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Tuberculosis
Initiation, scale-up and outcomes of the Cambodian National MDR-TB programme 2006–2016: hospital and community-based treatment through an NGO–NTP partnership
  1. Sophan Sam1,
  2. Adrienne E Shapiro1,2,
  3. Thim Sok1,
  4. Sokhan Khann1,3,
  5. Rassi So1,
  6. Sopheap Khem1,
  7. Sokhem Chhun1,
  8. Sarith Noun1,
  9. Bonamy Koy4,
  10. Prum Chhom Sayouen4,
  11. Chun Im Sin5,
  12. Heng Bunsieth1,
  13. Tan Eang Mao4 and
  14. Anne E Goldfeld1,6
  1. 1Cambodian Health Committee, Phnom Penh, Cambodia
  2. 2Department of Medicine, University of Washington, Seattle, Washington, USA
  3. 3WHO-Cambodia, Phnom Penh, Cambodia
  4. 4National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
  5. 5Khmer Soviet Friendship Hospital, Phnom Penh, Cambodia
  6. 6Program in Cellular and Molecular Medicine, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Anne E Goldfeld; anne.goldfeld{at}childrens.harvard.edu

Abstract

Introduction Prolonged inpatient multidrug-resistant tuberculosis (MDR-TB) treatment for all patients is not sustainable for high-burden settings, but there is limited information on community-based treatment programme outcomes for MDR-TB.

Methods The Cambodian Health Committee, a non-governmental organisation (NGO), launched the Cambodian MDR-TB programme in 2006 in cooperation with the National Tuberculosis Program (NTP) including a community-based treatment option as a key programme component. The programme was transferred to NTP oversight in 2011 with NGO clinical management continuing. Patients electing to receive home-based treatment were followed by a dedicated adherence supporter and a multidisciplinary outpatient team of nurses, physicians and community health workers. Patients hospitalised for >1 month of treatment (hospital based) received similar management after discharge. All patients received a standardised second-line MDR-TB regimen and were provided nutritional and adherence support. Outcomes were reviewed for patients completing 24 months of treatment and predictors of treatment success were evaluated using logistic regression.

Results Of 582 patients with MDR-TB who initiated treatment between September 2006 and June 2016, 20% were HIV coinfected, 288 (49%) initiated community-based treatment and 294 (51%) received hospital-based treatment. Of 486 patients with outcomes available, 364 (75%) were cured, 10 (2%) completed, 28 (6%) were lost to follow-up, 3 (0.6%) failed and 77 (16%) died. There was no difference between treatment success in community versus hospital-based groups (adjusted OR (aOR) 1.0, p=0.99). HIV infection, older age and body mass index <16 were strongly associated with decreased treatment success (aOR 0.33, p<0.001; aOR 0.40, p<0.001; aOR 0.40; p<0.001).

Conclusions Cambodia’s NGO–NTP partnership successfully developed and scaled up a model MDR-TB treatment programme. The first large-scale MDR-TB programme in Asia with a significant community-based component, the programme achieved equally high treatment success in patients with community-based compared with hospital-based initiation of MDR treatment.

  • multi-drug resistant-TB
  • Cambodia
  • HIV/AIDS
  • community-based treatment

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjresp-2017-000256

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    Footnotes

    • SS, AES and TS contributed equally.

    • Contributors Conception and design of the work: TS, SS, TEM, AES, AEG. Acquisition of data: SS, AES, TS, SKha, RS, SKhe, SC, SN, BK, PCS, HB, TEM. Analysis and interpretation of data: AES, SS, SKhe, TEM, AEG.

    • Funding The CHC Cambodian MDR-TB Program was funded by a grant from the Annenberg Foundation (2006 onwards), grants from the Blue Oak and Frankel Foundations, and a gift from Nancy and Steve Crown. The program also received support from USAID/WHO (2012–2014), Global Fund for TB, Malaria and AIDS (GFATM) (2015), and USAID/FHI360 (2016).

    • Disclaimer The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

    • Competing interests None declared.

    • Patient consent Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.