The results from previous national surveys showed that China had made great progress in TB control from 1990 to 2010 and had achieved the United Nations (UN) Millennium Development Goals (MDGs) targets before the target date (halving prevalence and mortality rates by 2015 compared with 1990 levels) (1). A new TB service network integrating “prevention, treatment, management, and patient care” has been established after that. In 2015, the World Health Organization (WHO) launched the post-2015 era END TB Strategy, in which 2020, 2035, and 2050 incidence and mortality milestones have been settled to measure global and regional progress in comparison to 2015 levels (2). There is a requirement for the national TB program (NTP) to evaluate its stage progress. Key indicators were derived from notification data collected from the national Tuberculosis Information Management System (TBIMS) (3). All five key indicators have maintained high levels or were significantly improved in the past decade. There were still some differences in the performance of indicators among different regions. The 14th Five-Year Plan will be a new start and NTP indicators should be readapted to the new strategies and requirements. The implications and definitions of the overall arrival rate should be changed. More efficient diagnostic tests should be scaled up to increase the bacteriologically-positive rate. Furthermore, the current two separated drug resistance screening indicators could be combined together.
Analytical notification data was extracted from TBIMS, and 5 key indicators were calculated based on cases between January 1, 2011 and December 31, 2020. Considering the socioeconomic circumstances varying among the 31 provincial-level administrations (PLADs), the PLADs were divided into 4 regions based on general social development indicators: JJH (Beijing, Tianjin, and Shanghai); East (Hebei, Liaoning, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, and Hainan); Central (Shanxi, Jilin, Heilongjiang, Anhui, Jiangxi, Henan, Hubei, and Hunan); West (Inner Mongolia, Guangxi, Chongqing, Sichuan, Guizhou, Yunnan, Tibet (Xizang), Shaanxi, Gansu, Qinghai, Ningxia, and Xinjiang).
The 5 key indicators were as follows:
1) Overall arrival rate was defined as the proportion of cases that ultimately arrived at TB designated health facilities among all pulmonary tuberculosis (PTB) or presumptive PTB cases reported in the National Notifiable Disease Reporting System (NNDRS) by non-designated health facilities. 2) Bacteriologically-positive rate was defined as the proportion of bacteriologically-confirmed cases through sputum smear, culture, or molecular tests among all PTB patients notified in TBIMS, with TB pleurisy not included. 3) PTB treatment success rate referred to the proportion of patients with “cured” or “treatment completed” outcomes after finishing standard treatment course among all PTB patients notified in TBIMS. 4) Drug susceptibility test (DST) -multidrug resistant (MDR)-TB high-risk population referred to the proportion of cases tested for rifampicin resistance among all MDR-TB high-risk populations notified in TBIMS. 5) DST-new cases was defined as the proportion of cases tested for rifampicin resistance among all new bacteriologically confirmed cases notified in TBIMS.
The overall arrival rate increased from 93.5% in 2011 to 97.3% in 2020 nationwide (Table 1). The bacteriologically-positive rate initially declined then rebounded in past decades to finally reach 55.3% in 2020 (Figure 1). The treatment success rate of more than 7 million PTB patients involved in NTP from 2011 to 2019 was continuously higher than 93% (Figure 2). DST-MDR-TB high-risk populations and DST-new cases both started from low levels to reach levels higher than 90% (Table 1).
Item 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Overall arrival rate, % Nationwide 93.5 94.7 95.1 89.5 90.2 90.9 90.7 93.4 96.0 97.7 JJH 92.6 92.9 92.6 87.4 91.7 86.3 93.3 94.4 95.2 97.0 East 92.2 93.8 94.9 91.1 91.6 91.3 90.3 91.9 94.7 97.6 Central 96.6 96.8 97.7 92.8 93.1 94.7 94.0 94.9 96.8 97.7 West 92.6 94.3 94.7 85.9 86.7 88.3 88.5 93.4 96.6 97.8 DST-MDR-TB high-risk populations, % Nationwide − − − 35.7 73.2 54.8 57.2 72.6 88.4 97.4 JJH − − − 91.2 88.9 70.8 69.1 84.3 91.8 97.0 East − − − 49.1 75.7 62.0 67.2 81.4 90.7 97.4 Central − − − 36.2 76.2 50.6 57.4 69.5 84.1 97.3 West − − − 16.0 66.3 48.2 45.2 65.7 89.3 97.5 DST-new cases, % Nationwide − − − 18.8 26.7 22.8 33.1 60.2 80.4 93.0 JJH − − − 57.5 28.5 45.5 48.0 85.6 95.4 95.4 East − − − 24.9 26.4 28.6 45.6 72.9 84.3 93.4 Central − − − 14.4 22.8 17.7 23.4 50.1 74.2 91.2 West − − − 16.2 32.9 21.1 31.0 55.6 81.5 94.1 Note: JJH: Beijing, Tianjin, and Shanghai; East: Hebei, Liaoning, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, and Hainan; West: Inner Mongolia, Guangxi, Chongqing, Sichuan, Guizhou, Yunnan, Tibet (Xizang), Shaanxi, Gansu, Qinghai, Ningxia, and Xinjiang, Ningxia, and Xinjiang; −: not available.
Abbreviations: DST=drug susceptibility test; PTB=pulmonary tuberculosis; MDR-TB=multidrug resistant tuberculosis.
* Monitoring of DST proportion of MDR-TB started from 2014.
Table 1. The change of overall arrival rate and DST proportions in China and sub-national regions, 2011–2020 (%)*.Figure 1. The change of bacteriologically-positive rate in China and sub-national regions comparing to global level, 2011–2020. Note: JJH: Beijing, Tianjin, and Shanghai; East: Hebei, Liaoning, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, and Hainan; Central: Shanxi, Jilin, Heilongjiang, Anhui, Jiangxi, Henan, Hubei, and Hunan; West: Inner Mongolia, Guangxi, Chongqing, Sichuan, Guizhou, Yunnan, Tibet (Xizang), Shaanxi, Gansu, Qinghai, Ningxia, and Xinjiang.Figure 2. Number and treatment success rate of PTB patients notified in NTP in China and subnational areas, 2011–2019. (A) Nationwide; (B) JJH (Beijing, Shanghai and Tianjing); (C) East; (D) Central; (E) West. Note: Result of successful treatment rate for PTB patients notified in 2020 cannot be evaluated yet at the moment of assessment. JJH: Beijing, Tianjin, and Shanghai; East: Hebei, Liaoning, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, and Hainan; Central: Shanxi, Jilin, Heilongjiang, Anhui, Jiangxi, Henan, Hubei, and Hunan; West: Inner Mongolia, Guangxi, Chongqing, Sichuan, Guizhou, Yunnan, Tibet, Shaanxi, Gansu, Qinghai, Ningxia, and Xinjiang. Abbreviations: PTB=pulmonary tuberculosis; NTP=national TB program.
The performance of indicators in different regions did not always show the same trend nationwide except for overall arrival rate. The bacteriologically-positive rate in the JJH region has changed from the lowest (39.4%) in 2011 to the highest (58.6%) in comparison to that of other regions while its treatment successful rates were almost always the lowest in the whole period. JJH showed good performance in DST indicators for both high-risk populations and new bacteriologically-confirmed cases from the beginning even they also varied during the middle sections of the study period. On the contrary, the starting level of DST indicators in East, Central, and West regions was relatively low; however, they quickly increased to more than 90% after descending in the first few years. Generally, indicators in the Central and East regions were higher than those in the West region, except that West PLADs showed better performance than central PLADs in the indicator of “DST-new cases”.