title: MDR-TB screening in a setting with molecular diagnostic techniques: who got tested, who didn't and why?
abstract: METHODS
  The Revised National Tuberculosis Control Programme, Puducherry, India, which has facilities for molecular diagnostic technique.
  
  
  OBJECTIVE
  To determine pre-diagnostic and pre-treatment attrition among presumptive multidrug-resistant tuberculosis (MDR-TB) patients and reasons for attrition.
  
  
  METHODS
  In this mixed-methods study, the quantitative component consisted of retrospective cohort analysis through record review of all presumptive MDR-TB patients recorded between October 2012 and September 2013. The qualitative component included in-depth interviews with key informants involved in programmatic management of drug-resistant tuberculosis services.
  
  
  RESULTS
  Of 341 eligible presumptive MDR-TB patients, pre-diagnostic and pre-treatment attrition was respectively 45.5% (155/341) and 29% (2/7). Patients with extra-pulmonary TB (RR = 2.3), those with human immuno-deficiency and TB co-infection (RR = 1.7), those registered during October-December 2012 (RR = 1.3) and those identified from primary/secondary health centres (RR = 1.8) were less likely to be tested. Themes that emerged during the analysis of the qualitative data were 'lack of a systematic mechanism to track referrals for culture and drug susceptibility testing', 'absence of courier service to transport sputum', 'lack of knowledge and ownership among staff of general health system', 'shortage of diagnostic kits' and 'patient non-adherence'.
  
  
  CONCLUSIONS
  Despite the introduction of molecular diagnostic techniques, operational issues in MDR-TB screening remain a concern and require urgent attention.
authors.affiliation: Department of Community Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India.
authors.forename: H D
authors.initials: HD
authors.lastname: Shewade
authors.affiliation: State Tuberculosis Cell, Directorate of Health Services, Puducherry, India.
authors.forename: S
authors.initials: S
authors.lastname: Govindarajan
authors.affiliation: Department of Community Medicine, Employees' State Insurance Corporation Medical College, Bengaluru, India.
authors.forename: B N
authors.initials: BN
authors.lastname: Sharath
authors.affiliation: Department of Community Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: J P
authors.initials: JP
authors.lastname: Tripathy
authors.affiliation: Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
authors.forename: P
authors.initials: P
authors.lastname: Chinnakali
authors.affiliation: International Union Against Tuberculosis and Lung Disease, South-East Asia Office, New Delhi, India.
authors.forename: A M V
authors.initials: AM
authors.lastname: Kumar
authors.affiliation: State Tuberculosis Cell, Directorate of Health Services, Puducherry, India.
authors.forename: M
authors.initials: M
authors.lastname: Muthaiah
authors.affiliation: State Tuberculosis Cell, Directorate of Health Services, Puducherry, India.
authors.forename: K
authors.initials: K
authors.lastname: Vivekananda
authors.affiliation: World Health Organization Country Office for India, New Delhi, India.
authors.forename: A K
authors.initials: AK
authors.lastname: Paulraj
authors.affiliation: Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
authors.forename: G
authors.initials: G
authors.lastname: Roy
keywords: India; SORT IT; delayed diagnosis; multidrug-resistant tuberculosis; operational research