Impact of Multiple Policy Interventions on the Screening and Diagnosis of Drug-Resistant Tuberculosis Patients: Cascade Analysis on 6 Cities from Eastern China
Authors: Ding Xiaoyan , Mao Wenhui , Lu Wei , Yu Hao , Liu Qiao , Lu Peng , Jiang Hui , Zhang Xing , Lu Feng , Xu Jie , Zhong Chongqiao , Hu Jinliu , Jiang Weixi , Guo Lei , Tang Shenglan , Zhu Limei 
Published: October 2020

Abstract
Background The detection of drug resistant tuberculosis (DR-TB) is a major concern in China. China has implemented multiple DR-TB interventions in partnership with development partners and via domestic policy reforms. We aim to summarize the interventions related to the screening and detection of DR-TB in Jiangsu Province, analyse their impact, and highlight policy implications for the prevention and control of DR-TB.Methods We selected six prefectures across Jiangsu Province, a relatively developed area in China with a long history of collaboration with development partners and provincial policy reforms. We collected policy documents between 2008 and 2019, and extracted routine TB patient registration data from the TB Information Management System (TBIMS) between 2013 and 2019. We used the High-quality Health System Framework to guide the analysis. We performed statistical analysis on the percentage of pulmonary TB cases confirmed by bacteriology, percentage of bacteriologically confirmed TB patients tested for drug susceptibility by prefecture and by year. We used logistic regression models on TB cases confirmed by bacteriology and bacteriologically confirmed TB patients tested for drug susceptibility to further assess the impact of different policy interventions. Results Our study found that three prefectures in Jiangsu introduced DR-TB related interventions between 2008 and 2010 in partnership with the Global Fund and the Bill and Melinda Gates Foundation. By 2017, all prefectures in Jiangsu had implemented provincial level DR-TB policies, such as increases in human resources for health, use of rapid molecular tests (RMT), expanded drug susceptibility testing (DST) for populations at risk of DR-TB, and allocation of funds specifically targeting DR-TB. With the use of RMT, the diagnostic process of DR-TB was optimized and the testing time shortened. The percentage of pulmonary TB cases confirmed by bacteriology increased from around 30% to over 50% between 2013 and 2019, indicating that the implementation of new diagnostics, including RMT, have provided more sensitive testing results than the traditional smear microscopy. At the same time, the proportion of bacteriologically confirmed cases tested for drug resistance has increased substantially, indicating that the intervention of expanding the coverage of DST has reached more of the population at risk of DR-TB. Prefectures that implemented interventions with the Global Fund and the Bill and Melinda Gates Foundation had better performance in detecting DR-TB patients. The disparities in detecting DR-TB among prefectures significantly narrowed after the implementation of provincial DR-TB polices. Conclusions The introduction of new diagnostics, including RMT, have improved the detection of DR-TB. Prefectures implementing interventions with the Global Fund and the Gates Foundation had better detection of DR-TB even after the end of the partnership. Additionally, the implementation of provincial DR-TB polices led to improvements in the detection of DR-TB across all regions.