- Email: [email protected]
Prevalence of Beijing family in Mycobacterium tuberculosis in world population: Systematic Review and Meta-Analysis
International Journal of Mycobacteriology
3 ( 2 0 1 4 ) 4 1 –4 5
Available at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/IJMYCO
Prevalence of Beijing family in Mycobacterium tuberculosis in world population: Systematic Review and Meta-Analysis Rashid Ramazanzadeh
a,* ,
Kourosh Sayhemiri
b
a Cellular & Molecular Research Center and Microbiology Department, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran b Center for Prevention of Psychosocial Trauma, Ilam University of Medical Science, Ilam, Iran
A R T I C L E I N F O
A B S T R A C T
Article history:
Background: In this present study we decided to consider the prevalence and distribution of
Received 5 January 2014
Beijing family in the world using meta-analysis based on systematic review of articles pub-
Received in revised form
lished and relation with drug resistance, which will provide more detailed information to
7 January 2014
clearly overview the status of this family and transmission of TB.
Accepted 8 January 2014
Methods: This study used the most available article published in literature database includ-
Available online 7 February 2014
ing PubMed, Science direct, Web of Science, Google Scholar, Biological abs, Iranmedex, and SID systematically reviewed prevalence of Beijing family. Data analyzed using meta-
Keywords:
analysis with random effects models.
Beijing
Results: Final analyses included 264 samples that have been selected from 2811 studies.
M. tuberculosis
Overall Beijing family prevalence in world was estimated to be 33.2% (95% CI 31.4–35.2).
Prevalence
Corresponding estimates by continent were Asia 44.7% (39.5–49.8), Europe 27.9% (25.6–
Meta-analysis
30.1), Africa 12Æ5% (8.9–16.2), and America 8.9% (6.9–10.9). In all world regions, Beijing families were associated with drug resistance 81.37%. Conclusions: According to the results, prevalence of Beijing family in Asia is higher than similar studies in other parts of the world and this family is associated with drug resistance. Effective control program is needed in world to control the spread of drug resistance strains specially Beijing family. Ó 2014 Asian-African Society for Mycobacteriology. Published by Elsevier Ltd. All rights reserved.
Introduction Tuberculosis (TB) is a major health problem in the world, and based on the World Health Organization (WHO) report the prevalence of TB is 1.7 million cases and the incidence rate is 9.27 million cases globally as of 2007 [1]. The emergence
of multidrug-resistant tuberculosis (MDR-TB) is going to worsen this problem and is a threat to infectious disease. TB has been caused by Mycobacterium tuberculosis (MTB). These bacteria are slow growth and need a well-equipped laboratory for culture and diagnosis. Culture and diagnose of TB agents are cumbersome and difficult. Therefore, molecular
* Corresponding author. Address: Cellular & Molecular Research Center and Microbiology Department, Faculty of Medicine, Kurdistan University of Medical Sciences, Pasdaran Street, Post cod. 6177-13446 Sanandaj, Iran, Tel.: +98 9143104424; fax: +98 (871) 6664674. E-mail addresses: [email protected], [email protected] (R. Ramazanzadeh). http://dx.doi.org/10.1016/j.ijmyco.2014.01.001 2212-5531/Ó 2014 Asian-African Society for Mycobacteriology. Published by Elsevier Ltd. All rights reserved.
42
International Journal of Mycobacteriology
methods are of great importance in permitting both rapid diagnosis and genotyping. Spoligotyping is a polymerase chain reaction (PCR)-based method that was introduced by Kamerbeek in 1997 [2] and can be used directly for clinical samples without culture. This technique detects polymorphism in the chromosomal direct repeat locus in order to diagnose and type the MTB complex. This method has been used to type isolates in several families, including Beijing, EAI, Haarlem, Lam, T, U, S, X and several others [3,4]. Based on reports, spoligotypes have their own geographical distribution and specifications [4,5]. One of the most important of them is the Beijing family, published from Beijing, China, since 1995. However, there are many reports from other parts of the world [6–8]. The Beijing families of MTB are associated with drug resistance and induce more severe forms of TB and generally have a higher treatment failure and relapse than others [6,9–21]. In this present study, it was decided to consider the prevalence and distribution of the Beijing family in the world using meta-analysis based on a systematic review of articles published between 1997 and 2012. The alternate aim is the relation with drug resistance and relevant estimates based on continent estimation and distribution, which will provide more detailed information to clearly overview the status of this family and transmission of TB.
Materials and methods Literature identification The available international and domestic literature database, which includes PubMed, Sciencedirect, Web of Science, Google Scholar, Biological abs, Iranmedex, and SID, has been searched for studies that report the prevalence of the Beijing family, published in English or the Persian language. The original articles were screened by using the key words tuberculosis, Beijing, Molecular epidemiology and Spoligotyping in combinational or individual formats.
Inclusion and exclusion criteria Studies reporting the prevalence of the Beijing family were considered. In duplicate articles, the evaluation of the date was considered. Excluded studies included review articles, congress abstracts, studies reported in languages other than English or Persian, and studies that were not available in abstract or full text. Two reviewers searched independently. When there were disagreements between them in the selection of articles, they discussed their concerns regarding its selection for the study.
Data extraction The following data were extracted from the original publications: first author and year of publication, association with drug resistance, literature database, and study enrollment time and population, prevalence of the Beijing family, source type (abstract or full text), and association with drug resistance.
3 ( 2 0 1 4 ) 4 1 –4 5
Statistical analysis Prevalence of the Beijing family of TB in all of the studies was chosen as the main outcome. The variance of prevalence was computed using binomial distribution. There was heterogeneity among studies. I2 and Q statistics tests were used to check heterogeneity among studies. Meta-analyses with random effect model was applied to combine prevalence among studies. Meta-analyses were carried out using Stata ver. 10. Stratified analyses were subsequently performed with respect to the geographic areas and the drug-resistant TB among the Beijing family isolates [20]. Random effects models were used, taking into account the possibility of heterogeneity between studies, which were tested with the Q test and the I2 test. Subgroup analyses were assessed by chi-square tests for continents.
Ethical approval This study project was approved by the Kurdistan University of Medical Science, scientific board research committee.
Results In the primary search, 2811 published articles have been saved in literature by using key word combinations. Articles that have no information about prevalence or extractable date were excluded, and finally 264 articles were selected for evaluation (Table 1). Out of the 264 articles, 6 were in Persian and the rest were in English. In the total of 264 studied articles, the prevalence was 0.33% in 118,348 as indicated in (Table 2). In considering prevalence based on continent, the Beijing family is prevalent in Asia 47.91%, as indicated in (Table 3). There was an association between drug resistance and prevalence of the Beijing family in the total continents of 81.6 % (Table 2). In most countries, the same rate of association in relation to drug resistance was present (Table 3). There are more reports from China (31.20%) among Asian countries, and Iran was (14.40%) as indicated in Table 4.
Discussion This study includes the most recent research with regard to the prevalence of TB in the world health population. The importance of TB and the Beijing family is evident for all scientists. The spreading of the Beijing family among different nationalities and the dynamics of transmission is helpful for tracking and designing a program for the control of TB. As shown in Table 1 and 264 articles were identified for meta-analysis. The difference in percent in the database is logic based on specialists in publishing medical journals and publicity. A search using Endnote software was used and overlap studies were deleted. Therefore, some database sites such as Pubmed (31.1%) (28.3–33.8) has more published articles on TB. Molecular epidemiology establishes a dynamic of transmission of infectious disease. Several molecular techniques
International Journal of Mycobacteriology
43
3 ( 2 0 1 4 ) 4 1 –4 5
Table 1 – Total searched and selected publication based on available sites in internet. No.
Site
totAl
Selected
ES
[95% Conf. Interval]
1 2 3 4 5 6 7
Science direct Iranmedex Pubmed Biological abs SID Google scholar Web of Science
258 10 711 91 16 1530 195
10 5 146 6 1 45 51
0.200 0.069 0.311 0.435 – 0.344 0.445
0.131 0.043 0.283 0.015 – 0.305 0.371
0.268 0.096 0.338 0.854 – 0.382 0.518
2811
264
–
–
–
Total
Table 2 – Association of Beijing family with drug resistance based on continents. Continent
Drug resistance association
Total
Yes
No
Asia Europe Africa America
50(82.0%) 27(81.8%) 4(80.0%) 3(75.0%)
11(18.0%) 6(18.2%) 1(20.0%) 1(25.0%)
61(59.22%) 33(32.04%) 5(4.85%) 4(3.88%)
Total
84(81.6%)
19(18.4%)
103(100%)
Table 3 – Drug resistance association with Beijing family based on study place (country). Country
Drug resistance association
Total
Yes
No
Bangladesh Belgium Bulgaria Cambodia China Colombia Czech Republic Estonia Georgia Honduras India Iran Japan Latin America Myanmar Netherlands Pakistan Poland Russia Saudi Arabia Sierra Leone South Africa South Korea Spain Sweden Taiwan Thailand Turkey UK Uzbekistan and Turkmenistan Venezuela Vietnam
1 1 0 3 13 1 0 1 1 0 6 8 0 1 1 1 1 1 16 1 1 3 2 1 1 6 1 3 1 1 1 6
0 0 1 0 5 0 1 0 1 1 1 1 2 0 0 0 0 0 1 0 0 1 1 0 1 1 0 1 0 0 0 0
Total
84 81.6%
19 18.4%
1 1 1 3 18 1 1 1 2 1 7 9 2 1 1 1 1 1 17 1 1 4 3 1 2 7 1 4 1 1 1 6 103 100%
44
International Journal of Mycobacteriology
Table 4 – Distribution of reports in Asian countries. Country Bangladesh Cambodia China India Indonesia Iran Japan Kazakhstan Myanmar Pakistan Russia Saudi Arabia Senegal South Korea Sri Lanka Taiwan Thailand Uzbekistan and Turkmenistan Vietnam Total
Reports (%) 4.00 2.40 31.20 14.40 1.60 14.40 4.00 0.80 0.80 1.60 0.80 1.60 0.80 3.20 0.80 10.40 1.60 0.80 4.80
3 ( 2 0 1 4 ) 4 1 –4 5
gions, not all of the world [5]. In this review, 264 studies were selected for analysis; therefore, the impact of this statistical analysis with regard to drug resistance association should weigh heavily against the total number of published reports. In conclusion, the prevalence of the Beijing family in the world population and its association with drug-resistance has been summarized in this systematic review. The results of this study indicate the dynamics of transmission of the Beijing family and its association with drug resistance, and this information should improve the vision concerning TB in the world population.
Acknowledgment This is part of our project. The authors wish to extend their gratitude to the Research Deputy of Kurdistan University of Medical Sciences for financial support.
R E F E R E N C E S
100.00
are used to fingerprint microbial agents. For M. tuberculosis, spoligotyping has been used extensively in the world and database SPODB has been established in order to trace the migration and dissemination of M. tuberculosis complex in a given population. Spoligotyping is better than other molecular methods in that data can be shared between laboratories. There are a lot of families in the M. tuberculosis complex, and the best known among them is the Beijing family. The meta-analysis prevalence of this family is 33.3% (31.4– 35.2%). The extreme data was excluded by statistical analysis. This type was more prevalent in Asia (44.7%) and lowest in America (8.9%). In published meta-analysis literature, the prevalence rate was the same, especially in Asian countries [5]. The present study is an update used to revise the vision of the prevalence of TB in the world. In this regard, a glance at the data indicates that the prevalence from Asia to America was diminished in transmission. The Beijing family originated from China; therefore, it is not surprising that the highest rate has been reported from this region. In contrast, America is far from the origin of emergence, so it is logical that the low prevalence of this type is predictable. The association of antibiotic resistance and the prevalence of the Beijing family is controversial. There are a lot of reports with regard to the relation of the Beijing family and its association with drug resistance [22–24]. On the other hand, some studies reported no correlation of drug resistance and the Beijing family [25–27]. This study considered all articles and analyzed them statistically, as shown in Tables 2 and 3) in the overall Beijing family associated with drug resistance. Overall, 81.60% were associated with drug resistance. Although there is a difference in the number of reports from the four continents, the percent is nearly the same in all. As indicated in the Tables 2 and 3, the highest rates were reported from China and Russia. In previous meta-analysis done by 16 studies, the relationship with drug resistance was restricted to some re-
[1] T. Vasankari, H. Soini, K. Liippo, P. Ruutu, MDR-TB in Finland – still rare despite the situation in our neighbouring countries, Clin. Respir. J. 6 (2012) 35–39. [2] J. Kamerbeek, L. Schouls, A. Kolk, M. van Agterveld, D. van Soolingen, S. Kuijper, et al, Simultaneous detection and strain differentiation of Mycobacterium tuberculosis for diagnosis and epidemiology, J. Clin. Microbiol. 35 (1997) 907– 914. [3] S. Ferdinand, G. Vale´tudie, C. Sola, N. Rastogi, Data mining of Mycobacterium tuberculosis complex genotyping results using mycobacterial interspersed repetitive units validates the clonal structure of spoligotyping-defined families, Res. Microbiol. 155 (2004) 647–654. [4] M. Sebban, I. Mokrousov, N. Rastogi, C. Sola, A data-mining approach to spacer oligonucleotide typing of Mycobacterium tuberculosis, Bioinformatics 18 (2002) 235–243. [5] J.R. Glynn, J. Whiteley, P.J. Bifani, K. Kremer, D. van Soolingen, Worldwide occurrence of Beijing/W strains of Mycobacterium tuberculosis: a systematic review, Emerg. Infect. Dis. 8 (2002) 843–849. [6] R. Jou, C.Y. Chiang, W.L. Huang, Distribution of the Beijing family genotypes of Mycobacterium tuberculosis in Taiwan, J. Clin. Microbiol. 43 (2005) 95–100. [7] D. van Soolingen, L. Qian, P.E. de Haas, J.T. Douglas, H. Traore, F. Portaels, et al, Predominance of a single genotype of Mycobacterium tuberculosis in countries of east Asia, J. Clin. Microbiol. 33 (1995) 3234–3238. [8] P.J. Bifani, B. Mathema, N.E. Kurepina, B.N. Kreiswirth, Global dissemination of the Mycobacterium tuberculosis W-Beijing family strains, Trends Microbiol. 10 (2002) 45–52. [9] A.A. Velayati, P. Farnia, M. Mirsaeidi, M. Reza Masjedi, The most prevalent Mycobacterium tuberculosis superfamilies among Iranian and Afghan TB cases, Scand. J. Infect. Dis. 38 (2006) 463–468. [10] A. Kruuner, S.E. Hoffner, H. Sillastu, M. Danilovits, K. Levina, S.B. Svenson, et al, Spread of drug-resistant pulmonary tuberculosis in Estonia, J. Clin. Microbiol. 39 (2001) 3339–3345. [11] G.E. Pfyffer, A. Strassle, T. van Gorkum, F. Portaels, L. Rigouts, C. Mathieu, et al, Multidrug-resistant tuberculosis in prison inmates, Azerbaijan, Emerg. Infect. Dis. 7 (2001) 855–861. [12] O.S. Toungoussova, P. Sandven, A.O. Mariandyshev, N.I. Nizovtseva, G. Bjune, D.A. Caugant, Spread of drug-resistant Mycobacterium tuberculosis strains of the Beijing genotype in
International Journal of Mycobacteriology
[13]
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the Archangel Oblast, Russ. J. Clin. Microbiol. 40 (2002) 1930– 1937. O. Toungoussova, A. Mariandyshev, G. Bjune, P. Sandven, D. Caugant, Molecular epidemiology and drug resistance of Mycobacterium tuberculosis isolates in the archangel prison in Russia: predominance of the W-Beijing clone family, Clin. Infect. Dis. 37 (2003) 665–672. K. Kremer, J.R. Glynn, T. Lillebaek, S. Niemann, N.E. Kurepina, B.N. Kreiswirth, et al, Definition of the Beijing/W lineage of Mycobacterium tuberculosis on the basis of genetic markers, J. Clin. Microbiol. 42 (2004) 4040–4049. N. Amirmozafari, R. Ramezanzadeh, P. Farnia, F. Ghazi, The frequency of Beijing genotype of Mycobacterium tuberculosis isolated from tuberculosis patients, Razi J. Med. Sci. 13 (2006) 7–17. M.Y. Lipin, V.N. Stepanshina, I.G. Shemyakin, T.M. Shinnick, Association of specific mutations in katG, rpoB, rpsL and rrs genes with spoligotypes of multidrug-resistant Mycobacterium tuberculosis isolates in Russia, Clin. Microbiol. Infect. 13 (2007) 620–626. D. Cowley, D. Govender, B. February, M. Wolfe, L. Steyn, J. Evans, et al, Recent and rapid emergence of W-Beijing strains of Mycobacterium tuberculosis in Cape Town, S. Afr. Clin. Infect. Dis. 47 (2008) 1252–1259. H.Y. Dou, F.C. Tseng, C.W. Lin, J.R. Chang, J.R. Sun, W.S. Tsai, et al, Molecular epidemiology and evolutionary genetics of Mycobacterium tuberculosis in Taipei, BMC Infect. Dis. 8 (2008) 170. P. Farnia, F. Mohammadi, M.R. Masjedi, A. Varnerot, A.Z. Zarifi, J. Tabatabee, et al, Evaluation of tuberculosis transmission in Tehran: using RFLP and spoligotyping methods, J. Infect. 49 (2004) 94–101. P. Farnia, M.R. Masjedi, M. Varahram, M. Mirsaeidi, M. Ahmadi, M. Khazampour, et al, The recent-transmission of Mycobacterium tuberculosis strains among Iranian and Afghan
[21]
[22]
[23]
[24]
[25]
[26]
[27]
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relapse cases: a DNA-fingerprinting using RFLP and spoligotyping, BMC Infect. Dis. 8 (2008) 109. G.S. Sharaf Eldin, I. Fadl-Elmula, M.S. Ali, A.B. Ali, A.L. Salih, K. Mallard. Tuberculosis in Sudan: a study of Mycobacterium tuberculosis strain genotype and susceptibility to antituberculosis drugs. BMC Infect Dis. 11:219 (2011). J. Zhang, S. Heng, S. Le Moullec, G. Refregier, B. Gicquel, C. Sola, et al, A first assessment of the genetic diversity of Mycobacterium tuberculosis complex in Cambodia, BMC Infect. Dis. 11 (2011) 42. V. Ritacco, M.J. Iglesias, L. Ferrazoli, J. Monteserin, E.R. Dalla Costa, A. Cebollada, Conspicuous multidrug-resistant Mycobacterium tuberculosis cluster strains do not trespass country borders in Latin America and Spain, Infect. Genet. Evol. 12 (4) (2012) 711–717. J. Makinen, M. Marjamaki, M. Haanpera-Heikkinen, H. Marttila, L.B. Endourova, S.E. Presnova, et al, Extremely high prevalence of multidrug resistant tuberculosis in Murmansk, Russia: a population-based study, Eur. J. Clin. Microbiol. Infect. Dis. 30 (2011) 1119–1126. J. Wang, Y. Liu, C.L. Zhang, B.Y. Ji, L.Z. Zhang, Y.Z. Shao, et al, Genotypes and characteristics of clustering and drug susceptibility of Mycobacterium tuberculosis isolates collected in Heilongjiang Province, China. J. Clin. Microbiol. 49 (2011) 1354–1362. H.L. Hsu, C.C. Lai, M.C. Yu, F.L. Yu, J.C. Lee, C.H. Chou, Clinical and microbiological characteristics of urine cultureconfirmed genitourinary tuberculosis at medical centers in Taiwan from, 1995 to 2007, Eur. J. Clin. Microbiol. Infect. Dis. 30 (2011) (1995) 319–326. S. Rosales, L. Pineda-Garcia, S. Ghebremichael, N. Rastogi, S.E. Hoffner, Molecular diversity of Mycobacterium tuberculosis isolates from patients with tuberculosis in Honduras, BMC Microbiol. 10 (2010) 208.
3 ( 2 0 1 4 ) 4 1 –4 5
Available at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/IJMYCO
Prevalence of Beijing family in Mycobacterium tuberculosis in world population: Systematic Review and Meta-Analysis Rashid Ramazanzadeh
a,* ,
Kourosh Sayhemiri
b
a Cellular & Molecular Research Center and Microbiology Department, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran b Center for Prevention of Psychosocial Trauma, Ilam University of Medical Science, Ilam, Iran
A R T I C L E I N F O
A B S T R A C T
Article history:
Background: In this present study we decided to consider the prevalence and distribution of
Received 5 January 2014
Beijing family in the world using meta-analysis based on systematic review of articles pub-
Received in revised form
lished and relation with drug resistance, which will provide more detailed information to
7 January 2014
clearly overview the status of this family and transmission of TB.
Accepted 8 January 2014
Methods: This study used the most available article published in literature database includ-
Available online 7 February 2014
ing PubMed, Science direct, Web of Science, Google Scholar, Biological abs, Iranmedex, and SID systematically reviewed prevalence of Beijing family. Data analyzed using meta-
Keywords:
analysis with random effects models.
Beijing
Results: Final analyses included 264 samples that have been selected from 2811 studies.
M. tuberculosis
Overall Beijing family prevalence in world was estimated to be 33.2% (95% CI 31.4–35.2).
Prevalence
Corresponding estimates by continent were Asia 44.7% (39.5–49.8), Europe 27.9% (25.6–
Meta-analysis
30.1), Africa 12Æ5% (8.9–16.2), and America 8.9% (6.9–10.9). In all world regions, Beijing families were associated with drug resistance 81.37%. Conclusions: According to the results, prevalence of Beijing family in Asia is higher than similar studies in other parts of the world and this family is associated with drug resistance. Effective control program is needed in world to control the spread of drug resistance strains specially Beijing family. Ó 2014 Asian-African Society for Mycobacteriology. Published by Elsevier Ltd. All rights reserved.
Introduction Tuberculosis (TB) is a major health problem in the world, and based on the World Health Organization (WHO) report the prevalence of TB is 1.7 million cases and the incidence rate is 9.27 million cases globally as of 2007 [1]. The emergence
of multidrug-resistant tuberculosis (MDR-TB) is going to worsen this problem and is a threat to infectious disease. TB has been caused by Mycobacterium tuberculosis (MTB). These bacteria are slow growth and need a well-equipped laboratory for culture and diagnosis. Culture and diagnose of TB agents are cumbersome and difficult. Therefore, molecular
* Corresponding author. Address: Cellular & Molecular Research Center and Microbiology Department, Faculty of Medicine, Kurdistan University of Medical Sciences, Pasdaran Street, Post cod. 6177-13446 Sanandaj, Iran, Tel.: +98 9143104424; fax: +98 (871) 6664674. E-mail addresses: [email protected], [email protected] (R. Ramazanzadeh). http://dx.doi.org/10.1016/j.ijmyco.2014.01.001 2212-5531/Ó 2014 Asian-African Society for Mycobacteriology. Published by Elsevier Ltd. All rights reserved.
42
International Journal of Mycobacteriology
methods are of great importance in permitting both rapid diagnosis and genotyping. Spoligotyping is a polymerase chain reaction (PCR)-based method that was introduced by Kamerbeek in 1997 [2] and can be used directly for clinical samples without culture. This technique detects polymorphism in the chromosomal direct repeat locus in order to diagnose and type the MTB complex. This method has been used to type isolates in several families, including Beijing, EAI, Haarlem, Lam, T, U, S, X and several others [3,4]. Based on reports, spoligotypes have their own geographical distribution and specifications [4,5]. One of the most important of them is the Beijing family, published from Beijing, China, since 1995. However, there are many reports from other parts of the world [6–8]. The Beijing families of MTB are associated with drug resistance and induce more severe forms of TB and generally have a higher treatment failure and relapse than others [6,9–21]. In this present study, it was decided to consider the prevalence and distribution of the Beijing family in the world using meta-analysis based on a systematic review of articles published between 1997 and 2012. The alternate aim is the relation with drug resistance and relevant estimates based on continent estimation and distribution, which will provide more detailed information to clearly overview the status of this family and transmission of TB.
Materials and methods Literature identification The available international and domestic literature database, which includes PubMed, Sciencedirect, Web of Science, Google Scholar, Biological abs, Iranmedex, and SID, has been searched for studies that report the prevalence of the Beijing family, published in English or the Persian language. The original articles were screened by using the key words tuberculosis, Beijing, Molecular epidemiology and Spoligotyping in combinational or individual formats.
Inclusion and exclusion criteria Studies reporting the prevalence of the Beijing family were considered. In duplicate articles, the evaluation of the date was considered. Excluded studies included review articles, congress abstracts, studies reported in languages other than English or Persian, and studies that were not available in abstract or full text. Two reviewers searched independently. When there were disagreements between them in the selection of articles, they discussed their concerns regarding its selection for the study.
Data extraction The following data were extracted from the original publications: first author and year of publication, association with drug resistance, literature database, and study enrollment time and population, prevalence of the Beijing family, source type (abstract or full text), and association with drug resistance.
3 ( 2 0 1 4 ) 4 1 –4 5
Statistical analysis Prevalence of the Beijing family of TB in all of the studies was chosen as the main outcome. The variance of prevalence was computed using binomial distribution. There was heterogeneity among studies. I2 and Q statistics tests were used to check heterogeneity among studies. Meta-analyses with random effect model was applied to combine prevalence among studies. Meta-analyses were carried out using Stata ver. 10. Stratified analyses were subsequently performed with respect to the geographic areas and the drug-resistant TB among the Beijing family isolates [20]. Random effects models were used, taking into account the possibility of heterogeneity between studies, which were tested with the Q test and the I2 test. Subgroup analyses were assessed by chi-square tests for continents.
Ethical approval This study project was approved by the Kurdistan University of Medical Science, scientific board research committee.
Results In the primary search, 2811 published articles have been saved in literature by using key word combinations. Articles that have no information about prevalence or extractable date were excluded, and finally 264 articles were selected for evaluation (Table 1). Out of the 264 articles, 6 were in Persian and the rest were in English. In the total of 264 studied articles, the prevalence was 0.33% in 118,348 as indicated in (Table 2). In considering prevalence based on continent, the Beijing family is prevalent in Asia 47.91%, as indicated in (Table 3). There was an association between drug resistance and prevalence of the Beijing family in the total continents of 81.6 % (Table 2). In most countries, the same rate of association in relation to drug resistance was present (Table 3). There are more reports from China (31.20%) among Asian countries, and Iran was (14.40%) as indicated in Table 4.
Discussion This study includes the most recent research with regard to the prevalence of TB in the world health population. The importance of TB and the Beijing family is evident for all scientists. The spreading of the Beijing family among different nationalities and the dynamics of transmission is helpful for tracking and designing a program for the control of TB. As shown in Table 1 and 264 articles were identified for meta-analysis. The difference in percent in the database is logic based on specialists in publishing medical journals and publicity. A search using Endnote software was used and overlap studies were deleted. Therefore, some database sites such as Pubmed (31.1%) (28.3–33.8) has more published articles on TB. Molecular epidemiology establishes a dynamic of transmission of infectious disease. Several molecular techniques
International Journal of Mycobacteriology
43
3 ( 2 0 1 4 ) 4 1 –4 5
Table 1 – Total searched and selected publication based on available sites in internet. No.
Site
totAl
Selected
ES
[95% Conf. Interval]
1 2 3 4 5 6 7
Science direct Iranmedex Pubmed Biological abs SID Google scholar Web of Science
258 10 711 91 16 1530 195
10 5 146 6 1 45 51
0.200 0.069 0.311 0.435 – 0.344 0.445
0.131 0.043 0.283 0.015 – 0.305 0.371
0.268 0.096 0.338 0.854 – 0.382 0.518
2811
264
–
–
–
Total
Table 2 – Association of Beijing family with drug resistance based on continents. Continent
Drug resistance association
Total
Yes
No
Asia Europe Africa America
50(82.0%) 27(81.8%) 4(80.0%) 3(75.0%)
11(18.0%) 6(18.2%) 1(20.0%) 1(25.0%)
61(59.22%) 33(32.04%) 5(4.85%) 4(3.88%)
Total
84(81.6%)
19(18.4%)
103(100%)
Table 3 – Drug resistance association with Beijing family based on study place (country). Country
Drug resistance association
Total
Yes
No
Bangladesh Belgium Bulgaria Cambodia China Colombia Czech Republic Estonia Georgia Honduras India Iran Japan Latin America Myanmar Netherlands Pakistan Poland Russia Saudi Arabia Sierra Leone South Africa South Korea Spain Sweden Taiwan Thailand Turkey UK Uzbekistan and Turkmenistan Venezuela Vietnam
1 1 0 3 13 1 0 1 1 0 6 8 0 1 1 1 1 1 16 1 1 3 2 1 1 6 1 3 1 1 1 6
0 0 1 0 5 0 1 0 1 1 1 1 2 0 0 0 0 0 1 0 0 1 1 0 1 1 0 1 0 0 0 0
Total
84 81.6%
19 18.4%
1 1 1 3 18 1 1 1 2 1 7 9 2 1 1 1 1 1 17 1 1 4 3 1 2 7 1 4 1 1 1 6 103 100%
44
International Journal of Mycobacteriology
Table 4 – Distribution of reports in Asian countries. Country Bangladesh Cambodia China India Indonesia Iran Japan Kazakhstan Myanmar Pakistan Russia Saudi Arabia Senegal South Korea Sri Lanka Taiwan Thailand Uzbekistan and Turkmenistan Vietnam Total
Reports (%) 4.00 2.40 31.20 14.40 1.60 14.40 4.00 0.80 0.80 1.60 0.80 1.60 0.80 3.20 0.80 10.40 1.60 0.80 4.80
3 ( 2 0 1 4 ) 4 1 –4 5
gions, not all of the world [5]. In this review, 264 studies were selected for analysis; therefore, the impact of this statistical analysis with regard to drug resistance association should weigh heavily against the total number of published reports. In conclusion, the prevalence of the Beijing family in the world population and its association with drug-resistance has been summarized in this systematic review. The results of this study indicate the dynamics of transmission of the Beijing family and its association with drug resistance, and this information should improve the vision concerning TB in the world population.
Acknowledgment This is part of our project. The authors wish to extend their gratitude to the Research Deputy of Kurdistan University of Medical Sciences for financial support.
R E F E R E N C E S
100.00
are used to fingerprint microbial agents. For M. tuberculosis, spoligotyping has been used extensively in the world and database SPODB has been established in order to trace the migration and dissemination of M. tuberculosis complex in a given population. Spoligotyping is better than other molecular methods in that data can be shared between laboratories. There are a lot of families in the M. tuberculosis complex, and the best known among them is the Beijing family. The meta-analysis prevalence of this family is 33.3% (31.4– 35.2%). The extreme data was excluded by statistical analysis. This type was more prevalent in Asia (44.7%) and lowest in America (8.9%). In published meta-analysis literature, the prevalence rate was the same, especially in Asian countries [5]. The present study is an update used to revise the vision of the prevalence of TB in the world. In this regard, a glance at the data indicates that the prevalence from Asia to America was diminished in transmission. The Beijing family originated from China; therefore, it is not surprising that the highest rate has been reported from this region. In contrast, America is far from the origin of emergence, so it is logical that the low prevalence of this type is predictable. The association of antibiotic resistance and the prevalence of the Beijing family is controversial. There are a lot of reports with regard to the relation of the Beijing family and its association with drug resistance [22–24]. On the other hand, some studies reported no correlation of drug resistance and the Beijing family [25–27]. This study considered all articles and analyzed them statistically, as shown in Tables 2 and 3) in the overall Beijing family associated with drug resistance. Overall, 81.60% were associated with drug resistance. Although there is a difference in the number of reports from the four continents, the percent is nearly the same in all. As indicated in the Tables 2 and 3, the highest rates were reported from China and Russia. In previous meta-analysis done by 16 studies, the relationship with drug resistance was restricted to some re-
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