title: Factors Associated with Tuberculosis and Rifampicin-Resistant Tuberculosis amongst Symptomatic Patients in India: A Retrospective Analysis.
abstract: BACKGROUND
  Tuberculosis remains a major public health challenge for India. Various studies have documented different levels of TB and multi-drug resistant (MDR) TB among diverse groups of the population. In view of renewed targets set under the End TB strategy by 2035, there is an urgent need for TB diagnosis to be strengthened. Drawing on data from a recent, multisite study, we address key questions for TB diagnosis amongst symptomatics presenting for care: are there subgroups of patients that are more likely than others, to be positive for TB? In turn, amongst these positive cases, are there factors-apart from treatment history-that may be predictive for multi-drug resistance?
  
  
  METHODS
  We used data from a multi-centric prospective demonstration study, conducted from March 2012 to December 2013 in 18 sub-district level TB programme units (TUs) in India and covering a population of 8.8 million. In place of standard diagnostic tests, upfront Xpert MTB/RIF testing was offered to all presumptive TB symptomatics. Here, using data from this study, we used logistic regression to identify association between risk factors and TB and Rifampicin-Resistant TB among symptomatics enrolled in the study.
  
  
  RESULTS
  We find that male gender; history of TB treatment; and adult age compared with either children or the elderly are risk factors associated with high TB detection amongst symptomatics, across the TUs. While treatment history is found be a significant risk factor for rifampicin-resistant TB, elderly (65+ yrs) people have significantly lower risk than other age groups. However, pediatric TB cases have no less risk of rifampicin resistance as compared with adults (OR 1.23 (95% C.I. 0.85-1.76)). Similarly, risk of rifampicin resistance among both the genders was the same. These patterns applied across the study sites involved. Notably in Mumbai, amongst those patients with microbiological confirmation of TB, female patients showed a higher risk of having MDR-TB than male patients.
  
  
  CONCLUSIONS
  Our results cast fresh light on the characteristics of symptomatics presenting for care who are most likely to be microbiologically positive for TB, and for rifampicin resistance. The challenges posed by TB control are complex and multifactorial: evidence from diverse sources, including retrospective studies such as that addressed here, can be invaluable in informing future strategies to accelerate declines in TB burden.
authors.affiliation: World Health Organization, Country Office for India, New Delhi, India.
authors.forename: Sreenivas Achuthan
authors.initials: SA
authors.lastname: Nair
authors.affiliation: Foundation for Innovative New Diagnostics, New Delhi, India.
authors.forename: Neeraj
authors.initials: N
authors.lastname: Raizada
authors.affiliation: Central TB Division, Government of India, New Delhi, India.
authors.forename: Kuldeep Singh
authors.initials: KS
authors.lastname: Sachdeva
authors.affiliation: Foundation for Innovative New Diagnostics, New Delhi, India.
authors.forename: Claudia
authors.initials: C
authors.lastname: Denkinger
authors.affiliation: Foundation for Innovative New Diagnostics, New Delhi, India.
authors.forename: Samuel
authors.initials: S
authors.lastname: Schumacher
authors.affiliation: Bill and Melinda Gates Foundation, New Delhi, India.
authors.forename: Puneet
authors.initials: P
authors.lastname: Dewan
authors.affiliation: Foundation for Innovative New Diagnostics, New Delhi, India.
authors.forename: Shubhangi
authors.initials: S
authors.lastname: Kulsange
authors.affiliation: Foundation for Innovative New Diagnostics, New Delhi, India.
authors.forename: Catharina
authors.initials: C
authors.lastname: Boehme
authors.affiliation: Foundation for Innovative New Diagnostics, New Delhi, India.
authors.forename: Chinnambedu Nainarappan
authors.initials: CN
authors.lastname: Paramsivan
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom.
authors.forename: Nimalan
authors.initials: N
authors.lastname: Arinaminpathy
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000904:Antibiotics, Antitubercular / Q000627:therapeutic use*; D002648:Child; D024881:Drug Resistance, Bacterial; D005260:Female; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012293:Rifampin / Q000627:therapeutic use*; D012307:Risk Factors; D012737:Sex Factors; D014376:Tuberculosis / Q000188:drug therapy*; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy*; D055815:Young Adult
chemical_list: D000904:Antibiotics, Antitubercular; D012293:Rifampin