Hypertension treatment outdated; Infants hit by Group B Streptococcal infections; Liver disease brings ruinously medical bills; Caesarean sections the norm; Li Keqiang unhappy with pace of health reforms

by MICHAEL WOODHEAD
Treatment of high blood pressure in China is quite backward because it is exactly that - treatment of just the raised blood pressure, with no attention to other cardiovascular risk factors. Cardiologists now emphasise that it is essential to treat a person's overall cardiovascular risk, not just focus on single risk factors such as blood pressure. But a study carried out in 274 hypertensive patients in Zhejiang found that  found that 28% were still smoking, 39% drank regularly and only 21% exercised frequently. The average salt intake per day was above the national recommended level of 6g. The study also found that most patients were taking only one drug for high blood pressure, which was inadequate to control their blood pressure. Many were taking 'herbal' medicines that actually contained out of date and dangerous western antihypertensives such as reserpine. As the authors conclude: "The study revealed outdated and inadequate treatment and health education for hypertensive patients, especially for those who have high risk scores for CVD. There is a need to review the community-based guidelines for hypertension management."

In Shenzhen, researchers at the Children's Hospital have shown that invasive group B streptococcal infection is an important pathogen in infants under 90 days old, resulting in in high mortality and neurological sequelae. The streptococcal infection strains showed strong resistance to clindamycin and erythromycin.

Liver disease is an expensive condition that often sees families facing ruinous medical bills in China. A study carried out at a Kunming hospital found that the average yearly cost of medical treatment for hepatitis B was 19,496 RMB, while patients with cirrhosis faced bills of up to 46,061 RMB. While public medical insurance helped pay for some of the costs, catastrophic health expenditure occurred for families affected by all these illnesses.

China's high rate of caesarean sections will be difficult to bring down to more healthy levels, according to researchers. In a  survey of a112,138 women they found the cesarean delivery rate was 55% and as high as 66% in some regions. Two thirds of the cesarean deliveries were scheduled and performed before labour  and about 40%%  were performed without any recognised medical indications. About 57% of the caesareans were done on request of the mother.

Meanwhile, the progress of health reform is obviously too slow for the Premier Li Keqiang. This month he has called for more medical reform measures to overcome 'difficulties' in the healthcare system. In written instructions he identified problems areas that needed attention, such as hospitals should be prevented from being "financed by drug sales" He also said that more effort should be given to reform of county-level hospitals and more serious diseases needed to be covered by medical insurance. His orders came after reform measures were introduced across all county-level hospitals and are now being piloted in 100 city-level hospitals.

The two H's that cause the most common cancers in China

Pre-cancerous cirrhotic liver

by Michael Woodhead
In western countries we are quite rightly focused on the high profile cancers and how to prevent them. Lung cancer is now in decline due to the very successful campaigns to stop smoking. Likewise in sunny Australia we are starting to see declines in skin cancer thanks to the campaigns that encourage people to cover-up and avoid carcinogenic UV rays. Other common cancers that are the focus of public attention are of course breast cancer, prostate cancer and to a lesser extent cervical and bowel cancer. All of these are the focus of major screening activities - some with official blessing, others (hello prostate cancer) despite a lack of evidence that they reduce cancer deaths.
In China it's a very different story. As you'd expect given the high rates of smoking, lung cancer is the most common malignancy seen in the country, but the other common cancers are those of the liver and digestive tract - hepatic cancer, gastric cancer and oesophageal cancer, in that order. A new review finds that the incidence of these cancers has increased dramatically since the 1980s. Perhaps because Chinese people now live longer or have better access to diagnostic services, but the gastric and liver cancers are now more common than ever. And the causes? It's the "H''s  - hepatitis and H. pylori. The high rates of hepatitis B in China are the reason for the country's huge rates of liver cancer. China has some of the highest rates of hepatitis B in the world (almost one in ten people have been infected) and new infections are still a major problem. The good news is that most children are now being immunised against hepatitis B, and the government believes that there will be far fewer hepatitis cases by 2050, when the current generation of immunised kids are adults.
Gastric cancer is the third most common cancer in China, and much of this may attributable to diet and chronic infection with the carcinogenic H. pylori pathogen. It has been estimated that the number of people in China infected with H. pylori infection rate is still above 50%, and as high as 80% in rural areas. Some hospitals are now implementing a 'test and treat' H. pylori screening approach and providing antibiotic-based eradication therapy to those found to be positive. There have also been some attempts to screen patients with endcoscopy - but is going to be a resource-intensive and logistically impossible approach to adopt nationally. Oesophageal cancer is another common cancer in China. To try prevent more cases, the government is focusing on diet in rural areas, and urging pubic health services to improve nutritional campaigns and avoid agents such as nitrosamines and harmful water contamination.
For the time being, however, China will continue to have high rates of liver and gastric cancers. Eradicating hepatitis and H. pylori will help in the long run, but Chinese people should be aware of the cancers that currently pose the greatest risk to themselves and their families.
[Based on an article by Dr Wang Rui and colleagaes at the Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, published in Clinics and Research in Hepatology and Gastroenterology)

Tropical diseases in China: one down, ten to go

by Michael Woodhead
China has eliminated one tropical disease - lymphatic filiarisis - but has ten others that are still affecting millions of people and some of which are becoming endemic again, according to a new report.
The good news from a review of China's tropical diseases published in The Lancet Infectious Diseases is that the country is on track to eradicate five major diseases (schistosomiasis, leishmaniasis, leprosy, rabies and trachoma) in the next five to ten years.  However, the not-so-good news is that some diseases are still uncontrolled and affect millions of people in poorer provinces of the south and west. The most problematic diseases are dengue fever, food-borne parasitic diseases such as liver flukes and Echinococcosis, according to the article by researchers at the Wuxi branch of the Ministry of Health. Professor Yang Guo Jing and colleagues from the Key Laboratory for Parasitic Diseases say that lymphatic filiarisis was eliminated from China in 2007 after a long campaign to remove it from 16 provinces by using mass drug administration techniques.
Tropical diseases in the 'near-elimination' stage include schistosomiasis, which has been successfully controlled in most parts of the country and numbers reduced from 12 million to 287,000 in 2011. The disease is spread by cattle and water buffalo, and thus changes in farming techniques are needed to help eliminate the disease. Similar improvements in control have been seen for leishmaniasis, the sandfly-spread protozoal infection which used to be common around the Yangtze river basin but now affects only about 2500 people a year. The bacterial infection trachoma that causes blindness is also close to elimination due to implementation of mass campaigns that apply WHO strategies such as facial cleanliness. Rabies has also been controlled, but still causes 2000-3000 cases a year. Immunisation of 70% of dogs at risk should break the cycle of infection, but currently only about 20% are vaccinated. Leprosy was reported to affect about 6000 people in China in 2010, of which about 1300 were new cases. Better surveillance and multi-drug treatment regimens should help eradicate the infection by 2020, the report suggests.
China has has less success with soil-transmitted helminthiasis, and there are about 85 million Chinese affected by roundworm and whipworm. De-worming of schoolchildren seems to have only modest efficacy, and so new strategies such as curbs on the use of human waste as fertiliser are needed, the report says.
The most problematic tropical diseases for China include dengue fever, with outbreaks of the mosquito-borne infection rapidly emerging as a major public health problem. Climate change is worsening the problem, which requires better monitoring and mosquito management strategies as there is no drug or vaccine for the disease.
Another major problem tropical disease for China are the food-borne parasitic zoonoses, such as liver flukes, lung flukes, and other trematodes that may be transmitted by fish, snails and freshwater plants. There are tens of millions of cases in China, which has the dubious honour of having 80% of the 15 million cases globally. New programs are needed to identify high risk disease areas and to address transmission of infection through occupational risk (eg farmers) and also consumption of high risk foods.
Control of these many tropical diseases will require huge  resources to build and design  programs specific for each disease and the high risk locations and populations they affect, the authors conclude.

New non-interferon antivirals will not eliminate hepatitis C overnight, say Chinese experts

by Michael Woodhead
New antiviral drugs offer the chance to eliminate hepatitis C from China, but over-optimistic predictions need a reality check, says a leading Chinese virologist.
In an article in Gastroenterology, Dr Lai Wei of the Peking University People’s Hospital and the Beijing Key Laboratory for Hepatitis C and Liver Disease Immunotherapy says there has been a lot of hype about new pipeline drugs bringing about a "hepatitis C revolution". It is claimed that a whole new range of drugs soon to be released will be able to treat the intractable blood-borne viral disease much more effectively and quickly than current treatments - and most importantly without the debilitating side effects of current drug regimens based on interferon. It is said that drugs such as simeprevir and sofosbuvir will be able to cure hepatitis C infection in 95% of people after a single 12-week course of treatment. If this is true then these drugs could potentially have a major impact in China, which has one of the highest rates of hepatitis C in the world.
It is estimated at least 2% of the Chinese population - about 30 million people - have chronic hepatitis C infection. The disease burden for China in terms of hepatitis C-related cirrhosis, liver failure and liver cancer is huge.
Hepatitis C is a chronic disease, and many of those with the infection remain undiagnosed and untreated until it progresses and the severe consequences such as cirrhosis and liver cancer become apparent. In China fewer than 3% of people with the infection are diagnosed, and only half of those diagnosed get any treatment. And the treatment itself is not very effective or tolerable. The best available agents are peg-interferon and ribavarin, which can produce a 'sustained viral response' in about 70% of patients with a 24-week course - but only in people with certain types of HCV (genotypes 2 or 3). Treatment success rates are much lower for people who have HCY type 1, even with much longer treatment courses. The side effects of treatment resemble a very bad case of flu, and many patients simply cannot or will not tolerate these effects and stop treatment.
The appeal of the new anti-hepatitis C drugs is therefore obvious. They are more effective and bettwr tolerated. Within five years it is theoretically possible for all types of hepatitis C to be cured with a single course of treatment lasting as little as eight weeks.
The reality for China, however, is not so simple. There are three major barriers to eliminating hepatitis C from China.

1. First and foremost is the problem of identifying the 97% of people in China who have hepatitis C infection but are not diagnosed. This will require some kind of screening program - and this may be very expensive unless there is an accurate and affordable test available. Identification of hepatitis C also requires the public to be aware of the disease and that it can be treated.

2.If patients with hepatitis C are identified they then need to be able and willing to access treatment. Many people with hepatitis C live in rural areas. Even in cities, China does not have a sufficiently large medical workforce with the skills to accurately diagnose hepatitis C and provide appropriate tailored treatment and follow up. A major medical workforce expansion and education program would be needed.

3. The new hepatitis C treatments are not affordable for a developing country like China . The costs of the new anti-hepatitis treatments are enormous. In the US a single course of sofosbuvir costs $84,000. Some countries such as India and Egypt have planned low cost programs for antiviral drugs for hepatitis C. But even if low cost versions of these new drugs are produced generically, the costs of treating 30 million people will still be huge. There is also a question of whether the new drug treatments can be used in sub-groups of patients with hepatitis C such as those with co-morbidities, cirrhosis the elderly and most importantly, in children

In summary, China has potentially much to gain from the new era of hepatitis C treatment - but huge practical problems lay ahead in identifying people with the infection and getting them into treatment.

China medical news headlines for Friday 17 January

Monitor and treat the best way for hepatitis B

Monitoring inactive chronic hepatitis B carriers is a cost-effective strategy for China, a study shows. The findings published in Hepatology, also show that increasing treatment, monitoring and adherence to therapy are necessary to achieve significant health benefits at the population level.
Shanghai researchers compared the current strategy of not monitoring inactive chronic HBV patients to a monitor and treat strategy which included twice-yearly assessment of HBV and ALT levels. For active HBV cases the researchers suggest treatment with the antiviral entecavir, which evidence shows to be a cost-effective antiviral therapy in China.
The study found that there were 1.5 million adult HBV arriers of HBV in Shanghai, of whom 63% were hepatitis B virus e antigen (HBeAg) positive. The number of active cases of chronic HBV, were 258,139 in the eAg-positive group and 152,384 in the HBeAg-negative group. A monitor and treat strategy would reduce liver cancer by 70% and reduce mortality caused by chronic HBV by 83%, according to News Medical.

China too hard for US generic drug maker

One of the world's biggest generic drug manufacturers has quit China, saying it is too hard to do business there. The US generic maker Actavis has said it will exit China because the business climate is just 'too risky' according to its CEO.
“It is not a business friendly environment,” CEO Paul Isaro is quoted as saying by Bloomberg.

Beijing wants foreign medical city

Beijing is to set up an International Medical Service Zone in Tongzhou District in 2014, Xinhua reports. The 15 square kilometre zone is intended to be a model of medical reform that will integrate social and foreign investment. Beijing hopes the zone will attract doctors and medical experts from Beijing's top public hospitals as well as draw in international medical institutions to set up shop in a healthcare hub. The aim is to have world-class medical facilities, education institutions, medical research personnel, rehabilitation and nursing homes and health management facilities all in one place.

TCM a leading cause of liver failure

Traditional Chinese Medicine is a major cause of acute liver failure in China, according to a report in PLOS One. In a review of 177 Chinese patients with liver failure, 17% had received herbal remedies, and TCM was believed to be a more frequent cause than any other factor, the Global Times reports. Of all the patients diagnosed with acute liver failure 44% developed the condition due to drug or herbal remedy toxicity, and herbal remedies, accounted for more liver failure than paracetamol.

Diabetes linked to liver cancer: Beijing study

Diabetes is strongly linked with the increased risk of liver cancer, especially in patients with hepatitis B infection, researchers from Peking Union Medical College Hospital have shown.

Their study found a strong association between diabetes and hepatocellular carcinoma regardless of the prevalence of hepatitis B and C infection, cirrhosis, gender, and age. However, there was also a synergistic interaction between diabetes and HBV in cancer occurrence. “Therefore, diabetes patients with HBV infection represent a very high hepatocellular carcinoma risk population and should be considered for hepatocellular carcinoma close surveillance program” the researchers said in PLOS One.

China medical research in the journals

No increase in obesity among rural children

There are no signs of an obesity epidemic among rural Chinese children, a study from has shown

Researchers from the Capital Institute of Paediatrics, Beijing, monitored overweight and obesity rates in more than 280,000 children from eight counties in Jiangsu and Zhejiang between 1998 and 2005. They found that the prevalence of overweight was barely changed from 3.7% in 1998 to 3.9% in 2005 and there was no increase in the 0.5% prevalence of obesity.  An increase in overweight/obesity was more likely in boys than girls, especially among those aged over three years. The study also found that the prevalence of stunting decreased dramatically.

Full study: Public Health

IVF conception for 1% of Chinese babies

About one in a hundred Chinese babies is born to women undergoing IVF or other assisted reproductive technology, Beijing researchers have shown. Dr Yang Xiaokui and co-researchers from the Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital analysed rates of ART among 112,403 deliveries from 14 provinces and 39 hospitals. They found the proportion of infants born as a result of ART in China was about 1.013% in 2011, compared to 4% in developed countries. Their study also found an increased maternal complications such as multiple gestation, higher cesarean section rate, low birth weight infants, higher infant mortality in women who conceived with the help of ART, compared with spontaneously pregnant women.
Full study: Fertility and Sterility

Urgent action needed on liver fluke infections in Heilongjiang

Liver fluke infestations are a common and increasing problem in China’s north east province of Heilonjiang, a study from Harbin Medical University has shown.

The infections, which are caused by eating undercooked fish,  were  seen commonly throughout Heilongjiang Province and mainly along the Songhua River, according to Dr Han Su and colleagues from the university. In a review of 4951 outpatients with suspected liver fluke infections the overall prevalence of clonorchiasis was 26%.  Rates of infection increased from 22.5% in 2009 to 34% in 2012. Farm labourers accounted for two thirds of cases and consumption of freshwater fish was the strongest risk factor. Cases of re-infection were common.

“The present study revealed that clonorchiasis remains widespread and prevalent in Heilongjiang Province. An integrated control programme is urgently needed to reduce the public health impact of clonorchiasis in this endemic area.”

Full study: PLOS One

Benzodiazepine use linked to benign brain tumours

Benzodiazepines may increase the risk of benign brain tumours, according to Taiwanese researchers. In a review of  62,186 patients who had been prescribed benzodiazepines, they found that rates of benign brain tumours were more than three times higher in patients using benzodiazepines. The risk of benign brain tumours was dose dependent and increased over time with increasing exposure to benzodiazepines. There was no increase seen in risk of malignant brain tumours, but this may have been due to the low number of such tumours in the study group.

Full study: Journal ofthe Neurological Sciences

SMS reminders improve allergy medication compliance

For patients with allergic rhinitis, a daily SMS reminder is an effective way to improve adherence with intranasal corticosteroid treatment medication and treatment outcomes, according to researchers from the Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital.

In a study of 50 patients with allergic rhinitis they showed that adherence to medication was 60% in the SMS group and 28% in the control group. Clinic attendance and allergy symptoms scores were also better for patients who received SMS reminders.

Full study: International Archives of Allergy and Immunology

Chinese medical news from the journals

Almost one in three Staphylococcus aureus strains found in humans by Yangzhou researchers were methicillin-resistant S. aureus (MRSA), with most being hospital-acquired MRSA. The superbugs were also found in food and animal samples. Writing in the journal Foodborne Pathogens and Diseases, the researchers say infection with multidrug-resistant MRSA strains acquired from food, animal, and human sources might also become a significant problem for human medicine.

One in four Chinese people with epilepsy has poor adherence to their anti-epilepsy medication and 70% have only moderate compliance, a new study shows. The reasons for nonadherence included forgetfulness (54%), being seizure-free for a period (49%), and fear of adverse drug effects (28%).
Epilepsy and Behavior.

Rotovirus and norovirus are the two most common causative agents for diarrhoea and vomiting in Chinese infants, a study from southeastren China has found. Rotovirus tended to cause more prolonged, frequent and severe illness and the viruses were seasonal, the study published in Pediatrics Infectious Diseases journal showed.

Smoking is a major risk factor for nonalcoholic fatty liver disease, especially in obese people, a Shanghai study has found. People who smoked and had a high BMI had a nine-fold higher risk of nonalcoholic fatty liver disease, their study in the Journal of Epidemiology showed. Passive smoking was also associated with a  25% increased risk of the disease, say researchers from the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine.

China has made progress in the prevention and control of major non-communicable diseases but there are still large action gaps in the fight against epidemic non-communicable diseases according to members of the Subcommittee of the Non-Communicable Diseases, the Expert Committee on Disease Control and Prevention established by China’s Ministry of Health.
Global Health Action.

Chinese people who have a more varied diet and especially a diet rich in fruit have a much reduced risk of bladder cancer, a study in Cancer Causes and Control shows

Type 2 diabetes is associated with the increased risk of  liver cancer within five years after diagnosis in Chinese population, researchers at the State Key Laboratory of Oncogene and Related Genes and the Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiaotong University School of Medicine have shown.  Writing in Annals of Oncology, they say the finding suggests that hyperinsulinaemia rather than hyperglycaemia is more likely to be a primary mediator for this association.