Incomplete tuberculosis reporting and registration to the surveillance system in southwestern China of Yunnan Province: an inventory survey

Abstract

Background: The real-world tuberculosis (TB) surveillance data was generally incomplete due to underreporting and underdiagnosis. The inventory study aimed to assess and quantify the incompletion of surveillance systems in southwestern China.

Methods: The inventory study was conducted at randomly selected health facilities (HF) by multi-stage stratified cluster sampling. The participants were included in the period between August of 2020 in province-level and prefecture-level HF, and in the period between June to December of 2020 in other categories of HF respectively. The clinical committee confirmed medical records were matched to the National Notifiable Disease Reporting System (NNDRS) and the Tuberculosis Information Management System (TBIMS) to define the report and register status. The underreporting and under-register rates were evaluated based on the matched data, and factors associated with underreport and under-register were assessed by the 2-level logistic multilevel model (MLM).

Results: We enrolled 7,749 confirmed TB cases in the analysis. The province representative overall underreport rate to NNDRS was 1.6% (95% confidence interval, 95% CI, 1.3 - 1.9), and the overall under-register rate to TBIMS was 9.6% (95% CI, 8.9-10.3). The various underreport and under-register rates were displayed in different stratifications of background TB disease burden, HF level, HF category, and data source of the medical record in HF among prefectures of the province. The intraclass correlation coefficient (ICC) was 0.57 for the underreporting null MLM, indicating the facility-level cluster effect contributes a great share of variation in total variance. The two-level logistic MLM showed the data source of medical records in HF, diagnostic category of TB, and type of TB were associated with underreporting by adjusting other factors (p < 0.05). The ICC for under-register was 0.42, and the HF level, HF category, data source of medical records in HF, diagnostic category of TB and type of TB were associated with under-register by adjusting other factors (p < 0.05).

Conclusion: The inventory study depicted incomplete TB reporting and registering to NNDRS and TBIMS in southwestern China. It implied that surveillance quality improvement would help advance the TB prevention and control strategy.

Keywords: Register; Report; Surveillance; Tuberculosis.

Fig. 1

The flowchart and Venn diagram of the study. A The flowchart of the study. B The Venn diagram of the relationship for the obtained medical records matched with NNDRS and TBIMS. Abbreviations: TB, tuberculosis; NTM, nontuberculous mycobacteria, NNDRS, National Notifiable Disease Reporting System; TBIMS, Tuberculosis Information Management System

Fig. 2

The brief information of investigation and the TB disease burden of study sites in Yunnan, China. A the reported and registered rate of TB in prefectures of Yunnan in 2020. B the reported and registered number of TB in prefectures of Yunnan in 2020. C the locations, levels, categories of investigated health facilities, and the enrolled number of participants. Abbreviations: TB, tuberculosis; HF, health facility; DHF, designated health facility; NDHF, non-designated health facility

Fig. 3

The circular plot of underreport and under-register TB at the facility level among prefectures in Yunnan, China. A the underreport rate stratified by prefectures and burden of TB disease. B the under-register rate stratified by prefectures and burden of TB disease. C the underreport rate stratified by prefectures and level of health facilities. D the under-register rate stratified by prefectures and level of health facilities. E the underreport rate stratified by prefectures and category of health facilities. F the under-register rate stratified by prefectures and category of health facilities. G the underreport rate stratified by prefectures and data source of MR in health facilities. H the under-register rate stratified by prefectures and data source of MR in health facilities. Abbreviations: TB, tuberculosis; HF, health facility; DHF, designated health facility; NDHF, non-designated health facility; MR, medical records

Fig. 4

The fixed effects of factors associated with underreport TB in Yunnan, China. A the unadjusted fixed effects of factors associated with underreport TB. B the adjusted fixed effects of factors associated with underreport TB. Abbreviations: TB, tuberculosis; HF, health facility; DHF, designated health facility; NDHF, non-designated health facility; PTB, pulmonary tuberculosis; TBP, tuberculous pleurisy; MDR-TB, multi-drug resistant tuberculosis

Fig. 5

The fixed effects of factors associated with under-register TB in Yunnan, China. A the unadjusted fixed effects of factors associated with under-register TB. B the adjusted fixed effects of factors associated with under-register TB. Abbreviations: TB, tuberculosis; HF, health facility; DHF, designated health facility; NDHF, non-designated health facility; PTB, pulmonary tuberculosis; TBP, tuberculous pleurisy; MDR-TB, multi-drug resistant tuberculosis