Overcoming the health system barriers to early diagnosis and management of multidrug-resistant tuberculosis in a rural setting in North India

Bashar MA, Aggarwal A, Bhattacharya S. BMJ Case Rep 2020;13:e231009. doi:10.1136/bcr-2019- 231009

According to the World Health organization (WHO), Tuberculosis (TB) is one of the top ten causes of mortality worldwide and the leading cause from a single infectious agent[1].

Though the incidence of TB is decreasing at a rate of 2% a year, the incidence in 2018 was estimated at 10 million people with India leading the count in disease burden[2]. The case presented to us by Bashar MA et al.[3] touches on disease burden in India as well as barriers to proper diagnostics with regards to patients with Multidrug-resistant tuberculosis (MDR-TB). MDR-TB occurs in a subset of patients who do not respond to two backbone medications in the first-line treatment of TB: isoniazid and rifampicin. India is one of the three countries carrying the heaviest MDR-TB patient burden[4]. The WHO considers MDR-TB a public health crisis as well as a health security alert. Of those diagnosed with MDR-TB only half are being treated. These numbers are unsettling.

This global health case report sheds light on a man whose MDR-TB diagnosis and treatment were delayed due to barriers to health. Whether in developing or developed countries a high index of suspicion must be maintained in patients who are from MDR-TB endemic areas and those patients who have failed to respond to treatment despite appropriate compliance. After two courses of DOTS regimens the patients was still symptomatic, which should have been cause for suspicion of MDR-TB. Due to lack of suspicion and further barriers which will promptly be mentioned the patient’s adequate treatment was delayed.

Furthermore once the potential diagnosis of MDR-TB was mentioned, the logistics on how to access testing were unclear to the local health official. This is an important point, which can be appreciated globally, where national testing is made available, yet at the local level it is unclear how to implement or access such tests. The diagnostic testing for MDR-TB are not currently homogeneously distributed around the India, causing gaps in areas where these diagnoses will most likely be missed, further explaining the lack of knowledge on how to access such resources.

Clinical acumen, educating local officials on potential cases of MDR-TB and how to access testing can shorten disease course of an individual and prevent the spread of such an infectious agent within their household and their community. The continuous adherence to the WHO DOTS five element model[5] for implementation of treatment of TB must be maintained and continually assessed for improvement within a country.


[1] https://www.who.int/news-room/fact-sheets/detail/tuberculosis

[2] https://www.who.int/news-room/fact-sheets/detail/tuberculosis

[3] Bashar MA, Aggarwal A, Bhattacharya S. BMJ Case Rep 2020;13:e231009. doi:10.1136/bcr-2019- 231009

[4] https://www.who.int/news-room/fact-sheets/detail/tuberculosis

[5] https://www.who.int/tb/dots/en/