149 experts call to find all TB to stop TB

Shobha Shukla / Bobby Ramakant *

One hundred and forty nine delegates of 78th National Conference of Tuberculosis and Chest Diseases ( NATCON) have endorsed a global call to find all TB to stop TB, which has 1 key ask: Stop missing TB cases, by taking 2 actions:

1) Replace smear microscopy 100% with WHO recommended molecular tests as soon as possible, along with a paradigm shift from a lab-centric to a fundamentally people-centric model to find TB, leaving no one behind

2) Find the missing millions! Screen everyone (and not just those with TB symptoms) in high burden settings with WHO recommended screening tools and confirm those with presumptive TB using molecular tests.

Break the chain of TB transmission

Injustice and inequality mars global health too. On one hand we have few countries that have broken the chain of TB infection transmission but on the other hand we have many high TB burden countries which have failed to stop the spread of TB infection, said Professor (Dr) Guy Marks, noted respiratory medicine expert and scientist from Australia, and President and interim Executive Director of the International Union Against Tuberculosis and Lung Disease (The Union).

He added: "TB is a communicable disease. There are 7 ways we can interrupt the cycle of being reinfected, out of which most effective way is to find all and treat all TB."

Dr Guy Marks shared an important study done in Ca Mau, Viet Nam where they screened everyone for TB (not just those with symptoms), and followed up with linkage to TB treatment and care for those who were found with the disease. TB rates declined by 72% in a four-years period. In communities where the TB rates declined in the adult population, TB rates halved among children too. "We need to break the chain of transmission," stressed Prof Guy Marks. "Find all (or nearly all) the TB cases. Most people with TB are not in high risk groups," he said. "Ensure all the TB cases found are linked to TB care. Sustain this [Find all TB, treat all TB] for ten years until TB rates drop below 50 per 100,000 population."

Dr Guy Marks added that "main beneficiaries are not the people with TB who are found [by active screening and upfront molecular testing], but those who are protected from getting TB infection and TB disease."

TB diagnosis is a critical entry-point to TB care continuum

"Early and accurate TB diagnosis is an important and critical entry-gate to the TB care pathway. It not only helps in reducing TB-related human suffering but also helps in stopping the spread of infection. To end TB, we need to find all TB cases, diagnose all of them by using WHO approved molecular tests upfront and link them to the full cascade of effective treatment, care, and support services," said Dr Kuldeep Singh Sachdeva, former head of India's TB elimination programme (former deputy director general of TB at Ministry of Health and Family Welfare, government of India). Dr Sachdeva was also the Director for Southeast Asia region of International Union Against Tuberculosis and Lung Disease (The Union) and currently leads Molbio Diagnostics as President - Chief Medical Officer.

Change paradigm of cascade of care

Dr Sachdeva rightly pointed out that cascade of TB care begins not from diagnosis but much earlier when active case finding is happening - it begins from willingness of healthcare workers to go closer to the communities or at the doorstep of people to find all TB. Cascade of care does not end with cure, instead it ends after a couple of years of a person being cured of TB. "If we do passive case finding [for new TB cases], we will never find all the TB cases," said Dr Sachdeva.

Verbal screening for TB is not enough

Dr Padmapriyadarsini Chandrasekaran, Director of National Institute for Research in Tuberculosis (NIRT), Indian Council of Medical Research (ICMR), stressed upon the importance of screening everyone (not just those with symptoms) with WHO recommended and evidence-based tools and offering WHO recommended molecular testing to those with presumptive TB. India's National TB Prevalence Survey 2019-2021 findings show that 42.6% TB patients would have been missed if they were not screened by an x-ray (and followed up with a confirmatory molecular test). "Use of ultraportable x-ray [as a screening tool] should be thought of at the community level," she said.

More importantly she said that "number of cases notified was way less than the number of TB cases shown by the prevalence survey."

Dr Padmapriyadarsini recommended that to make TB case finding more efficient, we need to scale up x-ray screening and offer upfront molecular testing to all those with presumptive TB. She also underlined the importance of screening all those with TB risk factors, such as those with diabetes, malnourishment, tobacco or alcohol use, HIV, among others.

Dr Guy Marks had visited NIRT-ICMR and posted on X: "As prevalence survey shows 55% of prevalent, microbiologically confirmed TB do not report symptoms, this will require annual mass screening, regardless of symptoms, with aim of finding at least 80% of prevalent infectious cases."

Progress happened but is it enough?

Globally, we could find a record number of new TB cases in a single year - historically. Over 7.5 million new TB cases were diagnosed in 2022 worldwide – highest ever in the age-old fight against TB (as per the WHO Global TB Report 2023). But, not able to find all TB cases continues to be worrisome.

In India, states like Uttar Pradesh have reported highest ever notification of new cases (around 625,000 as reported in news) in 2023 as more WHO recommended ultraportable x-ray screening and point-of-care and decentralised molecular test Truenat is being appropriately deployed at the block level across the state.

Of the 7.5 million new people who were diagnosed with TB in 2022 worldwide, only 47% were diagnosed using a WHO recommended molecular test. In India, as per the India TB Report 2023, only 23% of all TB testing was done on a molecular test. This is so unacceptable as we cannot afford to miss TB.

The WHO's highest level initiative – Find.Treat.All (first launched in 2018) - had called upon all governments to replace the old and poorly performing microscopy TB test with WHO recommended rapid molecular tests by 2027. World leaders at the 2023 UN High Level Meeting on TB had also re-echoed this call to completely phase out microscopy with upfront molecular test diagnosis for TB by 2027.

Upfront molecular testing for TB in India doubled in 2022

Despite glaring gaps, there is historic progress made in India too in fight against TB. India saw the largest-ever rollout of WHO recommended molecular tests across the nation. Molecular testing grew by 82% in India in 2022 as compared to the levels in 2021 – this is the largest jump in molecular testing figures so far (as per the data in India TB Reports of 2022 and 2023).

Point-of-care, decentralised, battery operated and laboratory independent Truenat is the most used molecular test in India. As compared to 2021, in 2022 India increased the rollout of Truenat by 90% (made by Molbio Diagnostics), and Gene Xpert by 67% (made by Cepheid). Microscopy increased during the same period by 68.1%. But when we look at absolute numbers, the rise in microscopy dwarfs the historic scale up of molecular testing in India in 2022.

Two Indian states (Goa and Lakshadweep) have completely phased out microscopy and transitioned to 100% use of molecular tests while one Indian state (Andhra Pradesh) is majorly using molecular tests (~70%) and has reduced microscopy. Most of the other Indian states have also increased the use of molecular tests manifold and are at different levels of scaling it up.

Before coming to 78th NATCON, Scientia Professor (Dr) Guy Marks, met the Indian Council of Medical Research (ICMR). “Excellent meeting today with the ICMR regarding evidence/ data-based interventions to end TB in India by breaking the chain of transmission. Need to find all, or nearly all, people with infectious TB (most of whom do not have symptoms)” he said on X.

Endorse the global call to find all TB: www.bit.ly/findalltb

The global call to find all TB to stop TB demands a paradigm shift from a lab-centric to a fundamentally people-centric model to find TB, leaving no one behind. It also reinforces the science-based call to “reach the unreached” by using WHO recommended point of care tools to screen and diagnose TB. If we act upon this key ask, imagine the difference it will make when no TB case is missed, and all people with TB are brought in the care fold in a rights-based manner. A people-centric approach to find all TB, treat all TB, and prevent TB is critical to end TB. Endorse the global call here: www.bit.ly/findalltb .