ObjectiveTo identify the composition of comorbidities among patients with newly diagnosed pulmonary tuberculosis and assess the impact of comorbidities on the clinical characteristics of patients.MethodsThis study was conducted in 13 hospitals across 13 counties in Zhejiang province, China. Patient data collected in this study included demographic characteristics, chest radiography results, etiological results, and comorbidities. Descriptive statistics were conducted to describe the composition of comorbidities of all participants. Univariate and multivariate logistic regression analyzes were performed to identify the effects of comorbidities on the clinical features of the participants.ResultsOf the 8,421 total participants, 27.6% reported cavities in the chest radiography results, 41.9% were Mycobacterium tuberculosis-positive in the etiology test results, and 38.7% (3,258/8,421) had at least one type of comorbidity. The most predominant comorbidity was pleuritis (1,833, 21.8%), followed by diabetes mellitus (763, 9.1%), other extrapulmonary tuberculosis (421, 5%), tracheobronchial tuberculosis (275, 3.3%), and silicosis (160, 1.9%). Participants with diabetes mellitus had the highest rate of chest cavities on X-ray (54.8%), followed by those with silicosis (33.1%). In addition, a higher percentage of the M. tuberculosis-positive etiology (45%) was observed in participants without comorbidities than in participants with comorbidities (37.1%). Compared to patients without comorbidities, patients with diabetes mellitus (adjusted odds ratio [AOR]: 2.88, 95% confidence interval [CI]: 2.42–3.43) were more likely to show cavities in chest X-ray, while patients with pleuritis (AOR: 0.27, 95% CI: 0.23–0.32), other extrapulmonary tuberculosis (AOR: 0.48, 95% CI: 0.36–0.64), and tracheobronchial tuberculosis (AOR: 0.40–0.79) were less likely to show chest cavities in X-ray. In addition, patients with diabetes mellitus (AOR: 2.05, 95% CI: 1.72–2.45), tracheobronchial tuberculosis (AOR: 3.22, 95% CI: 2.4–4.32) were more likely to show Mycobacterium tuberculosis-positive in the etiology, and patients with pleuritis (AOR: 0.25, 95% CI: 0.22–0.29), other extrapulmonary tuberculosis (AOR: 0.61, 95% CI: 0.48–0.76) were less likely to show Mycobacterium tuberculosis-positive in the etiology.ConclusionThe prevalence of comorbidities was high in patients newly diagnosed with pulmonary tuberculosis. Thus, integration of screening and personalized management is needed for the control of tuberculosis and its comorbidities.

Background: The tuberculosis incidence rate in China, previously declining, has plateaued in recent years. Given few targeted studies analysing this trend as per the ageing population, we analysed the age-specific notification rate of pulmonary tuberculosis (PTB) from 2008 to 2018.Methods: This longitudinal study collected data on PTB cases reported in the National TB Information Management System from 2008 to 2018, covering 31 provincial-level administrative divisions in mainland China. We analysed annual crude notification rates and age-adjusted rates using the 2008 population as reference. We determined the average annual percentage change using exponential linear regression and joinpoint regression for trend analysis.Findings: Between 2008 and 2018, a total of 9 242 525 PTB cases were notified, representing an average notification rate of 62·1 cases per 100 000 population. Annual rates were consistently higher in males, older people, Central China, and Western China. Overall, a declining trend was observed, with an absolute change of –21.0 cases per 100 000 population and a relative change of –27·7%. Average annual percentage changes of crude and age-adjusted rates were –3·4% (95% CI: –3·9 to –3·0) and –4·3% (95% CI: –4·8 to –3·8), respectively. The year of 2016 was a turning point of trend from decline to plateau in Western China.Interpretation: PTB notification rates in China have slowed due to the effects of population ageing and geographic disparities. Enhanced surveillance, age-sensitive analysis, and targeted proactive responses are recommended to achieve End TB targets.Funding Information: National Special Science and Technology Project for Major Infectious Diseases (Grant Number 2017ZX10201302007).Declaration of Interests: We declare no competing interests.Ethics Approval Statement: Permission for the study was obtained from the National Centre for Tuberculosis Control and Prevention, Chinese Centre for Diseases Control and Prevention. As this study involved analysis of routinely collected secondary data, a waiver of informed consent was sought and approved.

BACKGROUND:Tuberculosis (TB) in the elderly remains a challenge in intermediate disease burden areas like Hong Kong. Given a higher TB burden in the elderly and limited impact of current case-finding strategy by patient-initiated pathway, proactive screening approaches for the high-risk group could be optimal and increasingly need targeted economic evaluations. In this study, we examined whether and under what circumstance the screening strategies are cost-effective compared with no screening strategy for the elderly at admission to residential care homes.METHODS:A decision analytic process based on Markov model was adopted to evaluate the cost-effectiveness of four strategies: (i) no screening, (ii) TB screening (CXR) and (iii) TB screening (Xpert) represent screening for TB in symptomatic elderly by chest X-ray and Xpert® MTB/RIF respectively, and (iv) LTBI/TB screening represents screening for latent and active TB infection by QuantiFERON®-TB Gold In-Tube and chest X-ray. The target population was a hypothetical cohort of 65-year-old people, using a health service provider perspective and a time horizon of 20 years. The outcomes were direct medical costs, life-years and quality-adjusted life-years (QALYs) measured by incremental cost-effectiveness ratio (ICER).RESULTS:In the base-case analysis, no screening was the most cost-saving; TB screening (CXR) was dominated by TB screening (Xpert); LTBI/TB screening resulted in more life-years and QALYs accrued. The ICERs of LTBI/TB screening were US$19,712 and US$29,951 per QALY gained compared with no screening and TB screening (Xpert), respectively. At the willingness-to-pay threshold of US$50,000 per QALY gained, LTBI/TB screening was the most cost-effective when the probability of annual LTBI reactivation was greater than 0.155% and acceptability of LTBI/TB screening was greater than 38%. In 1,000 iterations of Monte Carlo simulation, the probabilities of no screening, TB screening (CXR), TB screening (Xpert), and LTBI/TB screening to be cost-effective were 0, 1.3%, 20.1%, and 78.6% respectively.CONCLUSIONS:Screening for latent and active TB infection in Hong Kong elderly people at admission to residential care homes appears to be highly effective and cost-effective. The key findings may be the next key factor to bring down TB endemic in the elderly population among intermediate TB burden areas.

China's childhood hepatitis B virus (HBV) vaccination programme is a great public health success, resulting in a prevalence of HBsAg of only 1% in children under 5 years. However, the burden of HBV infection in China is still the highest in the world, with one third of the world's 240 million people with chronic HBV living in China.1WHOGlobal hepatitis report 2017.http://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/Date: 2017Google Scholar Nevertheless, most people with HBV infection in China are unaware that they carry the disease, making HBV infection a truly silent epidemic.2WHOUp to 10 million people in China could die from chronic hepatitis by 2030—urgent action needed to bring an end to the 'silent epidemic'.http://www.wpro.who.int/china/mediacentre/releases/2016/20160727-china-world-hepatitis-day/en/Date: 2016Google Scholar Among the population with HBV infection in China, 28 million people require treatment, with 7 million of these being urgent because of advanced liver disease and the high risk of developing cancer.2WHOUp to 10 million people in China could die from chronic hepatitis by 2030—urgent action needed to bring an end to the 'silent epidemic'.http://www.wpro.who.int/china/mediacentre/releases/2016/20160727-china-world-hepatitis-day/en/Date: 2016Google Scholar However, less than one in 50 patients in need of treatment receive it, with the biggest barrier to treatment being affordability.2WHOUp to 10 million people in China could die from chronic hepatitis by 2030—urgent action needed to bring an end to the 'silent epidemic'.http://www.wpro.who.int/china/mediacentre/releases/2016/20160727-china-world-hepatitis-day/en/Date: 2016Google Scholar A 2016 study3Zhang S Ma Q Liang S et al.Annual economic burden of hepatitis B virus-related diseases among hospitalized patients in twelve cities in China.J Viral Hepat. 2016; 23: 202-210Crossref PubMed Scopus (38) Google Scholar sampled 4726 cases in China and revealed that the direct medical costs alone equalled 53·06% of the patient's annual household income. Six medications have been approved for the treatment of chronic HBV, but only lamivudine is included in the Chinese national drug list.4Zhang H Chao J Wang S Liu P The impact of health insurance on economic burden for hepatitis B inpatients in China.Iran J Public Health. 2016; 45: 107-108PubMed Google Scholar HBV-related diseases have become an important cause of poverty and continue to perpetuate the cycle between poverty and illness in China. Beyond the heavy economic burden, the discrimination attached to HBV infection remains a major problem in China. This can range from unwillingness to hug or shake hands with people with HBV infection, to losing a job or not being hired. Ignorance about the aspects of HBV is widespread, and many people believe that HBV can be transmitted through contact or by eating together.5Kan Q Wen J Xue R Discrimination against people with hepatitis B in China.Lancet. 2015; 386: 245-246Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar In 2016, to implement health-related Sustainable Development Goals, the Healthy China 2030 plan was officially approved by China's Central Committee. By the end of 2017, 30 of 31 provinces, autonomous regions, and municipalities in China had also issued their local Healthy 2030 plans, and full sections of 22 of these plans can be accessed online. All the accessible plans make a statement on the control of communicable diseases. For AIDS, HIV, and tuberculosis, these plans emphasise health education, screening, diagnosis, treatment, and financial reimbursement. However, for HBV, these plans are still restricted to vaccination and prevention of mother-to-child transmission, with five plans not even mentioning the word hepatitis. The attention paid to HBV is severely inadequate. In China, the disease burden of HBV is the highest among communicable diseases, and about 10 million people living with chronic HBV will die by 2030,2WHOUp to 10 million people in China could die from chronic hepatitis by 2030—urgent action needed to bring an end to the 'silent epidemic'.http://www.wpro.who.int/china/mediacentre/releases/2016/20160727-china-world-hepatitis-day/en/Date: 2016Google Scholar with most of these deaths being avoidable. The HBV immunisation programme is a great public health success story, but efforts to address other HBV-related problems are lagging behind. To really achieve the Healthy China 2030 goals, China should also mobilise a response to HBV on a scale similar to that of other communicable diseases, such as HIV, AIDS, and tuberculosis, including enhanced education, elimination of discrimination, enhanced screening, and the offer of affordable and effective treatment to patients. We declare no competing interests.

OBJECTIVETo analyze the changing trend of children's malnutrition and anemia rate in Taicang City, Jiangsu Province from 2009 to 2015.METHODSData of medical examination on children under 3 was retrived from Electronic Health Care Records in Taicang, Jiangsu, and children's malnutrition and anemia rates were assessed based on WHO children's growth standard in 2006 and anemia diagnosis standard in 2001. The differences of children's malnutrition and anemia rates from 2009 to 2015 were analyzed based on the data. The Mantel-Haenszel Estimation Method was used to standardize themalnutrition rate and the anemia rate. Mantel-Haenszel Chi-square test was used to compare the differences of count data.RESULTSThe average WAZ, HAZ and WHZ scores were 0. 51, 0. 23 and 0. 56, and the average rates of low weight, stunting, wasting, overweight and obesity were 0. 65%, 1. 54%, 0. 56%, 6. 37% and 1. 03%, respectively. The rates of low weight, wasting, overweight and obesity remained stable from 2009 to 2015. The overweight rate increased from 5. 84% in 2009 to 6. 99% in2012, and dropped to 6. 12% in 2015( MH χ~2= 5. 41, P < 0. 05). The boys had a higher malnutrition rate than the girls, and the migrant children had worse conditions in stunting, overweight and obesity than local children. The anemia rate in children under 3 declined from 24. 02% in 2009 to 9. 25% in 2015( Cochran-Armitage Z = 29. 41, P < 0. 05). The boys had a higher anemia rate than the girls, and the local children had a higher anemia rate than the migrant children.CONCLUSIONThe growth status of children under 3 in Taicang from 2009 to 2015 is better than the WHO reference standards. The overweight rates increase from 2009 to 2012 and decline from 2012 to 2015. The anemia rate in children decline from 2009 to 2015. This study indicates that controlling the high overweight rate and high anemia rate in young children under 3 are two predominating working directions in Taicang, Jiangsu.

BackgroundWith the rapid pace of population ageing, tuberculosis in older people has become a public health challenge in China. However, the age-structured epidemiological transition and its impact on achieving the end tuberculosis targets by 2035 have not been understood well. We analysed the age-structured incidence and mortality of pulmonary tuberculosis reported in China to inform current and future control programmes.MethodsIn this longitudinal study, we compared the trends of age-specific reported incidence and mortality of pulmonary tuberculosis from 2005 to 2015 in China. In addition to crude rates, we calculated age-adjusted rates from 2006 to 2015 by taking the population in 2005 as reference. We determined the annual crude and age-adjusted rates of reduction by fitting an exponential linear regression model, and extrapolated up to 2035 given fixed decline rates. All data were collected from national Infectious Disease Reporting System and Diseases Surveillance System.FindingsWe noted overall downward trends of reported tuberculosis incidence and mortality in all age and sex groups since 2005, whereas the proportion of older people (aged 65 years and older) among reported patients with tuberculosis and deaths increased gradually. The total tuberculosis incidence and mortality were significantly higher in older people (193·0 cases per 100 000 people and 18·7 deaths per 100 000 people, respectively) than in younger groups (66·6 cases per 100 000 and 1·7 deaths per 100 000 people). The average annual decline in crude incidence was 4·2% (95% CI 3·5–4·9) and 5·1% (4·3–5·9%) in age-adjusted incidence; the annual decline in crude mortality was 9·7% (95% CI 8·4–10·9) and 12·4% (10·9–13·8) in age-adjusted mortality. Extrapolating this trend, by 2035, the crude incidence of tuberculosis was expected to reach 26·8 cases per 100 000 people and the age-adjusted incidence to reach 20·6 cases per 100 000 people, which would result in a total reduction of 57·8% and 65·0%, respectively, compared with the rates in 2015. By 2035, the crude mortality was expected to reach 0·33 deaths per 100 000 people and the age-adjusted mortality to reach 0·15 deaths per 100 000 people, which would result in a total reduction of 86·0% and 92·0%, respectively, compared with the rates in 2015.InterpretationThese findings demonstrated an age transition of tuberculosis epidemic and the effects of population ageing on slowing down tuberculosis control progress made in China. An average 6–7% reduction would be cancelled out by 2035 given current tuberculosis decline trend and demographic change. An enhanced surveillance with age-sensitive analysis of patients with tuberculosis and a targeted response are needed.FundingNone.

With the rapid pace of population ageing, tuberculosis (TB) in the elderly increasingly becomes a public health challenge. Despite the increasing burden and high risks for TB in the elderly, targeted strategy has not been well understood and evaluated. We undertook a scoping review to identify current TB strategies, research and policy gaps in the elderly and summarized the results within a strategic framework towards End TB targets. Databases of Embase, MEDLINE, Global health and EBM reviews were searched for original studies, review articles, and policy papers published in English between January 1990 and December 2015. Articles examining TB strategy, program, guideline or intervention in the elderly from public health perspective were included. Nineteen articles met the inclusion criteria. Most of them were qualitative studies, issued in high- and middle-income countries and after 2000. To break the chain of TB transmission and reactivation in the elderly, infection control, interventions of avoiding delay in diagnosis and containment are essential for preventing transmission, especially in elderly institutions and aged immigrants; screening of latent TB infection and preventive therapy had effective impacts on reducing the risk of reactivation and should be used less reluctantly in older people; optimizing early case-finding with a high index of suspicion, systematic screening for prioritized high-risk groups, initial empirical and adequate follow-up treatment with close monitoring and evaluation, as well as enhanced programmatic management are fundamental pillars for active TB elimination. Evaluation of TB epidemiology, risk factors, impacts and cost-effectiveness of interventions, adopting accurate and rapid diagnostic tools, shorter and less toxic preventive therapy, are critical issues for developing strategy in the elderly towards End TB targets. TB control strategies in the elderly were comprehensively mapped in a causal link pathway. The framework and principals identified in this study will help to evaluate and improve current program, develop targeted strategy, as well as raise more discussions on the research priority settings and policy transitions. Given the scarceness of policy and evaluated interventions, as well as the unawareness of shifting TB epidemiology and strategy especially in developing countries, the increasing need of a ready TB program for the elderly warrants further research.

INTRODUCTION:Early and accurate diagnosis of imported malaria cases in clusters is crucial for protecting the health of patients and local populations, especially confirmed parasitic persons who are asymptomatic.METHODOLOGY:A total of 226 gold miners who had stayed in highly endemic areas of Ghana for more than six months and returned in clusters were selected randomly. Blood samples from them were tested with microscopy, nest polymerase chain reaction, and rapid diagnostic test (RDT). The sensitivity, specificity, predictive values, agreement rate, and Youden's index of each of three diagnostic methods were calculated and compared with the defined gold standard. A quick and efficient way to respond to screening such a clustered mobile population was predicted and analyzed by evaluating two assumed results of combining microscopy and RDT with or without symptoms of illness.RESULTS:The rate of the carriers of malaria parasites in the populations of gold miners was 19.47%, including 39 P. falciparum. Among the three diagnostic methods, the microscopy method showed the highest specificity, while the RDT method showed the highest sensitivity but the lowest specificity in detecting P. falciparum. The assumed results of combining RDT and microscopy with symptoms showed the best results among all the test results in screening P. falciparum.CONCLUSIONS:It was too complex and difficult to catch all parasite carriers in a short period of time among populations with such a complicated situation as that in Shanglin County. A strategy of combing microscopy and RDT for diagnosis is highly recommended.

Mobile text messaging and medication monitors (medication monitor boxes) have the potential to improve adherence to tuberculosis (TB) treatment and reduce the need for directly observed treatment (DOT), but to our knowledge they have not been properly evaluated in TB patients. We assessed the effectiveness of text messaging and medication monitors to improve medication adherence in TB patients.In a pragmatic cluster-randomised trial, 36 districts/counties (each with at least 300 active pulmonary TB patients registered in 2009) within the provinces of Heilongjiang, Jiangsu, Hunan, and Chongqing, China, were randomised using stratification and restriction to one of four case-management approaches in which patients received reminders via text messages, a medication monitor, combined, or neither (control). Patients in the intervention arms received reminders to take their drugs and reminders for monthly follow-up visits, and the managing doctor was recommended to switch patients with adherence problems to more intensive management or DOT. In all arms, patients took medications out of a medication monitor box, which recorded when the box was opened, but the box gave reminders only in the medication monitor and combined arms. Patients were followed up for 6 mo. The primary endpoint was the percentage of patient-months on TB treatment where at least 20% of doses were missed as measured by pill count and failure to open the medication monitor box. Secondary endpoints included additional adherence and standard treatment outcome measures. Interventions were not masked to study staff and patients. From 1 June 2011 to 7 March 2012, 4,292 new pulmonary TB patients were enrolled across the 36 clusters. A total of 119 patients (by arm: 33 control, 33 text messaging, 23 medication monitor, 30 combined) withdrew from the study in the first month because they were reassessed as not having TB by their managing doctor (61 patients) or were switched to a different treatment model because of hospitalisation or travel (58 patients), leaving 4,173 TB patients (by arm: 1,104 control, 1,008 text messaging, 997 medication monitor, 1,064 combined). The cluster geometric mean of the percentage of patient-months on TB treatment where at least 20% of doses were missed was 29.9% in the control arm; in comparison, this percentage was 27.3% in the text messaging arm (adjusted mean ratio [aMR] 0.94, 95% CI 0.71, 1.24), 17.0% in the medication monitor arm (aMR 0.58, 95% CI 0.42, 0.79), and 13.9% in the combined arm (aMR 0.49, 95% CI 0.27, 0.88). Patient loss to follow-up was lower in the text messaging arm than the control arm (aMR 0.42, 95% CI 0.18-0.98). Equipment malfunction or operation error was reported in all study arms. Analyses separating patients with and without medication monitor problems did not change the results. Initiation of intensive management was underutilised.This study is the first to our knowledge to utilise a randomised trial design to demonstrate the effectiveness of a medication monitor to improve medication adherence in TB patients. Reminders from medication monitors improved medication adherence in TB patients, but text messaging reminders did not. In a setting such as China where universal use of DOT is not feasible, innovative approaches to support patients in adhering to TB treatment, such as this, are needed.Current Controlled Trials, ISRCTN46846388.

Background China scaled up a tuberculosis control programme (based on the directly observed treatment, short-course [DOTS] strategy) to cover half the population during the 1990s, and to the entire population after 2000. We assessed the effect of the programme.Methods In this longitudinal analysis, we compared data from three national tuberculosis prevalence surveys done in 1990, 2000, and 2010. The 2010 survey screened 252 940 eligible individuals aged 15 years and older at 176 investigation points, chosen by stratified random sampling from all 31 mainland provinces. All individuals had chest radiographs taken. Those with abnormal radiographs, persistent cough, or both, were classified as having suspected tuberculosis. Tuberculosis was diagnosed by chest radiograph, sputum-smear microscopy, and culture. Trained staff interviewed each patient with tuberculosis. The 1990 and 2000 surveys were reanalysed and compared with the 2010 survey.Findings From 1990 to 2010, the prevalence of smear-positive tuberculosis decreased from 170 cases (95% CI 166-174) to 59 cases (49-72) per 100 000 population. During the 1990s, smear-positive prevalence fell only in the provinces with the DOTS programme; after 2000, prevalence decreased in all provinces. The percentage reduction in smear-positive prevalence was greater for the decade after 2000 than the decade before (57% vs 19%; p<0.0001). 70% of the total reduction in smear-positive prevalence (78 of 111 cases per 100 000 population) occurred after 2000. Of these cases, 68 (87%) were in known cases-ie, cases diagnosed with tuberculosis before the survey. Of the known cases, the proportion treated by the public health system (using the DOTS strategy) increased from 59 (15%) of 370 cases in 2000 to 79 (66%) of 123 cases in 2010, contributing to reduced proportions of treatment default (from 163 [43%] of 370 cases to 35 [22%] of 123 cases) and retreatment cases (from 312 [84%] of 374 cases to 48 [31%] of 137 cases; both p<0.0001).Interpretation In 20 years, China more than halved its tuberculosis prevalence. Marked improvement in tuberculosis treatment, driven by a major shift in treatment from hospitals to the public health centres (that implemented the DOTS strategy) was largely responsible for this epidemiological effect.

SETTING Multidrug-resistant tuberculosis (MDR-TB) has emerged as a serious global public health problem. In China, the risk factors for MDR-TB have not been systematically evaluated. OBJECTIVE To identify risk factors associated with MDR-TB among previously treated patients in China. DESIGN A case-control study was carried out. Cases were selected from previously treated MDR-TB patients who were resistant to both isoniazid and rifampin, and controls were selected from previously treated TB patients who were sensitive to isoniazid and rifampin (non-MDR-TB). Information was collected from the registration database and a structured questionnaire. RESULTS A total of 61 cases and 50 controls were recruited. A multivariate analysis showed that the family annual per-capita income ≤7,000 Yuan (odds ratio [OR]=3.238; 95% confidence interval [CI]: 1.270-8.252), no history of fixed dose combinations (FDCs) in anti-TB treatment (OR=4.027; 95% CI: 1.457-11.129), and adverse reactions in the course of TB treatment (OR=3.568; 95% CI: 1.402-9.085) were independent predictors of MDR-TB. Moreover, among the TB patients who had adverse reactions, quitting the treatment was shown as a risk factor for MDR-TB (p=0.009). CONCLUSION In the control of MDR-TB among previously treated patients, lower socioeconomic groups, the expanding use of FDCs, and improving adherence to treatment by implementing Directly Observed Therapy Short Course-Plus (DOTS-Plus), strictly should become a priority that requires strong commitment and collaboration among health organizations.

BACKGROUND:Previous treatment has been documented as a major risk factor for multidrug-resistant tuberculosis (MDR-TB). However, risk factors for MDR-TB among previously treated patients in China are unclear. This study aimed to ascertain the risk factors for MDR-TB in this particular population in China. METHODS:A case-control study was conducted from July through August 2011 in five cities of Zhejiang Province. Cases were previously treated TB patients who had disease resistant to at least isoniazid and rifampin, whereas controls were previously treated TB patients who had disease sensitive to isoniazid and rifampin. RESULTS:Ninety-eight cases and 83 controls were identified. Multivariate analysis showed that a duration of first treatment of more than 8 months (odds ratio (OR) 2.18, 95% confidence interval (CI) 1.05-4.52), more than three prior episodes of anti-TB treatment (more than 2 months of continuous treatment as one episode) (OR 5.57, 95% CI 2.38-13.00), adverse effects of anti-TB medication (OR 3.63, 95% CI 1.79-7.36), and more than three TB foci in the lung (OR 2.17, 95% CI 1.08-4.37) were associated with MDR-TB in previously treated TB patients. Low family income (p=0.056) was marginally significant in the univariate analysis. CONCLUSIONS:Particular clinical diagnostic results, such as more than three TB foci in the lung, non-standard or irregular therapy, and adverse effects of anti-TB medication, were found to be associated with MDR-TB in previously treated TB patients. High quality directly observed treatment should be strengthened to ensure that the previously treated patients can receive standard and regular regimens.

Objectives: To determine the length of delay in initial health-seeking in new pulmonary tuberculosis (PTB) cases among migrant population in the eastern part of China, and factors associated with it.Methods: A cross-sectional study was conducted using a structured questionnaire in six counties in Shanghai, Guangdong and Jiangsu from May to October, 2008, to estimate the extent and factors responsible for delayed initial health-seeking of the new PTB cases. The interval between self-reported onset of TB symptoms and date of first attendance at any medical institution was determined. More than the median duration was defined as delayed health-seeking.Results: A total of 323 new migrant PTB patients participated in the study. Only 6.5% had medical insurance. The median and mean durations to initial health-seeking were respectively 10 and 31 days. There was no significant association between socio-demographic factors and delayed initial health-seeking. Average monthly working days >24 (AOR, 1.61; 95% CI, 1.03-2.51), and hemoptysis or bloody sputum (AOR, 0.48; 95% CI, 0.28-0.85) were significantly associated with delayed initial health-seeking.Conclusions: Interventions to improve health seeking behavior among the migrant population in China must focus on strengthening their labor, medical security and health education.

Objective To understand the frequency and geographical distribution of people with suspected pulmonary tuberculosis(PTB) symptoms in China.Methods According to the fifth National Tuberculosis Epidemiological Sampling Survey,questionnaire survey was adopted to screen the people with suspected PTB symptoms(cough,expectoration ≥2 weeks and/or hemoptysis) aged 15 and above nationwide(excluding Hong Kong,Macao and Taiwan regions),the rates of people with suspected PTB symptoms in different population and areas were analyzed.Results The rate of people with suspected PTB symptoms in population aged 15 and above was 2.1%(5399/252 940).The rate in male was 2.8%(3324/116 939),higher than 1.5%(2075/136 001) of female(χ2=521.9,P0.001).There was a significant statistic difference among the rate of different age groups(χ2=2356.6,P0.001).People aged 65 and above was 2.976-3.335 times(OR=3.150,95%CI=2.976-3.335) more likely to develop suspected PTB symptoms than people aged 15 to 65.The rate in residence was 2.2%(5026/229 923),higher than 1.6%(373/23 017) of migrants(χ2=30.8,P0.001).The rate in rural area was 2.5%(3488/138 057),higher than 1.7%(1911/114 883) of urban area(χ2=214.4,P0.001).The rate in western,central and eastern regions were 3.6%(2522/69 896),2.0%(1603/80 926) and 1.2%(1274/102 118) respectively,with significant statistic differences(χ2=1066.9,P0.001).Significant statistic differences were also found among the rates in plain,hill,mountain and other areas(χ2=350.8,P0.001).Conclusion Various measures should be taken to increase the case detection efficiency of people with suspected PTB symptoms in China.