title: Community-based active tuberculosis case finding in poor urban settlements of Phnom Penh, Cambodia: a feasible and effective strategy.
abstract: BACKGROUND
  In light of the limitations of the current case finding strategies and the global urgency to improve tuberculosis (TB) case-detection, a renewed interest in active case finding (ACF) has risen. The WHO calls for more evidence on innovative ways of TB screening, especially from low-income countries, to inform global guideline development. We aimed to assess the feasibility of community-based ACF for TB among the urban poor in Cambodia and determine its impact on case detection, treatment uptake and outcome.
  
  
  METHODS
  Between 9/2/2012-31/3/2013 the Sihanouk Hospital Center of HOPE conducted a door-to-door survey for TB in deprived communities of Phnom Penh. TB workers and community health volunteers performed symptom screening, collected sputum and facilitated specimen transport to the laboratories. Fluorescence microscopy was introduced at three referral hospitals. The GeneXpert MTB/RIF assay (Xpert) was performed at tertiary level for individuals at increased risk of HIV-associated, drug-resistant or smear-negative TB. Mobile phone/short message system (SMS) was used for same-day issuing of positive results. TB workers contacted diagnosed patients and referred them for care at their local health centre.
  
  
  RESULTS
  In 14 months, we screened 315.874 individuals; we identified 12.201 aged ≥ 15 years with symptoms suggestive of TB; 84% provided sputum. We diagnosed 783, including 737 bacteriologically confirmed, TB cases. Xpert testing yielded 41% and 48% additional diagnoses among presumptive HIV-associated and multidrug-resistant TB cases, respectively. The median time from sputum collection to notification (by SMS) of the first positive (microscopy or Xpert) result was 3 days (IQR 2-6). Over 94% commenced TB treatment and 81% successfully completed it.
  
  
  CONCLUSIONS
  Our findings suggest that among the urban poor ACF for TB, using a sensitive symptom screen followed by smear-microscopy and targeted Xpert, contributed to improved case detection of drug-susceptible and drug-resistant TB, shortening the diagnostic delay, and successfully bringing patients into care.
authors.affiliation: Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia; Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Natalie
authors.initials: N
authors.lastname: Lorent
authors.affiliation: Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia.
authors.forename: Kimcheng
authors.initials: K
authors.lastname: Choun
authors.affiliation: Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia.
authors.forename: Sopheak
authors.initials: S
authors.lastname: Thai
authors.affiliation: Mycobacteriology Laboratory, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia.
authors.forename: Tharin
authors.initials: T
authors.lastname: Kim
authors.affiliation: Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia.
authors.forename: Sopheaktra
authors.initials: S
authors.lastname: Huy
authors.affiliation: Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia.
authors.forename: Reaksmey
authors.initials: R
authors.lastname: Pe
authors.affiliation: Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia; Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Johan
authors.initials: J
authors.lastname: van Griensven
authors.affiliation: Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Jozefien
authors.initials: J
authors.lastname: Buyze
authors.affiliation: Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium; Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium.
authors.forename: Robert
authors.initials: R
authors.lastname: Colebunders
authors.affiliation: Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium; Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium.
authors.forename: Leen
authors.initials: L
authors.lastname: Rigouts
authors.affiliation: Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Lutgarde
authors.initials: L
authors.lastname: Lynen
mesh_terms: D000328:Adult; D000368:Aged; D000995:Antitubercular Agents / Q000494:pharmacology / Q000627:therapeutic use; D002160:Cambodia / Q000453:epidemiology; D060085:Coinfection; D005260:Female; D005843:Geography; D015658:HIV Infections; D006801:Humans; D008297:Male; D008403:Mass Screening; D008856:Microscopy, Fluorescence; D008875:Middle Aged; D011159:Population Surveillance; D011204:Poverty Areas; D015995:Prevalence; D012959:Socioeconomic Factors; D013183:Sputum / Q000382:microbiology; D016896:Treatment Outcome; D014376:Tuberculosis / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D014504:Urban Health; D019037:Urban Health Services; D014505:Urban Population
chemical_list: D000995:Antitubercular Agents