Eff ect of a comprehensive programme to provide universal access to care for sputum-smear-positive multidrugresistant tuberculosis in China: a before-and-after study

Background China has a quarter of all patients with multidrug-resistant tuberculosis (MDRTB) worldwide, but less than 5% are in quality treatment programmes. In a before-and-after study we aimed to assess the eff ect of a comprehensive programme to provide universal access to diagnosis, treatment, and follow-up for MDRTB in four Chinese cities (population 18 million). Methods We designated city-level hospitals in each city to diagnose and treat MDRTB. All patients with smear-positive pulmonary tuberculosis diagnosed in Center for Disease Control (CDC) clinics and hospitals were tested for MDRTB with molecular and conventional drug susceptibility tests. Patients were treated with a 24 month treatment package for MDRTB based on WHO guidelines. Outpatients were referred to the CDC for directly observed therapy. We capped total treatment package cost at US$4644. Insurance reimbursement and project subsidies limited patients’ expenses to 10 (2011) to those from a retrospective survey of all patients with MDRTB diagnosed in the same cities during a baseline period (2006–09). Findings 243 patients were diagnosed with MDRTB or rifampicin-resistant tuberculosis during the 12 month programme period compared with 92 patients (equivalent to 24 per year) during the baseline period. 172 (71 243 individuals were enrolled in the programme. Time from specimen collection for resistance testing to treatment initiation decreased by 90 started on appropriate drug regimen increased 2·7 times (from nine [35 172), and follow-up by the CDC after initial hospitalisation increased 24 times (from one [4 163 [99 increased ten times (from two [8 programme period had negative cultures or clinical–radiographic improvement. Patients’ expenses for hospital admission after MDRTB diagnosis decreased by 78$796 to $174), reducing the ratio of patients’ expenses to annual household income from 17·6% to 3·5% (p<0·0001 for all comparisons between baseline and programme periods). However, 36 (15%) patients did not start or had to discontinue treatment in the programme period because of fi nancial diffi culties. Interpretation This comprehensive programme substantially increased access to diagnosis, quality treatment, and aff ordable treatment for MDRTB. The programme could help China to achieve universal access to MDRTB care but greater fi nancial risk protection for patients is needed

Insight to the Epidemiology and Risk Factors of Extrapulmonary Tuberculosis in Tianjin, China during 2006-2011.

BACKGROUND:The proportion of extrapulmonary tuberculosis (EPTB) among all the reported tuberculosis (TB) cases has increased in different populations. Despite the large burden of TB in China, the epidemiology of EPTB in China remains largely understudied and the risk factors for having EPTB diagnosis in China have not been identified. METHODS:To gain insight to EPTB epidemiology in China, we analyzed TB surveillance data collected in Tianjin, China, during 2006 to 2011. The frequency of EPTB among all TB cases and within different socio-demographic groups of the study patients aged 15 years and older was determined for EPTB in general and by specific types. The distribution of socio-demographic characteristics was compared between pulmonary TB (PTB) group and EPTB group by chi-square test. Crude and multiple logistic regression-derived adjusted odds ratios (aOR) and 95% confidence intervals (CI) were determined to assess the associations between having EPTB diagnosis and each individual explanatory variable in question. RESULTS:About one-tenth (1,512/14,561) of the patients investigated in this study had EPTB. Of these 1,512 EPTB cases, about two thirds were pleural TB. Significant difference in age, occupation, and urbanity of residence were found between PTB and EPTB groups (p<0.05). Patients with EPTB diagnosis were more likely to be 65 years or older (aOR = 1.22, 95% CI: 1.02, 1.46), to be retired (aOR = 1.37, 95% CI: 1.08, 1.75), and to live in urban areas (aOR = 1 38, 95% CI: 1.22, 1.55). CONCLUSIONS:The findings of this study extends the knowledgebase of EPTB epidemiology in developing countries and highlight the need for improved EPTB detection in China, especially in subpopulations with high risk for EPTB or having limited access to medical facilities with adequate capacity for EPTB diagnosis

Crude and multivariate logistic regression models to determine independent risk factors for having extrapulmonary tuberculosis.

<p>Crude and multivariate logistic regression models to determine independent risk factors for having extrapulmonary tuberculosis.</p

Distribution of socio-demographic characteristics among pulmonary tuberculosis (PTB) & extrapulmonary tuberculosis (EPTB) patients reported in Tianjin, China during 2006 to 2011.

a<p>Probability from chi-square analysis.</p>b<p>Occupations in the food industry, public transportation, public service attendants, and factory workers.</p><p>Distribution of socio-demographic characteristics among pulmonary tuberculosis (PTB) & extrapulmonary tuberculosis (EPTB) patients reported in Tianjin, China during 2006 to 2011.</p

Proportions (y-axis) of extrapulmonary tuberculosis (EPTB) among tuberculosis (TB) patients of different demographic characteristics (x-axis) in Tianjin, China during 2006–2011.

<p>A dark gray bar represents pleural TB and a light gray bar represents all the other forms of EPTB. Panel A, by age group; Panel B, by sex; Panel C, by education level; Panel D, by urbanity of residence; Panel E, by stability of residence; Panel F, by history of previous TB diagnosis; Panel G, by occupation. The vertical lines on each bar represent 95% confidence intervals from proportions.</p

Risk factors for measles among adults in Tianjin, China: Who should be controls in a case-control study?

Control groups in previous case-control studies of vaccine-preventable diseases have included people immune to disease. This study examines risk factors for measles acquisition among adults 20 to 49 years of age in Tianjin, China, and compares findings using measles IgG antibody-negative controls to all controls, both IgG-negative and IgG-positive.Measles cases were sampled from a disease registry, and controls were enrolled from community registries in Tianjin, China, 2011-2015. Through a best subsets selection procedure, we compared which variables were selected at different model sizes when using IgG-negative controls or all controls. We entered risk factors for measles in two separate logistic regression models: one with measles IgG-negative controls and the other with all controls.The study included 384 measles cases and 1,596 community controls (194 IgG-negative). Visiting a hospital was an important risk factor. For specialty hospitals, the odds ratio (OR) was 4.53 (95% confidence interval (CI): 1.28, 16.03) using IgG-negative controls, and OR = 5.27 (95% CI: 2.73, 10.18) using all controls. Variables, such as age or length of time in Tianjin, were differentially selected depending on the control group. Individuals living in Tianjin ≤3 years had 2.87 (95% CI: 1.46, 5.66) times greater odds of measles case status compared to all controls, but this relationship was not apparent for IgG-negative controls.We recommend that case-control studies examining risk factors for infectious diseases, particularly in the context of transmission dynamics, consider antibody-negative controls as the gold standard

Number of models that included each variable according to a best subsets selection, by model size.

<p>Results from the ten highest likelihood score statistics for each model size. For example, for models using IgG-negative controls and each limited to 5 explanatory variables, the variable ‘visited county hospital vs not’ appeared in 9 of the 10 models which had the highest likelihood score statistics.</p

Risk factors for measles based on logistic regression using two different control groups: IgG-negative controls and all controls, Tianjin, China, 2011–2015.

<p>Survey weights were used.</p

Diagram of how control and cases were enrolled into the study.

<p>Diagram of how control and cases were enrolled into the study.</p