Tuberculosis is a serious public health problem in China. China has the world's third largest cases of tuberculosis (after India and Indonesia), but progress in tuberculosis control was slow during the 1990s. Detection of tuberculosis had stagnated at around 30% of the estimated total of new cases, and multidrug-resistant tuberculosis was a major problem. These signs of inadequate tuberculosis control can be linked to a malfunctioning health system. The spread of severe acute respiratory syndrome (SARS) in 2003, brought to light substantial weaknesses in the country's public health system. After the government realized the impact that the SARS outbreak had on the country, they increased leadership in their health department. After the SARS epidemic was brought under control, the government increased its commitment and leadership to tackle public health problems and, among other efforts, increased public health funding, revised laws that concerned the control of infectious diseases, implemented the world's largest internet-based disease reporting system to improve transparency, reach and speed, and started a program to rebuild local public health facilities and national infrastructure.
These measures contributed to acceleration in efforts to control tuberculosis. By 2005, the detection of cases of tuberculosis had increased to 80% of the estimated total new cases, permitting China to achieve the 2005 global tuberculosis control targets. At the same time, specific efforts to improve tuberculosis control also contributed to strengthening of the public health system. In this case, the strengthening of the disease control program and the public health system had worked together to achieve a desired health outcome.
On February 23, 2007, the Chinese government undertook a review of the tuberculosis situation in China, which looked at the progress in tuberculosis control before the SARS epidemic, outlined the measures taken to improve the public health system after that epidemic, described how those measures contributed to the acceleration of tuberculosis control efforts, and discuss the challenges that China must address to halve the number of tuberculosis cases and deaths as part of the Millennium Development Goals (MDGs).
Epidemiology
China had one of the world's largest tuberculosis epidemics during the 1990s. The 1990 national tuberculosis survey reported a tuberculosis mortality of 21 per 100,000 population, and tuberculosis remained a major public health problem until the nationwide expansion of the DOTS strategy in the early 2000s.
Tuberculosis is one of China's major public health problems. According to the 2015 WHO estimates, China has the world's third largest number of tuberculosis cases, behind only India and Indonesia, comprising around 10% of the world total. Of the 37 notifiable communicable diseases in China, tuberculosis ranks first in terms of notified cases and deaths. Despite the serious nature of this disease, the country's progress in tuberculosis control was slow during the 1990s and early part of the new millennium. The estimated proportion of new cases of sputum smear-positive tuberculosis that were diagnosed and treated by the public health program—a key indicator of efforts to control tuberculosis—had stagnated at around 30%, far below the 70% target set by the WHO.
In 2003, an epidemic of severe acute respiratory syndrome (SARS) broke out in China. (See Progress of the SARS outbreak.) The spread of SARS brought to light substantial weaknesses in the country's public health system. After the SARS epidemic was brought under control, the Chinese government implemented a series of measures to strengthen its public health system. This effort coincided with acceleration in efforts to control tuberculosis. Within three years, implementation of the WHO-recommended DOTS (Directly Observed Therapy, Shortcourse) strategy to control tuberculosis increased from 68% to 100% of counties and the detection of cases of smear-positive tuberculosis by the public health system more than doubled, from 30% of new cases to 80%. Together with a tuberculosis treatment success rate of more than 90%, China achieved the 2005 global targets for tuberculosis control.
+ Progress of tuberculosis control in China,1991–2005 Year Proportion (%) of new smear-positive TB cases successfully treated Estimated proportion (%) of all new smear-positive TB cases detected Proportion (%) of counties implementing the WHO-recommended DOTS strategy 1991 69 4 5 1992 75 7 7 1993 79 10 19 1994 88 14 48 1995 92 21 58 1996 94 25 60 1997 94 26 61 1998 93 27 62 1999 92 28 63 2000 92 30 63 2001 91 29 65 2002 91 26 64 2003 92 44 77 2004 90 63 89 2005 90 80 100
Focusing on vulnerable groups One group of special concern are work migrants, most often poor men, who leave the countryside to join the wage economy in towns and cities all over China. Some come from areas such as Henan Province where huge numbers of peasants were infected with HIV from scandalous plasma-donor practices in the 1990s. Many male migrants are at risk of unprotected sex when away from home. And men are also at higher risk of tuberculosis than women in China because the male-to-female ratio of adults with pulmonary tuberculosis is about 2:1 or more, reflecting a real risk excess rather than differential detection or notification. So several factors converge in young male migrant workers to put them at risk of both HIV and tuberculosis, and this convergence has been of great concern. With this "floating" migrant population making up 10% of the total being poorer and having more tuberculosis than average, China has far more than its share of tuberculosis (disease burden) in the world. This problem is compounded because China's internal work migrants often live and work in circumstances that promote transmission of tuberculosis and impede its diagnosis and treatment. They are usually so poor that the cost of adequate diagnosis and treatment is prohibitively expensive. Indeed, they may not be able to get treated at all unless they return to their home village in the poor interior, because subsidized management of tuberculosis (and other social welfare) is only available through facilities in the area where they were registered at birth. Those born in rural zones are not allowed to switch registration to become urban residents. They have been allowed to leave their area (temporarily) or work since 1992 and now number more than 100 million. China's rapid economic growth depends on them, but if they get tuberculosis, they have to return home for treatment.
Going home for rural healthcare in China is not ideal either. Over the past 30 years, that part of the health system has run down because government funding has fallen while everything else has become more expensive. Health facilities attempted to make up shortfalls by charging ever larger fees for diagnosis and treatment, especially for a difficult disease like tuberculosis. In China today, patients' payments keep the health services running and the medical staff have been encouraged to supply profitable health goods and services, especially drugs. Their own jobs depend on adequate operational funds, which are largely generated through user fees. Meanwhile, over the same 30 years, the socialist system of universal rural health-insurance collapsed and was not replaced apart from some pilot tests of an under-resourced community-based scheme in the 1990s. Until recently, virtually all rural residents, 900 million in all, had no health insurance at all. This situation will change if the current experiments with community-based health-insurance succeed and are then adopted nationally, but in the meantime as many as 10% of rural households have catastrophic medical payments (exceeding 40% of their disposable income) every year.
Control and prevention
Tuberculosis control before SARS Tuberculosis control has been a part of China's public health program since the 1950s. China developed and implemented two five-year national plans in the 1980s and one 10-year plan in the 1990s to control tuberculosis. On the basis of national surveys in 1979 and 1990, the prevalence of tuberculosis fell by an average of 3.3% every year during the 1980s.Ministry of Public Health of the People's Republic of China. Nationwide random survey for the epidemiology of tuberculosis in 1990. Beijing: Ministry of Public Health of the People's Republic of China, 1992. In the 1990s, the government implemented two major tuberculosis control projects as part of its 10-year plan to control tuberculosis.
The first, funded in part by the World Bank loan of $58.2 million, covered half of China's population and implemented the DOTS strategy in 13 provinces between 1992 and 2001. The second used limited funding from the Ministry of Health to subsidize treatment for patients in an extra 10–15% of the population.
The project funded by the World Bank led to several important achievements. Nearly 1.5 million cases of smear-positive tuberculosis were diagnosed and cured. A large cadre of healthcare workers was trained in the fundamental elements of DOTS, firmly establishing these methods as the national strategy for tuberculosis control. Most importantly, on the basis of results from the 2000 national tuberculosis survey, there was a 36% reduction in disease prevalence between 1990 and 2000 in the half of China that implemented the projects.Ministry of Health of the People's Republic of China. Report on nationwide random survey for the epidemiology of tuberculosis in 2000. Beijing: Ministry of Health of the People's Republic of China, 2002.
Despite these achievements, there were signs of difficulties elsewhere in the country's tuberculosis control program. In the half of China that did not implement the project funded by the World Bank, the prevalence of tuberculosis did not fall during the 1990s. Thus, the fall in tuberculosis prevalence for the entire country slowed to 2.5% per year during the 1990s. The 2000 national tuberculosis survey revealed that one in ten patients with tuberculosis had multi-drug resistant (MDR) disease—i.e., resistant to both isoniazid and rifampicin. Other studies confirmed a serious epidemic of MDR tuberculosis in several Chinese provinces, with rates of multidrug resistance in previously untreated cases that were five to ten times higher than the global mean.WHO. Anti-tuberculosis drug resistance in the world: the WHO/IUATLD Global Project of Anti-tuberculosis Drug Resistance Surveillance. WHO/CDS/ TB/2000.278. Geneva: World Health Organization, 2000.WHO. Anti-tuberculosis drug resistance in the world: the WHO/IUATLD Global Project of Anti-tuberculosis Drug Resistance Surveillance. WHO/HTM/TB/2004.343. Geneva: World Health Organization, 2004.
The inadequate control of tuberculosis can be linked to a malfunctioning health system. From 1978 to 2002, the government's share of total health expenditure fell from 32% to 16%.China National Health Economics Institute. China national health accounts report. Beijing: China National Health Economics Institute, 2005. This reduction forced many Chinese health-care facilities and providers to focus on the generation of revenue, with little concern for public health. Hospitals and clinics essentially functioned (and continue to function) as for-profit entities. In 2000, nearly 90% of patients with tuberculosis initiated their diagnostic and treatment process in hospitals and non-public health-care facilities, where they were given tests and drugs as long as they could pay. Many patients who improved or ran out of money discontinued treatment. Thus, only 20% of patients with tuberculosis treated outside the public health system took their tuberculosis medications regularly in 2000. Such irregular treatment breeds drug-resistant tuberculosis.