The routine tuberculosis (TB) surveillance system in Cambodia has been strengthened under the National TB Programme (NTP). This paper provides an overview of the TB surveillance data for Cambodia at the national level for the period 2000 to 2013 and at the subnational level for 2013. The proportion of the total population that were screened for TB rose from 0.4% in 2001 to 1.1% in 2013, while the smear-positivity rate decreased from 28.9% to 8.1% in the same period. The total number of notified TB cases increased steadily from 2000; this has stabilized in recent years with 39 055 cases notified in 2013. The proportion of all TB cases that were smear-positive decreased from 78% in 2000 to 36% in 2013. Case notification rates (CNRs) for all forms of TB and new smear-positive TB in 2013 were 261 and 94 per 100 000 population, respectively. Higher CNRs were found in the north-west and south-east parts of the country and were higher for males especially in older age groups. The increase in TB screening, decline in the smear-positive rate and decline in notified smear-positive TB cases likely reflect a long-term positive impact of the NTP. A negative correlation between the proportion of the population screened and the smear-positivity rate at the subnational level helped identify where to find undiagnosed cases. Subnational differences in case notification of the elderly and in children provide more specific targets for case-finding and further encourage strategic resource allocation.

Introduction: Poverty is a risk factor for tuberculosis (TB); it increases the risk of infection and active disease but limits diagnostic opportunities. The role of poverty in the stagnant case detection in Cambodia is unclear. This study aims to assess the relationship between district household poverty rates and sputum-positive TB case notification rates (CNRs) in Cambodia in 2010. Methods: Poisson regression models were used to calculate the relative risk of new sputum-positive TB CNR for Operational Districts (ODs) with different poverty rates using data from the National Centre for Tuberculosis and Leprosy Control and the National Committee for SubNational Democratic Development. Models were adjusted for other major covariates and a geographical information system was used to examine the spatial distribution of these covariates in the country. Results: The univariate model showed a positive association between household poverty rates and sputum-positive TB CNRs. However, in multivariate models, after adjusting for major covariates, household poverty rates showed a significantly negative association with sputum-positive TB CNRs (relative risk [RR] = 0.95 per 5% increase in poverty rate). The negative association was stronger among males than females (RR = 0.93 versus 0.96 per 5% increase in poverty rate). Similar spatial patterns were observed between household poverty rates and other covariates, particularly OD population density. Conclusion: Household poverty rate is associated with a decrease in sputum-positive TB CNR in Cambodia, particularly in men. The potential of combining surveillance data and socioeconomic variables should be explored further to provide more insights for TB control programme planning.

Background
The national tuberculosis (TB) control program established Phnom Penh as a pilot area for TB and human immunodeficiency virus (HIV) infection collaborative activities because of the high prevalence of HIV among patients with TB.
Process
In 2005, we provided transportation fees so that patients could travel to an operational district referral hospital for HIV counseling and testing by dispatched counselors. However, only around 10.3 patients with TB (range 0-21) per month in all 4 operational districts made use of this service. In 2006, we modified the program by providing HIV counseling and testing by four trained TB/HIV coordinators in TB wards. Thereafter, in-depth, individual, semi-structured interviews were conducted with the TB staff (not the coordinators) of 18 health facilities from April through November 2006 to identify problems in the current TB/HIV collaborative activities in Phnom Penh and to investigate ways for further improving the program.
Results
TB staff members encouraged their patients to undergo an HIV test under directly observed treatment, short course. Some TB staff lacked confidence to discuss HIV issues because they lacked sufficient HIV/ acquired immunodeficiency disease syndrome (AIDS) knowledge. Furthermore, there was no formal referral structure between TB and HIV services or sharing of information on the treatment of patients co-infected with TB/HIV with the antiretroviral treatment clinic.
Conclusions
We started the program to enable TB patients to receive HIV counseling and testing at the same venue as they received TB treatment. However, problems such as low confidence among TB staff in discussing HIV/AIDS and weak collaboration between TB and HIV services were identified. We found that training of TB staff, development of Information, Education and Communication (IEC) materials, regular meetings among stakeholders, and encouragement for the TB/HIV coordinators to supervise all TB/HIV activities in their operational districts were needed to improve the program.