RESEARCH ARTICLE

Prevalence of bovine tuberculosis in dairy

cattle in China during 2010–2019: A
systematic review and meta-analysis
Qing-Long Gong ID1,2, Yu Chen3, Tian Tian2, Xiaobo Wen4, Dong Li2, Yu-Hao Song2,
Qi Wang2, Rui Du ID1*, Xiao-Xuan Zhang5
1 College of Chinese Medicine Materials, Jilin Agricultural University, Changchun, Jilin Province, PR China,
2 College of Animal Science and Technology, Jilin Agricultural University, Changchun, Jilin Province, PR
China, 3 College of Animal Science and Veterinary Medicine, Heilongjiang Bayi Agricultural University,
a1111111111 Daqing, Heilongjiang Province, PR China, 4 College of Animal Science and Technology, Hainan University,
a1111111111 Hainan Key Lab of Tropical Animal Reproduction and Breeding and Epidemic Disease Research, Haidian
a1111111111 Island, Haikou, Hainan Province, PR China, 5 College of Veterinary Medicine, Qingdao Agricultural
a1111111111 University, Qingdao, Shandong Province, PR China
a1111111111
* durui197101@sina.com

Abstract
OPEN ACCESS

Citation: Gong Q-L, Chen Y, Tian T, Wen X, Li D,

Song Y-H, et al. (2021) Prevalence of bovine Background
tuberculosis in dairy cattle in China during 2010– Bovine tuberculosis (bTB), caused by members of the Mycobacterium tuberculosis complex
2019: A systematic review and meta-analysis.
PLoS Negl Trop Dis 15(6): e0009502. https://doi.
bacteria, mainly Mycobacterium bovis (M. bovis), is a major threat to public health and eco-
org/10.1371/journal.pntd.0009502 nomic development. There has been no systematic epidemiological assessment concerning
Editor: Husain Poonawala, Lowell General Hospital,
bTB in dairy cattle in China.
UNITED STATES

Received: October 29, 2020

Methodology/principal findings
Accepted: May 24, 2021
Literature related to bTB in China was retrieved from China National Knowledge Infrastruc-
ture (CNKI), PubMed, ScienceDirect, VIP Chinese Journals Database, and Wan Fang Data-
Published: June 17, 2021
base to build the first meta-analysis for estimating the prevalence and infection moderators
Copyright: © 2021 Gong et al. This is an open of bTB in dairy cattle in China. A total of 100 relevant studies published from 2010 to 2019
access article distributed under the terms of the
Creative Commons Attribution License, which
were included. We estimated the overall prevalence of bTB was 2.4% (95% CI: 2.1–2.8) dur-
permits unrestricted use, distribution, and ing this decade. In the sampling year subgroup, the prevalence was lowest in 2017 or later
reproduction in any medium, provided the original at 0.8% (95% CI: 0.3–1.5). The lowest prevalence was 0.7% (95% CI: 0.5–1.0) in North-
author and source are credited.
western China. The lowest prevalence was 2.1% (95% CI: 1.8–2.5) using SIT test. Heifer
Data Availability Statement: All relevant data are cows had the highest prevalence, which was 27.1% (95% CI: 9.7–49.2). The prevalence in
within the manuscript and its Supporting
scale farming was 3.7% (95% CI: 3.1–4.3), significantly higher than that in free-range farm-
Information files.
ing (1.7%, 95% CI: 1.1–2.4). The prevalence of bTB was highest in summer at 4.0% (95%
Funding: Funding was provided by the National
CI: 1.7–7.0). In addition, the influence of different geographical factors (altitude, longitude,
Key R&D Program of China (2018YFD0500900) to
RD and XXZ (https://service.most.gov.cn/) and the latitude, precipitation, temperature, humidity) on the prevalence was analyzed.
Science and Technology Support Program of Jilin
Provincial Department of Science and Technology Conclusions/significance
(20180201010YY) to RD (https://service.most.gov.
cn/). The funders are responsible for the idea and The results showed that bTB was widespread in China but has been gradually reduced
concept of the paper. through concerted national intervention. It is suggested that different countries should

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Competing interests: The authors have declared formulate corresponding prevention and control measures according to the epidemic situa-
that no competing interests exist. tion in its cattle industry. Enhanced monitoring of warm and humid areas may play an impor-
tant role in reducing the incidence of bTB. In addition, when large-scale breeding is
promoted, attention should be paid to standardizing breeding management and improving
animal welfare to reduce the prevalence of bTB in cattle.

Author summary
bTB is a neglected zoonotic disease caused by members of the Mycobacterium tuberculosis
complex bacteria (M. bovis, mainly), which is also called “TB disease from bovine sources”
when it occurs in humans. It is still widespread in China although the prevalence has grad-
ually reduced through national intervention. Because beef and dairy products are impor-
tant human dietary sources of protein, bTB has a great impact on public health and safety.
We constructed the first meta-analysis to assess the epidemic of bTB in dairy cattle in
China over the past 10 years and analyzed the potential moderators of bTB. A total of 100
studies were included. The results showed that bTB was common and unevenly distrib-
uted in China. The potential moderators affecting the bTB epidemic were region, sam-
pling year, detection methods, age of dairy cattle, feeding mode, season, and certain
geographical and climatic factors (longitude, precipitation, mean temperature, humidity,
and altitude). These important findings may help in the formulation of policies to control
the prevalence of bTB in cattle, thereby reducing the economic losses caused by bTB and
reducing the threat of bTB to human health.

Introduction
Bovine tuberculosis (bTB), a chronic granulomatous inflammatory disease is caused mainly by
Mycobacterium bovis (M. bovis) [1]. Via the respiratory or digestive tract, M. bovis can infect a
wide range of hosts, including many common mammals such as cattle, humans, non-human
primates, giraffes, seals, goats, cats, dogs, pigs, buffalo, badgers, possums, deer, and bison [2–
4], but it also poses a major threat to some endangered species [5]. Before pasteurization of
milk, M. bovis was deemed the leading cause of death in children from abdominal tuberculosis
[6]. The disease poses a huge threat to public health and causes a related socioeconomic bur-
den [7]. The World Health Organization (WHO) has estimated that about 143,000 (71,200–
240,000) incident cases of zoonotic tuberculosis (caused by M. bovis) occurred globally in 2018
(https://apps.who.int/iris/handle/10665/329368) [8].
According to the FAO (2013), more than 6 billion people worldwide consume milk and
dairy products. Milk from dairy cattle represent about 85% of the total milk produced world-
wide [9]. Tuberculosis in cows results in low milk productivity, weight loss, infertility, mortal-
ity, and condemnation of carcasses. It is estimated that the global intended scope of loss to
livestock industry due to bTB is about US$3 billion a year [10]. Some countries have attained
bTB-free status through test-and-slaughter programs, while others have failed to eradicate the
disease because of multiple epidemiological conditions such as the presence of other mainte-
nance hosts for M. bovis [11,12]. However, the true burden of the disease is unknown in most
developing countries, where lack of epidemiological data and high economic costs often hin-
der strategies to control transmission of M. bovis [13].
China ranks second among the 22 countries with a high burden of tuberculosis listed by
WHO, behind only India [8]. By 2018, China had 14.8 million dairy cows, an increase of 4.1%

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

over 2017 [14]. To date, China has issued a series of control measures to prevent and control
bTB, such as establishing monitoring and early warning, emergency response, and other systems;
supporting intensive breeding, guiding farmers to unify epidemic prevention; and implementing
a disease eradication plan for breeding farms. However, data on the epidemiology of bTB in dairy
cows in China are still incomplete. Therefore, we constructed the first meta-analysis to assess the
prevalence of bTB and further analyzed the associated moderators, including geographical region
and various other geographic factors, sampling year, detection methods, age, sampling season,
and study quality level in an attempt to contribute to future prevention and control of the disease.

Methods
Search strategy
We performed this meta-analysis based on the PRISMA guidelines (Table A in S1 Text) [15,16].
The literature on the prevalence of bTB in dairy cattle in China published during 2010–2019 was
retrieved from databases including PubMed, ScienceDirect, China National Knowledge Infrastruc-
ture (CNKI), VIP Chinese Journals Database, and Wan Fang Database. In PubMed, we used the
MeSH terms “Cattle”, “Tuberculosis”, and “China” to retrieve medical subject headings and entry
terms concerning them. Then Boolean operators “AND” and “OR” were used to connect medical
subject headings and entry terms in an advanced search to generate the final search formula:
(“Cattle”[Mesh] OR Bos indicus OR Zebu OR Zebus OR Bos taurus OR Cow, Domestic OR
Cows, Domestic OR Domestic Cow OR Domestic Cows OR Bos grunniens OR Yak OR Yaks)
AND (“Tuberculosis”[Mesh] OR Tuberculoses OR Kochs Disease OR Koch’s Disease OR
Koch Disease OR Mycobacterium tuberculosis Infection OR Infection, Mycobacterium tubercu-
losis OR Infections, Mycobacterium tuberculosis OR Mycobacterium tuberculosis Infections)
AND (“China”[Mesh] OR People’s Republic of China OR Mainland China OR Manchuria
OR Sinkiang OR Inner Mongolia).
In ScienceDirect, the keywords of “Cattle”, “Tuberculosis”, “prevalence”, and “China” and
article type of “Research articles” were used to search. The same Chinese search formula with
fuzzy search and synonym expansion was used in advanced search of the three Chinese data-
bases (CNKI, Wan Fang, and VIP database):
(“tuberculosis” AND “cattle” OR “Mycobacterium tuberculosis” AND “cattle”)
To avoid missing valid literature, we also supplemented the advanced search results by
using the terms “cow disease”, “cow tuberculosis”, “bovine tuberculosis” in CNKI and the
term “cow tuberculosis” in the VIP with the default options.

Selection criteria
Three reviewers (TT, DL, and YC) extracted data from qualified studies. In case of disagree-
ment, the author (QLG) conducted further evaluation. We strictly selected qualified literature
according to the following criteria: (1) It was a cross-sectional prevalence study. (2) Data con-
cerned cattle in China. (3) The test was performed using standard bTB testing methods,
including single intradermal test (SIT), enzyme-linked immunosorbent assay (ELISA), IFN-γ-
ELISA, SIT&IFN-γ-ELISA, and colloidal gold test. (4) The study provided sample totals and
prevalence. (5) The subjects were dairy cattle. (6) The full text was available.

Data extraction
We used standardized forms in Microsoft Excel 2007 to collect the following information: first
author, publication year, sampling year, geographical region, sampling season, age, detection
method, feeding mode, total number of samples, and positive numbers.

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Quality assessment
According to the criteria derived from the Grading of Recommendations Assessment, Devel-
opment and Evaluation method (GRADE) [17], we assessed the quality of the eligible publica-
tions. One point per criteria was awarded if the study met the following criteria: “clear
detection objectives”, “clear detection methods”, “clear sampling time” and “four or more
moderators”. A paper with a final score of 0–1 was low quality, 2 was medium quality, and 3–4
was high quality. The low-quality studies were eventually excluded from the analysis.

Statistical analysis
We did all analyses using the “meta” package (version 4.12–0) in R software version 3.5.2 [18].
As suggested by previous studies, the Freeman-Tukey double arcsine transformation (named
PFT the meta package) has better variance stabilization performance, therefore, we used PFT
for rate conversion before meta to make the rate more consistent with the Gaussian distribu-
tion [19,20]. The formulas for PFT were as follows:
t ¼ arcsin ðsqrt ðr=ðn þ 1ÞÞÞ þ arcsin ðsqrt ððr þ 1Þ=ðn þ 1ÞÞÞ
seðtÞ ¼ sqrtð1=ðn þ 0:5ÞÞ
2
p ¼ ðsinðt=2ÞÞ

Note: t: transformed prevalence; n = sample size; r = positive number; se = standard error.

To facilitate reporting, we reconverted the transformed summary proportion and its confi-
dence interval [18]. The variation was quantified using the I2, Cochran’s Q, and χ2 tests. A ran-
dom-effects model was used to perform the meta-analysis due to the expected strong
heterogeneity. The publication bias was evaluated by the funnel plot, trim and fill analysis, and
Egger’s test. It has been shown that different subgroups may generate different funnel plots
because prevalence changes over time [21]. Therefore, each subgroup was used to generate
funnel plots and forest plots for further assessment. The stability of the study was determined
by sensitivity analysis. Forest plots are used to present results visually. The code in R for this
meta-analysis is shown in Table B in S1 Text.
Subgroup analysis and univariate meta-regression analysis were used to reveal factors that
may contribute to heterogeneity among studies. The factors included geographical region
(comparison of Northern China with others), sampling year (comparison of 2012 or before
with other groups), detection methods (comparison of SIT with other groups), age (compari-
son of heifer with others), sampling season (comparison of summer with others), quality level
(comparison of high with others). In addition, in order to reduce the heterogeneity caused by
different detection methods, when a study used multiple detection methods, we pooled the
data that came from the SIT method (because most of the studies we included used SIT).
China has a vast territory and significant climatic differences between different regions.
Thus, we also assessed the impact of different geographical factors on the study, including lati-
tude (comparison of 30–35˚ with other groups), longitude (comparison of >110˚ with other
groups), average annual precipitation (comparison of >1500 mm with other groups), average
annual temperature (comparison of 10–15˚C with other groups), average annual humidity
(comparison of >70% with other groups), altitude (comparison of <1000 m with other
groups). All surface meteorological data are from China Integrated Meteorological Informa-
tion Sharing System (CIMISS). For sampling sites without weather stations, we selected
weather station data from nearby counties through high-resolution maps. In case that was
unavailable as well, meteorological station data from the nearest city were selected. For sam-
pling sites without sampling years, we extracted data concerning only the altitude, longitude,

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

and latitude. In addition, correlation analysis was conducted for each subgroup with detection
methods and provinces respectively to trace the source of heterogeneity. The explained hetero-
geneity of the covariates is expressed in R2.

Results
Search results and eligible studies
According to the inclusion and exclusion criteria, there were two low-quality papers (which
were excluded), 15 medium-quality papers, and 85 high-quality papers; ultimately, 100
included studies were used for meta-analysis (Figs 1 and 2 and Tables 1 and 2, and Table C in
S1 Text).

Publication bias and sensitivity analysis

The forest plot shows great heterogeneity between selected studies (Fig 2). The funnel plot
indicates that there may be publication bias or small-sample bias in our studies (Fig 3). Hetero-
geneity was further quantified using Egger’s test, which showed that publication bias did exist
between studies (P = 0.0001; S1 Fig and Table D in S1 Text). We used trim and fill analysis to
evaluate the impact of publication bias on the study results. The estimated value of the com-
bined effect size did not change significantly after supplementing part of the study and per-
forming the meta-analysis again, which indicated that publication bias had little impact and

Fig 1. Flow diagram of eligible studies for searching and selecting.

https://doi.org/10.1371/journal.pntd.0009502.g001

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Fig 2. Forest plot of bovine tuberculosis prevalence among studies conducted in China. The horizontal line represents the 95% confidence interval, and
the diamond represents the summarized effect.
https://doi.org/10.1371/journal.pntd.0009502.g002

the results were relatively robust (S2 Fig). The meta-analysis results and publication bias of
each subgroup are shown in the Supplementary Figures (S3–S16 Figs). In sensitivity analysis,
each study removed had little impact on the result, indicating that our results were stable
(Fig 4).

Pooling analyses
As suggested by previous studies, we finally chose PFT to perform rate conversion (Table E in
S1 Text) [19]. The overall prevalence of M. bovis among dairy cattle in China was 2.4% (95%
CI 2.1–2.8, 16,825/2,393,265; Fig 2 and Table 2).

Bovine tuberculosis infection in China

The highest prevalence was in Eastern China, and the lowest was in Northwestern China
(Table 2). In terms of province level, the prevalence was highest in Shandong, while Gansu and
Guangdong had the lowest prevalence (Table 3). Based on data from the Chinese Animal Hus-
bandry and Veterinary Yearbook in 2018, we estimated the number of dairy cattle infected
with M. bovis in China at 259,176 (226,779–302,372) (Table 4).

Other moderators associated with bTB

Our analysis manifested that region, sampling year, detection method, age, feeding mode,
sampling season, and article quality level are related moderators (P < 0.05). Among them, the
prevalence in 2012 or before was much higher than in the other two time periods. Compared
with other detection methods, IFN-γ-ELISA yields higher values of the prevalence. The preva-
lence of bTB in heifers was highest. The prevalence of bTB in cattle with scale breeding was
higher than that in free-range breeding. The prevalence was much higher in summer than in
other seasons. Medium-quality articles showed the highest prevalence (Table 2). The heteroge-
neity of each subgroup explained by detection methods (the covariate) ranged from 0–2.49%
(R2-methods), and that explained by provinces (the covariate) was 5.51%–41.78% (R2-prov-
inces) (Table 2).

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Table 1. Included studies of bTB infection in dairy cattle in China.

Study ID Sampling time Province Detection method a bacterial isolation Positive samples/total Prevalence Quality score
samples
Central China
Chen (2011) UN b Hunan SIT Yes 1/60 1.67% 2
Li et al. (2014) 2010–2013 Hubei SIT No 122/7,357 1.66% 4
Chen (2017) 2015.03–2016.10 Henan SIT No 38/840 4.52% 4
Zhao et al. (2019a) 2018 Henan SIT No 169/12,417 1.36% 3
Eastern China
Li (2010) UN Shandong SIT No 44/473 9.30% 3
Zhang (2010) 2009.08 Jiangxi SIT No 4/418 0.96% 4
Hu et al. (2011) 2007–2010 Zhejiang SIT No 300/7,013 4.28% 3
Jin et al. (2011) 2003–2010 Zhejiang SIT No 893/12,245 7.29% 4
Wang et al. 2003–2009 Fujian SIT No 273/111,003 0.25% 3
(2011a)
Qu et al. (2012) 2007–2011 Shanghai SIT No 73/73,018 0.10% 4
(exclude2009)
Shen et al. (2013) UN Shanghai SIT No 13/205 2.08% 3
Xu et al. (2013b) 2009–2011 Jiangsu SIT No 16/769 29.92% 4
Han et al. (2014) 2010–2012 Shandong SIT No 502/1,678 3.48% 4
Hao et al. (2014) 2012.06–2013.06 Shandong SIT No 20/574 2.38% 4
Jiang et al. (2014a) 2010–2012 Shanghai SIT No 223/9,355 0.87% 4
Xu et al. (2014) 2007–2013 Jiangsu SIT No 7,708/889,156 9.30% 4
Duan et al. (2015) UN Zhejiang SIT No 3/184 1.63% 3
Gu et al. (2015) 2011–2013 Jiangsu SIT No 292/25,613 1.14% 4
Yang et al. (2015) UN Shanghai SIT&IFN-γ-ELISA No 12/84 14.29% 3
Chen et al. (2016) 2014.08–2015.02 Shandong Test strip No 46/187 24.60% 4
Sun et al. (2016) 2013–2015 Jiangsu SIT No 18/892 2.02% 4
Yang et al. (2017) UN Shanghai SIT No 10/483 2.07% 3
Tian et al. (2017) 2016.03 Shandong SIT No 3/1,523 0.20% 4
Wu et al. (2017) 2015.07 Shanghai SIT No 25/314 7.96% 4
Northern China
Zhao et al. (2012) UN Beijing SIT No 0/127 0.00% 3
Yang et al. (2013) UN Beijing SIT No 4/300 1.33% 2
Li (2014) UN Inner ELISA No 119/2,112 5.63% 3
Mongolia
Lu et al. (2014) UN Hebei SIT No 15/115 13.04% 3
Wang et al. (2015) UN Hebei SIT No 60/2,204 2.72% 2
Huang et al. 2015 Beijing SIT No 0/17,520 0.00% 4
(2016)
Zhang (2016) UN Inner ELISA No 110/2,478 4.44% 2
Mongolia
Song et al. (2019) 2017.10–2018.06 Beijing SIT No 29/8,000 0.36% 4
Zhang et al. (2019) 2017.06 Beijing IFN-γ-ELISA No 36/173 20.81% 4
Northeastern China
Zhang (2018) 2014–2017 Liaoning SIT No 33/2,005 1.65% 3
Liu et al. (2019) UN Heilongjiang SIT No 22/950 2.32% 3
Song (2019) UN Heilongjiang ELISA No 12/327 3.67% 2
Northwestern China
Cheng (2010) 2003–2008 Xinjiang SIT No 892/126,696 0.70% 3
Hao et al. (2010) 2007.04–2007.06 Qinghai SIT No 9/1,677 0.54% 4
(Continued )

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Table 1. (Continued)

Study ID Sampling time Province Detection method a bacterial isolation Positive samples/total Prevalence Quality score
samples
Hu (2010) 2006–2009 Qinghai SIT No 64/7,608 0.84% 3
La (2010) 2009.06–2009.09 Qinghai SIT No 22/4,000 0.55% 3
Chang (2011) UN Gansu SIT No 0/67 0.00% 3
Lv (2011) 2009.04–2009.06 Qinghai SIT No 7/599 1.17% 3
Wang et al. 2007–2010 Xinjiang SIT No 199/47,085 0.42% 3
(2011b)
Yang (2011) 2008.06–2010.07 Qinghai SIT No 54/10,308 0.52% 4
Li et al. (2012) 2007–2011 Xinjiang SIT No 298/57,389 0.52% 4
Liu et al. (2012) 2008–2011 Qinghai SIT No 60/13,308 0.45% 4
Sang et al. (2012) 2010 Xinjiang SIT No 3/512 0.59% 4
Wu et al. (2012) 2011.06–2011.07 Xinjiang SIT No 6/262 2.29% 3
Ai (2013) 2011.01–2013.05 Xinjiang SIT No 18/6,323 0.28% 4
Guan et al. (2013) 2010–2012 Xinjiang SIT No 173/77,368 0.22% 3
Li (2013) 2013.7 Qinghai SIT No 0/800 0.00% 3
Sa (2013) UN Xinjiang SIT No 203/58,238 0.35% 3
Xie (2013) 2012.04–2012.06 Qinghai SIT No 3/225 1.33% 4
Zhang et al. (2013) UN Shaanxi SIT No 1/121 0.83% 2
Zhou (2013) UN Xinjiang SIT No 35/2,624 1.33% 2
Chen et al. (2014) 2008–2012 Qinghai SIT No 35/59150 0.06% 3
Lei (2014) 2012.04–2012.06 Qinghai SIT No 2/419 0.48% 4
Zhou et al. (2014) UN Xinjiang SIT No 138/3,000 4.60% 2
Kong (2015) UN Gansu SIT No 0/47 0.00% 2
La et al. (2015) 2009–2014 Qinghai SIT No 103/170,203 0.06% 3
Liu et al. (2015) 2012–2015 Xinjiang SIT No 131/4,702 2.79% 4
Tan et al. (2015) UN Ningxia SIT No 1/150 0.67% 3
Wu (2015) 2010–2014 Shaanxi SIT No 83/11,515 0.72% 4
Zhang (2015) 2015.02–2015.05 Ningxia SIT No 57/1,429 3.99% 3
Li et al. (2016) 2015.09–2015.10 Qinghai SIT No 10/1,380 0.72% 4
Wu et al. (2016) 2015 Ningxia SIT No 72/2,230 3.23% 4
He et al. (2017) 2014–2016 Shaanxi SIT No 24/606 3.96% 3
Lin (2017) 2015.06–2015.11 Qinghai SIT No 40/3,270 1.22% 4
Ma (2017) 2016.02 Qinghai SIT No 0/90 0.00% 4
Wang (2017) 2016.03 Qinghai SIT No 0/724 0.00% 4
Zhao et al. (2017) 2015 Shaanxi SIT No 33/1,995 1.65% 3
Gao (2018) 2016.06–2017.10 Shaanxi SIT No 4/715 0.56% 4
Shi et al. (2018a) UN Xinjiang SIT No 26/2,106 1.23% 2
Shi et al. (2018b) 2012–2018.06 Xinjiang SIT No 532/56,668 0.94% 3
Yu (2018) 2011–2016 Gansu SIT No 183/326,651 0.06% 3
Southern China
Xu et al. (2010) 2010 Guangxi SIT No 29/2,818 1.03% 3
Xu et al. (2013a) 2008–2011 Guangxi SIT No 63/5,478 1.15% 4
Jiang et al. (2014b) 2003–2013 Guangxi SIT No 88/860 10.23% 3
Yan et al. (2014) 2004.01–2013.12 Guangxi SIT No 105/20,223 0.52% 4
Situ et al. (2016) 2012–2015 Guangdong SIT No 0/2,993 0.00% 4
Southwestern China
Bian et al. (2010) 2007–2009 Sichuan SIT No 37/3,702 1.00% 3
(Continued )

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Table 1. (Continued)

Study ID Sampling time Province Detection method a bacterial isolation Positive samples/total Prevalence Quality score
samples
Xiong et al. (2011) 2010.02–2010.03 Yunnan SIT No 20/2,075 0.96% 4
Wang et al. (2012) 2010–2011 Yunnan SIT No 54/5,060 1.07% 4
Deng et al. (2014) UN Sichuan SIT No 96/10,200 0.94% 2
He et al. (2014) 2009.06–2009.08 Yunnan SIT No 28/97 28.87% 4
Wu et al. (2014a) UN Guizhou SIT No 24/1,200 2.00% 3
Yang et al. (2014) UN Guizhou SIT No 17/100 17.00% 3
Du (2017) 2016.06–2016.11 Yunnan SIT No 12/3,547 0.34% 4
Ran (2018) 2013–2017 Sichuan SIT No 16/5,598 0.29% 4
Yang et al. (2019) 2016–2017 Sichuan SIT&IFN-γ-ELISA No 6/15,453 0.04% 3
Ye (2019) 2017–2018 Guizhou IFN-γ-ELISA No 10/20,478 0.05% 4
Zhao et al. (2019b) 2012–2018 Yunnan SIT No 111/31,240 0.36% 3
Missing
Zhu et al. (2011) UN UN SIT No 123/182 67.58% 2
Bing (2013) 2011.10–2012.06 UN IFN-γ-ELISA Yes 286/1,187 24.09% 4
Wu et al. (2014b) 2012 UN SIT No 17/856 1.99% 4
Yuan (2014) UN UN SIT No 37/59 62.71% 3
Shao et al. (2016) UN UN IFN-γ-ELISA No 74/470 15.74% 2
Zhang et al. (2016) UN UN SIT No 280/600 46.67% 3
Xu et al. (2017) UN UN SIT No 367/3,367 10.90% 2
Zhang et al. (2018) UN UN IFN-γ-ELISA No 156/990 15.76% 2
a
Detection methods: SIT: single intradermal test (SIT); ELISA: enzyme-linked immunosorbent assay, detection antibody in serum; IFN-γ-ELISA: detection of IFN-γ in
whole blood; SIT&IFN-γ-ELISA: SIT is use for the first detection, and the positive samples obtained from SIT are tested again using IFN-γ-ELISA.
b
UN: Unclear.

https://doi.org/10.1371/journal.pntd.0009502.t001

After subgroup analysis of geographical factors, we found that the prevalence in the groups
of latitude 30–35˚, longitude >110˚, average annual precipitation >1500 mm, average annual
temperature 10–15˚C, average annual humidity 70%, altitude < 100 m was significantly higher
than in the corresponding other groups (P < 0.05; Table 5).

Discussion
Bovine TB is a global zoonotic disease, which has caused huge economic losses and serious
public health problems [22]. Therefore, a deeper understanding of bTB epidemiology is crucial
for future prevention and control. Our assessment of the prevalence of bTB in dairy cattle in
China showed that the prevalence was 2.4%, lower than in the developing country India
(7.3%) and comparable to that in the developed country Spain (2.87%), which reflects the high
degree of control of bTB in China in the past decade. In the year subgroup, the prevalence of
2013–2016 was significantly lower than that of 2012 or before (P < 0.05). In May 2012, China
launched the National Plan for the Prevention and Control of Medium and Long-term Animal
Epidemics (2012–2020), which classified bTB as a class II animal epidemic and formulated
comprehensive prevention and control measures [23]. In June 2013, the International Cooper-
ation Committee of Animal Welfare (ICCAW) of China was established to facilitate coopera-
tion with regard to experience and information on farm animal welfare at home and abroad
and to introduce international advanced welfare farming concepts and technology to China.
National disease control and information exchange with foreign countries have played a

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Table 2. Pooled prevalence and potential infection moderators of bTB infection in dairy cattle in China.
No. No. tested No. % (95% CI) Heterogeneity Univariate meta- Correlation Analysis c
a
studies positive regression
χ2 P I2 (%) P b Coefficient (95% R2- R 2-
CI) methods provinces
Region d Northern China 19 33,029 373 3.2% (1.1– 994.75 0.00 99.2% < 0.084 (0.059 to 0.00% 26.13%
6.3) 0.001 0.108)
Central China 4 20,674 330 2.0% (1.2– 31.47 < 90.5%
3.0) 0.01
Eastern China 20 1,135,187 10,478 3.9% (2.9– 5986.55 0.00 99.7%
5.0)
Northeastern 3 3,282 67 2.3% (1.4– 5.68 0.06 64.8%
China 3.3)
Northwestern 39 1,062,260 3,528 0.7% (0.5– 4106.18 0.00 99.1%
China 1.0)
Southern China 5 32,372 285 1.5% (0.4– 296.12 < 98.6%
3.1) 0.01
Southwestern 12 98,750 431 1.1% (0.6– 528.58 < 97.9%
China 1.6) 0.01
Sampling year 2012 or before 44 1,696,615 12,841 1.6% (1.2– 11141.71 0.00 99.6% 0.003 0.031 (0.011 to 0.00% 40.80%
1.9) 0.052)
2013–2016 30 521,530 1,618 0.9% (0.6– 2866.28 0.00 99.0%
1.2)
2017 or later 8 62,760 300 0.8% (0.3– 438.27 < 98.4%
1.5) 0.01
Detection ELISA 3 4,917 241 4.8% (3.8– 4.44 0.11 55.0% < -0.149 (-0.189 to 2.49% 19.85%
methods e 5.8) 0.001 -0.110)
IFN-γ-ELISA 5 23,298 562 12.7% (0.9– 1899.76 0.00 99.8%
34.8)
SIT 89 2,349,200 16,108 2.1% (1.8– 18294.77 0.00 99.5%
2.5)
SIT&ELISA 2 15,537 18 - - - - - - - -
Colloidal gold 1 187 46 - - - - - - - -
test
Age f Calf 5 17,991 150 11.5% (0.0– 735.99 < 99.5% < 0.256 (0.134 to 0.00% 5.51%
45.9) 0.01 0.001 0.378)
Heifer 4 747 175 27.1% (9.7– 111.03 < 97.3%
49.2) 0.01
Adult cow 17 209,974 1,093 6.7% (4.1– 3625.75 0.00 99.6%
9.8)
Young cow 1 47 15 - - - - - - - -
Feeding mode Free-range 15 179,062 677 1.7% (1.1– 826.34 < 98.3% 0.008 0.048 (0.012 to 0.00% 30.14%
2.4) 0.01 0.083)
Scale 62 1,633,651 13,649 3.7% (3.1– 15594.09 0.00 99.6%
4.3)
Season g Spring 8 16,123 105 0.8% (0.1– 278.90 < 97.5% 0.013 0.104 (0.022 to 0.00% 41.78%
2.1) 0.01 0.187)
Summer 10 15,241 185 4.0% (1.7– 349.45 < 97.4%
7.0) 0.01
Autumn 5 26,673 915 1.4% (0.0– 1746.09 0.00 99.8%
6.6)
Winter 4 29,180 116 0.4% (0.0– 83.83 < 96.4%
1.3) 0.01
(Continued )

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Table 2. (Continued)

No. No. tested No. % (95% CI) Heterogeneity Univariate meta- Correlation Analysis c
a
studies positive regression
χ2 P I2 (%) P b Coefficient (95% R2- R 2-
CI) methods provinces
Quality level Medium 15 28,476 1203 5.9% (3.1– 1481.57 0.00 99.1% < -0.050 (-0.072 to 1.94% 28.00%
9.3) 0.001 -0.028)
High 85 2,364,789 15,622 2.2% (1.9– 18024.12 0.00 99.5%
2.5)
Total 100 2,393,265 16,825 2.4% (2.1– 20446.92 0.00 99.5%
2.8)
a
Confidence interval.
b
P < 0.05 is statistically significant.
c
Correlation analysis: Joint analysis with prevalence of detection methods and provinces of China; R2: Proportion of between-study variance explained.
d
Northern China: Beijing, Hebei, Inner Mongolia; Northwestern China: Gansu, Ningxia, Qinghai, Shaanxi, Xinjiang; Southwestern China: Guizhou, Sichuan, Yunnan;
Northeastern China: Heilongjiang, and Liaoning; Central China: Hubei, Henan, Hunan; Eastern China: Fujian, Jiangsu, Jiangxi, Shandong, Shanghai, Zhejiang;
Southern China: Guangdong, Guangxi.
e
ELISA: SIT: single intradermal test (SIT); ELISA: enzyme-linked immunosorbent assay, detection antibody in serum sample; IFN-γ-ELISA: detection of IFN-γ in
whole blood sample; SIT&IFN-γ-ELISA: SIT is use for the first detection, and the positive samples obtained from SIT are tested again using IFN-γ-ELISA.
f
Calf: 0–6 months old; Young cow: 7–15 months old; Heifer: 16 months old to first delivery; Adult cow: after first delivery.
g
Spring: March through May; Summer: June through August; Autumn: September through November; Winter: December through February.

https://doi.org/10.1371/journal.pntd.0009502.t002

positive role in reducing bTB [24]. The prevalence has been lowest since 2017. In June 2017,
the Ministry of Agriculture issued the National Guidelines for Controlling Bovine TB among
Dairy Cattle (2017–2020) [25], which adopted comprehensive prevention and control mea-
sures such as quarantine culling, risk assessment, movement control, and strengthening health
management for domestic dairy cows. The policy aims to strengthen international cooperation

Fig 3. Funnel plot with pseudo 95% confidence limits intervals for the examination of publication bias.
https://doi.org/10.1371/journal.pntd.0009502.g003

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Fig 4. Sensitivity analysis. After removing one study at a time, the remaining studies were re-combined using a random-effects model to verify the impact of a
single study on the overall results.
https://doi.org/10.1371/journal.pntd.0009502.g004

Table 3. Pooled prevalence of tuberculosis infection in dairy cattle in different provinces of China.
Province Region Study No. No. tested No. positive % (95% CI) Heterogeneity Univariate meta-regression
χ2 P I2 (%) P Coefficient (95% CI)
Beijing Northern China 5 26,120 69 1.5% (0.3–3.6) 224.98 < 0.01 98.2% < 0.001 0.199 (0.155 to 0.243)
Fujian Eastern China 1 111,003 273 0.3% (0.2–0.3) 0.00 < 0.01 –
Gansu Northwestern China 3 326,765 183 0.0% (0.0–0.0) 0.82 < 0.01 0.0%
Guangdong Southern China 1 2,993 0 0.0% (0.0–0.1) 0.00 < 0.01 –
Guangxi Southern China 4 29,379 285 2.2% (0.7–4.4) 226.36 < 0.01 98.7%
Guizhou Southwestern China 3 21,778 51 3.2% (0.1–9.7) 130.06 < 0.01 98.5%
Hebei Northern China 2 2,319 75 6.7% (0.2–20.3) 18.95 < 0.01 94.7%
Heilongjiang Northeastern China 2 1,277 34 2.8% (1.6–4.2) 1.72 < 0.01 41.9%
Henan Central China 2 13,257 207 2.7% (0.4–6.7) 30.57 < 0.01 96.7%
Hubei Central China 1 7,357 122 1.7% (1.4–2.0) 0.00 < 0.01 –
Hunan Central China 1 60 1 1.7% (0.0–7.0) 0.00 < 0.01 –
Inner Mongolia Northern China 2 4,590 229 5.0% (3.9–6.2) 3.42 < 0.01 70.8%
Jiangsu Eastern China 4 916,430 8,034 1.2% (0.9–1.6) 36.93 < 0.01 91.9%
Jiangxi Eastern China 1 418 4 1.0% (0.2–2.2) 0.00 < 0.01 –
Liaoning Northeastern China 1 2,005 33 1.7% (1.1–2.3) 0.00 < 0.01 –
Ningxia Northwestern China 3 3,809 137 3.2% (2.1–4.5) 5.85 < 0.01 65.8%
Qinghai Northwestern China 15 273,761 409 0.4% (0.2–0.6) 463.97 < 0.01 97.0%
Shaanxi Northwestern China 5 14,952 145 1.3% (0.5–2.5) 42.79 < 0.01 90.7%
Shandong Eastern China 5 4,435 615 10.4% (0.6–29.3) 970.11 < 0.01 99.6%
Shanghai Eastern China 6 83,459 356 3.9% (1.3–7.6) 676.09 < 0.01 99.3%
Sichuan Southwestern China 4 34,953 155 0.5% (0.1–1.2) 177.59 < 0.01 98.3%
Xinjiang Northwestern China 13 442,973 2,654 0.9% (0.7–1.3) 917.03 < 0.01 98.7%
Yunnan Southwestern China 5 42,019 225 1.6% (0.7–2.8) 142.03 < 0.01 97.2%
Zhejiang Eastern China 3 19,442 1,196 4.5% (2.4–7.2) 84.62 < 0.01 97.6%
a
Correlation analysis: Joint analysis with prevalence of provinces of China; R2: Proportion of between-study variance explained; I2-res: Residual variation due to
heterogeneity.

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

Table 4. Estimated number of bTB infection in dairy cattle in China.

Region Estimated number of dairy cattle in Prevalence of tuberculosis Estimated number of dairy cattle with tuberculosis
China� infection infection
Northern China 3,012,000 3.2% (1.1–6.3) 96,384 (33,132–189,756)
Northeastern China 1,656,000 2.3% (1.4–3.3) 38,088 (23,184–54,648)
Eastern China 1,368,000 3.9% (2.9–5.0) 53,352 (39,672–68,400)
Central China 439,000 2.0% (1.2–3.0) 8,780 (5,268–13,170)
Southern China 111,000 1.5% (0.4–3.1) 1,665 (444–3,441)
Southwestern China 1,405,000 1.1% (0.6–1.6) 15,455 (8,430–22,480)
Northwestern 2,808,000 0.7% (0.5–1.0) 19,656 (14,040–28,080)
China
Total 10,799,000 2.4% (2.1–2.8) 259,176 (226,779–302,372)
�
Estimates of the number of dairy cattle in each region were obtained from 2018 data of the Chinese Animal Husbandry and Veterinary Yearbook.

https://doi.org/10.1371/journal.pntd.0009502.t004

with the FAO, the World Organisation for Animal Health (OIE), and other organizations
(2017). In December of the same year, the OIE, the WHO, the FAO, and the International
Union Against Tuberculosis and Lung Disease (The Union) jointly launched the first-ever

Table 5. Geographical and climatic factors of bTB infection in dairy cattle in China.
No. studies No. tested No. positive % (95% CI) Heterogeneity Univariate meta-regression
2 2
χ P I (%) P-valuea Coefficient (95% CI)
Latitude 20–30˚ 18 205,658 1,956 2.12% (1.15–3.35) 3,203.38 0.00 99.5 0.032 0.029 (0.002 to 0.056)
30–35˚ 9 113,111 645 2.13% (1.10–3.47) 869.66 < 0.001 99.1
35–40˚ 39 151,475 707 0.97% (0.63–1.37) 1,263.15 < 0.001 97.0
40–50˚ 15 359,074 2,270 0.70% (0.50–0.92) 506.56 < 0.001 97.2
Longitude 85–100˚ 11 355,819 2,179 0.47% (0.32–0.64) 351.08 < 0.001 97.2 < 0.001 0.072 (0.049 to 0.095)
100–105˚ 29 145,833 515 0.49% (0.27–0.74) 528.35 < 0.001 94.7
105–110˚ 11 50,418 466 1.46% (0.87–2.20) 281.83 < 0.001 96.5
> 110˚ 30 277,248 2,418 2.74% (1.88–3.74) 4,683.20 0.00 99.4
Precipitation (mm) < 400 18 108,437 954 0.95% (0.65–1.30) 293.13 < 0.001 94.2 0.029 0.060 (0.006 to 0.114)
400–1000 24 144,549 562 1.40% (0.91–1.98) 1,079.93 < 0.001 97.9
1000–1500 12 143,723 804 1.26% (0.69–1.98) 955.16 < 0.001 98.8
> 1500 6 133,618 1,496 3.31% (0.44–8.40) 2,832.49 0.00 99.8
Mean temperature (˚C) < 10 29 409,072 2,357 0.50% (0.34–0.68) 854.05 < 0.001 96.7 < 0.001 0.068 (0.034 to 0.101)
10–15 10 38,703 324 3.46% (1.69–5.80) 853.18 0.00 98.9
15–20 18 284,168 2,268 2.03% (1.23–3.03) 3,763.88 < 0.001 99.5
> 20 6 29,554 256 1.85% (0.51–3.90) 309.94 < 0.001 98.4
Humidity (%) 40–50 13 127,493 721 0.92% (0.61–1.29) 258.61 < 0.001 95.4 < 0.001 0.059 (0.031 to 0.087)
50–60 23 315,819 1,857 0.59% (0.33–0.90) 1,285.71 < 0.001 98.3
60–70 9 64,106 388 1.55% (0.92–2.33) 280.51 < 0.001 97.1
> 70 18 254,079 2,239 2.67% (1.62–3.96) 4,001.01 0.00 99.6
Altitude (m) < 100 27 177,844 1,974 2.66% (1.65–3.88) 4,039.47 0.00 99.4 < 0.001 0.058 (0.034 to 0.081)
100–1000 10 130,537 554 2.05% (1.07–3.32) 546.50 < 0.001 98.4
1000–2000 29 453,477 2,936 0.69% (0.54–0.86) 791.94 < 0.001 96.5
> 2000 15 67,460 114 0.35% (0.04–0.89) 192.77 < 0.001 92.7
a
Amount of heterogeneity accounted.
b
Estimated amount of residual heterogeneity.

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

roadmap to tackle zoonotic TB [26]. Continuous reduction in prevalence of bTB has been the
result of a concerted national and global effort. Targeted prevention and control policies (such
as the timely culling of sick cattle) and comprehensive policy implementation may be the key
to prevention and control of bTB. In addition, livestock production systems in developed
countries are primarily based on intensive dairy farming as opposed to extensive small-scale
production systems in developing countries which are known to have low prevalence of bTB.
Therefore, another main reason for the low prevalence of bTB in China may be due to the
extensive production system.
In the subgroup of feeding mode, the prevalence of scale cultivation was significantly higher
than that of free-range (P < 0.05). More intuitively, except for Xinjiang Province, the areas
with high prevalence of dairy cow tuberculosis in China were generally concentrated in prov-
inces with large dairy cow populations. Intensive farming has been shown to be a contributing
factor to bTB in animals [14,27]. It is well known that bTB can be transmitted through the
respiratory tract, which is exacerbated by the closure of cattle sheds on scale farms, and higher
stocking density also tends to be associated with regional epidemic of bTB [28]. The relatively
high levels of sunlight outside, lower farming density, and better air circulation in free-range
cattle reduce the burden of M. bovis, relative to that in scale farming [29]. In recent years, mass
movement of dairy cattle between large-scale farms in China and the introduction of foreign
cattle breeds may also accelerate the spread of bTB [30]. However, we still need to treat this
result with caution because the funnel plot indicates publication bias in this subgroup. In gen-
eral, there are still deficiencies in intensive farming. Therefore, we suggest standardizing the
breeding and management, improving the environment of the barn, and increasing animal
welfare when developing the scale breeding of cows, which may have a better prevention and
control effect [31].
Understanding age-specific risks is critical to accurately interpreting trends in pooled epi-
demiological data and to designing and evaluating control strategies such as vaccination [32].
Almost all previous studies have shown an increase in infection rates with age, and the rela-
tionship is generally monotonic or linear, with a U-shaped relationship reported [33]. How-
ever, our study showed that the prevalence was significantly different at different age stages
and decreased with age (P < 0.001). It is worth noting that the sample size of the calf, young
cow, and heifer groups is much smaller than that of the adult cow group, so small-study effects
may lead to unstable results. Moreover, the funnel plot of this subgroup also suggests publica-
tion bias. Therefore, the relationship between the two requires further study.
In the seasonal subgroup, the prevalence in summer was significantly higher than in winter
(P < 0.05). Cattle are more stressed in the hotter and wetter summer months [28,31]. In addi-
tion, the days are longer than the nights in summer, giving cows that are active for a prolonged
time more opportunity to come into contact with sick animals [34]. The correlation analysis
shows that provinces can explain 43.15% of the heterogeneity of the season subgroup. Summer
has different characteristics in the different regions of China’s vast territory, so we further ana-
lyzed this result by combining geographical factors. The results showed that the incidence was
significantly higher in regions with higher humidity and rainfall, similarly to that in previous
studies [35]. In the mean temperature subgroup, the prevalence increased with temperature,
but the relationship was not linear as expected. The prevalence peaked at 10–15˚C and then
declined as temperatures rose. Previous studies have shown that M. bovis does not easily sur-
vive in a hot and dry environment [36], so we speculated that 10–15˚C may be the optimum
temperature for M. bovis to survive or to spread, and that a humid environment is conducive
to its spread. It is therefore recommended to strengthen epidemic prevention in moist and
warm areas to create a healthy living environment for livestock and reduce the incidence of
diseases.

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

In terms of regional subgroups, the prevalence was lowest in Northwestern China and high-
est in Easthern China (P < 0.05). The geographical factors showed that the longitude range
was >110˚ and the latitude was 20–35˚, the highest prevalence was consistent with the regional
results. This range belongs to subtropical humid monsoon climate and temperate monsoon
climate. It is hot and rainy in summer, mild and humid in winter. The results were basically
consistent with the above seasonal and geographical factors. We speculated that warm and
humid weather may exacerbate the prevalence of bTB [28,29,31].
Among provinces of China, Shandong had the highest prevalence, while Guangdong and
Gansu had the lowest prevalence (P < 0.001). In recent years, a number of modern standard-
ized dairy enterprises that are strong on fundamentals have emerged in Gansu. They have
abandoned the extensive model and focused on quantity and quality, so that the dairy farming
industry in Gansu has developed well [37]. However, the need for disease prevention and con-
trol in cattle in Shandong is still great, and zoonoses occur from time to time due to the low
level of cow breeding technology and nonstandard technical operation [38]. In addition, the
animal husbandry of Shandong is characterized by early start and high density. Currently, the
average carrying capacity per square kilometer of land is 618 standard livestock units, 6.5
times the average in China. Aquaculture pollution and increasing environmental pressure may
also contribute to the higher prevalence of bTB [38]. Furthermore, the altitude of Gansu was
lower, while that of Shandong was higher, and the prevalence at altitude < 1000 m was signifi-
cantly higher than other areas. Altitude is inversely related to economy [39]. Transportation is
more convenient in economically developed areas, so more animal trade also creates favorable
conditions for the spread of bTB [40]. It is worth noting that although 21 provinces or munici-
palities were included in the study, many provinces had only one or two studies, which could
lead to unstable results. It is recommended that all provinces and cities strengthen bTB moni-
toring to clearly show the regional diversity of bTB in China.
The 100 studies included five methods (ELISA, IFN-γ-ELISA, SIT, SIT& IFN-γ-ELISA, and
colloidal gold test). Diverse detection methods usually bring heterogeneity to the meta-analysis
of prevalence. Therefore, we used detection methods as a covariate to perform joint analysis
with other moderators, and the range of heterogeneity explained by the detection method was
only 0–4.95%, which implied that the detection methods had a small influence on each sub-
group. The SIT is the standard method for detection of bovine tuberculosis. It involves mea-
suring skin thickness, injecting bovine tuberculin intradermally into the measured area, and
measuring any subsequent swelling at the site of injection 72 hours later. SIT (n = 89), which
has been approved by the OIE and the European Commission as the main screening tool for
bTB, is most frequently used in China [41,42]. The IFN-γ-ELISA uses ELISA to determine
gamma interferon in the whole blood sample. It can be tested only by anticoagulation, which
is suitable for laboratory diagnosis and early diagnosis of tuberculosis. Cellular immunity and
humoral immunity occur in turn when animals are infected with bTB. SIT and the interferon-
gamma test are both markers of cellular immunity in the early stage of infection, while ELISA
(detection antibody in serum sample) is indicated as a diagnostic method for relatively later
infection [43]. Given the prevalence of bTB in different regions, the detection scheme should
also be adjusted accordingly. Areas with more severe infection and economic problems should
adopt sensitive, scalable, low-cost testing methods to rapidly isolate and remove infected ani-
mals to maximize outbreak control. In the regions with stable prevalence, a variety of methods
should be adopted for comprehensive testing, which is conducive to improving the accuracy
and reducing the incidence of unnecessary slaughter [44]. The colloidal gold test is easy to
operate [45]. It should be noted that due to a paucity of studies, the colloidal gold test group
and SIT&INF-γ-ELISA group may not fully reflect the true situation of infection; therefore, we
have presented these two groups without data pooling in the detection methods subgroup. In

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

conclusion, we believe that the detection of bTB should be tailored to local conditions, and dif-
ferent regions should choose a method based on their actual situation. Without regard to cost
and equipment, it is recommended that the SIT, the standard practice recommended by the
OIE be used as the main screening experiment and other complementary experiments be used
to improve the accuracy of the results. This kind of comprehensive experiment can eliminate
infected animals more thoroughly, thereby preventing continuous transmission [46].
We analyzed the research quality and found that most of the articles of medium quality
lacked detailed sampling methods and clear sampling time. It is suggested that personnel
record relevant information in detail when conducting epidemiological investigation, to pro-
vide scientific data and theoretical support for the follow-up study of bTB.
This study’s large sample size and rigorous methods, including comprehensive analysis of
moderators, provide a reference for the prevention and control of bTB. However, several limi-
tations may affect this meta-analysis. Firstly, due to the different retrieval strategies of different
databases, we used several different retrieval forms and five databases in order to retrieve more
qualified studies. Yet there may still be studies that have fallen through the cracks. Secondly,
insufficient research on some subgroups (province, season, detection methods, and age) will
affect the analysis results to some extent. Thirdly, due to lack of data, we were unable to extract
all the potential moderators that are considered important, such as the number of calves pro-
duced and cattle breeds [47].

Conclusion
Our study has shown that bTB is widespread among cattle in China. From our findings about
factors affecting prevalence in China, we recommend that countries adapt their own preven-
tion and control policies to local conditions, particularly strengthening the screening of cattle
in warm and wet areas, strengthen the breeding of animals and management of animal welfare,
and slaughter sick cattle in a timely manner. Carrying out bTB epidemiological investigation
in more areas can extend the good foundation that has been laid for the prevention and control
of bTB in the future.

Supporting information
S1 Fig. Egger’s test for publication bias.
(TIF)
S2 Fig. Funnel plot with trim and fill analysis for the publication bias test.
(TIF)
S3 Fig. Funnel plot with pseudo 95% confidence limit intervals for the examination of pub-
lication bias in the feeding mode subgroup.
(TIF)
S4 Fig. Funnel plot with pseudo 95% confidence limit intervals for the examination of pub-
lication bias in the age subgroup.
(TIF)
S5 Fig. Funnel plot with pseudo 95% confidence limit intervals for the examination of pub-
lication bias in the region subgroup.
(TIF)
S6 Fig. Funnel plot with pseudo 95% confidence limit intervals for the examination of pub-
lication bias in the sampling year subgroup.
(TIF)

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

S7 Fig. Funnel plot with pseudo 95% confidence limit intervals for the examination of pub-
lication bias in the detection methods subgroup.
(TIF)
S8 Fig. Funnel plot with pseudo 95% confidence limit intervals for the examination of pub-
lication bias in the season subgroup.
(TIF)
S9 Fig. Funnel plot with pseudo 95% confidence limit intervals for the examination of pub-
lication bias in the quality level subgroup.
(TIF)
S10 Fig. Forest plot of the feeding mode subgroup.
(TIF)
S11 Fig. Forest plot of the age subgroup.
(TIF)
S12 Fig. Forest plot of the region subgroup.
(TIF)
S13 Fig. Forest plot of the sampling year subgroup.
(TIF)
S14 Fig. Forest plot of the detection methods subgroup.
(TIF)
S15 Fig. Forest plot of the season subgroup.
(TIF)
S16 Fig. Forest plot of the quality level subgroup.
(TIF)
S1 Text. Supplementary tables. Table A. PRISMA Checklist item. Table B. The code in R for
this meta-analysis. Table C. Egger’s test for publication bias. Table D. Included studies and
quality scores. Table E. Normal distribution test for the normal rate and the different conver-
sion of the normal rate
(DOCX)

Author Contributions
Conceptualization: Rui Du, Xiao-Xuan Zhang.
Data curation: Tian Tian, Dong Li, Qi Wang.
Formal analysis: Yu Chen, Qi Wang.
Funding acquisition: Rui Du, Xiao-Xuan Zhang.
Methodology: Qing-Long Gong.
Software: Yu Chen.
Writing – original draft: Qing-Long Gong.
Writing – review & editing: Xiaobo Wen, Yu-Hao Song.

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PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

References
1. Sibhat B, Asmare K, Demissie K, Ayelet G, Mamo G, Ameni G. Bovine tuberculosis in Ethiopia: A sys-
tematic review and meta-analysis. Prev Vet Med. 2017; 147: 149–157. https://doi.org/10.1016/j.
prevetmed.2017.09.006 PMID: 29254713
2. Hlokwe TM, Michel AL, Mitchel E, Gcebe N, Reininghaus B. First detection of Mycobacterium bovis
infection in Giraffe (Giraffa camelopardalis) in the Greater Kruger National Park Complex: Role and
implications. Transbound Emerg Dis. 2019; 66: 2264–2270. https://doi.org/10.1111/tbed.13275 PMID:
31233666
3. Mostowy S, Inwald J, Gordon S, Martin C, Warren R, Kremer K,et al. Revisiting the evolution of Myco-
bacterium bovis. J Bacteriol. 2005 Sep; 187(18):6386–95. https://doi.org/10.1128/JB.187.18.6386-
6395.2005 PMID: 16159772; PMCID: PMC1236643.
4. O’Reilly LM, Daborn CJ. The epidemiology of Mycobacterium bovis infections in animals and man: a
review. Tuber Lung Dis. 1995 Aug; 76 Suppl 1:1–46. https://doi.org/10.1016/0962-8479(95)90591-x
PMID: 7579326.
5. Du Y, Qi Y, Yu L, Lin J, Liu S, Ni H, et al. Molecular characterization of Mycobacterium tuberculosis com-
plex (MTBC) isolated from cattle in northeast and northwest China. Res Vet Sci. 2011; 90: 385–391.
https://doi.org/10.1016/j.rvsc.2010.07.020 PMID: 20797738
6. Good M, Bakker D, Duignan A, Collins DM. The history of in vivo tuberculin testing in bovines: Tubercu-
losis, a “one health” issue. Front Vet Sci. 2018; 5: 59. https://doi.org/10.3389/fvets.2018.00059 PMID:
29686992
7. Xin YJ, Xiang L, Jiang JN, Lucas H, Tang SL, Huang F. The impact of increased reimbursement rates
under the new cooperative medical scheme on the financial burden of tuberculosis patients. Infect dis
poverty. 2019; 8: 67. https://doi.org/10.1186/s40249-019-0575-z PMID: 31370909
8. WHO. Global Tuberculosis Report. Geneva: World Health Organization. 2019. License: CC BY-NC-SA
3.0 IGO. https://apps.who.int/iris/handle/10665/329368.
9. Vargas-Bello-Pérez E, Márquez-Hernández RI, Hernández-Castellano LE. Bioactive peptides from
milk: animal determinants and their implications in human health. J Dairy Res. 2019; 86: 136–144.
https://doi.org/10.1017/S0022029919000384 PMID: 31156082
10. Srinivasan S, Easterling L, Rimal B, Niu XM, Conlan AJK, Dudas P, et al. (2018). Prevalence of bovine
tuberculosis in India: A systematic review and meta-analysis. Transbound Emerg Dis. 2018; 65: 1627–
1640. https://doi.org/10.1111/tbed.12915 PMID: 29885021
11. Caminiti A, Pelone F, LaTorre G, De Giusti M, Saulle R, Mannocci A, et al. Control and eradication of
tuberculosis in cattle: a systematic review of economic evidence. Vet Rec. 2016; 179: 70–75. https://
doi.org/10.1136/vr.103616 PMID: 27422918
12. Dorn-In S, Körner T, Büttner M, Hafner-Marx A, Müller M, Heurich M, et al. Shedding of Mycobacterium
caprae by wild red deer (Cervus elaphus) in the Bavarian alpine regions, Germany. Transbound Emerg
Dis. 2020; 67: 308–317. https://doi.org/10.1111/tbed.13353
13. Refaya AK, Bhargavi G, Mathew NC, Rajendran A, Krishnamoorthy R, Swaminathan S, et al. A review
on bovine tuberculosis in India. Tuberculosis (Edinb). 2020; 122: 101923. https://doi.org/10.1016/j.tube.
2020.101923 PMID: 32275234
14. Yu XJ, Song J. Chinese Animal Husbandry and Veterinary Yearbook. Chin Agri Press, Beijing. 2018.
(In Chinese)
15. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. PLoS Med. 2009; 6: e1000097. https://doi.org/10.1371/journal.
pmed.1000097 PMID: 19621072
16. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for
systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4, 1.
https://doi.org/10.1186/2046-4053-4-1 PMID: 25554246
17. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. (2008). GRADE: an
emerging consensus on rating quality of evidence and strength of recommendations. Bmj. 2008; 336,
924–926. https://doi.org/10.1136/bmj.39489.470347.AD PMID: 18436948
18. Wang N. How to conduct a meta-analysis of proportions in R: A comprehensive tutorial. 2018. https://
doi.org/10.13140/RG.2.2.27199.00161
19. Barendregt JJ, Doi SA, Lee YY, Norman RE, Vos T. Meta-analysis of prevalence. J Epidemiol Commu-
nity Health, 67(11), 974–978. https://doi.org/10.1136/jech-2013-203104 PMID: 23963506
20. Li X, Ni HB, Ren WX, Jiang J, Gong QL, Zhang XX, et al. Seroprevalence of Toxoplasma gondii in
horses: A global systematic review and meta-analysis. Acta Trop, 201, 105222. https://doi.org/10.
1016/j.actatropica.2019.105222 PMID: 31639325

PLOS Neglected Tropical Diseases | https://doi.org/10.1371/journal.pntd.0009502 June 17, 2021 18 / 20

PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

21. Ni HB, Gong QL, Zhao Q, Li XY, Zhang XX. Prevalence of Haemophilus parasuis “Glaesserella para-
suis” in pigs in China: A systematic review and meta-analysis. Prev Vet Med, 182, 105083. https://doi.
org/10.1016/j.prevetmed.2020.105083 PMID: 32652336
22. Canto Alarcon GJ, Rubio Venegas Y, Bojorquez Narvaez L, Pizano Martı́nez OE, Garcı́a Casanova L,
Sosa Gallegos S, et al. Efficacy of a vaccine formula against tuberculosis in cattle. PLoS One, 8(10),
e76418. https://doi.org/10.1371/journal.pone.0076418 PMID: 24204624
23. General Office of the State Council, PRC. A mid-to-long-term animal disease prevention plan (2012–
2020). General Office of the State Council, PRC, Available at: http://www.gov.cn/zwgk/2012-05/25/
content_2145581.htm.
24. Wang YQ. Focus on animal welfare and promote human health– 2013 China Forum on Animal Welfare
and Quality Safety of Livestock and Poultry Products was held in Beijing. J Feed Wide-angle, 20(1). (In
Chinese)
25. Ministry of Agriculture and Rural Affairs, PRC. The National Guidelines for Controlling Bovine TB
among Dairy Cattle (2017–2020). J Dairy Sci Technol. http://d.wanfangdata.com.cn/periodical/
rykxyjs201703011
26. OIE. Bovine Tuberculosis: Roadmap for zoonotic tuberculosis. World Organisation for Animal Health.
Available at: https://www.oie.int/en/animal-health-in-the-world/animal-diseases/Bovine-tuberculosis/
27. Ghebremariam MK, Michel AL, Nielen M, Vernooij JCM, Rutten V. Farm-level moderators associated
with bovine tuberculosis in the dairy sector in Eritrea. Transbound Emerg Dis. 2018; 65: 105–13. https://
doi.org/10.1111/tbed.12622 PMID: 28332294
28. Yahyaoui Azami H, Ducrotoy MJ, Bouslikhane M, Hattendorf J, Thrusfield M, Conde-Álvarez R, et al.
The prevalence of brucellosis and bovine tuberculosis in ruminants in Sidi Kacem Province, Morocco.
PloS one 13. 2018: e0203360. https://doi.org/10.1371/journal.pone.0203360 PMID: 30226847
29. Ghebremariam MK, Michel AL, Vernooij JCM, Nielen M, Rutten V. Prevalence of bovine tuberculosis in
cattle, goats, and camels of traditional livestock raising communities in Eritrea. BMC Vet Res. 2018; 14:
73. https://doi.org/10.1186/s12917-018-1397-0 PMID: 29514650
30. Bing R. Serological screening and pathogen isolation of Bovine tuberculosis in China. Gansu Agri Uni.
2013. (In Chinese)
31. Kemal J, Sibhat B, Abraham A, Terefe Y, Tulu KT, Welay K, et al. Bovine tuberculosis in eastern Ethio-
pia: prevalence, moderators and its public health importance. BMC Infect Dis. 2019; 19: 39. https://doi.
org/10.1186/s12879-018-3628-1 PMID: 30630431
32. Brooks-Pollock E, Conlan AJ, Mitchell AP, Blackwell R, McKinley TJ, Wood J L. Age-dependent pat-
terns of bovine tuberculosis in cattle. Vet Res. 2013; 44: 97. https://doi.org/10.1186/1297-9716-44-97
PMID: 24131703
33. Broughan JM, Judge J, Ely E, Delahay RJ, Wilson G, Clifton-Hadley RS, et al. A review of moderators
for bovine tuberculosis infection in cattle in the UK and Ireland. Epidemiol Infect. 2016; 144: 2899–926.
https://doi.org/10.1017/S095026881600131X PMID: 27452974
34. Silk MJ, Weber N, Steward LC, Delahay RJ, Croft DP, Hodgson DJ, et al. Seasonal variation in daily
patterns of social contacts in the European badger Meles meles. Ecol Evol. 2017; 7: 9006–15. https://
doi.org/10.1002/ece3.3402 PMID: 29152194
35. Boukary AR, Thys E, Rigouts L, Matthys F, Berkvens D, Mahamadou I, et al. Moderators associated
with bovine tuberculosis and molecular characterization of Mycobacterium bovis strains in urban set-
tings in Niger. Transbound Emerg Dis. 2012; 59: 490–502. https://doi.org/10.1111/j.1865-1682.2011.
01302.x PMID: 22226088
36. Huang ZYX, Xu C, Langevelde FVAN, Prins HHT, Jebara KB, Boer WFDE. Dilution effect and identity
effect by wildlife in the persistence and recurrence of bovine tuberculosis. Parasitology. 2014; 141:
981–987. https://doi.org/10.1017/S0031182013002357 PMID: 24612552
37. He MY, Shen QY, Pan XR. Situation and outlet of Gansu dairy industry–survey report on development
of Gansu dairy industry in 2014. Gansu agri. 2015; 15: 28–31. (In Chinese)
38. Zhao Y, Xiao WD. Development status and transformation ideas of Dairy farming in Shandong Prov-
ince. Chin J of Anim Husb. 2018; 54: 141–146. (In Chinese)
39. Zhai SX, Sun AC. On the relationship between altitude and economy–and on the enlightenment of “alti-
tude effect” to the economic development of Qinghai-Tibet Plateau. Qinghai Ethnic Studies. 2012; 23:
152–159. (In Chinese)
40. Rossi G, Aubry P, Dubé C, Smith RL. The spread of bovine tuberculosis in Canadian shared pastures:
Data, model, and simulations. Transbound Emerg Dis. 2019; 66: 562–577. https://doi.org/10.1111/
tbed.13066 PMID: 30407739

PLOS Neglected Tropical Diseases | https://doi.org/10.1371/journal.pntd.0009502 June 17, 2021 19 / 20

PLOS NEGLECTED TROPICAL DISEASES bTB prevalence in dairy cattle in China

41. Bezos J, Casal C, Romero B, Schroeder B, Hardegger R, Raeber AJ, et al. Current ante-mortem tech-
niques for diagnosis of bovine tuberculosis. Res Vet Sci. 2014; 97 Suppl, S44–52. https://doi.org/10.
1016/j.rvsc.2014.04.002 PMID: 24768355
42. OIE. (2018). Manual of Diagnostic Tests and Vaccines for Terrestrial Animals. World Organisation for
Animal Health. Bovine Tuberculosis, Chapter 3.4.6. Available at: https://www.oie.int/fileadmin/Home/
eng/Health_standards/tahm/3.04.06_BOVINE_TB.pdf
43. Xu F, Tian LL, Qi YY, Sun SS, Sun XX, Yan GQ, et al. Comprehensive diagnosis and pathogen isolation
and identification of extrapulmonary tuberculosis in dairy cows. China Anim Health Inspect. 2017; 34:
1–4,19.(In Chinese)
44. Ashford RT, Anderson P, Waring L, Davé D, Smith F, Delahay RJ, et al. Evaluation of the Dual Path
Platform (DPP) VetTB assay for the detection of Mycobacterium bovis infection in badgers. Prev Vet
Med. 2020; 180: 105005. https://doi.org/10.1016/j.prevetmed.2020.105005 PMID: 32473415
45. Shi Q, Yuan LG, Pu JW, Sha L, Liu W. The coincidence rate between two methods of tuberculosis
detection in cows and PPD detection was compared. China Anim Quarantine. 2018; 35(10): 87–9. (In
Chinese)
46. Sinclair JA, Dawson KL, Buddle BM. The effectiveness of parallel gamma-interferon testing in New
Zealand’s bovine tuberculosis eradication programme. Prev Vet Med. 2016; 127: 94–9. https://doi.org/
10.1016/j.prevetmed.2016.03.020 PMID: 27094146
47. Akinseye VO, Adebayo MD, Genesis OO, Adelakun OD, Cadmus SIB. Prevalence and moderators of
mycobacterial infections in farm and trade cattle in southwestern Nigeria. Trop Anim Health Prod. 2018;
50(4): 761–72. https://doi.org/10.1007/s11250-017-1492-4 PMID: 29274054

PLOS Neglected Tropical Diseases | https://doi.org/10.1371/journal.pntd.0009502 June 17, 2021 20 / 20