Ethiopia is one of the 30 highest burdens of TB, TB/HIV co-infection, and multidrugrnresistance TB countries. The objective of the paper was to determine the impact of alternativernlaboratory diagnostic algorithms on the patient, health system and population level usingrnvirtual implementation approach; to determine drug resistance, molecular, and spatial patternrnof tuberculosis transmission; and to identify factors associated with the transmission in AddisrnAbaba, Ethiopia.rnA mathematical modeling was used for assessing the impact of alternative diagnosticrnalgorithms. BACTECTM MGIT 960TM TB system (first-line anti-TB drugs) and GenoTypernMTBDRsl (second-line anti-TB drugs) were utilized for assessing drug susceptibility pattern.rnIS6110 Restriction Fragment Length Polymorphism, spoligotyping, and mycobacterialrninterspersed repetitive unit -variable number tandem repeat 24-loci typing (MIRU-VNTR)rnwere used to analyze DNA fingerprinting. SaTScan and ArcMap were used for a purely spatialrnand space-time cluster analysis and mapping. Isolates were collected from pulmonary highrnMDR-TB risk group patients.rnThree of the modeled diagnostic algorithms are cost-effective. The full roll-out of XpertrnMTB/RIF as the primary test for all presumptive TB cases would avert 91170 DALYs (95%rncredible interval [CrI] 54888 â€“ 127448) with an additional health system cost of US$ 11.6rnmillion over the next 10 years. The incremental cost-effectiveness ratio (ICER) is $370 perrnDALY averted. Same day LED fluorescence microscopy for all presumptive TB casesrncombined with Xpert MTB/RIF targeted to HIV-positive and High MDR-TB risk groupsrnxvrnwould avert 73600 DALYs (95% CrI 48373 - 99214) with an additional cost of US$5.1 millionrnover the next 10 years. The ICER is $169per DALY averted. Same-day LED fluorescencernmicroscopy for all presumptive TB cases (and no Xpert MTB/RIF) would avert 43580 DALYsrnwith a reduction cost of US$ 0.2 million over the next 10years. The ICER is $13 per DALYrnaverted.rnAbout 70% of the isolates were resistance to one or more of the first-line drugs, 61% of thernisolates were multi-drug resistant, and 19% were resistant to all first-line drugs. Any resistancernto INH, RMP, STM, EMB, PZA was 69%, 61%, 58%, 26% and 55% respectively. Fourrnisolates were resistant to fluoroquinolones (pre-XDR), and belonging to T3_ETH linage. Thernrest isolates were susceptible to all second-line anti-TB drugs. The linage CAS1_KILI was arnrisk factor for MDR, resistance to one or more anti-tuberculosis drugs, and drug-resistant tornINH, RMP, STM, and PZA. The linage T3_ETH was found to be a risk factor for EMBrnresistant.rnAbout 119 genetic profiles and 15 clusters were observed. T3_Eth International familyrnconstitutes the most predominant followed by the CAS1_KILI and CAS1_DELHI. OtherrnInternational families found were CAS, H1, H3, H4, LAM9, T1, T2, T3, and T5. Some isolatesrnwere designated as an orphan. The predominantly clustered isolates were 3 bands. Clusteringrnamong 4 spoligotypes T3_ETH (41.8%), CAS1_KILI (29.4%), CAS_DELHI (10.5%), and T1rn(33.3%) were observed with the overall clustering rate of 27.3%. The linage T3_ETH wasrnsignificantly associated with clustering.rnUsing spatial analysis, significant high and low rate most likely spatial and space-time clustersrnwere identified. A significant secondary cluster was also obtained. The most likely cluster ofrnxvirnthe high rate from both the purely special and space-time analyses was almost from the samernarea. Population density and per capita income was significantly associated with spatialrnclustering.rnThe full roll-out of Xpert MTB/RIF is predicted to be the best option to substantially reducernthe TB burden in Addis Ababa and is considered cost effective. Targeted use of XpertrnMTB/RIF for HIV positive and high MDR risk groups with same-day LED fluorescencernmicroscopy for all other presumptive TB cases is an alternative choice in case of budgetrnshortage. A substantial number of drug-resistance TB, high rate of molecular clustering andrnexistence of drug resistance hot spot indicated that the presence of recent drug- resistant TBrntransmission and inefficiency of TB control program in Addis Ababa city. T3_ETH andrnCAS1_KILI was the predominant linage and related to drug resistance tuberculosis in the city.rnThus strengthen TB control program is crucial to interrupt the transmission of TB.