National and sub-national level prevalence and patterns of drug resistant pulmonary tuberculosis - a systematic review and meta-analysis of Indian studies

Drug resistant tuberculosis (DR TB) is a major global public health threat. India, sharing a large fraction of the world's TB burden, is in a critical phase due to the rise of drug resistance. Monitoring the prevalence and patterns of drug resistance is essential to measure the progress of TB control programs. We aimed to systematically review Indian studies on the prevalence and patterns of drug resistant TB among various treatment types and risk groups. A systematic search was conducted in PubMed, Google Scholar, IndMed, major TB journals and other databases for English language articles published till March 2018 that estimated the prevalence of DR TB in new, previously treated, presumptive MDR, paediatric and HIV co-infected pulmonary TB patients. Two authors independently conducted the search, assessed study quality and extracted relevant data. Pooled prevalence of DR TB and its types were calculated byDerSimonian-Laird random effects meta-analysis. Heterogeneity was investigated by subgroup and sensitivity analyses. Ninety non-duplicate studies were included. Prevalence of multidrug resistance (MDR), any drug resistance and extensive drug resistance was 3.5%, 24.9% and 0.06% (among new) and 26.7%, 58.4% and 1.3% (among previously treated), respectively. MDR prevalence among presumptive MDR, paediatric and HIV co-infected TB patients was 23.3%, 5.1% and 18.8%, respectively. MDR prevalence among new TB patients was highest in Maharashtra and lowest in Telangana. There was high heterogeneity between studies. Study period, place of study and zone were significantly associated with MDR prevalence. India suffers from a significant burden of DR TB. Its patterns and prevalence are very heterogeneous across time, region and setting. Implementation of Universal drug susceptibility testing in all districts and continuous DR TB surveillance is crucial to ensure programmatic success.