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Vital Surveillances: Characteristics and Morbidity of the Tuberculosis Epidemic — China, 2019

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  • [1] Herbert N, Sharma V, Masham BS, Sheehan BS, Hauser J, Zumla A. Concrete action now: UN high-level meeting on tuberculosis. Lancet Infect Dis 2018;18(7):709 − 10. http://dx.doi.org/10.1016/S1473-3099(18)30171-3CrossRef
    [2] Action Plan to End TB (2019-2022). http://www.nhc.gov.cn/jkj/s3589/201906/b30ae2842c5e4c9ea2f9d5557ad4b95f.shtml.[2020-03-08]. (In Chinese).http://www.nhc.gov.cn/jkj/s3589/201906/b30ae2842c5e4c9ea2f9d5557ad4b95f.shtml.[2020-03-08]
    [3] World Health Organization. Global tuberculosis report 2019. https://www.Who.int/tb/publications/global_report/en/. [2020-03-08].https://www.Who.int/tb/publications/global_report/en/
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    [5] Mao Q, Zeng CH, Zherng DC, Yang YH. Analysis on spatial-temporal distribution characteristics of smear positive pulmonary tuberculosis in China, 2004-2015. Int J Infect Dis 2019;80 Suppl:S36 − 4. http://dx.doi.org/10.1016/j.ijid.2019.02.038CrossRef
    [6] Ragonnet R, Trauer TM, Geard N, Scott N, McBryde ES. Profiling Mycobacterium tuberculosis transmission and the resulting disease burden in the five highest tuberculosis burden countries. BMC Med 2019;17(1):208. http://dx.doi.org/10.1186/s12916-019-1452-0CrossRef
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    [8] Guo ZY, Xiao D, Wang XH, Wang YY, Yan TC. Epidemiological characteristics of pulmonary tuberculosis in mainland China from 2004 to 2015: a model-based analysis. BMC Public Health 2019;19(1):219. http://dx.doi.org/10.1186/s12889-019-6544-4CrossRef
    [9] Cai XT, Du YH, Zhong J, He G, Jiang KH. Epidemiological characteristics of tuberculosis patients in Haizhu District of Guangzhou from 2014 to 2018. J Tubercul Lung Health 2019;8(2):100 − 5. http://dx.doi.org/10.3969/j.issn.2095-3755.2019.02.006 (In Chinese)CrossRef
    [10] Lin HH, Wang LX, Zhang H, Ruan YZ, Chin DP, Dye C. Tuberculosis control in China: use of modelling to develop targets and policies. Bull World Health Organ 2015;93(11):790 − 8. http://dx.doi.org/10.2471/BLT.15.154492CrossRef
    [11] Guo Y, Huang YM. New challenges for tuberculosis control in China. Lancet Glob Health 2016;4(7):e434 − 5. http://dx.doi.org/10.1016/S2214-109X(16)30112-7CrossRef
    [12] The outline of the healthy China 2030 plan. http://www.nhc.gov.cn/guihuaxxs/s3586s/201610/21d120c917284007ad9c7aa8e9634bb4.shtml. [2020-03-08]. (In Chinese).http://www.nhc.gov.cn/guihuaxxs/s3586s/201610/21d120c917284007ad9c7aa8e9634bb4.shtml
  • FIGURE 1.  Geographical distribution of the reported pulmonary tuberculosis (PTB) in 31 PLADs of China, 2019. (A) Rate of reported PTB; (B) Number of reported PTB.

    TABLE 1.  The number and case notification rate of reported pulmonary tuberculosis (PTB) in China, 2015–2019.

    Year Population
    (10,000)
    No. of reported PTB Rate of reported PTB (1/100,000)
    PTB Bac+* PTB Bac+
    2015 136,247 864,015 247,168 63.42 18.14
    2016 137,343 836,236 237,942 61.00 17.36
    2017 137,923 835,193 244,302 60.53 17.71
    2018 138,910 823,342 277,439 59.27 19.97
    2019 139,654 775,764 349,307 55.55 25.01
    * Bac+: bacteriologically confirmed.
    Download: CSV

    TABLE 2.  The number and case notification rate of reported pulmonary tuberculosis (PTB) in different gender and age groups, 2019.

    Age group
    (years)
    Population (10,000) No. of reperted PTB Rate of reported PTB
    Male Female Total Male Female Total Male Female Total
    0– 4,406 3,992 8,397 398 350 748 0.90 0.88 0.89
    5– 8,272 7,032 15,303 3,558 3,810 7,368 4.30 5.42 4.81
    15– 8,187 7,239 15,425 66,038 38,929 104,967 80.67 53.78 68.05
    25– 11,834 11,293 23,127 70,973 41,444 112,417 59.97 36.70 48.61
    35– 10,260 9,948 20,207 56,276 27,233 83,509 54.85 27.38 41.33
    45– 12,248 11,923 24,171 98,033 35,739 133,772 80.04 29.98 55.35
    55– 8,311 8,212 16,523 100,432 34,821 135,253 120.84 42.40 81.86
    ≥65 7,831 8,668 16,500 138,273 59,457 197,730 176.56 68.59 119.84
    Total 71,348 68,305 139,654 533,981 241,783 775,764 74.84 35.40 55.55
    Download: CSV

    TABLE 3.  Reported pulmonary tuberculosis (PTB) cases by occupation, 2019.

    Category No. of reported PTB Proportion (%)
    Child 1,433 0.18
    Student 47,732 6.15
    Teacher 4,280 0.55
    Service staff 16,087 2.07
    Healthcare worker 4,018 0.52
    Factory worker 34,094 4.39
    Farmer 470,932 60.71
    Government official 12,742 1.64
    Retiree 41,324 5.33
    House worker 111,006 14.31
    Others 20,547 2.65
    Not applicable 115,69 1.49
    Total 775,764 100.00
    Download: CSV

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Characteristics and Morbidity of the Tuberculosis Epidemic — China, 2019

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  • 1 National Center for TB Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
  • Corresponding author:

    Yanlin Zhao, zhaoyl@chinacdc.cn

    Online Date: March 20 2020
    • Introduction: The year 2019 was crucial for the implementation of China’s National “13th 5-Year” Tuberculosis (TB) Control Plan. We conducted this study to evaluate the characteristics and progress towards controlling TB in China.

      Methods: We collected and analyzed the pulmonary tuberculosis (PTB) data of China between January 1, 2015 and December 31, 2019 from the National Notifiable Disease Reporting System (NNDRS).

      Results: In 2019, there were 775,764 PTB cases reported in NNDRS, of which 349,307 were bacteriologically-confirmed (Bac+) cases. The PTB case notification rate (CNR) was 55.55 per 100,000, and the Bac+ CNR was 25.01 per 100,000. From 2018 to 2019, the number of PTB cases fell by 6.3%, but the number of Bac+ cases increased by 25.9%. The annual decrease in the rate of reported PTB was 3.4% from 2015 to 2019.

      The 5 provincial-level administrative divisions (PLADs) with the highest PTB CNR were as follows: Tibet (182.38 per 100,000), Xinjiang (169.05 per 100,000), Qinghai (134.53 per 100,000), Guizhou (102.51 per 100,000), and Hainan (90.22 per 100,000).

      The rate of reported PTB was 74.84 per 100,000 for males and 35.40 per 100,000 for females. There were 8,116 cases (1.0%) among children aged 0–14 years, and 197,730 cases (25.5%) among adults aged 65 years and over. Of the reported cases, 470,932 were farmers, which was the most common occupation at 60.7%.

      Conclusions and Implications for Public Health Practice: The TB epidemic has decreased dramatically year by year. Most PTB cases were in the central and western regions of China, and the high-risk groups were farmers and elderly people aged 65 years and over.

    • Tuberculosis (TB) is a top ten cause of death worldwide and the leading cause of death due to infectious disease in the world. TB is caused by Mycobacterium tuberculosis and is spread through the air from one person to another. China is one of the 30 high TB burden countries (HBCs) in the world with an estimated 0.87 million (0.74–1.00 million) TB cases in 2018. The incidence rate, however, was 61 per 100,000 population, below the world average of 132 per 100,000. China ranked 2 for new TB cases among 30 HBCs, but ranked 27 for TB incidence rate.

      In 2018, the United Nations held its first ever high-level meeting on TB, discussing the status of the TB epidemic and how to end it (1). In order to end the TB epidemic, the National Health Commission of China constructed the Action Plan to End TB (2019–2022) in 2019 (2). The year was also important for China to implement the National “13th 5-Year” TB Control Plan. To understand the epidemic situation of TB in China, we collected and reported pulmonary TB (PTB) data from the National Notifiable Disease Reporting System (NNDRS) and systematically analyzed the epidemiological characteristics of TB and progress towards controlling TB in China.

    • Data on reported PTB cases between January 1, 2015 and December 31, 2019 were downloaded from the NNRDS. We analyzed the characteristics and morbidity of the TB epidemic by year, provincial-level administrative divisions (PLADs), and population using Microsoft Excel (version 2007) and the spatial distribution of the TB epidemic with ArcGIS (version 10.2; Esri Institute).

    • In 2019, there were 775,764 reported PTB cases in the NNDRS, of which 349,307 were bacteriologically-confirmed cases. The rate of reported PTB was 55.55 per 100,000, and the rate of reported bacteriologically-confirmed (Bac+) was 25.01 per 100,000. Compared with 2018, PTB cases fell by 6.3%, while the Bac+ cases increased by 25.9%. The annual rate of decrease of reported PTB was 3.4% during 2015–2019 (Table 1). The number of reported PTB cases was ranked 2 in Class A and Class B notifiable infectious diseases during 2015–2019, right behind hepatitis B.

      Year Population
      (10,000)
      No. of reported PTB Rate of reported PTB (1/100,000)
      PTB Bac+* PTB Bac+
      2015 136,247 864,015 247,168 63.42 18.14
      2016 137,343 836,236 237,942 61.00 17.36
      2017 137,923 835,193 244,302 60.53 17.71
      2018 138,910 823,342 277,439 59.27 19.97
      2019 139,654 775,764 349,307 55.55 25.01
      * Bac+: bacteriologically confirmed.

      Table 1.  The number and case notification rate of reported pulmonary tuberculosis (PTB) in China, 2015–2019.

      In 2019, the five PLADs with the highest rate of reported PTB were: Tibet (182.38 per 100,000), Xinjiang (169.05 per 100,000), Qinghai (134.53 per 100,000), Guizhou (102.51 per 100,000), and Hainan (90.22 per 100,000 (Figure 1A); the five PLADs with highest number of reported PTB cases were: Guangdong (66,261), Hunan (56,620), Sichuan (50,337), Henan (49,753), and Xinjiang (42,043) (Figure 1B).

      Figure 1.  Geographical distribution of the reported pulmonary tuberculosis (PTB) in 31 PLADs of China, 2019. (A) Rate of reported PTB; (B) Number of reported PTB.

      TB affects both males and females in all age groups. There were 533,981 reported male PTB cases with a case rate of 74.84 per 100,000 population and 241,783 reported female cases with a case rate of 35.40 per 100,000. There were 8,116 cases in children aged 0–14 years (1.0%), and 197,730 cases in the adults aged 65 years and over (25.5%). The case rate of reported PTB increased with age and was higher in older age groups (Table 2).

      Age group
      (years)
      Population (10,000) No. of reperted PTB Rate of reported PTB
      Male Female Total Male Female Total Male Female Total
      0– 4,406 3,992 8,397 398 350 748 0.90 0.88 0.89
      5– 8,272 7,032 15,303 3,558 3,810 7,368 4.30 5.42 4.81
      15– 8,187 7,239 15,425 66,038 38,929 104,967 80.67 53.78 68.05
      25– 11,834 11,293 23,127 70,973 41,444 112,417 59.97 36.70 48.61
      35– 10,260 9,948 20,207 56,276 27,233 83,509 54.85 27.38 41.33
      45– 12,248 11,923 24,171 98,033 35,739 133,772 80.04 29.98 55.35
      55– 8,311 8,212 16,523 100,432 34,821 135,253 120.84 42.40 81.86
      ≥65 7,831 8,668 16,500 138,273 59,457 197,730 176.56 68.59 119.84
      Total 71,348 68,305 139,654 533,981 241,783 775,764 74.84 35.40 55.55

      Table 2.  The number and case notification rate of reported pulmonary tuberculosis (PTB) in different gender and age groups, 2019.

      Of the reported cases, 470,932 were farmers (60.71%), the highest among all occupations, 111,006 were house workers (14.31%), 47,732 were students (6.15%), 41,324 were retirees (5.33%), and 34,094 were factory workers (4.39%) (Table 3).

      Category No. of reported PTB Proportion (%)
      Child 1,433 0.18
      Student 47,732 6.15
      Teacher 4,280 0.55
      Service staff 16,087 2.07
      Healthcare worker 4,018 0.52
      Factory worker 34,094 4.39
      Farmer 470,932 60.71
      Government official 12,742 1.64
      Retiree 41,324 5.33
      House worker 111,006 14.31
      Others 20,547 2.65
      Not applicable 115,69 1.49
      Total 775,764 100.00

      Table 3.  Reported pulmonary tuberculosis (PTB) cases by occupation, 2019.

    • TB is one of the major infectious diseases affecting public health in both China and the world. The TB epidemic in China is still severe. China is one of the highest 30 HBCs, and the number of new estimated TB cases is second only after India (3-6). Reported PTB cases ranked second in Class A and Class B notifiable infectious diseases in China from 2015 to 2019.

      During the period of 13th 5-Year National Plan, the Central Government of China regarded TB as one of the priority infectious diseases to be controlled. Government at different levels, from the national level to the county level, have made political commitments on TB control. With such measures as optimizing the TB service provision systems and improving the quality of case detection and treatment management, TB cases have decreased dramatically year by year. The annual decrease of the TB incidence rate in China was 3.4% during 2015–2019, which was higher than the global average (1.6%). Compared with 2018, the reported number of cases of PTB in 2019 decreased by 6.3% (3,4,6), while the number of Bac+ cases increased by 25.9%. This indicates that designated TB hospitals have attached importance to sputum collection and testing. As a result, the bacteriological confirmation rate has been improved remarkably.

      The number of reported PTB cases and the case rates were higher in Xinjiang, Guizhou, Guangxi, Hunan and Jiangxi, which are located in the central and western part of China, the priority regions for TB control in the country. TB cases were mainly distributed in low-income and other high-risk groups, such as farmers in the central and western regions and elderly people aged 65 years and over. In addition, the case rate of students aged 15–25 years increased dramatically, so these groups of people will be the priority for TB control in the future (7-9).

      This study is subject to some limitations. The reported number cases of PTB by the NNDRS was affected by the severity of the epidemic situation and the work of case detection, so considering these factors upon comparing the reported rate with different provinces is necessary to assess the level of the TB morbidity.

      Although much progress has been made in TB control, TB still remains a major public health threat in China. Further progress in controlling the disease could be long, complex, and arduous. More funding and specialized human resources are needed for TB high burden areas, such as poor areas in the central and the western areas with a focus on some high risk groups, such as farmers, elderly people aged 65 years and over, and students aged 15–25 years (10-11). By implementing comprehensive control measures, we could decrease TB incidence and mortality dramatically in China. This will in turn contribute to achieving the goals of “Health China 2030” and “Poverty Alleviation in China” (12).

    • The authors would like to thank all participants of the national surveillance program. Many thanks to Zhijun Li from US CDC China Office for reviewing and editing the manuscript. Lijia Yang and Yanfei Liu for reviewing the reference literature. This work was supported by the China National TB Program and the National Special Science and Technology Project for Major Infectious Diseases of China (2017ZX10201302007).

    • All authors have completed and submitted the ICMJE form. And no conflicts of interest were reported.

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