The World Health Organisation’s 2008 Global Tuberculosis report shows that TB continues to be a major cause of illness and death worldwide and that the death toll from TB is rising. China carries roughly one quarter of the world's TB burden and ranks second on the list of the top five TB endemic countries; India, China, Indonesia, South Africa and Nigeria.
In 2006 China had 4.5 million cases of TB with the annual number of new cases estimated to be 1.3 million, according to the WHO report on Global TB control . As elsewhere, TB hits the poor hardest and in particular in China, the millions of migrants who move from rural to urban areas where their access to health care is limited.
In view of the seriousness of the problem, the Chinese government started a national TB programme in 1991 together with the World Health Organisation. Since the introduction of the programme, the detection of TB cases in China has improved and free treatment is available in specialised TB centres. However despite the government’s efforts, the challenges remain numerous.
Challenges of poor detection rates and the rise of drug resistance
Globally, the WHO has estimated that for every five cases of the disease that are detected, four further cases go undetected . This lack of case detection is a major concern for TB control in China and has lead to a continued spread of the epidemic. And the spread of multi drug resistant (MDR) TB in China is of even bigger concern.
"TB is a curable disease. In fact curing TB is not extremely difficult. However the treatment usually lasts for six months, and therefore good adherence is essential. If patients do not adhere to their treatment or are being prescribed substandard drugs it is possible to create drug-resistance during their first line treatment”, says Dr. Cornelia Hennig, a WHO Medical Officer.
Poverty is driving the epidemic
Poor detection rates and poor adherence to treatment means that the disease is spreading in China. Poverty is the underlying reason for this - for instance although TB drugs are free in government programmes, China’s poor cannot pay for the multiple tests and X-rays required to diagnose the disease. Poverty also leads to poor drug adherence to the first list treatment because the TB treatment centres are often far away from the places where people live and work and they cannot travel to get their treatment easily if at all. And if people are on the move, migrating from one area to another, this too throws up obstacles to treatment adherence and is more likely to lead to the creation of drug resistance.
HIV co-infection multiplies the difficulties of diagnosis
Further challenges include the lack of modern diagnostic tools for TB. Diagnosis of TB with the current medical tools is particularly difficult in people infected with HIV. In MSF's HIV/AIDS project in Nanning,10% of the HIV-infected patients develop active TB infections a year. Yet of these infections only 23.5% were easily diagnosed (smear positive tests) whilst another 45% were diagnosed with a significant delay (smear negative tests).
“Delays in diagnosis may lead to delay of treatment which usually means loss of lives in late-stage HIV infection" says Dr. Peter Saranchuk, Medical Advisor of MSF’s Nanning project.
More worrying now however, is the trend of strains of drug resistant TB to infect patients who have not previously been exposed to TB drugs at all - at least half of the MDR-patients in China have never taken any TB drugs before. The situation is getting worse because referrals from the general health centres to the TB centres are not taking place, partly due to a lack of awareness amongst patients and health staff
MSF and TB in China
China’s growing TB pandemic and the lack of access to affordable treatment for drug resistant TB have motivated MSF to move ahead with plans to expand its programmes in collaboration with the provincial and central authorities to treat TB. In the two provinces of Inner Mongolia Autonomous Region and Jilin province, both in northern China where the situation is more severe according to government statistics, MSF has been involved in in-depth negotiations to establish a drug resistant TB prevention and management programme.
“The goal of MSF is to set up a sustainable model for prevention and management of DR-TB in collaboration with the TB-authorities in China" says Dr. Philip Tavernier, Head of Mission of the Belgian section of MSF in China.
To curb the TB epidemic in China, improved adherence, improvements in the health system, better diagnostic tools and access to second line anti-TB drugs are urgently needed.