Opinion: India’s pioneering TB tech can pave the way for rest of G-20

India has the highest burden of tuberculosis in the world, and when you have a health problem of this size, the only way forward is to come together to strongly address it with a united front.

With a disease as old, stubborn, and difficult to defeat as the airborne pandemic of TB, strong leadership for action is essential. This moment came in 2018, with the first United Nations high-level meeting on TB which spurred India's Prime Minister Narendra Modi to commit to ending TB in India by 2025 through unified action.

Taking action

This political commitment and leadership have led to remarkable attention, effort, funding, and work, which have saved or improved millions of lives of people with TB in India and globally.

It has led to the development of numerous tools for TB diagnosis, prevention, and treatment. And it has also prompted improvements in service delivery — including innovations to better support people with TB, in models of financing, and overall progress toward ending TB by 2025.

The G-20 health track, under India’s G-20 presidency, focuses on digital health, so it is important to highlight some pioneering digital and artificial intelligence tools that have been developed in India and are being used in the TB response — which serve as strong examples of what is possible for the G-20 discussions.

Real-time TB data

Globally, we lack real-time data on the diagnosis and treatment of people with TB, restricting both policy and action.

India has demonstrated that it is possible to gain and analyze real-time digital TB data at every level of the health system, helping to prompt action and help to plan health care interventions.

The program supporting that goal is NIKSHAY — an advanced digital TB surveillance platform. It tracks real-time TB notification and monitoring of people with TB through the entire continuum of care at all levels.

It starts with presumptive TB enrollment and referral for testing, then it tracks progress through laboratory diagnosis by integrating with the lab system, and with notification and contract-tracing apps to alert the community.

Finally, it collects information on drug prescriptions and provides people on TB treatment with technologies that support adherence to medication and treatment outcome monitoring. 

Comprehensive care

India’s National TB Elimination Programme, or NTEP, then analyzes the data from NIKSHAY using developed interactive dashboards that are being used to plan and prioritize interventions. The live dashboards help program managers at all levels to identify specific interventions required to achieve the goal of ending TB.

To support people with TB for their nutritional needs, the government of India has implemented the nationwide direct benefit transfer, or DBT, scheme Nikshay Poshan Yojana. Under this scheme, people with TB in the Nikshay system who have been notified receive 500 Indian rupees ($6) per month throughout the course of treatment.

The digital cash transfer is primarily for nutrition support, though it also helps in timely TB notification and increasing treatment adherence. Using the same system, cash transfers are also provided as DBT to treatment providers, including private health care providers.
The e-RUPI payment mechanism is a digital initiative from the Indian government that provides a person and purpose-specific payment with limited touch points between the government and the beneficiary. NTEP is currently in the process of operationalizing the e-RUPI voucher for its own Direct Benefit Transfer (DBT) schemes.

AI solutions

The use of artificial intelligence technology for medical diagnostics has rapidly accelerated in the past decade, with AI-powered deep learning neural networks increasingly being used to analyze medical images, such as chest X-rays, for TB screening.

Several commercial AI algorithms have emerged in recent years, promising to identify tuberculosis-related abnormalities from digital chest X-ray images. In March 2021, the World Health Organization updated its TB screening guidelines to recommend computer-aided detection software instead of human readers for analysis of digital chest X-rays for tuberculosis screening and triage. India is a leader in this field, with a number of AI solutions for chest X-ray reading now used in the program.

Those innovations include an AI solution to read, interpret, and transmit results of the laboratory test for drug-resistant TB called line probe assay. This AI solution aids in the early diagnosis and appropriate treatment of patients with drug-resistant TB by reducing time and improving the accuracy of LPA test results.

Patient follow-up

Another AI solution has been devised that helps to predict patients who might experience “loss to follow-up” — meaning their course of treatment is interrupted for two or more months. The purpose of this solution is to stratify TB patients who are at risk of treatment pausing or stopping, which would help front-line staff to make proactive decisions for differentiated care for TB patients who are at the highest risk of loss to follow-up.

There are even AI solutions for screening TB from the sound of a cough, including some being developed in India. This technology provides automatic analysis of cough sounds using short-term spectral information to distinguish between the coughs of people with TB and healthy controls with satisfactory accuracy.

Trailblazing apps

Digital platforms are being used to link together state-of-the-art TB care — from identifying people with symptoms of TB to X-ray screening, molecular diagnosis, and placement of treatment.

Logistic solutions such as using drones to transport samples for testing and delivering drug boxes in remote areas are already in the field. Mobile phone apps have been developed for educating people on TB, creating platforms for precounseling, identifying service delivery points, and community-led monitoring.

Digital Adherence Technologies, or DATs, are digital tools that utilize mobile phone, computer, web-based, and/or electronic sensor technology to support the capture of daily, patient-specific adherence information.

These technologies can help support people affected by TB with their treatment in a modern and effective way. DATs offer the opportunity for health care providers to follow and support the person with TB during treatment and identify people who need additional assistance. India is a trailblazer in this technology, with a number of solutions such as medication sleeves, smart pillboxes, and video-supported treatment linked to an adherence platform.

Future digital health

There are many more tools and approaches in the development phase currently. We know that these are working, and we know that digital health is the future. The member countries of the Group of 20 leading economies together represent 50% of all people with TB and drug-resistant TB in the world.

The type of digital solutions implemented in India for the TB program are concrete, practical solutions that can be used and scaled up in every country.

The G-20 discussions and resolutions in digital health can benefit from all these examples and the TB response can serve as a pathfinder for digital technology in health more generally.

It will help our goal to end TB and strengthen our health systems with nationally led and developed solutions that can address not only TB but any other airborne infectious disease.

Visit the Talking TB series for more coverage on how we can eliminate tuberculosis by 2030. The time for a paradigm shift and a renewed focus on funding, research, and global solutions is now. Join the conversation by using the hashtag #TalkingTB.