Multidrug-resistant tuberculosis (MDR TB), is a significant threat to TB control efforts. Previous prevailing views that resistance was mainly acquired through poor treatment led to decades of focus on drug-sensitive rather than drug-resistant (DR) TB. This scenario was driven by the World Health Organization’s (WHO) directly observed therapy, short course strategy. The paradigm has now shifted towards the recognition that most DR TB is transmitted and that there is a need for increased efforts to control DR TB. Yet most people with DR TB are untested and untreated, driving transmission in the community and in health systems in high-burden settings. The risk of nosocomial transmission is high for patients and staff alike. This article discusses a comprehensive approach, strategies available, and associated challenges to lower the transmission risk of MDR TB, globally. It concludes that instead of focusing on diagnosed MDR TB cases, recognition that transmission is driven largely by undiagnosed, untreated cases, both in the community and in healthcare settings, is necessary.
