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; 366:2161-2170June 7, 2012DOI: 10.1056/NEJMoa1108789

Drug-resistant tuberculosis, especially multidrug-resistant (MDR) and extensively

drug-resistant (XDR) tuberculosis, is a major threat to the control of tuberculosis
worldwide.1-3 To date, estimates of drug-resistant tuberculosis in countries with the
highest burden of tuberculosis, including China, have relied on local or regional
surveys. China has carried out surveys of antituberculosis-drug resistance in 10 of its
31 provinces. All the provinces had levels of MDR tuberculosis above the global
median, and some have been classified as global hotspots of MDR tuberculosis.4-6

Studies have consistently identified prior treatment for tuberculosis as a risk factor for
drug-resistant tuberculosis.7-12 Although other risk factors have been identified, they
have generally not been useful in developing effective responses to this public health
threat.8,9,11-16 To help China develop a national response to drug-resistant
tuberculosis, the Chinese Center for Disease Control and Prevention (CDC)
conducted a national surveillance survey of drug-resistant tuberculosis. The objectives
of the survey were to determine the proportion of tuberculosis cases that are resistant
to drugs, estimate the incidence of drug-resistant tuberculosis, and identify the factors
that are linked to drug-resistant tuberculosis, especially to MDR tuberculosis.

Methods

Sampling Method

The National Tuberculosis Reference Laboratory (NTRL) of the Chinese CDC

conducted the survey. Cluster-randomized sampling was used to obtain a
representative sample of patients with tuberculosis in China.17 The sample size for
patients with new cases of smear-positive tuberculosis was set at 3542 patients, with
the assumption that 6% of the tuberculosis cases would be resistant to rifampin and
that 15% of the culture samples would be lost owing to failure to recover the culture
or to growth of nontuberculous mycobacteria, with a precision of 1.2% for the 95%
confidence interval and a design effect of 2 (which translates into a doubling of the
sample size). The design effect was set at 2 (by convention) to account for
heterogeneity in resistance between clusters. The sample size for patients with
previously treated tuberculosis was set at 1189 patients, with the same assumptions,
except that the expected proportion of rifampin resistance was 16% and the desired
precision for the 95% confidence interval was 3.2%.
On the basis of the requirements for sample size and the desire to complete the study
in 9 months, the decision was made to select 70 clusters nationwide. The number of
clusters assigned to each province was proportional to the number of new smear-
positive cases reported by that province relative to the total number of cases
nationwide in 2004 and 2005; in addition, it was determined that all provinces should
have at least one cluster. The recruitment target per cluster was 51 patients with new
cases of tuberculosis and 17 with previously treated cases.

For the cluster sampling, the primary sampling unit was the local tuberculosis clinic at
the county or district level; the tuberculosis clinic is the public health center that
provides outpatient tuberculosis services throughout China and is usually located at
the local site of the CDC. In 2005, there were 2635 local tuberculosis clinics in China.
The list of tuberculosis clinics in each province, with the average number of patients
with new cases of smear-positive tuberculosis who were notified in 2004 and 2005,
was used as the sampling frame. Cluster sampling with a probability proportional to
the number of patients with new cases of smear-positive tuberculosis was used to
select the local tuberculosis clinics in each province.

Eligible patients had smear-positive tuberculosis that was newly registered during the
survey period at tuberculosis clinics selected as sample sites. Patients with new cases
were those who had tuberculosis that had never been treated with tuberculosis drugs
or that had been treated for less than 1 month. Patients with previously treated cases
were those who had been treated for tuberculosis for 1 month or longer.18
Consecutive patients with new or previously treated cases of smear-positive
tuberculosis were enrolled in each cluster.

Study Oversight

The study was approved by the Tuberculosis Research Ethics Review Committee of
the China CDC. Written informed consent was obtained from each participant. All the
authors vouch for the completeness and accuracy of the data presented.

Collection of Patient Information

Two trained interviewers separately interviewed each enrolled patient, with the use of
a standard questionnaire, to collect sociodemographic data and information on
previous treatment for tuberculosis. No information on status with respect to human
immunodeficiency virus (HIV) infection was collected. Discrepant interview data
were resolved by a third interviewer.

Bacteriologic Examinations

Two sputum samples for culturing were obtained from each eligible patient before the
initiation of treatment. For isolation of the culture, each specimen was treated with
one volume of 4% sodium hydroxide per one volume of sputum and was then
homogenized by vigorous stirring. An aliquot of 0.1 ml of the resulting specimen was
inoculated into two tubes of acidified LwensteinJensen medium and incubated at
37C. The culture was assessed during week 1 for rapidly growing bacteria and again
every week thereafter for slower growing bacteria; if no bacteria grew by 8 weeks, the
result was recorded as negative. Cultures with growing colonies were sent to the
NTRL for identification and drug-susceptibility testing. Growth characteristics,
morphologic characteristics of the colony, and the test for inhibition by P-nitrobenzoic
acid were used to differentiate Mycobacterium tuberculosis from other mycobacteria.

Drug-susceptibility testing was performed after subculturing with the use of

LwensteinJensen medium. Drug susceptibility was determined by means of the
proportion method, with the following concentrations for the six tuberculosis drugs in
the survey: 0.2 g per milliliter for isoniazid, 4 g per milliliter for streptomycin, 40
g per milliliter for rifampicin, 2 g per milliliter for ethambutol, 2 g per milliliter
for ofloxacin, and 40 g per milliliter for kanamycin.19 The critical growth
proportion for resistance was 1% for all drugs. The NTRL participates in the annual
proficiency review of drug-susceptibility testing organized by the Hong Kong
Supranational Tuberculosis Reference Laboratory and has passed each review since
2003.

Statistical Analysis

Data were entered independently by two persons with the use of Epi Info software,
version 3.5 (CDC). The study design was taken into account in the statistical analyses.
The standard error was adjusted for clustering on the primary sampling unit. The
sampling design requires an equal number of new cases in all the clusters. Because of
variation among the clusters in the number of cases with drug-susceptibility testing,
the sampling weight was given as the reciprocal of the numbers of patients with
results of drug-susceptibility testing in each cluster.

Methods published by the World Health Organization (WHO) were used to calculate
the incidence of drug-resistant tuberculosis in China.4 We estimated the incidence of
drug-resistant cases among patients with new or relapsed cases of tuberculosis by
multiplying the 2007 WHO estimate of the incidence of tuberculosis in China (which
includes both new and relapsed cases) by the proportion of new and relapsed cases
that were drug-resistant.4,20 A patient was considered to have had a relapsed case of
tuberculosis if he or she was given drugs for the treatment of tuberculosis and
completed a course of treatment or was cured, and tuberculosis developed again. We
estimated the incidence of acquired drug-resistant tuberculosis by multiplying the
estimated incidence of previously treated but nonrelapsed cases of tuberculosis by the
proportion of those cases that were drug-resistant.

The odds ratio was used to evaluate univariate risk factors associated with MDR
tuberculosis and with drug-resistant (but not MDR) tuberculosis. Variables with a P
value of less than 0.15 in the univariate analysis and other relevant variables were
used in logistic-regression modeling designed for survey data. All variables were
initially included in the model, and the backward method was used to select the final
variables; the models were compared with the use of the maximum rescaled R2
statistic. The statistical interaction between relevant variables was explored. The
statistical analyses were performed with the use of SAS software, version 9.1 (SAS).

Results

Patients
Patient recruitment began on April 1, 2007, and ended on December 31, 2007. A total
of 4606 patients were enrolled in the study; an additional 17 patients were invited to
participate but declined. Cultures of specimens from 537 patients (11.7%) did not
grow mycobacteria or were contaminated. Of the 4069 patients with a positive
mycobacterial culture, 140 patients (3.4%) had nontuberculous mycobacteria. Results
of drug-susceptibility testing were available for 3929 patients (85.3% of all enrolled
patients): 3037 patients had new cases of tuberculosis and 892 had previously treated
tuberculosis. A total of 730 patients with previously treated tuberculosis were
recruited during the period in which the 3037 patients with new cases of tuberculosis
were recruited. Therefore, the actual proportion of patients with previously treated
cases among all patients seen at the local tuberculosis clinics was 19.4%.
Subsequently, another 162 patients with previously treated cases were recruited, for a
total of 892.

Drug-Resistant Tuberculosis

In this survey, 34.2% of the new cases of tuberculosis (95% confidence interval [CI],
30.9 to 37.6) and 54.5% of the previously treated cases (95% CI, 49.6 to 59.4) were
resistant to at least one of the four first-line antituberculosis drugs (isoniazid,
rifampin, ethambutol, and streptomycin). Overall, 5.7% of new cases (95% CI, 4.5 to
7.0) and 25.6% of previously treated cases (95% CI, 21.5 to 29.8) were MDR
tuberculosis, which was defined as disease with resistance to at least isoniazid and

rifampin (Table 1Table 1Drug Susceptibility and Resistance to First-Line and Second-
Line Antituberculosis Drugs., and Table S1 in the Supplementary Appendix, available
with the full text of this article at NEJM.org).

Another 11.2% (95% CI, 8.4 to 14.2) of patients with new cases and 16.1% (95% CI,
8.9 to 24.7) of those with previously treated cases had resistance to either isoniazid or
rifampin (but not both). Taking into account the actual proportion of previously
treated patients among all patients, approximately 1 of 4 patients with tuberculosis
had disease that was resistant to isoniazid, rifampin, or both, and 1 of 10 had MDR
tuberculosis.

Among the patients with MDR tuberculosis, 8.3% with new cases of tuberculosis
(95% CI, 2.9 to 13.6) and 8.0% with previously treated tuberculosis (95% CI, 2.2 to
13.9) had XDR tuberculosis, which was defined as resistance to at least isoniazid,
rifampin, ofloxacin, and kanamycin; in addition, 31.4% of the patients with new cases
(95% CI, 18.3 to 44.5) and 33.3% of those with previously treated cases (95% CI,
25.6 to 41.0) had disease that was resistant to either ofloxacin or kanamycin. Among
all patients with new or previously treated cases of tuberculosis, 0.5% (95% CI, 0.2 to
0.8) and 2.1% (95% CI, 0.6 to 3.5), respectively, had XDR tuberculosis.
Overall, 2.7% of patients with new cases of tuberculosis (95% CI, 1.8 to 3.6) and
8.7% of patients with previously treated tuberculosis (95% CI, 6.1 to 11.2) had
resistance to ofloxacin. However, among patients with MDR tuberculosis, 24.9% of
those with new cases of tuberculosis (95% CI, 13.1 to 36.8) and 27.5% of those with
previously treated tuberculosis (95% CI, 20.8 to 34.3) had resistance to ofloxacin.

In 2007, an estimated 110,000 incident cases of MDR tuberculosis (95% CI, 97,000 to
130,000) developed: 86,000 cases (95% CI, 76,000 to 101,000) of new or relapsed
tuberculosis and 24,000 cases (95% CI, 21,000 to 29,000) of acquired MDR
tuberculosis. There were an estimated 8200 incident cases (95% CI, 7200 to 9700) of
XDR tuberculosis: 7000 cases (95% CI, 6200 to 8300) of new or relapsed tuberculosis
and 1200 cases (95% CI, 1000 to 1400) of acquired XDR tuberculosis. Primary
transmission of drug-resistant disease accounted for 78% and 86% of incident cases of
MDR and XDR tuberculosis, respectively.

Factors Linked to Drug-Resistant Tuberculosis

Table 2

Table 2Univariate Analysis of Risk Factors for Drug-Resistant Tuberculosis (TB) in

Patients with New Cases of Tuberculosis. and Table 3Table 3Univariate Analysis of
Risk Factors for Drug-Resistant TB in Patients with Previously Treated TB. show the
results of analyses of univariate risk factors for MDR and drug-resistant (but not
MDR) tuberculosis in patients with new cases and in those with previously treated
cases, respectively, and Table 4Table 4Multivariate Analysis of Risk Factors for Drug-
Resistant TB in New and Previously Treated Cases of TB. shows the results of an
analysis of independent risk factors. In the analysis of risk factors for MDR
tuberculosis in previously treated patients, there was an interaction between the
number of prior treatment episodes and the health facility at which the last treatment
had been received; the highest risk of drug resistance was observed among patients
with multiple previous treatment episodes whose last treatment had been received in a
tuberculosis hospital. Tuberculosis hospitals are hospitals that specialize in the
treatment of tuberculosis, especially difficult-to-treat cases.

Among 226 patients with MDR tuberculosis who had received previous treatment, 99
(43.8%) had not completed their last tuberculosis treatment, whereas 127 (56.2%) had

completed their last treatment (Figure 1Figure 1Patients with Previously Treated
Tuberculosis in Whom Multidrug-Resistant Tuberculosis Was Detected, According to
Completion or Noncompletion of Their Last Treatment Course and Location of Their
Last Treatment.). Among those who had completed their last treatment, 115 (90.6%)
had relapsed tuberculosis; 71 of the patients with relapsed tuberculosis (61.7%) had
received their last treatment in the CDC system.

Discussion

The results of this nationwide survey in China confirm that the country has a serious
epidemic of drug-resistant tuberculosis. In 2007, one third of the patients with new
cases of tuberculosis and one half of the patients with previously treated tuberculosis
had drug-resistant disease. At 5.7%, the prevalence of MDR tuberculosis among new
cases was 3.5 times the global median and nearly twice the global average.4,5 In
addition, one quarter of the patients with previously treated tuberculosis had MDR
tuberculosis. XDR tuberculosis is also widespread, as evidenced by the fact that 8%
of patients with MDR tuberculosis also had XDR tuberculosis. An estimated 110,000
cases of MDR tuberculosis and 8200 cases of XDR tuberculosis developed in 2007.
With the use of the WHO estimate of MDR tuberculosis in various countries as a
reference,4 China has the highest annual number of cases of MDR tuberculosis in the
world a quarter of the cases worldwide.

Although China already has a serious epidemic of drug-resistant tuberculosis, the

situation could easily be much worse. This 2007 survey showed that, in addition to
patients with MDR tuberculosis, 11% of the patients with new cases and 16% of those
with previously treated cases had disease that was resistant to either isoniazid or
rifampin, placing them just one step away from having MDR tuberculosis. Similarly,
among patients with MDR but not XDR tuberculosis, more than one third had disease
that was resistant to either ofloxacin or kanamycin, placing them only one step away
from having XDR tuberculosis.
Prevention of drug-resistant tuberculosis, especially MDR tuberculosis, is an essential
part of tuberculosis-control programs.1 In this survey, more than 40% of patients with
MDR tuberculosis who had received previous treatment for tuberculosis had not
completed their last treatment course. This finding points to the need for interventions
that will increase continuity of treatment and reduce the rate of treatment default,
especially among patients treated within the hospital system.21 In China, patients
with tuberculosis receive treatment either at the local site of the CDC or in the
hospital system. Hospitals provide limited outpatient follow-up of patients with
tuberculosis. Therefore, the Ministry of Health has strengthened the reporting,
referral, and follow-up of patients with tuberculosis who are seen in the hospital
system.22 However, more needs to be done. The CDC system, which is responsible
for monitoring patients with tuberculosis in the community, can pilot new approaches
to improving adherence to treatment, such as mobile-phone text messaging, and can
expand their use if they prove to be effective.23,24

In addition to direct efforts to prevent MDR tuberculosis, effective treatment for MDR
and other drug-resistant forms of tuberculosis is needed to decrease the number of
prevalent cases and reduce transmission of drug-resistant M. tuberculosis.
Transmission of MDR and XDR strains of M. tuberculosis will continue to go
unchecked if there is no effective treatment program. In the coming years, China plans
to expand an effective treatment program for MDR tuberculosis that is modeled after
international best practice.20 However, the high level of resistance to ofloxacin a
drug that is in an important class of second-line tuberculosis drugs may reduce the
effectiveness of current treatment for MDR tuberculosis and of drug regimens under
development.25

Other results of our survey point to the need for additional interventions to prevent
MDR tuberculosis in China. First, 11% of patients with new cases of tuberculosis and
16% of those with previously treated tuberculosis in China's CDC system already had
disease that was resistant to either isoniazid or rifampin (but not both) before they
received standard first-line short-course treatment. Resistance to these drugs is usually
not detected because culturing and drug-susceptibility testing are not routinely
performed at the local tuberculosis clinics. The use of standard first-line drugs in the
treatment of these patients increases the risk of relapse, treatment failure, and acquired
resistance.26-29 To prevent MDR tuberculosis from developing in patients who are
being treated at the local tuberculosis clinics, testing for drug resistance should be
performed before the initiation of treatment, and the choice of treatment should be
based on the results of that testing.

Second, patients who had received multiple treatments for tuberculosis and who had
received their last treatment in a tuberculosis hospital were 13 times as likely to have
MDR tuberculosis as those who had received one prior treatment elsewhere. There are
several possible explanations for this finding: the patients may already have had MDR
tuberculosis when they were admitted to the tuberculosis hospital and then did not
receive effective treatment for MDR tuberculosis; they may have been admitted
without MDR tuberculosis and received improper treatment, which led to the
development of MDR tuberculosis; or they may have acquired MDR tuberculosis
from nosocomial transmission. Regardless of the cause, a major effort to improve
treatment in tuberculosis hospitals is needed.
Third, 11% of patients with new cases in this survey reported that they had been
treated previously with tuberculosis drugs even though they had never received a
diagnosis of tuberculosis. These patients had a higher risk of MDR tuberculosis. One
possible explanation is that these patients were suspected to have tuberculosis and
were started on tuberculosis drugs but did not actually receive a definitive diagnosis
of tuberculosis. Without a tuberculosis diagnosis, many were not followed up for this
disease. MDR tuberculosis developed in some of these patients when they took their
drugs improperly. Recently, the WHO recommended the use of the GeneXpert system
(Cepheid) to evaluate patients who are suspected to have MDR tuberculosis and those
with negative sputum smears for acid-fast bacilli.30,31 The use of this diagnostic
system can provide a definitive diagnosis for nearly all patients with pulmonary
tuberculosis. Thus, it is possible to accurately determine who needs treatment and
follow-up for tuberculosis. Appropriate follow-up of these patients during treatment
could help prevent MDR tuberculosis.32

There are several limitations of this survey. First, the burden of drug-resistant
tuberculosis was probably underestimated because patients in the hospital system
who are more likely to have drug-resistant disease were not included in the survey.
Second, the burden of XDR tuberculosis was underestimated because only resistance
to ofloxacin and kanamycin not resistance to capreomycin or other
aminoglycosides was used in the identification of XDR tuberculosis. Third, this
survey did not collect information on HIV infection status because patients with
tuberculosis in China are not routinely tested for HIV. Fourth, information on previous
treatment was based only on interviews with patients; this may have resulted in
inaccurate information regarding treatment.

This survey presents a comprehensive view of the epidemic of drug-resistant

tuberculosis in China. The country has the world's largest number of patients with
MDR tuberculosis, and primary transmission is responsible for most cases. MDR
tuberculosis is also linked to inadequate treatment in both the public health system
and the hospital system. One in four patients with tuberculosis treated in the public
health system are receiving inadequate treatment because they have disease that is
resistant to isoniazid or rifampin (or both) but are still given these first-line
tuberculosis drugs as part of standard treatment. Therefore addressing MDR
tuberculosis in China will require selection of treatment regimens on the basis of
testing for initial drug resistance. It is also important to improve treatment in
tuberculosis hospitals and enhance the continuity of treatment after patients leave the
hospitals. Ultimately, by treating patients with drug-resistant tuberculosis, China can
prevent the development of more drug-resistant forms of tuberculosis and reduce the
transmission of drug-resistant tuberculosis.

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.