A new disease reporting system increases TB case detection in China

Abstract

In the base paper, Enarson & Billo provide a critical evaluation of the Global DOTS Expansion Plan and addressed many of the challenges confronting global tuberculosis control. They did not, however, elaborate on one of the key challenges – the low percentage of infectious tuberculosis (TB) patients identified and treated in DOTS programmes. In this report, we describe a key intervention taken by China to address this important problem. In 1992, China began wide-scale implementation of what eventually became known as the DOTS strategy. In the half of China that implemented this strategy, the TB treatment success rate rapidly exceeded 85%.1 However, during the 1990s, the TB case-detection rate only reached 30% nationwide.2 The reason for the low case-detection rate was well known within China. Over 90% of patients confirmed to have TB initially access care in China’s vast hospital system, but less than 30% of these patients eventually end up in the Center for Disease Control and Prevention (CDC) system where DOTS was implemented.3 Because most hospitals diagnose TB using only chest X-rays, it can only be confirmed after evaluation by the CDC, where sputum examination is also used. In 1996, the Ministry of Health (MOH) set up a regulation requiring all hospitals to report and refer suspected TB patients and cases identified in these institutions to the CDC system for further follow-up. But this regulation proved difficult to enforce, because it was difficult to monitor whether hospitals were in fact reporting and referring all their TB cases and suspected cases. In 2003, the SARS epidemic broke out in China. The epidemic brought to light weaknesses in the public health system, especially the problem of incomplete and delayed reporting of SARS and other communicable diseases. Following SARS, the government worked to improve the reporting of communicable diseases, revising the Law on Controlling Infectious Diseases and making it a legal requirement to report all cases of 37 communicable diseases.4 In January 2004, the MOH launched the nationwide internet-based communicable disease reporting system.5 By the end of 2005, 93.3% of 19 716 health facilities at and above the county level and 66.1% of 38 518 township-level health facilities were using this system to report the country’s 37 notifiable diseases. The average length of time to report from a county-level health facility to the central level has been reduced from 29 days to 1 day. The MOH has instructed all local CDCs to regularly visit hospitals at and above the county level and to monitor the reporting and referral of suspected and confirmed TB cases. As a result, the number of these cases and suspected cases reported by hospitals has increased. Hospitals are required to refer all patients suspected of having TB or diagnosed with it to the local CDC for further evaluation and treatment. Some referred patients report to the local CDC and some do not. Although the absolute number of referred patients coming to the local CDC has increased over time, the percentage of patients arriving on their own has not. Every working day, CDC staff members across the country access the central database to collect information on recently reported confirmed or suspected TB cases in their area. These staff members seek to contact patients who fail to come to the local CDC within three days of being reported. In 2005, 686 742 confirmed or suspected TB cases were reported from the hospital system. Among them, 301 938 (44%) came to the CDC system by themselves for further evaluation. Of the remaining 384 804 patients, the CDC attempted to contact 282 706 (73.5%) of them, and successfully found and evaluated 134 023 patients (or 47.4% of those sought for follow-up). Overall, 435 961 (63.5%) of all patients reported by the hospital system were eventually evaluated by the CDC system. In 2005, China achieved the global tuberculosis control target of 70% case-detection and 85% treatment success. Of the 562 788 smear-positive tuberculosis cases reported in 2005, 127 467 (22.6%) were initially reported by hospitals through the Internet. Thus implementation of the system and policies mentioned above has played an important role in tuberculosis case detection. Nevertheless, to ensure that even more patients benefit from DOTS services, more work is needed to ensure that a higher percentage of referred cases get to the CDC before they are followed up, a higher percentage of patients are followed up, and a higher percentage of those who are followed up actually arrive at the CDC system. ■