title: Recurrent tuberculosis in an urban area in China: Relapse or exogenous reinfection?
abstract: Recurrent tuberculosis is an important indicator of the effectiveness of tuberculosis control and can occur by relapse or exogenous reinfection. We conducted a retrospective cohort study on all bacteriologically confirmed tuberculosis cases that were successfully treated between 2000 and 2012 in Shanghai, an urban area with a high number but a low prevalence rate of tuberculosis cases and a low prevalence of HIV infection. Genotyping the Mycobacterium tuberculosis from clinical isolates was used to distinguish between relapse and reinfection. In total, 5.3% (710/13,417) of successfully treated cases had a recurrence, a rate of 7.55 (95% CI 7.01-8.13) episodes per 1000 person-years, more than 18 times the rate of tuberculosis in the general population. Patients who were male, age 30-59, retreatment cases, had cavitation, diabetes, drug-resistant or multidrug-resistant tuberculosis in their initial episode of tuberculosis, were at high risk for a recurrence. Among 141 recurrent cases that had paired isolates, 59 (41.8%) had different genotypes, indicating reinfection with a different strain. Patients who completed treatment were still at high risk of another episode of tuberculosis and exogenous reinfection contributed a significant proportion of the recurrent tuberculosis cases. Targeted control strategies are needed to prevent new tuberculosis infections in this setting.
authors.affiliation: Department of Tuberculosis Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhong Shan Road, Shanghai, 200336, China; The Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Institutes of Biomedical Sciences and Institute of Medical Microbiology, School of Basic Medical Science, Fudan University, Shanghai, 200032, China.
authors.forename: Xin
authors.initials: X
authors.lastname: Shen
authors.affiliation: The Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Institutes of Biomedical Sciences and Institute of Medical Microbiology, School of Basic Medical Science, Fudan University, Shanghai, 200032, China; Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, 60 College Street, New Haven, CT, 06510, USA.
authors.forename: Chongguang
authors.initials: C
authors.lastname: Yang
authors.affiliation: Department of Tuberculosis Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhong Shan Road, Shanghai, 200336, China.
authors.forename: Jie
authors.initials: J
authors.lastname: Wu
authors.affiliation: Department of Tuberculosis Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhong Shan Road, Shanghai, 200336, China.
authors.forename: Senlin
authors.initials: S
authors.lastname: Lin
authors.affiliation: The Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Institutes of Biomedical Sciences and Institute of Medical Microbiology, School of Basic Medical Science, Fudan University, Shanghai, 200032, China.
authors.forename: Xu
authors.initials: X
authors.lastname: Gao
authors.affiliation: Department of Tuberculosis Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhong Shan Road, Shanghai, 200336, China.
authors.forename: Zheyuan
authors.initials: Z
authors.lastname: Wu
authors.affiliation: The Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Institutes of Biomedical Sciences and Institute of Medical Microbiology, School of Basic Medical Science, Fudan University, Shanghai, 200032, China.
authors.forename: Jiyun
authors.initials: J
authors.lastname: Tian
authors.affiliation: The Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Institutes of Biomedical Sciences and Institute of Medical Microbiology, School of Basic Medical Science, Fudan University, Shanghai, 200032, China.
authors.forename: Mingyu
authors.initials: M
authors.lastname: Gan
authors.affiliation: The Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Institutes of Biomedical Sciences and Institute of Medical Microbiology, School of Basic Medical Science, Fudan University, Shanghai, 200032, China.
authors.forename: Tao
authors.initials: T
authors.lastname: Luo
authors.affiliation: Department of Tuberculosis Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhong Shan Road, Shanghai, 200336, China.
authors.forename: Lili
authors.initials: L
authors.lastname: Wang
authors.affiliation: Department of Tuberculosis Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhong Shan Road, Shanghai, 200336, China.
authors.forename: Chenlei
authors.initials: C
authors.lastname: Yu
authors.affiliation: Department of Tuberculosis Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhong Shan Road, Shanghai, 200336, China.
authors.forename: Jian
authors.initials: J
authors.lastname: Mei
authors.affiliation: Department of Tuberculosis Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhong Shan Road, Shanghai, 200336, China.
authors.forename: Qichao
authors.initials: Q
authors.lastname: Pan
authors.affiliation: School of Medicine, University of California, Davis, One Shields Avenue, Davis, CA, 95616, USA. Electronic address: kderiemer@ucdavis.edu.
authors.forename: Kathryn
authors.initials: K
authors.lastname: DeRiemer
authors.affiliation: Department of Tuberculosis Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhong Shan Road, Shanghai, 200336, China. Electronic address: yuanzhengan@scdc.sh.cn.
authors.forename: ZhengAn
authors.initials: Z
authors.lastname: Yuan
authors.affiliation: The Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Institutes of Biomedical Sciences and Institute of Medical Microbiology, School of Basic Medical Science, Fudan University, Shanghai, 200032, China. Electronic address: qiangao@fudan.edu.cn.
authors.forename: Qian
authors.initials: Q
authors.lastname: Gao
mesh_terms: D000293:Adolescent; D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use; D015373:Bacterial Typing Techniques; D002681:China / Q000453:epidemiology; D005260:Female; D005838:Genotype; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000235:genetics; D015995:Prevalence; D016016:Proportional Hazards Models; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014376:Tuberculosis / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission*; D014504:Urban Health; D055815:Young Adult
chemical_list: D000995:Antitubercular Agents
keywords: China; Exogenous reinfection; Recurrence; Tuberculosis