New diagnostic tools help Cambodia tackle MDR-TB

Shobha Shukla - CNS
(Based on an exclusive interview given to CNS by Dr Mao Tan Eang, NTP Manager, Cambodia, during the 44th Union World Conference on Lung Health)
Cambodia, with a population of 15 million, is one of the 22 high TB burden countries. It has implemented two national TB prevalence surveys, during the last 10 years—one in 2002 and the other in 2011.The repeat survey provided robust evidence of a decline in TB burden in Cambodia, following DOTS (Directly Observed Treatment Short course) expansion in 2002. Results indicate a 45% reduction in the prevalence of bacteriologically-confirmed cases over a period of only 9 years since the first survey conducted in 2002. This amounts to an annual decrease of over 4.5% which is quite remarkable as compared to the global average of 2%.

As far as MDR-TB is concerned, the burden of MDR-TB in 2012 was 1.4% in new cases and 11% in retreatment cases. 110 patients were started on MDR--TB treatment in 2012.  Dr Mao Tan Eang, Director of National Centre for TB and Leprosy Control, Cambodia, has led the national TB programme in Cambodia since last 13 years. Dr Eang attributes the success story of TB control in Cambodia to two main factors— a patient centric approach to TB treatment and lately the induction of new molecular diagnostic tools. He said that, “The rolling out of new diagnostic technologies in Cambodia has been very beneficial to the programme, especially with regard to identification of MDR-TB cases.

GeneXpert MTB/RIF has been in routine service in Cambodia since 2011. Case findings of MDR-TB have doubled since induction of these machines between 2011 and 2012. Only 56 cases of MDR-TB were identified in 2011 by the programme with the conventional means including culture DST. But after the new machines came, 110 cases were identified and put on treatment in 2012. As of now, this year we have 150-160 MDR-TB patients on treatment. The good thing about the machine is that it rapidly identifies the cases and we can then immediately put them on treatment.  Quick diagnosis allows us to put patients on treatment very quickly—as soon as they are diagnosed. We plan to introduce these machines in all our hospitals by 2015. Of course there are challenges in managing the machines like proper maintenance and continuous electricity supply. Else there can be errors in the results. So far we have been able to maintain them well with a very very low rate of errors.”

The supply of GeneXpert MTB/RIF in Cambodia has been supported by various donors like TB CARE, TB REACH, USAID and UNITAID (8 machines have just been received from them). There are now 20 machines with the programme and in 2014 another 7 machines will be provided by the Global Fund to fight AIDS, Tuberculosis and Malaria (The Global Fund).

Dr Eang was happy that, “Unlike Myanmar, in Cambodia we have been able to ensure sufficient supply of drugs for both types of TB—drug susceptible as well as MDR-TB. There is no waiting list of patients to be put on treatment in our programme; rather the drugs are waiting for the patients to come to our programme.”

In Cambodia a community-based approach to MDR-TB has been developed that compliments hospital based care and seems to be working very well. Treatment adherence is very good for both types of TB, primarily because of community based monitoring of patients through community volunteers as well as health centre staff and collaboration with NGOs. DR Eang informed that, “More than 80% of the health centres in Cambodia have C-DOTS (community DOTS) activity which has helped in making the treatment success/cure rate very high—for the last two years treatment success rate has been 70%-75%, largely because of C-DOTS. For drug sensitive TB there are around 30,000 volunteers helping with DOTS within the programme at community level. We follow a patient centric treatment approach which is tailored according to the needs of the patients. Under this scheme, the patients are provided injections and drugs at their house under the community DOTS approach for both types of TB. There are treatment guidelines for this patient centric care approach in which the patient and the DOTS provider of the health centre agrees upon a place to give the drug—either at the healthcare facility or in the patient’s house. We have community volunteers as well as our staff to monitor and we also have partnership with NGOs who help us keep the patients in the programme.”

Although Cambodia is on track for reaching the MDG goal on schedule so far (the prevalence rate till 2011 had decreased by 51% and death rate by 60% with reference to 1990 baseline), but it still remains a high burden country. Dr Eang hopes to see an improvement in Cambodia’s response to TB. According to him, “We have been able to reduce TB prevalence by 4.5% per year which is quite incredible, but we are aiming to reduce it faster and better than that. In our next draft TB plan for 2014-2020 we will have some additional innovative approaches for more active case finding and reaching out to all the segments of population—prisoners, migrants, slum dwellers, poor people—with the aim to cut prevalence by more than 5% annually. There is collaboration with private health care providers under PPM DOTS and we are planning to scale up that too. Right now cases identified by PPM DOTS are around 6-8% of the total cases notified in the programme. But the benefit of PPM DOTS extends beyond just identifying TB cases. They are equal partners of the public health system for TB care and control.”

Shobha Shukla, Citizen News Service - CNS
November 2013
(The author is the Managing Editor of Citizen News Service - CNS and is supported by Lilly MDR TB Partnership to provide conference coverage from 44th Union World Conference on Lung Health. She is a J2J Fellow of National Press Foundation (NPF) USA and received her editing training in Singapore. She has earlier worked with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also co-authored and edited publications on childhood TB, childhood pneumonia, Hepatitis C Virus and HIV, violence against women and girls, and MDR-TB. Email: shobha@citizen-news.org, website: www.citizen-news.org) 

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