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Rifampicin-resistant tuberculosis (RR-TB) is defined as having any resistance to rifampicin, including mono-resistance, multidrug resistance (MDR), and polydrug resistance (1). RR-TB is a more serious type of tuberculosis (TB) and is currently the focal point of TB control in China. Students are of special concern for TB control, as once a case of infectious TB occurs, it is easily spread, which will cause public health events and arouse widespread concern in the community. To strengthen the control and prevention of TB among students, the Guidelines for the Control and Prevention of Tuberculosis in Schools (2017 Edition) was issued and the single-case early warning system for TB in schools was launched with the China Infectious Diseases Automated-Alert System in July 2018 (2). Therefore, although the absolute size of the national TB epidemic is shrinking year by year, the number of the TB cases in schools have grown since 2015 (3-4). In addition, the prevalence of students with RR-TB is still unclear because of a lack of information on the national drug resistance baseline among children under 15 in the student population. Therefore, it is imperative to analyze the characteristics of the RR-TB epidemic among students.
The Programmatic Management of Drug-Resistant Tuberculosis (PMDT) was initiated in China in 2006. In order to achieve the End TB Strategy’s vision and goals proposed by the World Health Organization (WHO) in 2015, China rapidly scaled up coverage of PMDT and expanded the drug resistance screening population for Rifampicin-resistant (RR) from screening high-risk groups of RR-TB to screening all bacteriologically-confirmed TB patients since 2015. The number of RR-TB patients notified after 2015 can better reflect the trends of RR-TB. Therefore, based on the nationwide Tuberculosis Information Management System (TBIMS), this study analyzed the epidemiological characteristics of RR-TB patients registered as students in the occupational classification in the TBIMS from January 1, 2015 to December 31, 2019.
The analysis results showed that the number of students with RR-TB that were reported and the detection rate of RR-TB among student TB patients continued to increase year by year from 2015 to 2019. The number of patients in 2019 was 3.7 times that of 2015 (732 compared to 197), which was higher than the 1.4 (47,732/34,260) times increase of students with TB in the same period. The most significant increase was observed in the western region. Since 2017, the proportion of RR-TB patients has surpassed that of the central and eastern region, ranking first, while the proportion was relatively low in the previous two years (Table 1). The proportion of students with RR-TB in all RR-TB patients also increased year by year (Figure 1).
Item 2015 2016 2017 2018 2019 Total No. of students with TB 34,260 36,094 40,656 48,289 47,732 207,031 No. of students with RR-TB (%)* 197 (0.6) 274 (0.8) 383 (0.9) 546 (1.1) 732 (1.5) 2,132 (1.0) Classification of registration New cases (%) 116 (58.9) 180 (65.7) 253 (66.1) 398 (72.9) 570 (77.9) 1,517 (71.2) RR-TB high-risk groups (%) 81 (41.1) 94 (34.3) 130 (33.9) 148 (27.1) 162 (22.1) 615 (28.8) Sex Male (%) 115 (58.4) 157 (57.3) 201 (52.5) 319 (58.4) 420 (57.4) 1,212 (56.8) Female (%) 82 (41.6) 117 (42.7) 182 (47.5) 227 (41.6) 312 (42.6) 920 (43.2) Age Primary school: 6–12 years (%) 0 (0) 0 (0) 1 (0.3) 9 (1.6) 9 (1.2) 19 (0.9) Middle school: 13–15 years (%) 0 (0) 5 (1.8) 6 (1.6) 27 (4.9) 65 (8.9) 104 (4.9) High school: 16–18 years (%) 9 (4.6) 14 (5.1) 45 (11.7) 103 (18.9) 257 (35.1) 428 (20.1) University: ≥19 years (%) 186 (94.4) 255 (93.1) 330 (86.2) 407 (74.5) 403 (55.1) 1,581 (74.2) Region East (%) 85 (43.1) 102 (37.2) 125 (32.6) 173 (31.7) 248 (33.9) 733 (34.4) Central (%) 50 (25.4) 107 (39.1) 122 (31.9) 151 (27.7) 218 (29.8) 648 (30.4) West (%) 62 (31.5) 65 (23.7) 136 (35.5) 222 (40.7) 266 (36.3) 75 1(35.2) Note: High-risk groups refer to at least one of the following: (a) chronic TB patients /failure of retreatment TB patients; (b) close contact with a known RR-TB patient; (c) new TB patients of initial treatment failure; (d) relapsed or returned TB patients; or (e) new TB patients with remaining sputum culture or positive smear at the end of the second month after treatment. The ages of students were divided into primary school, middle school, high school, and university categories according to the ages of 6–12, 13–15, 16–18, and 19 years and above. The eastern region included the following provincial-level administrative divisions: Beijing, Tianjin, Hebei, Liaoning, Shanghai, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, and Hainan; the central region: Shanxi, Jilin, Heilongjiang, Anhui, Jiangxi, Henan, Hubei, and Hunan; and the western region: Inner Mongolia, Guangxi, Chongqing, Sichuan, Guizhou, Yunnan, Tibet (Xizang), Shaanxi, Gansu, Qinghai, Ningxia, and Xinjiang.
* Detection rate of RR-TB among student TB patients.
Abbreviations: TB=tuberculosis, RR-TB=rifampicin-resistant tuberculosis.Table 1. The number of student with TB and with RR-TB, classification of registration and distribution of sex, education level and region of students with RR-TB in China, 2015–2019
Figure 1.The proportion of students with rifampicin-resistant tuberculosis (RR-TB) among all RR-TB patients in the same period in China, 2015–2019.
From Table 1, the number of students with RR-TB notified was predominantly male. The RR-TB patients were mainly college students, followed by high school students. The fewest were primary school patients, with less than 20 cases reported in the 5-year period. Although college students notified the most patients, their proportion decreased year by year, from 94.4% in 2015 to 55.1% in 2019. At the same time, the proportion of RR-TB patients in middle schools and high schools increased year by year, especially in high schools. The increases in students with RR-TB in 2019 were mainly from middle schools and high schools, and the same patients from universities decreased slightly. The majority of students with RR-TB were new patients (71.2%) with no history of TB treatment or treatment duration less than 1 month. The proportion of new patients to the total number of patients increased year by year, from 58.9% in 2015 to 77.9% in 2019. The number of RR-TB patients reported monthly did not show obvious trends (Figure 2).
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