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N Engl J Med. National Survey of Drug-Resistant Tuberculosis in China
[Source: The New England Journal of Medicine, full text: (LINK). Abstract, edited.]
Original Article
National Survey of Drug-Resistant Tuberculosis in China
Yanlin Zhao, Ph.D., Shaofa Xu, M.D., Lixia Wang, M.S., Daniel P. Chin, M.D., Shengfen Wang, Ph.D., Guanglu Jiang, B.S., Hui Xia, M.S., Yang Zhou, M.S., Qiang Li, M.S., Xichao Ou, M.S., Yu Pang, Ph.D., Yuanyuan Song, B.S., Bing Zhao, B.S., Hongtao Zhang, Ph.D., Guangxue He, B.S., Jing Guo, Ph.D., and Yu Wang, M.D.
N Engl J Med 2012; 366:2161-2170 - June 7, 2012
Background
The available information on the epidemic of drug-resistant tuberculosis in China is based on local or regional surveys. In 2007, we carried out a national survey of drug-resistant tuberculosis in China.
Methods
We estimated the proportion of tuberculosis cases in China that were resistant to drugs by means of cluster-randomized sampling of tuberculosis cases in the public health system and testing for resistance to the first-line antituberculosis drugs isoniazid, rifampin, ethambutol, and streptomycin and the second-line drugs ofloxacin and kanamycin. We used the results from this survey and published estimates of the incidence of tuberculosis to estimate the incidence of drug-resistant tuberculosis. Information from patient interviews was used to identify factors linked to drug resistance.
Results
Among 3037 patients with new cases of tuberculosis and 892 with previously treated cases, 5.7% (95% confidence interval [CI], 4.5 to 7.0) and 25.6% (95% CI, 21.5 to 29.8), respectively, had multidrug-resistant (MDR) tuberculosis (defined as disease that was resistant to at least isoniazid and rifampin). Among all patients with tuberculosis, approximately 1 of 4 had disease that was resistant to isoniazid, rifampin, or both, and 1 of 10 had MDR tuberculosis. Approximately 8% of the patients with MDR tuberculosis had extensively drug-resistant (XDR) tuberculosis (defined as disease that was resistant to at least isoniazid, rifampin, ofloxacin, and kanamycin). In 2007, there were 110,000 incident cases (95% CI, 97,000 to 130,000) of MDR tuberculosis and 8200 incident cases (95% CI, 7200 to 9700) of XDR tuberculosis. Most cases of MDR and XDR tuberculosis resulted from primary transmission. Patients with multiple previous treatments who had received their last treatment in a tuberculosis hospital had the highest risk of MDR tuberculosis (adjusted odds ratio, 13.3; 95% CI, 3.9 to 46.0). Among 226 previously treated patients with MDR tuberculosis, 43.8% had not completed their last treatment; most had been treated in the hospital system. Among those who had completed treatment, tuberculosis developed again in most of the patients after their treatment in the public health system.
Conclusions
China has a serious epidemic of drug-resistant tuberculosis. MDR tuberculosis is linked to inadequate treatment in both the public health system and the hospital system, especially tuberculosis hospitals; however, primary transmission accounts for most cases. (Funded by the Chinese Ministry of Health.)
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
No potential conflict of interest relevant to this article was reported.
Drs. Y. Zhao and Xu and Ms. L. Wang contributed equally to this study.
We thank the provincial and local CDC staffs for their help in carrying out this survey and Dr. Shuigao Jin for assistance with data analysis.
Source Information
From the Chinese Center for Disease Control and Prevention (Y. Zhao, L.W., S.W., H.X., Y. Zhou, Q.L., X.O., Y.P., Y.S., B.Z., G.H., Y.W.), the Beijing Tuberculosis and Thoracic Tumor Research Institute (Y. Zhao, S.X., G.J., H.Z.), the Bill and Melinda Gates Foundation, China Office (D.P.C.), and People's University (J.G.) ? all in Beijing.
Address reprint requests to Dr. Y. Wang at the Chinese Center for Disease Control and Prevention, Beijing 102206, China, or at wangyu@chinacdc.cn; or to Dr. Chin at the Bill and Melinda Gates Foundation, China Office, Beijing 100027, People's Republic of China, or at daniel.chin@gatesfoundation.org.
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Original Article
National Survey of Drug-Resistant Tuberculosis in China
Yanlin Zhao, Ph.D., Shaofa Xu, M.D., Lixia Wang, M.S., Daniel P. Chin, M.D., Shengfen Wang, Ph.D., Guanglu Jiang, B.S., Hui Xia, M.S., Yang Zhou, M.S., Qiang Li, M.S., Xichao Ou, M.S., Yu Pang, Ph.D., Yuanyuan Song, B.S., Bing Zhao, B.S., Hongtao Zhang, Ph.D., Guangxue He, B.S., Jing Guo, Ph.D., and Yu Wang, M.D.
N Engl J Med 2012; 366:2161-2170 - June 7, 2012
Background
The available information on the epidemic of drug-resistant tuberculosis in China is based on local or regional surveys. In 2007, we carried out a national survey of drug-resistant tuberculosis in China.
Methods
We estimated the proportion of tuberculosis cases in China that were resistant to drugs by means of cluster-randomized sampling of tuberculosis cases in the public health system and testing for resistance to the first-line antituberculosis drugs isoniazid, rifampin, ethambutol, and streptomycin and the second-line drugs ofloxacin and kanamycin. We used the results from this survey and published estimates of the incidence of tuberculosis to estimate the incidence of drug-resistant tuberculosis. Information from patient interviews was used to identify factors linked to drug resistance.
Results
Among 3037 patients with new cases of tuberculosis and 892 with previously treated cases, 5.7% (95% confidence interval [CI], 4.5 to 7.0) and 25.6% (95% CI, 21.5 to 29.8), respectively, had multidrug-resistant (MDR) tuberculosis (defined as disease that was resistant to at least isoniazid and rifampin). Among all patients with tuberculosis, approximately 1 of 4 had disease that was resistant to isoniazid, rifampin, or both, and 1 of 10 had MDR tuberculosis. Approximately 8% of the patients with MDR tuberculosis had extensively drug-resistant (XDR) tuberculosis (defined as disease that was resistant to at least isoniazid, rifampin, ofloxacin, and kanamycin). In 2007, there were 110,000 incident cases (95% CI, 97,000 to 130,000) of MDR tuberculosis and 8200 incident cases (95% CI, 7200 to 9700) of XDR tuberculosis. Most cases of MDR and XDR tuberculosis resulted from primary transmission. Patients with multiple previous treatments who had received their last treatment in a tuberculosis hospital had the highest risk of MDR tuberculosis (adjusted odds ratio, 13.3; 95% CI, 3.9 to 46.0). Among 226 previously treated patients with MDR tuberculosis, 43.8% had not completed their last treatment; most had been treated in the hospital system. Among those who had completed treatment, tuberculosis developed again in most of the patients after their treatment in the public health system.
Conclusions
China has a serious epidemic of drug-resistant tuberculosis. MDR tuberculosis is linked to inadequate treatment in both the public health system and the hospital system, especially tuberculosis hospitals; however, primary transmission accounts for most cases. (Funded by the Chinese Ministry of Health.)
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
No potential conflict of interest relevant to this article was reported.
Drs. Y. Zhao and Xu and Ms. L. Wang contributed equally to this study.
We thank the provincial and local CDC staffs for their help in carrying out this survey and Dr. Shuigao Jin for assistance with data analysis.
Source Information
From the Chinese Center for Disease Control and Prevention (Y. Zhao, L.W., S.W., H.X., Y. Zhou, Q.L., X.O., Y.P., Y.S., B.Z., G.H., Y.W.), the Beijing Tuberculosis and Thoracic Tumor Research Institute (Y. Zhao, S.X., G.J., H.Z.), the Bill and Melinda Gates Foundation, China Office (D.P.C.), and People's University (J.G.) ? all in Beijing.
Address reprint requests to Dr. Y. Wang at the Chinese Center for Disease Control and Prevention, Beijing 102206, China, or at wangyu@chinacdc.cn; or to Dr. Chin at the Bill and Melinda Gates Foundation, China Office, Beijing 100027, People's Republic of China, or at daniel.chin@gatesfoundation.org.