Are China's Rural Clinics Doing Enough to Fight TB?

In a new study conducted in China, researchers found that patients with symptoms of tuberculosis (TB) are too often receiving incorrect or poor-quality care.

In 2015, the United States saw 9,557 TB cases, with 493 TB deaths reported in the previous year, according to the Centers for Disease Control and Prevention (CDC). However, the vast burden of TB falls elsewhere in the world, with the World Health Organization (WHO) noting that 30 countries reported 87% of the estimated 10.4 million TB cases that occurred worldwide in 2016. India, Indonesia, China, Philippines, Pakistan, Nigeria, and South Africa account for 64% of all new TB cases. About 1.7 million individuals die from TB each year, 250,000 of whom are children. Young children, individuals with HIV, and other individuals with weakened immune systems are at greater risk for developing TB disease, typically marked by a prolonged bad cough along with other symptoms. Antibiotic-resistant strains of the Mycobacterium tuberculosis bacteria that cause TB, exacerbate efforts to stem the impact of this deadly disease.

Early detection and proper treatment of the disease are key to stopping the progression and spread of TB. In a recent study published in the journal PLOS Medicine though, researchers found that TB patients in rural China — where the disease remains all too prevalent – are not being diagnosed or treated quickly enough. Thanks in part to China’s socioeconomic improvements and better treatment for individuals diagnosed with TB, smear-positive prevalence of TB fell by 65% overall in the country from 1990 to 2010. Yet only India has a higher TB burden than China, and the study authors note that the disease is three times as prevalent in China’s rural areas than the national average.

Examining the village clinics, township health clinics, and county hospitals that make up the three tiers of China’s rural health system, the study aimed to determine whether patients are being properly diagnosed and treated for TB. In addition, the authors assessed health care providers’ knowledge of correct procedures and aimed to better integrate the three tiers to improve TB management and care referrals. The study deployed unannounced standardized patients (SPs) — actors trained to portray patients – for a total of 274 interactions with providers across the three tiers of care in the provinces of Sichuan, Shaanxi, and Anhui. The SPs reported symptoms that included a cough lasting 2 to 3 weeks, fever with night sweats, as well as loss of appetite and weight to the providers. The researchers also presented providers with clinical vignettes to assess their knowledge of diagnosis and treatment, comparing those responses to what the providers did in practice with SPs.

The study’s researchers identified a “know-do gap” among providers, a marked difference between knowing what to do and what they actually did in practice when faced with TB symptoms. Village and township doctors correctly managed 81% of the TB cases in the clinical vignettes, but only 41% of SPs, overall, were correctly given either a referral, chest X-ray, or sputum test, with village and township clinics scoring much lower than county hospitals.

“We find that rates of correct management are low among village and township level providers in rural areas,” the authors wrote. “Given that most rural patients with TB symptoms initially see providers at these levels, our results suggest that deficits in performance can contribute significantly to delayed detection of TB in China.”

The authors attribute the gap between TB treatment guidelines and practice to factors such as the “wait and see” approach, lack of necessary equipment, and high patient loads. They conclude that unless rural clinics make improvements to manage suspected TB, village providers will undermine China’s efforts to adequately fight TB.