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Diagnostic accuracy of three morning sputum versus standard sputum smears for pulmonary tuberculosis
  1. Ya-Ning Wang1,
  2. Chao Han2,
  3. Jun-Ling Wang3,
  4. Mao-Shui Wang3,4,
  5. Jun-Li Wang5
  1. 1 The Second High School of Licheng, Jinan, China
  2. 2 Department of Geriatrics, Shandong Mental Health Center, Jinan, China
  3. 3 Department of Lab Medicine, Shandong Provincial Chest Hospital, Jinan, China
  4. 4 Department of Pediatrics, Qilu Hospital, Shandong University, Jinan, China
  5. 5 Center of Clinical Laboratory, Affiliated Hospital of Youjiang Medical College for Nationalities, Baise, China
  1. Correspondence to Dr Mao-Shui Wang, Department of Lab Medicine, Shandong Provincial Chest Hospital, Jinan 250013, China; wangmaoshui{at} and Dr Jun-Li Wang, Center of Clinical Laboratory, Affiliated Hospital of Youjiang Medical College for Nationalities, Baise, China; 13907768146{at}

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In 2015, there were an estimated 10.4 million new tuberculosis (TB) cases worldwide, 1.4 million TB deaths, and 480,000 new multidrug-resistant TB cases, according to the WHO report.1 Early diagnosis and immediate initiation of treatment are essential for an effective TB control program. Delay in diagnosis is significant to both disease prognosis at the individual level and transmission within the community.2 To date, several new rapid TB tests (such as Xpert MTB/RIF Ultra, Real time-PCR) have been developed.3 However, sputum smear remains the only readily available TB diagnostic test throughout most of the low-income and middle-income countries.

The National Institute for Health and Care Excellence guideline on TB recommends that multiple sputum samples (at least three, with one early morning sample) were collected for TB microscopy for patients with suspected pulmonary TB (PTB).4 Similar recommendation was made in China.5 However, in Brazil, two sputum samples, including one morning sputum sample, was recommended.6 Remarkably, these recommendations did not contain specific implications on performing multiple smears in 1 day or on different days for PTB. The Shandong Provincial Chest Hospital (SPCH) is a provincial TB referral hospital of approximately 800 beds. Each year, about 1000 patients with TB were diagnosed, with positive results on acid-fast bacilli (AFB) sputum smear examination. The SPCH TB reference laboratory had been accredited by ISO15189 in 2010 and is participating in an external …

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  • Y-NW and CH contributed equally.

  • Contributors Y-NW and J-LW (3th) collected the data and did the analysis. CH supervised the data collection and analysis, and revised the manuscript. M-SW and J-LW (5th) designed the study and wrote the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval The ethics committee of Shandong Provincial Chest Hospital has approved the study and written informed consent was waived, according to article 39.1 of the ethics guidelines enacted by the National Health and Family Planning Commission of the PRC (

  • Provenance and peer review Not commissioned; externally peer reviewed.