INT J TUBERC LUNG DIS 18(6):655–662

Q 2014 The Union

http://dx.doi.org/10.5588/ijtld.13.0516

Survey of tuberculosis drug resistance among

Tibetan refugees in India

F. Salvo,* K. Dorjee,† K. Dierberg,‡ W. Cronin,§ T. D. Sadutshang,† G. B. Migliori,¶ C. Rodrigues,#

F. Trentini,** C. Di Serio,** R. Chaisson,‡ D. M. Cirillo*
*Emerging Pathogens Unit, San Raffaele Scientific Institute, Milan, Italy; †Tibetan Delek Hospital, Central Tibetan
Administration, Dharamsala, India; ‡Division of Infectious Diseases, Center for Tuberculosis Research, Johns
Hopkins University School of Medicine, Baltimore, Maryland, §Maryland Department of Health and Mental
Hygiene, Baltimore, Maryland, USA; ¶WHO Collaborating Centre for TB and Lung Diseases, Fondazione S Maugeri,
Care and Research Institute, Tradate, Italy; #Department of Microbiology, Parmanand Deepchand Hinduja Hospital
and Medical Research Centre, Mumbai, India; **University Center for Statistics in the Biomedical Sciences,
Università Vita-Salute San Raffaele, Milan, Italy

SUMMARY

S E T T I N G : Tuberculosis (TB) is a major health problem
among Tibetans living in exile in India. Although drug-
resistant TB is considered common in clinical practice,
precise data are lacking.
O B J E C T I V E : To determine the proportion of drug-
resistant cases among new and previously treated
Tibetan TB patients.
D E S I G N : In a drug resistance survey in five Tibetan
settlements in India, culture and drug susceptibility
testing (DST) for first-line drugs were performed among
all consecutive new and previously treated TB cases
from April 2010 to September 2011. DST against
kanamycin (KM), ethionamide, para-aminosalicylic acid
and ofloxacin (OFX) was performed on multidrug-
resistant TB (MDR-TB) isolates.
R E S U LT S : Of 307 patients enrolled in the study, 264
(193 new and 71 previously treated) were culture-
positive and had DST available. All patients tested for
the human immunodeficiency virus (n ¼ 250) were
negative. Among new TB cases, 14.5% had MDR-TB
and 5.7% were isoniazid (INH) monoresistant. Among
previously treated cases, 31.4% had MDR-TB and
12.7% were INH-monoresistant. Of the MDR-TB
isolates, 28.6% of new and 26.1% of previously treated
cases were OFX-resistant, while 7.1% of new cases and
8.7% of previously treated cases were KM-resistant.
Three patients had extensively drug-resistant TB.
C O N C L U S I O N S : MDR-TB is common in new and
previously treated Tibetans in India, who also show
additional complex resistance patterns. Of particular
concern is the high percentage of MDR-TB strains
resistant to OFX, KM or both.
K E Y W O R D S : MDR-TB; drug resistance survey;
tuberculosis in refugees; Tibetan refugees

THE INCREASING INCIDENCE of drug-resistant
tuberculosis (TB) is a major challenge for the control
of TB epidemics worldwide. Disease caused by strains
of Mycobacterium tuberculosis resistant to isoniazid
(INH) and rifampicin (RMP) (i.e., multidrug-resis-
tant TB [MDR-TB]) is an increasingly common
finding worldwide, and 84 countries have reported
at least one case of extensively drug-resistant TB
(XDR-TB, defined as MDR-TB plus resistance to a
fluoroquinolone and at least one of three second-line
injectable agents).1,2
The World Health Organization (WHO) has
emphasised the importance of collecting precise data
on the proportion of TB cases that are MDR- or
XDR-TB through the implementation of continuous
surveillance systems or periodic surveys in each
country. Despite recent efforts by the WHO and its
partners, reliable data from more than 30% of
countries are still unavailable due to the lack of
human and financial resources to implement these
studies, as well as insufficient laboratory capacity.1,3
Tibetan refugees first arrived in India in 1959,
when thousands fled Tibet across the Himalayan
mountains, following the fourteenth Dalai Lama into
exile. Since then, many Tibetans have resettled in
India during various waves of migration. The largest
settlements are now located in the Indian States of
Karnataka and Himachal Pradesh; however, Tibetan
enclaves are located throughout India, including in
Delhi, Mumbai and Bangalore. A 2009 demographic
survey conducted by the Central Tibetan Adminis-
tration (CTA) in India reported 94 203 Tibetans

Correspondence to: Fulvio Salvo, Emerging Pathogens Unit, San Raffaele Scientific Institute, via Olgettina 60, Milan 20132,
Italy. Tel: (þ39) 022 643 5684. Fax: (þ39) 022 643 5183. e-mail: salvofulvio@hotmail.com
Article submitted 22 August 2013. Final version accepted 14 January 2014.
656 The International Journal of Tuberculosis and Lung Disease
living in India.4 They are one of the most mobile
populations in the world, as a high percentage
migrate within India or abroad. More than 50% (n
¼ 50 433) of Tibetan refugees in India reside in
congregate settings, such as boarding schools, mon-
asteries and nunneries.4 The CTA Department of
Health (CTA-DOH) oversees all Tibetan health
centres and clinics throughout India.
TB is one of the major causes of morbidity and
mortality among Tibetans living in India. Very few
studies have been published on the incidence of TB
among Tibetans in exile. One study reported an
overall TB incidence of 835 cases per 100 000
population between 1994 and 1996.5 Based on
unpublished data from 2010, TB incidence was 431/
100 000, which is substantially higher than the rate in
India (181/100 000) in 2011 based on WHO
estimates.1 The CTA-DOH has been working in close
collaboration with the Revised National Tuberculosis
Control Programme (RNTCP) of the Government of
India and the WHO to improve the effectiveness of
TB control among the Tibetan population (Appen-
dix).* The CTA-DOH provides anti-tuberculosis
treatment under directly observed therapy (DOT) to
every Tibetan patient refugee in India, and all
treatment regimens adhere to international recom-
mendations. Treatment is provided free of charge or
for a symbolic fee based on the patient’s income.
Nevertheless, TB control in the Tibetan population in
India faces many challenges, such as high rates of
migration, use of different health care providers and
residence in congregate living settings such as
monasteries and schools.
MDR-TB rates were thought to be high among
Tibetan TB patients in India; however, before 2010
the diagnosis of TB was rarely confirmed by culture
and drug susceptibility testing (DST). No systematic
survey has been performed, and there are few
published reports describing the high rate of MDR-
TB (7–19%) among Tibetans; most of these are
immigrants to the United States and Canada.6–8
The main objective of the present study was to
determine the proportion of drug-resistant pulmo-
nary TB cases among new and previously treated
Tibetan TB patients in India. Specifically, we assessed
resistance to first-line drugs (INH, RMP, ethambu-
tol [EMB], streptomycin [SM]), and to second-line
drugs (kanamycin [KM], ofloxacin [OFX], ethion-
amide [ETH], para-amino salicylic acid [PAS])
among all MDR-TB cases. We also assessed the
relationship between specific sociodemographic and
behavioural risk factors and the presence of drug-
resistant TB.
* The Appendix is available in the online version of this article,
at http://www.ingentaconnect.com/content/iuatld/ijtld/2014/
00000018/00000006/art00007
METHODS
Study design
The survey was designed to recruit through 100%
sampling of TB suspects at the five main Tibetan TB
centres. In the absence of available data, the study
sample was calculated based on the estimated average
annual number of new sputum smear-positive cases
reported in 2007–2009. The sample size was estab-
lished based on recommended principles.9 For a total
expected number of 250 patients in 1 year with an
expected frequency of 10% MDR-TB as a conserva-
tive estimate and an expected error of 61% at 95%
confidence level, the size of the sample required was
estimated to be 215 cases. This number was inflated
to .300 to adjust for false sputum smear-positives,
contamination and loss during transport.
Study centres
The five major health centres serving the Tibetan
community in India under the CTA-DOH were
selected for inclusion in the study. The main hospital
and referral centre for all Tibetan TB patients in India
is the Tibetan Delek Hospital in Dharamsala,
Himachal Pradesh, a designated microscopy centre
under the RNTCP and which served as the study
headquarters. There were three study centres in the
state of Karnataka (Tso-Jhe-Khangsar Hospital in
Bylakuppe, Doeguling Tibetan Resettlement Hospital
in Mundgod and Kunkyap Dophenling Hospital in
Kollegal) and one in Uttarakhand (Dekyiling Settle-
ment Hospital, Dehradun). Health centres in smaller
settlements, monasteries and schools were instructed
to refer TB patients to these main health centres for
enrolment. The total population covered in the study
was estimated to be 60 000.
Patient enrolment
All consecutive new sputum smear-positive TB
patients who presented to the five study sites were
enrolled from May 2010 to September 2011. Sputum
smear-negative patients with strong clinical and
radiological evidence of TB were enrolled in the
study after discussion with the study coordinators
(criteria for enrolment are provided in the Appendix).
Medical staff interviewed each patient enrolled in the
study, and sociodemographic information was re-
corded on living setting, country of birth, year of
migration, comorbidities, chronic medications, his-
tory of smoking, alcohol or drug use. Voluntary
human immunodeficiency virus (HIV) testing was
offered to every new TB patient.
Based on the interview and review of medical
records, if available, each patient was classified as a
new or previously treated case. New cases were
defined as patients who had never been treated for TB
or who had received treatment for ,30 days.
Previously treated cases were defined as patients

who had received anti-tuberculosis treatment for .30
days. For previously treated cases, the outcome and
other details about previous TB episode(s) were
recorded, if available.
Patients with extra-pulmonary TB, including pleu-
ral TB, were ineligible for the study unless they also
had a positive sputum smear at diagnosis. Patients
were suitable for enrolment only once: patients
relapsing during the study period were not included
again.
Laboratory methods
An early-morning sputum sample was collected from
each patient after enrolment. The sample was
refrigerated at 48C for a maximum of 2 days and
transported to the Mycobacteriology Laboratory,
Paramchand Deepchand Hinduja National Hospital
and Medical Research Centre, Mumbai, India, for
culture and DST.
Culture was performed using liquid medium
(BACTECe MGITe 960 culture; BD, Franklin
Lakes, NJ, USA). Isolates from positive cultures were
confirmed as Mycobacterium tuberculosis complex
using the p-nitrobenzoic acid assay and tested for
susceptibility to first-line drugs (INH, RMP, EMB,
SM) using the BACTECe MGITe 960 SIRE Kit
(BD).10 MDR-TB isolates were then tested for
susceptibility to second-line drugs (KM 2.5 lg/ml,
OFX 2.0 lg/ml, ETH 5.0 lg/ml, PAS 4.0 lg/ml) per
international standards.11
Ethical considerations
The study protocol was approved by the CTA-DOH.
Verbal consent and consent for HIV testing was
obtained from each patient before enrolment. All
suspected TB patients referred to the study centres for
diagnosis were offered mycobacterial culture with
DST at no cost, irrespective of ethnicity. However,
only Tibetan patients were included in the data
analysis. Culture and DST results were forwarded to
the diagnostic centre of each patient and used to guide
treatment decisions. Data collected during patient
interviews only included information routinely re-
corded on TB treatment cards.
Data collection and statistical analysis
All study forms and laboratory reports were sent to
the Tibetan Delek Hospital, where data were entered
into an Excel database (MicrosoftQ Excel 2010,
Redmond, WA, USA). Analyses were performed using
R statistical software, version 2.15.2 (R Foundation
for Statistical Computing, Vienna, Austria). For the
preliminary analysis, we used contingency tables to
explore relationships between binary variables. The
association between MDR-TB and variables such as
sex, age, living setting, country of birth and previous
treatment was examined using the v2 test at P , 0.05
level of significance.
TB DRS among Tibetan refugees 657
A binary logistic regression model was adopted to
estimate whether covariates were associated with
MDR-TB. Odds ratios (ORs) were computed with
95% confidence intervals (CIs) and v2 test-related P
values. We also considered several stratifications to
avoid confounding issues. The Fisher’s exact test was
used whenever needed due to reduced sample size.
We also investigated the impact of several covar-
iates (qualitative and quantitative) on the probability
of having MDR-TB through a multiple logistic
regression model. Variables were selected through a
stepwise regression with backward selection. We also
studied interactions between variables, such as sex
and living setting; however, none were found to be
significant (Appendix).
RESULTS
Patient characteristics
A total of 307 consecutive patients were recruited
from April 2010 to September 2011; 37 (12%)
specimens were culture-negative for mycobacteria,
269 patients (88%) were culture-positive for M.
tuberculosis and one patient had non-tuberculous
mycobacteria. Four patients with positive cultures
were excluded from the analysis, as they were not of
Tibetan ethnicity and were not living in the Tibetan
community. One culture-positive specimen failed to
grow during DST.
DST results were available for analysis for 264
patients. Of these, 193 (73%) were new and 71
(27%) were previously treated cases. The majority of
the patients were male (73.9%); the mean age was
29.4 years (616.5; median 24); 58% were born in
India, 39.8% in Tibet, 1.5% in Nepal and ,1% in
Bhutan. For those born in Tibet, Nepal and Bhutan,
the mean duration of stay in India was 20 years. At
the time of enrolment, 58.7% of the patients were
residing in congregate living settings (such as schools,
monasteries and hostels), whereas 41.3% were living
in private households. All 250 patients tested for HIV
were negative. Results were not available for 13
patients. One patient refused the test. Socio-demo-
graphic characteristics are summarised in Table 1.
Drug resistance
The prevalence of resistance to any first-line drug
(INH, RMP, EMB, SM) was 21.8% in new cases and
47.9% in previously treated cases. Among new TB
cases, 14.5% were resistant to both INH and RMP
(i.e., MDR-TB) and 5.7% had isolates resistant to
INH (6 EMB and/or SM) but not to RMP. Among
previously treated patients, 32.4% had MDR-TB
strains, and 12.7% were resistant to INH (6 to EMB
and/or SM) but not to RMP. RMP monoresistance
was not detected in either group. First-line DST
results drugs are summarised in Table 2.
In the MDR-TB subgroup, 97.9% of patients were
658 The International Journal of Tuberculosis and Lung Disease

Table 1 Sociodemographic characteristics of enrolled patients by study centre

Tibetan Delek Hospital,
Overall Dharamsala Bylakuppe Mundgod Deckyiling Kollegal
(n ¼ 264) (n ¼ 135) (n ¼ 47) (n ¼ 53) (n ¼ 22) (n ¼ 7)
n (%) n (%) n (%) n (%) n (%) n (%)
Sex
Male 195 (73.9) 96 (71.1) 35 (74.5) 46 (86.8) 12 (54.5) 6 (85.7)
Female 69 (26.1) 39 (28.9) 12 (25.5) 7 (13.2) 10 (45.5) 1 (14.3)
Age, years
Mean (median) 29.4 (24) 28 (24) 30.5 (27) 32.3 (22) 23.6 (20) 43.4 (25)
Age group, years
,20 73 (27.7) 39 (28.9) 7 (14.9) 16 (30.2) 10 (45.5) 1 (14.3)
20–39 147 (55.7) 78 (57.8) 30 (63.8) 26 (49.1) 10 (45.5) 3 (42.9)
40–59 21 (8.0) 8 (5.9) 7 (14.9) 3 (5.7) 2 (9.1) 1 (14.3)
760 23 (8.7) 10 (7.4) 3 (6.4) 8 (15.1) 0 2 (28.6)
Living setting
Monastery, school or hostel 155 (58.7) 91 (67.4) 23 (48.9) 28 (52.8) 13 (59.1) 0
Private house 109 (41.3) 44 (32.6) 24 (51.1) 25 (47.2) 9 (40.9) 7 (100)
Country of birth
Tibet 105 (39.8) 62 (45.9) 10 (21.3) 22 (41.5) 8 (36.4) 3 (42.9)
India 153 (58.0) 68 (50.4) 37 (78.7) 30 (56.6) 14 (63.6) 4 (57.1)
Nepal 4 (1.5) 4 (3.0) 0 0 0 0
Bhutan 2 (0.8) 1 (0.7) 0 1 (1.9) 0 0
Years in India (for those born abroad)
Mean (median) 20 (14) 17 (14) 20 (16) 28 (23) 12 (12) 53 (53)
Anti-tuberculosis treatment in the past
Never received treatment (new patient) 193 (73.1) 97 (71.9) 30 (63.8) 43 (81.1) 18 (81.8) 5 (71.4)
Previously treated 71 (26.9) 38 (28.1) 17 (36.2) 10 (18.9) 4 (18.2) 2 (28.6)
Drug resistance
Non-MDR-TB 213 (80.7) 113 (83.7) 35 (74.5) 46 (86.8) 14 (63.6) 5 (71.4)
MDR-TB 51 (19.3) 22 (16.3) 12 (25.5) 7 (13.2) 8 (36.4) 2 (28.6)
MDR-TB ¼ multidrug-resistant tuberculosis.

resistant to at least one additional drug, and the mean
number of drugs to which MDR-TB isolates were
resistant was 5.1 (median 5). Pre-XDR-TB, defined as
additional resistance to OFX or to KM but not both,
was common: resistance to OFX (but not KM) was
found in 28.6% of the new and 21.7% of the
previously treated MDR-TB cases, and resistance to
KM (but not OFX) in 7.1% of new cases and 8.7% of
previously treated cases. Three patients (two new, one
previously treated) had XDR-TB strains. The previ-
ously treated XDR-TB case was resistant to all eight
tested drugs. Therefore, 42.9% of new and 34.8% of
previously treated MDR-TB patients had isolates
resistant to OFX, KM or both.
Resistance to ETH was a common finding among
both new and previously treated MDR-TB patients,
with the proportion of resistant isolates being 75%
and 69.6%, respectively. PAS-resistant strains were
less common, at 14.3% among new cases and 17.4%
among previously treated cases. Second-line DST
results are summarised in Table 3.
Risk factor analysis
The results of the univariate analysis of the

Table 2 Susceptibility and resistance to first-line anti-tuberculosis drugs

Patients with previously
Patients with new TB treated TB
(n ¼ 193) (n ¼ 71) Retreatment vs. new cases
Susceptibility or resistance n (%) n (%) OR (95%CI) P value (v2)
Susceptibility to all first-line drugs 151 (78.2) 37 (52.1)
Resistance to first-line drugs
Any first-line drug 42 (21.8) 34 (47.9) 3.3 (1.8–5.9) ,0.0001
INH 39 (20.2) 34 (47.9) 3.6 (2.0–6.4) ,0.0001
RMP 28 (14.5) 23 (32.4) 3.35 (1.73–6.5) 0.0002
EMB 23 (11.9) 18 (25.4) 3.2 (1.6–6.5) 0.001
SM 35 (18.1) 26 (36.6) 3 (1.6–5.6) 0.0003
INH alone (6 EMB or SM) 11 (5.7) 9 (12.7) 3.3 (1.3–8.6) 0.01
RMP alone (6 EMB or SM) 0 0 NA NA
Multidrug resistance 28 (14.5) 23 (32.4) 3.3 (1.7–6.5) 0.0002
TB ¼ tuberculosis; OR ¼ odds ratio; CI ¼ confidence interval; INH ¼ isoniazid; RMP ¼ rifampicin; EMB ¼ ethambutol; SM ¼ streptomycin; NA ¼ not available.
 TB DRS among Tibetan refugees 659

Table 3 Susceptibility and resistance to second-line anti-tuberculosis drugs in MDR-TB patients

New patients Previously treated
with MDR-TB patients with MDR-TB
(n ¼ 28) (n ¼ 23) Retreatment vs. new cases
Susceptibility or resistance n (% n (%) OR (95%CI) P value*
Susceptibility to OFX and KM 16 (57.1 15 (65.2)
Resistance to second-line drugs
OFX or KM (not XDR-TB) 10 (35.7) 7 (30.4) 0.7 (0.2–2.5) 0.8
OFX but not KM 8 (28.6) 5 (21.7) 0.7 (0.18–2.5) 0.7
KM but not OFX 2 (7.1) 2 (8.7) 1 (0.1–8.6) 1.0
XDR-TB 2 (7.1) 1 (4.3) 0.5 (0.04–6.5) 1.0
Ethionamide 21 (75.0) 16 (69.6) 0.8 (0.3–2.2) 0.8
PAS 4 (14.3) 4 (17.4) 1 (0.2–5.0) 1.0
* Fisher’s exact test.
MDR-TB ¼ multidrug-resistant tuberculosis; OR ¼ odds ratio; CI ¼ confidence interval; OFX ¼ ofloxacin; KM ¼
kanamycin; XDR-TB ¼ extensively drug-resistant tuberculosis.

association between sociodemographic characteris- DISCUSSION

tics and MDR-TB and other drug-resistant forms of
TB is shown in Table 4. A history of previous
treatment for TB was significantly associated with
MDR-TB (OR 2.8, 95%CI 1.1–5.3). In addition,
female sex (OR 2.2, 95%CI 1.1–4.1) and country of
birth other than Tibet (OR 2.0, 95%CI 1.0–3.9)
were significantly associated with an increased risk
of MDR-TB. In multivariate analysis, the odds of
MDR-TB were significantly higher for females, for
persons living in congregate settings and for patients
with a history of TB. Moreover, the odds of MDR-
TB decreased with age. The multivariate analysis is
summarised in Table 5.
The most recent data from the United Nations High
Commission for Refugees demonstrate that the
number of refugees and internally displaced persons
worldwide was approximately 25 million in 2013,
with most originating from and/or seeking asylum in
high TB burden countries.12 The high risk of TB in
this population is probably related to the coexistence
of various predisposing factors, such as malnutrition,
acute stress, HIV infection and the increased trans-
mission of TB in overcrowded and poor living
conditions.13
During the first several years in India, Tibetans
suffered from severe malnutrition and lived in

Table 4 Risk factors for drug-resistant TB

MDR-TB þ resistance to MDR-TB þ resistance to

OFX or KM and
Non-MDR-TB MDR-TB OFX or KM and XDR-TB
MDR- vs. non-MDR-TB* XDR-TB vs. non-MDR-TB†
(n ¼ 213) (n ¼ 51) (n ¼ 20)
Variable n (%) n (%) OR (95%CI) P value n (%) OR (95%CI) P value
Sex
Male 164 (77.0) 31 (60.8) Reference 11 (55.0) Reference
Female 49 (23.0) 20 (39.2) 2.2 (1.1–4.1) 0.018 9 (45.0) 2.5 (1.0–6.35) 0.062
Age group. years
,20 61 (28.6) 12 (23.5) Reference 5 (25.0) 0.8 (0.3–2.4) 1
20–39 114 (53.5) 33 (64.7) 1.5 (0.7–3.0) 0.3 14 (70.0) 2.0 (0.8–5.5) 0.24
40–59 16 (7.5) 5 (9.8) 1.6 (0.5–5.2) 0.4 1 (5.0) 0.6 (0.1–5.2) 1
760 22 (10.3) 1 (2.0) 0.23 (0.03–1.9) 0.14 0 NA
Living settings
Private house 81 (38.0) 26 (51.0) 1.7 (0.9–3.1) 10 (50.0) Reference
School, monastery, hostel 132 (62.0) 25 (49.0) Reference 0.09 10 (50.0) 0.6 (0.3–1.6) 0.16
Country of birth
Tibet 91 (42.7) 14 (27.5) Reference 4 (20.0) Reference
India, Nepal or Bhutan 122 (57.3) 37 (72.5) 2.0 (1.0–3.9) 0.045 16 (80.0) 2.8 (0.9–8.7) 0.094
History of previous treatment
Never received treatment 165 (77.5) 28 (54.9) Reference 12 (60.0) Reference
Previously treated 48 (22.5) 23 (45.1 2.8 (1.5–5.3) 0.001 8 (40.0) 1.9 (0.75–4.9) 0.19
Risk factor
HIV positivity 0 0 NA NA 0 NA NA
Smoke 30 (14.1) 8 (15.7) 1.1 (1.5–2.6) 0.94 1 (5.0) NA NA
Alcohol or illicit drugs 22 (10.3) 6 (11.8) 1.2 (0.4–3.0) 0.96 1 (5.0) NA NA

* v2 test.
†
Fisher’s exact test.
TB ¼ tuberculosis; MDR-TB ¼ multidrug-resistant TB; OFX ¼ ofloxacin; KM ¼ kanamycin; XDR-TB ¼ extensively drug-resistant TB; OR ¼ odds ratio; CI ¼ confidence
interval; NA ¼ not available; HIV ¼ human immunodeficiency virus.
660 The International Journal of Tuberculosis and Lung Disease
Table 5 Multivariate analysis
Variables
Age
Sex (male vs. female)
Community (congregate vs. open)
Patient (new vs. retreatment)
OR ¼ odds ratio; CI ¼ confidence interval.
overcrowded and poor conditions, and TB could have
spread in the population during this period. The
results of our study demonstrate that MDR-TB is
common in both new and previously treated Tibetan
patients presenting to the main Tibetan health centres
in India. The prevalence of MDR-TB is particularly
alarming among new TB cases (14.5%), and is much
higher than estimates for India (2.1%), China
(5.7%), the WHO South-East Asia Region (SEAR)
(2.1%) and globally (4.3%).1,14 Among previously
treated TB patients, MDR-TB prevalence (32.4%) is
again higher than that described in India (15%),
China (25.6%), SEAR (16%) and globally (20%).1
The prevalence of fluoroquinolone resistance is
higher than that reported from 67 other countries,
with 35.7% among new MDR-TB cases and 26.1%
among retreatment MDR-TB cases compared to
14.5% reported by the WHO. This is also higher
than the median 12% prevalence reported in a recent
meta-analysis of 26 studies by Falzon et al.15
However, the prevalence of KM resistance (14.2%
in new and 13% in previously treated patients)
among Tibetan TB patients is lower than the 21%
prevalence reported in the above meta-analysis.
Grouped together, pre-XDR and XDR-TB constitute
42.9% of new and 34.8% of previously treated
MDR-TB cases.
The selection of M. tuberculosis strains with
resistance to multiple drugs in the Tibetan population
in India has several possible explanations. First, both
first- and second-line TB medications of unverifiable
quality are still easily available on the open market in
India.16,17 In the past, such medications were
commonly used to treat Tibetan TB patients. Second,
among patients treated in Tibetan clinics in the past,
erratic funding resulted in intermittent disruption of
drug supplies, leading to treatment interruptions. In
addition, some patients stopped treatment due to the
inability to pay for drugs from the private sector.
Third, human resource constraints and insufficient
infrastructure limited the capability of the pro-
gramme to track highly mobile patients from one
settlement to another to ensure continuity of treat-
ment, often resulting in treatment interruption or
default. Fourth, many Tibetan patients receive health
care services from non-Department of Health facili-
ties, including local private practitioners and monas-
tery clinics. In these settings, standard international
treatment guidelines are not followed consistently,
Estimate Standard error OR (95%CI) P value
0.03 0.01 0.74 (0.72–0.76) 0.034
0.96 0.36 0.38 (0.19–0.77) ,0.001
0.71 0.36 0.49 (0.24–0.98) 0.045
1.28 0.36 0.28 (0.14–0.56) ,0.001
leading to an increase in the number of patients
receiving inadequate management. These include
prescribing fluoroquinolones for respiratory symp-
toms, inadequate numbers of anti-tuberculosis med-
ications, inappropriate selection of drugs, inadequate
dosage and insufficient treatment duration, particu-
larly for MDR-TB. Fifth, the lack of easily accessible
quality-assured laboratory facilities have greatly
restricted the use of culture and DST to guide
treatment and monitoring. Cultures were shipped to
quality-assured laboratories only when financial
resources were available and for the most difficult
cases.
Finally, drug-resistant strains selected by the
aforementioned mechanisms have likely spread with-
in the Tibetan community due to the increased risk of
transmission between people living in congregate
settings and the presence of language and cultural
barriers that limit access to medical attention. It is
also possible that Tibetans have a genetic suscepti-
bility to TB, although there is currently no strong
evidence to support this.18
The results of this study also highlight some
important factors for diagnosis and treatment of TB
in this population. The absence of RMP monoresist-
ance confirms that a rapid molecular diagnostic test
that detects RMP resistance, such as Xpertw MTB/
RIF (Cepheid, Sunnyvale, CA, USA), would be
effective for rapid and accurate screening for MDR-
TB in this setting. 19 Rapid TB and MDR-TB
diagnosis using the Xpert test has recently been
initiated at the Tibetan Delek Hospital and two other
Tibetan settlements, and preliminary data confirm
that detection of RMP resistance is a highly accurate
surrogate for MDR-TB.20
The pattern of resistance in the Tibetan population
is complex, in terms of both the number of drugs to
which isolates are susceptible and the high prevalence
of resistance to essential second-line drugs such as
fluoroquinolones and injectables, which are impor-
tant for treatment success.15,21,22 The current WHO
MDR-TB treatment guidelines recommend that
patients with MDR-TB should be treated with a
regimen containing a fluoroquinolone, an injectable
and ETH; however, routine use of this regimen in
Tibetan MDR-TB patients would result in a high
proportion of patients receiving inadequate treat-
ment. Rather than using a standardised MDR-TB
regimen, our data strongly suggest that patients

should receive individually tailored regimens based
on culture and DST results. Phenotypic DST must still
be considered mandatory if RMP resistance is
detected using Xpert. As delays in obtaining DST
results are inevitable, constructing initial empirical
regimens for our patients is challenging.
Interestingly, the high rates of TB and MDR-TB in
the Tibetan population in India are similar to rates
seen in parts of sub-Saharan Africa, where TB-HIV
coinfection is common.1 However, none of the
Tibetan patients enrolled was HIV-positive. HIV
preventive activities should be further strengthened
to avoid the negative impact that HIV coinfection
would have on the spread of TB in this community.
The history of previous treatment in this study is
clearly associated with the risk of resistance to first-
line drugs, including MDR-TB; however, the same
association was not identified with resistance to
second-line drugs. A possible explanation for this is
that strains resistant to second-line drugs persisting in
the community are more likely to be primarily
acquired by new as well as previously treated
patients, while resistance to first-line drugs is more
likely to be generated in single patients by inadequate
previous treatment. Although an association was
observed between female sex and MDR-TB, there are
no clear reasons for this, as among Tibetans in exile
the gender issue is not relevant and women are
usually not discriminated against. A possible con-
founding bias is the presence of few clusters of MDR-
TB in female patients residing in the same institu-
tions.
Over the past few years, the CTA-DOH has
substantially improved standards for TB control,
developed new guidelines based on current interna-
tional recommendations and recruited expert profes-
sional human resources. These achievements were
made possible through the support of and collabora-
tion with the RNTCP, the WHO TB REACH
programme and other international partners. These
partnerships have helped to provide technical assis-
tance and supervision to promote the rational use of
anti-tuberculosis drugs, specifically second-line
agents, and reduce the risk of developing more
resistance.23 Particular attention to the use of existing
drugs potentially useful for XDR-TB treatment (line-
zolid, meropenem and cotrimoxazole) and new drugs
(bedaquiline, PA-824, delamanid) will be essential to
ensure that these agents continue to be effective for
treating MDR- and XDR-TB in this population.24–29
Our study has some limitations. First, a substantial
number of Tibetan TB patient undergo diagnosis and
treatment in private health care centres or in Indian
RNCTP centres, and these cases were not enrolled in
the study. Moreover, due to logistic and geographical
barriers only the major five diagnostic centres could
be included. Data recording on previous TB episode(s)
were scattered, and often no precise information on
TB DRS among Tibetan refugees 661
previous treatment regimens and outcomes were
available.
In summary, our study highlights the need for direct
interventions to reduce transmission of all TB strains,
particularly in congregate living settings, by further
strengthening infection control strategies and by
promoting active case finding and precise contact
tracing. It will also be critical to improve early
diagnosis of MDR-TB and to provide effective
treatment to all MDR-TB cases in order to prevent
the development of additional resistance in this
vulnerable population.
Acknowledgements
The authors are grateful to T Paldon and T Youdon for their
precious field work and dedication to this project.
This study was funded by the Italian Development Cooperation
(Directorate General for Development Cooperation of the Italian
Minister of Foreign Affairs) as part of a development cooperation
project granted to AISPO (Italian Association for Solidarity among
People) (‘Support to the TB control programme in the Tibetan
Community in India’ project no AISPO/INDIA/8688). FS was the
project director. DMC served as a scientific supervisor. KeD and
KuD were actively involved in a project of active case finding
implemented by Johns Hopkins University Centre for TB Research
(JHU-CTR) in collaboration with the Centrol Tibetan Administra-
tion Department of Health (CTA-DOH) and the Tibetan Delek
Hospital. KeD was the project manager and KuD the local project
coordinator. This Academic Clinical Fellow project was supported
by a TB REACH grant from the Stop TB Partnership, World Health
Organization, Geneva, Switzerland. RC is the director of the JHU-
CTR.
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APPENDIX
Tibetan TB Control Programme
The Tibetan Tuberculosis Control Programme is a
collaborative initiative based at the Tibetan Delek
Hospital in Himachal Pradesh State in northern India.
It is run by Tibetan physicians and nurses and a large
group of community health care workers. Tubercu-
losis (TB) services provided in other health centres in
Tibetan refugee settlements, including Mundgod and
Bylakuppe settlements in Karnataka State, are also
part of the Tibetan TB Control Programme. The
Tibetan Tuberculosis Programme Manual, developed
in 2009 and based on the World Health Organization
(WHO) and India’s national guidelines, provides
structure and policy for TB control interventions. It
has provided clinicians and other hospital staff with
standardised procedures for diagnosis and treatment,
infection control, surveillance, record keeping, pa-
tient and community education. The programme is
jointly supported by the Central Tibetan Administra-
tion Department of Health (CTA-DOH), the Tibetan
Delek Hospital, and three international non-govern-
mental partners, namely the Johns Hopkins Univer-
sity Center for TB Research, Baltimore, MD, USA;
the Friends of the Delek Hospital, Dharamsala, India;
and the Italian Association for Solidarity among
Peoples (AISPO), Milan, Italy. A steering committee
of members representing each of the partners oversees
the programme.
The Tibetan TB Control Programme works in close
collaboration with the India’s Revised National TB
Control Programme (RNTCP), and all data on TB
diagnosis and treatment outcome are currently
reported to the RNTCP. In patients with suspected
extensively drug-resistant (XDR-) and multidrug-
resistant TB (MDR-TB), sputum specimens are sent
for sputum culture at the Hinduja Microbiology
Laboratory in Mumbai, a WHO-approved laborato-
ry facility.
All patients who meet the criteria for treatment can
receive anti-tuberculosis treatment at Delek Hospital,
at CTA-DOH primary health centres and at local
Indian government health clinics. Some Tibetan
refugees also receive treatment through health facil-
ities run by the RNTCP. First-line anti-tuberculosis
drugs are provided free of cost by Delek Hospital, the
CTA-DOH and the RNTCP, depending on where a
patient seeks care.
All Tibetan patients from any CTA-DOH clinic
with suspected MDR- or XDR-TB are managed
under the supervision of a panel of physicians
experienced in the treatment of MDR- and XDR-
TB. The panel, based at Delek Hospital, regularly
reviews all potential cases of MDR- and XDR-TB,
provides advice and assistance to doctors in the field
and makes recommendations for anti-tuberculosis
treatment regimens. Once these recommendations
TB DRS among Tibetan refugees i
have been made, patients can receive treatment at
Delek Hospital or another CTA-DOH facility with
second-line medications purchased by the pro-
gramme. A large network of community health
providers helps to provide treatment to all the TB
patients; every single dose of medication is currently
provided under directly observed therapy.
Criteria for enrolment of TB cases in the study
1 Any new sputum smear-positive TB case
2 A TB suspect with three sputum smear-negative
samples with both clinical and radiological char-
acteristics highly suggestive of TB, defined as:
i Cough of .2 weeks plus any of the following:
 Unexplained weight loss
 Fever or night sweats
 Blood in sputum
and
ii Chest X-ray showing one of the following:
 Cavity/ies
 Fibro-nodular consolidation involving apical/
posterior segments of the upper lobes or supe-
rior segments of the lower lobes
Statistical methods
A preliminary analysis was carried out using contin-
gency tables to explore relationships between binary
variables. Association between MDR-TB group (Yes/
No) and variables such as sex, age, living settings,
country of birth and previous treatment was evalu-
ated using the v2 test at 0.05 level of significance.
A binary logistic regression model was adopted to
estimate whether and how covariates measured such
as age, country of birth, previous history of TB, etc.,
affect the probability of developing MDR-TB. Odds
ratios (ORs) were computed with their 95% confi-
dence intervals (CIs) and v2 test-related P values.
Analyses were prepared with R statistical software,
version 2.15.2 (R Foundation for Statistical Comput-
ing, Vienna, Austria).
We also considered several stratifications to avoid
confounding issues, such as resistance vs. country of
birth separately for female and male patients. Fisher’s
exact test was used whenever needed in case of
smaller sample size. After an explorative analysis, a
multivariate analysis was performed. A multiple
logistic regression model enabled us to investigate
the joint impact on probability of being in the MDR-
TB group of a large set of covariates (both quantita-
tive and qualitative) such as sex, age, country of birth
(categorised as Tibet vs others [India, Nepal, Bhu-
tan]), immigration to India (1 if immigrant, 0
otherwise), year of immigration, living setting (1 if
patients live in a closed community, 0 otherwise) and
history of previous treatment (1 old patient, 0 new
patient). Variables were selected through stepwise
ii The International Journal of Tuberculosis and Lung Disease

regression with backward selection. We also investi- Table Model selected to interpret results
gated interactions between variables, such as sex and Coefficients OR 95%CI
living setting, but none yielded statistically significant
Community 0.49 (enclosed vs open) 0.24–0.98
results. Age 0.74 (every 10 years more) 0.72–0.76
The final model selected four covariates as signif- Sex 0.38 (male vs. female) 0.19–0.77
icant (at a significance level of 0.05): age, sex, New patient 0.28 (new vs. retreatment cases) 0.14–0.56
community and history of previous treatment. The OR ¼ odds ratio; CI ¼ confidence interval.
model selected to interpret the results is that in which
age is treated as a continuous variable (Table).
Using the coefficients obtained from the model compared to patients who live in open communities,
with age as a continuous variable, we calculated the 2) about three quarters in patients for every 10 years
OR for the different variables and their CIs, and of age, 3) about 20% in male compared to female
obtained the probability that the Mycobacterium patients, and 4) about a quarter in patients with
tuberculosis strain is MDR-TB decreases by 1) about history of TB compared to patients with a previous
half in patients who live in enclosed communities history of TB.

CONTEXTE : La tuberculose (TB) constitue l’un des
principaux problèmes de santé des Tibétains en exil en
Inde. Les cliniciens trouvent fréquemment des TB
pharmaco-r ésistantes, mais des donn ées précises
manquaient.
O B J E C T I F : Déterminer la proportion de cas résistants
parmi les patients tibétains tuberculeux nouveaux et
ceux déjà traités.
S C H E M A : Nous avons réalisé une enquête de résistance
aux médicaments dans cinq collectivités tibétaines en
Inde. Une culture et un test de sensibilit é aux
médicaments (DST) de première ligne ont été réalisés
chez tous les patients nouveaux ou déjà traités entre avril
2010 et septembre 2011. Les DST pour la kanamycine
(KM), l’éthionamide, l’acide para-aminosalicylique et
l’ofloxacine (OFX) ont été réalisés sur des isolats de TB
multirésistante (TB-MDR).
R E S U LT A T S : De 307 patients enrôlés, 264 ont eu une
culture positive et un DST disponible ; 193 étaient des
M A R C O D E R E F E R E N C I A: La tuberculosis (TB) es uno
de los principales problemas de salud en la comunidad
tibetana en exilio en la India. Se acepta que la TB
farmaco-resistente es frecuente en la práctica clı́nica,
pero se carece de datos precisos.
O B J E T I V O: Determinar la proporci ón de
farmacorresistencia en los casos nuevos y los casos con
antecedente de tratamiento en los pacientes tibetanos
con diagnóstico TB.
M É T O D O: Se llevó a cabo una encuesta de farmaco-
resistencia en cinco asentamientos tibetanos en la India,
con cultivo y prueba de sensibilidad a los medicamentos
antituberculosos (DST) de primera lı́nea en todos los
casos consecutivos de TB, nuevos y previamente
tratados, que se diagnosticaron entre abril del 2010 y
septiembre del 2011, además de DST a kanamicina
(KM), etionamida, ácido para-aminosalicı́lico y
ofloxacino (OFX) a los aislados clı́nicos TB
multidrogorresistentes (TB-MDR).
R E S U LT A D O S: Participaron en el estudio 307 pacientes
y 264 obtuvieron cultivos positivos y contaban con DST.
TB DRS among Tibetan refugees iii
RESUME
nouveaux cas et 71 avaient déjà été traités. Tous les
patients testés pour le virus de l’immunodéficience
humaine (n ¼ 250) étaient négatifs. Parmi les nouveaux
cas, 14,5% étaient TB-MDR et 5,7% étaient résistants
seulement à l’isoniazide (INH). Parmi les cas déjà traités,
31,4% étaient TB-MDR et 12,7% étaient résistants à
l’INH seulement. Parmi les isolats TB-MDR, 28,6% des
nouveaux cas et 26,1% des cas déjà traités étaient
résistants à l’OFX et 7,1% des nouveaux cas et 8,7% des
cas déjà traités étaient résistants à la KM. Trois patients
avaient une TB ultrarésistante.
C O N C L U S I O N : La TB-MDR est fréquente chez les
nouveaux cas et les cas déjà traités parmi les Tibétains en
Inde. Les patients tibétains TB-MDR présentaient
d’autres profils de r ésistance complexes. Le
pourcentage élevé de souches de TB-MDR résistantes à
l’OFX, à la KM ou aux deux est particulièrement
préoccupant.
RESUMEN
De estos, 193 eran casos nuevos y 71 habı́an recibido
tratamiento previamente. Todos los pacientes en quienes
se practicó la prueba diagnóstica del virus de la
inmunodeficiencia humana obtuvieron un resultado
negativo (n ¼ 250). En los casos nuevos se observó un
14,5% de TB-MDR y el 5,7% era monorresistente a
isoniazida (INH). En los casos con antecedente de
tratamiento se observó un 31,4% de casos TB-MDR y
un 12,7% de monorresistencia a INH. En los aislados
TB-MDR, el 28,6% de los casos nuevos y el 26,1% de
los casos previamente tratados eran resistentes a OFX y
el 7,1% de los casos nuevos y el 8,7% de los casos con
tratamiento previo eran resistentes a KM. Tres pacientes
presentaron TB extremadamente drogorresistente.
C O N C L U S I O N E S: La TB-MDR es frecuente en los casos
nuevos y en los casos con antecedente de tratamiento
antituberculoso en la población tibetana de la India. Los
pacientes provenientes del Tı́bet que presentan TB-
MDR exhiben otros tipos complejos de resistencias.
Suscita una preocupación especial el alto porcentaje de
cepas TB-MDR con resistencia a OFX, KM o a ambos.