Pune: Every month, for the past two years, Dr Rajlakshmi Chepuru and her team go to remote Hukumpeta and Paderu in ASR district of Andhra Pradesh, lugging a 10kg backpack.
Back
They are on a crucial mission screening the most vulnerable and primitive tribal groups in the country for TB with a 1.8kg handheld X-ray device that scans around 100 suspected tuberculosis patients and detects lesions.
The next day, they deliver these X-rays to the nearest radiologist or doctor for examination. When the lesions are confirmed, the state machinery follows it up with the mandatory sputum test, Dr Rajyalakshmi, associate professor in community medicine, at Gitam Institute of Medical Sciences and Research, said.
The team is part of Indian Council for Medical Research's ( ICMR) tribal TB management programme, a multi-centric study that will be carried out in the country, including Visakhapatnam and Chittoor in Andhra Pradesh, and in Madhya Pradesh, Kerala, Karnataka, Odisha, and Meghalaya.
Dr Rajlakshmi said, “Earlier, tribal people would have to go to the nearest medical college or district hospital to undergo the scan and sputum collection, before treatment could be started. Now, we are going to the community and taking on-the-spot scans. This is a remote area and for them to go to the hospital would mean losing a day’s wages. So, their first preference is the traditional healers.”
The new handheld devices to detect TB appear to be changing the game. “We can take about 100-150 scans in a single day, connect it to our laptop camera and digitize the X-ray. If we have a network connection, we send them to the radiologist or doctor who gives the image diagnosis. When the lesions are confirmed, we reach out to the state TB team. A sputum test is conducted and then the treatment begins,” Dr Rajlakshmi said.
Across the country, innovations by health startups, especially those powered by AI, are catching up to crush TB. As per US Centers for Disease Control and Prevention, TB can be traced back to 9,000 years, but despite eradication of polio and smallpox, it remains a challenge.
In the past eight years, India’s TB notifications have gone up. As per the central TB division’s Nikshay portal, in 2017, there were 17.45 lakh notifications which went up in 2023 to 25.48 lakh. There has been a year-on-year increase across the country in the past decade.
Given the high burden in the country, health startups have jumped into the race to collaborate with state govts and ICMR to eradicate TB.
In Mon district of Nagaland, Dr James Tinenlo Katiwa, the district TB officer uses the qure.ai’s qXR, an AI-enabled scanning tool that needs no radiologist.
The district is sandwiched between Assam and Myanmar and the Konyak Nagas of Mon and the Nagas of Myanmar are homogenous communities. The porous border means patients trickle in from Myanmar as well.
Dr Tinenlo said with the qXR app he uses his cellphone camera to convert the X-ray into a digital one which the app analyses and concludes if the X-ray is suggestive of TB or not.
"We then begin treatment. Since the past two years, the app has helped us find our missing TB cases and patients have responded well to treatment. We can assume that the app is working well for us,” he added.
Only those with symptoms or with the sputum test through NAAT testing and those tested for TB are referred for the X-ray analysis. These could be the close contacts of the TB positive patients and as part of clinical diagnosis, treatment starts.
“When the network connection is good, the analysis is completed in less than a minute, when it is slow it takes up to three minutes,” Dr Tinenlo said.
In Tamil Nadu, Deeptek’s ‘Genki’ is helping find missing TB cases. State TB officials said that the AI supported mobile diagnostic unit is retrofitted with a digital X-ray machine.
It operates in six districts of Tamil Nadu, including Tirunelveli. “Since October 2022, of the 98,000 X-rays taken, some 14,500 were suggestive of TB by the AI technology. Till February 2024, 606 TB cases were diagnosed in the community across the six districts,” project in-charge Dr K Ravishankar, consultant for the state TB centre, said.
He added that they were diagnosing missing TB cases, sometimes even before the symptoms could occur. “However, Genki is only a screening tool. While selecting these six districts we looked at a combination of high and low prevalence and a mix of geographical locations. Over a period, we have noted that false negatives are nominal as the sensitivity of the scan is high,” he added.
Dr Brajaraj Sunder Ghosh, scientific consultant with ICMR, said that various research projects have been taken up in TB diagnostics, therapeutics, vaccines, and implementation research.
The Tribal TB project was started in 2022 for a specific population in nine states. As per a recent survey, of the total tribal population in India, 10.6% suffer from TB, five times more than the general prevalence in the country.
For the tribal population, it is not just a clinical condition but has social stigmas too. Their poor housing conditions, poor nutrition and substance addiction makes it a bigger challenge.
Dr Ghosh said they are working on reducing the drug regime from two years to two-four months depending on the drug sensitivity or resistance to cut the burden of TB on the public healthcare system.
Panchayat leaders, community leaders and traditional healers are all part of the plan. “Our intention is to create this as a model and use it in other states with such challenging communities,” he added.
Experts agree that TB eradication needs innovation in diagnosis, finding missing and suspected TB cases to faster results. The next step is detecting drug-resistant TB cases to which Goa has found a solution.
Doctors here have been using Molbio Diagnostics's portable Truenat MTB and Truenat MTB-RIF Dx kits to determine if the patient is suffering from drug-sensitive TB or drug-resistant TB.
Goa State TB Officer Dr Manish Gaunekar said they were the first to start using Molbio Diagnostics's Truenat and CBNAAT in Dec 2022 for diagnostics.
“It is a better and more sensitive test as it also indicates rifampicin resistance, which is the first line of treatment for TB as per guidelines. We have set up testing in all our 40 TB sites, CBNAAT is available at Govt Medical College, TB Hospital and South Goa district hospital. All remaining sites have Truenat,” he said.
As they directly go for NAAT, false negatives have gone down, which helps them decide the first line of treatment for the first contacts of the TB patients which prevents its spread, he added.
