China has seen a radical change in political commitment to TB control during 2003 and 2004. There has been a clear government decision to meet the global targets for diagnosis and treatment of TB by the end of 2005. This decision was endorsed by the State Council at a meeting on TB control in September 2004, and a pledge was secured to make an eight-fold increase in central government funding for TB control. Following the accelerated DOTS expansion undertaken in recent years, coverage will reach 95% by the end of 2004 and is expected to reach 100% in 2005. Building on the experience of the severe acute respiratory syndrome (SARS) epidemic, China has further recognized the importance of a public health approach to communicable diseases and has set up a new national Internet-based reporting system, under which all cases of several specified communicable diseases, including TB, must be notified. The recently revised law on infectious diseases also strengthens the mandatory reporting of TB, and this is expected to improve TB case reporting substantially. The main challenge is to ensure the quality of TB services during a phase of rapid expansion and to address the shortages of staff and laboratory services needed to support the expanding programme.
System of TB control
China introduced DOTS on a wide scale in 1992 by expanding DOTS to 13 of 31 mainland provinces, municipalities and autonomous regions (“provinces” hereafter) using funds from a World Bank loan. By 2000, most counties (1132 of 1208) in these 13 provinces had been using DOTS for at least five years. Further expansion of DOTS activities in other parts of China followed in 2002. By 2003, 91% of the population lived in areas covered by the DOTS strategy. Nationwide coverage is planned for the end of 2005.
The government is increasing its investment in public health substantially, and the MoH has put the control of TB among its top priorities. In 2004, an eight-fold increase in funding for the NTP has been pledged for TB control activities. A recent evaluation of the progress towards the 10-year national TB control plan carried out by the MoH, Ministry of Finance, and the National Development and Reform Commission has resulted in further government commitment to TB control at all levels.
The TB laboratory network operates under the guidance of the NTP manager and consists of one national reference laboratory, 31 provincial TB reference laboratories, 336 TB laboratories at the prefecture/city level and 2683 peripheral laboratories. Microscopy is performed by all laboratories, while 16% carry out culture and less than 2% do drug susceptibility testing. Culture is occasionally performed in 5–10% of county laboratories, except in some major cities including Beijing where culture is done routinely for all TB suspects. Drug susceptibility testing is available to diagnose drug resistance at some provincial and prefecture level laboratories.
Surveillance and monitoring
The estimated incidence rate for China was revised during 2004 2 and is believed to be falling by 1% per year, as is the measured rate of decline in the annual risk of TB infection over the decade since 1990. However, on the basis of the currently available data, these assessments of trend should be treated as approximate.
China made the second largest contribution to the increase in global case detection between 2002 and 2003, after India. The case detection rate achieved by the DOTS programme was 30% in 2002, and increased sharply to 43% by the end of 2003 as population coverage reached 91%. A rapidly implemented TB control programme faces the challenging task of maintaining quality as the programme expands. At least two aspects of the monitoring data from China need closer scrutiny. One is the steady decrease in the proportion of DOTS patients diagnosed as smear-positive from 1996 to 2003; the other is the exceptionally high treatment success rate, reported to be 93% for the 2002 cohort of new smear-positive patients.
A full analysis of the year 2000 prevalence survey has confirmed that, in the 13 World Bank project provinces implementing DOTS between 1991 and 2000, culture-positive TB prevalence fell by 37% more than in other areas of the country, with a 30% decline directly attributable to DOTS. 3 Although the geographical coverage of DOTS increased substantially between 2002 and 2003, the case detection rate within DOTS areas was only 47% in 2003. Case detection will be improved by the new communicable disease surveillance system (implemented by the Chinese Center for Disease Control and Prevention), which has begun to notify TB patients via the Internet from all major hospitals and health centres as well as the TB dispensaries.
Improving programme performance
During 2003, 27 of 31 provinces in China began scaling up existing and new TB control projects, and the country’s two largest projects – funded by the World Bank/DFID and GFATM – are now fully operational. With anti-TB drugs provided free of charge by grants from the Government of Japan and the central government, 2003 is the first year that all provinces in China have had sufficient resources to implement the complete DOTS technical package. This is the main reason for the increase in case detection for both old and new DOTS areas and accounts for the increase in the case detection rate in DOTS areas from 35% in 2002 to 47% in 2003.
Insufficient human resources – both the quantity and expertise of staff – is a major constraint to TB control. China has begun to address this problem by developing a new national TB training plan. With new funding from the GFATM and the ISAC initiative, China plans to recruit and train additional staff at the central and provincial levels.
With the aim of reaching the global targets by 2005, China has developed a national TB health promotion strategy to increase case detection and cure rates, especially among the poor and vulnerable. Special efforts are being made to increase public awareness of TB. The capacity of TB control staff to carry out health promotion activities at national and provincial levels will be enhanced, as will their communication and outreach skills.
Given the size of China, drug resistance surveys are carried out in individual provinces rather than nationally. The first survey began in 1996 in Henan Province, and since then six additional mainland provinces and Hong Kong SAR have reported drug-resistance data. China has an organized DRS plan, and many provinces are in various stages of planning and implementation. Another three provinces have completed drug resistance surveys; four more provinces have surveys in progress. A nationwide survey in 2000 estimated that 10% of prevalent bacteriologically confirmed TB cases have MDR-TB disease. MDR-TB patients are treated on an individual basis and have to pay for the services. Second-line drugs are produced in the country and are widely available.
Diagnostic and laboratory services, TB/HIV coordination and links with other health-care providers are three priority areas in which programme performance needs to be improved.
Diagnostic and laboratory services
With 500 000 people for every microscopy diagnostic unit, diagnostic services offer a challenge to TB control in China. As activities expand, improving the quality of laboratory services is a priority. Rapid expansion of the new internationally recommended EQA system is also a priority for China, and a new national EQA manual for smear microscopy was developed and issued to TB control institutions at each level. Training courses are being held on EQA implementation. Quality assurance for smear microscopy currently includes a quarterly review, on-site evaluation and panel testing. The national reference laboratories have set an EQA target for 2004 to cover 100% of provincial and prefecture laboratories and 60% of county laboratories. There are, however, no quality assurance systems in place for culture testing.
The Chinese government estimates that there are currently 840 000 people living with HIV in the country, but by the end of 2003, only around 62 000 had been reported to the authorities, of which nearly 9000 were reported with AIDS; reported AIDS deaths have been rapidly increasing. While less than 0.2% of Chinese adults are currently infected with HIV, high rates of HIV infection have been found among intravenous drug users and among people who sold blood plasma to supplement their incomes in provinces such as Anhui, Henan and Shandong. 4 The Government of China is planning to collect data on HIV prevalence among TB patients in provinces known to have a relatively high HIV prevalence, and to use sentinel surveillance or surveys to determine trends in HIV prevalence among TB patients in provinces where the prevalence of HIV is not known. The MoH plans to establish a national TB/HIV coordinating body.
Links with other health-care providers
TB suspects and patients seek care from public hospitals at all levels. The focus of PPM DOTS in China is to link hospitals to TB dispensaries, which is potentially the most important way to increase case detection and to improve the quality of patient care. Data from the prevalence survey conducted in 2000 indicate that more than 75% of smear-positive cases are initially managed in either county general hospitals or township hospitals in China. In the past, many cases diagnosed and treated in hospitals were not reported to the TB dispensaries. Patients in hospitals should now also be reported through the new surveillancesystem. Pilot initiatives to involve hospitals are in place and are showing encouraging results.
In addition to the government funding for TB control, funds are provided for TB control projects from outside sources, with technical assistance from WHO and KNCV. The World Bank/DFID project provides funding for 16 project provinces. The Government of Japan provides funds for anti-TB drugs, microscopes and health promotion materials in 12 provinces. The GFATM has approved US$ 25.4 million for the first two years of a five-year TB project, with initial funds disbursed to 24 provinces. Another GFATM project was approved in July 2004. The Damien Foundation Belgium supports TB control activities in Tibet (since 1995), Inner-Mongolia (since 2001) and Qinghai (since 2003). CIDA began funding TB control activities through WHO in 2003, and the project now covers a population of 75 million in its second year. FIDELIS, run by IUATLD, is exploring new approaches to improve quality of DOTS services and increase case detection.
Budgets and expenditures
In line with plans to reach the global targets for case detection and treatment in 2005, the budget is projected to increase from around US$ 100 million in 2002 and 2003 to US$ 160 million in 2005. Due to a large funding gap, actual expenditures were only around US$ 60 million in 2002.
Budgets from 2003 onwards have been substantially boosted by increased government funding, a new World Bank loan and successful applications to the GFATM. Despite this progress, a funding gap of US$ 21 million still exists for 2005. This funding gap reflects faster than expected expansion of DOTS to new areas, greater than anticipated increases in case detection and plans to introduce additional initiatives to increase case detection in 2005 (e.g. tracing of patients reported through the general communicable disease reporting system, an increased number of sputum examinations at subcounty level and more IEC activities). Some of the funding gap may be filled by an increase in local government funding, but the extent to which this will occur is currently unclear. An increasing budget for first-line drugs is planned to meet the increase in treated cases, with the cost per patient treated remaining at about US$ 20 for the period 2002–2005. If expenditures match budgets in 2004 and 2005, the total cost of TB control activities per patient treated will increase from about US$ 130 in 2002 to US$ 190 in 2005.
2 Using the annual risk of TB infection (ARTI) measured in 2000, and by applying St´yblo’s rule of thumb relating TB incidence to ARTI (smear-positive incidence increases by 50/100 000 population for every 1% increase in ARTI).
3 China Tuberculosis Control Collaboration. The effect of tuberculosis control in China. Lancet, 2004, 364:417–422.
4 UNAIDS 2004 Report on the global AIDS epidemic. Geneva, Joint United Nations Programme on HIV/AIDS, 2004.