Background
Tuberculosis remains one of the most infectious diseases worldwide. There are wide regional variations in the burden and incidence rate of TB due to important factors such as global migration [1].
Shanghai is the largest metropolitan area in China, with a resident population of 13 million. Shanghai has an integrated TB control network involving TB hospitals, Centers for Disease Control (CDC), as well as community health centers (CHCs). TB hospitals are mainly responsible for TB diagnosis and treatment; CDC is mainly responsible for surveillance and developing TB control strategies; and CHCs are responsible for finding suspect TB cases, case management and follow-up. The notification rate of pulmonary TB in Shanghai was 38.6 per 100,000 population in 2008, much lower than the national rate of 88.5 per 100,000 [2].
However, the number of active TB cases among rural-to-urban migrants in Shanghai increased from 2,968 in 2001 to 3,277 in 2008. The migrant population in Shanghai increased from 3.87 million in 2001 to 5.17 million in 2008. Due to the high cost of living, low socio-economic status and incomplete health insurance, migrants face barriers to access TB care in Shanghai [3]. The TB Control Program of the Shanghai CDC sought to strengthen TB case detection and treatment among migrants in Shanghai. Funding for a five-year project, from Oct. 1, 2006 until Sept. 30, 2011, was provided by the Shanghai government and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Round 5.
Methods
Project areas
Eight of the 19 districts of Shanghai were selected as project areas, based on the number of TB cases detected annually and the area’s socioeconomic and geographic characteristics. The project started in one district in Year 1, and in eight districts by Year 2.
A rural-to-urban migrant was defined as an individual who leaves the hometown, where he/she was registered after birth, and stays in Shanghai for three months or longer. A TB case was defined as an individual who was sputum smear positive or culture positive for Mycobacterium tuberculosis.
Project interventions
Under the project, the designated hospital in each district increased the working hours for migrant TB patients by one hour per weekday and one day per weekend. Free chest X-ray screening was provided to migrant workers who went to the hospital for a routine physical examination, which was required to get a job in the city.
Shanghai CDC extended free screening to migrants who were TB suspects, free treatment with first- and second-line anti-TB drugs, and free liver function assays and protective drugs. Each migrant TB patient could also get 130 Yuan RMB (US $20) per month during the treatment course, as a subsidy for living expenses and transportation.
Project Data Collection and Statistical Analysis
Data was collected quarterly and was entered and analyzed using EpiData Analysis (EpiData Analysis, EpiData Association, Odense. Denmark. Version 1.1.8.68). By year, we calculated the case detection rate and the percentage of sputum smear-positive TB cases who were cured. We compared the case detection rate and treatment success rates of different areas and different years using the chi-square test of proportions.
Results
In Year 1, the case detection rate and the treatment success rate among migrant TB cases were significantly higher in the district that implemented the interventions. In Year 2, the treatment success rate among migrant TB cases was significantly higher in the eight districts that implemented the interventions.
The case detection rate decreased significantly in project areas from Year 1 to Year 2, but no significant difference was found in non-project areas. No significant difference in the treatment success rate was found in the project area and non-project areas. (Table 1)
Discussion
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Free X-Ray Screening is offered to migrant workers in Shanghai |
Tuberculosis is a disease whose treatment outcome is influenced by socioeconomic factors, as well as biological factors. Since 2004, the Shanghai government has provided free TB diagnosis and treatment (first-line drugs only) to migrant TB patients, as well as the local residents who are TB patients. However, before the project started, less than half of the migrant TB patients were successfully treated. Another study found that migrants in Shanghai had financial concerns such as the cost of living in the metropolitan area, an important barrier for completion of their TB treatment [3].
This project was the first project in Shanghai that provided a living and transportation subsidy to migrant TB patients. The subsidies, plus the changes in the TB program that made health care more accessible, significantly improved treatment outcomes in the districts where the project was implemented in Shanghai. The project continues to be implemented, and additional evaluations will determine the long-term benefits and sustainability of the project.
References
1. Global tuberculosis control: surveillance, planning, financing. WHO report 2006. WHO/HTM/TB2006.362. Geneva, Switzerland: WHO, 2006.
2. Ministry of Health of the People's Republic of China http://www.moh.gov.cn/publicfiles/business/htmlfiles/zwgkzt/ptjnj/year2009/t-9.htm
3. Xiaolin Wei. Barriers to TB care for rural-to-urban migrant TB patients in Shanghai: a qualitative study. Tropical Medicine and International Health.2009, Vol 14(7): 754-760.
By Jing Chen1 Kathy DeRiemer2 Xin Shen1 Jian Mei1
1 Department of TB Control, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, PR China
2 School of Medicine, University of California, One Shields Avenue, Davis, California, USA