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Meta-Analysis
. 2017 Oct 17;17(1):817.
doi: 10.1186/s12889-017-4779-5.

Prevalence of drug-resistant pulmonary tuberculosis in India: systematic review and meta-analysis

Vishal Goyal  1 , Vijay Kadam  2 , Prashant Narang  1 , Vikram Singh  1
Affiliations
Meta-Analysis

Prevalence of drug-resistant pulmonary tuberculosis in India: systematic review and meta-analysis

Vishal Goyal et al. BMC Public Health. .

Abstract

Background: Drug-resistant pulmonary tuberculosis (DR-TB) is a significant public health issue that considerably deters the ongoing TB control efforts in India. The purpose of this review was to investigate the prevalence of DR-TB and understand the regional variation in resistance pattern across India from 1995 to 2015, based on a large body of published epidemiological studies.

Methods: A systematic review of published studies reporting prevalence of DR-TB from biomedical databases (PubMed and IndMed) was conducted. Meta-analysis was performed using random effects model and the pooled prevalence estimate (95% confidence interval [CI]) of DR-TB, multidrug resistant (MDR-) TB, pre-extensively drug-resistant (pre-XDR) TB and XDR-TB were calculated across two study periods (decade 1: 1995 to 2005; decade 2: 2006 to 2015), countrywide and in different regions. Heterogeneity in this meta-analysis was assessed using I2 statistic.

Results: A total of 75 of 635 screened studies that fulfilled the inclusion criteria were selected. Over 40% of 45,076 isolates suspected for resistance to any first-line anti-TB drugs tested positive. Comparative analysis revealed a worsening trend in DR-TB between the two study decades (decade 1: 37.7% [95% CI = 29.0; 46.4], n = 25 vs decade 2: 46.1% [95% CI = 39.0; 53.2], n = 36). The pooled estimate of MDR-TB resistance was higher in previously treated patients (decade 1: 29.8% [95% CI = 20.7; 39.0], n = 13; decade 2: 35.8% [95% CI = 29.2; 42.4], n = 24) as compared with the newly diagnosed cases (decade 1: 4.1% [95% CI = 2.7; 5.6], n = 13; decade 2: 5.6% [95% CI = 3.8; 7.4], n = 17). Overall, studies from Western states of India reported highest prevalence of DR-TB (57.8% [95% CI = 37.4; 78.2], n = 6) and MDR-TB (39.9% [95% CI = 21.7; 58.0], n = 6) during decade 2. Prevalence of pre-XDR TB was 7.9% (95% CI = 4.4; 11.4, n = 5) with resistance to fluoroquinolone (66.3% [95% CI = 58.2; 74.4], n = 5) being the highest. The prevalence of XDR-TB was 1.9% (95% CI = 1.2; 2.6, n = 14) over the 20-year period.

Conclusion: The alarming increase in the trend of anti-TB drug resistance in India warrants the need for a structured nationwide surveillance to assist the National TB Control Program in strengthening treatment strategies for improved outcomes.

Keywords: Drug-resistant tuberculosis; India; Prevalence.

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Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

Drs. Goyal, Kadam, Narang and Singh are employees of Janssen India and hold company stocks. The authors declare that they have no other competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow diagram for selection of studies
Fig. 2
Fig. 2
Forest plot of prevalence of DR-TB and MDR-TB. (a) Decade 1995–2005 (DR-TB) (b) Decade 2006–2015 (DR-TB) (c) Decade 1995–2005 (MDR-TB) (d) Decade 2006–2015 (MDR-TB). Abbreviations: DR-TB, drug resistant tuberculosis; MDR-TB, multidrug resistant tuberculosis
Fig. 3
Fig. 3
Subgroup analysis – prevalence of DR-TB and MDR-TB. (a) Decade 1995–2005 (Region-wise, DR-TB) (b) Decade 2006–2015 (Region-wise, DR-TB) (c) Decade 1995–2005 (Region-wise, MDR-TB) (d) Decade 2006–2015 (Region-wise, MDR-TB). Abbreviations: CI, confidence interval; DR-TB, drug resistant tuberculosis; ES, estimate; MDR-TB, multidrug resistant tuberculosis; n, number of studies. Notes: Negative I2 was set to zero. Any missing data means that studies conducted in that region did not present results eligible for inclusion in this analysis
Fig. 4
Fig. 4
Subgroup analysis- prevalence of MDR-TB among previously treated and newly diagnosed patients. (a) Decade: 1995 to 2005 (previously treated patients) (b) Decade: 2006 to 2015 (previously treated patients) (c) Decade: 1995 to 2005 (newly diagnosed patients) (d) Decade: 2006 to 2015 (newly diagnosed patients). Abbreviations: CI, confidence interval; ES, estimate; MDR-TB, multidrug resistant tuberculosis; n, number of studies Notes: Negative I2 was set to zero. Any missing data means that studies conducted in that region did not present results eligible for inclusion in this analysis. Figure 4b and 4d: Countrywide prevalence includes 1 study from Central_East region (not presented individually)
Fig. 5
Fig. 5
Subgroup analysis- Countrywide prevalence of Pre-XDR and XDR-TB. Abbreviations: CI, confidence interval; ES, estimate; FQ, Fluoroquinolone; Inj, aminoglycoside injectable; XDR-TB, extensively drug-resistant TB; n, number of studies. Notes: Negative I2 was set to zero. Any missing data means that studies conducted in that region did not present results eligible for inclusion in this analysis
Fig. 6
Fig. 6
Subgroup analysis- prevalence of mono-drug resistance. (a) Decade 1995-2005 (North India) (b) Decade 2006-2015 (North India) (c) Decade 1995-2005 (South India) (d) Decade 2006-2015 (South India) (e) Decade 1995-2005 (West India) (f) Decade 2006-2015 (West India) (g) Decade 1995-2005 (Central & East India) (h) Decade 2006-2015 (Central & East India) Abbreviations: CI, confidence interval; EMB, ethambutol; ES, estimate; INH, isoniazid; MDR-TB, multidrug resistant tuberculosis; n, number of studies; RMP, rifampicin; SM, streptomycin. Notes: Negative I2 was set to zero. Any missing data means that studies conducted in that region did not present results eligible for inclusion in this analysis
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