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E047023.Draft-Revisions.Pdf BMJ Open: first published as 10.1136/bmjopen-2020-047023 on 12 April 2021. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 29, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-047023 on 12 April 2021. Downloaded from Policy changes and the screening, diagnosis and treatment of DRTB patients from 2015-2018 in Zhejiang Province, China: a cascade analysis ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-047023 Article Type: Original research Date Submitted by the 18-Nov-2020 Author: Complete List of Authors: Jiang, Weixi; Duke Kunshan University, Global Health Research Center Peng, Ying; Zhejiang Provincial Center for Disease Control and Prevention Wang, Xiaomeng; Zhejiang Provincial Center for Disease Control and Prevention Elbers, Chris; Vrije Universiteit Amsterdam Tang, Shenglan; Duke University, Duke Global Health Institute Huang, Fei; Centers for Disease Control China, National Center for Tuberculosis Control and Prevention Chen, Bin; Zhejiang Provincial Center for Disease Control and Prevention Cobelens, Frank ; AIGHD, Amsterdam Institute for Global Health and Development and Department of Global Health http://bmjopen.bmj.com/ Tuberculosis < INFECTIOUS DISEASES, Health policy < HEALTH Keywords: SERVICES ADMINISTRATION & MANAGEMENT, HEALTH SERVICES ADMINISTRATION & MANAGEMENT on September 29, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 32 BMJ Open 1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2020-047023 on 12 April 2021. 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Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 32 1 2 3 Policy changes and the screening, diagnosis and treatment of DRTB patients from 2015-2018 4 BMJ Open: first published as 10.1136/bmjopen-2020-047023 on 12 April 2021. Downloaded from 5 in Zhejiang Province, China: a cascade analysis 6 7 Corresponding author: 8 Bin Chen 9 10 Postal address: Zhejiang Provincial Center for Disease Control and Prevention, No. 3399 Binsheng 11 Road, Binjiang District, Hangzhou, China 12 Email: [email protected] 13 14 15 List of authors: 16 Weixi Jiang 17 18 Global Health ResearchFor Center, peer Duke Kunshan review University, Kunshan, only Jiangsu, China 19 Email: [email protected] 20 21 22 Ying Peng 23 24 Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China 25 Email: [email protected] 26 27 28 Xiaomeng Wang 29 Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China 30 Email: [email protected] 31 32 33 Chris Elbers 34 Faculty of Economics and Business Administration, Vrije Universiteit Amsterdam, Amsterdam, the 35 36 Netherlands http://bmjopen.bmj.com/ 37 Email: [email protected] 38 39 40 Shenglan Tang 41 42 Duke Global Health Institute, Duke University, Durham, NC, US 43 Email: [email protected] 44 on September 29, 2021 by guest. Protected copyright. 45 46 Fei Huang 47 48 National Center for Tuberculosis Control and Prevention, China CDC, Beijing, China 49 Email: [email protected] 50 51 52 Bin Chen 53 Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China 54 55 Email: [email protected] 56 57 Frank Cobelens 58 59 The Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 32 BMJ Open 1 2 3 Email: [email protected] 4 BMJ Open: first published as 10.1136/bmjopen-2020-047023 on 12 April 2021. Downloaded from 5 6 Word count: 3781 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 29, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 32 1 2 3 ABSTRACT 4 BMJ Open: first published as 10.1136/bmjopen-2020-047023 on 12 April 2021. Downloaded from 5 6 Introduction 7 Drug-resistant Tuberculosis (DRTB) has become a serious concern globally and in China. Several 8 policies have been issued to improve DRTB case finding and treatment. We conducted a cascade 9 10 analysis on DRTB case finding and care in Zhejiang during 2015-2018 and explored the impacts of 11 these policies. 12 Methods 13 14 A questionnaire was designed to undertake a survey of all prefecture-level CDCs in Zhejiang on 15 DRTB-replated policies/programs active or introduced during 2015-2018. De-identified registration 16 data of presumptive and diagnosed DRTB patients from 2015-2018 in Zhejiang were used to 17 18 construct a seven-stepFor cascade peer of case finding review and care. Mixed-effect only two-level logistic regressions 19 were conducted to explore factors associated with patient registration, treatment initiation and 20 treatment completion. The DRTB policies active per prefecture per year were categorized according 21 to the combinations of policies on each step of the cascade, and included in the model to explore 22 23 their impacts. 24 Results 25 The number of reported presumptive DRTB patients and the percentage with drug susceptibility 26 27 testing (DST) records largely increased during 2015-2018, and the percentage of registered patients 28 that received anti-DRTB treatment also increased from 59.0% to 86.5%. Patients under the policies 29 of equipping GeneXpert plus expanded criteria for DST had a higher likelihood of being registered 30 31 compared with no GeneXpert (adjusted odds ratio, aOR=2.57), while for treatment initiation the 32 association was only when further expanding the registration criteria (aOR=2.38). Patients with 33 registered residence inside Zhejiang were more likely to be registered (aOR=1.96), treated 34 (aOR=3.83) and complete treatment (aOR=1.92) compared with those outside. 35 36 Conclusion http://bmjopen.bmj.com/ 37 The policy changes on DST and registration have effectively improved DRTB case finding and care. 38 Nevertheless, challenges remain in servicing the vulnerable group like the migrants and improving 39 40 equity in the access to TB care. Future policies should provide comprehensive support for migrants 41 to complete treatment at their current place of residence.
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