Overview of TB Control Program
in Yunnan Province
Yunnan Provincial Anti-Tuberculosis Association
Yunnan Provincial Center for Disease Prevention and Control
Xu Lin
August 2013
Outline
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
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
Epidemiological survey results of TB in Yunnan
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
_
_
Reported incidence and mortality rate of PTB in Yunnan
(1997-2012)
(/100,000)
80.00
0.400
73.70
70.00
0.350
0.347
0.330
Started DOTS
in 2002
60.00
60.42
0.323
62.12
62.22
0.300
58.01
59.29
0.275
53.67
50.00
55.60
0.247
0.235
59.580.300
0.250
0.242
43.70
40.00
37.28
33.45
37.73
0.200
38.67
0.170
32.72
0.172
30.00
30.38
0.150
20.00
0.094
0.100
0.066
10.00
0.077
0.056
DOTS coverage 100% in 2004
0.084
0.060
0.050
0.00
0.000
Incidence
Mortality rate
Reported PTB incidence of Yunnan
compared with national average (1997-2012)
(/100,000)
Reported incidence(1/100,000)
120
100
National average
80
60
Yunnan
40
20
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
The TB reported incidence have consecutively stand at the second
place for seven years in Yunnan.
PTB case detection progress of TB program
( 2002-2012)
Number of PTB cases
Year
Total
Local resident
Mobil population
Number of
SS+ cases
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
Reported incidence of PTB by age group in 2012
Male
All
Female
Age group of more than 60 years suffered higher PTB incidence
Big difference of PTB burdens among 16 prefectures (2012)
Cases
Di Qing
Zhao Tong
3000- ﹤ 4000
Li Jing
Nu
Jiang
4663
2000- ﹤ 3000
Da Li
Chu Xiong
Kun
Ming
1000- ﹤ 2000
Qu
Jing
500- ﹤ 1000
196- ﹤ 500
Bao SHan
De Hong
Yu Xi
Lin Cang
Wen SHan
Pu Er
Xi Shuang Ban Na
Hong He
Total reported TB cases of first
five prefectures were near 60%
of whole province
Big difference of PTB burdens among 129 counties (2012)
Cases
1959
600- ﹤ 700
500- ﹤ 600
Zhao Yang
Zhen Xiong
400- ﹤ 500
300- ﹤ 400
Xuan Wei
Xiang Yun
QiLin
Fu Yuan
200- ﹤ 300
100- ﹤ 200
21- ﹤ 100
Guang Nan
Fu Ning
Hong He
Lan Cang
Yan SHan
Big regional difference of TB burden in Yunnan
from January to June in 2013
The first five region of high
reported number of TB
The first five region of high reported
incidence of TB
①
②
③
④
⑤
①
②
③
④
⑤
Zhaotong（3134
Qujing （1830
Wenshan （1696
Honghe （1656
Kunming （1309
cases）
cases）
cases）
cases）
cases）
Nujiang （92.21/100,000）
Zhaotong（60.28/100,000）
Lincang （49.80/100,000）
Wenshan （48.07/100,000）
Puer
（47.00/100,000）
M/XDR-TB in Yunnan Province
Baseline survey of TB drug resistance in Yunnan from 2008 to 2010
New Cases (%)
Retreatment Cases (%)
All Cases (%)
National
Yunnan
MDR
5.71
4.44
XDR
0.47
0.19
MDR
25.64
22.22
XDR
2.06
1.39
MDR
8.32
7.46
XDR
0.68
0.39
Anti-tuberculosis Efforts
in Yunnan Province
Brief progress of TB control
in 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
Expanding DOTS under NTP since 2002
-- Issued Yunnan TB control and prevention plan 2002-2010 and 2011-2015
by Yunnan provincial government
Tuberculosis in Yunnan Province
Health care system for TB diagnosis and treatment in Yunnan
---- Expanding basic DOTS under NTP since 2002
Provincial
Hospital
Prefecture-level
Hospital
County-level
Hospital
County TB Center
free diagnosis
free treatment
Township-level
Health Unit
Private Clinic
Community/
Village Health Worker
TB
Suspects and Patients
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
Successful treatment rate (Smear Positive)10
0
Percentage (%)
Percentage (%)
Achieved Main Goals of DOTS since 2005
0
2002
DOTS Coverage
2003
2004
2005
2006
2007
Case Detection Rate (New Smear Positive)
2008
2009
2010
2011
Treatment
Success
Rate (New
Smear Positive)
Successful
treatment
rate (Smear
19
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)
M/XDR-TB Control

Government commitment: set up very clear targets in
Yunnan provincial TB control and prevention plan 20112015.
– 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
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 (classⅡ), autoclave, incubator, refrigerator etc.
• 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.
Expanding of MDR-TB control program
2013-2014
Kun
Ming
The first MDR-TB program started in 2012 in
Kunming
Population： 6.28 million, occupy 13.74% of total
population
Supported by GF、 CAP-TB project
Hong He
Expanding two prefectures in 2013 and
2014
Population：13 million, occupy
28.46% of total population
Supported by GF、 NTP
CAP-TB？？
Yu Xi
Main Challenges of TB control
in Yunnan Province
Main Challenges of TB control in Yunnan
• 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.
Main Challenges of TB control in Yunnan
• 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
Main Challenges of TB control in Yunnan
• 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.
Main Challenges of TB control in Yunnan
• 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 secondline anti-TB drug treatment
Main Challenges of TB control in Yunnan
• 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
Lessons of MDR-TB treatment
from national CDC
For MDR-TB patients started on treatment in GF project area in 2008 in China
Failure
China
合计
The
Cases Cured completion
Other
of treatment ADR reasons
614
253
24
45
104
lose
Death
Other
49
58
53
What will happen in Yunnan in future ?
The
To
success
continue
rate of
treatment
Treatment
（%）
28
45.1
谢谢！
Thank You!