ORIGINAL ARTICLE Factors contributing to the high prevalence of multidrug-resistant tuberculosis: a study from China Libo Liang, 1 Qunhong Wu, 1 Lijun Gao, 1 Yanhua Hao, 1 Chaojie Liu, 2 Yanguang Xie, 3 Hong Sun, 1 Xinglu Yan, 4 Fabin Li, 4 Honghai Li, 4 Hongxia Fang, 4,5 Ning Ning, 1 Yu Cui, 1 Liyuan Han 1 ABSTRACT Background The rapid spread of multidrug-resistant tuberculosis (MDR-TB) has attracted global concerns. This study aimed to identify factors contributing to the high prevalence of MDR-TB in China’s Heilongjiang province. Methods A cross-sectional survey following the WHO/ International Union Against Tuberculosis and Lung Disease guidelines was conducted with consecutive recruitment of patients with TB in 30 counties selected at random in Heilongjiang in 2004. A total of 1995 patients were tested for MDR-TB. Factors associated with MDR-TB were identified through multilevel models and traditional logistic regression analysis, along with in-depth interviews with nine patients, five healthcare managers and four doctors. Results 241 patients (12%) were identified with MDR- TB. The retreatment patients were 5.48 times (95% CI 4.04 to 7.44) more likely to have MDR-TB than newly diagnosed patients. The patients who were treated with isoniazid and rifampin for >180 days were 4.82 times (95% CI 2.97 to 7.81) more likely to develop MDR-TB than those treated <180 days. Age and delay in initiating TB treatment were associated with MDR-TB. Financial burden, poor knowledge and side effects of TB treatment were perceived by the interviewees as influencing factors. Lack of coordination of services, unsatisfactory supervision of treatment and infection control jeopardised the control of MDR-TB. Conclusions Inappropriate treatment is the most important influencing factor of MDR-TB. Increasing people’s awareness of TB, early detection and appropriate treatment of patients with TB should become a priority, which requires strong commitment and collaboration among health organisations and greater compliance with TB treatment guidelines by service providers and patients. INTRODUCTION The rapid expansion of multidrug-resistant tuber- culosis (MDR-TB; ie, resistance to isoniazid and rifampin) has jeopardised global control of TB. 1 MDR-TB exacerbates the existing grim TB epidemic, poses a great threat to global TB control and incurs a huge burden on developing countries due to its difficult, expensive, less effective and toxic treatment. 12 China carries the greatest burden of MDR-TB. The number of MDR-TB cases is the highest in the world despite having the second highest number of TB cases. 3 4 It has been estimated that about 100 000 new MDR-TB cases emerge every year in China. 3 Alarmed by the serious MDR-TB epidemic, the Chinese government has commenced action. 5 Joint TB control programmes with international partners have been initiated but progress has been far from satisfactory. 6 The prevalence of MDR-TB has continued to rise. 7 It is critical to identify the underlying reasons for MDR-TB so that more feasible and cost-effective approaches can be developed to control MDR-TB. Studies in some countries have identified retreat- ment, alcohol abuse, age, and immigrant status as factors influencing MDR-TB. 8e11 This study was undertaken in Heilongjiang province, in northeast China, where the proportion of MDR-TB (12.1%) was estimated to be one of the three highest in the country, much higher than the national average of 8.32% in 2007. 12 Unfortunately, there is a conspicuous gap in research into MDR-TB between high and low prevalence regions in China. 7 Despite some studies carried out in low-prevalence regions, 13 14 the factors influencing MDR-TB in high-prevalence regions have rarely been investi- gated. This study aimed to identify the factors contributing to the high prevalence of MDR-TB in Heilongjiang province. METHODS Study population Heilongjiang has a population of 38.1 million and is divided into 113 counties (or districts). Thirty Key messages What is the key question? < The rapid spread of multidrug-resistant tubercu- losis (MDR-TB) has caused serious concerns in China. What is the bottom line? < The underlying causes of MDR-TB are still not clear. Why read on? < This study aimed to identify the factors contributing to the high prevalence of MDR-TB in China’s Heilongjiang province. 1 Department of Social Medicine, School of Public Health, Harbin Medical University, Harbin, Heilongjiang, People’s Republic of China 2 School of Public Health, La Trobe University, Victoria, Australia 3 Heilongjiang Provincial Center for STD Prevention and Control, Harbin, Heilongjiang, People’s Republic of China 4 Heilongjiang Provincial Center for Tuberculosis Prevention and Control, Harbin, Heilongjiang, People’s Republic of China 5 School of Public Health, Peking University, Beijing, People’s Republic of China Correspondence to Professor Qunhong Wu, School of Public Health, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, Heilongjiang 10081, People’s Republic of China; wuqunhong@163.com Libo Liang, Lijun Gao, Yanguang Xie contributed equally to this article. Received 12 February 2011 Accepted 4 January 2012 Published Online First 8 March 2012 632 Thorax 2012;67:632e638. doi:10.1136/thoraxjnl-2011-200018 Tuberculosis group.bmj.com on April 22, 2016 - Published by http://thorax.bmj.com/ Downloaded from