Article Text

Download PDFPDF

Under-reporting of diagnosed tuberculosis to the national surveillance system in China: an inventory study in nine counties in 2015
  1. Tao Li1,
  2. Hemant Deepak Shewade2,3,
  3. Kyaw Thu Soe4,
  4. Jeanette J. Rainey5,
  5. Hui Zhang1,
  6. Xin Du1,
  7. Lixia Wang1
  1. 1 National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
  2. 2 South-East Asia Regional Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
  3. 3 International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
  4. 4 Department of Medical Research (Pyin Oo Lwin Branch), Ministry of Health and Sports, Pyin Oo Lwin, Myanmar
  5. 5 Division of Global Health Protection, United States Centers for Disease Control and Prevention (CDC), Beijing, China
  1. Correspondence to Dr Xin Du; duxin{at}


Objective The WHO estimates that almost 40% of patients diagnosed with tuberculosis (TB) are not reported. We implemented this study to assess TB under-reporting and delayed treatment registration in nine counties in China.

Design A retrospective inventory study (record review).

Setting Counties were selected using purposive sampling from nine provinces distributed across eastern, central and western regions of China in 2015.

Primary and secondary outcome measures Under-reporting was calculated as the percentage of patients with TB not reported to TB Information Management System (TBIMS) within 6 months of diagnosis. Delayed registration was estimated as the percentage of reported cases initiating treatment 7 or more days after diagnosis. Multivariable logistic regression and an alpha level of 0.05 were used to examine factors associated with these outcomes.

Results Of the 5606 patients with TB identified from project health facilities and social insurance systems, 1082 (19.3%) were not reported to TBIMS. Of the 4524 patients successfully reported, 1416 (31.3%) were not registered for treatment within 7 days of diagnosis. Children, TB pleurisy, patients diagnosed in the eastern and central regions and patients with a TB diagnosis recorded in either health facilities or social insurance system—but not both—were statistically more likely to be unreported. Delayed treatment registration was more likely for previously treated patients with TB, patients with negative or unknown sputum results and for patients diagnosed in the eastern region.

Conclusion Almost one in every five patients diagnosed with TB in this study was unknown to local or national TB control programmes. We recommend strengthening TB data management practices, particularly in the eastern and central regions, and developing specific guidelines for reporting paediatric TB and TB pleurisy. Patient education and follow-up by diagnosing facilities could improve timely treatment registration. Additional studies are needed to assess under-reporting elsewhere in China.

  • tuberculosis
  • surveillance
  • under-reporting
  • inventory study
  • treatment registration
  • data quality

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Patient consent for publication Not required.

  • XD and LW contributed equally.

  • Contributors TL, HDS and KTS were involved in conception and study design. TL was involved in data extraction. TL, HDS, KTS, XD, JJR, HZ and LW were involved in analysis and interpretation of data. XD and LW were involved in overall supervision. HDS and KTS are involved as mentors. TL is the first author. XD and LW contributed equally to the article as senior authors.

  • Funding This project was funded by the China-US Collaborative Program on Emerging and Re-emerging Infectious Diseases (grant number (2014-2015 and 2015-2016)–3.1). The training programme was funded by the Department for International Development (DFID), UK. Project implementation was funded by the US CDC International Emerging Infections Program cooperative agreement. The study implementation as well as the open access fee for the publication is funded by the US CDC Atlanta through Combating Antimicrobial Resistant Bacteria (CARB) funds.

  • Disclaimer The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

  • Competing interests None declared.

  • Ethics approval We obtained approval for this project from the Ethics Committee of Chinese Center for Disease Control and Prevention (No 201704) and the Ethics Advisory Group of International Union Against Tuberculosis and Lung Disease (The Union) Paris, France (No 15/17, 4 April 2017). We also obtained approval from the National Center for Tuberculosis Control and Prevention of China (NCTB). The project was reviewed and approved by the US CDC. As this study involved secondary data, waiver for informed consent was sought and approved by the ethics committees.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All the data are fully available without restriction (online supplementary S1 annex).

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.