Rate of Patient Delay among Students with Pulmonary Tuberculosis in China: A Meta-Analysis

Jiaxin Du, Dongxia Cai, Yongfa Chen^*

International Pharmaceutical Business School, China Pharmaceutical University, Nanjing, China.

DOI: 10.4236/jbm.2023.114020                

Abstract

Objective: To systematically review the rate of patient delay of pulmonary tuberculosis (PTB) patients among students in China. Methods: Databases including Web of Science Core Collection, PubMed, The Cochrane Library, CBM, CNKI, VIP, and WANFANG DATA were electronically searched to collect cross-sectional studies on the incidence of delayed consultation in students with PTB in China from January 1, 2000, to November 15, 2022. Two researchers independently screened studies, extracted data, and assessed the risk of bias of the included studies. Meta-analysis was then performed by Stata 16.0 software. Results: In total, 60 cross-sectional studies with 260,707 cases involving 136,701 delayed consultation PTB patients were included. The results of meta-analysis showed that the rate of patient delay was 46.4% (95% CI 44.3% to 48.4%) among students with PTB in China. Results of subgroup analyses showed that: 1) The rates were 46.8% and 50.4% for male and female students, respectively. 2) The rates for the East, Central and West parts of China were 42.3%, 45.6% and 50.5%, respectively. 3) The rates were increased first and then decreased during 2007 to 2020. 4) The rates of students from primary school, junior high school, senior high school and university were 50.3%, 49.8%, 40.7% and 44.9%, respectively. 5) The rates for the Han and the other nationalities were 50.3% and 53.9%, respectively. 6) The rates for local and non-local students were 47.2% and 50.5%, respectively. 7) The rates of patients detected by consultation due to symptoms, recommendation due to symptoms, referral, tracking and healthy physical examination were 50.5%, 51.6%, 46.6%, 55.6% and 16.2%, respectively. 8) The rates of patients with initial PTB and retreatment PTB were 53.1% and 59.6%, respectively. 9) The rates of patients with positive etiology, negative etiology and without etiological results were 55.9%, 47.0% and 51.6%, respectively. 10) The rates of severe and non-severe patients were 59.4% and 52.9%, respectively. Conclusion: The patient delay rate for Chinese students with PTB is generally at a high level. There are substantial differences in the patient delay rate for students with PTB among different genders, regions, study stages, nationalities, household registration types, detection methods, and treatment classifications.

Keywords

China, Student, Pulmonary Tuberculosis, Patient Delay, Meta-Analysis, Cross-Sectional Study

1. Introduction

Tuberculosis (TB) is a chronic infectious disease that seriously endangers the health of the population, which can affect most organs of the body. Pulmonary tuberculosis (PTB) caused by infection of the lungs accounts for 80% to 90% of all tuberculosis cases [1] . China is one of the 30 countries with high disease burden of TB in the world. The number of reported cases of PTB ranks the forefront of Class A and B infectious diseases, and the situation of TB prevention and control is very serious [2] . As a highly concentrated place for students, schools are prone to cause strong repercussions from students’ families and society after an outbreak of PTB. Therefore, the prevention and control of PTB in schools is particularly important in TB prevention and control in China [3] . In recent years, school PTB have occurred from time to time, and the main reason for its occurrence is the patient delay of the first case [4] . Patient delay refers to the time interval from the onset of symptoms to the first visit to a medical institution more than two weeks [5] . Due to the long incubation period, the high proportion of atypical symptoms after the onset of students, coupled with academic and public opinion pressure, students with PTB are prone to patient delay [6] , which in turn leads to adverse outcomes such as transmission of infection and even cluster epidemics on campus [7] . At present, many scholars have studied the patient delay among students with PTB in various regions of China, but the results are different due to various factors. Therefore, this study systematically evaluated the status of patient delay among students with PTB in China, in order to provide a basis for further optimizing school TB prevention and control measures.

2. Material and Methods

2.1. Inclusion and Exclusion Criteria

2.1.1. Study Type

Cross-sectional study.

2.1.2. Study Object

Students who were diagnosed as PTB by clinicians according to the Guideline for the Implementation of Tuberculosis Prevention and Control Program in China [8] , and who experienced patient delay.

2.1.3. Outcome Indicator

The rate of patient delay = the number of patients with patient delay in a certain period/the total number of patients in a certain period.

2.1.4. Exclusion Criteria

1) Studies with incomplete data or data that cannot be extracted. 2) Repeated publication. 3) Studies published in languages other than English and Chinese. 4) For the study on PTB survey of the whole population or school teachers and students in one region, the relevant data of non-students were excluded.

2.2. Search Strategies

CNKI, VIP, WANFANG DATA, CBM, Web of Science Core Collection, PubMed and The Cochrane Library databases were searched through computer to collect cross-sectional studies related to the patient delay rate of PTB patients among Chinese students. The search period was restricted from January 1, 2000, to November 15, 2022. Key search terms were “China”, “Chinese”, “student”, “school”, “college”, “pulmonary tuberculosis”, “tuberculosis”, “diagnose”, “consultation”, “delay”, and “patient delay”. Logical operators (i.e., OR, AND) were used to shape the search strategy. The detailed search strategy for PubMed is presented as examples (Figure 1).

2.3. Studies Screening and Data Extraction

Two researchers independently screened studies retrieved, extracted data from studies included, and cross-checked the results. In case of disagreement, it was resolved through discussion or negotiation with a third person. When screening

Figure 1. The search strategy for PubMed.

studies, read the title and abstract first. After excluding the obviously unrelated studies, read the full text to determine whether it is finally included. When necessary, we would contact the original research author to obtain the missing data. Data extraction included: first author, year of publication, study area, gender, study stage, sample size, the number of patients with patient delay and the patient delay rate.

2.4. Bias Risk Assessment of Included Studies

Two researchers independently evaluated the risk of bias of the included studies and cross-checked the results. The risk of bias was assessed using the cross-sectional study bias risk assessment criteria recommended by the Agency for Healthcare Research and Quality (AHRQ) [9] . The answer was “yes”, “no” or “unclear”, where “yes” represents 1 point, and “no or unclear” represents 0 point.

2.5. Statistical Analysis

Stata 16.0 software was used for statistical analysis. The heterogeneity between the included studies was analyzed by Q test (test level α = 0.1), and the heterogeneity was quantitatively judged by I-square, with I² statistics of 25%, 50%, and 75% set as the cut-offs for low, moderate, and high heterogeneity, respectively [10] . If there was no statistical heterogeneity between the results of each study (I² ≤ 50%), the fixed effect model was used for meta-analysis. If there was (I² > 50%), the source of heterogeneity was further analyzed. After excluding the influence of obvious clinical heterogeneity, a random effect model was used for meta-analysis. Subgroup analysis or sensitivity analysis was used for severe heterogeneity, or only descriptive analysis was performed.

3. Results

3.1. Search Outcomes

A total of 4756 relevant studies were obtained. After careful screening, 60 cross-sectional studies were finally included, including 260,707 students with PTB and 136,701 PTB students with patient delay. The flow of screening of studies for inclusion is shown in Figure 2.

3.2. Main Characteristics and Bias Risk Assessment Results of Included Studies

The main characteristics of the included studies are shown in Table 1, and the results of bias risk assessment are shown in Table 2.

3.3. Results of Meta-Analysis

3.3.1. Rate of Patient Delay

A total of 60 studies were included. The results of meta-analysis using a random effect model showed that the patient delay rate of Chinese students with PTB was 46.4% (95% CI 44.3% to 48.4%) (Table 3).

Figure 2. Flow diagram of screening of studies for inclusion. *The retrieved database and the number of studies searched are as follows: PubMed (n = 1191), Web of Science Core Collection (n = 233), The Cochrane Library (n = 284), CBM (n = 712), CNKI (n = 1044), WANFANG DATA (n = 1116), and VIP (n = 176).

Table 1. Main characteristics of the studies included.

Table 2. Results of bias risk assessment of included studies.

1) Define the source of information (survey, record review). 2) List inclusion and exclusion criteria for exposed and unexposed subjects (cases and controls) or refer to previous publications. 3) Indicate time period used for identifying patients. 4) Indicate whether or not subjects were consecutive if not population-based. 5) Indicate if evaluators of subjective components of study were masked to other aspects of the status of the participants. 6) Describe any assessments undertaken for quality assurance purposes (e.g., test/retest of primary outcome measurements). 7) Explain any patient exclusions from analysis. 8) Describe how confounding was assessed and/or controlled. 9) If applicable, explain how missing data were handled in the analysis. 10) Summarize patient response rates and completeness of data collection. 11) Clarify what follow-up, if any, was expected and the percentage of patients for which incomplete data or follow-up was obtained.

Table 3. Meta-analysis results of the patient delay rate of Chinese students with PTB.

3.3.2. Results of Subgroup Analyses

Subgroup analyses were performed according to gender, region, study stage, nationality, household registration type, detection method, treatment classification, diagnosis results and other factors. Meta-analysis results showed that: 1) The patient delay rates of male and female students with PTB were 46.8% and 50.4%, respectively. 2) The patient delay rates for the East, Central and West parts of China were 42.3%, 45.6% and 50.5%, respectively. 3) In 2007-2011, 2012-2014, 2015-2017 and 2018-2020, the patient delay rates of PTB patients in Chinese students were 39.7%, 46.4%, 49.0% and 28.3% respectively. 4) The patient delay rates of PTB students from primary school, junior high school, senior high school, and university were 50.3%, 49.8%, 40.7% and 44.9%, respectively. 5) The patient delay rates for the Han and the other nationalities were 50.3% and 53.9%, respectively. 6) The patient delay rates for local and non-local students were 47.2% and 50.5%, respectively. 7) The rate of PTB students detected by consultation due to symptoms was 50.5%, recommendation due to symptoms was 51.6%, referral was 46.6%, tracking was 55.6%, and healthy physical examination was 16.2%. 8) The patient delay rates of students with initial PTB and retreatment PTB were 53.1% and 59.6%, respectively. 9) The patient delay rate of patients with positive etiology was 55.9%, that of patients with negative etiology was 47.0%, and that of patients without etiological results was 51.6%. 10) The patient delay rates of severe and non-severe students were 59.4% and 52.9%, respectively. The results of subgroup analyses are detailed in Table 3.

3.4. Results of Sensitivity Analysis

Sensitivity analysis was performed by eliminating individual studies one by one. The results showed that the patient delay rate of Chinese students with PTB fluctuated within the range of 46.0% - 46.9%, suggesting that the results of meta-analysis were relatively stable.

4. Discussion

The meta-analysis results of this study showed that the patient delay rate of PTB patients among students in China was 46.4%, which was different from other related studies. Results of subgroup analyses found that the possible influencing factors leading to the patient delay of PTB patients in Chinese students included gender, study stage, nationality, household registration type, detection method, treatment classification, etc.

The results of subgroup analyses in this study showed that the patient delay rate of female students was higher than that of male students. The reason could be that the proportion of male PTB patients in students is generally higher than that of female [3] , and female patients are more likely to be ignored [52] . However, there is still a lack of relevant studies and reports at home and abroad, which needs further research. From the perspective of the detection method, the patient delay rate of patients detected through healthy physical examination was much lower than that of patients detected through consultation due to symptoms, recommendation due to symptoms, referral and tracking. This could be because students do not first visit TB prevention and control specialized agencies after the suspicious symptoms appeared, and they are prone to fail to go to the agencies in time due to various problems in the process of consultation, recommendation, referral and tracking, while the detection method of healthy physical examination is better than passive detection methods in shortening the detection time and the early use of imaging diagnostic techniques [4] . Among the passive detection methods, the patient delay rate of tracking was the highest. The reason could be that tracking is for patients who are not referred in time, so it is time-consuming and inefficient. In addition, there are also poor implementation of the TB “trinity” prevention and treatment mode in some areas, which makes the patient referral and tracking work slack, and further prolongs the treatment time [26] . The patient delay rate of students in the western region was higher than that in the eastern and central regions, which could be related to the regional economic level, medical conditions and other factors. On the one hand, due to the relatively backward economy in the western region, there is a lack of sufficient financial and material resources in the implementation of healthy physical examination, health education, school environmental health management and other measures in the school TB prevention and control. Therefore, the implementation of above-mentioned projects are relatively poor, affecting the detection rate or leading to most students do not understand the common symptoms and treatment procedures of TB [22] . On the other hand, studies have shown that medical facilities and resources are one of the important factors causing the patient delay of TB patients in China [69] . The medical and health conditions in the western region are relatively poor. Geographical obstacles and the lack of qualified health workers will affect the accessibility of students’ medical treatment. From the perspective of time, the patient delay rate of students with PTB increased first and then decreased (2018-2020). The reason could be that the release of a series of documents, such as the 13th Five-Year National Tuberculosis Control Plan and Regulation for School Tuberculosis Prevention and Control (2017 Version), has highlighted the importance of TB prevention and control in schools, and the prevention and control work has become increasingly standardized. What’s more, new diagnostic techniques have been continuously promoted in various provinces since 2017, so the diagnostic cycle of student patients has also been continuously shortened [31] . From the perspective of the distribution of study stages, the patient delay rate of students from junior high school and below was higher than that of students from senior high school and above. The possible reason is that the students are young with not-obvious symptoms, and it is not easy to carry out health education on TB prevention and control knowledge for them. Therefore, their cognitive level of relevant knowledge is low, which affects the timeliness of consultation [34] . The patient delay rate of senior high school students was the lowest, which could be related to the implementation of active health examination projects screening TB, such as senior high school entrance physical examination and college entrance physical examination [17] . The patient delay rate of minority students was slightly higher than that of the Han students. It could be related to the fact that ethnic minorities are mainly distributed in the western region [70] , where cultural exchanges are relatively blocked so that the disease stigma of students is heavy and the consultation willingness of students is low [16] . The patient delay rate of non-local students was higher than that of local students. It could be because the parents of non-local students are usually not around, and the students’ health awareness is relatively weak, so they do not seek medical advice in time [24] . The patient delay rate of students with retreatment PTB was higher than that of students with initial PTB. The possible reason is that the diagnostic specificity of imaging examination and molecular biology detection methods for retreatment PTB is low, so retreatment PTB requires longer diagnostic time than initial PTB [71] . At the same time, after the recurrence of tuberculosis-related symptoms, patients have a high probability of self-medication. Only when the drug does not work will they choose to go to the institution for treatment, resulting in a higher risk of delayed consultation [4] . From the perspective of diagnostic results, the rate of PTB patients with positive etiology was higher than that of PTB patients with negative etiology and without etiological results. The patients with positive etiology are an important source of infection for PTB, suggesting that schools should strengthen the daily monitoring work such as morning and afternoon examinations and absenteeism due to illness, and that students with suspicious symptoms of PTB should be properly examined and diagnosed as soon as possible, to reduce the risk of epidemic transmission in schools [23] . The patient delay rate of severe patients was higher than that of non-severe patients. The reason could be that severe patients are generally combined with other serious complications. When visiting medical institutions, other diseases will be diagnosed and treated first, and then TB after the condition is stable [72] . The result also suggests that patient delay may be one of the important causes of severe PTB.

The World Health Organization endorsed the End TB Strategy in 2014. China actively responded and issued the Technical Specifications for TB Prevention and Control in China (2020 Edition), indicating that China’s strategy has changed from stopping TB to ending TB [2] . Therefore, for one of the key groups of TB prevention and control plan, school students, early detection, diagnosis, and treatment should be achieved to effectively reduce the spread of TB on campus and to accelerate the decline of TB epidemic. In this regard, health departments, education administrative departments, disease control institutions, medical institutions and schools should strengthen coordination and linkage to implement the necessary measures of TB prevention and control, such as healthy physical examination, contacts screening and epidemic disposal. At the same time, it is also necessary to clarify the main responsibilities of schools in the prevention and control work, improve schools’ monitoring ability, and pay attention to the implementation of daily monitoring work, such as improving the morning and afternoon inspection of students and the monitoring of absenteeism due to illness, so as to ensure the timely and accurate early warning of TB on campus [73] . In addition, school TB health education should be strengthened to improve the cognition of TB knowledge among students, school staff and parents. Make full use of diversified ways such as courses, lectures, and new media to disseminate easy-to-understand tuberculosis-related information, establish reasonable TB awareness, reduce the disease stigma of students, improve the timeliness of patient consultation, and ensure patient treatment compliance and treatment effects.

The limitations of this study: 1) The vast majority of the data included in the study came from the Chinese Tuberculosis Information Management System, so the information obtained was limited. Factors such as the level of TB awareness, family economic level, and the category of the first consultation institution may have an impact on the patient delay rate of student patients, which needs further investigation. 2) Limited by the characteristics of single-rate meta-analysis, there was high heterogeneity in the included studies. Although subgroup analyses were performed, the heterogeneity among different studies was still high. 3) The included studies were all cross-sectional studies, and the risk of bias was difficult to avoid due to the influence of research design and subjective factors of respondents.

5. Conclusion

In summary, although the patient delay rate of PTB patients among Chinese students has declined in recent years, it is generally at a high level. Students in the western region, female students, students from junior high school and below, students with retreatment PTB, and students detected by passive detection methods still have a high patient delay rate. Due to the limited quantity and quality of the included studies, more high-quality studies are needed to verify the above conclusions.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References

[1]	Miao, R.F., Wang, R., Li, C., Yang, C., Xu, K., Zhang, D.W. and Jiang, Y. (2022) Epidemiological Characteristics and Temporal Trends of Pulmonary Tuberculosis in Nanjing from 2005 to 2020. Journal of Nanjing Medical University (Natural Sciences), 42, 1605-1613, 1620. (In Chinese)
[2]	Yao, S. and Fang, X.H. (2020) Interpretation and Consideration of 2020 Edition Technical Specifications for TB Prevention and Control in China. Journal of Tropical Diseases and Parasitology, 18, 137-141. (In Chinese)
[3]	Chen, H., Xia, Y.Y., Zhang, C.Y., Cheng, J. and Zhang, H. (2019) Epidemic Trends and Characteristics of Pulmonary Tuberculosis in Students in China from 2014 to 2018. Chinese Journal of Antituberculosis, 41, 662-668. (In Chinese)
[4]	Ma, B.Z., Zhao, X.Y., Liang, D., Wei, Y.J., Li, E.C., Wang, Z.C. and Jiang, M.X. (2022) Health-Care Seeking Delay in Students with Pulmonary Tuberculosis and Its Influencing Factors in Qinghai, 2011-2020. Disease Surveillance, 37, 1032-1036. (In Chinese)
[5]	Tuberculosis Control Project Office of the Ministry of Health of the People’s Republic of China (1995) Working Manual of World Bank Loaned China tuberculosis Control Project. 2nd Edition, Tuberculosis Control Project Office of the Ministry of Health of the People’s Republic of China, Beijing, 22-23. (In Chinese)
[6]	Chen, W., Chen, Q.L., Xia, Y.Y. and Cheng, S.M. (2013) Analysis of the Characteristics of National TB Epidemic Situation in Schools from 2008 to 2012. Chinese Journal of Antituberculosis, 35, 949-954. (In Chinese)
[7]	Ding, S.H., Wan, Q.L. and Pan, E.C. (2019) Epidemiological Investigation of a Tuberculosis Cluster Epidemic in One School. Chinese Journal of School Health, 40, 1423-1425. (In Chinese)
[8]	Bureau of Disease Control and Prevention, Ministry of Health of China (2009) Guideline for the Implementation of Tuberculosis Prevention and Control Program in China (2008). Peking Union Medical College Press, Beijing.
[9]	Rostom, A., Dube, C., Cranney, A., et al. (2004) Celiac Disease. Appendix D. Quality Assessment Forms. Evidence Reports/Technology Assessments, No. 104, Agency for Healthcare Research and Quality (US), Rockville, MD. http://www.ncbi.nlm.nih.gov/books/NBK35156/
[10]	Higgins, J.P., Thompson, S.G., Deeks, J.J. and Altman, D.G. (2003) Measuring Inconsistency in Meta-Analyses. BMJ, 327, 557-560. https://doi.org/10.1136/bmj.327.7414.557
[11]	Xie, Y.T., Gao, H.J., Wu, Y., Wang, S.S., Kang, W.L. and Liu, Y. (2021) Influencing Factors of Patient Delay and Diagnosis Delay among Tuberculosis Patients in Schools of Tongzhou District, Beijing, 2014-2019. Chinese Journal of Antituberculosis, 43, 506-512. (In Chinese)
[12]	Lin, S., Lu, L., Yang, Y., Liu, W.J., Ma, Y.Z., Wang, Y.Z. and Zhang, G.Y. (2012) Analysis of the Causes and Countermeasures of Delayed Treatment of Newly Diagnosed Pulmonary Tuberculosis Patients in Mountainous Areas of Northern Hebei. Hebei Medical Journal, 34, 1395-1397. (In Chinese)
[13]	Fan, H., Liu, Z.H., Chen, Q.C., Liu, G.B., Chen, J.F., Gong, F., Lin, X.S., Zhang, Y.B., Hu, J.X. and Liu, J.X. (2021) Screening Data of Contacts with Pathogen Positive Cases of Pulmonary Tuberculosis in College and Middle School Students at Yuexiu District, Guangzhou from 2014 to 2018. International Medicine & Health Guidance News, 27, 1593-1596. (In Chinese)
[14]	Wang, Y.H., Zhu, G.Y., Ge, R., Mao, R. and Chen, Z.W. (2022) Epidemiology and Associated Factors of Delay for Tuberculosis Treatment among Schools in Jiaxing during 2011-2020. Chinese Journal of School Health, 43, 1561-1564. (In Chinese)
[15]	Wang, B.P., Zhao, X., Yang, J.Y., Li, J.L. and Chen, W. (2022) Health-Care Seeking Delay among Local and Nonlocal Pulmonary Tuberculosis Patients and Its Influencing Factors in Guizhou, 2015-2020. Disease Surveillance, 37, 1015-1020. (In Chinese)
[16]	Liu, Y., Ma, X.X., Huang, A.J., Chen, H.J. and Li, J.L. (2022) Prevalence of Tuberculosis among Han and Minority Students in Guizhou, 2010-2019. Modern Preventive Medicine, 49, 2744-2750. (In Chinese)
[17]	Pang, Y., Wu, C.G., Wang, Q.Y. and Zhang, T. (2021) Pulmonary Tuberculosis Epidemic Characteristics among Students of Chongqing, 2014-2020.China Tropical Medicine, 21, 861-864. (In Chinese)
[18]	Xu, L.J., Wu, X.F., Lang, S.L. and Zhang, X. (2022) Incidence Trend and Epidemiological Characteristics of Pulmonary Tuberculosis in Students in Inner Mongolia, 2015-2020. Disease Surveillance, 37, 331-335. (In Chinese)
[19]	Xiao, Y., Xia, L., Xia, Y., Rao, Z.Y., Li, Y.K. and Chen, C. (2022) Analysis of Epidemic Characteristics of Pulmonary Tuberculosis among Students in Sichuan from 2016 to 2020. Chinese Journal of Antituberculosis, 44, 777-783. (In Chinese)
[20]	Lin, X.S. and Chen, Q.C. (2021) Epidemic Characteristics and Screening of Pulmonary Tuberculosis among Students in Yuexiu District, Guangzhou from 2016 to 2020. Guangzhou Medical Journal, 52, 101-107. (In Chinese)
[21]	Hu, J., Gu, W.L., Wang, Y.H., Chen, Z.W., Du, Z.Q., Shen, G.C. and Xu, R.Q. (2021) Influencing Factors for Delay of Pulmonary Tuberculosis Case Finding in Students in Jiaxing, Zhejiang, 2010-2019. Disease Surveillance, 36, 1021-1024. (In Chinese)
[22]	Cao, H., Ning, Z. and Xie, Y. (2021) Epidemiological Characteristics of Tuberculosis among Students in Zigong from 2014 to 2019. Journal of Preventive Medicine Information, 37, 301-307. (In Chinese)
[23]	Li, Y., Gao, F.H., Bian, W.J. and Wang, M. (2021) Analysis on the Delay and Influence Factors of Tuberculosis Detection among Students in Zibo from 2010 to 2019. Modern Preventive Medicine, 48, 1115-1118. (In Chinese)
[24]	Bai, L.L., Chen, H., Huang, Y., Zhang, B.B. and Tian, Y.Q. (2021) Determinants of the Delay in Case-Finding, Treatment, and Diagnosis among Students Tuberculosis Patients in Guiyang from 2014 to 2020. Chinese Journal of School Health, 42, 1776-1780, 1784. (In Chinese)
[25]	Qiu, Q.W. (2021) Epidemic Trend Prediction of Tuberculosis and Influencing Factors of Delay in Medical Treatment in Panyu District, Guangzhou from 2005 to 2020. Jinan University, Guangzhou. (In Chinese)
[26]	Ma, X.X., Guo, X.L., Chen, H.J., Zhou, J., Hong, F. and Li, J.L. (2021) Delay of Pulmonary Tuberculosis Care-Seeking and Its Influencing Factors among Students in Guizhou Province. Modern Preventive Medicine, 48, 3210-3215. (In Chinese)
[27]	Ma, X.X., Chen, H.J., Guo, X.L., Liu, Y., Zhou, J., Lei, S.G., Hong, F. and Li, J.L. (2021) Epidemiological Characteristics of Pulmonary Tuberculosis in Schools in Guizhou, 2011-2019. Disease Surveillance, 36, 1133-1137. (In Chinese)
[28]	Chen, W.H., Zhou, Q., Liu, Y.M., Zheng, M.L., Zhuo, W.J., Yu, M.L. and Liu, Z.H. (2022) Delay in Diagnosis and Treatment of 723 Students with Pulmonary Tuberculosis in Some Specialized Hospital. International Medicine & Health Guidance News, 28, 2722-2726. (In Chinese)
[29]	Li, W.H. (2021) Study on the Spatio-Temporal Clustering Rules and Influence Factor of Pulmonary Tuberculosis in Dongguan City. Guangdong Pharmaceutical University, Guangzhou. (In Chinese)
[30]	Chen, W.K. (2012) Epidemiological Analysis of Pulmonary Tuberculosis among Middle School Students in Rizhao City from 2007 to 2010. Preventive Medicine Tribune, 18, 711-712. (In Chinese)
[31]	Li, C., Ding, S.N., Yang, C. and Zhang, H.Y. (2021) Epidemiological Characteristics Analysis of Pulmonary Tuberculosis among Students in Nanjing, 2011-2019. Modern Preventive Medicine, 48, 1165-1168. (In Chinese)
[32]	Cheng, D.M. and Tao, R. (2021) Analysis on the Situation and Influencing Factors of Treatment Delay of Pulmonary Tuberculosis Patients, Taiyuan City, 2015-2019. Preventive Medicine Tribune, 27, 110-112, 117. (In Chinese)
[33]	Chen, D., Liu, X.Y. and Zhang, X.Y. (2020) Analysis of Pulmonary Tuberculosis among Students in Huangshan City from 2013 to 2018. Anhui Journal of Preventive Medicine, 26, 49-51, 18. (In Chinese)
[34]	Sun, H.Y., Li, S., Wang, Z.D., Ren, Z.S., Song, S., Xue, B., Zhang, H.Q. and Dai, X.Q. (2020) Characteristics of the Tuberculosis Epidemic in Schools in Qingdao in 2010-2019. Chinese Journal of Antituberculosis, 42, 994-997. (In Chinese)
[35]	Fan, L.Y. (2020) Epidemiological Characteristics of Active Tuberculosis among Students in Shanxi Province and the Prediction Effect of ARIMA-Elman Combination Model. Shanxi Medical University, Taiyuan. (In Chinese)
[36]	Sun, H.Y., Peng, B., Duan, J.C., Yang, X.R., Xu, Q., Yan, C.W., Luo, L. and Tang, G. (2019) Analysis of Epidemiological Characteristics of 414 Middle School Students with Tuberculosis in Mianyang City from 2014 to 2018. Journal of Preventive Medicine Information, 35, 1018-1022. (In Chinese)
[37]	Sun, H.Y., Duan, J.C., Yan, C.W., Yang, X.R., Luo, L. and Tang, G. (2019) Analysis of Characteristics of Delayed Visiting in the Students’ Patients with Tuberculosis in Mianyang City from 2014 to 2018. Journal of Tuberculosis and Lung Health, 8, 90-93. (In Chinese)
[38]	Feng, D.Z., He, F.H., Ding, S.H. and Wan, Q.L. (2019) Epidemiological Analysis of Pulmonary Tuberculosis among Students in Huaian, 2012-2017. Modern Preventive Medicine, 46, 411-414. (In Chinese)
[39]	Xie, T., Liu, C.G., Duan, X.F. and Liu, H. (2017) Epidemiological Characteristics of Tuberculosis in Schools in Shihezi District, 2015-2017. Journal of Bingtuan Medicine, 105, 63-65. (In Chinese)
[40]	Wang, X.Y. and Sun, G.H. (2018) Epidemiologic Feature of Pulmonary Tuberculosis among Students in Guangyuan City from 2011 to 2017. Journal of Preventive Medicine Information, 34, 1323-1328. (In Chinese)
[41]	Wang, L. and Liao, X.W. (2018) Epidemiological Characteristics of Pulmonary Tuberculosis among Students in Zhuzhou. Jiangsu Journal of Preventive Medicine, 29, 189-190. (In Chinese)
[42]	Wang, B. (2018) Analysis and Trend Forecast of the Prevalence of Tuberculosis in Schools from 2007 to 2017 in Gansu Province. Lanzhou University, Lanzhou. (In Chinese)
[43]	Ma, X.P. (2018) Study on the Delay in Detection and Influencing Factors among Patients with New Active Pulmonary Tuberculosis in Jining. Shandong University, Jinan. (In Chinese)
[44]	Ma, J.J., Yuan, Y.L., Zhang, T.J., Gao, Y. and Wang, Y.L. (2018) Epidemiological Characteristics of Tuberculosis Patients and Clinic Visiting among Floating Population in Jilin Province. Chinese Journal of Public Health, 17, 29-32. (In Chinese)
[45]	Lu, J., Liao, P., Wang, D.X., Xia, Y. and He, J.G. (2018) Analysis of Diagnosis and Treatment Delay of New Smear Positive Pulmonary Tuberculosis Patients in Sichuan, China, 2015. The 32nd National Academic Conference of China Anti-Tuberculosis Association and the First China Anti-Tuberculosis Science and Technology Awards Conference, Ningbo, 25 April 2018, 534-540. (In Chinese)
[46]	Li, P.F. (2018) Study on Influencing Factors of Health-Seeking Delay of Patients with Pulmonary Tuberculosis in Xinjiang during 2010-2015. Xinjiang Medical University, Urumqi. (In Chinese)
[47]	He, F.H. (2018) Analysis on Epidemic Feature of Pulmonary Tuberculosis among Students in Jinhu County in 2010-2017. Henan Journal of Preventive Medicine, 29, 904-907. (In Chinese)
[48]	Shang, X.S. (2017) Analysis of Incidence, Diagnosis and Treatment of Pulmonary Tuberculosis in Schools in Qianjiang City of Hubei Province from 2006 to 2015. Journal of Medical Pest Control, 33, 341-345. (In Chinese)
[49]	Qu, Y.H. and Huang, Y.P. (2017) Epidemiological Analysis of Pulmonary Tuberculosis among Students in Kaifeng City from 2009 to 2015. Henan Journal of Preventive Medicine, 28, 537-539. (In Chinese)
[50]	Dai, B., Jiang, H., Chen, Z.Q., Shen, J.W. and Liu, C. (2016) Epidemiological Characteristics of Pulmonary Tuberculosis among Students in Zhenjiang from 2010 to 2015. Jiangsu Journal of Preventive Medicine, 27, 315-316. (In Chinese)
[51]	Gao, H.Q., Lu, Q.L. and Niu, W.K. (2016) Epidemiological Analysis of Tuberculosis among Students in Shaoxing from 2010 to 2014. Chinese Journal of School Health, 37, 788-791. (In Chinese)
[52]	Yang, Y.B. (2015) Analysis of Tuberculosis Epidemic Characteristics and Awareness in Students Yunnan Province from 2005 to 2014. Kunming Medical University, Kunming. (In Chinese)
[53]	Zhao, Y., Luo, X.N., Li, Y. and Li, T.R. (2014) Epidemiological Analysis on TB among Students in Shapingba District of Chongqing from 2009 to 2011. Chongqing Medical Journal, 43, 2632-2636. (In Chinese)
[54]	Wu, Z.D. (2014) Analysis on the Incidence Characteristics of Pulmonary Tuberculosis among Students in Fuzhou from 2008 to 2012. Strait Journal of Preventive Medicine, 20, 76-78. (In Chinese)
[55]	Wang, W., Lian, H. and Hao, X.G. (2014) Epidemiological Characteristics of Tuberculosis among Students in Quzhou during 2005-2012: Prevention and Control. Chinese Journal of School Health, 35, 866-867. (In Chinese)
[56]	Gu, Y.Q. and Shi, Y.F. (2014) Epidemiological Characteristics of Student Cases with Pulmonary Tuberculosis in Yuyao District 2005-2011. Chinese Rural Health Service Administration, 34, 50-52. (In Chinese)
[57]	Li, J.S., Zhang, X.L. and Chen, Y. (2014) Analysis of Initial Treatment for Pulmonary Tuberculosis Patients in Active Treatment Delay Factor. Journal of Qiqihar University of Medicine, 35, 2376-1278. (In Chinese)
[58]	Shen, T.Y. and Fu, L.J. (2014) Analysis on Epidemiological Characteristics of Pulmonary Tuberculosis among Students in Shaoxing County from 2010 to 2012. Chinese Rural Health Service Administration, 34, 157-158. (In Chinese)
[59]	Zhu, X.C. (2013) Active Pulmonary Tuberculosis among Students in Shengzhou from 2005 to 2011. Chinese Rural Health Service Administration, 33, 1123-1124. (In Chinese)
[60]	Yang, Y.J., Yang, S.M., Zhuang, X.R. and Wang, N. (2013) Epidemiological Analysis on Pulmonary Tuberculosis among Middle School Students in Rizhao City, 2008-2011. Chinese Journal of Urban and Rural Industrial Hygiene, 28, 88-90. (In Chinese)
[61]	Liu, W., Zeng, L.C., Du, X.L. and Wang, Y.F. (2013) Prevalence of Pulmonary Tuberculosis among Students in Xi’an, 2005-2011. Chinese Journal of School Health, 34, 193-198. (In Chinese)
[62]	Luo, X.N., Liu, X.E. and Li, T.R. (2013) Analysis on Tuberculosis Epidemic in College Students in Shapingba District of Chongqing. Chinese Journal of Antituberculosis, 35, 891-895. (In Chinese)
[63]	Liu, Y. (2013) Analysis of the Incidence of Pulmonary Tuberculosis in Schools in Beihai from 2009 to 2012. Journal of Frontiers of Medicine, 3, 389-391. (In Chinese) https://doi.org/10.3969/j.issn.2095-1752.2013.27.488
[64]	Zhang, H.F. (2012) Epidemiology of Pulmonary Tuberculosis in Students in Taizhou, Zhejiang, 2006-2010. Disease Surveillance, 27, 375-378. (In Chinese)
[65]	Zhou, C.C., Chu, J., Geng, H., Liu, Z.M., Tao, W.W., Li, H.T., Bi, X.L., Zhen, Y.C. and Xu. L.Z. (2011) Studying the Influence of Socio-Economic Status on Delay of Treating Floating People with Pulmonary Tuberculosis. Chinese Health Service Management, 28, 554-556. (In Chinese)
[66]	Zhou, B.B., Lu, H.C., Gong, D.G. and Xu, G.Z. (2011) Epidemiological Characteristic of Student Cases with Pulmonary Tuberculosis in Yinzhou District of Ningbo City 2005-2009. Chinese Journal of School Health, 32, 599-600. (In Chinese)
[67]	Zeng, W. (2011) Study on Influencing Factors and Controlling Strategy of Delay in Consultation, Diagnosis and Treatment of New Tuberculosis (TB) Patients in Chaohu City of Anhui Province. Anhui Medical University, Hefei. (In Chinese)
[68]	Chen, H.G., Wang, T.W. and Cheng, Q.X. (2019) Gender and Time Delays in Diagnosis of Pulmonary Tuberculosis: A Cross-Sectional Study from China. Epidemiology and Infection, 147, e94. https://doi.org/10.1017/S0950268819000049
[69]	Li, Y., Ehiri, J., Tang, S., Li, D., Bian, Y., Lin, H., Marshall, C. and Cao, J. (2013) Factors Associated with Patient, and Diagnostic Delays in Chinese TB patients: A Systematic Review and Meta-Analysis. BMC Medicine, 11, Article No. 156. https://doi.org/10.1186/1741-7015-11-156
[70]	Yan, Y.P. and Li, X.Y. (2018) The Research of Ethnic Population’s Distribution and Population Gravity. Population and development, 24, 96-104. (In Chinese)
[71]	Liu, Y.D. (2021) Expert Consensus on the Diagnosis and Treatment of Retreatment Pulmonary Tuberculosis. Chinese Journal of Antituberculosis, 43, 1226-1238. (In Chinese)
[72]	Shu, Q., Zhu, J.M., Qian, H.W., Wang, Z.L. and Zhu, S.Y. (2016) Analysis of the Status and Influencing Factors of Delayed Treatment of Pulmonary Tuberculosis Patients in Jinshan District of Shanghai from 2005 to 2014. Tuberculosis Prevention and Treatment Service System Construction Seminar in 2016, Xi’an, 23 September 2016, 199-202. (In Chinese)
[73]	Sun, M.L., Zhao, J., Wang, C., Zou, D.D., Liu, J.P., Liu, Z.X., Liang, L.B. and Guan, L. (2021) School Tuberculosis Epidemic and Strategies for Prevention and Control. Chinese Journal of School Health, 42, 1444-1448. (In Chinese)