A comprehensive analysis of epidemiology, diagnostic advances, and future directions for eliminating childhood TB in China
In the bustling cities and vast countryside of China, a quiet battle is being waged against one of humanity's oldest infectious diseases—tuberculosis (TB). While often considered a disease of adults, TB casts a long shadow over the nation's children, with China ranking third globally in estimated TB incidence and accounting for 6.8% of all cases worldwide 1 . Each year, thousands of Chinese children confront this disease, facing diagnostic challenges and treatment regimens that test the resilience of young bodies and devoted families alike.
The story of childhood TB in China is one of both remarkable progress and persistent challenges. Over the past three decades, China has made impressive strides in reducing the TB burden, yet certain groups of children remain particularly vulnerable.
This article explores the current landscape of childhood TB in China, demystifying the science behind diagnosis and treatment, highlighting groundbreaking research, and examining the path toward eliminating this ancient scourge from the nation's youngest generation.
China's efforts in tuberculosis control have yielded significant results over the past three decades. Between 1990 and 2021, the country achieved a dramatic reduction in TB burden among children and adolescents aged 0-19 years 1 . The incidence rate dropped from 64.64 to 14.24 per 100,000 population—a decrease of nearly 78% 1 . Even more impressively, the death rate plummeted from 5.35 to 0.13 per 100,000 population, representing a staggering 97.6% reduction 1 .
Reduction in TB Incidence
(1990-2021)
Reduction in TB Mortality
(1990-2021)
Reduction in DALYs
(1990-2021)
Data sourced from the Global Burden of Disease Study 2021 1
This progress didn't occur uniformly across the entire period. Researchers have identified particularly pronounced reductions during 2010-2015, when incidence fell by 8.64% annually, and during 2019-2021, with an annual decline of 6.09% 1 . These accelerated reductions suggest that specific public health interventions and policies implemented during these periods yielded particularly effective results.
Looking ahead, projections indicate that this downward trajectory is expected to continue through 2031, though persistent gender and age disparities will likely remain 1 . These promising trends reflect the cumulative impact of China's investments in TB control programs, healthcare infrastructure, and specific interventions targeting pediatric populations.
The burden of childhood TB in China doesn't fall equally across all age groups. Research reveals a distinct pattern of vulnerability, with the highest incidence rates observed in adolescents aged 15-19 years (31.75 per 100,000), followed by children younger than 5 years (12.51 per 100,000) 1 . The lowest incidence occurs during middle childhood (ages 5-9 years), with a rate of just 5.53 per 100,000 1 .
This bimodal distribution reflects different risk factors and biological vulnerabilities at various developmental stages. Young children, particularly infants under one year, face heightened risks of severe disease progression and mortality due to their immature immune systems 5 . Their vulnerability is reflected in the highest death (0.27 per 100,000) and DALYs rates (34.88 per 100,000) among all pediatric age groups 1 .
The risk of TB in Chinese children isn't uniform across the country. Studies indicate higher burdens in western regions and among migrant populations 3 . The northwest region of China reports the highest rate of TB meningitis hospitalizations (28.01%) and the longest hospital stays . This geographic disparity likely reflects differences in healthcare access, socioeconomic factors, and possibly environmental conditions.
Most severe outcomes with 13.3% mortality and 31% liver injury from treatment 5 .
Highest incidence rate at 31.75 per 100,000 due to biological and social factors 1 .
Highest TB meningitis burden with 28.01% of hospitalizations .
Longer hospital stays and higher diagnostic costs despite smaller population percentage .
Ethnic minorities also experience a disproportionate burden, with one study showing that minority children accounted for 24.09% of TB meningitis hospitalizations despite comprising a smaller percentage of the general population . These patients experienced longer hospital stays and higher diagnostic costs compared to their Han counterparts .
One of the most critical aspects of TB control in children lies in preventing latent infections from progressing to active disease. Approximately 5-10% of individuals with latent TB infection (LTBI) will develop active disease during their lifetime, with the highest risk occurring within the first two years after initial infection 3 . In China, which has the highest burden of LTBI globally with nearly 350 million people infected, this represents an enormous reservoir of potential future cases 3 .
A condition where Mycobacterium tuberculosis bacteria are present in the body but are inactive, causing no symptoms and not being contagious. However, these bacteria can become active later and cause TB disease.
Until recently, tuberculosis preventive treatment (TPT) acceptance among Chinese children identified with LTBI was dishearteningly low. A 2019 survey in Shanghai found that among 37 student contacts with LTBI identified through screening in 19 school outbreaks, none received TPT 3 . This startling statistic revealed critical barriers at multiple levels, including: limited policy and financial support, physician concerns about drug resistance and side effects, insufficient understanding among students and parents, and logistical challenges in accessing TPT services 3 .
To address this implementation gap, researchers in Shanghai developed and tested a novel two-step approach to increase TPT acceptance 3 . The method was implemented during a campus TB outbreak that began in June 2024, when a 19-year-old student was diagnosed with bacteriologically confirmed TB.
All 142 close contacts of the index case underwent symptom screening, ESAT6-CFP10 skin tests, and chest X-rays. Students with abnormal results were referred to designated TB hospitals for further evaluation, ultimately identifying 52 students with LTBI 3 .
The innovative intervention consisted of two distinct components:
The two-step approach yielded impressive results, achieving a TPT acceptance rate of 42.3% among the 52 students with LTBI—a substantial improvement over the previous rate of zero 3 . The study also provided valuable insights into the reasons for TPT refusal and knowledge gaps that need addressing.
This study demonstrates that with targeted educational approaches and structural support, significant improvements in TPT acceptance are achievable. The findings offer a roadmap for other regions in China struggling with similar implementation challenges.
The accurate and timely diagnosis of childhood TB requires a sophisticated array of tools and technologies. Over the past decade, diagnostic capabilities have improved dramatically, though challenges remain, particularly in resource-limited settings.
These molecular tests detect mycobacterial DNA or RNA with high specificity and have revolutionized TB diagnosis. The Centers for Disease Control recommends that a NAAT be performed on the first sputum sample of all suspected TB patients regardless of smear status 8 .
These blood tests measure the immune response to TB-specific antigens and represent a significant advance in detecting latent TB infection. IGRAs such as the QuantiFERON-TB Gold and T-SPOT.TB tests offer improved accuracy over the traditional tuberculin skin test (TST) 8 .
Perhaps one of the most exciting advances in TB diagnostics, LiPAs simultaneously detect MTB infection and resistance to key drugs like rifampin and isoniazid 8 . The WHO has endorsed LiPAs for culture and smear-positive clinical specimens, representing a crucial tool in the fight against drug-resistant TB 8 .
While culture remains the gold standard for detection and drug susceptibility testing, traditional solid media (Lowenstein-Jensen) may take 4-6 weeks. Modern liquid culture systems like BACTEC and MGIT offer more sensitive and rapid alternatives, detecting growth in 1-3 weeks 8 .
China's remarkable progress against childhood tuberculosis provides a strong foundation, but the path toward elimination requires addressing persistent challenges. Several key strategies will be crucial in the coming years:
Expanding successful TPT models like the Shanghai two-step approach to other regions could dramatically reduce progression from latent infection to active disease. Simplifying regimens to shorten duration and improving follow-up management could address major refusal reasons identified in the study 3 .
While advanced diagnostics exist, their deployment across China's vast and varied healthcare landscape remains uneven. Expanding access to molecular diagnostics and rapid drug susceptibility testing at peripheral health facilities would reduce diagnostic delays 8 .
Research indicates that microbiological diagnosis significantly reduces the risk of loss to follow-up before treatment completion (HR 0.463) 5 . Strengthening laboratory capacity to increase the proportion of children with bacteriologically confirmed TB would improve both individual outcomes and surveillance data.
The battle against childhood tuberculosis in China represents both a formidable challenge and an inspiring story of public health progress. Through decades of dedicated effort, China has achieved remarkable reductions in TB incidence, mortality, and disability among its youngest citizens 1 . The scientific advances in diagnostics and prevention, coupled with innovative implementation strategies like Shanghai's two-step TPT approach, provide powerful tools to accelerate progress 3 8 . With continued effort and innovation, the goal of a China where no child suffers from tuberculosis moves increasingly within reach.