project NameCoverage Area

Public-Private Mix-DOT in
Factory (work place)
Active Case Finding
among Elderly and other
Vulnerable Communities

14 Factories, Phnom Penh
12 Operational Districts in 8Provinces.

TB Control in Factory (1)1. Background:• Factories, the poor ventilated settings where thousandsof workers work and share room air are at high risk forTB• Patients with TB symptoms may receive symptomatic
treatment at the factories as factory clinics support only
primary health care, leading to diagnostic delay.
• Untreated, some one with chronic TB may face being
dismissed from employment due to frequent
absenteeism , and bring additional hardship to thevulnerable family.

TB Control in Factory (2)2. Current Methods:• Trained peers to conduct peer contact activities.
• Conduct follow up (FU) meetings with peers• Refer suspected TB case from factory to public healthcenter• Implement DOT in factories ( work place)TB Control in Factory (3)3. Results:• 14 garment factories were implemented.
• 11,553 workers were contacted by peer educators( 11 months ).
• 12 sessions of FU were conducted• 108 TB suspects referred to HC (11mths).
• 10 TB cases registered (5s+, 4s- and 1EP) for
treatment by DOT in factory (11 months).

TB Control in Factory (4)4. Cases notified by TB types/years
EPBKBK+25520615127105221059644533433779950

2007 2008 2009 2010 2011 2012 2013 2014

TB Control in Factory (5)5. Lesson Learnt:• Lack of awareness raising activity, the discrimination
among workers might be not reduced leading to lessnumber of referral• Limited budget for FU meeting with Peers is the causeof less peers’ activity.
• TB patients can work regularly during the course oftreatment( in the exception of 1st month therapy ofsmear positive cases).
• In congregated settings, one case treated can prevent
hundreds of co-workers from TB

Active Case Finding (1)1. Backgrounds:•TB burden in Cambodia has decreased by > 50% byend 2015 compared to 1990 data.
• Cambodia still one of the highest TB prevalence in theworld- Prevalence all form : 668 cases/100,000 population- Prevalence survey in 2011, TB burden in elderly is≥3time higher than the general population.
- Prevalence/Notification ratio in >55 years = 1.5• Hypothesis: poor access to TB diagnosis and treatment

Active Case Finding (2)2. Methods:• Active case finding using mobile teams equipped with a chest xray (CXR) and Xpert machine in 12 Operational Districts.
• 1 to 2 weeks before field operation, each health centre wasvisited for one day by the team:- Volunteers performed door to door symptom screening
prior to CXR screening day.
- TB suspects with a positive CXR were then tested by
Xpert MTB/RIF assay- TB cases were registered and put on treatment• Elderly were primarily targeted.
• Project yield and TB notification data were analysed to assess
impact on treatment initiation.

Active Case Finding (3)3. Results (1):Year 1 (2014)
Indicators

Year 2 (2015)

Annual Planned
TargetAchieved
Target%Annual Planned
TargetAchieved
Target%1) #of people screened

113735

68846

61%

57810

56996

99%

(2) #of TB suspects

21840

11995

55%

16830

16043

95%

(3) #of people tested by TB X
ray.

18055

11650

65%

15810

12147

77%

(4) #of TB suspects tested byGene Xperts.

3276

2520

77%

3478

2084

60%

(5) #of people confirmed as SS+/B+ (yield SS+/B+)

663

397

60%

557

334

60%

(6) #of people confirmed as TB
all forms (yield all forms)

1243

1064

86%

1265

1094

86%

Active Case Finding (4)3. Results (2):••••12 operational districts visited.
193 health facilities visited.
23,797 individuals screened by CXR.
4,604 (19.0%) individuals were tested using the Xpert
MTB/RIF assay,• Resulting in the detection of 731 (16%) MTB-positivepatients.
• Total cases : 2158 (MTB positive + others)Active Case Finding (4)3. Results (3):New bacteriologically-positive notifications
increased +119.2% for all ages and +262.7% for those ≥55 years
during the ACF quarters compared to trend expected notifications.
Changes in new Bac+ and All Forms of TB treatment initiation and reporting in 4 Operational Districts of Year 1
Trend
ActualExpected
Additional
Patients Detected Intervention
Additional
Intervention
Notifications(Project Yield)
Quarter
Notifications
Quarterto Yield Ratio
Notifications
Notifications
New Bac+, All Ages
319
399
182
217 (+119.2%)
68.00%
Ang Roka
35
58
24
34 (+141.7%)
97.10%
Battambong
68
115
56
59 (+105.4%)
86.80%
Kong Pisey
110
105
45
60 (+133.3%)
54.50%
106
Sampovmeas
121
57
64 (+112.3%)
60.40%New Bac+, ≥55 Years
231
243
67
176 (+262.7%)
76.20%
Ang Roka2934
8
26 (+325.0%)
89.70%
Battambong
62
61
13
48 (+369.2%)
66.70%
Kong Pisey
6871
24
47 (+195.8%)
69.10%
62
Sampovmeas
77
22
55 (+250.0%)88.70%All Forms of TB, All Ages
893
1,232
653
579 (+88.7%)
73.10%
Ang Roka
98
152
68
84 (+122.4%)
69.40%
Battambong
230
445
196
249 (+126.6%)
85.20%
Kong Pisey
318
344
245
99 (+40.3%)
77.00%
247
Sampovmeas291
143
148 (+103.6%)
57.90%

Active Case Finding (4)3. Results (4):NTP notifications in intervention period compared toexpected notifications based on 3 year trend:New Bac+ notifications
were +54.0% and +109.2% higher than expected for all ages and ≥55years respectively.
New Bacteriologically-positive TB Notifications by Age Group
400350TB Patients Treated300

250200
150

100
500

TB Patients Treated, All Ages

Pre-Intervention Trend

TB Patients Treated, ≥55 Years

Trend Expected TB Patients TreatedActive Case Finding (5)4. Lesson Learnt (1):• The factors contributing to the success are the involvementfrom stakeholders and the trust to the project for its newtechnology, and quick diagnosis.
• The conditions for success to be continued are:1)
proper maintenance of all equipment to avoid being broken
during implementation,2) well calculation and implementation of project’s resources
supplied and demand3) continue providing transport cost to the poor and those
who live far away from HCs, and;4)
The use of communication skills and incentive provided toall stakeholders for better involvement is still key factors forsuccess.

Active Case Finding (6)4. Lesson Learnt (2):• The conditions to replicate and expand the successful
strategy are:
– The combination of the team 1 and team 2 to work
together for:• Increasing the number screened by CXR,
• Saving fuel needed to supply 2 generators thatoperated separately.
• Minimizing interruption of the operation due to unsafe
power supply.
– Procure a set of new CR machine to avoid interruption
due to Prima console system error or broken.

Active Case Finding (7)4. Lesson Learnt (3):• The strategy used is likely appropriate for ACF but there aresome constraints factors as following:– Road conditions are bad due to rainy season, causing
difficulty to reach the HCs, leading to implementation timeis short.
– Elderly need to look after their grandchildren at home andsometime cannot come to HCs.
• The project screens/tests a lot of patients per day for a long
period of time, so it may cause to damage the material. To
avoid that and ensure the project run smoothly, CATA seeksfund to buy new equipment especially CR and X-ray
machine for security.

Active Case Finding (8)5. Conclusion:• ACF using mobile teams was able to increase accessto TB diagnosis, especially the elderly people.
• Compare to baseline data, the intervention can detectand treat many patients who previously missed routine
TB services.
• We recommend to consider targeted ACF interventionsin other settings where access to diagnosis andtreatment is limited.