overview of tb control program in yunnan province august 2013 yunnan provincial anti-tuberculosis...

Overview of TB Control Programin Yunnan Province

August 2013

Yunnan Provincial Anti-Tuberculosis Association

Yunnan Provincial Center for Disease Prevention and Control

Xu Lin

Tuberculosis in Yunnan Province• Background of Yunnan Province• Tuberculosis in Yunnan Province

Anti-Tuberculosis Efforts in Yunnan Province• Anti-tuberculosis efforts• TB/HIV Control Efforts• MDR-TB Control Efforts

Main Challenges of TB control in Yunnan Province

Outline

Yunnan Province

Most southwestern province in China

Yunnan Province 16 Administrative Prefectures:

•8 prefecture level municipalities•8 autonomous prefectures

Population: 45.9 million (12th)•26 Ethnic Groups (67% Han)•65.2% rural residents

Area: 394,100 km2 (8th)•94% is mountainous areas

Lagged economic develepment• GDP per capita : 19,038 RMB in 2011

Tuberculosis in Yunnan Province

Tuberculosis in Yunnan Province

1979 1990 2000 2010

Prevalence, All Pulmonary TB Cases

(1/100,000)380 538.2 496.8 1,192.9

Prevalence, Smear Positive

(1/100,000)64 77.7 171.3 150.5

TB mortality （ 1/100,000)

_ 17.6 _ _

Epidemiological survey results of TB in Yunnan

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

0.000

0.050

0.100

0.150

0.200

0.250

0.300

0.350

0.400

30.38 33.45 32.72

37.28 37.73 38.67

43.70

53.67

73.70

60.42 62.12 62.22

59.29

55.60 58.01

59.58

0.094

0.066 0.056

0.077 0.084

0.060

0.170 0.172

0.347 0.330

0.323

0.235

0.275

0.247

0.300

0.242

Incidence Mortality rate

Started DOTS in 2002

DOTS coverage 100% in 2004

Reported incidence and mortality rate of PTB in Yunnan (1997-2012) (/100,000)

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

20

40

60

80

100

120Reported incidence(1/100,000)

National average

Yunnan

Reported PTB incidence of Yunnan compared with national average (1997-2012) (/100,000)

The TB reported incidence have consecutively stand at the second place for seven years in Yunnan.

Year Number of PTB cases

Number of SS+ casesTotal Local resident Mobil population

2002 1113 —— —— 560

2003 10686 —— —— 5797

2004 24936 —— —— 14324

2005 21362 20625 737 13954

2006 22229 21615 614 14323

2007 23173 22613 560 14398

2008 22814 22203 611 14094

2009 22607 21718 889 13552

2010 22733 21684 1049 13560

2011 24429 23012 1417 13894

2012 25987 24639 1348 9575

PTB case detection progress of TB program( 2002-2012)

Reported incidence of PTB by age group in 2012

Male

Female

All

Age group of more than 60 years suffered higher PTB incidence

Big difference of PTB burdens among 16 prefectures (2012)

Cases

4663

3000- 4000﹤

2000- 3000﹤

1000- 2000﹤

500- 1000﹤

196- 500﹤

Zhao Tong

Qu Jing

Wen SHanHong He

Da Li Kun Ming

Di Qing

Chu Xiong

Pu Er

Xi Shuang Ban Na

Lin Cang

Li Jing

De Hong

Bao SHan

NuJiang

Yu Xi

Total reported TB cases of first five prefectures were near 60% of whole province

Big difference of PTB burdens among 129 counties (2012)

Zhen Xiong

Zhao Yang

Xuan Wei

Guang Nan

Fu Yuan

QiLin

Lan Cang

Fu Ning

Xiang Yun

Cases

1959

600- 700﹤

500- 600﹤

400- 500﹤

300- 400﹤

200- 300﹤

100- 200﹤

21- 100﹤

Hong He

Yan SHan

The first five region of high reported number of TB

① Zhaotong （ 3134 cases ） ② Qujing （ 1830

cases ） ③ Wenshan （ 1696

cases ） ④ Honghe （ 1656

cases ） ⑤ Kunming （ 1309

cases ）

The first five region of high reported incidence of TB

① Nujiang （ 92.21/100,000 ） ②

Zhaotong （ 60.28/100,000） ③ Lincang

（ 49.80/100,000 ） ④ Wenshan

（ 48.07/100,000 ）⑤ Puer （ 47.00/100,000 ）

Big regional difference of TB burden in Yunnanfrom January to June in 2013

M/XDR-TB in Yunnan Province

National Yunnan

New Cases (%)

MDR 5.71 4.44

XDR 0.47 0.19

Retreatment Cases (%)

MDR 25.64 22.22

XDR 2.06 1.39

All Cases (%)

MDR 8.32 7.46

XDR 0.68 0.39

Baseline survey of TB drug resistance in Yunnan from 2008 to 2010

Anti-tuberculosis Efforts in Yunnan Province

Brief progress of TB controlin Yunnan Province

• 1947, Yunnan Chapter of China Anti-TB Association Founded in Kunming

• 1978, No. 3 People’s Hospital Set Up as Designated Treatment Center

• 2001, Yunnan Provincial CDC Founded

• 2002, Scale-up of national “Free Diagnosis &Treatment” program in Yunnan Province

• 2004 Dec, 100% DOTS coverage achieved

• 2005, • Yunnan Provincial TB control program, funding from provincial government• National TB control program, funding from Central Government• Online TB reporting and recording system introduced

• 2008/2010, Provincial Drug-Resistance Survey

-- Issued Yunnan TB control and prevention plan 2002-2010 and 2011-2015 by Yunnan provincial government

Expanding DOTS under NTP since 2002

Provincial Hospital

Seeking health

care

Seeking health

care

County TB Centerfree diagnosisfree treatment

TBSuspects and Patients

County-levelHospital

Prefecture-level Hospital

referring

Township-levelHealth Unit Community/

Village Health Worker

Private Clinic

referring

Tuberculosis in Yunnan ProvinceHealth care system for TB diagnosis and treatment in Yunnan

---- Expanding basic DOTS under NTP since 2002

19

Achieved Main Goals of DOTS since 2005

Successful treatment rate (Smear Positive)

2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

10

20

30

40

50

60

70

80

90

100

0

10

20

30

40

50

60

70

80

90

100

DOTS Coverage Case Detection Rate (New Smear Positive) Treatment Success Rate (New Smear Positive)

Perc

enta

ge (

%)

Perc

enta

ge (

%)

Successful treatment rate (Smear Positive)

TB/HIV Co-infection Control

Screening TB for HIV/AIDS patients in 2012 TB symptoms screening rate: 90.32 % (53914/59689) Physical check-up with chest X-ray or sputum smear:

69.36 % (41403/59689)The positive rate :0.84% (346/41403)

HIV antibody screening test for TB patients in 2012 HIV screening rate: 73.59% (18898 /25678)The positive rate : 0.47% (88 /18898)

Government commitment: set up very clear targets in Yunnan provincial TB control and prevention plan 2011-2015.

– Improve TB lab capacity: Over 60% county-level labs with sputum culture skill, 100% prefecture-level labs with DST (solid medium).

– Build up MDR-TB clinical centers for regular diagnosis and treatment: cover 50% prefectures.

– MDR-TB suspects screening: 60%

M/XDR-TB Control

M/XDR-TB Control

Laboratory Capacity Strengthening

• Building DST lab network in whole province• Purchased lab equipments for culture and DST in 2007 and 2008 for

each county-level and prefecture-level lab• biosafety cabinet (class ), autoclave, incubator, refrigerator etc.Ⅱ

• Special training: 294 lab technicians were trained in 2009 and 2010

• By the end of 2012• 128 county-level labs (99%) were qualified for sputum culture • 16prefecture-level labs (100% ） were qualified for DST• Rapid identification of bacteria at the provincial level Gene-Xpert

M/XDR-TB Control

Yunnan Provincial TB Treatment Center

With the support of Global Fund, set up first MDR-TB clinical center in Kunming in 2012

Goal: Provide free diagnosis and treatment of MDR-TB cases in Kunming, and being a top center of M/XDR-TB of whole province

M/XDR-TB Control Efforts

Commitment from Yunnan provincial government for CAP-TB program

• All levels of health bureaus supported this program, and want to integrate it with NTP.

• Provided 40 thousand RMB as counterpart funding for each year

• Provided funding to purchase reagents for GeneXpert test

• We are re-designing and rebuilding and isolating the wards for MDR-TB patients based on suggestion from CAP-TB.

• Yunnan CDC paid the fee about 200 thousand RMB.

M/XDR-TB Control

• Total 48 MDR-TB cases were diagnosed and 26 of them received anti-TB treatment.– Reasons for not receiving treatment: patient

decline, be too busy, living too far, afraid of stigma or default during waiting for DST result etc.

• 2 XDR-TB cases were diagnosed and both of them received anti-TB treatment.

The first MDR-TB program started in 2012 in KunmingPopulation ： 6.28 million, occupy 13.74% of total population Supported by GF 、 CAP-TB project

Kun Ming

Hong HeYu Xi

Expanding two prefectures in 2013 and 2014Population ： 13 million, occupy 28.46% of total population Supported by GF 、 NTP

CAP-TB ？？

Expanding of MDR-TB control program 2013-2014

Main Challenges of TB control in Yunnan Province

• High TB burden in Yunnan province– Near 25,000 PTB cases reported every year– Ranked second among 39 statutory reported infectious

diseases since 2005– Annual decrease rate of reported TB incidence is much

slower than national average from 2002 to 2012• Yunnan province: 1.89%• National average: 3.40%

– Much bigger regional difference of TB burden• Remote rural area: Zhao tong

Main Challenges of TB control in Yunnan

High-risk groups lack of active and efficient TB screening

– TB examination of elder people has not integrated into

community-based health service.

– No special funds to support the active screening for migrant

population .

– TB screening among diabetes just began 2 month at 10

communities supported by CAP-TB project.

– Lower case detection for HIV/AIDS population.


• Very weak community support for TB control– Longer delay when seeing a doctor for TB patients and

suspects

Year Median of total delay

(day)Inter quartile of total

delay (day)

2005 100 44-258

2006 90 42-208

2007 86 40-186

2008 81 42-188

2009 63 31-126

2010 60 29-110

2011 58 28-106


• Low awareness of TB prevention and control in public– A KAP survey in 2010 showed:– Knowledge rate of the public was 43.5% in Yunnan – National average rate was 57%.

• DOT can not be conducted due to lack of support of community in some region– For example, Zhenxiong county ： total 2258 PTB cases

including 299 re-treatment cases in 2012, which meant very poor follow-up and treatment.


• There was no mature model of community-based TB/MDR-TB management.

– Only focusing on technical part of medicine rather than patients feelings

– Low detection of MDR-TB patients– Low rate of enrolled MDR-TB patients for receiving second-

line anti-TB drug treatment


• Most MDR-TB patients are very poor and feel desperate – based on face to face interview of total 24 MDR-TB

patients supported by CAP-TB project– 61% cases with less than 300 dollars monthly income– 12% cases without any medical insurance– Only 30% cases with strong confidence of successful

treatment in future


China Cases Cured The

completion of treatment

Failure

lose Death OtherTo

continue treatment

The success rate of

Treatment（ %）

ADROther

reasons

合计 614 253 24 45 104 49 58 53 28 45.1

For MDR-TB patients started on treatment in GF project area in 2008 in China

Lessons of MDR-TB treatment from national CDC

What will happen in Yunnan in future ?

谢谢！Thank You!

overview of tb control program in yunnan province august 2013 yunnan provincial anti-tuberculosis...

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