Patient delay in the diagnosis and treatment of tuberculosis in China: findings of case detection projects.

OBJECTIVE: 1) To assess patient delay among new smear-positive pulmonary tuberculosis (PTB) patients in accessing health services in seven FIDELIS (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) projects from 2003 to 2008 in China; 2) to compare treatment delay by province; and 3) to assess factors associated with delay. METHOD: Records of new smear-positive PTB patients were reviewed. Data sources were the consultation book, laboratory register, patient record, treatment card and the PWLAHS (people with limited access to health services) evaluation form. Data were collected using a standard questionnaire, cross-checked by staff from the sites and by the International Union Against Tuberculosis and Lung Disease (The Union) and analysed by The Union. RESULTS: Of the 75 401 new smear-positive PTB patients included in the study, 63-89% were PWLAHS. The average gross domestic product of the project sites and at national level were respectively US$557 and US$998. The median patient delay was 93 days (range 68-128). Delays were longer among females, older patients, rural residents and PWLAHS. Delayed access to health services was significantly associated with a greater number of symptoms. CONCLUSION: Patient delay in accessing health care in China was lengthy; TB care and control needs to be improved.

Objectif : Evaluer le délai d'accès aux services des santé de nouveaux patients atteints de tuberculose pulmonaire (TBP) à frottis positif détectés au sein de sept projets FIDELIS (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) exécutés en Chine entre 2003 et 2008 ; 2) comparer les retards du traitement par province ; et 3) évaluer les facteurs associés aux retards.Méthode : Les dossiers des patients TPB à frottis positif ont été revus. Les données émanaient du registre des consultations, de celui du laboratoire, des dossiers des patients, des cartes de traitement et des formulaires d'évaluation des personnes ayant un accès limité aux services de santé (PWLAHS). Les données ont été recueillies grâce à un questionnaire standard et vérifiées par le personnel des sites et de l'Union Internationale contre la Tuberculose et les Maladies Respiratoires (L'Union) et analysées par L'Union.Résultats : De 75 401 nouveaux patients atteints de TBP à frottis positif, 63­89% étaient des PWLAHS. Le produit intérieur brut moyen des sites du projet et du niveau national était de 557 et 998 $US respectivement. Le délai médian d'accès aux soins était de 93 jours (extrêmes 68­128). Ce délai était plus long pour les femmes, les patients âgés, les résidents ruraux et ceux estimés être des PWLAHS. Ce délai d'accès aux services était significativement associé à un nombre de symptômes plus élevé.Conclusions : Le délai d'accès aux services de santé en Chine est long et offre des opportunités d'amélioration en matière de lutte contre la TB et de traitement.

Objetivo: 1) Evaluar el retraso en el acceso a los servicios de salud de los pacientes en quienes se diagnosticó tuberculosis pulmonar (TBP) con baciloscopia positiva en siete centros del Proyecto FIDELIS (Fondo para la Expansión Innovadora de DOTS por conducto de Iniciativas Locales a fin de poner Alto a la Tuberculosis) del 2003 al 2008 en la China; 2) comparar el retraso en el tratamiento entre provincias; y 3) evaluar los factores asociados con estos retrasos.Método: Se analizaron las historias clínicas de los pacientes con TBP y baciloscopia positiva. Las fuentes de los datos fueron los libros de consulta, el registro de laboratorio, las historias clínicas, las tarjetas de tratamiento y el formulario de evaluación de las personas con acceso limitado a los servicios de salud. Se recogieron los datos mediante un cuestionario normalizado y verificado que analizaron profesionales de los centros locales y de la Unión contra la Tuberculosis y las Enfermedades Respiratorias.Resultados: Se incluyeron en el estudio 75 401 casos nuevos de TBP con baciloscopia positiva. El producto interno bruto promedio por habitante a escala de los centros del proyecto era 557 USD y a escala nacional era 998 USD. De los pacientes con TB, entre el 63% y el 89% contaban con un acceso limitado a los servicios de salud. La mediana del retraso de los pacientes en acceder a la atención fue 93 días (extremos 68 a 128 días). Los retrasos fueron más prolongados en las mujeres, los pacientes de mayor edad, los residentes en zonas rurales y las personas que se calificaron con un acceso limitado a los servicios sanitarios. El acceso tardío a los servicios de salud se asoció de manera significativa con una mayor cantidad de síntomas.Conclusión: Se observó un retraso considerable de los pacientes para acceder a la atención de salud; esta situación ofrece oportunidades para mejorar la atención y el control de la TB.

Asthma as a hidden disease in rural China: opportunities and challenges of standard case management.

OBJECTIVE: To assess the implementation of standard case management of asthma in Huaiyuan County, Anhui Province, China, in 2008. DESIGN: The study project began with the local adaptation of international asthma guidelines, followed by a situation analysis, pre-intervention study, training and intervention. Inhaled beclomethasone (US$15 for a 200-puff [250 µg/puff] inhaler) was prescribed for patients with persistent asthma. Treatment outcome was assessed at 1 year after enrolment. RESULTS: Asthma was never diagnosed in the participating facilities before the project was introduced. Of the 95 patients diagnosed with persistent asthma, 72 (75.8%) were prescribed inhaled beclomethasone, and 23 (24.2%) were not, because they either refused to use inhaled beclomethasone or did not return after the initial visit. At 1 year evaluation, of the 72 patients with persistent asthma treated with inhaled corticosteroids, 12 (16.7%) improved, 7 (9.7%) remained stable, none were worse, 1 (1.4%) had died, and 52 (72.2%) were lost to follow-up. Of the 52 patients lost to follow-up, 25 (48%) were found to be alive but had stopped using inhaled beclomethasone. CONCLUSION: Asthma is more frequently disabling and costly than had been recognised earlier. Asthma patients can be provided the care that they require, but affordable access to inhaled corticosteroids remains a challenge.

Mobilising elementary and secondary school students for tuberculosis case finding in Anhui, China.

OBJECTIVES: To evaluate the implementation of a FIDELIS (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) project in Anhui Province, China. DESIGN: A survey card was designed for students to identify individuals who might have tuberculosis (TB) in their family. Teachers provided health education on TB before distributing the survey cards. Survey cards identifying individuals with respiratory symptoms for ≥3 weeks were sent by the teachers to village doctors who were trained to visit symptomatic individuals and advise them to undergo sputum examination. Data were routinely collected in the implementation of the FIDELIS project, and quarterly reports from the National Tuberculosis Programme were analysed. The detection of new smear-positive TB cases before and after FIDELIS, as well as with and without FIDELIS, were compared. RESULTS: In the first year, a total of 2 387 405 students were involved and 23 079 symptomatic individuals were examined, among whom 2307 (10.3%) were diagnosed with smear-positive TB. Case detection in FIDELIS counties increased by a factor of 3.5 during the FIDELIS period compared with before FIDELIS, and that in non-FIDELIS counties by a factor of 3.1 (P = 0.001). CONCLUSION: It was feasible to massively mobilise students for TB case finding through collaboration between the health care and education systems.