Download: 
-
It is estimated that about 1/4 of the world’s population is latently infected with mycobacterium tuberculosis (MTB) (1). Previous studies showed that 5% to 10% of latent tuberculosis infection patients (LTBIs) might develop active tuberculosis (TB) if left untreated (2). Tuberculosis preventive treatment (TPT), with no effective vaccines, is essential for decreasing TB incidence. The World Health Organization (WHO) has made TPT an essential component of the “End TB Strategy” since 2010. TPT pilot studies among college students, close contacts of infectious patients, and people living with human immunodeficiency virus (PLHIV) in some provinces in China started in the 1990s. China is the second highest TB burden country, accounting for 8.5% of estimated incident cases globally (3). At present, there are no implementation requirements for high-risk groups in the National TB Program (NTP), except for student close contacts of pulmonary tuberculosis (PTB) patients.
A questionnaire was generated using an online survey tool Wenjuanxing (WJX,
https://www.wjx.cn/ , in Chinese). Considering TB burden status and economic levels, we selected Beijing, Tianjin, Shanghai, and five provinces in each of China’s eastern, central, and western regions. The survey was conducted from November 18 to December 9 in 2020. Questionnaires were delivered to the heads of provincial-level CDCs, who then distributed the questionnaires to other leaders at the municipal and county levels, which were then distributed to WeChat groups to be filled out voluntarily by healthcare workers (HCWs). Questions included demographic characteristics, whether HCWs have heard of TPT, acceptability to implement TPT, the reasons for disagreeing with TPT, and preconditions that China should have to implement TPT. Data were collected through WJX, cleaned in Microsoft Office Excel (version 2016; Microsoft Corp, Washington, USA) and analyzed with SAS (version 9.4, SAS Institute, Inc. Cary, NC, USA). We presented categorized variables as frequencies and proportions. Logistic regression was used to assess associations between demographic characteristics and survey responses with a significance of α=0.05. Multivariable analysis included adjustment for age, gender, education level, institution, region, and years of experience as a TB HCW.A total of 5,547 HCWs participated in the survey, with a mean age of (40.9±8.9) years. Among them, 2,057 (37.1%) were males, 1,965 (35.4%) were from central region, 2,788 (50.3%) had bachelor degrees and 3,382 (61.0%) had engaged in TB control for 10 years or fewer. Of all participants, 4,796 (86.5%) HCWs heard of TPT.
Fewer female HCWs had heard of TPT than male HCWs [adjusted odds ratio (OR)=0.735, 95% confidence interval (CI): 0.616–0.876, P<0.001]. A higher proportion of HCWs with postgraduate or higher education (adjusted OR=4.515, 95% CI: 2.134–9.550, P<0.001) had heard of TPT compared with those with secondary or lower education. Compared to the CDC, a lower proportion of HCWs in TB designated hospital (adjusted OR=0.621, 95% CI: 0.497–0.776, P<0.001) and primary health care institutions (adjusted OR=0.360, 95% CI: 0.283–0.457, P<0.001) had heard of TPT. Years of experience as a TB HCW was positively associated with having heard of TPT (Table 1).
Among HCWs who had heard of TPT, 1,421 (29.6%) agreed to implement TPT among all LTBIs, 2,698 (56.3%) agreed to implement TPT among high-risk populations with LTBI, 528 (11.2%) held neutral attitudes, and 139 (2.9%) did not agree. In CDC and TB designated hospitals, a high proportion of HCWs agreed to carry out TPT among high-risk populations with LTBI. In primary healthcare institutions, HCWs agreeing to implement TPT among all LTBIs were in roughly the same proportions as HCWs agreeing to implement TPT among high-risk populations with LTBI (Table 2).
Among the 139 HCWs who disagreed with TPT, the reasons why they disagreed with TPT were the following, in order: “Worrying about acquired drug resistance” (72.7%, 101/139); “Worrying about adverse events” (70.5%, 98/139); “Unguaranteed efficacy” (69.8%, 97/139); “Lacking financial support” (35.3%, 49/139); “Lacking sufficient staff” (34.5%, 48/139); “Troublesome administration of medication” (28.1%, 39/139); and “No policy support” (28.1%, 39/139).
This showed how HCWs think that “high acceptability of TPT of the TPT target population and their families,” “HCWs with enough professional knowledge of TPT,” and “policy support” were three primary preconditions for China to implement TPT. The proportions of HCWs in CDC and TB designated hospitals were roughly the same. In multivariable logistic regression, statistically significant differences in the perceptions were found in “HCWs with professional knowledge of TPT” and “adequate staff” among HCWs in different institutions (Table 3).
-
The results showed that 86.5% of HCWs had heard of TPT. Although TPT is not included in the NTP, it is regarded as an important technical measure in the “Chinese Technical Specification for Tuberculosis Prevention and Control” issued in 2020. This shows a certain basis of TPT in China, and thus a high percentage of HCWs have heard of TPT. However, primary HCWs (PHCWs) were the least familiar with TPT. HCWs with more years of experience in TB control and higher education have a stronger ability to obtain information actively, so they are more likely to have heard of TPT.
TPT should be selectively implemented on populations with the highest risk of progression to active TB, who would benefit most from it. Most HCWs (56.3%) agreed to carry out TPT among high-risk populations with LTBI, as the risk of developing active TB is particularly elevated among children under the age of 5 years, human immunodeficiency virus /acquired immunodeficiency syndrome, and people with compromised immunity (4-5). It was estimated that about 360 million people are latently infected with MTB in China, which makes TPT challenging because of difficult medication management, enormous costs, and the risk of severe adverse events. However, nearly half (44.4%) of the PHCWs lack awareness of recommendations on TPT proposed by WHO. To change this situation, we should strengthen the professional training of PHCWs and HCWs on TPT understanding.
In this study, a minority of HCWs were against TPT due to their perception of drug resistance, adverse events, and unguaranteed efficacy, resulting from insufficient TPT knowledge. Currently, there is no evidence of drug resistance caused by TPT. The incidence of adverse events is low, and TPT efficacy is high (6). TPT has not been effectively used in the past, and standardized treatment of LTBI will help to achieve NTP. Therefore, there is a need to provide updated evidence related to TPT to improve understanding of the benefits and risks of TPT among HCWs.
This study was subject to some limitations. This was an online survey using a convenience sampling method. Although this study had extensive geographic coverage across China and a large sample size, participants’ representativeness might be limited. Futhermore, the acceptability of TPT was self-reported, and there were no repeated verification questions or detailed resources included in the questionnaire.
In order to further promote the implementation of TPT in China, the government and other relevant departments need to provide adequate personnel, funding, and policy support for TPT. Further studies are necessary to model the impact of TPT on morbidity, evaluate the economic benefits of TPT reducing TB burden, and assess patients’ perceptions of TPT and efficacy in order to address the concerns of the government, TB HCWs, and patients and promote the implementation of TPT in China (7).
-
The staff in the provincial-level CDCs, local CDCs, TB designated hospitals, and primary healthcare institutions.
-
No conflicts of interest.
Factor HCWs who had heard of TPT (n, %) HCWs who had not heard of TPT (n, %) Unadjusted OR
(95% CI)P value Adjusted OR
(95% CI)P value Total 4,796/5,547 (86.5) 751/5,547 (13.5) Age, years ≤30 719 (84.0) 137 (16.0) 1.000 1.000 31–40 1,521 (86.3) 241 (13.7) 1.203 (0.958–1.510) 0.112 0.965 (0.762–1.222) 0.766 41–50 1,790 (87.2) 264 (12.8) 1.293 (1.033–1.616) 0.025 0.958 (0.749–1.225) 0.730 ≥50 766 (87.5) 109 (12.5) 1.339 (1.021–1.757) 0.035 0.783 (0.569–1.078) 0.134 Gender Male 1,835 (89.2) 222 (10.8) 1.000 1.000 Female 2,961 (84.8) 529 (15.2) 0.677 (0.573–0.801) <0.001 0.735 (0.616–0.876) <0.001 Education Level Senior high school degree or below 585 (81.9) 129 (18.1) 1.000 1.000 Junior college 1,488 (84.0) 284 (16.0) 1.155 (0.919–1.453) 0.217 1.013 (0.794–1.291) 0.919 Bachelor degrees 2,458 (88.2) 330 (11.8) 1.642 (1.315–2.052) <0.001 1.209 (0.940–1.553) 0.139 Postgraduate and above 265 (97.1) 8 (2.9) 7.303 (3.524–15.135) <0.001 4.515 (2.134–9.550) <0.001 Institution CDC 1,454 (92.1) 124 (7.9) 1.000 1.000 Designated TB hospital 2,292 (87.6) 324 (12.4) 0.603 (0.486–0.750) <0.001 0.621 (0.497–0.776) <0.001 Primary health care institutions 1,050 (77.6) 303 (22.4) 0.296 (0.236–0.370) <0.001 0.360 (0.283–0.457) <0.001 Region Beijing, Tianjin, Shanghai 321 (88.9) 40 (11.1) 1.000 1.000 East 1,731 (88.7) 220 (11.3) 0.980 (0.686–1.402) 0.913 1.215 (0.839–1.760) 0.302 Middle 1,626 (82.8) 339 (17.2) 0.598 (0.422–0.847) 0.004 0.713 (0.497–1.023) 0.067 West 1,118 (88.0) 152 (12.0) 0.917 (0.633–1.327) 0.644 0.961 (0.656–1.409) 0.840 Years of experience as a TB HCW, year ≤10 2,830 (83.7) 552 (16.3) 1.000 1.000 11–20 1,164 (90.6) 120 (9.4) 1.892 (1.535–2.332) <0.001 1.596 (1.274–2.001) <0.001 21–30 674 (90.7) 69 (9.3) 1.905 (1.463–2.481) <0.001 1.823 (1.352–2.458) <0.001 ≥31 128 (92.8) 10 (7.2) 2.497 (1.303–4.782) 0.006 2.555 (1.271–5.137) <0.001 Abbreviations: HCWs=healthcare workers; TPT=tuberculosis preventive treatment; OR=odds ratio; CI=confidence interval; TB=tuberculosis. Table 1. Characteristics of HCWs who had heard of TPT in China, 2020.
Organization Agree TPT for all people
with LTBI, n (%)Agree TPT for key groups
with LTBI, n (%)Neutrality, n (%) Disagree, n (%) Total, n CDC 309 (21.3) 915 (62.9) 171 (11.8) 59 (4.1) 1,454 Designated TB hospital 646 (28.2) 1,313 (57.3) 275 (12.0) 58 (2.5) 2,292 Primary health care institutions 466 (44.4) 470 (44.8) 92 (8.8) 22 (2.1) 1,050 Total 1,421 (29.6) 2,698 (56.3) 538 (11.2) 139 (2.9) 4,796 Abbreviations: HCWs=healthcare workers; TPT=tuberculosis preventive treatment; LTBI=latent tuberculosis infection; TB=tuberculosis. Table 2. Acceptability of HCWs on TPT in different institutions in China, 2020.
Question Yes, n (%) No, n (%) Unadjusted OR
(95% CI)P value Adjusted OR
(95% CI)P value Q1：Do you think the TPT target population and their families should have high acceptability toward TPT? All 4,123/4,796 (86.0) 673/4,796 (14.0) CDC 1,232 (84.7) 222 (15.3) 1.000 1.000 TB designated hospital 1,990 (86.8) 302 (13.2) 1.187 (0.985–1.432) 0.072 1.140 (0.941–1.382) 0.182 Primary healthcare institutions 901 (85.8) 149 (14.2) 1.090 (0.870–1.364) 0.454 1.263 (0.990–1.611) 0.060 Q2：Do you think HCWs should have enough professional knowledge of TPT? All 3,850/4,796 (80.7) 946/4,796 (19.3) CDC 1.089 (74.9) 365 (25.1) 1.000 1.000 TB designated hospital 1,904 (83.1) 388 (16.9) 1.645 (1.400–1.933) <0.001 1.585 (1.343–1.870) <0.001 Primary healthcare institutions 857 (81.6) 193 (18.4) 1.489 (1.224–1.811) <0.001 1.737 (1.404–2.150) <0.001 Q3：Do you think implementing TPT should have adequate staff? All 2,958/4,796 (62.0) 1,838/4,796 (38.0) CDC 844 (58.1) 610 (41.9) 1.000 1.000 TB designated hospital 1,429 (62.4) 863 (37.6) 1.197 (1.047–1.369) 0.009 1.181 (1.029–1.355) 0.018 Primary healthcare institutions 685 (65.2) 365 (34.8) 1.356 (1.151–1.599) <0.001 1.313 (1.100–1.568) 0.003 Q4：Do you think implementing TPT needs financial support? All 3,284/4,796 (68.5) 1,512/4,796 (31.5) CDC 1.002 (68.9) 452 (31.1) 1.000 1.000 TB designated hospital 1,553 (67.8) 739 (32.2) 0.948 (0.823–1.092) 0.459 0.955 (0.827–1.104) 0.533 Primary healthcare institutions 729 (69.4) 321 (30.6) 1.024 (0.863–1.217) 0.783 1.083 (0.900–1.304) 0.399 Q5：Do you think implementing TPT needs professional guidance from relevant experts? All 3,222/4,796 (67.2) 1,573/4,796 (32.8) CDC 981 (67.5) 473 (32.5) 1.000 1.000 TB designated hospital 1,539 (67.2) 753 (32.8) 0.985 (0.857–1.134) 0.838 0.984 (0.852–1.136) 0.823 Primary healthcare institutions 702 (66.9) 348(33.1) 0.973 (0.821–1.152) 0.748 0.999 (0.832–1.200) 0.994 Q6：Do you think implementing TPT needs policy support? All 3,315/4,796 (69.1) 1,481/4,796 (30.9) CDC 1,010 (69.5) 444 (30.5) 1.000 1.000 TB designated hospital 1,620 (70.7) 672 (29.3) 1.060 (0.918–1.223) 0.427 1.075 (0.928–1.245) 0.334 Primary healthcare institutions 685 (65.2) 365 (34.8) 0.825 (0.697–0.977) 0.026 0.883 (0.735–1.061) 0.185 Abbreviations: TPT=tuberculosis preventive treatment; HCWs=healthcare workers; OR=odds ratio; CI=confidence interval; TB=tuberculosis. Table 3. The opinions on preconditions for implementing TPT among HCWs in China, 2020.
HTML
| Citation: |
|