1. Over a 20-year period, China reduced prevalence of smear-positive tuberculosis by more than half by shifting tuberculosis treatment from hospitals to public health centers that implemented the directly observed treatment, short-course (DOTS) strategy.
2. The directly observed treatment, short-course (DOTS) regimen was particularly effective at reducing prevalence of known cases of tuberculosis, implying that overall prevalence decrease was primarily due to better treatment rather than by earlier diagnosis of tuberculosis.
Evidence Rating Level: 2 (Good)
Study Rundown: In the 1990s, China extended tuberculosis control to half the population by providing directly observed treatment, short-course (DOTS). By 2000, DOTS was available to the entire population. This study assessed the impact of the DOTS scale-up over a 20-year period. Results of three national tuberculosis prevalence surveys from 1990, 2000, and 2010 were analyzed. In the 1990s, smear-positive disease prevalence decreased only in provinces that had implemented DOTS. After 2000, prevalence was decreased in all provinces, paralleling the extended implementation of DOTS. Overall, smear-positive prevalence fell by 65%. This study’s findings are strengthened by the large sample size and geographical area, which ensured a more accurate national representation of the population. A limitation of this study was that in 1990 and 2000, chest fluoroscopy was used for screening and in 2010 chest radiography was used. Due to the increased sensitivity of radiography reduction of pulmonary cases may have been masked.
In-Depth [prospective study]: This study analyzed longitudinal data from the 1990, 2000, and 2010 national tuberculosis prevalence surveys in China. Individuals 15 years and older from 31 provinces were screened with chest imaging, and those with abnormal imaging findings and/or persistent cough were classified as having suspected tuberculosis. Results were confirmed with chest radiography, sputum-smear, and culture. From 1990 to 2010 smear-positive tuberculosis prevalence fell from 170 cases (95% CI 166-174) to 59 cases (49-72) per 100,000 population. 68 (87%) of these cases were known cases (diagnosed before the survey) comprised the majority of the reduction in overall prevalence. From 1990 to 2000 programmatic changes were minimal. Reporting of cases to the CDC system increased from 460 (19%) of 2453 to 93 (23%) of 374 (p=0.0055), and the proportion of patients who received tuberculosis treatment increased from 2313 (94%) of 2453 to 370 (99%) of 374 (p=0.00014.)
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