Tuberculosis (TB) remains a critical global public health challenge, significantly impacted by its mode of airborne transmission and the rise of drug-resistant strains. Despite advancements in medical science and the availability of effective treatments, TB continues to be the second leading cause of death from infectious agents, following closely behind COVID-19. The persistence of TB is due in part to its ability to spread through the air, making it highly contagious, and the increasing incidence of multidrug-resistant TB (MDR-TB) strains, which complicates treatment efforts. This comprehensive review explores the latest updates and strategies in TB control and elimination, focusing on insights from global and national reports, innovative treatment regimens, advanced diagnostic methods, and robust patient support systems.^[1-3]

Global TB Report 2023: A Snapshot^[4,5]

The World Health Organization (WHO) has released the Global TB Report 2023, which provides a detailed overview of the current state of TB worldwide, highlighting significant trends and persistent challenges:

• Incidence and Mortality: In 2022, TB incidence reached a staggering 7.5 million new cases, marking the highest number since WHO began systematic global TB monitoring in 1995. This increase reflects a 3.9% rise in the TB incidence rate between 2020 and 2022. TB also remains a leading cause of mortality, with deaths nearly doubling those caused by HIV/AIDS. These figures underscore the enduring and severe impact of TB on global health.

• Drug-Resistant TB: The report estimates that 410,000 people globally were affected by multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB) in 2022. India alone reported 110,000 of these cases, highlighting the country's significant burden and the urgent need for effective interventions to combat MDR-TB. The prevalence of drug-resistant TB continues to pose a substantial public health crisis, complicating treatment protocols and reducing the efficacy of standard treatment regimens.

• Treatment Success: The global treatment success rate for drug-resistant TB stands at 63%, revealing a critical gap in effective treatment and patient support systems. This statistic indicates that nearly one-third of patients with drug-resistant TB do not successfully complete treatment, emphasizing the need for improved regimens, better healthcare infrastructure, and enhanced support systems to ensure adherence and successful outcomes.

• Latent TB Infection: Approximately 25-30% of the world’s population is estimated to have latent TB infection, representing a vast reservoir of individuals at risk of developing active TB. This latent infection pool is a significant concern, as it can perpetuate the cycle of TB transmission and complicate eradication efforts. Addressing latent TB infection through preventive treatment strategies is essential to control the spread and achieve global TB elimination goals.

India TB Report 2024: Progress and Challenges^[6,7]

India, which bears the highest burden of TB globally, has made noteworthy progress in its fight against the disease, as detailed in the India TB Report 2024:

• Incidence and Mortality: In 2023, the estimated incidence of TB in India was 2.8 million cases. Remarkably, there was a significant reduction in TB-related mortality, with deaths decreasing from 494,000 in 2021 to 331,000 in 2022. This reduction represents a substantial improvement in TB management and highlights the effectiveness of intensified efforts in diagnosis, treatment, and patient care. The decline in mortality also suggests improvements in healthcare delivery and increased access to TB treatment services.

• Private Sector Engagement: There has been a marked increase in TB cases reported by the private healthcare sector, which now accounts for nearly 33% of total notifications. This increase indicates better collaboration and integration between public health programs and private healthcare providers. Engaging the private sector is crucial in ensuring comprehensive TB control, as it expands the reach of TB services and enhances early diagnosis and treatment.

• Diagnostic Expansion: The number of Nucleic Acid Amplification Test (NAAT) facilities has grown from 5,090 in 2022 to 6,496 in 2023, reflecting a significant expansion in diagnostic capabilities. This increase in diagnostic infrastructure is complemented by the extensive use of smear microscopy, with over 18.93 million patients tested at 24,573 centers. Additionally, 3.12 lakh patients were tested using CBNAAT and TrueNat technologies, leading to a diagnosis rate of 3.0% (578,297 cases). This expansion in diagnostic services facilitates early detection, accurate diagnosis, and timely initiation of treatment, which are critical components in controlling TB spread and improving patient outcomes.

India’s progress in TB control is commendable, yet challenges remain, particularly in managing drug-resistant TB and ensuring comprehensive patient support. Continued efforts to enhance diagnostic infrastructure, engage the private sector, and implement effective treatment regimens are essential to sustain and build on the gains made in TB control and move towards the goal of TB elimination by 2025.

Expansion of Treatment Services^[8-11]

The National TB Elimination Program (NTEP) in India has introduced several updates and new initiatives to enhance TB treatment, reflecting a robust and evolving strategy to combat the disease more effectively:

• Daily Regimen Expansion: NTEP has expanded the use of daily treatment regimens across all forms of TB, which significantly eliminates the need for injectable regimens that were previously part of the treatment protocols. This change simplifies treatment for patients and healthcare providers, ensuring a more consistent and manageable approach to medication adherence. Daily regimens are now standardized, improving patient outcomes and reducing the burden of administration associated with injections.

• Shorter Oral Regimens for MDR-TB: The introduction of shorter oral regimens for multidrug-resistant TB (MDR-TB) represents a major advancement in TB treatment. Notably, the BPaL (Bedaquiline, Pretomanid, and Linezolid) regimen offers a more manageable treatment option with fewer side effects and a shorter duration compared to traditional regimens. This shift towards shorter, all-oral regimens enhances patient compliance and improves overall treatment success rates.

• TB Preventive Treatment (TPT): Preventive treatment protocols have been expanded to include contacts of drug-resistant TB patients, which is a crucial step in curbing the spread of resistant TB strains. This proactive approach targets the prevention of TB among high-risk groups, particularly those in close contact with TB patients, thereby reducing the potential for further transmission and development of drug-resistant TB.

Detailed Treatment Regimens^[12-14]

Updated treatment regimens under the NTEP reflect a comprehensive and targeted approach to addressing different forms of TB:

• Drug-Susceptible TB (DS-TB): The standard regimen for drug-susceptible TB includes an initial 2-month phase of four drugs (HRZE - Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol) followed by a continuation phase of 4 months with three drugs (HRE - Isoniazid, Rifampicin, and Ethambutol). This regimen is designed to ensure effective eradication of the TB bacteria, minimizing the risk of relapse and drug resistance.

• H Mono/Poly DR-TB: For cases with mono or poly resistance to isoniazid (H), a 6-month regimen is recommended. This regimen comprises levofloxacin (Lfx), rifampicin (R), ethambutol (E), and pyrazinamide (Z), tailored to effectively manage and cure TB in patients with these specific drug resistances.

• MDR/RR-TB: Treatment regimens for MDR-TB and rifampicin-resistant TB (RR-TB) have been updated to include shorter regimens featuring bedaquiline (BDQ) and longer regimens that can extend up to 20 months. These regimens also incorporate additional drugs such as linezolid (Lzd) and clofazimine (Cfz) to address complex drug resistance patterns and improve treatment efficacy.

New 6-Month Regimen – BPaLM/BPaL^[15,16]

The BPaLM/BPaL regimen is a groundbreaking 6-month treatment protocol specifically designed for MDR/RR-TB, offering significant improvements over traditional treatments:

• Components: The regimen includes Bedaquiline (B), Pretomanid (Pa), Linezolid (L) at a dose of 600 mg, and Moxifloxacin. This combination of drugs is selected for their high efficacy and ability to work synergistically to combat MDR/RR-TB.

• Benefits: The BPaLM/BPaL regimen offers numerous benefits, including a shorter treatment duration of just six months, which is a substantial reduction compared to the traditional 20-month regimens. The regimen is also associated with a lower cost and reduced pill burden, making it more accessible and easier for patients to adhere to. Furthermore, the high efficacy of this regimen significantly improves treatment outcomes for patients with MDR/RR-TB or pre-XDR-TB (extensively drug-resistant TB), providing a promising solution in the fight against drug-resistant TB.

DT3C Clinics - Difficult-to-Treat TB Clinic^[17-19]

DT3C Clinics have been established to enhance the management of drug-resistant TB cases through a structured and supportive framework:

• Objectives: The primary goal of DT3C Clinics is to enhance the clinical expertise of peripheral physicians in managing TB and drug-resistant TB (DR-TB). These clinics aim to provide specialized training and support to healthcare providers at the periphery, ensuring that patients receive high-quality care even in decentralized locations.

• Structure: The clinics operate on a three-tier system using a hub-and-spoke model. This model facilitates the dissemination of knowledge and expertise from central hubs to peripheral spokes, ensuring comprehensive coverage and support. Monthly virtual learning sessions are conducted to provide continuous education and updates to physicians. These sessions focus on providing solutions to difficult cases and building the capacity of peripheral doctors to manage complex TB cases effectively. This structured approach ensures that healthcare providers are well-equipped to handle the challenges of drug-resistant TB, ultimately improving patient outcomes and contributing to the national goal of TB elimination.

These initiatives and updates reflect a robust, multi-faceted approach to TB treatment and control, addressing the complexities of the disease with innovative strategies and comprehensive support systems.

IT-Enabled Treatment Adherence Support^[20-22]

Ensuring adherence to TB treatment is critical for successful outcomes, as it helps to prevent the development of drug resistance and ensures that patients complete their treatment regimen. The National TB Elimination Program (NTEP) in India has implemented several IT-enabled tools and platforms to support treatment adherence:

• Nikshay Portal: The Nikshay Portal is a comprehensive digital platform designed to track patient treatment, adherence, and outcomes. It provides a centralized system for registering TB patients, recording medical test details, monitoring treatment adherence, and managing patient data. The portal allows healthcare providers to update patient records in real-time, facilitating better coordination and follow-up. Features include reminders for patients to take their medication, notifications for healthcare workers about missed doses, and tracking of Direct Benefit Transfer (DBT) payments to patients for nutritional support.

• 99 DOTS: 99 DOTS is an innovative IT-enabled 'pill-in-hand' adherence monitoring system that uses mobile phones to ensure patients take their TB medications. Patients receive blister packs wrapped in custom envelopes with hidden phone numbers that are revealed when doses are dispensed. Patients make free calls to these numbers, confirming their medication intake. This system allows healthcare providers to monitor adherence in real-time and intervene promptly if a patient misses doses.

• MERM Box: The Medicine Event Reminder Monitor (MERM) Box is a GPS-enabled device that tracks medication intake. Patients receive their TB medications in the MERM Box, which records the date and time each time the box is opened. This data is transmitted to the Nikshay dashboard, allowing healthcare providers to monitor compliance and follow up with patients who miss doses. The MERM Box also provides audio and visual reminders to patients to take their medications, further supporting adherence.

These IT-enabled tools are crucial for improving treatment adherence, reducing the risk of drug resistance, and ensuring that TB patients complete their treatment regimens successfully.

Preventive Strategies^23-25

Effective TB control requires not only treating active TB cases but also implementing preventive strategies to reduce the risk of transmission and address co-morbid conditions. The NTEP has developed several key preventive strategies:

• Nation-Wide Scale-Up of TPT: Tuberculosis Preventive Treatment (TPT) is essential for preventing the development of active TB in individuals who are at high risk, such as contacts of TB patients and other at-risk populations. The NTEP has scaled up the implementation of TPT across the country through the Pradhan Mantri TB Preventive Treatment (PMTPT) initiative. This program aims to identify and treat individuals with latent TB infection (LTBI) before they develop active TB.

• Air-Borne Infection Control (AIC): To reduce the risk of TB transmission in healthcare settings, the NTEP has implemented Air-Borne Infection Control (AIC) measures. These measures include the use of personal protective equipment (PPE) such as masks and respirators, strict hand hygiene practices, and the establishment of airborne infection isolation rooms. Proper ventilation systems and ultraviolet germicidal irradiation (UVGI) are also used to minimize the spread of TB bacteria in health facilities.

• TPT Regimens for Contacts: Different TPT regimens are used based on the drug resistance profile of the TB strain to which the contacts have been exposed:

  • 6H: A 6-month regimen of daily isoniazid monotherapy for contacts of drug-susceptible TB patients. This regimen is effective in preventing the progression from latent TB infection to active TB disease.

  • 3HP: A 3-month regimen of weekly doses of isoniazid and rifapentine, offering a shorter and effective preventive treatment option with a lower pill burden.

  • 6Lfx: A 6-month regimen of daily levofloxacin for contacts of MDR/RR-TB patients. This regimen targets individuals at high risk of developing drug-resistant TB.

  • 4R: A 4-month regimen of daily rifampicin for contacts of patients with H-resistant TB. This regimen is designed to prevent TB in individuals exposed to isoniazid-resistant strains.

These preventive strategies are crucial for breaking the chain of TB transmission, reducing the incidence of active TB cases, and addressing the co-morbid conditions that can complicate TB management. Through a combination of treatment adherence support and preventive measures, the NTEP aims to significantly reduce TB incidence and move closer to the goal of TB elimination in India.

Diagnostic Advancements^[25-27]

Innovative diagnostic tools and methods are crucial for the early detection and effective treatment of TB. Advancements in diagnostic technology enhance the ability to identify TB infections quickly and accurately, facilitating timely intervention and better patient outcomes. Key diagnostic advancements include:

• Cy TB: The Cy TB skin test is a novel diagnostic tool for TB infection, employing the Mantoux technique. It features a single cut-off of 5 mm, simplifying interpretation. Unlike traditional tuberculin skin tests, Cy TB is not influenced by prior Bacille Calmette-Guérin (BCG) vaccination, making it more reliable in BCG-vaccinated populations. This test offers a significant improvement in identifying latent TB infections and ensures appropriate preventive measures can be taken.

• Interferon-Gamma Release Assays (IGRA): Recommended by the WHO, IGRAs are blood tests that measure the immune response to TB antigens. They are highly specific and are not affected by BCG vaccination, reducing false-positive results. IGRAs are used for detecting latent TB infections and are particularly useful in settings where BCG vaccination is common. Their implementation improves the accuracy of TB infection screening and aids in the effective management of TB control programs.

• Ultraportable Handheld X-ray (HHX-ray) Devices: These devices represent a significant advancement in TB diagnostics, offering mobility and ease of use in point-of-care settings. HHX-ray devices are particularly beneficial for screening and diagnosing TB in remote and underserved areas where traditional diagnostic infrastructure may be lacking. They facilitate on-the-spot diagnosis, allowing for immediate initiation of treatment and reducing the delay in TB management.

• Indian TB Genomic Surveillance Consortium (InTGS Consortium): The InTGS Consortium plays a vital role in monitoring genomic variations in Mycobacterium tuberculosis. By conducting comprehensive genomic surveillance, the consortium aids in understanding the evolution of drug resistance and the transmission dynamics of TB. This information is critical for developing targeted interventions and improving the effectiveness of TB treatment regimens. The consortium's work supports the development of more precise diagnostic tools and personalized treatment plans for TB patients.

Addressing Co-Morbidities and Bi-Directional Screening^[28-30]

Comprehensive TB care involves not only treating the infection but also addressing co-morbid conditions that can complicate TB management. Bi-directional screening and integrated care for co-morbidities enhance patient outcomes and reduce the burden of TB. Key strategies include:

• HIV and TB Co-Infection: Given the high prevalence of HIV among TB patients, all TB patients are routinely tested for HIV. Those who are co-infected receive cotrimoxazole preventive therapy (CPT) to reduce the risk of opportunistic infections and antiretroviral therapy (ART) to manage HIV. INH Preventive Therapy (IPT) is provided to all people living with HIV (PLHIV) who do not have active TB, reducing their risk of developing TB. Rifabutin is used in cases where patients are on second-line ART, ensuring effective TB treatment without compromising HIV management. This integrated approach ensures that co-infected patients receive comprehensive care, improving their overall health outcomes.

• Diabetes and TB: The bidirectional screening approach includes testing TB patients for diabetes and screening diabetes patients for TB. Diabetes is a known risk factor for TB, and managing both conditions simultaneously is crucial for successful treatment. Intensified TB case finding among diabetes patients helps in early detection and treatment of TB, reducing the risk of severe disease and transmission. Additionally, counseling for tobacco cessation is provided to TB patients, as smoking can worsen TB outcomes and complicate diabetes management. This holistic approach ensures that co-morbid conditions are effectively managed, improving treatment adherence and patient outcomes.

By integrating advanced diagnostic tools and addressing co-morbid conditions, TB control programs can significantly enhance the detection, treatment, and prevention of TB. These strategies are crucial for achieving the goal of TB elimination and improving public health outcomes.

Patient Support Systems^[31,32]

Robust patient support systems are essential for ensuring adherence and successful treatment outcomes in TB control efforts. These systems provide critical financial, informational, and emotional support to TB patients, helping to address barriers to treatment adherence and improve overall health outcomes. Key components of patient support systems include:

• Direct Benefit Transfer (DBT): The Nikshay Poshan Yojana provides financial support of INR 500 per month to TB patients to aid in nutritional support, recognizing the role of proper nutrition in enhancing recovery. Additional support mechanisms include transport assistance for TB patients in tribal, hilly, and difficult-to-reach areas, ensuring that patients can access health facilities for treatment. Furthermore, honoraria are provided to treatment supporters, incentivizing community members to assist in patient care and adherence monitoring. This holistic financial support aims to reduce the economic burden on TB patients and their families, thereby improving treatment adherence and outcomes.

• Helpline and Applications: Digital tools and helplines play a vital role in patient support. The TB Aarogya Saathi app offers comprehensive information, counseling, and support to TB patients, facilitating better understanding and management of their condition. The Ni-kshay Sampark toll-free number (1800-11-6666) provides immediate access to support services, ensuring that patients can get timely help. Additionally, the e-Sanjeevani platform enables tele-consultation services, allowing Community Health Officers (CHOs) to assist in ruling out active TB among household contacts (HHCs) of TB patients. These digital platforms ensure continuous support and connectivity, enhancing patient care and adherence.

Community Engagement and Multisectoral Collaboration^[33-35]

Community involvement and collaboration across various sectors are critical for the successful elimination of TB. Engaging the community and leveraging resources from multiple sectors can significantly enhance TB control efforts. Key initiatives include:

• Transformation of TB Survivors to TB Champions: Training TB survivors to become advocates and champions for TB elimination is a powerful strategy. These individuals support current patients, help sensitize communities, combat stigma, and monitor TB control efforts within their communities. By sharing their experiences and providing peer support, TB champions play a crucial role in motivating patients and ensuring adherence to treatment.

• Capacity Building and Mentoring: Continuous capacity building and mentoring are essential for sustaining effective TB control efforts. Virtual sessions like TB Tuesdays and TB Wednesday (Nidaan Samvaad) provide regular training and updates for healthcare providers at the state and district levels. Additionally, Nikshay Diwas, observed at Health and Wellness Centers (HWCs) on the 15th of every month, promotes community engagement and awareness, fostering a supportive environment for TB patients.

• Pradhan Mantri TB Mukt Bharat Abhiyaan: This national campaign aims to accelerate TB elimination by uniting community stakeholders and enhancing community involvement. The campaign leverages Corporate Social Responsibility (CSR) initiatives and has seen participation from over 1.57 lakh Ni-kshay Mitras (supporters), who provide various forms of assistance to TB patients, including nutritional support. This collaborative approach ensures that communities are actively involved in TB control efforts, increasing the reach and impact of TB programs.

• Ni-kshay Mitra Program: This program engages donors to provide monthly nutritional support to TB patients, significantly improving treatment outcomes and reducing out-of-pocket expenses for patients. By ensuring that TB patients receive adequate nutrition, the program helps improve their immune response and overall health, which are critical for successful treatment completion.

• TB Mukt Panchayat: This initiative engages Panchayati Raj Institutions (PRIs) in TB control efforts, ensuring active community participation in TB case finding, treatment adherence, and addressing social determinants of health. By involving local governance structures, the initiative aims to create a supportive environment for TB patients and enhance the effectiveness of TB control programs at the grassroots level.

Multisectoral Engagement^36-39

Multisectoral engagement involves collaboration with various government departments, autonomous bodies, and the private sector, recognizing that TB control requires a comprehensive approach that addresses multiple determinants of health. Key collaborative efforts include:

• Ministry of AYUSH: Collaborative actions with the Ministry of AYUSH include the revival of Technical Working Groups (TWGs) towards TB Mukt Palika (urban local bodies). This partnership aims to integrate traditional medicine and wellness practices into TB control programs, enhancing patient care and treatment adherence.

• Indian Oil Corporation Limited (IOCL): IOCL has contributed TrueNat machines for rapid molecular testing, particularly in aspirational and tribal districts. This collaboration ensures that advanced diagnostic tools are available in remote and underserved areas, improving the speed and accuracy of TB diagnosis.

• Ministry of Coal and CTD: An MoU with Coal PSUs focuses on addressing TB among coal mining workers, a high-risk group due to occupational exposure and living conditions. This partnership aims to enhance TB screening, treatment, and prevention efforts within the coal mining community.

• Corporate TB Pledge (CTP): The private sector plays a vital role in TB control through the Corporate TB Pledge (CTP), which involves generating awareness, integrating TB services, and providing nutritional support through CSR activities. This initiative mobilizes resources and expertise from the private sector, complementing public health efforts.

• State-Specific Initiatives: States like Himachal Pradesh have implemented innovative strategies for TB control, including wall paintings for public awareness, partnerships with Chemist Associations, and collaboration with Central Universities for TB prevention and control activities. These localized efforts ensure that TB control measures are tailored to the specific needs and contexts of different regions, enhancing their effectiveness.

By integrating patient support systems, community engagement, and multisectoral collaboration, TB control programs can significantly enhance their reach, impact, and sustainability, moving closer to the goal of TB elimination.

Newer Initiatives and Future Directions^[40-42]

Continued innovation and the integration of cutting-edge technologies drive progress in TB control. Key initiatives include:

• Integration of TrueNat Machines with Ni-kshay: The integration of TrueNat machines with the Ni-kshay digital platform has been piloted to facilitate direct data transfer, streamlining the diagnostic process. This enhances diagnostic management by providing real-time data on TB cases, improving the accuracy and speed of diagnosis, and enabling better tracking of treatment outcomes.

• Laboratory Quality Improvement Workshops: These workshops are conducted to enhance the quality of laboratory services across the country. By focusing on reducing turnaround times and improving the accuracy of diagnostic tests, these workshops ensure that patients receive timely and precise diagnoses, which is critical for effective treatment.

• Adult BCG Vaccination: Targeting high-risk adults, this initiative aims to reduce the severity of TB infections. By administering BCG vaccines to adults in high-risk categories, such as healthcare workers and individuals with compromised immune systems, the initiative seeks to provide additional protection against TB. Careful monitoring and follow-up are conducted to assess the effectiveness of the vaccination and ensure patient safety.

Detailed Initiatives and Progress in Himachal Pradesh^[43,44]

Himachal Pradesh has implemented several innovative steps to combat TB effectively, making significant progress in TB control:

• Current Status: TB remains a significant public health issue in Himachal Pradesh, with approximately 15,000 new cases registered annually. In 2023, Una district recorded 819 TB cases with 57 deaths. The state's case detection rate and treatment success rate are above the national average, indicating effective TB control measures.

• Differentiated TB Care Model Guidelines: These guidelines focus on reducing TB-related mortality and morbidity by providing comprehensive evaluation and supportive treatment services at various health facility levels. The model categorizes TB patients based on their risk level and refers them to appropriate care levels (L1, L2, and L3 facilities), ensuring that patients receive the right level of care based on their needs.

• Drone for NTEP: The use of drones to transport TB drugs and sputum samples in remote areas has significantly improved diagnosis and treatment timelines. In February-March 2023, drones transported 53 drug boxes and 169 sputum samples across five hard-to-reach PHIs in Mandi district, demonstrating the effectiveness of drones in overcoming logistical challenges and ensuring timely medical support in remote regions.

• Ultraportable Handheld X-Ray: A pilot project in Kinnaur, Hamirpur, and Una districts utilizes ultraportable handheld X-ray devices. These devices provide crucial mobility and ease of use for TB screening and diagnosis, particularly in remote and hard-to-reach areas. Their deployment has enhanced the ability to perform on-the-spot screenings, leading to quicker diagnosis and treatment initiation.

• AIML Tools: AI and machine learning tools for reading digital X-rays have shown high sensitivity and specificity, improving diagnosis accuracy. These tools assist healthcare providers in interpreting X-rays more accurately and quickly, leading to better patient outcomes and more efficient use of resources.

Several critical points emerge from these initiatives and reports:

• Improve TB Notification Rate: Ensuring mandatory TB notification from the private sector is crucial. Engaging private healthcare providers to report TB cases can significantly improve the accuracy of TB surveillance and ensure that all cases are captured and managed appropriately.

• Active TB Case Finding: Reaching unreached populations through active case finding is essential. By conducting systematic screenings in high-risk and hard-to-reach populations, health authorities can identify and treat TB cases early, reducing transmission and improving treatment outcomes.

• Optimum Utilization of CBNAAT Machines: Enhancing diagnostic capabilities through the optimal use of CBNAAT machines is vital. These machines provide rapid and accurate TB diagnosis, including drug resistance testing, which is critical for effective treatment planning.

• Expand Universal Drug Susceptibility Testing: Covering more patients with universal drug susceptibility testing helps in identifying drug-resistant TB cases early and tailoring treatment regimens accordingly. This approach improves treatment outcomes and prevents the spread of resistant strains.

• Nikshay Poshan Yojana: Ensuring nutritional support for every TB patient through the Nikshay Poshan Yojana is a key strategy. Adequate nutrition is crucial for TB patients to recover and adhere to treatment, reducing the likelihood of treatment failure and relapse.

• 100% Reporting through NIKSHAY: Ensuring comprehensive data collection and monitoring through 100% reporting via the Ni-kshay platform is essential for effective TB control. Accurate data helps in tracking progress, identifying gaps, and making informed decisions for TB elimination.

• Collaboration with Line Ministries: Tackling social determinants of TB, such as poverty, undernourishment, HIV infection, smoking, and diabetes, requires collaboration with various line ministries. Integrating TB control efforts with broader social and health initiatives can address underlying factors contributing to TB incidence and improve overall health outcomes.

• Community Participation: Active engagement and support from the community are vital for TB elimination. Community participation in TB case finding, treatment adherence, and addressing social determinants of health can significantly enhance the effectiveness of TB control programs. Initiatives like the Pradhan Mantri TB Mukt Bharat Abhiyaan and the TB Mukt Panchayat involve local communities in TB control efforts, fostering a supportive environment for TB patients and ensuring sustained efforts towards TB elimination.

By integrating these newer initiatives, detailed regional strategies, and key takeaways, TB control programs can significantly enhance their reach, impact, and sustainability, moving closer to the goal of TB elimination.

Table-1: Key aspects of TB control, diagnosis, treatment, and patient support initiatives

In conclusion, the multi-faceted approach to TB control and elimination detailed in this review highlights significant progress and ongoing challenges. Global and national efforts, particularly in India, have been bolstered by innovative diagnostic tools, advanced treatment regimens, and robust patient support systems. The expansion of daily regimens, shorter oral regimens for MDR-TB, and preventive treatments for high-risk contacts are pivotal in reducing TB incidence and improving patient outcomes. IT-enabled tools like the Nikshay Portal and 99 DOTS enhance treatment adherence, while community engagement and multisectoral collaboration drive the success of TB programs. Initiatives such as the Pradhan Mantri TB Mukt Bharat Abhiyaan and regional efforts like those in Himachal Pradesh exemplify effective TB control strategies. Continued innovation, integration of cutting-edge technologies, and expanded collaborative efforts are essential for sustaining momentum towards TB elimination. Achieving the goal of TB elimination by 2025 will require unwavering commitment, sustained efforts, and collective action from all stakeholders to improve public health outcomes and save lives.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Indira Gandhi Medical College, Shimla, Himachal Pradesh.

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