The right diagnosis for tuberculosis

uberculosis, commonly known as TB, is a disease which continues to impact millions globally. Ending the TB epidemic by 2030 is among the health targets of the United Nations’ Sustainable Development Goals. Last year, Prime Minister Narendra Modi said that India is working towards eliminating TB five years ahead of the global 2030 target. This is an ambitious time frame. How wellpositioned is India to achieve this?

A macro view suggests that India has done exceptionally well so far. A strong political intent is driving the right policies. In fact, in November 2023, the World Health Organization (WHO) acknowledged India’s success on two major fronts: in reducing TB incidence by 16% from 2015 to 2022 (close to double the pace at which global TB incidence is declining) and in reducing TB mortality by 18% during the same period, keeping in line with the global trend.

TThe weakest aspect

However, as Dr. Madhukar Pai, Dr. Puneet K. Dewan, and Dr. Soumya Swaminathan pointed out in ‘Transforming tuberculosis diagnosis’ in Nature, globally, diagnosis continues to be the “weakest aspect of TB care”. According to the WHO’s ‘Global Tuberculosis Report 2023’, for the first time globally, 7.5 million patients were diagnosed with TB in 2022; yet there remained a large gap of some 3.1 million people who probably fell ill with TB but were not diagnosed and reported to national TB programmes. As the article surmised succinctly, “If we cannot find TB, we cannot treat TB. And if we cannot treat TB, we cannot end TB”.

So, how do we find TB? We can detect it largely by leveraging and optimising the systems and processes already in place, as well as by quickly deploying newer proven technologies that take diagnosis as close to the point of care as possible.

Take, for instance, the first step is Regional Technical Director, India and South-East Asia at FIND of screening patients: India regularly conducts active casefinding drives across the country. But it will be useful to reassess the screening procedures in place. A recent Lancet study as well as the Indian Council of Medical Research’s ‘National TB Prevalence Survey in India’ showed that while screening people for symptoms is good, it is not substantive. Studies also show that in many cases, despite not showing any apparent symptoms, people may have infectious TB and may even be transmitting it.

Xray imaging is a quick and efficient way to find these patients. Xray technology has advanced dramatically. Now, we not only have portable handheld devices, but also software driven by Artificial Intelligence that can read digital Xray images and detect possible TB with a high degree of certainty. This must be used on a wider scale so that we can find and absorb potential patients into the care cascade faster.

While Xrays are good screening tools, it is imperative to detect TB bacteria in the patient with absolute certainty. The ageold sputum microscopy test has its limitations which are addressed by the newer molecular tests that are rapid, accurate, and even detect resistance against drugs. To be sure, India has scaled up molecular diagnostic capacity significantly. The NAAT (nucleic acid amplification test) machines in India have gone up from 651 in 2017 to more than 5,000 in 2022. But the utility of these tests is limited due to their high costs and issues with accessibility. Moreover, a large number of existing technologies including molecular testing are reliant on sputum collection and testing. This comes with its own challenges. First, it may not be as easy for everyone, especially young children, to produce sputum. Second, sample transportation, especially in remote and hilly districts, remains a challenge. During the COVID19 pandemic, when an alternative to nasopharyngeal swabs was introduced in the form of simpler nasal swabs, saliva, and selfcollection, the testing coverage greatly increased. We must therefore be on the lookout for newer technologies and approaches to diagnosis.

Other collection techniques

It is time to actively explore other collection techniques such as tongue swabs which can be a true game changer. Here, the sample is extracted by simply rubbing the swab in the oral cavity. This augments our pointofcare testing abilities and also reduces the costs for overall diagnosis of TB. We could also better utilise another invaluable resource: PCR machines, which served us well during the COVID19 pandemic. These are already fitted with the right diagnostic technology and can get to the last mile across the country effectively. Newer technologies such as the urine LAM test can also be used to detect cases in the general population effectively. This is a rapid test which is easily performed. It can help in screening for both pulmonary TB (lungs) and extrapulmonary TB (organs other than the lungs).

The TB diagnostics pipeline is rich with several new innovative tests on the anvil. However, to maximise these tests, their rapid validation and adoption under the programme is critical. To ensure we truly reach the last mile, pointofcare testing and diagnosis is imperative. The good news is we already have a diagnostic framework that is forwardlooking. We need to simply improve implementation and be more proactive in deploying new technologies. We need to ensure that new technologies are streamlined and rolled out faster and build capacity at the subdistrict level to conduct such tests as needed. Minor readjustments will make a major contribution to India’s TB elimination drive. jaideep.deobhanj@thehindu.co.in

olitics in the national capital has come a full circle with the arrest of Delhi Chief Minister Arvind Kejriwal on corruption charges by the Enforcement Directorate (ED). Mr. Kejriwal, who rose to power a decade ago by launching scathing attacks over corruption against the Congress, and particularly former Delhi Chief Minister Sheila Dikshit, now finds himself having to prove his and his party’s “kattar imandar” (very honest) credentials and that too from prison.

PAn uneasy alliance

While Mr. Kejriwal’s Aam Aadmi Party (AAP) faces its biggest challenge yet, just before the Lok Sabha elections, the Congress too finds itself in a predicament. The party, which ruled Delhi for 15 years before the AAP rode to power in 2015, has no seats in the Delhi Legislative Assembly and no representation from Delhi in Parliament. In this context, the 43 seatsharing arrangement for Delhi’s seven Lok Sabha seats under the Indian National Developmental Inclusive Alliance (INDIA) bloc can be seen as an attempt by the Congress to stay in the political mix in Delhi. This alliance is an uneasy one, however, given that the two parties are rivals elsewhere. In Punjab, for instance, the AAP and Congress have chosen to fight it alone; this is where the AAP came to power defeating the Congress in 2022. While the cadre of both the parties are still awaiting instructions from their leadership on how they plan to support each other after being bitter rivals for so many years, the factor that unites them is a dominant opponent in the form of the Bharatiya Janata Party (BJP).

On the night of March 21, when the ED whisked away Mr. Kejriwal from outside his residence, it was Ms. Dikshit’s son Sandeep Dikshit, a vociferous critic of Mr. Kejriwal, who was present outside his house, along with other Congress leaders, expressing solidarity and calling the arrest “illegal”. The irony is that the alleged Delhi liquor scam that is being probed by Central agencies was an issue that was raked up by the Congress. In 2022, Ch. Anil Kumar, who was the Delhi Congress president, was among the first to file a complaint with the Delhi Police alleging a “multicrore” scam in the formation and implementation of the policy. Other Congress leaders such as party treasurer Ajay Maken have also raised allegations of corruption against Mr. Kejriwal, attacking him for spending public funds on building a lavish residence and office.

Reacting to Mr. Kejriwal’s arrest, Congress leader and former President of India Pranab Mukherjee’s daughter Sharmistha Mukherjee posted on X (formerly Twitter) that “karma catches up”. She said, “He and [the] Anna Hazare gang were responsible for making [the] most irresponsible, baseless and wild allegations against [the] Congress including Sheila Dikshit saying he has “trunk loads” of evidence against her. No one has seen the ‘trunk’ so far.”

However, leaders from both parties have said that they will respect the “alliance dharma” and put aside their differences to fight the BJP. They believe that they will have a mathematical advantage if they do not split the antiBJP votes.

Jubilance in BJP

Meanwhile, the BJP remains confident. Union Home Minister Amit Shah, while addressing an event in Delhi’s Dwarka recently, commented on the alliance saying “0+0 is still zero” and expressed confidence that the BJP will win all seven seats for a third consecutive time. The mood at a Holi Milan organised in the Delhi BJP office a day after the arrest of Mr. Kejriwal was jubilant with leaders saying corruption has been “slayed” as Mr. Kejriwal, his former Deputy Chief Minister Manish Sisodia, former Health Minister Satyendar Jain, and Rajya Sabha MP Sanjay Singh are all in jail.

The AAP has spent the weekend reacting angrily to Mr. Kejriwal’s arrest. It has deputed Cabinet Ministers Atishi, Saurabh Bharadwaj, and Gopal Rai to take stock of the situation along with Rajya Sabha MP Sandeep Pathak. All of them have been reiterating that Mr. Kejriwal will continue to be the Chief Minster even if he is in jail. The Congress is yet to announce its candidates for its three seats. Meetings on how both these parties are going to tackle the elections are yet to be conducted. On March 31, the AAP, Congress, and other Opposition parties are scheduled to hold a rally at Ramlila Maidan against Mr. Kejriwal’s arrest. Mr. Kejriwal, who has often publicly called top leaders of the parties that will be present at the rally “corrupt”, will find solace in seeing them show up for him.

We can detect TB largely by leveraging the systems already in place, as well as by quickly deploying newer proven technologies