Tuesday, 18 March 2014

Tuberculosis in China - the good news and the bad news

by Michael Woodhead
China has succeeded in more than halving its tuberculosis prevalence with a major campaign launched in the 1990s, according to a new report from the Chinese Ministry of Health.
The campaign produced dramatic reductions in tuberculosis because it shifted treatment out of hospitals and into the community via public health centre TB dispensaries, according to an article published in The Lancet this week.
The report assesses the impact of China's tuberculosis control program based on the directly observed treatment, short-course [DOTS] strategy which was scaled up to cover half the population during the 1990s, and to the entire population after 2000.
Between 1990 and 2009 the prevalence of tuberculosis fell from 170 cases to 59 cases per 100 000 population. The decreases were attributable to the program because declines were only seen in areas where it was operating in the 1990s. The reduction in tuberculosis was greater after 2000 than the 90s (57% vs 19%), with 70% of the total reduction in tuberculosis seen in the last decade.
The proportion treated by the public health system using the DOTS strategy increased from 15% of cases in 2000 to 66% of cases in 2010.
The health ministry said China had shown that it was possible to achieve ambitious targets in reducing tuberculosis, which had not been achieved in other developing countries. However, despite this success, China still had an estimated 1 million new tuberculosis cases in 2010.
China now faces the problems of a widening urban-rural gap in tuberculosis prevalence and tuberculosis not being picked up in hospitals. Also, further reductions in tuberculosis prevalence are likely to be less impressive because the DOTS program is more effective in reducing the prevalence of tuberculosis in known cases than in new cases, and the number of known cases is now low.
Therefore other control efforts in addition to the DOTS strategy need to be implemented, the report authors say.
Another problem is that the cost of treating tuberculosis is becoming prohibitively expensive for patients due to hospital profiteering, according to another report released this week. The study by Chinese and international researchers found that many patients are being treated at hospitals with second-line drugs when they should have been treated with first-line drugs in community TB dispensaries. The reason for this seems to be because hospitals want to retain patients to make more profits, the researchers surmised.
The study also found that patients faced crippling costs for treatment despite China's supposedly free TB treatment policy and despite most patients being covered by medical insurance. Insurance coverage for outpatient care generally reimbursed only a small percentage of fees and the free TB treatment policy does not cover costs on auxiliary examinations, drugs and hospitalisation, the report notes.
"A large proportion of patients borrowed money for TB care, and incurred catastrophic expenditure due to TB care," the researchers said.

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