TB prevalence in China dramatically reduced since 1990 - Can India follow?

China’s tuberculosis (TB) control policies are being credited for leading to a marked reduction in the prevalence of the disease in the country by over a half in the past 20 years.

A recently published study, involving a 20-year-long analysis of China’s national survey data, has indicated a drop in TB prevalence from 170 to 59 per 100,000 people. [Lancet 2014. doi.org:10.1016/S0140-6736(13)62639-2]

The fall follows a scale-up of the directly observed treatment short-course (DOTS) strategy from half the population when it was first introduced in the 1990s, to the entire country after 2000.

“One of the key global TB targets set by the Stop TB Partnership aims to reduce tuberculosis prevalence by 50 percent between 1990 and 2015. This study in China is the first to show the feasibility of achieving such a target, and China achieved this 5 years earlier than the target date,” said Dr. Yu Wang, study leader, Chinese Center for Disease Control and Prevention, based in Beijing, China. “Huge improvements in TB treatment, driven by a major shift in treatment from hospitals to local public health centers implementing the DOTS strategy, were largely responsible for this success.”

China is one of the largest contributors to the global TB pandemic, with 1 million new cases each year, accounting for 11 percent of all new cases globally. In the 1990s, the country began addressing this issue, launching the internationally recommended DOTS strategy in 13 provinces containing half the population. 

Two national surveys on the prevalence of TB were conducted in 1990, and in 2000, when the program was rolled out across the country. Over that decade, it was found that the number of TB cases was reduced by about 30 percent in the areas where the DOTS program was implemented. Nationally however, the number of cases dropped by just 19 percent.

Most recently, a survey of TB prevalence was conducted in 2010 to explore the impact, if any, of the introduction of the DOTS program nationwide. Around 253,000 individuals aged 15 years and above took part in the survey and the results showed a drop of 57 percent, with 70 percent of the total reduction in smear-positive prevalence (78 of 111 cases per 100,000 population) taking place after 2000. Of these, 87 percent were cases already diagnosed with TB prior to the survey, with the number of cases treated using the DOTS strategy increasing from 15 percent in 2000, to 66 percent in 2010. These cases also contributed to a reduction in the percentage of treatment default (from 43 percent to 22 percent; p<0 .0001="" 31="" 84="" and="" cases="" from="" p="" percent="" retreatment="" to="">

“The DOTS program has been much more effective in reducing the prevalence of tuberculosis in known cases than in new cases,” wrote the study authors.

In an accompanying editorial, Dr. Giovanni Battista Migliori, director, WHO Collaborating Center for Tuberculosis and Lung Diseases in Italy, and Dr. Giovanni Sotgiu, University of Sassari-Research in Italy, said these data are important for the global TB control and elimination agenda. “[T]he new tuberculosis targets likely to be considered by the 2014 World Health Assembly include a 50 percent reduction in tuberculosis between 2015 and 2025.

“The results from China show the feasibility of achieving such a target by aggressively scaling up the basic programmatic elements of tuberculosis control both within and outside the public 
sector.”

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