Tuberculosis Pathways to Care and Transmission of Multidrug-Resistance in India

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American Journal of Respiratory and Critical Care Medicine

Rationale: India is experiencing a regional increase in cases of multidrug-resistant tuberculosis (MDR-TB). Given the complexity of MDR-TB diagnosis and care, we sought to address key knowledge gaps in MDR risk factors, care delays, and drivers of delay to help guide disease control. Methods: From 1/2018-9/2019, we conducted interviews with adults registered with the National TB Elimination Program (NTEP) for MDR (n=128) and non-MDR-TB (n=269) treatment to quantitatively and qualitatively study care pathways. We collected treatment records and GeneXpert-TB/RIF diagnostic reports. Measurement and Main Results: MDR-TB was associated with young age, and crowded residence. GeneXpert rifampicin resistance diversity was measured at 72.5% Probe E. Median time from symptom onset to diagnosis of MDR was 90 days vs. 60 days for non-MDR, Wilcoxon-P<0.01. Delay decreased by a median of 30 days among non-MDR patients with wider access to GeneXpert, Wilcoxon P=0.02. Pathways to care were complex with a median of 4 (3-5) and 3 (2-4) encounters for MDR and non-MDR respectively. Of MDR-TB patients, 68% had their first encounter in the private sector and this was associated with a larger number of subsequent healthcare encounters and catastrophic expenditure. Conclusions: The association of MDR with young age, crowding and low genotypic diversity raise concerns of ongoing MDR transmission fueled by long delays in care. Delays are decreasing with GeneXpert use, suggesting the need for routine use in presumptive TB. Qualitatively, we identify the need to improve patient retention in the NTEP and highlight patients’ trust relationship with private providers. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (

Atre SR, Jagtap JD, Faqih MI, Dumbare YK, Sawant TU, Ambike SL, Bhawalkar JS, Bharaswadkar SK, Jogewar PK, Adkekar RS, Hodgar BP, Jadhav V, Mokashi ND, Golub JE, Dixit A, Farhat MR. Tuberculosis Pathways to Care and Transmission of Multidrug-Resistance in India. Am J Respir Crit Care Med. 2021 Oct 27. doi: 10.1164/rccm.202012-4333OC. Epub ahead of print. PMID: 34706203.