Geographic, Health-System and Socioeconomic Drivers of MDR-TB Burden in District Mandi, Himachal Pradesh: Insights for Achieving India’s End TB 2030 Targets

Background: Multidrug-resistant tuberculosis (MDR-TB) remains a critical public health challenge in India, despite notable declines in TB incidence and mortality under the National Tuberculosis Elimination Programme (NTEP). Mountainous districts such as Mandi in Himachal Pradesh face amplified barriers to timely diagnosis and treatment. This study analyzes block-wise MDR-TB characteristics to identify diagnostic delays, treatment gaps, resistance patterns and socioeconomic factors shaping outcomes. Methods: A retrospective observational analysis was conducted using secondary data from all 28 Designated Microscopy Centres (DMCs) in District Mandi during 2018–19. Data on institutional inputs, diagnostic infrastructure, sputum testing, drug-resistance profiles, treatment initiation timelines, geographic accessibility, clinical complaints, and sociodemographic variables were analysed descriptively across blocks. Results: The district reported 919 sputum-positive TB cases and notable gaps in laboratory capacity, with only 35.7% of DMCs equipped with LED microscopes. Mean distance to the nearest CBNAAT facility was 50.75 km, reaching 150 km in remote blocks. Primary MDR-TB accounted for 11–100% of cases, and XDR-TB was concentrated in Bagsiad (36.4%). Diagnostic delays >7 days ranged from 22.2% to 78.6%, particularly high in Ratti. Treatment initiation within 7 days varied widely (12.5–87.5%). Significant socioeconomic vulnerabilities were observed, including unemployment post-diagnosis (up to 75%), overcrowding (20–57.1%), and presence of concurrent TB cases within families and communities. Patients often travelled >100 km for diagnosis and specialist care, prioritizing perceived quality over proximity. Conclusion: MDR-TB control in Mandi district is challenged by geographic inaccessibility, limited diagnostic capacity, socioeconomic distress and substantial block-level disparities. Strengthening decentralised molecular diagnostics, ensuring rapid treatment initiation, improving transport and social support, and targeting high-burden blocks are critical for aligning district performance with India’s End TB goal.