Commentary / World

Tuberculosis showing a resurgence in China

by Cesar Chelala

China now has the second-largest tuberculosis epidemic — second only to India — with more than 1.3 million new cases of tuberculosis every year.

What makes the situation particularly serious, says the Chinese Center for Disease Control, is that China has the largest number of patients with Multiple Drug Resistant Tuberculosis (MDR-TB). Extremely Resistant Drug Tuberculosis (XDR-TB) is also widespread.

This shows the need to step up efforts to combat the disease. In 1993, the World Health Organization (WHO) instituted a cost-effective treatment called DOTS (a directly observed treatment of a short course of drugs) that was very effective in combating TB in low-income countries. Over time, though, patients began developing resistance to the drugs used for treatment, causing MDR-TB to spread.

Less than one-quarter of those believed to have MDR-TB have been diagnosed, according to WHO.

“We have managed by a combination of complacency and incompetence to allow this bacillus to mutate to a virtually untreatable form,” wrote Dr. Zarir Udwadia, an Indian world expert on tuberculosis and author of the book “Principles of Respiratory Medicine.”

Tuberculosis becomes resistant to drugs in patients who don’t complete the treatment. The current treatment for nonresistant tuberculosis is relatively cheap and consists of drugs called first-line drugs for TB.

In MDR-TB the patient is resistant to at least the two most powerful anti-TB drugs. This form of the disease is much more costly to treat, and it is much more toxic (it has more serious side effects), which explains patients’ reluctance to complete the treatment.

China has a large migrant worker population who leave the countryside to join the wage economy in China’s main towns and cities. Many practice unprotected sex and contract HIV/AIDS, which weakens the immune system and increases susceptibility to tuberculosis.

In addition, they live in circumstances that facilitate the transmission of the disease and impede diagnoses and proper treatment.

Many of migrant workers cannot afford the cost of treatment in the cities and must return to their place of birth, because subsidized management of tuberculosis (and other social welfare benefits) is only allowed in the areas where they were registered at birth.

Migrants born in rural areas are not allowed to switch registration to become urban residents. Returning home for care is not the ideal solution because the rural health system doesn’t have the same quality as the one in the cities.

Although tuberculosis control has been part of the country’s public health program since the 1950s, it is only since the SARS epidemic in 2003 was effectively controlled has the Chinese government increased its efforts to revitalize tuberculosis control programs.

In that regard, increased political commitment to public health as a result of the SARS epidemic benefited tuberculosis control. In March 2004, the government revised the law on control of infectious diseases, providing instructions on how to improve reporting and effective interventions aimed at the control of those diseases.

This law benefited tuberculosis control by improving the reporting of tuberculosis at health facilities across the country. As a result, tuberculosis must be reported to local public health authorities within 24 hours of detection.

In January 2004, the Ministry of Health implemented the world’s largest Internet-based communicable-disease reporting system, which allows tuberculosis patients to be rapidly identified to ensure proper treatment.

In addition, the government started a massive effort to improve public health facilities. Still, more needs to be done in terms of training health workers to implement DOTS, improving the recording and reporting systems and increasing awareness of the dangers of the disease.

Also important is to control the increasing numbers of MDR-tuberculosis patients. According to WHO, China has a third of MDR-TB cases in the world, despite having only 15 percent of TB cases in general.

To lower the prevalence of tuberculosis, particularly in its resistant forms, requires further improvement of the public health system.

So far, considerable progress has been achieved. The estimated prevalence rate of tuberculosis per 100,000 people fell from 215 in 1990 to 59 in 2013, and its mortality rate declined steadily at an average rate of 8.6 percent between 1990 and 2010.

China now has the opportunity and obligation to continue these remarkable achievements.

Cesar Chelala, M.D. and Ph.D., is a winner of the Overseas Press Club of America award.