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TB in China – TB control, DOTS, MDR-TB

TB burden in China

The level of TB in China makes it a major public health problem. China has the world’s second largest TB epidemic after India, with a quarter of the word’s TB burden. In 2014 there were an estimated 930,000 new cases of TB in China, and an estimated 120,000 cases of pulmonary MDR TB.  Overall China has 10% of the global burden of TB with 400 million people having latent TB.1“Global Tuberculosis Report”, WHO, Global tuberculosis report 2015

TB control in China

A National Tuberculosis Program was established in 1981 to reform TB control efforts and to expand the reporting system and TB treatment. However, a lack of money hampered the program’s capacity in many areas. This was particularly the case in the poorer provinces with the weakest primary health care infrastructure.2J Fischer-Mackey, “Controlling Tuberculosis in China, Case Study 3”, 2010, Center for Global Development

A nationwide survey in 1990 showed only a slight improvement in TB prevalence compared with rates in 1979 and 1985.

The Chinese Infectious and Endemic Disease Control (IEDC) TB Project

DOTS to stop TB

DOTS to stop TB

So in 1991 China launched the 10 year Infectious and Endemic Disease Control (IEDC) project to curb the TB epidemic in 13 of it’s 31 mainland provinces. Part funded by a World Bank loan of $58 million the project adopted the TB DOTS strategy and short course drug treatment which had been developed by the World Health Organisation (WHO) in 1989.3B Andrews, “Medical Transitions in Twentieth-Century China”, Indiana University Press

The project set out to improve the finding of new smear positive cases from 35 percent to 70 percent. It also aimed to increase the cure rate from less than 50% to more than 90% by 2005. If the project could achieve these goals it was estimated that it would save 100,000 deaths every year. It would also cut the TB prevalence by half in those provinces covered by the project.4J Fischer-Mackey, “Controlling Tuberculosis in China, Case Study 3”, 2010, Center for Global Development

The IEDC project started with a pilot project in five counties in Hebei province in April 1991. The program was then expanded first to 65 counties, and then to approximately half of China’s counties. By 1994 the project involved 1,208 counties in 12 provinces and a population of 573 million people.

Was the IEDC project succeessful?

The IEDC project was extraordinarily successful with the target of curing 85% of identified patients, achieved within the first two years of the implementation of DOTS. There were not only extremely good cure rates for new TB cases but also for relapsed and re-treatment cases. As a result between 1990 and 2000 the number of people with TB in the DOTS area declined by 36.1%, about 4.1% each year. This compared with a decline of about 4.1 percent in non DOTS areas. However even after seven years the IEDC had only been able to identify about 55% of the TB cases in the project areas.

A patient being treated for TB in China &#169 WHO

A patient being treated for TB in China © WHO

Also the IEDC project was committed to a free TB service being provided, and it was clear from the start that many provincial and local officials considered a free TB service too expensive. Some considered it unnecessary given China’s cost recovery system for ‘fee for services’. It was clear from the start that senior officials of some project provinces were not prepared to spend significantly increased money, and as a result the project could not reach 100% coverage in all provinces.5“Project Appraisal Document on a Proposed Loan in the amount of US$104 million to the People’s Republic of China”, World Bank, 2002, China – Tuberculosis Control Project (English)

The free TB treatment was in most places also only available to permanent residents. Urban migrants who had relocated from poor rural areas to seek a better life were not eligible for such free services. The predominantly young migrants, numbering more than 150 million, tended to live and work in crowded environments and were unlikely to seek medical care immediately they became ill, increasing the likelihood of them passing on the infection.

The project showed that DOTS can be rapidly expanded provided that two critical elements are achieved. Firstly, there was political commitment by government leaders, and secondly a system of TB institutions which allowed the rapid dissemination and implementation of a single set of technical guidelines for TB control. Although the use of directly observed therapy was important, other elements of DOTS were equally important.6X Chen, “The DOTS strategy in China: results and lessons after ten years”, Bulletin of the World Health Organisation 2002, 2002, DOTS strategy in China The experience in China encouraged the WHO to launch DOTS worldwide.

Political commitment to TB control

Despite the achievements of the IEDC project there were still problems with China’s TB control program and China still had one of the highest TB burdens in the world. Each year an additional 1.3 million people developed active TB and 150,000 people died. The rate of TB in impoverished rural areas was believed to be nearly three times higher than in the economically developed urban areas.7“Project Appraisal Document on a Proposed Loan in the amount of US$104 million to the People’s Republic of China”, World Bank, 2002, China – Tuberculosis Control Project (English)

A nurse giving drugs to a patient with MDR-TB

A nurse giving drugs to a patient with MDR-TB

Hospitals and clinics continued to function as “for profit” entities, resulting in people who were unable to pay having to abandon their treatment. There were also the issues of Multi-Drug Resistant TB (MDR-TB) and TB/HIV co-infection neither of which were helped by DOTS. Some parts of China had some of the highest rates of MDR-TB in the world.8“China: Tuberculosis Control Project”, The World Bank,  2010, China: Tuberculosis Control Project

However in 2000 the central government began efforts to revitalise its TB control program with there being increased political commitment. Another survey of prevalence was carried out in 2000, allowing comparison with the one carried out in 1990.

The estimated prevalence of pulmonary TB, in the 13 provinces in which the DOTS program was implemented, was 573 per 100,000 in 1990, and it had fallen to 298 per 100,00 in 2000, a remarkable reduction of 48%. In the remaining 15 provinces the prevalence fell from 493 per 100,000 to 412 per 100,000 a reduction of 16%. Although this was a remarkable achievement, the results were not fully explained, and it was not clear how much of the effect was due to DOTS.9China Tuberculosis Control Collaboration, “The effect of tuberculosis control in China”,  The Lancet, 2004, The effect of tuberculosis control in China 10S Bertel Squire, “How much of China’s success in tuberculosis control is really due to DOTS?”, The Lancet, 2004, TB control in China

Funding for TB

In 2002 the central government increased its funding for TB from US$300,000 per year to $4.8 million per year. Also in 2002 the government arranged a $104 million loan with the World Bank and in the same year they received a $48 million grant from the Global Fund to fight AIDS, TB and Malaria. By late 2002 with increased governmental and international support, DOTS began to expand to all provinces.11L, Wang, “Progress in tuberculosis control and the evolving public-health system in China”, The Lancet, 2007, Progress in TB control The World Bank funding was used for the China Tuberculosis Control Project, the largest TB control project funded by the World Bank. There was also a smaller project funded by the Department of Health subsidized treatment for patients in the provinces not covered by the World Bank project.

The China Tuberculosis Control Project 2002 – 2009

Tuberculosis Control Project &#169 World Bank

Tuberculosis Control Project © World Bank

The TB Control Project covered 16 provinces, selected for their low per capita incomes, high prevalence of TB and a commitment to implementing the program with local financial support. The project would cover the entire populations of the 16 provinces which totaled 688 million in 1999. The project included special measures to benefit vulnerable populations like ethnic minorities, poor women, and older people.12“Project Appraisal Document on a Proposed Loan in the amount of US$104 million to the People’s Republic of China”, World Bank, 2002, China – Tuberculosis Control Project (English)

The project used the WHO DOTS strategy which had been very successfully implemented under the IEDC project. This involved not just finding and curing infectious TB patients, but it also ensured  that they received free care as well as taking their full six months of treatment. However, the IEDC project only identified 55% of the TB patients in the project area. So the China Tuberculosis Control Project aimed to have much more extensive and innovative Information, Education & Communication (IEC) programs to raise awareness among the population. It also aimed to reduce the stigma associated with the disease. The programs would involve village committees, women’s groups, traditional health workers and patient support groups among others.

In addition to a free “check and treatment” policy, the project also offered incentives to patients and medical personnel to raise the detection and cure rate. The project also reimbursed patients’ travel expencses between their home and the clinics. Doctors got 20 yuan if the reported a case. They also received 100 to 120 yuan for each patient under their supervision. However the free check and treatment policy only covered diagnosis and first line drugs. Patients still had to pay for drugs that reduced side effects and test such as liver tests.13Tian Ying, “China’s tuberculosis control project benefits millions”, 2010, China’s tuberculosis control project

From 2002 to 2009, the project treated approximately 1.598 million new smear positive patients. 1.505 million patients completed their treatment (94.2%) and 1.499 (93.8%) million patients were cured. The project achieved a number of other objectives, including reducing the number of TB associated deaths by 770,000.

5th Nationwide TB Prevalence Survey

In 2010 the 5th Nationwide TB Prevalence Survey took place in China. The survey showed that the estimated number of TB patients in the whole population was 5.2 million, giving a prevalence for pulmonary TB of 459 per 100,000. This meant that there had only been a slight decline in prevalence since 2000 when the figure was 466 per 100,000. For smear positive patients however there was a very large decline from 169 per 100,000 in 2000 to 66 per 100,000 in 2010.

China’s case detection rate of new TB cases was 80% and it’s cure rate for new TB cases was above 90%. More than 4.5 million smear positive patients were cured between 2001 and 2010, and China achieved its millennium development goal for TB control five years early.

Drug resistant TB in China

WHO Magaret Chan, Bill Gates, and Minister Chen Zhu from China

Beijing meeting, with Director General of the WHO Magaret Chan, Bill Gates, and Minister Chen Zhu from China

This didn’t however solve the problem of drug resistant TB in China. The 2000 national TB prevalence survey had shown that one in ten patients with TB had MDR-TB. Other studies confirmed a serious epidemic of MDR TB in in several Chinese provinces, with rates of MDR in previously untreated cases that were five to ten times higher than the global average. 14L, Wang “Progress in tuberculosis control and the evolving public health system in China”, The Lancet, 2007, Progress in tuberculosis control The National Survey of Drug-Resistant TB in 2007, showed one third of new TB cases and one half of previously treated cases showed some drug resistance. 15Q Long, “Drug-resistant tuberculosis control in China: progress and challenges”, Infect Dis Poverty, 2016, Drug-resistant tuberculosis control

This survey was referred to at the ministerial meeting of high burden M/XDR-TB countries held in Beijing in April 2009. The preliminary findings of the survey were said to show that 8.32% of pulmonary TB patients in China have MDR-TB and 0.68% have XDR-TB. Based on these data it was estimated that there are 120,000 new cases of pulmonary MDR-TB in China each year.16“Speech at the Ministerial Meeting of High M/XDR-TB Burden Countries”, 2009, Speech by Minister Chen Zhu  The actions that the Chines health authorities were going to take to tackle drug resistant TB were also set out by Minister Chen Zhu.

References

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1. “Global Tuberculosis Report”, WHO, Global tuberculosis report 2015
2. J Fischer-Mackey, “Controlling Tuberculosis in China, Case Study 3”, 2010, Center for Global Development
3. B Andrews, “Medical Transitions in Twentieth-Century China”, Indiana University Press
4. J Fischer-Mackey, “Controlling Tuberculosis in China, Case Study 3”, 2010, Center for Global Development
5. “Project Appraisal Document on a Proposed Loan in the amount of US$104 million to the People’s Republic of China”, World Bank, 2002, China – Tuberculosis Control Project (English)
6. X Chen, “The DOTS strategy in China: results and lessons after ten years”, Bulletin of the World Health Organisation 2002, 2002, DOTS strategy in China
7. “Project Appraisal Document on a Proposed Loan in the amount of US$104 million to the People’s Republic of China”, World Bank, 2002, China – Tuberculosis Control Project (English)
8. “China: Tuberculosis Control Project”, The World Bank,  2010, China: Tuberculosis Control Project
9. China Tuberculosis Control Collaboration, “The effect of tuberculosis control in China”,  The Lancet, 2004, The effect of tuberculosis control in China
10. S Bertel Squire, “How much of China’s success in tuberculosis control is really due to DOTS?”, The Lancet, 2004, TB control in China
11. L, Wang, “Progress in tuberculosis control and the evolving public-health system in China”, The Lancet, 2007, Progress in TB control
12. “Project Appraisal Document on a Proposed Loan in the amount of US$104 million to the People’s Republic of China”, World Bank, 2002, China – Tuberculosis Control Project (English)
13. Tian Ying, “China’s tuberculosis control project benefits millions”, 2010, China’s tuberculosis control project
14. L, Wang “Progress in tuberculosis control and the evolving public health system in China”, The Lancet, 2007, Progress in tuberculosis control
15. Q Long, “Drug-resistant tuberculosis control in China: progress and challenges”, Infect Dis Poverty, 2016, Drug-resistant tuberculosis control
16. “Speech at the Ministerial Meeting of High M/XDR-TB Burden Countries”, 2009, Speech by Minister Chen Zhu