In Cambodia, just over 100 kilometres up the Mekong River northeast of the capital Phnom Penh, lies a provincial town called Kampong Cham. Here, a small Médecins Sans Frontières (MSF) team are working hard to improve comprehensive tuberculosis (TB) care in the provincial hospital and fill gaps in a national system that is struggling to adequately manage the region's high TB burden.

MSF built a TB ward for Kampong Cham Provincial Hospital in 2009, and upgraded the laboratory facilities. Since then MSF has been providing staff, training, medicines and material support to the hospital to improve the facility staff’s ability to diagnose and treat TB patients effectively. The last quarter of 2010 saw big improvements, with a 25 per cent higher TB detection rate achieved. Currently the team in Kampong Cham is seeing about 120 patients each week with roughly one third of those being new suspected TB cases.

With the World Health Organization estimating that 64 per cent of all Cambodians are carrying the tuberculosis mycobacterium, and with an active TB prevalence of 0.69 per cent, it ranks in the top 22 countries globally for TB infection. Tuberculosis is an opportunistic infection, which means that it takes advantage of weakened immune systems, and it is commonly spread through the air by an infected person coughing. In Cambodia, weakened immune systems are all too common due to malnutrition, HIV infection, age, or poor hygiene and living conditions.

Gaps in the national health system

Adrien Marteau, an MSF medical doctor working in the TB ward that MSF built within Kampong Cham provincial hospital, recounts the story of a patient under his care that he says had slipped through the cracks of Cambodia's healthcare system as it tries to tackling tuberculosis. She is a young woman, about 21 years old, and had been on two consecutive lengths of ineffective treatment for TB at a health centre for a year and a half with no improvement. It was only then when the treatment failed a second time that they referred her to the MSF-supported TB ward in Kampong Cham provincial hospital, where she was diagnosed with multidrug-resistant TB.

"It's really a pity for this patient – both her lungs are very damaged, she will no longer be able to do any hard physical activity, to have a normal life," says Marteau. "Now she is in the hospital because she's experiencing severe side-effects from the drug-resistant TB drugs. She cannot feed well... she's very malnourished so the drugs are less effective. We don't know if she will be able to be cured or not – and it's very challenging. All of that because of a failing system, a lack of referral, and a problem of access to good care and a proper diagnosis."

Sadly, just two weeks later this patient passed away. She had started treatment for multidrug-resistant TB too late to save her life. The impact of cases such as this, where multidrug-resistant TB was not detected early enough, can be devastating for patients and their families, and demonstrates the reasoning behind MSF’s efforts to improve early detection and treatment strategies in the region.

Poverty compounds the problem

Cambodia's TB problems are compounded by poverty, with more than 30 per cent of all Cambodians living below the poverty line according to the latest World Bank estimate from 2008. Many cannot afford to see a doctor when they become sick – it is often only when their illness becomes much worse that they arrive at the hospital for treatment.

For this reason, MSF supports TB patients in Kampong Cham provincial hospital with free medicines, treatment, nutritious food during their hospital stay, and transport when necessary.

"You're speaking here of a disease that is impacting the lives of tens and tens of thousands in Cambodia. So you're talking of people who cannot go to school, that cannot learn, cannot work. Knowing that poverty is very high in Cambodia, you can imagine the overall impact. It's one of the biggest challenges for public health in the country today," says MSF's head of mission for Cambodia, Emmanuel Lavieuville.

The paradox of children: More vulnerable, under-diagnosed

One of the most vulnerable groups for contracting TB is young children who have not yet developed a strong immune system. TB is also very difficult to detect in children, stemming primarily from an inability of young children to produce a sputum sample for microscopic analysis. Even when they can their samples usually have the TB mycobacterium present in much smaller numbers.

Children under five years old cannot easily communicate their symptoms or complaints, so doctors are left with more time-consuming means to diagnose them – which further delays treatment for a disease that is known to have a high mortality rate in young children. An improved TB diagnostic test urgently needs to be developed for children living in Cambodia and other resource-poor settings.

This past February, a specialist medical advisor in diagnosing TB in children went to Cambodia to train the MSF team and Ministry of Health hospital staff in the latest techniques.

"It was quite clear that, just by visiting some of the wards at the hospital, that there are children there with TB that we're just not able to pick up at the moment," says Marianne Gale, a the specialist medical advisor and MSF doctor. "And similarly at the district hospital level, there were children there that I saw that were highly suggestive of having TB. So I think as the project continues to develop, and staff continue to be more aware of pediatric TB, the numbers of children being detected and treated here are only going to improve – and that will be really great to see."

Coping with isolation and economic hardship

Hospital isolation can be difficult for patients with drug-resistant forms of TB in Kampong Cham, especially when they are the key source of income for their family. They are required to stay in hospital for longer periods than general TB patients, and without being able to return to work quickly their whole family can suffer economically.

To minimize this problem, once drug-resistant TB patients have finished the first phase of their treatment and are stable, MSF sends them home to continue their treatment with support. MSF identifies a local nurse in their area for home-based care, and supplies them with drugs and other necessary supplies and support. MSF staff visit regularly to assess the patient's home and ensure they are adhering to their treatment.

"We have to make sure that the nurse goes everyday to visit and give the medication to the patient," says Claire Villeneuve, MSF's TB nurse supervisor in Kampong Cham. "Also, we ask them about the side-effects, how they are feeling, do they have any support from their family, and do they have any social issues – MSF can support them with these issues. Also, we have to assess their house to know if it's safe for the patient and their family to be at home. Sometimes MSF can support them with that, and can build a new room, a specific room for this patient to isolate them from the other members of the family.".

Planning for the future

MSF will soon acquire new equipment to allow more efficient screening, and will continue to strengthen its work in Kampong Cham provincial hospital. The team plans to expand their assistance over the coming months and years to also include a select number of district hospitals, helping some marginalized groups in the region to access treatment.

It's difficult to anticipate how long MSF's assistance will be needed in Cambodia. Tuberculosis will likely remain a considerable challenge for Cambodia’s health system for many years. However, through MSF’s consistent involvement in the field of TB in rural Cambodia and through the training of Ministry of Health staff in quality TB comprehensive care, it is hopeful that this project will help formulate new approaches and contribute to the development of new tools to facilitate the diagnosis and treatment of tuberculosis. In parallel, Cambodia's healthcare system in the coming years, with increased international donor involvement, may scale-up and be more able to manage its TB burden.

Says Lavieuville, MSF head of mission in Cambodia:

MSF has been working with Cambodians since 1979, and until recently was focused on treating HIV/AIDS patients in several locations throughout the country. MSF has steadily handed over most of its HIV programs to the Ministry of Health and has shifted its focus to tuberculosis.

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