Tuberculosis control programs and challenges in developed cities with intermediate disease burden: China experience

J Thorac Dis 2017;9(5):E525-E528 jtd.amegroups. com Tuberculosis (TB) remains one of the world’s deadliest infectious disease (1). Historically, it not only posed threats in developing countries, but also affected population in the developed world. From a global perspective, more guidance and focus were prioritized in low-income countries and rural areas due to their high TB burdens. Recently, the World Health Organization (WHO) proposed the End TB Strategy targets (90% reduction in TB incidence and 95% reduction in TB deaths by 2035) and the action framework in low-incidence countries (1,2). However, how to strive for TB elimination in urban areas with intermediate disease burden is still not well understood. China had made great efforts and achievements in TB control. The TB notification rates, in most developed cities like Hong Kong Special Administrative Region (Hong Kong) and Shanghai, decreased sharply in last few decades and became stable within the intermediate level. Despite the different organizational health structures and TB control schemes, Hong Kong and Shanghai represent two of the most successful TB control models in China. A comparative viewpoint of context and public health system in TB control would enable us to identify the diverse programs, experiences and challenges. Hopefully it can raise more discussions, provide insights for each other, and also for other cities which will eventually evolve into economically “rich” and endemically “intermediate” ones. Applying a structure-process-outcome model, a conceptual framework is adopted to facil itate the understanding in a comprehensive way (see in Figure 1) (3). From macro context perspective, despite the stable political, better social-economic and population health status in Hong Kong and Shanghai, the large population size (7.2 and 24.2 million in 2013), high density of population and per capita living space, urbanization, increasing number of the elderly (aged 65 years and older, accounted for 14% and 18% in 2013), mobile residents, people living with high-risk factors for TB (such as HIV, diabetes and lung cancer), pose new challenges for the TB control programs (4,5). The overall goal of a TB control program is to reduce TB morbidity and mortality by breaking the chain of transmission. In Shanghai, strategic targets within TB program were formulated and updated every five or ten years. TB is a notifiable disease in Hong Kong since 1939 by Quarantine and Prevention of Disease Ordinance and Occupational Safety and Health Ordinance (6). In Shanghai, TB report is statutory since 1959 in line with the Law on the Prevention and Treatment of Infectious Diseases (7). However, no exclusive TB laws or regulations exist for more strict policy such as compulsory isolation or treatment. Integrated healthcare systems are fundamental for TB control programs in two cities but organized in different ways (6,7). It poses a challenge for Hong Kong which has a mixed public-private provider and financing system. The majority of TB patients are managed in 17 Hong Kong public chest clinics which provide primary ambulatory care. The chest clinics are also responsible for TB surveillance, treatment, defaulter and contact tracing, health education, Bacille Calmette-Guerin (BCG) vaccination and research. Public outpatient clinics and private practitioners can also provide clinical services and/or refer them to chest clinics. In secondary care, TB patients are treated for multi-drug Viewpoint