Status of tuberculosis in Korea
Korea had been suffered from TB that mortality rate of TB was estimated to 71.7 per 100,000 in 1942 and such mortality rate reached roughly 5-fold higher than that of 1942 in 1954, 350 per 100,000, when the Korean war was over (13, 21). In 1954, total prevalence of TB was estimated as 1.3 million over 20 million in Korea (21, 22). Since of 1962, Korea actively engaged in TB control program, resulted significant decreases in TB prevalence rate to 59.0 per 100,000 in 2019 (6, 23) (Figure 1). Despite significant declining of TB prevalence, Korea still shows the higher TB mortality rate than that of Organization for Economic Co-operation and Development (OECD), 4.0 versus 0.9 per 100,000 (6, 21).
Along with high prevalence of tuberculosis, Multi-Drug Resistant Tuberculosis (MDR-TB) rate of Korea of 4.1% is slightly higher than that of OECD average, 2.6% (21, 24). The MDR-TB, as its unique feature, requires second-line antitubercular drugs along with prolonged treatment. It is widely known that second-line drugs are relatively less effective to that of first-line drugs, MDR-TB treatment often involves side effects and medical complications hence is major public health concern (25, 26). With effort to eliminate MDR-TB, cases of MDR-TB are decreased from 975 in 2011 to 580 cases in 2019. Similarly, XDR-TB cases was decreased from 140 to 33 cases from 2011 to 2019 (Figure 1). However, proportion of MDR-TB among foreigners was increased to 20.5% from 4.5% when 2019 was compared to 2011, indicating an influx of tuberculosis cases from abroad (23).
Latent Tuberculosis Infection (LTBI) is a state of M. tb infection without any clinical manifestation and/or symptoms of active TB (27, 28). Roughly one-thirds of global populations are estimated to be infected with LTBI globally according to WHO (29). Each individual infected with LTBI often unaware of the condition and among these individuals, roughly 5 to 15% of LTBI cases progress to active TB (30). This LTBI emerges as one of the most important sources of TB (31). In case of Korea back in 1960, the LTBI rate was estimated to be 64.2% when tuberculin skin test carried out. Such LTBI rate estimate is decreasing rapidly as it can be seen through periodic analysis that in 2016, LTBI rate was estimated to be 33.2% that is similar to that of global average (23, 32, 33).
Strategies in Korea
TB still remains as a serious public health challenge in Korea (21). To overcome prevalent TB, Korea have employed several strategies and legislated laws to take action against TB for control and prevention purposes. Several acts such as the infectious disease control and prevention act in 1957 and the tuberculosis prevention act in 1968 were legislated to effectively control TB, specifying for the formulation and implementation of a comprehensive tuberculosis control plan for TB research, education, and training (20, 34).
One of the main strategies to TB elimination is Public-Private Mix (PPM) project, which was initiated in 2009 (35, 36). The objective of PPM project is to disseminate technical knowledge regarding TB to private hospitals by assigning trained TB management-specialized nurses for improvement in TB treatment success rate. As part of PPM project, registered nurses should be trained first in prior to be assigned as TB management-specialized nurses through TB management-specialized nurses training courses, provided by collaboration of KDCA, KNA and KNTA (36-38). Then these nurses are assigned in each hospital and are responsible for compliance management and TB prevention education provision (21, 35). As of 2019, 258 TB management-specialized nurses have been assigned in 150 private hospitals. These assignment of TB management-specialized nurses have increased national average of TB treatment success rate from 79.8% to 90.5% from 2012 to 2018 (39, 40).
Korea Disease Control and Prevention Agency
In 2003, the Korea Centers for Disease Control and Prevention (KCDC) was established to promote public hygiene and conduct prevention, investigation, quarantine, testing, and research on infectious diseases and chronic diseases (41, 42). In 2020, the KCDC was reformed and elevated to KDCA, which allows KDCA to stand as independent infectious disease control tower(43).
The one of the main roles of KDCA is TB control and prevention. The KDCA conducts activities related to TB control and prevention at national, provincial, and local levels such as TB surveillance, promoting TB training and prevention education. Hence, the KDCA closely engaged with city and provincial department of public hygiene to promote TB training to officers in public health centers (36). The KNTA is commissioned by KDCA or projects to conduct trainings on medical doctors and nurses, and related officers from public and private hospitals. The first TB trainings for Healthcare Workers were conducted in 1954; since 2000, the TB training and education programs broaden its coverage such as BCG vaccine, TB-vulnerable social groups, and LTBI (36, 44, 45). Other than the training mentioned above, other training consists of TB management exclusively for public health doctors, including conscripted medical doctors, military medical officers, and medical doctors from public health centers, hospitals, and correctional facilities. This training program handles policy related to national tuberculosis program, treatment and diagnosis for TB, resistant TB, and LTBI as well as TB epidemiological investigation (44). The Korea Institute of Tuberculosis, a sub-affiliate of KNTA, is in charge of conducting technical support and related training for TB medical technicians as commissioned by KDCA and Ministry of Health and Welfare (MoHW) since 1954 (44, 46).
Even before KDCA was elevated, the KCDC was in charge for production and dissemination of publications related to TB. Since 2011, the KDCA are publishing Korean Guidelines for TB and National TB Control Guideline periodically. The national tuberculosis control guideline comprises of international and national TB status, national tuberculosis program, TB notification process, treatment and management and its related epidemiology for TB, MDR-TB, and LTBI patients as well as TB diagnostics. This guideline conveys up-to-date information related to TB to maximize performance in TB control and prevention (36). Also, training and educational materials such as laboratory manuals and others have been published (Table 1).
Table 1. Publications related to TB by KDCA from 2011 to 2020
No.
|
Guidelines and Manuals
|
Co-publishing institute*
|
Year of publication
|
1
|
Korean Guidelines for Tuberculosis (1st – 4th Ed)
|
1
|
2011 – 2020
|
2
|
National Tuberculosis Control Guideline (1st – 16th Ed)
|
N/A
|
2003 – 2021
|
3
|
Tuberculosis “Close Contact Investigation on Crowded Facility” Major Casebook (1st – 5th Ed)
|
2
|
2014 – 2019
|
4
|
Tuberculosis Control Guide for Medical Institutes
|
N/A
|
2016
|
5
|
Manual of Laboratory Tests for Tuberculosis (1st, 2nd Ed)
|
4, 5
|
2013 – 2016
|
6
|
Tuberculin Skin Test Guidebook for examiners
|
3
|
2019
|
7
|
Family-contact Examination participating Medical Institutes. Training material for Physicians
|
6
|
2019
|
8
|
Basic Training for Tuberculosis management-specialized nurses
|
6
|
2019
|
*1. The Korean Academy of Tuberculosis and Respiratory diseases; 2. Ministry of Health and Welfare; 3. Korea Institute of Tuberculosis; 4. Korea National Institute of Health; 5. The Korean Society of Clinical Microbiology; 6. Korean National Tuberculosis Association
Korea Human Resource Development Institute of Health and Welfare
KOHI is an institution specialized in public health education and training to build and increase related officers’ specialties and capabilities to successfully convey public health practices. The KOHI initially initiated its role, public health education and training in particular, as public health education division of National health center in 1946 and though centuries and numbers of reorganizations, KOHI was established in 2007 as quasi-governmental institution. Since its establishments, numbers of education and training programs were organized and conducted where categories of programs vary from general capability building education to public health and public health industry training (47).
Since even before establishment of KOHI, Public health training department of Korea National Institute of Health, precursor of KOHI, carried out public health trainings as commissioned by MoHW (47). The KOHI is also known to provide TB-specialized trainings and other related programs periodically (Table 2). As time passes from 2018, the training programs became more specified.
As of 2020, there are 3 representative TB-centered training programs provided by KOHI and these are TB diagnosis and interpretation, TB control, and advance TB control. 1) The TB diagnosis and interpretation program is offered to officers from public health centers and Public Health and Environmental Research Institutes, governmental institutes for infectious disease analysis and research as well as environmental and public health promotion and investigation, to increase basic acid-fast bacilli smear staining techniques as well as TB diagnosis techniques ; 2) In case of TB control program, this is prone to practical-oriented as these primarily focus on LTBI treatment principles, case study based on TB patient treatment, close contact investigation and epidemiology, and TB control status analysis. Also, this program recommends related programs such as advanced TB control program and getting to know tuberculosis series after completion as part of advanced TB control and treatment as well as continuing education; 3) For advanced TB control program, this program is intended for those who completed TB control program hence covers wider aspects of TB control such as establishment of TB prevention promotion strategies, figuring out of current status on local TB management as well as case study(47, 48). Upon completion of this program, the participants are expected to implement appropriate TB control and prevention strategies based on regional or local TB conditions. Also, understanding and designing TB-related promotional materials is one of the main capabilities that participants gain as go through the program (47).
TB is handled in other programs as well such as nosocomial infection control for medical doctors and infectious disease risk response program. These programs covers TB infection control in practice and TB containing sputum packaging while getting to know TB programs are introductory TB series that is generally intended for public hence consist of brief introduction, treatment, and prevention of TB and LTBI (47, 49).
Table 2. TB prevention education program provided by KOHI in 2020
No.
|
Participants*
|
Training program
|
Description
|
Hours
|
1
|
Medical doctors
|
Nosocomial infection control for medical doctors
|
- National nosocomial infection surveillance system
- National policy related to nosocomial infection
- Infection control practice such as TB and Carbapenem-Resistant Enterobacteriaceae
- Infection control statistics
and analysis
|
16
|
2
|
Public officers1,2
|
Tuberculosis diagnosis and
interpretation
|
- M. tuberculosis
characteristics and genotyping
- TB diagnosis and treatment
- TB-related biosafety
|
21
|
3
|
Public officers3,4
|
Tuberculosis control
|
- National policy related to TB control and prevention
- LTBI diagnosis and treatment management
- TB prevention promotion
- TB epidemiological investigation on crowded facilities
|
21
|
4
|
Public officers1,5,6
|
Infectious disease risk response simulation
|
- Sputum collection and clinical TB sample packaging
|
3
|
5
|
Public
|
Getting to know tuberculosis series
|
- Introduction to TB and LTBI
-TB prevention, control,
treatment and management of antitubercular drug side effects
- TB notification and case study
|
3
|
6
|
Tuberculosis control program participants
|
Advanced tuberculosis control
|
- Utilization of public media for TB prevention
- Analysis on TB status in local governments
- Designing and analysis on promotion for TB prevention
|
12
|
*1. Public Health Centers, 2. Public Health and Environmental Research Institutes, 3. MoHW, 4. Local Governments, 5. KDCA, 6. National Quarantine Stations
Masan National Tuberculosis Hospital
The MNTH was initiated on March of 1941 as a sanatorium with mission to treat and care TB-suffered veterans. Since May, 2002, it was renamed as MNTH and has become representative TB-specialized hospital in Korea.
The MNTH was an affiliated institution under MoHW and since of September of 2020 when KCDC was elevated to KDCA and turned to be independent from MoHW, the MNTH transferred and changed its affiliation from MoHW to KDCA. The MNTH conducts multiple roles other than TB treatment such as leading National Tuberculosis Program, performing TB research, and TB prevention education and training. The MNTH is a medical institute specialized in MDR-TB treatment (50).
The MNTH promotes public health through TB treatment and research thus advancing TB control and prevention capability (51). As of 2020, there are 2 TB medical specialist (TB-Spc) training institutes, the Seobuk hospital and the MNTH, remained(52) in Korea. Since the MNTH was designated as TB-Spc training institute by MoHW in 1993, institute trained total number of 14 TB-Spc since year of 1993 (50, 51). Other than TB-Spc training, the MNTH is actively educating HCWs and students for TB control and prevention on monthly basis starting from year of 2016. So far, total number of 67,426 people were educated over 272 education sessions as of 2019, indicating significant contribution to TB control and prevention through education (51).