Question

Create a case study "Controlling tuberculosis in China" with the info below:

Health Condition: Tuberculosis ranks as the third leading cause of disease and disability among adults in the world, and nearly one-third of the world's population is infected with the tuberculosis bacillus. Of these cases, more than 9 million people become sick with TB when their immune system is weakened and 1.76 million die each year. In China, tuberculosis is the leading cause of death from infectious disease among adults. Every year, 1.4 million people develop active TB. In 1990, 360,000 people in China died from the disease.

Intervention or Program: In 1991, China revitalized its ineffective tuberculosis program and launched the 10-year Infectious and Endemic Disease Control project to curb its TB epidemic in 13 of its 31 mainland provinces. The program adopted the WHO-recommended TB control strategy, DOTS, through which trained health workers watched patients take their treatment at local TB county dispensaries. Information on each treatment was sent to the county TB dispensary, and treatment outcomes were sent in quarterly reports to the National Tuberculosis Project Office.

Impact: China achieved a 95 percent cure rate for new cases within two years of adopting DOTS, and a cure rate of 90 percent for those who had previously undergone unsuccessful treatment. The number of people with TB declined by over 37 percent in project areas between 1990 and 2000, and 30,000 TB deaths have been prevented each year. More than 1.5 million patients have been treated, leading to the elimination of 836,000 cases of pulmonary TB.

Cost and Cost-Effectiveness: The program cost $130 million in total. The World Bank and the WHOestimated that success­ful treatment was achieved at less than $100 per person. One healthy life was saved for an estimated $15 to $20, with an economic rate of return of $60 for each dollar invested. The World Bank ranks DOTS as one of the most cost-effective of all health interventions.

Answer 1

Case study on TB in china

From above given database we can summaries the current senarios about tuberculosis in China and predict upcoming future conditions. Below summary would help in strategic planning to manage the upcomimg complications related to TB.

What is tuberculosis

TB is caused by the bacteria Mycobacterium tuberculosis contracted by inhaling infected air droplets spread by active TB carriers when they cough, sneeze, or talk. The majority of the people who came into contact with the bacteria can fight the progression of the disease, and the bacteria then lie dormant in the body without the development of any symptoms. Carriers of latent TB can't spread the infection to others but are still at risk of developing it at some point in their lives if their immune system becomes depressed between 5 to 10 percent of those infected with TB will fall ill.

1. TB occurs when a weakened immune system allows the bacteria to multiply and active disease to develop TB in the lungs, or pulmonary

2. TB is the most common form, although the bacilli can cause the disease in any part of the body. The main symptom of pulmonary TB is a persistent worsening cough.

If left untreated, night sweats, malaise, weight loss, blood in sputum, and shortness of breath take hold as the lungs are slowly destroyed.

Treatment and the Age of DOTS
For more than half a century, antibiotics have been available to cure standard cases of TB, but their effectiveness depends on strict patient adherence. The drugs must be taken for at least six months, but many patients discontinue use once their coughing subsides, when they suffer from side effects such as vomiting, jaundice, and confusion, or can no longer afford or access treatment.

Patients who are only “half-cured” can still transmit TB, which poses a serious public health problem by enabling multidrug-resistant TB (MDR-TB) to develop rendering first-line drugs ineffective in MDR-TB patients.

In the 1970s, Dr. Karel of the International Union Against Tuberculosis and Lung Disease pioneered a new approach to TB treatment with the ministries of health of Tanzania, Malawi, and Mozambique. The new strategy promoted the integration of TB diagnosis, treatment, and follow-up with an existing health unit.

This approach eventually evolved into the DOTS strategy, through which health workers or lay people encourage compliance by watching patients take their medicine.

The essential elements of DOTS includes following:
A. Government commitment to sustaining TB control activities Case detection by microscopic examination of a sputum sample among symptomatic patients who seek health services.

B. Standardized treatment regimen of six to eight months for at least all patients with positive sputum exams, using DOTS for at least the initial two months.

Tackling of TB in China
In China, where 400 million people are infected with TB, the burden is especially heavy. TB ranks as the leading cause of death from infectious disease, with 1.4 million people developing active TB each year. A national tuberculosis program was first established in 1981 to reform control efforts, and to expand the reporting system and treatment. Inadequate financial support,

however, hampered the program’s human resource and technical capacity in many areas, particularly in poorer provinces with the weakest primary health care infrastructure. Although some important progress was achieved during the 1980's, the program was plagued by poor treatment compliance, a deficient network of diagnostic laboratories, and an inadequate system of reporting and evaluating cases. Furthermore, the treatment offered at urban hospitals was too expensive for many victims of the disease, and patients often abstained from treatment altogether or abandoned the drug regimen early.

As a result, a third nationwide TB random sample survey in 1990 revealed only a slight improvement in TB prevalence compared with rates in 1979 and 1985.

In 1990, according to vital registration data, 360,000 people died from TB, making it the leading cause of death among adults. As is typical with TB, the poorest communities were most acutely affected.

Recognizing that the widespread incidence of the disease served as an obstacle to its ambitious social and economic goals, the government of China decided to formally evaluate its TB control program with assistance from the World Bank and the WHO.

The analysis highlighted the need for a more effective and efficient method of TB surveillance and treatment of infected patients.
In 1991, with $58 million in financial support from the World Bank, China embarked on a 10-year Infectious and Endemic Disease Control (IEDC) project to help curb its TB epidemic in 13 of its 31 mainland provinces. The project adopted the DOTS strategy and shortcourse chemotherapy. It set out to improve findings of new smear-positive cases from 35 percent to 70 percent and increase the cure rate from less than 50 percent to more than 90 percent of these cases by 2005. Accomplishing these goals would avoid an estimated 100,000 deaths each year and slash TB prevalence in half by 2015 in provinces covered by the program.

A Rapid Rollout of DOTS The IEDC program was the largest natural experiment in TB control in history.

Starting with a pilot project in five counties in Hebei province in April 1991, the program was quickly expanded first to 65 counties and then to approximately half of China’s counties. By 1994, the IEDC project in China involved 1,208 counties in 12 provinces and a population of 573 million people. With this expansion of services, China’s health system bolstered its TB control support and management services with logistic systems, provincial and township supervision, and monitoring and reporting systems.

DOTS implementation.
1. The IEDC program demonstrated extraordinary cure rates of not only new cases but also of relapsed and retreatment cases.

2. The cure rate for people treated with DOTS who had previously undergone unsuccessful treatment for TB was 90 percent. These successes have contributed to an MDR-TB rate three times lower in the 12 provinces covered by DOTS than in non-DOTS provinces. Considering China’s status as the country with the highest MDR-TB cases in the world—approximately 30 percent—the success of the IEDC program in reducing MDR-TB cases provides hope to the rest of the world.
From 1990 to 2000, the number of people with TB in the DOTS area declined by 36.1 percent, about 4.1 percent each year, compared with a decline of 3.1 percent in non-DOTS areas.

In western China, for example, where five provinces implemented DOTS and seven provinces did not, the prevalence in the DOTS area decreased by 33.3 percent while the prevalence in the non-DOTS area decreased by just 11.7 percent.

The magnitude of this difference in TB prevalence between DOTS and non-DOTS provinces may also have been influenced by factors other than the DOTS program, such as socioeconomic differences.
Since DOTS was introduced in China, more than 1.5 million patients have been treated, and approximately 30,000 TB deaths have been prevented each year. DOTS is now available to 96 percent of the population with a 94 percent treatment success rate A national TB prevalence survey carried out in 2000 estimated that the program eliminated 836,000 cases of pulmonary TB disease, 382,000 cases of culture-positive disease, and 280,000 cases of smear-positive disease. The Price Tag Funding for China’s IEDC project came from the Chinese government at both national and local levels and was supplemented by a World Bank loan.

Lessons for the Future
Several lessons can be drawn from both the outstanding success and the limitations of the Chinese national TB program.

DOTS can be rapidly scaled up, while simultaneously achieving high coverage rates. In less than five years, DOTS coverage increased from 0 percent to 90 percent in the program areas.
Under rapid expansion, such programs face the risk of sacrificing treatment quality and case management unless adequate levels of training, supervision, and quality control are maintained. In such a scenario, drug resistance could increase. China’s experience,

however, demonstrated that it is possible to increase the cure rate and lower the treatment failure rate under rapid scale-up and expansion.
Political commitment is essential. Strong political commitment at various levels of government in China contributed to the program’s success.
Project-leading groups led by the vice-governor or vice-mayor were established at each government level to supervise the program.
Creative incentives work. The provision of incentives to both patients and providers proved essential to the success of the IEDC project. Free diagnosis and treatment for TB patients helped dramatically increase treatment rates over the previous program, and incentives provided to doctors to diagnose and treat patients also contributed to program’s success. The resistance from hospitals to refer patients to TB dispensaries exposed a weakness of the program and created the need for further innovative incentives to address this shortcoming.