World Tuberculosis Day丨Drug-resistant tuberculosis patients have the heaviest burden, how to reduce the burden?

On February 6, 2021, beijing subway station hall, tuberculosis prevention and control public service advertisement. (Visual China/Photo)

As one of the oldest infectious diseases in the history of human health, tuberculosis is still the "number one killer" of infectious diseases.

WHO's previous Global Tb Report 2021 (the "Report") shows that 10 million more people will be affected by TB worldwide in 2020, resulting in the deaths of around 1.5 million people.

A more worrying thing is that the number of TB patients diagnosed and found and treated under the impact of the COVID-19 pandemic is declining. According to the report, about 4.1 million people who fell ill undiagnosed and untreated in 2020 may worsen and continue to spread in the absence of an untreated condition. Combined with the global reduction in spending on TB, about 47% of TB patients have incurred catastrophic household expenditures (personal out-of-pocket expenses account for more than 20% of annual household income).

24 March 2022 is the 27th World TB Day, with the theme "Life First, Action for All, Shared Health, Ending TB". Three days ago, at the series of seminars on global health and innovation communication at Peking University, "coordinating multiple forces to reduce the burden on tuberculosis patients" became the theme of attention of experts from all sides.

"Elderly patients, especially rural elderly patients, have poor economic conditions, many underlying diseases, difficult treatment, high costs, and are prone to 'catastrophic' expenditures, and there is a situation of 'poverty due to illness and return to poverty due to illness'." Professor Mao Zongfu of the School of Public Health of Wuhan University said that it is necessary to "reduce the burden" for patients from many aspects, such as improving public policies, increasing capital investment, increasing central financial transfer payments, and reducing drug prices with volume procurement.

Catastrophic expenditure ratio should be "cleared"

The global strategic goal of ending TB by 2030 is facing a range of challenges.

According to the report, global spending on TB prevention, diagnosis and treatment has declined in 2020, with actual spending less than half of the target: at the HIGH-level Meeting of the UNITED Nations General Assembly on TB, the global target was set at US$ 13 billion per year, but only US$6.5 billion in 2020.

"And in terms of the decline in tuberculosis incidence and deaths, the current pace of progress is not fast enough." Tang Shenglan, executive deputy director of the Global Health Institute at Duke University, said that in accordance with the requirements of the United Nations Sustainable Development Goals (SDGs), in 2015-2020, the incidence of tuberculosis should be reduced by 20%, and the current decline is only 9%; the number of deaths should be reduced by 35%, and the actual decline is only 14%.

The amount of tb prevention and control is not only related to the basic services of tuberculosis prevention and diagnosis treatment, but also to the economic burden of tuberculosis patients, and nearly half of the world's patients have incurred catastrophic expenditures. According to the original SDG's planned target, the number of TB patients with catastrophic expenditure should be "cleared" by 2020.

"China is slightly better than the global average, but it hasn't hit the target yet." Tang Shenglan believes that China's basic medical insurance coverage rate is very high, may exceed 96%, and the national medical insurance has a tilt policy for tuberculosis, such as the basic medical insurance of residents to include tuberculosis in outpatient chronic diseases, the reimbursement ratio has reached 60%-70%, etc., and a lot of progress has been made.

Tang Shenglan also stressed that for low-income households in China, catastrophic expenditure is still relatively common. There is no coordination between medical insurance and medical policies, and the medical insurance threshold is high; some drugs and examinations used by patients, especially some drugs used by drug-resistant patients, have not yet been included in the scope of medical insurance reimbursement; the lack of special tuberculosis social security mechanisms, especially medical assistance mechanisms, are all current deficiencies in China, and relevant policies need to be further improved.

Drug-resistant patients bear the heaviest burden

Tuberculosis is a public health disease, a contagious tuberculosis patient can infect 10-15 people per year, prevention is the most economical means of prevention and control. "It is necessary to prevent infection, to prevent infection of others, and to prevent the development of acquired drug resistance and complications." Mao Zongfu said.

Mao Zongfu pointed out that the current burden of tuberculosis disease in China mainly comes from drug-resistant tuberculosis patients. Compared with ordinary tuberculosis, drug-resistant tuberculosis has a longer treatment cycle, more complex treatment, higher cost, and a more prominent disease burden.

"Of those with drug-resistant TB, 50 per cent are acquired as a result of irregular treatments and 50 per cent are primaryly resistant to being directly infected with drug-resistant Mycobacterium tuberculosis." Mao Zongfu said when sharing the "Measures and Suggestions for Reducing the Burden of Tuberculosis Patients" at the seminar.

Due to the long treatment cycle of tuberculosis, the average treatment of ordinary patients is 6-8 months, and the treatment of drug-resistant tuberculosis needs to last about 24 months, how to standardize medical service behavior, reduce the cost burden of patients, and improve treatment compliance is particularly critical.

At present, the mainland implements a "trinity" model of tuberculosis prevention and control – mainly designated hospitals at the prefectural (city) and county levels, which are responsible for the diagnosis, treatment and management of tuberculosis. Medical insurance has an impact on the behavior of both supply and demand sides, and reforming the payment method around medical insurance and establishing a constraint and incentive mechanism for medical institutions will help guide and encourage medical institutions to actively find patients and take the initiative to manage patients.

"Medicare is not only responsible for payment, but more importantly, it is about ensuring that the insured has access to high-quality medical services. To ensure the quality of medical services while carrying out payment reforms and controlling medical costs, this is not only the treatment of tuberculosis, but also in the treatment of other diseases, and in the management of the entire medical insurance. Chen Jiaying, director of the Health Policy Research Center of Nanjing Medical University, said.

Mao Zongfu also talked about the importance of deepening the prevention and control of tuberculosis at the meeting, "The current is also the best window period (to eliminate tuberculosis). If the tuberculosis bacteria change further, there may really be no cure and no cure in the future, which is very bad. ”

Southern Weekend reporter Cui Huiying