The Role of Chest X-ray in Tuberculosis Detection for High School Students in China: A Cross-sectional Study

The Role of Chest X-ray in Tuberculosis Detection for High School Students in China: A Cross-sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Role of Chest X-ray in Tuberculosis Detection for High School Students in China: A Cross-sectional Study Mei Wang, Jin Yin, Chengguo Wu, Yaling Shi, Ying Liu, Jun Rao, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4762610/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background In China, pulmonary tuberculosis (PTB) screening for children and adolescents is not only focused on family contacts, but also students in high schools. The research objective is to investigate chest X-ray (CXR) abnormalities and its risk factors. Methods From January 2022 to December 2022, PTB screening was conducted among 24577 Senior 1 and Senior 2 students in Chongqing using the Tuberculin Skin Test (TST) and CXR. Results The detection rate for suspected PTB through CXR was 0.5% (95% Confidence Interval [CI], 0.3%-0.8%), and the detection rate for PTB through CXR was 0.4% (95% CI, 0.2%-0.6%). Participants in Southeast Districts were more likely to develop PTB (Adjusted Odds Ratio [AOR], 9.6; 95% CI, 1.3–70.4). Conclusions CXR has played a significant role in PTB screening in high schools in the Chongqing. It is necessary to strengthen policy support for the Southeast Districts in Chongqing. Tuberculosis Child Adolescent Chest X-ray Figures Figure 1 Introduction Tuberculosis (TB) was the second leading cause of death from a single infectious disease in the world, after corona virus disease (COVID-19) in 2022, and the number of deaths from TB was twice that of HIV/AIDS [ 1 ]. About 1.3 million children and adolescents (aged 0–14 years) became ill with TB every year, equivalent to 12% of all people with TB globally [ 2 ]. The cumulative number of children treated between 2018 and 2022 was 2.5 million, which was 71% of the five-year target of 3.5 million set at the UN high level meeting in 2018 [ 1 ]. The treatment coverage gap is prevalent among children and adolescents. Among children and adolescents aged 5–14, 45% of cases have not been reported and treated, and 30% of cases have not been reported and treated in adolescents aged 15 and above [ 3 ]. The average notification rate of PTB among schoolchildren and adolescents in China from 2004 to 2021 was 19.3 cases per 100000 population [ 4 ]. Chongqing is a city in western of China, with notification rate of PTB among schoolchildren and adolescents at 15.4 cases per 100000 population in 2023 according to national TB surveillance system, making it the sixth highest city in China. Globally, TB screening for children and adolescents is typically focused on family contacts. In China, in addition to screening PTB among family contacts, large-scale PTB screening has also been carried out in schools, including middle school freshmen [ 5 ]. In addition, Chongqing has implemented PTB screening for Senior 2 students [ 6 ]. CXR is an important tool for PTB screening in Chinese schools, which is usually carried out by community-level medical and health care institutions, which have not received regular quality control. There was a lack of research on conducting large-scale CXR in schools for PTB screening. It was also found that there may be a PTB detection gap from previous investigation due to poor quality of CXR in school PTB screening, leading to the subsequent spread of TB epidemic [ 7 , 8 ]. The current situation of PTB screening using CXR in schools needs comprehensive investigations. Methods Study design This was a cross-sectional study which was conducted among high school students in Chongqing, China between January 2022 and December 2022 by Chongqing Municipal Institute of Tuberculosis. The radiologists and doctors who participated in this study received standardized training in reading of CXR. We evaluated the role of CXR in the TB screening among high school students. According to Guidelines for Tuberculosis Prevention and Control in Chinese Schools [ 9 ] and the local policy [ 6 ], high school students should be screened for active PTB. Freshmen in high school should undergo PTB screening upon enrollment, and they should receive another PTB screening in their second year of high school. Procedures Standardized training was provided for all radiologists and doctors for reading of CXR involved in this study, including clinical and imaging theory, as well as CXR reading practical skill. PTB screening in high school students mainly includes a consultation on suspicious symptoms of PTB, immunological examination, and a chest X-ray examination. If there was an abnormality in symptom screening or immunological examination, CXR would be conducted. For participants with contraindications to TST, or those who were unable to complete the entire process of TST, CXR would be recommended in this study. For every participant who enrolled, demographic and social information was collected, including region, age, gender and educational level. The Mantoux method was conducted in TST. During the TST procedure, which utilized either Purified Protein Derivative (PPD) from Xiang Rui, China or Chengdu Institute of Biology, China. A volume of 0.1 mL (5IU) of PPD was administered intradermally into the volar aspect of the left forearm. The measurement of the induration was taken in millimeters at the injection site after 72 hours. The national policy in China mandates the administration of the Bacillus Calmette-Guérin (BCG) vaccine at birth, with a consistently high vaccination rate that could potentially impact the reactivity of TST. Taking this into account, an induration cut-off point of ≥ 15mm (TST strong positive) was considered the criterion for conducting CXR among participants [ 10 , 11 ]. CXR was conducted at high schools using the mobile health examination vehicle equipped with digital radiography (DR) X-ray machine. Each mobile health examination vehicle needed one radiology team. Each radiology team was composed of two radiologists and at least one clinical physician. During the chest radiography process, if a suspected TB case was identified, the radiologist would immediately notify the clinical physician for confirmation, and would also promptly inform the school administrators. After the chest radiography session was concluded in a school, the radiologist and clinical physician would conduct a CXR collective review of this school to identify any abnormalities. Those with abnormal CXR went to designated medical institutions for further examination. Participants with PTB and suspected PTB were diagnosed based on China national diagnostic criteria for TB [ 12 ]. According to this diagnostic criteria, a suspected PTB case refers to an individual in whom abnormal findings are detected through chest imaging. Sample Size According to the previous PTB screening investigation in high school in Chongqing, the PTB detection rate is 34.82 cases per 100000 population [ 13 ]. The sample size was estimated at 7533 participants using the following formula, based on the allowable error of 0.1%, Type I error of 1%, and Type II error of 1%. Randomisation and Cluster Selection In this study, a stratified cluster random sampling method was utilized. Chongqing was segmented into four distinct areas based on the delineation by the local administration: the Central Urban Districts, the New West Urban Development Districts, the Northeast Districts, and the Southeast Districts. These areas varied in socioeconomic development levels. The clusters for the study were identified as high schools situated within these four regions. It was stipulated that each cluster must have a minimum of 500 participants enrolled from January 2022 to December 2022. Study participants The inclusion criteria were as follows: (1) students in high school, and (2) participants who can participate in the entire PTB screening process. The exclusion criteria were as follows: (1) participants who are unable to undergo CXR for various reasons, and (2) participants who are unwilling to participate in PTB screening. According to the inclusion and exclusion criteria, participants were continuously selected from the selected clusters until they were fully enrolled. Risk factor analysis To explore risk factor associated with PTB and suspected PTB detection in high schools in Chongqing, we have analyzed potential risk factors including grade, sex, region, and school type. Statistical analysis We calculated the proportion and 95% CI for PTB and suspected PTB detection rate. The chi-square test was used to test different detection rates. The missing data analysis for participants who were unable to undergo CXR was implemented by chi-square test. A logistic regression model was performed to assess association between detection rates and risk factors. P < 0.05 was taken as statistically significant. Statistical analyses were performed with the SPSS 22.0 software (SPSS, Inc, Chicago, IL, USA). Results The screening process for participants From January 2022 to December 2022, 24577 high school students in 21 schools participated in the research. After excluding 20843 participants (84.8%) for various reasons, 3734 (15.2%) remained with CXR implemented (Fig. 1 ). Those participants who missed the CXR due to leave or other reasons were excluded from the statistical analysis. This exclusion was made because the missing data were considered completely random and constituted a small proportion of 3.5% (129/3734). Additionally, no significant disparities were observed in the distribution of gender, grade, region, and school type between participants with and without CXR outcome (appendix, p2). Screening results In participants who were enrolled in the PTB screening, PTB detection rate was 57 cases per 100000 population. Suspected PTB detection rate was 0.5% (95%CI, 0.3%-0.8%), and PTB detection rate was 0.4%(0.2%-0.6%) through CXR (Table 1 ). Table 1 PTB screening results using TST by our team between January 2022 and December 2022 Characteristics Subgroup Participants required for CXR Participants without CXR results Suspected PTB Active PTB Suspected PTB detection rate (95% CI) PTB detection rate (95% CI) Gender Male 1723 55 10 6 0.6% (0.2%-1%) 0.4% (0.1%-0.6%) Female 2011 74 9 8 0.5%(0.2%-0.8%) 0.4%(0.1%-0.7%) Grade Senior One 1042 31 6 3 0.6%(0.1%-1.1%) 0.3%(0%-0.6%) Senior Two 2692 98 13 11 0.5%(0.2%-0.8%) 0.4%(0.2%-0.7%) Region Central Urban Districts 1472 52 3 2 0.2%(0%-0.5%) 0.1%(0%-0.5%) New West Urban Development Districts 520 25 2 1 0.4%(0%-1.5%) 0.2%(0%-1.1%) Northeast Districts 601 22 4 1 0.7%(0%-1.4%) 0.2%(0%-1%) Southeast Districts 1141 30 10 10 0.9%(0.3%-1.5%) 0.9%(0.3%-1.5%) School type Public school 2821 100 17 12 0.6%(0.3%-0.9%) 0.4%(0.2%-0.7%) Private school 913 29 2 2 0.2%(0%-0.8%) 0.2%(0%-0.8%) Total 3734 129 19 14 0.5%(0.3%-0.8%) 0.4%(0.2%-0.6%) Risk factors associated with PTB detection through CXR The risk factors associated with PTB detection through CXR were analyzed (Table 2 ). In single variable analysis, participants in Southeast Districts were more likely to develop PTB (Crude Odds Ratio [COR], 6.5; 95% CI, 1.4–29.7), and this factor was still correlated in multiple variable analysis (AOR, 9.6; 95% CI, 1.3–70.4). There were not any other risk factors identified. Table 2 Risk factors associated with PTB detection through CXR Factors Single variable analysis Multiple variable analysis COR 95% CI P AOR 95%CI P Gender (Compared with "Male") Female 0.9 0.3–2.5 0.8 0.9 0.3–2.5 0.8 Grade(Compared with "Senior One") Senior Two 0.7 0.2–2.5 0.6 0.8 0.2–3.1 0.8 Region(Compared with "Central Urban Districts ") New West Urban Development Districts 0.1 0.7–41.5 5.3 0.1 0.7–46.1 5.8 Northeast Districts 0.2 0.6–35.9 4.6 0.2 0.5–81.2 6.4 Southeast Districts 0.02 1.4–29.7 6.5 0.03 1.3–70.4 9.6 School type(Compared with "Public school") Private school 1.9 0.4–8.7 0.4 0.89 0.68–1.15 0.36 Discussion CXR for PTB screening in high schools were performed by community-level medical and health care institutions in most cases in China. Usually, there were no external quality control measures over the CXR reading in PTB screening in high schools. The current situation of CXR implementation lacked baseline surveys. Through this study, we have obtained PTB and suspected PTB burden among high school students in Chongqing. In this study, active PTB diagnoses are all derived from suspected cases with abnormal CXR results, and CXR played an important role in PTB screening in high schools. A study found that asymptomatic children with abnormal radiographs were 25.1-fold more likely to have TB in 4468 TB-exposed children between September 2009 and August 2012 [ 14 ]. Amanda G et al [ 15 ] have found that 60 had CXR findings suggestive of TB in 268 TB-infected children. A mass CXR programme have significantly contributed to TB control in high-burdened population in Cape Town, South Africa [ 16 ]. It could be seen that CXR played an important role in TB screening in different regions and populations. The PTB detection rate conducted by Chongqing Municipal Institute of Tuberculosis was 57 cases per 100000 population between January 2022 and December 2022in high schools in Chongqing. PANG Y et al [ 13 ] have found that the PTB detection rate conducted by community-level medical and health care institutions was 34.8 cases per 100000 population in 2021 in high schools in Chongqing, which was lower than PTB detection rate conducted by Chongqing Municipal Institute of Tuberculosis. A study has found that the quality of CXR conducted by community-level medical and health care institution was poor in contact investigation of a school clustered outbreak in Chongqing, resulting in failure to detect cases who have already suffered from PTB [ 8 ]. The suspected PTB detection gap from CXR may exist in schools. The occurrence of suspected PTB detection gap from CXR may be due to the instability of CXR reading. Andronikou S et al [ 17 ] have found that inter-reader agreement was only moderate (kappa 0.4–0.6) in a retrospective study for interobserver agreement between paediatric radiologists interpreting PTB screening CXR in children in the UK. A study found that Only 60% of the CXR were reported as moderate to good quality, and interobserver agreement on quality was slight to moderate (kappa 0.16–0.35) the context of community-based screening of child PTB contacts [ 18 ]. Berteloot L et al [ 19 ] have found that CXR showed poor-to-fair inter-reader agreement and limited diagnostic accuracy for PTB in HIV-infected children in resource-limited countries. This situation may be common in community-level medical and health care institutions that lack regular standardized training and quality control. Solutions to this problem include conducting regular standardized training to CXR reading in PTB screening in schools. A study found that correct diagnosis has been increased and sensitivity has been improved for CXR interpretation of suspected PTB after a short skill-development course [ 20 ]. Seddon JA et al [ 21 ] have found that teaching clinicians with a 1-day training course would lead to a limited improvement in CXR reading ability ( P = 0.017). María ML et al [ 22 ] have found that a standardized CXR reading protocol showed good agreement and improves the CXR interpretation reproducibility, and global agreement reached 91.3% (kappa = 0.51). Teleradiology was also a way to address the quality of CXR interpretation. Teleradiology is a mechanism to overcome the lack of on-site experienced radiologists and can benefit children in developing countries [ 23 ]. In recent years, artificial intelligence (AI) has made rapid progress in the interpretation of CXR and has begun to be applied to community-based PTB screening. Shibu V et al [ 24 ] have found that approximately 15.8% PTB detection increase could be attributed to AI in a active case-finding program in a resource-limited region in India where AI was used for PTB screening using CXR. Kosuke O et al [ 25 ] have found that the human reading needed fell to 21%, and AI was applicable to community-based active case-finding in high TB burden settings where experienced human readers for CXR images were scarce. In our study, the suspected PTB detection rate in Southeast Districts was the highest, and the PTB detection rate was also the highest. This regional disparity indicates that the PTB screening efforts in this region need to be further strengthened. According to Chongqing Statistical Yearbook, the GDP per capita of Southeast Districts was the lowest in all four regions in Chongqing. The lowest socioeconomic status may lead to the highest suspected PTB detection. Other previous studies have also identified similar regional disparity. In a student TB spatiotemporal analysis in 2014–2019 in Chongqing, PANG Y et al [ 26 ] have found that Southeast Districts was a high PTB burden region and also a high-risk region for transmission due to socioeconomic status and screening quality. FAN J et al [ 27 ] have found that the student PTB epidemic in Southeast Districts was the highest with an average annual notification rate of 88.31 cases per 100000 population from 2008 to 2019. The impact of socioeconomic status on the prevalence of student PTB was also found when comparing Chongqing with other developed regions. A study has found that the notification rate of PTB among students in Shanghai remained between 15 and 20 cases per 100000 population from 2009 to 2017, which was far lower that in Chongqing [ 28 ]. A study has also found that the western region in China had a higher PTB epidemic, which included Chongqing [ 29 ]. CXR has limitations in imaging modalities for PTB. A study has found that findings compatible with TB were more frequently detected on computed tomography (CT) than CXR, which could be performed when in doubt [ 30 ]. Charlotte CH et al have found that ultrasound detected abnormalities more frequently than CXR with higher inter-reader agreement, which may be a promising modality for detecting abnormalities in PTB [ 31 , 32 ]. In conclusion, CXR has played a significant role in PTB screening in high schools in the Chongqing, effectively controlling the student TB epidemic. However, there may be a need to focus on the CXR quality control at the grassroots level and strengthen policy support for Southeast Districts in Chongqing. Abbreviations PTB Pulmonary Tuberculosis TB Tuberculosis CXR Chest X-ray TST Tuberculin Skin Test AOR Adjusted Odds Ratio COR Crude Odds Ratio PPD Purified Protein Derivative BCG Bacillus Calmette-Guérin DR Digital Radiography CT Computed Tomography GDP Gross Domestic Product AI Artificial Intelligence Declarations Ethics approval and consent to participate The study was approved by the ethics committee of Chongqing Municipal Institute of Tuberculosis (202202, 26 September 2022). As PTB screening in students was mandatory physical examination in Chongqing and all individual information was removed before analysis, the ethics committee of the Chongqing Municipal Tuberculosis Institute granted an exemption from the requirement for informed consent for participation. Consent for publication Not applicable. Availability of data and materials The data collected from PTB screening in this research has been stored in the provincial tuberculosis surveillance database. However, access to these data is subject to certain limitations, as it was utilized under a specific license for the purposes of the current study, making it not accessible to the general public. Upon a legitimate request and with the necessary permission from the provincial TB surveillance system, the data can be obtained from the corresponding author. Competing interests The authors declare that they have no competing interests. Funding The data collection and data analysis of the study was supported by Chongqing Science and Health Joint Research Project (2023ZDXM027 and 2023MSXM143), Chongqing Health Commission Medical Science Research Project (2024WSJK08), Chongqing Municipal Institute of Tuberculosis Research Project(2022CQJFS04), and Chongqing Public Health Key Specialties (Disciplines) Construction Fund. Authors' contributions MW, BW and JF designed the study. JR, CGW, YLS, YL, DL, JY, QS, YY, ZYZ and XYH were involved in conducting the study. BW, JY, JR, DL and MW were involved in data analysis. BW and MW wrote the draft manuscript. MW, BW, JY and JR had access to and verified the existence of the raw data. All authors read and approved the final manuscript before submission. BW was responsible for the decision to submit the manuscript. Acknowledgments We thank the field workers Gang Zhou, Xi Li, Ruxia Li, Jing Wu, Yanping Feng, Jia Luo and Xiabo Zeng. References World Health Oragnization. Global tuberculosis report 2023. Geneva, Switzerland: World Health Organization. 2023. https://www.who.int/publications/i/item/9789240083851. Accessed May 10, 2024. WHO consolidated guidelines on tuberculosis Module 5: Management of tuberculosis in children and adolescents. Geneva, Switzerland: World Health Organization. 2023. https://www.who.int/publications/i/item/9789240046764. Accessed May 10, 2024. World Health Oragnization. Roadmap towards ending TB in children and adolescents, Third edition. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4762610","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":338483402,"identity":"70d6673f-f50a-4c01-9aae-9b19a454ec9f","order_by":0,"name":"Mei Wang","email":"","orcid":"","institution":"Chongqing Municipal Institute of Tuberculosis","correspondingAuthor":false,"prefix":"","firstName":"Mei","middleName":"","lastName":"Wang","suffix":""},{"id":338483403,"identity":"7ca4b680-bb31-4081-be6e-40b50c454464","order_by":1,"name":"Jin Yin","email":"","orcid":"","institution":"Chongqing Municipal Institute of 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Tuberculosis","correspondingAuthor":false,"prefix":"","firstName":"Qian","middleName":"","lastName":"Su","suffix":""},{"id":338483410,"identity":"645f4773-17de-400d-95a8-151e929f33d8","order_by":8,"name":"Zhengyu Zhang","email":"","orcid":"","institution":"Chongqing Municipal Institute of Tuberculosis","correspondingAuthor":false,"prefix":"","firstName":"Zhengyu","middleName":"","lastName":"Zhang","suffix":""},{"id":338483411,"identity":"5a068355-1f6f-4bac-8832-44c384f4dfae","order_by":9,"name":"Xueyong Huang","email":"","orcid":"","institution":"Chongqing Municipal Institute of Tuberculosis","correspondingAuthor":false,"prefix":"","firstName":"Xueyong","middleName":"","lastName":"Huang","suffix":""},{"id":338483412,"identity":"4dd09eae-cf3e-47cb-83da-699f0a0c1709","order_by":10,"name":"Ya Yu","email":"","orcid":"","institution":"Chongqing Municipal Institute of Tuberculosis","correspondingAuthor":false,"prefix":"","firstName":"Ya","middleName":"","lastName":"Yu","suffix":""},{"id":338483413,"identity":"c9a7aa1c-0ac2-47da-bc1e-3451b2109efa","order_by":11,"name":"Jun Fan","email":"","orcid":"","institution":"Chongqing Municipal Institute of Tuberculosis","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Fan","suffix":""},{"id":338483414,"identity":"caab4c4a-a96e-4ec9-b0a9-7bb9ecfb9b2f","order_by":12,"name":"Bo Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBACfvnz3z//Majh4WdvIFKL5AwGMwaegmMykj0HiNRicAOk5QOzjcGMBGK13G5IeyBhwMZjIPl44w2GGptowg67c+C4gYGBDI+5dFqxBcOxtNwGQlr4DiQ2SCQAbbGcnWMmwdhwmLAWhgPJDBIHDJh5DG6eIVKLwI00NskGkJYbPERqkew5w2zMYHCMR7IH6JcEYvzCz97D+JjhT409P/vhjTc+1NgQ4RckYCCRQIpyiBZSdYyCUTAKRsHIAADNwTyRXKwcqgAAAABJRU5ErkJggg==","orcid":"","institution":"Chongqing Municipal Institute of Tuberculosis","correspondingAuthor":true,"prefix":"","firstName":"Bo","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2024-07-18 12:24:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4762610/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4762610/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62661746,"identity":"0bf09b6b-5af0-44ed-aedf-04285fa79249","added_by":"auto","created_at":"2024-08-17 02:47:26","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":312666,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of participants screened by CXR between January 2022 and December 2022 in Chongqing\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4762610/v1/887368014cd51bea6967ad9a.jpeg"},{"id":85178771,"identity":"eababc96-9c26-4f5e-ab29-a5d8dbeffa9f","added_by":"auto","created_at":"2025-06-23 07:02:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1071259,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4762610/v1/f64a5d6b-3c89-4b61-b87d-18f95be6ce03.pdf"},{"id":62661237,"identity":"435f0bd9-eeff-41e3-aabc-20f12b2ed0c7","added_by":"auto","created_at":"2024-08-17 02:39:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21339,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryappendix20240614.docx","url":"https://assets-eu.researchsquare.com/files/rs-4762610/v1/e0af4a83d03a1a3dc8340ddc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Role of Chest X-ray in Tuberculosis Detection for High School Students in China: A Cross-sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTuberculosis (TB) was the second leading cause of death from a single infectious disease in the world, after corona virus disease (COVID-19) in 2022, and the number of deaths from TB was twice that of HIV/AIDS [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. About 1.3\u0026nbsp;million children and adolescents (aged 0\u0026ndash;14 years) became ill with TB every year, equivalent to 12% of all people with TB globally [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The cumulative number of children treated between 2018 and 2022 was 2.5\u0026nbsp;million, which was 71% of the five-year target of 3.5\u0026nbsp;million set at the UN high level meeting in 2018 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The treatment coverage gap is prevalent among children and adolescents. Among children and adolescents aged 5\u0026ndash;14, 45% of cases have not been reported and treated, and 30% of cases have not been reported and treated in adolescents aged 15 and above [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe average notification rate of PTB among schoolchildren and adolescents in China from 2004 to 2021 was 19.3 cases per 100000 population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Chongqing is a city in western of China, with notification rate of PTB among schoolchildren and adolescents at 15.4 cases per 100000 population in 2023 according to national TB surveillance system, making it the sixth highest city in China.\u003c/p\u003e \u003cp\u003eGlobally, TB screening for children and adolescents is typically focused on family contacts. In China, in addition to screening PTB among family contacts, large-scale PTB screening has also been carried out in schools, including middle school freshmen [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, Chongqing has implemented PTB screening for Senior 2 students [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e CXR is an important tool for PTB screening in Chinese schools, which is usually carried out by community-level medical and health care institutions, which have not received regular quality control. There was a lack of research on conducting large-scale CXR in schools for PTB screening. It was also found that there may be a PTB detection gap from previous investigation due to poor quality of CXR in school PTB screening, leading to the subsequent spread of TB epidemic [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The current situation of PTB screening using CXR in schools needs comprehensive investigations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional study which was conducted among high school students in Chongqing, China between January 2022 and December 2022 by Chongqing Municipal Institute of Tuberculosis. The radiologists and doctors who participated in this study received standardized training in reading of CXR. We evaluated the role of CXR in the TB screening among high school students.\u003c/p\u003e \u003cp\u003eAccording to Guidelines for Tuberculosis Prevention and Control in Chinese Schools [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and the local policy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], high school students should be screened for active PTB. Freshmen in high school should undergo PTB screening upon enrollment, and they should receive another PTB screening in their second year of high school.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eStandardized training was provided for all radiologists and doctors for reading of CXR involved in this study, including clinical and imaging theory, as well as CXR reading practical skill.\u003c/p\u003e \u003cp\u003ePTB screening in high school students mainly includes a consultation on suspicious symptoms of PTB, immunological examination, and a chest X-ray examination. If there was an abnormality in symptom screening or immunological examination, CXR would be conducted. For participants with contraindications to TST, or those who were unable to complete the entire process of TST, CXR would be recommended in this study.\u003c/p\u003e \u003cp\u003eFor every participant who enrolled, demographic and social information was collected, including region, age, gender and educational level.\u003c/p\u003e \u003cp\u003eThe Mantoux method was conducted in TST. During the TST procedure, which utilized either Purified Protein Derivative (PPD) from Xiang Rui, China or Chengdu Institute of Biology, China. A volume of 0.1 mL (5IU) of PPD was administered intradermally into the volar aspect of the left forearm. The measurement of the induration was taken in millimeters at the injection site after 72 hours. The national policy in China mandates the administration of the Bacillus Calmette-Gu\u0026eacute;rin (BCG) vaccine at birth, with a consistently high vaccination rate that could potentially impact the reactivity of TST. Taking this into account, an induration cut-off point of \u0026ge;\u0026thinsp;15mm (TST strong positive) was considered the criterion for conducting CXR among participants [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCXR was conducted at high schools using the mobile health examination vehicle equipped with digital radiography (DR) X-ray machine. Each mobile health examination vehicle needed one radiology team. Each radiology team was composed of two radiologists and at least one clinical physician. During the chest radiography process, if a suspected TB case was identified, the radiologist would immediately notify the clinical physician for confirmation, and would also promptly inform the school administrators. After the chest radiography session was concluded in a school, the radiologist and clinical physician would conduct a CXR collective review of this school to identify any abnormalities. Those with abnormal CXR went to designated medical institutions for further examination.\u003c/p\u003e \u003cp\u003eParticipants with PTB and suspected PTB were diagnosed based on China national diagnostic criteria for TB [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. According to this diagnostic criteria, a suspected PTB case refers to an individual in whom abnormal findings are detected through chest imaging.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSample Size\u003c/h2\u003e \u003cp\u003eAccording to the previous PTB screening investigation in high school in Chongqing, the PTB detection rate is 34.82 cases per 100000 population [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The sample size was estimated at 7533 participants using the following formula, based on the allowable error of 0.1%, Type I error of 1%, and Type II error of 1%.\u003c/p\u003e\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\" width=\"195\" height=\"63\"\u003e\u003c/p\u003e\u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRandomisation and Cluster Selection\u003c/h2\u003e \u003cp\u003eIn this study, a stratified cluster random sampling method was utilized. Chongqing was segmented into four distinct areas based on the delineation by the local administration: the Central Urban Districts, the New West Urban Development Districts, the Northeast Districts, and the Southeast Districts. These areas varied in socioeconomic development levels. The clusters for the study were identified as high schools situated within these four regions. It was stipulated that each cluster must have a minimum of 500 participants enrolled from January 2022 to December 2022.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStudy participants\u003c/h2\u003e \u003cp\u003eThe inclusion criteria were as follows: (1) students in high school, and (2) participants who can participate in the entire PTB screening process. The exclusion criteria were as follows: (1) participants who are unable to undergo CXR for various reasons, and (2) participants who are unwilling to participate in PTB screening.\u003c/p\u003e \u003cp\u003eAccording to the inclusion and exclusion criteria, participants were continuously selected from the selected clusters until they were fully enrolled.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRisk factor analysis\u003c/h2\u003e \u003cp\u003eTo explore risk factor associated with PTB and suspected PTB detection in high schools in Chongqing, we have analyzed potential risk factors including grade, sex, region, and school type.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eWe calculated the proportion and 95% CI for PTB and suspected PTB detection rate. The chi-square test was used to test different detection rates. The missing data analysis for participants who were unable to undergo CXR was implemented by chi-square test. A logistic regression model was performed to assess association between detection rates and risk factors. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was taken as statistically significant. Statistical analyses were performed with the SPSS 22.0 software (SPSS, Inc, Chicago, IL, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThe screening process for participants\u003c/h2\u003e \u003cp\u003eFrom January 2022 to December 2022, 24577 high school students in 21 schools participated in the research. After excluding 20843 participants (84.8%) for various reasons, 3734 (15.2%) remained with CXR implemented (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThose participants who missed the CXR due to leave or other reasons were excluded from the statistical analysis. This exclusion was made because the missing data were considered completely random and constituted a small proportion of 3.5% (129/3734). Additionally, no significant disparities were observed in the distribution of gender, grade, region, and school type between participants with and without CXR outcome (appendix, p2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eScreening results\u003c/h2\u003e \u003cp\u003eIn participants who were enrolled in the PTB screening, PTB detection rate was 57 cases per 100000 population. Suspected PTB detection rate was 0.5% (95%CI, 0.3%-0.8%), and PTB detection rate was 0.4%(0.2%-0.6%) through CXR (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePTB screening results using TST by our team between January 2022 and December 2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubgroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants required for CXR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipants without CXR results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSuspected PTB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActive PTB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSuspected PTB detection rate (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePTB detection rate (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1723\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.6% (0.2%-1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.4% (0.1%-0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.5%(0.2%-0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.4%(0.1%-0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior One\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.6%(0.1%-1.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.3%(0%-0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior Two\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2692\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.5%(0.2%-0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.4%(0.2%-0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral Urban Districts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1472\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.2%(0%-0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.1%(0%-0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew West Urban Development Districts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.4%(0%-1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.2%(0%-1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNortheast Districts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e601\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.7%(0%-1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.2%(0%-1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSoutheast Districts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.9%(0.3%-1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.9%(0.3%-1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2821\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.6%(0.3%-0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.4%(0.2%-0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e913\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.2%(0%-0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.2%(0%-0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3734\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e0.5%(0.3%-0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.4%(0.2%-0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRisk factors associated with PTB detection through CXR\u003c/h2\u003e \u003cp\u003eThe risk factors associated with PTB detection through CXR were analyzed (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In single variable analysis, participants in Southeast Districts were more likely to develop PTB (Crude Odds Ratio [COR], 6.5; 95% CI, 1.4\u0026ndash;29.7), and this factor was still correlated in multiple variable analysis (AOR, 9.6; 95% CI, 1.3\u0026ndash;70.4). There were not any other risk factors identified.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factors associated with PTB detection through CXR\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSingle variable analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eMultiple variable analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Compared with \"Male\")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u0026ndash;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.3\u0026ndash;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade(Compared with \"Senior One\")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior Two\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.2\u0026ndash;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.2\u0026ndash;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion(Compared with \"Central Urban Districts \")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNew West Urban Development Districts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.7\u0026ndash;41.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.7\u0026ndash;46.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNortheast Districts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.6\u0026ndash;35.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.5\u0026ndash;81.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoutheast Districts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.4\u0026ndash;29.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.3\u0026ndash;70.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool type(Compared with \"Public school\")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u0026ndash;8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.68\u0026ndash;1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e CXR for PTB screening in high schools were performed by community-level medical and health care institutions in most cases in China. Usually, there were no external quality control measures over the CXR reading in PTB screening in high schools. The current situation of CXR implementation lacked baseline surveys. Through this study, we have obtained PTB and suspected PTB burden among high school students in Chongqing.\u003c/p\u003e \u003cp\u003eIn this study, active PTB diagnoses are all derived from suspected cases with abnormal CXR results, and CXR played an important role in PTB screening in high schools. A study found that asymptomatic children with abnormal radiographs were 25.1-fold more likely to have TB in 4468 TB-exposed children between September 2009 and August 2012 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Amanda G et al [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] have found that 60 had CXR findings suggestive of TB in 268 TB-infected children. A mass CXR programme have significantly contributed to TB control in high-burdened population in Cape Town, South Africa [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. It could be seen that CXR played an important role in TB screening in different regions and populations.\u003c/p\u003e \u003cp\u003eThe PTB detection rate conducted by Chongqing Municipal Institute of Tuberculosis was 57 cases per 100000 population between January 2022 and December 2022in high schools in Chongqing. PANG Y et al [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] have found that the PTB detection rate conducted by community-level medical and health care institutions was 34.8 cases per 100000 population in 2021 in high schools in Chongqing, which was lower than PTB detection rate conducted by Chongqing Municipal Institute of Tuberculosis. A study has found that the quality of CXR conducted by community-level medical and health care institution was poor in contact investigation of a school clustered outbreak in Chongqing, resulting in failure to detect cases who have already suffered from PTB [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The suspected PTB detection gap from CXR may exist in schools.\u003c/p\u003e \u003cp\u003eThe occurrence of suspected PTB detection gap from CXR may be due to the instability of CXR reading. Andronikou S et al [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] have found that inter-reader agreement was only moderate (kappa 0.4\u0026ndash;0.6) in a retrospective study for interobserver agreement between paediatric radiologists interpreting PTB screening CXR in children in the UK. A study found that Only 60% of the CXR were reported as moderate to good quality, and interobserver agreement on quality was slight to moderate (kappa 0.16\u0026ndash;0.35) the context of community-based screening of child PTB contacts [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Berteloot L et al [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] have found that CXR showed poor-to-fair inter-reader agreement and limited diagnostic accuracy for PTB in HIV-infected children in resource-limited countries. This situation may be common in community-level medical and health care institutions that lack regular standardized training and quality control.\u003c/p\u003e \u003cp\u003eSolutions to this problem include conducting regular standardized training to CXR reading in PTB screening in schools. A study found that correct diagnosis has been increased and sensitivity has been improved for CXR interpretation of suspected PTB after a short skill-development course [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Seddon JA et al [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] have found that teaching clinicians with a 1-day training course would lead to a limited improvement in CXR reading ability (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017). Mar\u0026iacute;a ML et al [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] have found that a standardized CXR reading protocol showed good agreement and improves the CXR interpretation reproducibility, and global agreement reached 91.3% (kappa\u0026thinsp;=\u0026thinsp;0.51).\u003c/p\u003e \u003cp\u003eTeleradiology was also a way to address the quality of CXR interpretation. Teleradiology is a mechanism to overcome the lack of on-site experienced radiologists and can benefit children in developing countries [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In recent years, artificial intelligence (AI) has made rapid progress in the interpretation of CXR and has begun to be applied to community-based PTB screening. Shibu V et al [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] have found that approximately 15.8% PTB detection increase could be attributed to AI in a active case-finding program in a resource-limited region in India where AI was used for PTB screening using CXR. Kosuke O et al [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] have found that the human reading needed fell to 21%, and AI was applicable to community-based active case-finding in high TB burden settings where experienced human readers for CXR images were scarce.\u003c/p\u003e \u003cp\u003eIn our study, the suspected PTB detection rate in Southeast Districts was the highest, and the PTB detection rate was also the highest. This regional disparity indicates that the PTB screening efforts in this region need to be further strengthened. According to Chongqing Statistical Yearbook, the GDP per capita of Southeast Districts was the lowest in all four regions in Chongqing. The lowest socioeconomic status may lead to the highest suspected PTB detection. Other previous studies have also identified similar regional disparity. In a student TB spatiotemporal analysis in 2014\u0026ndash;2019 in Chongqing, PANG Y et al [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] have found that Southeast Districts was a high PTB burden region and also a high-risk region for transmission due to socioeconomic status and screening quality. FAN J et al [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] have found that the student PTB epidemic in Southeast Districts was the highest with an average annual notification rate of 88.31 cases per 100000 population from 2008 to 2019.\u003c/p\u003e \u003cp\u003eThe impact of socioeconomic status on the prevalence of student PTB was also found when comparing Chongqing with other developed regions. A study has found that the notification rate of PTB among students in Shanghai remained between 15 and 20 cases per 100000 population from 2009 to 2017, which was far lower that in Chongqing [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. A study has also found that the western region in China had a higher PTB epidemic, which included Chongqing [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCXR has limitations in imaging modalities for PTB. A study has found that findings compatible with TB were more frequently detected on computed tomography (CT) than CXR, which could be performed when in doubt [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Charlotte CH et al have found that ultrasound detected abnormalities more frequently than CXR with higher inter-reader agreement, which may be a promising modality for detecting abnormalities in PTB [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn conclusion, CXR has played a significant role in PTB screening in high schools in the Chongqing, effectively controlling the student TB epidemic. However, there may be a need to focus on the CXR quality control at the grassroots level and strengthen policy support for Southeast Districts in Chongqing.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePTB \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pulmonary Tuberculosis\u003c/p\u003e\n\u003cp\u003eTB \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Tuberculosis\u003c/p\u003e\n\u003cp\u003eCXR \u0026nbsp; \u0026nbsp; \u0026nbsp; Chest X-ray\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTST \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Tuberculin Skin Test\u003c/p\u003e\n\u003cp\u003eAOR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Adjusted Odds Ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Crude Odds Ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePPD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Purified Protein Derivative\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBCG \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bacillus Calmette-Gu\u0026eacute;rin\u003c/p\u003e\n\u003cp\u003eDR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Digital Radiography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computed Tomography\u003c/p\u003e\n\u003cp\u003eGDP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Gross Domestic Product\u003c/p\u003e\n\u003cp\u003eAI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Artificial Intelligence\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee of Chongqing Municipal Institute of Tuberculosis (202202, 26 September 2022). As PTB screening in students was mandatory physical examination in Chongqing and all individual information was removed before analysis, the ethics committee of the Chongqing Municipal Tuberculosis Institute granted an exemption from the requirement for informed consent for participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collected from PTB screening in this research has been stored in the provincial tuberculosis surveillance database. However, access to these data is subject to certain limitations, as it was utilized under a specific license for the purposes of the current study, making it not accessible to the general public. Upon a legitimate request and with the necessary permission from the provincial TB surveillance system, the data can be obtained from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collection and data analysis of the study was supported by Chongqing Science and Health Joint Research Project (2023ZDXM027 and 2023MSXM143), Chongqing Health Commission Medical Science Research Project (2024WSJK08), Chongqing Municipal Institute of Tuberculosis Research Project(2022CQJFS04), and Chongqing Public Health Key Specialties (Disciplines) Construction Fund.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMW, BW and JF designed the study. JR, CGW, YLS, YL, DL, JY, QS, YY, ZYZ and XYH were involved in conducting the study. BW, JY, JR, DL and MW were involved in data analysis. BW and MW wrote the draft manuscript. MW, BW, JY and JR had access to and verified the existence of the raw data. All authors read and approved the final manuscript before submission. BW was responsible for the decision to submit the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the field workers Gang Zhou, Xi Li, Ruxia Li, Jing Wu, Yanping Feng, Jia Luo and Xiabo Zeng.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Oragnization. Global tuberculosis report 2023. Geneva, Switzerland: World Health Organization. 2023. https://www.who.int/publications/i/item/9789240083851. Accessed May 10, 2024.\u003c/li\u003e\n\u003cli\u003eWHO consolidated guidelines on tuberculosis Module 5: Management of tuberculosis in children and adolescents. Geneva, Switzerland: World Health Organization. 2023. https://www.who.int/publications/i/item/9789240046764. Accessed May 10, 2024.\u003c/li\u003e\n\u003cli\u003eWorld Health Oragnization. Roadmap towards ending TB in children and adolescents, Third edition. Geneva, Switzerland: World Health Organization. 2023. https://www.who.int/publications/i/item/9789240084254. Accessed May 10, 2024.\u003c/li\u003e\n\u003cli\u003eChen H, Zhang CY, Zhang H, Cheng J, Li T. Analysis of National School Tuberculosis Epidemics from 2004 to 2021. Chinese Journal of Antituberculosis. 2022;44(08):768-776.\u003c/li\u003e\n\u003cli\u003eNational Health Commission of the People\u0026apos;s Republic of China, Ministry of Education of the People\u0026apos;s Republic of China. Guidelines for Tuberculosis Prevention and Control in Chinese Schools (2020 Edition). Beijing, China: National Health Commission of the People\u0026apos;s Republic of China, Ministry of Education of the People\u0026apos;s Republic of China; 2020.\u003c/li\u003e\n\u003cli\u003eChongqing Municipal Health and Family Planning Commission, Chongqing Municipal Education Commission. Chongqing Municipal Guidelines for Tuberculosis Prevention and Control in Schools (2017 Edition). Chongqing, China: Chongqing Municipal Health and Family Planning Commission, Chongqing Municipal Education Commission; 2017.\u003c/li\u003e\n\u003cli\u003eWang Q, Zhou L, Liu EY, Zhao YL, Li T, Chen MT, et al. Current Status of Tuberculosis Diagnostic Capability at Tuberculosis Designated Medical Institutions at the County Level in China: A Survey Study. Chinese Journal of Antituberculosis. 2020;42(9):926-930.\u003c/li\u003e\n\u003cli\u003eFan J, Su Q, Chen J, Yu Y, Wang QY, Zhang T, et al. 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The international journal of tuberculosis and lung disease. 2014;18(7):763-9.\u003c/li\u003e\n\u003cli\u003eMaria ML, Maria AR, Lina MC, Guillermo V, Beatriz M, Diana MM, et al. Reproducibility of a protocol for standardized reading of chest X-rays of children household contact of patients with tuberculosis. BMC pediatrics. 2022;22(1):307. doi: 10.1186/s12887-022-03347-6.\u003c/li\u003e\n\u003cli\u003eSavvas A. Pediatric teleradiology in low-income settings and the areas for future research in teleradiology. Frontiers in public health. 2014;2:125. doi: 10.3389/fpubh.2014.00125.\u003c/li\u003e\n\u003cli\u003eShibu V, Vaishnavi J, Tripti P, Amera K, Miranda B, Asha H, et al. Implementing a chest X-ray artificial intelligence tool to enhance tuberculosis screening in India: Lessons learned. PLOS digital health. 2023;2(12):e0000404. doi: 10.1371/journal.pdig.0000404.\u003c/li\u003e\n\u003cli\u003eKosuke O, Norio Y, Kiyoko T, Yuta H, Yoshiro K, Yutaka H, et al. 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Chinese Antituberculosis Association. 2020;42(05):498-502.\u003c/li\u003e\n\u003cli\u003eChen H, Xia YY, Zhang CY, Cheng J, Zhang H. Analysis of the Trend and Characteristics of Pulmonary Tuberculosis Epidemic Among Students in China from 2014 to 2018. Chinese Antituberculosis Association. 2019;41(06):662-668.\u003c/li\u003e\n\u003cli\u003eErle OT, Marie F, Anja P, Ulrikka N, Liselotte H, Lise B. Imaging modalities for pulmonary tuberculosis in children: A systematic review. European journal of radiology open. 2022;10:100472. doi: 10.1016/j.ejro.2022.100472.\u003c/li\u003e\n\u003cli\u003eCharlotte CH, Sabine B, Savvas A, Henrique L, Halvani M, Martin PG, et al. Chest ultrasound compared to chest X-ray for pediatric pulmonary tuberculosis. Pediatric pulmonology. 2019;54(12):1914-1920.\u003c/li\u003e\n\u003cli\u003eMichael N, Zoe FS, Tanyia P, Savvas A, Heather JZ. Chest Imaging for Pulmonary TB-An Update. Pathogens. 2022;11(2):161. doi: 10.3390/pathogens11020161.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Tuberculosis, Child, Adolescent, Chest X-ray","lastPublishedDoi":"10.21203/rs.3.rs-4762610/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4762610/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn China, pulmonary tuberculosis (PTB) screening for children and adolescents is not only focused on family contacts, but also students in high schools. The research objective is to investigate chest X-ray (CXR) abnormalities and its risk factors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom January 2022 to December 2022, PTB screening was conducted among 24577 Senior 1 and Senior 2 students in Chongqing using the Tuberculin Skin Test (TST) and CXR.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe detection rate for suspected PTB through CXR was 0.5% (95% Confidence Interval [CI], 0.3%-0.8%), and the detection rate for PTB through CXR was 0.4% (95% CI, 0.2%-0.6%). Participants in Southeast Districts were more likely to develop PTB (Adjusted Odds Ratio [AOR], 9.6; 95% CI, 1.3\u0026ndash;70.4).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCXR has played a significant role in PTB screening in high schools in the Chongqing. It is necessary to strengthen policy support for the Southeast Districts in Chongqing.\u003c/p\u003e","manuscriptTitle":"The Role of Chest X-ray in Tuberculosis Detection for High School Students in China: A Cross-sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-17 02:39:21","doi":"10.21203/rs.3.rs-4762610/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"12292aef-be8e-49c5-a769-08a9d8bd6d76","owner":[],"postedDate":"August 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-13T15:38:32+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-17 02:39:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4762610","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4762610","identity":"rs-4762610","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}