Multidrug resistant leprosy, Tuberculosis costs; Clinical trial problems; Milk formula mispercetions, Rheumatoid arthritis drug unavailable

Doctors in Shandong have reported China's first cases of multidrug resistant leprosy. Testing 85 samples of the causative bacteria Mycobacterium leprae, doctors found that some were resistant to  standard antibiotic treatments including dapsone, rifampin and ofloxacin.

In theory, tuberculosis treatment is free in China, but in reality patients  still face enormous out-of-pocket costs for treatment, a study from Jiangsu show. In a survey of treatment costs for people in the province, researchers from Nanjing Medical University found that the average cost per patient was as high as 19,000 yuan (US$3000). Even for patients who could claim back medical costs on their health insurance, out of pocket costs were still around 14,000 yuan ($2260) a year for clinic visits, hospital stays, tests and drug therapy.

Clinical trials are difficult to set up and run in China due to a lack of qualified and experienced clinical research staff and poor research infrastructure, an experts says. Dr Wu Yangfeng Wu of the Peking University Clinical Research Institute (PUCRI) said clinical trials required a pool of many hundreds of clinicians who were educated and well versed in basic research techniques - something which China lacked. He told Forbes that China's medical institutions also lacked  basic infrastructure and research management systems to conduct trials. There were also few allowances or rewards for doctors who took part in research, he added.

As many as one in five village doctors have latent tuberculosis, according to a study carried out in the Chinese province of Inner Mongolia. Dr He Guangxue and colleagues at the Chinese Center for Disease Control and Prevention, Beijing, surveyed 880 village doctors and found that 19.5% had positive tuberculin skin reactions. Latent tuberculosis risk was highest in doctors who had been in practice for a long time and for doctors who had more exposure to patients, they showed in PLOS One.

About 90% of Chinese mothers opt for milk formula within a month of giving birth, often driven by misguided beliefs and fears, a study from Sichuan has found. In a survey of 695 new mothers, 88% had initiated formula within 4 weeks of giving birth, often believing that babies slept better after fed with formula, and many believing they had insufficient breastmilk.

One of the best drug treatments for rheumatoid arthritis is out of reach for many Chinese patients because of cost, rheumatologists say. Chinese clinical experience with tocilizumab (Actemra) showed that it was highly effective and safe.  However, the high cost of the drug limits its prescribing in China, according to Dr Wang Geng of the Department of Rheumatology and Immunology, Changzheng Hospital, The Second Military Medical University, Shanghai.

Rural doctors in China; Free cancer screening; New TB vaccine; Do doctors have good cardiac skills?

by MICHAEL WOODHEAD

In a sign of the increasing concern about the demise of rural healthcare, China's 1.4 million rural doctors have now been given their own professional organisation.
Although it's not quite a trade union, the Chinese Medical Association has established a rural doctors section that will represent the interests of the many village doctors. The move is in response to the ageing of the semi-skilled workforce, most of whom lack medical degrees and have only high school education and a short training course on healthcare provision. According to the CMA, the new Rural Doctors Association "will assist the government to strengthen and promote rural doctor team building for the survival and development of rural medicine and safeguard the legitimate rights and interests of rural doctors."
Earlier this year Premier Li Keqiang acknowledged that it was important to retain doctors in rural areas, because their primary care role was "more effective than building a large hospital." The State Council acknowledged that rural doctors were the cornerstone of primary healthcare for hundreds of millions of rural residents.
However, most rural doctors are approaching retirement and younger people do not want to work in remote 'backward' areas in a role that is poorly paid and has few career prospects. Rural doctors by decree are paid the same salary as rural teachers - which is a pittance.Their miniscule pensions are an even greater cause for complaint.

Free screening programs for breast cancer and cervical cancer are to be developed nationally in China, according to the National Health and Family Planning Commission. The ministry said 48 million women in rural China had already received cancer screening interventions since 2009,  and there were now plans to increase promotion of screening services, co-ordinated by the All-China Women's Federation.

Despite studying medicine for seven years, China's junior doctors are unable to manage the basics of dealing with a heart attack, a study shows. A survey of 362 new medical graduates found they had little knowledge about basic cardiac diagnosis and resuscitation. Only about 50% of the doctors were able to identify common normal and abnormal ECG changes such as ventricular fibrillation. Likewise only half knew the basics of which drugs should be given for such conditions. The findings showed that many medical graduates were unprepared to manage the most common cardiac emergencies said researcher Dr Xi Huijun and colleagues from the Changhai Hospital, Shanghai.

China is leading the world in developing a new TB vaccine to replace the largely ineffective BCG vaccine against tuberculosis. At a TB vaccine conference held in Shanghai, researchers heard that a vaccine called Vaccae developed by an Anhui pharmaceutical company is in Phase 3 trials, whereas other candidate vaccines from other countries are only in the preliminary stages. Researchers said the vaccine would probably of most use in the elderly, who are expected to account for more than half of tuberculosis cases in the future.

In China's hospitals, one in three doctors have latent tuberculosis infection

by Michael Woodhead
It's an avoidable occupational hazard that Chinese doctors could well do without: tuberculosis. 

A  study carried out in a general hospital in Henan has found that one in three healthcare staff have latent tuberculosis infection. The figures are even worse for a nearby infectious diseases hospital where almost 60% of doctors had latent tuberculosis infection.

First some clarification: as the CDC points out:

Persons with latent TB infection do not feel sick and do not have any symptoms. They are
infected with M. tuberculosis, but do not have TB disease. The only sign of TB infection is a
positive reaction to the tuberculin skin test or TB blood test. Persons with latent TB infection
are not infectious and cannot spread TB infection to others. Overall, without treatment, about 5 to 10% of infected persons will develop TB disease at some time in their lives.

So, people with latent TB do not pose a serious risk to patients, but they themselves face a high risk of developing active tuberculosis disease.

In the study of 712 healthcare workers at a 1600-bed general hospital and a 600-bed infectious diseases hospital in Zhengzhou, researchers found that the tuberculin skin test-positive prevalence was 34% in the general hospital and 58% in the infectious disease hospital.

Dr Zhou Feng and colleagues who did the study said that health staff faced high risks of tuberculosis if they worked with infected people, such as those with HIV who often have co-infection with tuberculosis. Rates of infection were also highest in staff with longer years of working in the hospitals, presumably due to greater duration of exposure to risk.

Writing in PLOS One they said many staff did not use personal protective equipment such as  face masks and N95 respirators when working with infectious patients, despite this being recommended in guidelines.

Another problem with detecting and treating tuberculosis in healthcare workers was the low rate of tuberculin skin testing for the infection: many healthcare workers refused testing, and the most effective testing kits were too expensive for many Chinese hospitals. The findings also highlighted the limitations of the regular chest X-rays used to screen workers for active tuberculosis disease.

As the authors conclude - more emphasis is needed on observing and adhering to basic infection control and prevention practices in Chinese hospitals:

"Comprehensive guidelines should be developed for different types of medical institutions to reduce tuberculosis transmission and ensure the health of healthcare workers," they suggest.

Tuberculosis in China - the good news and the bad news

by Michael Woodhead
China has succeeded in more than halving its tuberculosis prevalence with a major campaign launched in the 1990s, according to a new report from the Chinese Ministry of Health.
The campaign produced dramatic reductions in tuberculosis because it shifted treatment out of hospitals and into the community via public health centre TB dispensaries, according to an article published in The Lancet this week.
The report assesses the impact of China's tuberculosis control program based on the directly observed treatment, short-course [DOTS] strategy which was scaled up to cover half the population during the 1990s, and to the entire population after 2000.
Between 1990 and 2009 the prevalence of tuberculosis fell from 170 cases to 59 cases per 100 000 population. The decreases were attributable to the program because declines were only seen in areas where it was operating in the 1990s. The reduction in tuberculosis was greater after 2000 than the 90s (57% vs 19%), with 70% of the total reduction in tuberculosis seen in the last decade.
The proportion treated by the public health system using the DOTS strategy increased from 15% of cases in 2000 to 66% of cases in 2010.
The health ministry said China had shown that it was possible to achieve ambitious targets in reducing tuberculosis, which had not been achieved in other developing countries. However, despite this success, China still had an estimated 1 million new tuberculosis cases in 2010.
China now faces the problems of a widening urban-rural gap in tuberculosis prevalence and tuberculosis not being picked up in hospitals. Also, further reductions in tuberculosis prevalence are likely to be less impressive because the DOTS program is more effective in reducing the prevalence of tuberculosis in known cases than in new cases, and the number of known cases is now low.
Therefore other control efforts in addition to the DOTS strategy need to be implemented, the report authors say.
Another problem is that the cost of treating tuberculosis is becoming prohibitively expensive for patients due to hospital profiteering, according to another report released this week. The study by Chinese and international researchers found that many patients are being treated at hospitals with second-line drugs when they should have been treated with first-line drugs in community TB dispensaries. The reason for this seems to be because hospitals want to retain patients to make more profits, the researchers surmised.
The study also found that patients faced crippling costs for treatment despite China's supposedly free TB treatment policy and despite most patients being covered by medical insurance. Insurance coverage for outpatient care generally reimbursed only a small percentage of fees and the free TB treatment policy does not cover costs on auxiliary examinations, drugs and hospitalisation, the report notes.
"A large proportion of patients borrowed money for TB care, and incurred catastrophic expenditure due to TB care," the researchers said.

Tuberculosis in China often resistant to most drugs: researchers sound the alarm

by Michael Woodhead
The emergence of strains of tuberculosis that show multiple resistance to almost all available anti-TB drugs is causing great concern among Chinese clinicians.
A  study of more than 200 patients with tuberculosis in Harbin has found that one in four patients had tuberculosis that was resistant to at least one drug, and more than one in twenty had extensively drug resistant tuberculosis (XDR-TB) that was untreatable by commonly used anti-TB drugs such as isoniazid, rifampin, ethambutol, streptomycin, ofloxacin, and kanamycin.
Dr Yang Ying and colleagues from Harbin University of Science and Technology found that 26.3% of tuberculosis patients had isolates that showed resistance to at least one drug, while multidrug-resistant TB (MDR-TB) was seen in 6.8%of patients (3% of newly diagnosed patients and 22% of previously treated cases).
"The results of this analysis of drug resistance in Mycobacterium tuberculosis reflect the situation in a local hospital and indicate that the morbidity related to TB, especially MDR-TB, is still a serious health problem. Thus, the timely detection of drug resistance is of great importance to optimize treatment and to direct infection control measures to block the transmission of MDR-TB."
The results are published in the International Journal of Infectious Diseases.

My top10 medical stories from China for Saturday 22 February

1. Smoking with a water pipe confers a 'profound' risk of chronic obstructive pulmonary disease (COPD) among people in south west China and also carries a high risk from passive smoking, researchers have shown.

2. Patients with pneumonia of unexplained origin should be promptly investigated for H7N9 risk factors such as exposure to poultry and they should also be given pre-emptive antiviral treatment such as Tamiflu, the Beijing health department has ordered.

3. About 85% of Chinese doctors experience burnout, with those who are younger, unmarried and working in emergcncy medicine having the highest risk of serious burnout, a study shows.

4. Fertility clinics in China need to become more patient-friendly as they are perceived as too impersonal and lacking in transparency and respect for patient informed consent, researchers say.

5. The stigma of mental illness in Chinese culture means that patients with schizophrenia often do not understand their medication and are unwilling to take any anti-psychotic medication, according to a study from the Guangzhou Psychiatric Hospital.

6. H. Pylori infection rates are over 90% among people in their thirties in Jiangsu, which may explain high rates of gastric cancer in the region, say researchers from Nanjing.

7. Babies in Shenyang have increased rates of neurodevelopmental deficits because their mothers were exposed to high levels of organophosphorous pesticides during pregnancy, according to a study in PLOS One.

8. Adenovirus has emerged as a significant cause of serious pneumonia in China, with a study showing that 5% of cases are attributable to the virus.

9.  People with tuberculosis are also at high risk of HIV, with rates of around 3% in groups tested in TB patients from Guangxi, Henan and Sichuan, say Chinese researchers.

10. A mediation service for patients involved in medical disputes with hospitals is to be launched in Shanghai and it will be open to patients where compensation claims exceed 30,000 yuan ($2900) regardless of whether the hospital refers them.

Pollution decreases Chinese men's sperm | H5N1 virus carried by wild birds | Adenovirus threat to PLA | Tuberculosis control failing

Pollution reduces Chinese men's fertility
The high levels of pollution found in Chinese cities are reducing the quality of men's semen, a study form Chongqing has shown. Researchers from the the Institute of Toxicology, College of Preventive Medicine, Third Military Medical University, Chongqing measured air pollution levels in Chongqing and in surrounding rural areas. They found an inverse correlation between measures of pollution such as PM10, SO2 and NO2 and semen quality. Published in the journal Environmental Pollution, their findings show that the highest sperm concentrations were seen in rural areas, whereas the lowest were seen in downtown areas of Chongqing. Conversely, the highlest levels of pollution were seen in urban areas, peaking in winter months.
"Exposure to higher concentrations of PM10, SO2, and NO2 in urban ambient air may account for worse semen quality in urban males," the researchers concluded.

Migratory birds carry pathogenic influenza virus
Wild birds migrating through Yunnan have been found to carry the highly pathogenic influenza H5N1 virus. A sampling of birds trapped by researchers found that the average carriage rate of H5N1 was 5%, but in some species such as cuckoos the rates were as high as 22%. The researchers said the birds could be possible vectors of influenza, especially if they shared ponds and drinking water with domestic birds. The findings are published in the Virology Journal.

Tuberculosis control failing because of migrant workers and the elderly
Doctors in rural Jiangsu say tuberculosis control is a problem because of difficulty in diagnosing and treating the disease in migrant workers and the elderly. These two groups were repeatedly documented as the main obstacles in effective tuberculosis control by doctors in a rural county near Suzhou. When interviewed by researchers, doctors also expressed their frustration with the lack of new drugs for treating tuberculosis patients. They said elderly patients were less health conscious and more prone to side effects, so doctors had to put extra effort into convincing elderly patients to adhere to TB treatment. Migrant workers were another probelm for TB control because they were often poorly educated, had little awareness of TB and had difficulty completing long term treatment because of their transient lifestyle. Difficulties also arose because migrant workers were poor and not covered by local health insurance schemes to pay for medical treatment and drugs for TB.
"Migrant workers coming from rural parts of China present a gloomy prospect for TB control in China," the researcher from the School of Public Health, Nanjing Medical University said in PLOS One.

Respiratory virus threat to PLA
Clinicians in Sichuan have reported that a novel adenovirus is posing a serious threat to the health of China's military. The human adenovirus 55 (HAdV-55) has caused outbreaks of sever acute respiratory disease among adults and seems to be common in military trainee institutions. In an analysis of the virus found in samples from almost 200 young Chinese infected in recent years they found that it often caused severe pneumonia. They charactrised the makeup of the virus and warned that it posed a threat, but more research was needed to understand its diversity, dissemination, and transmission in China.

China medical news headlines for Wednesday 29th January

Tuberculosis rates fall by 80%
Rates of tuberculosis in Shandong have fallen by 80% in the last decade, a study of 55,000 adults has shown.The prevalence rate of bacteriologically confirmed TB ases was 34 per 100,000 for adults in 2010. However, diagnosis of TB is now more difficult as half of bacteriologically confirmed cases did not present persistent cough, researchers said in BMC Infectious Diseases.

Man arrested for spreading H7N9 rumours
China's internet is full of stories of doctors and medical staff who have died of H7N9 influenza. Social networks such as Sina Weibo, QQ and WeChat have stories circulated by netizens of deaths of medical staff in Shanghai, Tianjing, Shenzhen and Nantong, according to CRI. However, health authorities have branded the stories as rumours and have arrested one man for spreading false information. In one case, a doctor who was named as having died of H7N9 influenza has startled patients by being on duty at hospital.

Shanghai life expectancy is 82
Life expectancy in Shangahi is 82 and a half years old, the Shanghai Health and Family Planning Commission has said. Women have a life expectancy four and a half years longer than, a report in ECMS said. LIfe expectancy in the city is on a par with developed countries but infant mortality including migrant families, rose from 5.04 per 1,000 in 2013 to 5.73 per 1,000.

High alert as H7N9 cases increase
China has gone on to high alert for H7N9 influenza as the number of cases continues to increase. Bird markets have been shut down in Shanghai and quarantine authorities have stepped up monitoring at airports. However, health authorities have played down the risk of a pandemic, saying the infection is not spread by human-to-human transmission. A vaccine against the H7N9 virus is being developed but is not ready for use in humans yet, authorities have reported.

China's can't cope with dementia
People in China are ill prepared to cope with the huge number of elderly people with dementia and Alzheimers disease, according to an article in SCMP. China has almost six million patients with Alzheimer's, 50% higher than a decade ago and twice as many as earlier estimated by the international health community. However, caring for dementia sufferers in China is left to family members with limited or no training and no support from the state.

Red Cross resuscitation ads are wrong
An advertising campaign by the Red Cross that urges Chinese to help those who have collapsed and need resuscitation is technically inaccurate, according to emergency specialists The picture on the ad shows a woman pressing the soft tissue of the patient's neck, which will lead to obstruction of the airway. First-aid practitioners should place their index finger and middle finger on the patient's chin bone, a doctor has pointed out.

Beijing TB more common but has milder symptoms

A study of TB genotypes in China has found that about two thirds are caused by the 'Beijing' genotype.
The Beijing genotype was more common in younger people and in those living in urban areas, while people of Uyghur and Zhuang ethnicity were less likely to have the Beijing infection. A high rate of chest symptoms such as haemoptysis was seen in the one third of patients with the non-Beijing genotype.
Source: BMC Infectious Diseases.

Multiple drug resistant TB spreads in China

One in four cases of recurrent TB in China are drug resistant

Those fighting tuberculosis (TB) say it is better not to treat the disease than to treat it badly, because doing so just produces more powerful, drug-resistant bacteria, making the world's second-most fatal disease stronger by the day.
The mainland has more cases of multiple-drug-resistant TB (MDR TB) than any other country, with 120,000 new cases each year. Poor case management and a lack of new drugs makes the fight against the disease extremely difficult.
Dr Zhao Yanlin, director of the National TB Reference Laboratory, has said that the mainland has a "serious epidemic" of drug-resistant TB, but the situation "could easily be much worse".
Also deputy director of the National Centre for Tuberculosis Control and Prevention at the Chinese Centre for Disease Control and Prevention (CDC), Zhao contributed to a paper published in The New England Journal of Medicine in June about a mainland-wide survey of drug resistant TB.
The survey found that 5.7 per cent of new TB cases and a quarter of previously treated cases were multiple-drug resistant.
Drug-resistant TB emerges when patients fail to follow treatment regimens, which takes six to eight months and use a cocktail of drugs, or stop treatment too soon.
Some patients stop taking medicine after one or two months of treatment, when the coughing stops and the symptoms are gone, but the bacteria are not eliminated and the symptoms will come back. When the TB bacteria is not fully eliminated, it can mutate, re-emerging later as a strain resistant to the small range of drugs able to fight the disease. Other people can then be infected with MDR TB.
Wang Weibing, an associate professor in the school of public health at Shanghai's Fudan University, said the improper treatment of TB patients played a large part in the prevalence of MDR TB but that patients were not the only ones to blame.
"We can't always blame patients who do not follow the treatment regime," he said. "They should not be held entirely responsible, because of the side effects, such as nausea. We need to invent a much shorter or better treatment regime."
In the mainland-wide survey, more than 40 per cent of patients with MDR TB who had previously had treatment for TB had not completed their last treatment course.
The paper said a quarter of TB patients treated in the public health system received inadequate treatment because they had MDR TB but were still given first-line TB drugs as part of standard treatment.
"Addressing MDR TB in China will require selection of treatment regimens on the basis of testing for initial drug resistance," the paper said. "It is also important to improve treatment in TB hospitals and enhance the continuity of treatment after patients leave the hospitals."
Mainland TB patients receive treatment at either local disease control and prevention centres or designated TB-treatment hospitals. Hospitals provide limited outpatient follow-up, while the CDC system does a better job because it is responsible for monitoring patients with TB in the community.
Patients being treated at local TB clinics should be tested for drug resistance before the start of treatment, with treatment options based on the results, but such tests are not routinely performed at TB hospitals. Furthermore, 11 per cent of patients with new cases of TB in the survey reported that they had been given TB drugs in the past, even though they had never been diagnosed with TB. The paper said such patients had a higher risk of developing MDR TB.
Professor Xu Biao, director of Fudan's TB Research Centre, said county-level hospitals were not following national guidelines when treating TB patients, resulting in increased drug resistance.
"The use of second-line anti-TB medicines was found in newly diagnosed TB patients without bacteriological confirmation and the prescription of the second-line medicines mainly depended on the treatment history of the patients rather than the patients' drug resistance profiles," she said.
"It may have to do with poor TB training or simply wanting to see a quick improvement, but the side effect is that it leads to a high rate of drug resistance or even extensive drug resistance."
A former CDC official said the mainland's treatment protocol was only strictly followed in 41 cities involved in a co-operative project managed by the Global Fund to Fight Aids, Tuberculosis and Malaria and mainland health authorities. According to a Ministry of Health treatment guideline, each patient should receive individual diagnosis, treatment and case management, but she said a lack of funding and shortage of staff meant it was followed poorly in other areas.
"We need really professional doctors with extensive experience in treating TB, but only provincial-level hospitals can guarantee that," she said.
All these problems point to the importance of quick diagnosis tools, more effective drugs and a shorter treatment regimen.
TB is mostly diagnosed through a combination of X-rays, liquid culture, microscopic examination and the TB sensitivity skin test, but these methods have flaws in terms of sensitivity, specificity and speed.
In 2010, the World Health Organisation recommended the use of GeneXpert, a tool that can detect TB and drug resistance in less than two hours.
Even though the Swiss NGO Foundation for Innovative New Diagnostics has negotiated a concessional price of US$17,000 for the equipment and a fee of US$10 per test, the savings were not yet apparent on the mainland.
"So far no government agency has taken the lead in negotiating the concessional price," said Huan Shitong, senior programme officer with the Bill & Melinda Gates Foundation's Beijing office.
The foundation invited bids from more than 100 companies in September to develop and produce a similar but cheaper version of GeneXpert in China.
Source: SCMP

Tuberculosis still deadly for Chinese infants

Extra-pulmonary TB is more severe and life threatening, especially in infants

by Michael Woodhead
A study of the impact of childhood tuberculosis (TB) in China has found it is most severe in young infants, many of whom still die from the infection.
Researchers assessed the outcomes of children with TB treated at one of China's main referral centres for paediatric tuberculosis, the Beijing Children's Hospital.
The review of the cases of 1212 children admitted to the hospital for the treatment of TB from 2002 to 2010. found that 54%  had extrapulmonary tuberculosis (EPTB), 39% had tuberculous meningitis, and 31% had disseminated TB. The last two types were defined as severe TB. Most patients with TB (82%) were cured or completed treatment.
However, there were more children aged under five and from rural areas with extrapulmonary tuberculosis than with pulmonary tuberculosis. More severe cases of TB were found in children under one year of age, and infants and those with severe TB were also more likely to have poor treatment outcomes (failed to improve or died).Patients with no BCG vaccination and a contact history at home had a significantly risk of contracting severe TB.
 Among those with extrapulmonary tuberculosis, only 61% had positive results with either tuberculin skin tests or chest X-rays.
The researchers conclude that "patients with no BCG vaccination and contact history at home might have a higher risk of contracting severe TB. Thus, prevention
and health care in paediatric TB should focus on both extrapulmonary tuberculosis  and severe TB, and patients aged under one year of age should be treated with special care."
Read more: Pediatrics