Preplanned Studies: Implementation Performance of Tuberculosis Control in China: 2011–2020

TB control in China continues making great progress since 2011. Five key indicators have maintained high levels or improved significantly. Based on these performances, the target of decreasing the incidence rate of PTB that was marked in the “13th Five-Year Plan for National TB Control (2016–2020)” has already been successfully completed, and its annual avarege decline rate (3.2%) is significantly higher than the global average (1.7%) (4).

The proportion of reported PTB and presumptive PTB cases arriving at designated hospitals maintained a high level after 2011. The high performance of referral work is the premise of guaranteeing patients involved in NTP diagnosis cascade and initiation of standardized treatment. Meanwhile, the adaption of this indicator also reflected essential implication for China’s NTP patients management work. Before 2014, the overall arrival rate was only monitored among TB patients reported in resident county. With expansion to reported patients outside resident counties, NTP has greatly enhanced its migrant patients management since 2014. Therefore, it declined at the beginning of strategy changing but quickly rebounded and reached at 97.7% at the end of 2020.

The proportion of bacteriologically-confirmed cases among PTB patients has raised to 55.3% in China in 2020. It has already met the requirement (50%) posted in the National “Stop TB Action Plan (2019–2022)”(5) but was still relatively low comparing to other countries. In 2019, bacteriologically-confirmed cases accounted for 57% of PTB worldwide and about 80% in high-income countries (4). This indicator also fluctuated, which may be related with the changing of TB diagnosis and treatment service models. General hospitals historically preferred to use imaging methods to clinically diagnose TB rather than perform bacteriological examinations for every patient. Therefore, the bacteriologically-positive rate has declined more than one-third nationwide in the first serveral years. The decline was also affected by the scale of system reforming. In the West where most treatment centers were previous CDCs and shifted to general hospitals, the bacteriologically-positive rate declined by almost half. While in JJH areas where the service systems were relatively stable, the rate only declined slightly at the beginning and then increased step by step.

Another indicator with a stable high level is the treatment success rate that contributed to a relatively low TB death burden. The mortality rate in China fell by 35.3% from 2011 to 2019 and became the lowest in 30 High Burden Countries (4). But several challenges still exist. Ageing could be a serious problem in the future for China’s TB control, especially in big cities and eastern PLADs (6). In our study, the relative lower treatment success rate in the East and JJH (Beijing, Shanghai and Tianjing) also remain concerning.

The coverage of drug susceptibility tests increased significantly in recent years. The proportion of drug resistance test screening among high-risk populations has reached a high level, which can be attributed to the continuously strengthened drug-resistant TB control strategies, e.g. scaling up the coverage of new diagnostic tools, involving screening expenditure to social medical insurances. As a result, the number of identified laboratory-confirmed rifampicin resistant (RR)-TB or MDR-TB cases has increased from 5,807 in 2014 to 18,246 in 2019 (4). But on the other hand, we should also notice that it is not enough to only screen among high-risk populations. The RR rate of new patients in China is also high and has raised from 6.7% in 2007 (7) to 7.1% in 2013 (8), which is about 2 times the average level of MDR-TB high burden countries. These types of patients are especially concerning and need to be found among new patients.

Our study has limitations. These five key indicators can not describe the whole complete frame of China’s NTP practice. There were still many challenges and barriers that need to be carefully analyzed and addressed in future studies. In addition, our study only focuses on the performance of patients involved in the national surveillance system. There were still considerable TB patients not notified in TBIMS (9) that need to be further investigated.

All five key indicators has been greatly improved in the past decade, but the road towards a “Zero TB” world remains difficult. The 14th five-year plan will be a new start and NTP indicators should be readapted to new strategies and requirements. More and more designated centers were referred to general hospitals, and institutional referral may not be the focus for patient detection. Instead, all the reported patients should be restrictly involved in NTP management and the implication and definition of the overall arrival rate should be changed accordingly. Monitoring and scaling up more efficient diagnostic tests (e.g. rapid molecular tests) to increase the bacteriologically-positive rate will ensure patients are correctly diagnosed and receive effective treatment as early as possible, which can both benefit treatment outcomes and be the premise of drug resistance screening. Furthermore, the two separated drug resistance screening indicators can be combined into DST proportion among bacteriologically-positive patients.

Acknowledgments: Participants of the national TB surveillance system.

Funding: The China National TB Program and the National Special Science and Technology Project for Major Infectious Diseases of China (2017ZX10201302007).

Conflicts of interest: All authors have completed and submitted the ICMJE form. And no conflicts of interest were reported.