Tuberculosis Pathways to Care and Transmission of Multidrug Resistance in India

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. From January 2018 to Septe...

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Published in:	American journal of respiratory and critical care medicine Vol. 205; no. 2; pp. 233 - 241
Main Authors:	Atre, Sachin R, Jagtap, Jayshri D, Faqih, Mujtaba I, Dumbare, Yogita K, Sawant, Trupti U, Ambike, Sunil L, Bhawalkar, Jitendra S, Bharaswadkar, Sandeep K, Jogewar, Padmaja K, Adkekar, Ramji S, Hodgar, Balasaheb P, Jadhav, Vaishali, Mokashi, Nitin D, Golub, Jonathan E, Dixit, Avika, Farhat, Maha R
Format:	Journal Article
Language:	English
Published:	United States American Thoracic Society 15-01-2022
Subjects:	Adolescent Adult Aged Aged, 80 and over Antibiotics, Antitubercular - therapeutic use Cross-Sectional Studies Female Genotype & phenotype Health care Humans India - epidemiology Male Middle Aged Multidrug resistant organisms Mycobacterium tuberculosis - drug effects Original Rifampin - therapeutic use Risk Factors Time-to-Treatment - statistics & numerical data Tuberculosis Tuberculosis, Multidrug-Resistant - diagnosis Tuberculosis, Multidrug-Resistant - drug therapy Tuberculosis, Multidrug-Resistant - epidemiology Tuberculosis, Multidrug-Resistant - transmission Young Adult India multidrug-resistant tuberculosis pathways National TB Elimination Program private sector delays
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Summary:	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. From January 2018 to September 2019, we conducted interviews with adults registered with the National TB Elimination Program for MDR ( = 128) and non-MDR-TB ( = 269) treatment to quantitatively and qualitatively study care pathways. We collected treatment records and GeneXpert-TB/RIF diagnostic reports. 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 versus 60 days for non-MDR, Wilcoxon < 0.01. Delay decreased by a median of 30 days among non-MDR patients with wider access to GeneXpert, Wilcoxon = 0.02. Pathways to care were complex, with a median (interquartile range) of 4 (3-5) and 3 (2-4) encounters for MDR and non-MDR, respectively. Of patients with MDR-TB, 68% had their first encounter in the private sector, and this was associated with a larger number of subsequent healthcare encounters and catastrophic expenditure. The association of MDR with young age, crowding, and low genotypic diversity raises 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 National TB Elimination Program and highlight patients' trust relationship with private providers.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	1073-449X 1535-4970
DOI:	10.1164/rccm.202012-4333OC