One of the best kept secrets in global public health is how China achieved the tuberculosis (TB) targets in the United Nation’s Millennium Development Goals (MDG). The MDG’s TB targets were to reduce the prevalence and mortality of TB by 50% between 1990 and 2015. By 2010, China had reduced its TB prevalence and mortality by 65% and 80%, (1−2) which meant China exceeded the MDG targets 5 years before the MDG deadline. This impressive achievement helped China to move from a high to a medium TB-incidence country. Today, China still has the world’s third highest number of new TB cases each year. But when adjusted for population size, it has the lowest TB incidence per capita among the 30 high TB-burden countries (3).
In 2015, the global community committed to the 2030 Sustainable Development Goals (SDG), which included two new TB targets — reducing TB incidence and deaths by 80% and 90%, respectively, compared to their 2015 levels (3). World Health Organization (WHO) went further by setting the 2035 END TB targets of reducing TB incidence and deaths by 90% and 95%, respectively (3). WHO estimates that China’s TB incidence in 2015 was around 65 cases per 100,000 population (4). A 90% reduction would bring TB incidence to less than 7 cases per 100,000 population, a level seen in most high-income countries. Achieving this will mean that China has eliminated TB as a major public health problem.
Although the SDG and END TB targets seem difficult to achieve, we can learn from how China achieved the MDG TB targets, which was made possible by China’s renewed commitment to control major infectious diseases following the 2003 SARS epidemic (5). Today, we are in similar situation. China is once again impacted by the spread of another coronavirus. The country has been strengthening its health system to be more responsive to both current and future pandemics. Perhaps TB can once again benefit from the renewed focus on controlling infectious diseases. This commentary will discuss how China can apply the lessons and approaches from its COVID-19 response to make progress toward eliminating TB as a major public health problem.
To achieve the MDG targets, China had to achieve an earlier set of global TB control targets: WHO’s 2005 targets of finding 70% estimated TB cases and successfully treating 85% of them (5). Between 2000 and 2005, China implemented WHO’s DOTS strategy nationwide through its CDC system (Table 1). The proportion of TB patients treated in the CDC system increased four-fold, and a much greater proportion of TB patients in China completed their treatment (1). This achievement was extremely important because, without this, China would not have achieved the MDG TB targets. In retrospect, among the 22 high TB-burden countries in 2005, China was the only country to achieve these WHO targets.
DOTS strategy as basis for old TB control model (2001−2010) Transition to new national TB control model (2011−2020) Post-pandemic acceleration toward TB elimination (2021−2035) TB control network County/district CDC and township/village clinics form TB control network:
● CDC: Responsible for diagnosis and treatment, reporting, and monitoring of township and village doctors in carrying out their TB control functions; traced TB suspects who did not come for evaluation after being referred; responsible for maintaining program quality and achieving program targets.
● Township and village clinics: Doctors referred TB suspects to CDC for evaluation, traced those who did not reach CDC, and monitored patient’s treatment in community.
● Hospitals: Required to report and refer TB suspects to CDC.
Designated hospitals for TB, county/district CDC, and township/village clinics form 3-in-1 TB control network:
● Hospitals: Designated county/district hospitals provide diagnosis, treatment and reporting of routine TB patients; city/prefectural hospitals responsible for MDR/XDR-TB diagnosis and treatment. Other hospitals required to report and refer TB suspects to designated hospitals
● CDC: Responsible for monitoring of township and village doctors in carrying out their TB control functions; traced TB suspects who did not come for evaluation after being referred; monitor reporting by hospitals.
● Township and village clinics: Doctors refer TB suspects to hospitals for evaluation, trace those who did not reach hospitals, and monitor patient’s treatment in community.
Strengthening of health system to address COVID-19 pandemic can help TB:
● Hospitals: Designated hospitals providing COVID-19 diagnosis and treatment will have the capabilities to treat complicated respiratory illnesses with improved infection control system; staff are more knowledgeable about respiratory infection control. Such capacities are now more decentralized down to county level and can improve TB treatment.
● CDC: Capabilities to identify, trace, screen, and quarantine contacts are widely available. These can be used for TB contract investigation.
● Township and village clinics: Doctors are much more aware of respiratory symptoms and diseases and are on the look out for patients with respiratory symptoms. They can help look for TB patients.
Technical approaches Implemented in CDC clinics as DOTS strategy:
● Diagnosis: sputum smear microscopy and chest x-ray
● Treatment: Standard short-course chemotherapy with first-line TB drugs
● Management of treatment: Primarily provided by family members; some directly observed therapy, especially during intensive phase of treatment.
● TB surveillance system: internet-based disease reporting system allowed real-time reporting of TB suspects, and case-based electronic registry of notified TB cases.
Implemented in hospitals according to national TB diagnosis and treatment guidelines:
● Diagnosis: CT scan and chest x-ray; smear microscopy, culture, and rapid molecular tests to detect M. tuberculosis and drug resistance.
● Treatment: Standard short-course chemotherapy with first-line TB drugs for drug-sensitive TB; second-line TB drug regimen for rifampin-resistant/MDR TB. Bedaquiline introduced as a new TB drugs.
● Management of treatment: Primarily self-administered or monitoring by family members; use of digital adherence technologies.
● TB surveillance system: internet-based disease reporting system allowed real-time reporting of TB suspects, and case-based electronic registry of notified TB cases. Capture TB data directly from hospital medical information system.
● Use of the digital medium: Provide online training for health care workers, track TB patients using the medication monitor.
Technical and programmatic approaches used in COVID-19 pandemic can apply to TB:
● Diagnosis: Large-scale network of molecular testing down to county level; laboratory network of genomic sequencing available. This can be used for rapid molecular testing for TB on a large scale, including for drug resistance.
● Treatment: Specific COVID-19 treatment guidelines provided to hospitals and implemented rapidly. TB treatment, including for MDR/XDR-TB, can be implement the same way.
● Contact investigation: Health care workers are trained to elicit contact information and better understand the environments facilitating airborne transmission; patients are much more aware of who they have been in contact with. Use of electronic surveillance have improved contact identification. TB can use this for contact tracing, testing, and treatment for LTBI.
● Large-scale screening and testing of COVID-19 in communities: Health departments and health care workers have experience from community screening programs; this can be used to implement active case-finding for TB.
● Large-scale COVID-19 vaccination in communities: Health departments and health care workers gain experience from vaccination programs; this can be used to implement TB vaccination programs for adults.
● Information system: Data on COVID-19 cases quickly shared in real-time from health facilities to government and used to monitor pandemic. TB data from hospitals and other sources can be made available in real-time for monitoring.
Funding Predominantly domestic funding but with significant international contribution; funding, mostly provided from national level:
● Increasing amount of dedicated TB funding by central government; provincial and prefectural/county TB funding also increased.
● Simple diagnosis and first-line TB drugs provided largely free of charge. Limited funds for township/village doctors to carry out TB services.
● Funding from international organizations (World Bank, DFID, GFATM, JICA, CIDA, WHO) supported scale-up of DOTS strategy.
Entirely domestic funding, mostly provided by provincial and local governments:
● Dedicated TB funding by central government for first-line drugs and basic TB diagnosis; variable level of dedicated TB funding from provincial and local governments.
● National health insurance important in paying for TB services provided by hospitals (including diagnosis, treatment, and hospitalization), but patient out-of-pocket (OOP) payment still substantial, especially for MDR-TB.
● Government funding for township/village clinics to carry out public health functions, including TB services.
● Supplemental funding provided by some government sources to reduce patient OOP expenses for TB services.
Government funding to strengthen pandemic preparedness and responsiveness can enhance support for TB:
● Funding to hospitals, CDC’s, laboratory network, primary health care clinics, and health promotion can all potentially benefit TB diagnosis and treatment.
● In addition to government insurance, government provided subsidies to reduce out-of-pocket payment for COVID-19 treatment. COVID-19 vaccinations free of charge. These can apply to provide entirely free diagnosis and treatment or substantially reduced cost of care for TB patients.
Table 1. Evolution of tuberculosis (TB) control models and approaches to eliminate TB following the COVID-19 pandemic.
Three main factors contributed to the successes of TB control following the SARS epidemic (5). First and foremost, there was strong government commitment to improve the control of infectious diseases and reach the 2005 WHO TB targets. Governments at all levels were held accountable for 3 key TB targets: DOTS coverage, case-detection, and treatment success. Second, the government improved the public health system, including the development of an internet-based reporting system for notifiable infectious diseases. This greatly facilitated the reporting and follow-up of TB patients in the hospital system. Third, increased domestic and international resources were combined into a single plan focused on achieving the government targets.