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A new tuberculosis (TB) treatment service model called the “trinity model” has been established in China since 2010. The majority of TB-designated treatment centers have been adapted from traditional CDCs to designated general hospitals in the past decade. The profiles of TB treatment health facilities from the national TB surveillance system were collected and analyzed for the current situation of TB control network and treatment service models in China. In 2020, more than one-third (38.3%) of health facilities diagnosed less than 100 TB cases, about one-fourth (24.9%) diagnosed less than 200 cases, and 92 health facilities diagnosed more than 800 cases. Among 2,960 county level TB management areas, 157 (5.3%) counties were dominated by CDCs, 364 (12.3%) by TB/infectious disease-specific hospitals, 370 (12.5%) by independent TB dispensaries/chronic disease stations①, and 2,069 (69.9%) by general hospitals. The new “trinity” TB treatment service model has been broadly implemented and proved to be successful in China’s National TB Control Program (NTP).
Pulmonary tuberculosis (PTB) was officially categorized as a Class B notifiable infectious diseases in China in 1997 (1). TB patient detection and notification have been greatly improved, but there still exists a significant gap between the estimated TB incidence number and cases notified in NTP. The fourth National TB Epidemiological Survey in 2000 (1) showed that 91% of TB patients went to general hospitals or clinics rather than TB dispensaries when they first had TB symptoms, and only 13% of them could be referred to NTP treatment center for standard management. Therefore, an integrated collaboration mechanism was started to explore potential opportunities between general health facilities (including general hospitals, clinics, and all other health facilities outside of NTP) and NTP components. Data was collected from the national TB Management Information System (TBMIS) on January 28, 2021. Profiles of TB treatment facilities were extracted and analyzed in an MS Excel® (version 2016; Microsoft Corporation) spreadsheet. Provincial, prefectural, and county level TB management areas were counted as defined in the NTP surveillance system. Treatment service models at the county level were categorized as “CDC dominated,” “Independent TB dispensary/chronic diseases station dominated” (both were public health providers rather than hospitals, but independent from CDC), “TB/infectious diseases specific hospital dominated” and “General hospital dominated” according to the type of health facilities providing diagnosis and treatment in each county.
There were 40 provincial-level TB treatment facilities in 31 PLADs, none of which were affiliated with the provincial CDC, 3 were independent TB dispensaries, 21 were TB/infectious disease specific hospitals, and the other 16 were general health facilities. There were also 364 prefectural (including 2 CDCs, 45 independent TB dispensaries, 120 TB/infectious disease specific hospitals, and 197 general health facilities), and 2,517 county level treatment facilities (including 180 CDCs, 275 independent TB dispensaries, 39 TB/infectious disease specific hospitals, and 2,023 general health facilities) in 343 prefectural areas and 2,960 county level areas, respectively.
The 2,921 health facilities that were appointed as TB treatment centers diagnosed 633,309 TB cases in 2020. More than one-third (36.5%) of health facilities diagnosed less than 100 TB cases and about one-fourth (25.5%) diagnosed 100 to 200 TB cases. There were 94 health facilities that diagnosed more than 800 TB cases in 2020, among which 11 were provincial, 45 were prefectural, and 38 were county level (Figure 1).
Figure 1.Distribution of number of patients diagnosed in tuberculosis treatment health facilities in China, 2020.
Provincial and prefectural health facilities generally diagnosed more patients than county level health facilities, the median and interquartile range (IQR: Q1, Q3) were 329 (2,176: 75, 2,251), 343 (440: 167, 607), and 125 (191: 53, 243). The number of patients diagnosed by CDCs, general hospitals, independent TB dispensaries/chronic diseases stations, and TB/infectious specific hospitals increased gradually at all levels except that the prefectural-level CDCs diagnosed more patients than general hospitals (Figure 2).
Figure 2.Number of patients diagnosed in different types and levels of tuberculosis (TB) treatment health facilities in China, 2020 (median and interquartile range). (A) Patients diagnosed in different level of health facilities. (B) Patients diagnosed in different level and type of health facilities.
Note: A: CDCs; B: General health facilities; C: Independent TB dispensaries/chronic disease stations; D: TB/infectious disease-specific hospitals.At the end of 2020, among 2,960 county level TB management areas, 157 (5.3%) counties were dominated by CDCs, 364 (12.3%) by TB/infectious disease-specific hospitals, 370 (12.5%) by independent TB dispensaries (or chronic disease stations), and 2,069 (69.9%) by general hospitals. In most western and central areas, general hospitals already dominate as basic management units in treatment. However, independent TB dispensaries or chronic disease stations still played important roles in many northeastern and central southern areas. CDCs were less responsible for treatment and care except in Beijing Municipality, Henan Province, and a few other areas (Table 1).
PLADs CDC dominated (%) TB dispensary or chronic diseases station dominated (%) TB/infectious diseases specific hospital dominated (%) General hospital dominated (%) Beijing 37.5 25.0 0.0 37.5 Tianjin 0.0 62.5 0.0 37.5 Hebei 1.2 0.0 12.9 86.0 Shanxi 0.0 0.0 2.6 97.4 Inner Mongolia 1.9 10.5 15.2 72.4 Liaoning 14.0 36.0 43.0 7.0 Jilin 14.5 76.8 5.8 2.9 Heilongjiang 2.4 35.2 31.2 31.2 Shanghai 0.0 0.0 6.3 93.8 Jiangsu 0.0 0.0 35.2 64.8 Zhejiang 0.0 0.0 0.0 100.0 Anhui 0.0 0.0 13.5 86.5 Fujian 0.0 0.0 13.6 86.4 Jiangxi 4.0 12.0 4.0 80.0 Shandong 0.0 23.2 28.9 47.9 Henan 52.9 21.8 24.7 0.6 Hubei 7.5 14.2 10.4 67.9 Hunan 0.0 0.8 7.7 91.5 Guangdong 4.7 76.6 4.7 14.1 Guangxi 0.9 1.7 20.5 76.9 Hainan 0.0 19.4 0.0 80.6 Chongqing 0.0 17.9 0.0 82.1 Sichuan 3.7 0.0 5.8 90.5 Guizhou 1.1 0.0 1.1 97.8 Yunnan 0.0 0.0 4.7 95.3 Tibet 1.3 0.0 0.0 98.7 Shaanxi 0.0 0.0 5.4 94.6 Gansu 0.0 0.0 4.5 95.5 Qinghai 0.0 0.0 0.0 100.0 Ningxia 0.0 0.0 13.6 86.4 Xinjiang* 0.0 0.0 1.8 98.2 Abbreviations: PLADs=provincial-level administrative divisions; CDC=Center for diseases control and prevention.
* Including Xinjiang Production and Construction Corps (XPCC).Table 1. Proportions of tuberculosis (TB) treatment service model at county level in 31 PLADs of China, 2020.
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① | Note: TB dispensaries and chronic diseases stations were categorized as one group since they were all government-funded public health providers based on the CDC system. TB dispensaries usually only focused on treatment and management of TB while chronic diseases stations also addressed other conditions like leprosy and sexually transmitted diseases. |
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