You are on page 1of 9

Tropical Medicine and International Health

volume 10 no 7 pp 689697 july 2005

Community-based surveillance: a pilot study from rural

Sophal Oum1, Daniel Chandramohan2 and Sandy Cairncross2
1 Ministry of Health, Phnom Penh, Cambodia
2 Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK


objective This study seeks to assess the performance of a community-based surveillance system
(CBSS), developed and implemented in seven rural communes in Cambodia from 2000 to 2002 to
provide timely and representative information on major health problems and life events, and so permit
rapid and effective control of outbreaks and communicable diseases in general.
methods Lay people were trained as Village Health Volunteers (VHVs) to report suspected
outbreaks, important infectious diseases, and vital events occurring in their communities to local health
staff who analysed the data and gave feedback to the volunteers during their monthly meetings.
results Over 2 years of its implementation, the system was able to detect outbreaks early, regularly
monitor communicable disease trends, and to provide continuously updated information on pregnancies,
births and deaths in the rural areas. In addition, the system triggered effective responses from both
health staff and VHVs for disease control and prevention and in outbreaks.
conclusion A CBSS can successfully fill the gaps of the current health facility-based disease surveillance system in the rapid detection of outbreaks, in the effective monitoring of communicable diseases, and in the notification of vital events in rural Cambodia. Its replication or adaptation for use in
other rural areas in Cambodia and in other developing countries is likely to be beneficial and costeffective.
keywords community based surveillance, village health worker, outbreak, communicable disease
control, Cambodia

The World Health Organization asserts that effective
communicable disease control relies on effective response
systems, and effective response systems rely on effective
disease surveillance (WHO 2000). Routine health facility
based disease surveillance systems, such as those on which
most developing countries depend, could provide neither a
complete nor a representative picture of health problems in
the communities because patients who cannot get access to
public health facilities or who choose not to use them are
not reported by these systems. In order to overcome this
limitation of facility-based health information systems,
community-based surveillance systems (CBSS), based upon
a network of lay people involved in the systematic
detection and reporting of health-related events from their
community, have been employed in a variety of settings.
The operational characteristics and the performance of
these CBSS have varied. For example, the type of data

2005 Blackwell Publishing Ltd

collected has varied, depending on the objectives of each

CBSS. It has included the incidence of specific infectious
diseases such as Guinea worm infection (Cairncross et al.
1999), yaws (Anselmi et al. 1995), malaria (Ruebush et al.
1994; Ghebreyesus et al. 2000), and tuberculosis (Balasubramanian et al. 1995); pregnancy outcomes (Ahluwalia
et al. 1999); nutritional status of children (Valyasevi et al.
1995); and vital events (Jaravaza et al. 1982). CBS systems
have been shown to provide useful information for
monitoring disease control programmes (Cairncross et al.
1996; Ghebreyesus et al. 2000; Howard-Grabman 2000).
However, these programmes have each focussed on a single
disease and thus did not maximize the value of scarce
resources available at the peripheral level. A CBSS targeting all common diseases and vital events would be more
appropriate and resource-efficient (Manderson 1992;
Cairncross et al. 1996). In this paper, we report the
experience of a CBSS in rural Cambodia, including its
development and feasibility, its performance in terms of

Tropical Medicine and International Health

volume 10 no 7 pp 689697 july 2005

S. Oum et al. Community-based surveillance in Cambodia

sensitivity and positive predictive value, and its usefulness

to local health services.
Materials and methods
A CBSS has been developed and implemented since July
2000 in seven rural communes located in four provinces in
Cambodia (Figure 1). The four provinces chosen for this
pilot study were among those in the Border Malaria
Control Project funded by the European Commission,
which provided financial support for the surveillance
system. The seven communes comprised 52 villages and
had a total population of about 30 000 inhabitants in the
year 2000. They were served by four health centres, each
with a catchment population of 700010 000, and by four
referral hospitals, each serving about 10 such catchments.
Other providers of health care included traditional healers,
private practitioners, Traditional Birth Attendants, and
drug sellers.

The events to be reported by the CBSS were identified

through discussion with health staff and Village Health
Volunteers (VHVs) based on their public health importance, severity and potential for an outbreak as well as the
existence of a control programme. They included malaria,
chronic cough, acute severe diarrhoea, measles and haemorrhagic fever, and births and deaths. A standard case
definition was used throughout the system to collect data at
the village level. It was adapted from case definitions used
at the health centre level:
Suspected malaria: Any person with high and intermittent fever associated with chills. Separate episodes
were considered as different cases.
Suspected measles: Any child (under 15 years) with
fever and maculo-papular rash and any of the
following: cough, runny nose, or red eyes.
Severe acute diarrhoea: Any person aged five years or
more with acute watery diarrhoea of more than three

Figure 1 Map of Cambodia showing the location of communes for pilot study, 20002002.


2005 Blackwell Publishing Ltd

Tropical Medicine and International Health

volume 10 no 7 pp 689697 july 2005

S. Oum et al. Community-based surveillance in Cambodia

motions a day and severe dehydration characterized

by sunken eyes and intense thirst. Here too, separate
episodes were considered as different cases.
Haemorrhagic fever: Any child with high and persistent fever of abrupt onset, associated with maculopapular rash and petechiae/gingival bleeding/bloody
Chronic cough: Any person with cough for more than
21 days. VHVs have to report the same case every
month until the patient is cured or has died.
Cluster of cases: A group of five or more similar cases
occurring unusually closely together in any village
within a week.
Data on these events were collected by VHVs and
reported to data collation and analysis teams based in
health centres. VHVs reported immediately any clustering
of cases (more than five cases within a week) and deaths
because of acute diarrhoea to the data collation and
analysis team. Health centre staff considered such events to
be potential outbreaks and reported them immediately to
the staff based at operational district offices who investigated and took measures to control outbreaks. The VHVs
also reported every month the total number of cases of
each event included in the surveillance system using a
monthly report form (Figure 2). This was done in a
monthly meeting of VHVs and health centre staff in which
the data were collated and analysed, and remedial actions
discussed. The collated data were reported to the team in
the Operational District office who gave feedback and
investigated any unusual increase in the number of cases
and neonatal deaths.
At least one VHV was enrolled per village, either
selected by health centre staff or elected by the villagers.
Health staff involved in the CBSS included three staff at
each health centre, two at each Operational District and
one at each Provincial Health Department.
A series of 3-day initial training workshops was held for
both VHVs and health staff at each project site shortly
before the implementation of the system. It was followed
by a monthly half day of refresher training separately for
VHVs and health staff and further training in collation and
analysis of data for the health staff. The training of VHVs
focused on disease recognition using a syndromic approach
and on methods for prevention. Slides and videocassettes
were used to train VHVs to recognize diseases and events
accurately, and to contribute better to disease prevention
and control.
A household survey was conducted in July 2001 in all
villages in three of the seven communes, in order to obtain
village-based data to validate VHVs case reports of
diseases and other health-related events during the

2005 Blackwell Publishing Ltd

preceding month (for cases of disease) and year (for vital

events). The CBSS standard case definitions were used.
Causes of deaths were assessed by verbal autopsy based on
the standard CBSS definitions; deaths of infants under
28 days were investigated for neonatal tetanus using a
standard verbal autopsy questionnaire, and so were deaths
suspected to be because of measles. Each case and vital
event reported during this survey was then matched to the
CBSS data using household identifiers. Matching of reports
was carried out in the field, when the VHVs were present
for clarification if needed. Survey and outbreak investigation data were taken as the reference value. Cases reported
by VHVs that matched those detected by the household
survey or an outbreak investigation were considered as
true positive for the estimation of the sensitivity and
positive predictive value of the CBSS.

Disease surveillance
Table 1 shows the total number of cases of malaria,
measles, severe diarrhoea and haemorrhagic fever as well
as person-months with chronic cough, as reported by the
CBSS from September 2000 to August 2002. Only a third
of malaria, chronic cough, and haemorrhagic fever cases,
just over a quarter of severe diarrhoea cases, and less than
one in 20 cases of measles had contacted a health facility.
The monthly incidence of malaria, severe diarrhoea,
measles and haemorrhagic fever reported by the CBSS from
September 2000 to August 2002 is shown in Figures 35,
with comparison between the total cases (including cases
treated at home and health facilities) with those treated at
health facility alone. With the exception of July 2001, the
total monthly incidence of malaria had steadily declined
from over 250 cases in September 2000 to around 100
cases in August 2002. The decline of malaria cases reported
by the CBSS as treated at health facility alone over the
same period was substantially less marked than that the
total malaria incidence, which also reflects a relative
increase of the use of public health facility for malaria
treatment. The CBSS data also show that a relatively small
number of cases of haemorrhagic fever, measles, and severe
diarrhoea had contacted a health facility.
Vital events
CBSS data show that 95% of births and deaths occurred at
home. Home deliveries were assisted almost exclusively
by Traditional Birth Attendants (TBAs) and 90% of
perinatal deaths occurred at home. Most deaths because


Tropical Medicine and International Health

volume 10 no 7 pp 689697 july 2005

S. Oum et al. Community-based surveillance in Cambodia

Reporting Month:

Commune: .


I. Vital events
1. Pregnancies (

= No TT vaccination;

= Received 1 TT dose;

< 7 months gestational age

2. Newborns (Delivered at:

= Received 2+ TT doses)

79 months gestational age

= home and by TBA;

= public health facility;

= home by trained midwife)

Died within 7 days





3. Deaths


Place (tick)




Presumed cause of death**

Principal syndromes preceding
death (specify)

If maternal
death: tick

* Age = in days if under a month; in months if under a year; in years if 1+ years
** Immediate report if death due to diarrhoea
II. Communicable diseases

(Cough more
than 21 days)

(Acute watery
diarrhoea +

(High &
intermittent fever +

Haemorrhagic fever
(High fever of abrupt
onset + maculo-papular
rash + petechiae /
gingival bleeding /
bloody stool)

(Fever + maculo
papular rash +
cough/ runny
nose/ red eye)




= 1 case NOT treated at any public health facility;
= 1 case treated at health centre, referral or
national hospital. NOTE: Immediate report to health centre if clustering of cases (i.e. 5 + similar cases) in a given week

Figure 2 English translation of VHVs monthly recording and reporting form: (a) front, and (b) back (TT, tetanus toxoid; TBA, traditional
birth attendant).


2005 Blackwell Publishing Ltd

Tropical Medicine and International Health

volume 10 no 7 pp 689697 july 2005

S. Oum et al. Community-based surveillance in Cambodia

Table 1 Number of cases of diseases* reported by CBSS,

Cambodia September 2000 to August 2002


Treated at
health facility,
n (%)

at home,
n (%)


Chronic cough
Severe diarrhoea
Haemorrhagic fever






* For chronic cough, the table shows person-months with cough.

For malaria and diarrhoea, separate episodes are considered as
different cases.

of malaria, chronic cough, diarrhoea, haemorrhagic fever

and measles also occurred at home (Table 2).
The infant and under-five mortality rates, calculated
from data generated by the CBSS from all project
communes in the second year of project implementation,
were 72.9 and 89.0 per 1000 live births respectively,
slightly lower than those of the previous year which had
been 80.0 and 107.5 per 1000 live births respectively
(Table 3).
Detection of outbreaks
From August 2000 to September 2002 two outbreaks of
malaria were detected in a commune; seven outbreaks of

Malaria: total
Malaria: health facility alone

No. of cases





Figure 3 Monthly incidence of malaria

reported by CBSS, showing proportion
treated in health facility alone, all pilot
study communes, 20002002.

Sep'00 Oct Nov Dec Jan'01 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan'02 Feb Mar Apr May Jun Jul Aug


Measles: total
Measles: health facility alone
Diarrhoea: total
Diarrhoea: health facility alone


Number of cases


Figure 4 Monthly incidence of measles

and severe diarrhoea reported by CBSS,
showing proportions treated in health
facility alone, all pilot study communes,

2005 Blackwell Publishing Ltd

Sep'00 Oct Nov Dec Jan'01 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan'02 Feb Mar Apr May Jun Jul Aug


Tropical Medicine and International Health

volume 10 no 7 pp 689697 july 2005

S. Oum et al. Community-based surveillance in Cambodia

Haemorrhagic fever: total
Haemorrhagic fever: health facility alone

No. of cases

Sep'00 Oct Nov Dec Jan'01 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan'02 Feb Mar Apr May Jun Jul Aug

suspected outbreak of measles were brought to the attention of the commune health centre, a team of health centre
staff immediately went to the affected villages to verify the
reports and subsequently undertook necessary control
measures as well as further investigations of the outbreak.

Table 2 Place of births and deaths reported by CBSS, pilot study

communes, Cambodia September 2000 to August 2002

Vital events
Total births
Total deaths
Causes of death
Perinatal causes
Chronic cough
Haemorrhagic fever
All other causes

At health
n (%)

n (%)


89 (5)
22 (5)

1594 (95)
424 (95)






Accuracy of the reported cases of common syndromes and

vital events


The sensitivity of VHVs reporting of cases of communicable disease ranged from 65% for malaria to 93% for
measles. The positive predictive value (PPV) of VHVs
report on communicable diseases ranged from 82% for
severe diarrhoea to 90% for measles. Concerning vital
events, 76% of women 79 months pregnant and 82% of
births in the three surveyed communes were reported by
VHVs (Table 4). The CBSS detected 95% of all deaths in
the three communes during the year prior to the survey.

severe acute diarrhoea were reported in two communes; 10

outbreaks of measles were detected in three communes;
and two clusters of haemorrhagic fever cases were reported
in one commune. All these, with the exception of one
measles outbreak, were confirmed to be true outbreaks.
The information obtained by the CBSS drove local
health staff to respond rapidly and investigate outbreaks.
For instance, in Chan Mul commune, when reports of a

Project period

Number of
live births

Year 1 (September 2000 to August 2001)

Year 2 (September 2001 to August 2002)


Figure 5 Monthly incidence of haemorrhagic fever reported by CBSS, showing

proportion treated in health facility alone,
all pilot study communes, 20002002.

A large proportion of cases of major infectious diseases did
not seek medical treatment at public health facilities and
were therefore not reported by the health facility-based


Under5 mortality







Table 3 Infant and under-5 mortality

rates, all pilot study communes, Cambodia

* Rate per 1000 live births.


2005 Blackwell Publishing Ltd

Tropical Medicine and International Health

volume 10 no 7 pp 689697 july 2005

S. Oum et al. Community-based surveillance in Cambodia

Table 4 Sensitivity and positive predictive

value (PPV) of the CBSS, household survey
of three communes, July 2001


in survey*





Chronic cough
Severe diarrhoea
Measles (7/2000 to 6/2001)
Pregnancy (79 months)






* Gold standard for estimating sensitivity and PPV of CBSS: Household Survey for malaria,
chronic cough, and pregnancy (recall period 1 month) and outbreak investigations for
measles (1 year).

surveillance system. Health facility data therefore could

not allow the detection of all measles, severe diarrhoea or
haemorrhagic fever outbreaks. They also could not capture
all births and deaths in the rural areas because the majority
of these vital events occurred at home. In contrast, the
CBSS captured more comprehensive and representative
data for major communicable diseases and detected disease
outbreaks more frequently and more rapidly than the
routine disease surveillance system.
An additional factor is that in Cambodia, health staff
sometimes inflate the number of cases they have treated
in their routine monthly reports, in order to receive
additional quantities of drugs and supplies, either for
private practice or to replace date-expired stocks.
Surveillance data collected by the CBSS are not subject
to such bias.
Most importantly, the CBSS provided a forum for
information sharing and joint decision-making between
local health staff and VHVs, which led to better collaboration and active community participation between these
two sets of key players in disease control and prevention.
The system also empowered the local health staff and
community in disease surveillance and outbreak response,
based on which they could take effective follow-up and
corrective action.
A tendency for malaria and diarrhoea incidence to
decline with time can be seen in Figures 3 and 4. Both
tendencies can also be seen in the health facility data. This,
and the maintained level of reported incidence of measles
and haemorrhagic fever, supports the view that any such
decline is not attributable to a fall in sensitivity of the
CBSS. It would be tempting to attribute the decline to
improved preventive interventions and outbreak response,
but such year-on-year variations are common in infectious
disease surveillance. A longer time series, or reliable data
from non-CBSS communes, would be required to confirm
that the CBSS had contributed to a sustained decline in
disease incidence.

2005 Blackwell Publishing Ltd

Factors underlying the performance of the CBSS

The high performance of the Cambodian CBSS is linked to
the importance of events monitored, the system design and
its key players. Events monitored by it were multiple,
important, relevant and relatively easy for local people to
identify. The diseases or syndromes to be reported were
locally the most important communicable diseases in terms
of severity, burden or epidemic potential. They are all
targets of national control programmes, and effective
control measures are available. Births and deaths, on the
contrary, constitute important and relevant information
needed for appropriate planning of disease control and
prevention activities as well for monitoring infant and child
mortality, as birth and death registration are not available
in Cambodia. All these events have elicited the interest of
health staff and VHVs, who are the end users of the data
they collect.
The system design, including two-way flow of information, instant feedback, local use of data, and simplicity as
well as its decentralized management contributed to the
success of the operation of the CBSS. The monthly
feedback meeting is a central feature of the Cambodia
CBSS and is crucial for its success. It enables information to
be fed back to all participants of the system and decisions
to be made to address identified issues within the same day
of data reporting and minimizes the related workload of
the health staff as well. This process challenges all
participants to take necessary remedial action together, the
results of which can be closely monitored by them at the
next monthly feedback meeting. The system has, therefore,
overcome constraints that have hampered many previous
CBS systems including delayed feedback and non-participation of local health staff and communities in data
analysis, decision-making and action-taking. Additionally,
the feedback meeting provides an opportunity for continuing training of VHVs and health staff, thereby contributing to the improvement of the system.

Tropical Medicine and International Health

volume 10 no 7 pp 689697 july 2005

S. Oum et al. Community-based surveillance in Cambodia

The Cambodia CBSS, in which data are actively

collected through periodic home visits, yields a higher
proportion of cases reported than passive data collection
surveillance systems. The use of tally sheets to record
and report events is most appropriate for semi-literate
VHVs in remote areas and helps to reduce errors in data
collection. Furthermore, a CBS system which is
developed with local participation and locally managed
is likely to be more effective than vertically-run programmes and projects developed and implemented by
national, international or non-governmental organizations.
Finally, another contributing factor in the success of CBSS
is the motivational mechanism to maintain VHVs voluntary
work. It included travel costs, per diem and food given to
VHVs who attended their monthly meeting with health staff
at the health centre, free medical care, training, rewards and
recognition as well as the immediate response of health staff
to the information reported by VHVs and instant feedback
of information to them. As a result, VHVs were willing to
travel quite frequently to collect data in their own village as
well as to travel by foot or motorbike to the health centre,
located typically 411 km from their home, for the monthly
meeting, which almost all regularly attended.
The VHVs were sometimes unable to collect data from
people living too far away from their house, especially
those temporarily moving to camp by their farm land
during the rice-planting and harvesting seasons. For
instance, the majority of households not visited by VHVs
in June 2001 were located further than 1.5 km from their
house. Also, the response of health staff to the information
generated by the CBSS was not yet optimal in many project
communes because of low salaries and inadequate funding
for health services.
Costs and sustainability
The annual cost of the Cambodia CBSS was about US$0.5
per capita including occasional visits from Phnom Penh for
training, supervision, and evaluation. This cost would be
lower by half if the system were operated by the District
alone; that is, without the research and development input
by one of us (SO). It appears to be lower than that of many
similar systems running in developing countries to date,
because of its use of existing health infrastructure and staff,
which costs much less than projects run by non-governmental organizations where additional staff and facilities
have to be funded (ONeill 1993; Cairncross et al. 1997).
The amount of staff time required to manage the system
was relatively small; 1 day per month for the monthly

meeting, plus a half day of training, and time spent on

outbreak response, if any. The VHVs spent 34 half days
per month on home visits for data collection, in addition to
their day at the monthly meeting.
In 2004, the system proved to be replicable as it has been
implemented, with support from Save the Children Australia, throughout an operational district of 100 000
inhabitants. It is being implemented in two more districts,
and a fourth is planned for early 2005.
The Cambodian CBSS has many attributes that could
make it more viable that is sustainable than other
CBSSs. First, VHVs and health staff have the capability to
run and manage the system by themselves, with little
technical or supervisory support from the central level.
Second, the system is built on the existing health system
and resources, following the Ministry of Health policy and
strategy to strengthen the Operational District structure. It
gives the Operational District and health centre a mechanism to fulfil their role in disease prevention and control
in the communities. Third, the Cambodian CBSS comprises
mechanisms to maintain VHVs motivation to continue the
CBSS. The mechanisms include continuous training, supportive supervision, health care benefits, work recognition,
instant feedback, and involvement in data analysis and
We conclude that a community based surveillance
system run by VHVs and local health staff is feasible and
that this system can produce useful information for
monitoring trends and to identify potential outbreaks of
common infectious diseases.
This study would not have been possible without financial
assistance from the European Commission and Cambodias Ministry of Health for which we are very grateful. We
wish to thank in particular Dr Frederick Gay, Dr Andrew
Corwin, Ms Sarah McFarlane, Dr Kyi Minn, Prof Felicity
Cutts, Ms Susanne Wise, Dr Gertrud Schmid-Ehry and
many other people for their encouragement and inputs
during the development and refinement of the CBSS in
Ahluwalia I, Kouletio M, Curtis K et al. (1999) Community
empowerment: CDC collaboration with the CARE CommunityBased Reproductive Health Project in two districts in Tanzania.
Journal of Womens Health and Gender-Based Medicine 8,
Anselmi M, Araujo E, Narvaez A, Cooper PJ & Guderian RH
(1995) Yaws in Ecuador: impact of control measures on the

2005 Blackwell Publishing Ltd

Tropical Medicine and International Health

volume 10 no 7 pp 689697 july 2005

S. Oum et al. Community-based surveillance in Cambodia

disease in the Province of Esmeraldas. Genitourinary Medicine

71, 343346.
Balasubramanian R, Sadacharam K, Selvaraj R et al. (1995)
Feasibility of involving literate tribal youths in tuberculosis
case-finding in a tribal area in Tamil Nadu. Journal of
Tuberculosis and Lung Disease 76, 355359.
Cairncross S, Braide EI & Bugri SZ (1996) Community
participation in the eradication of guinea worm disease. Acta
Tropica 61, 121136.
Cairncross S, Cutts FT & Perie`s H (1997) Vertical programmes;
what are they good for? Authors reply. Lancet 350,
Cairncross S, Anemana SD, Olsen A (1999) Towards the eradication of Guinea worm: a Danish-Ghanaian collaboration.
Parasitology Today 5, 127129.
Ghebreyesus TA, Witten KH, Getachew A et al. (2000) The
community-based malaria control programme in Tigray, northern Ethiopia; a review of programme set-up, activities, outcomes and impact. Parassitologia 42, 255290.
Howard-Grabman L (2000) Bridging the gap between communities and services providers: developing accountability
through community mobilisation approaches. IDS Bulletin 31,

Jaravaza VS, McCoy MC, Dando BC (1982) Unified National

Health Information System. Pat II: the village health worker
health information system. Central African Journal of Medicine
28, 5764.
Manderson L (1992) Community participation and malaria control in Southeast Asia: defining the principles of involvement.
Southeast Asian Journal of Tropical Medicine and Public Health
23 (Suppl. 1), 916.
ONeill K. (1993). Community-based surveillance: a critical
examination of nine case-studies. MSc Dissertation. London
School of Hygiene and Tropical Medicine, University of London, London.
Ruebush TK 3rd, Zeissig R, Koplan JP, Klein RE, Godoy HA
(1994) Community participation in malaria surveillance and
treatment. III. An evaluation of modifications in the Volunteer
Collaborator Network of Guatemala. American Journal of
Tropical Medicine and Hygiene 50, 8598.
Valyasevi A, Winichagoon P, Dhanamitta S (1995) Communitybased surveillance for action towards health and nutrition:
experience in Thailand. Food and Nutrition Bulletin 16, 120
WHO (2000) An integrated approach to communicable disease
surveillance. Weekly Epidemiological Record 75, 18.

Sophal Oum, Ministry of Health, Phnom Penh, Cambodia. Tel: +855-12-500-565; Fax: +855-23-883-561; E-mail: Sophal_oum@
Daniel Chandramohan (corresponding author) and Sandy Cairncross, London School of Hygiene and Tropical Medicine, Keppel
Street, London WC1E 7HT, UK. Tel.: 00-44-20-7927 2322; E-mail:, sandy.cairncross@lshtm.

2005 Blackwell Publishing Ltd