Study On Current Situation Andstrategy For Multi-Drug Resistanttuberculosis Control In China

Multi-drug resistant tuberculosis (MDR-TB) has come to refer to cases in which the TB strain is resistant at least to isoniazid and rifampicin. With a long duration of treatment and high mortality rate, it’s difficult and expensive to treat the disease, and the cure rates is low. Following the prevalence of AIDS and the increase of resistance to anti-tuberculosis drugs, it’s a great influence for the control of TB. As one of the 27 high MDR-TB burden countries in the world, China’s MDR-TB epidemic is very serious. According to WHO, emerging MDR-TB cases is 500,000, and 131,000 in India,112,000 in China every year. The prevention and treatment of MDR-TB has become the major problems in China.For the problems caused by MDR-TB, a series of global activities have been undertaken to control its development. Since 1994, WHO and the International Union against Tuberculosis and Lung Disease have begun to conduct drug surveillance project in the world. WHO proposed DOTS-Plus strategy for MDR-TB, and proposed MDR-TB into national TB control plans in 1998. WHO published "The drug-resistant TB planning and management guidelines:revision 2008 Emergency", and proposed for management of drug-resistant TB DOTS framework in 2008. The core elements of the framework were basically the same with control non-drug-resistant TB DOTS framework. By review, we found that MDR-TB diagnostic techniques are also needed further study. Based on the sensitivity test, the implementation of standardized treatment is an effective treatment program, but ensures availability of drugs is the key. Learn from the experience of PPM. explore and establish management for MDR-TB. AIMSThe objective of this research is to analyze the current status of MDR-TB, in order to provide basic information for improving the treatment effectiveness and make rational recommendations for the establishment of new treatment and management model of MDR-TB. The following specific objectives are included:analyzing the current situation of MDR-TB control system and financing; identifying the factors influencing the current situation of diagnosis and treatment of MDR-TB; investigating the factors influencing the management of MDR-TB; proposing recommendations to establish standardized treatment and management model of MDR-TB. MethodsData was from the baseline survey data of the major special project "model of TB" of the Ministry of Science and the Ministry of Health-Gates Foundation "hospitals and disease control systems model of co-management of TB", and include household survey, organization investigation, medical record and interviews with key figures in the investigation. In this study, the purpose of sampling was adopted. The 8 cities or districts that Tianjin city, Daqing city of Heilongjiang province, Quzhou city of Zhejiang province, Wanzhou district of Chongqing city, Puyang city of Henan province. Hohhot city of Neimenggu province, Kaifeng city of Henan province and Lianyungang city of Jiangsu province. Finally, we investigated 153 MDR-TB patients in all, and 87 patients by laboratory diagnosis and 66 patients by clinical diagnosis of which.140 medical records of MDR-TB patients and 40 key figures were investigated in all. We developed the tables, and issued them a week before we arrived the city.Both quantitative and qualitative analysis methods were used in the study. Quantitative data was checked before input in computers, and excluded unqualified questionnaires. Investigation database of patients and medical record were established by software EpiData3.1 with second input data. The data was analysed by software SPSS 13.0 for statistical analysis. The qualitative interview data were written before analyses, and then were imported in the Weft Qualitative Data Project software, classified by subject and related issues after the inductive analysis. ResultsThe vast majority of MDR-TB patients correctly answer the transmission of tuberculosis, but small knew the national free treatment policy. Nearly 30% of MDR-TB patients don’t believe that MDR-TB can be cured. The MDR-TB patients are poor mental health. More developed regions, patients with debt are more likely suffer from mental disorders.The central transfer payments and TB project funds are major source to support the local TB control. The key figures said that the work funds were no problem, but lacked the staff resources. That is the incentive fees to engage doing supervision and management work. TB treatment services currently provide only a very small proportion of hospital revenue. In the current three medical insurance system types in the urban and rural, the hospital costs of TB patients are included into compensation range. Reimbursement is in accordance with established programs, Generally use the settings from the pay line and cap lines, sub-reimbursement method. The average reimbursement percentage is 50% or more. The median treatment time of MDR-TB patients is 537 days. The total medical cost of the MDR-TB patients is 22500 Yuan. Before reimbursement, medical expenses account for 123.1% of the annual non-food expenditure. That is the anti-TB treatment is 1.23 times of the patient’s family non-food expenditure.82.3% of MDR-TB patients have catastrophic medical expenses due to treatment of tuberculosis.70.1% of patients for treatment of tuberculosis have borrowed money from others.79.6% of patients indicate that the burden is heavy.67.3% of patients obtain health insurance compensation during treatment. After reimbursement, medical expenses account for 64.1% of the annual non-food expenditure, significantly reduced than 123.1% before reimbursement. 53.7% of MDR-TB patients have catastrophic medical expenses, lower than 82.3% before reimbursement. Most patients are reimbursed for medical expenses in 8 cities. But the reimbursement proportion of medical expenses account for total cost is not high, and the patients’pay costs remain above 70%.The number of personnel is from 3 to 71 in the 8 Cities’municipal TB control project. According to the requirements of National TB control program guidelines, only the number of personnel of Wanzhou District, Hohhot City and Kaifeng City achieve the national requirements. The number of personnel of Quzhou City and Lianyungang City are serious short. Low TB staff qualifications, there are higher proportion of management personnel and lower proportion of laboratory personnel. Institution for treatment capability, the 8 hospitals and TB specialist agencies are equipped with a certain number of TB diagnosis and treatment equipment, but there are different degrees of loss.4 hospitals can diagnose MDR-TB with sensitivity test. Learned through interviews, the main reason not to carry out sensitivity test is that conditions and the laboratory equipment aren’t qualified. The second-line anti-TB drugs are not an ideal situation in the hospitals, and most of the WHO recommended second-line anti-TB drugs aren’t equipped. This will definitely affect the MDR-TB patients’treatment. The MDR-TB patients seeking medical treatment process analysis, 153 patients receive anti-TB treatment for several different agencies. Some patients seek treatment process is relatively simple and only have treatment of tuberculosis in the specialist hospitals. Some patients have repeated treatment in a number of medical institutions. Most of the patients have the first anti-tuberculosis treatment in other TB prevention and control organizations, followed by general hospitals and tuberculosis hospitals. Different occupations of MDR-TB patients take statistically significant difference to choose the first treatment agencies, and non-farmers patients choose more specialized medical institutions in the first treatment. The MDR-TB patients’ interval of surveyed from the earliest onset of symptoms to first treatment is 36.39 days on average.31.6% of the patients have delay treatment, and the average delay interval is 110.82 days. Most patients were diagnosed in specialist tuberculosis hospitals, followed by tuberculosis control agencies and the general Hospitals. Degree of different cultures in patients diagnosed with professional medical units significantly, the higher the educational level of patients, diagnosed with the more professional medical units. The MDR-TB patients’average interval from the first visit to diagnosed is 115.65 days.33.3% of the patients are with diagnosed delay, the average interval is 343.83 days.In MDR-TB case management, there is 14.7% of patients with the phenomenon of drug withdrawal over 2 week during the first treatments.35.3% of the MDR-TB patients receive directly observed therapy in the first anti-TB treatment. But most are under family members’observation,11.8% patients take medicine under doctor’s observation.35.3% patients have received telephone or home visits during the first treatment, and the majority are TB staff. Patients diagnosed with MDR-TB as cut-off point, the MDR-TB patients’treatment process are divided into two stages that are before diagnosis and after diagnosis. The results show that only 11.6% patients take medicine under doctor’s observation.42.9% patients have received telephone or home visits. After diagnosis, only 7.7% patients take medicine under doctor’s observation and 52.4% patients have received telephone or home visits. Confirmed either before or after diagnosis, the proportion that patients take medicine under observation is very low, less than 15%. And in the course of treatment, nearly 50% patients didn’t receive medical staff telephone or home visits. Conclusions and policy implicationsThe awareness and trust of TB institutions for farmers are insufficient, lack of funds, poorly equipped, low quality personnel in some areas. That affects the implementation of TB control measures.Most of the patients had a catastrophic medical expense due to treatment of tuberculosis. While medical expenses can be reimbursed a certain percentage, but the proportion of claims after reimbursed that the patient pays is still more than 70%.53% patients still had a catastrophic medical expense. Diagnoses of MDR-TB in hospitals are a long time. And the treatment of MDR-TB is not the standardized treatment program recommended by the WHO. Only a small number of the MDR-TB patients have standardized treatment in the specialist hospitals. The effective information exchange mechanism between medical institutions and CDC has not really set up. Information of the patients after discharge from hospital can not be timely relevant to CDC. The management of the patients do not truly realize the "closed-loop management." The MDR-TB patients have poor mental health, and their risk of suffering from mental disorders was high.To solve the above conclusions, we put forward the followed suggestions:1) Increase the local TB control input, improve human resource and equipment in CDC. provide the primary supervisors with effective incentive and management to improve them initiative to manage MDR-TB patients.2) Further improve the 3 medical insurance systems, design special compensation measures target MDR-TB patients. 3) Strengthen the capacity building of the specialist hospitals laboratories from the device inputs, technology and personnel training, and develop novel technologies for rapid detection of drug resistance gradually.4) Establish and recommend standardized MDR-TB diagnostic and treatment practices, and carry out MDR-TB training.5) Further improve the cooperation of anti-tuberculosis agencies, and strengthen the cooperation between the tuberculosis specialist hospitals and CDC.6) Concerned about the mental health of patients to increase their confidence in curing TB.