After the new crown epidemic, what is Zhang Wenhong busy with?
The latest news that appeared in the public eye was that during the National Two Sessions, Zhang Wenhong, director of the National Medical Center for Infectious Diseases and director of the Department of Infectious Diseases of Huashan Hospital affiliated to Fudan University, put forward suggestions such as free treatment of tuberculosis as a member of the National Committee of the Chinese People's Political Consultative Conference. TB treatment is one of his current priorities.
Today coincides with World Tuberculosis Day on March 24, as the "smartest" infectious disease, tuberculosis is one of the ten leading causes of death in the world, ranking ahead of AIDS, second only to the new crown.
Although many people mistakenly believe that tuberculosis is long gone, China is still one of the countries with a high burden of tuberculosis in the world, with the latest estimate of 780,000 new cases in 2021, ranking third in the world, and the number of deaths estimated at 30,000. Among them, MDR-TB has further made the prevention work more difficult, with a course of up to 2 years, a treatment success rate of only 50%, and a significant increase in cost, which may even be 100 times the cost of ordinary tuberculosis treatment. Difficulties in controlling infectious agents, vaccines, new drugs, accurate diagnostic equipment, money, and attention are the dilemma of tuberculosis prevention and control, and we are still a long way from achieving the goal of eliminating tuberculosis. "That's why after COVID ended, I went back to TB and worked non-stop with the team on this area." He said.
Since becoming a doctor, Zhang Wenhong has been paying attention to this disease. He wants to eliminate TB. TB makes life worse for the poor and discourages patients from expensive and long and painful treatment, explaining that this is one of the reasons why free TB treatment was recommended during the National People's Congress and the National People's Congress (NPC).
After nearly 30 years of diagnosis and research, Zhang Wenhong's team has collaborated in Guizhou, Yunnan Province and other places in recent years to explore the elimination of drug-resistant tuberculosis in the region. Taking Guizhou as an example, in December 2021, the National Medical Center for Infectious Diseases and the Guizhou Provincial Health Commission signed and launched the "Guizhou Province Elimination of the Harm of Drug-resistant Tuberculosis Promotion Project", aiming to improve the treatment rate, treatment success rate and household disastrous expenditure of drug-resistant tuberculosis in Guizhou.
Recently, on Tuberculosis Day, Zhang Wenhong went to Guizhou to continue the work of the tuberculosis project.
After more than two years of cooperative practice, he felt that "the results achieved basically reached the expected goals". He suggested that the country should increase the centralized management of tuberculosis, "isolation treatment must be very beneficial to eliminate the tuberculosis epidemic." ”
Here is his dictation:
Zhang Wenhong (Source: Fudan University official website)
After the end of the new crown, tuberculosis was eliminated non-stop
TB is an infectious disease that is transmitted through the respiratory tract, but it is not a virus, it is a special bacterium called Mycobacterium tuberculosis.
This bacterium appeared very old, but it is very tolerant, it has a strong resistance to the natural environment, if the human body is infected, immune cells are not easy to kill it.
After a person carries tuberculosis bacteria, if not treated, he may carry tuberculosis bacteria for life, even if it is better for a while, it will hide in the body and become a latent state, that is, latent tuberculosis. When it moves, it invades our lungs or other parts of the body, and in the lungs, it passes on to the next person with breathing.
In human history, after entering the agricultural society 10,000 years ago, human beings began to settle, and large-scale high-density gatherings appeared. TB accompanies human migration, from one place to another, never to leave.
TB is very widespread in poor communities, and the poorer and less nourished the now, the more difficult it is to treat TB.
I've been a doctor for almost 30 years. After coming out of medical school, we have seen a lot of infectious disease cases in my career. At the end of the 1990s, I discovered that in many parts of China, especially among low-income people, the prevalence of tuberculosis was still very high, not only high, but also very serious, and infections caused by drug-resistant bacteria could not be cured with existing methods.
For a hospital affiliated to a medical school and the former General Hospital of the Red Cross Society of China, we have a tradition to regard these more difficult infectious diseases, especially affecting low-income people, as our key diseases. So at that time, I started to pay attention to tuberculosis and do research.
In the past 20 years, some of the treatment research and diagnostic research we have done are related to the elimination of tuberculosis. I will also go to many places in China where low-income people are widely distributed to carry out a series of activities to promote the elimination of tuberculosis, including some research and treatment activities.
Over the years, the group with a high incidence of tuberculosis has not changed much, but there have been some very big improvements in medical treatment, one is the treatment plan, and the other is the level of treatment.
Especially in recent years, we have been promoting precision treatment for MDR-TB, as well as short-course treatment for latent TB. Recently, we have pushed for the early detection and treatment of clinical TB, which has not been clearly promoted before. There are also recommendations for centralized hospitalization management of patients with MDR-TB and Mycobacterium tuberculosis, such as these experiences, which are some relatively new methods that disease control and doctors have been promoting clinically in recent years, and I think they will do better in the future.
In the past, it was the patient who went to the doctor when he had symptoms, and we treated him for sensitive tuberculosis free of charge, but once he entered MDR-TB treatment, there was no very good plan. But now, great strides have been made in this regard. Some treatment regimens such as those now promoted by our team have been written into the "Chinese Expert Consensus on Short-course Treatment Options for Multidrug-resistant TB", and the treatment success rate of the regimen can be increased to 85%-90%.
Moreover, for patients with MDR-TB, they used to have to take injections for 2 years, but now after short-term treatment, that is, 6-9 months of oral drugs, MDR-TB can be treated well. For the treatment of latent TB infection, the duration of treatment can now be shortened to one month.
Inside a hospital in Beijing, a doctor examines X-rays of tuberculosis patients
We still have a lot of work to do to end TB.
Why have I returned to TB in the recent period, especially after COVID? Because of the current progress in the elimination of tuberculosis, there is still a long way to go before the domestic elimination goal.
Our goal is to reduce the incidence of tuberculosis in the country to 10 per 100,000 per year by 2030, and the proportion of catastrophic expenditures to 0 (note: catastrophic expenditures are defined as personal out-of-pocket expenses of more than 10% of annual household income).
10/100,000 is equivalent to one in 10,000, and if we extrapolate from China's population of 1.4 billion, it means that the number of cases we have every year is about 140,000. But in fact, China now has 780,000 new cases a year. What is the concept of 780,000? We account for about 7.4% of the world's new cases each year. From 780,000 a year to 140,000 a year, we definitely have a long way to go.
There is not much time left until 2030, this year is already 2023, there are only 7 years, so the time is very short and the task is very heavy. That's why after the coronavirus ended, I'm now working non-stop with the team on this area. Recently, I also went to Guizhou with my team to carry out tuberculosis treatment with local disease control and doctors.
See the heavy burden of drug-resistant patients
Drug-resistant tuberculosis is very difficult to treat, and many new drugs and new treatment options must be used, and the total cost of the patient's course of treatment may be as much as 100,000-200,000 yuan. In this case, if a family wants to treat drug-resistant TB, it may need the government or health insurance to pay for it in full.
But now, not everywhere is fully covered for these patients. Expenses that cannot be covered by health insurance may require some families to pay for it themselves. But sometimes a part of the burden, even two or three thousand yuan, for a low-income family, will become a difficult reality to accept.
If the treatment is not standardized, the success rate of treatment is very low, and the patient does not get standardized treatment at the beginning, it is easy to relapse, and then treat when it recurs, generally speaking, the patient has no confidence, because it takes a lot of money, but it may not be cured.
In the past, treatment for drug-resistant TB had a long treatment period, often taking 20 months or more. Some people feel better after a few months of treatment, but they are reluctant to come, and after a while, they begin to relapse again, so that the recurrence rate will also be high. After abandoning treatment, it is possible to spread the germs to others, causing new drug-resistant tuberculosis.
Members of the 10th batch of Shandong Aid Kashgar Pulmonary Hospital team discussed the patient's condition with local medical staff
I remember a patient from the Baoshan area of Yunnan, whose name was A Xiang, from an ethnic minority area. She relapsed after her first treatment, her condition worsened, and she required a high cost of full-course treatment for MDR-TB. The family can support her as her husband, who works locally, and her income is very low, which makes her not active in treatment.
When we saw the patient, she was still in a bad condition, and one lung was basically destroyed.
At that time, we encouraged her to give her all the medication free of charge, using the best and latest treatment proposed by our team, that is, the precise treatment plan for MDR-TB.
We used this treatment model at that time, the government and our team worked together to promote all aspects of the process, encouraging local doctors to cure every MDR-TB patient as much as possible.
After one year of treatment, Ah Xiang not only turned yin, but the whole person's condition also began to improve rapidly. By the time we visited her at her house the following year, she was already fully recovered. Now it's time to prepare for a second child.
There are actually quite a few such cases. If a family like this has an annual income of 560,000 yuan a year, a farmer in a mountainous area like this, 560,000 yuan may not have it, if half of the money is to be used for treatment, he has to pay 20,000 or 30,000 yuan, his income will drop by nearly 50%, and there will be catastrophic expenses, so that sometimes the family will refuse to receive treatment.
This is why during the National Two Sessions, I specially proposed that tuberculosis should be treated free of charge.
In the past, we only provided free treatment for sensitive TB, but this time I proposed that all TB should be treated free of charge so that we can be sure of eliminating TB.
The "Guizhou Model" addresses the challenge of multidrug resistance
The overall treatment success rate of MDR-TB in China is generally about 50% per year, and we proposed a "Guizhou model" in 2021, hoping that in 4-5 years, the treatment rate and treatment success rate of local MDR-TB patients can reach 90%.
More importantly, we hope to carry out effective etiological diagnosis for every TB patient found, that is, to try to find all MDR-TB patients, preferably more than 90% of MDR-TB can be found. Otherwise, if he is resistant and you do not find it, going to treatment again is equivalent to Baizhi.
The detection rate is 90%, the treatment rate is 90%, the treatment success rate is 90%, and if these can be achieved, I think we can finally solve the problem of MDR-TB.
However, it is easier said than done, requiring the cooperation of the government, patients, families and society, and the all-round and whole-process management of medical staff. At that time, the Guizhou model not only hoped that medical expenses could be solved, but also carried out whole-process management of patients, reaching three 90%.
Although the treatment of MDR-TB is very expensive, there are many ways to explore a sustainable and innovative model of "government + enterprise + social welfare" diversified financing to support the elimination of infectious diseases, such as the Guizhou provincial government at that time to increase medical insurance coverage, and our team also relied on some forces of society to solve some patient expenses that could not be fully covered. We will discuss with the patient to see how much the patient can pay by himself, and if there is real difficulty, we will rely on some social forces to solve the part of the part that is not enough to pay for some patients.
During this period of practice in Guizhou, the Guizhou provincial government and disease control have carried out a lot of support in this regard, and our team has also worked very hard, and we feel that the results achieved have basically reached our expected goals.
Zhang Wenhong and his team previously conducted research in the Third People's Hospital of Bijie City (Source: Guizhou CDC public number)
Recently, on World TB Day, we will go to Guizhou again to meet with local disease control and government departments. In addition to MDR-TB, we may discuss other plans to eliminate TB, including interventions for latent infection so that people with latent infection do not develop the disease; It also includes the detection of tuberculosis further, not only active tuberculosis, but also some subclinical TB patients with very insidious and inconspicuous symptoms.
We hope to find all potential subclinical tuberculosis patients in the whole community, like the experience of the new crown, fully discover, early interventional treatment, early treatment effect will be very good, later patients will not have similar aggravation, cavities, bleeding symptoms and disability.
In this way, we can also find the source of infection in a wider area as much as possible and make it non-infectious through treatment. By reducing the infection of Mycobacterium tuberculosis, and eventually reducing its transmission rate, so that everyone can be cured to the greatest extent, so that the R0 value of tuberculosis is reduced to less than 1, it is possible to eliminate a disease.
It is recommended to increase the centralized management of tuberculosis
China's requirement for sputum-positive tuberculosis patients is to be able to isolate and treat, and China CDC has always advocated that all localities can increase resource investment so that positive patients can be hospitalized.
But in terms of specific circumstances, there are of course some difficulties in achieving 100% hospitalization of positive patients throughout the country. One is limited by isolation resources, the distribution of resources in various places is uneven, and where there are more patients, sometimes isolation treatment cannot be achieved for every patient, and the patients themselves are not necessarily willing.
Some people have asked, can the isolation scheme of the new crown be transplanted to tuberculosis? In fact, many of the solutions to the new crown are not unique to it. Isolation of infectious sources, cutting off transmission routes, and protecting susceptible people are the three basic measures for infectious disease prevention, and we will decide according to the severity of each infectious disease.
For example, when the early stage of the new crown was very serious, China adopted complete isolation to stop the spread, but recently adjusted to "Class B tube" because of its pathogenicity down.
And tuberculosis is not like the new crown, which will cause serious consequences in the short term, but in the long term, its continuous transmission will also lead to serious consequences, so we do not have the same mandatory management of tuberculosis as Class A infectious diseases. In other words, our current management of tuberculosis is not mandatory, we just hope that patients can be treated intensively and discharged after turning negative. This is the same as we hope that after the new crown positive person finds out that he is infected, he can take leave from work at home and do not spread it to others.
Therefore, in China, some tuberculosis patients are hospitalized, and some patients are also isolated at home if they are really not conditionally hospitalized. But home isolation can be passed on to family members, so hospitalization is encouraged, but not mandatory.
Generally speaking, according to the current treatment, if it is sensitive tuberculosis, many patients will turn negative after 2 weeks of treatment, that is, there is no contagiousness, even if it is multidrug-resistant tuberculosis, it will turn negative after 4-8 weeks of treatment. We recommend that patients with MDR-TB and TB bacillus positive be centrally managed in the future until the bacteria turn negative, so as to reduce its social transmission.
Isolation treatment must be very beneficial to eliminate the TB epidemic. The isolation treatment of positive patients should be through full communication with the patient, and then the hospital will expand the isolation treatment place, that is, empower the infectious disease department or tuberculosis department to promote this area.
In recent years, we hope that the government can increase the centralized management of tuberculosis and provide more resources for tuberculosis hospitalization, so as to ensure that every TB patient can be hospitalized during the active period, during the sputum positive and transmission stage, which still needs a lot of investment.
Although this has been proposed in the past, it has not been fully implemented, and the requirements in this area have been strengthened in recent years, and I think this should be what everyone has focused on in recent years.
Reporter/Zhou Shiling
Editor/Lui
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