Background Tuberculosis (TB) remains a leading cause of death globally, with India accounting for 25% of the total disease burden. A significant barrier to elimination is delayed or inequitable access to diagnostic services, often accelerated by a lack of granular administrative health boundaries for effective planning. Additionally, identifying the exact locations of TB diagnostic facilities is relevant for understanding the geographic coverage of diagnostic services. Methods – Diverse types of data were obtained from multiple health and non-health sources. The study mapped 77 Tuberculosis Units (TUs) in Kerala by standardising heterogeneous LSGI and district-level administrative data into a unified GIS database. 642 government and private TB diagnostic facilities were available in Kerala during the study period. Researchers utilised ArcGIS to integrate these spatial boundaries and performed topology checks to ensure accuracy before plotting 642 geocoded diagnostic facilities. QGIS-generated Euclidean buffers were applied to these locations to visualise and analyse geographic inequities in service accessibility relative to population density Results The study successfully created the first digital sub-district health boundaries (TU level) in India for TB. The number of TUs ranged from 3 to 8 across various districts of Kerala. Mapping revealed a non-uniform distribution of TB diagnostic facilities, with high concentrations in densely populated coastal and central regions (up to 6,540 persons per $kmˆ2). Conversely, facilities were sparse in the eastern hilly and northern districts. Mapping revealed that a 2-km buffer leaves many populated areas underserved, but a 4-km buffer covers nearly all residents, indicating that moderate travel distances significantly improve geographic accessibility. Conclusion GIS as a critical tool for public health, providing the first sub-district level digital health boundaries in India to address geographic inequities in TB diagnostic access. Integrating GIS into the National Tuberculosis Elimination Program (NTEP) provides actionable evidence to address intra-district disparities and improve resource allocation. The created digital TU boundaries are available as an open-source resource to support future health research and policy planning.
Background Tuberculosis is a social malady and should not be confined to biomedical boundaries. A complex set of sociocultural factors local to particular communities shapes the disease. Given this background, this study aims to understand perceptions, fear and distress, and moral conduct, and how these shape the social construction of Tuberculosis. Methods This study employed a qualitative descriptive design, and in-depth interviews were conducted with purposively selected TB patients (n = 24), their caregivers (n = 5), DOTS providers (n = 11), and Senior Treatment Supervisors (STS) (n = 2) in two contrasting districts of Odisha: Ganjam and Mayurbhanj. The analysis followed Braun and Clarke's six-phase thematic analysis. Results Our study found that the social construction of TB was shaped by three broad themes in these two contrasting districts of Odisha, namely “moral conduct in life”, which is influenced by 'moral innocence' and 'Tuberculosis as a result of moral misconduct'; “perception of the disease”, which is influenced by 'mis-recognition of TB based on symptoms', and 'alternative biomedical and lay causal explanations'; and “fear and distress”, which is influenced by 'fear of death', 'succumbing to fate', 'fear and family', and 'hopelessness'. Although geographically and socio-culturally, the two districts present a contrasting picture, Ganjam being an urban and non-tribal district and Mayurbhanj being a rural and tribal district, the social construction of TB did not differ, and both painted a similar picture. Conclusions As TB is a social illness, understanding its social construction can help improve patients’ health-seeking behaviour and alleviate associated stigma, thereby indirectly improving treatment outcomes.
Background To improve TB surveillance systems in South-East Asia Region countries’ TB control programs, it is vital to understand the existing scenario, assess the gaps and needs through a systematic situation analysis. Here we report an analysis of the existing TB surveillance systems, the challenges faced and the way forward in these countries. Methods A narrative questionnaire collected information regarding the different information systems currently in operation. A focused group discussion to understand each country's system and short communications to clarify aspects or seek missing information was conducted subsequently. Results We studied 21 separate information systems used in National TB programs of seven countries of the South-East Asia Region (Bangladesh, Bhutan, India, Indonesia, Maldives, Nepal, and Sri Lanka). Each country had more than one information system in place. Indonesia and India have more advanced systems, have implemented a life cycle approach and were able to link all major service-related information to one citizen together. It is also inclusive of all forms of TB and across all sectors. Common implementation challenges observed included, increased workload, operational delays, reduced data quality, the need for continuous training and bold decision and policy reform. Conclusion The information systems in SEAR countries are evolving from traditional data entry and reporting systems, towards information systems that enable service delivery, with data capture as a by-product. There is a wealth of experience and a significant scope of collaboration among SEAR countries to define new standards and generate common information.
Background In India, nearly half of patients with tuberculosis (TB) seek care from the private healthcare sector, where concerns regarding quality of TB care, microbiological confirmation, and adherence to Standards for TB Care in India (STCI) continue to exist. The System for TB Elimination in Private Sector (STEPS) model was developed to strengthen quality-assured TB care through a patient-centric single-window approach within private hospitals. This study describes the implementation of a STEPS Centre and its impact on indicators of quality TB care in a private tertiary care hospital in northern India. Methods A retrospective comparative operational research study was conducted at a private tertiary care hospital in Uttar Pradesh, India. Programmatic indicators from the pre-implementation period (2023) were compared with post-implementation data from 2024 and 2025 following establishment of the STEPS Centre in March 2024. Data were obtained from Nikshay records, laboratory registers, radiology records, and STEPS Centre program records. Indicators assessed included microbiological confirmation, baseline rifampicin resistance testing using Nucleic Acid Amplification Test (NAAT), NAAT offering among clinically diagnosed TB cases, HIV and diabetes mellitus status documentation, and treatment outcomes. Results Following implementation of the STEPS Centre, utilization of TB diagnostic services increased substantially. The number of NAATs performed increased from 1,485 in 2023 to 2,418 in 2025, while chest X-rays increased from 31,405 to 39,353 during the same period. The proportion of microbiologically confirmed TB cases increased from 22% (87/395) in 2023 to 30% (118/392) in 2025. Baseline rifampicin resistance testing using NAAT improved from 11% (43/395) to 65% (256/392) over the period of two years. Among clinically diagnosed TB patients, the proportion offered NAAT increased from 20% to 59%. Documentation of diabetes mellitus status improved from 0% to 91%. TB deaths among notified patients decreased from 3.3% (13/395) in 2023 to 2.3% (9/392) in 2025. Conclusion Implementation of the STEPS Centre was associated with improvement in microbiological confirmation, baseline drug resistance testing, co-morbidity assessment, and adherence to STCI recommendations in a private tertiary care hospital. The findings support the potential role of STEPS as a practical and scalable model for strengthen the quality TB care in the private healthcare sector.
Background Effective implementation of tuberculosis (TB) control programmes requires programme managers to possess leadership and management competencies in addition to technical expertise. To strengthen these competencies among District TB Officers (DTOs) in India, a six-month Program Manager's Executive Course (PMEC) incorporating leadership training and workplace-based Plan-Do-Study-Act (PDSA) projects was implemented. This study evaluated participants' experiences and the characteristics of the PDSA projects undertaken during the course. Methods A mixed-methods implementation assessment was conducted across seven PMEC batches. Qualitative interviews were completed with 143 DTOs selected through convenience sampling to explore participants' perceptions of the training, application of PDSA, and recommendations for programme improvement. In addition, 377 eligible PDSA worksheets were reviewed to describe the programme areas addressed, implementation level, and duration of the quality improvement initiatives. Results Participants reported perceived improvements in communication, team leadership, delegation, and data-informed decision-making following the course. The structured PDSA approach was perceived as useful for systematic problem-solving and team coordination, while mentorship provided by Quality Improvement Consultants (QIC)s was identified as a key facilitator of implementation. Of the 377 PDSA projects analysed, 203 (53.8%) focused on strengthening TB notification, and most were implemented over two to three months at treatment unit or block level. Continued use of formal PDSA cycles after course completion was limited by competing programme responsibilities, time constraints, and the lack of ongoing mentorship. Conclusion A structured leadership and management programme combined with workplace-based quality improvement projects is a feasible approach to strengthening managerial competencies among TB programme managers. Integrating leadership development and quality improvement methods into routine programme capacity-building may support sustained improvements in programme implementation.
Background State Tuberculosis (TB) Training and Demonstration Centres (STDCs) were established to serve as the technical backbone of India’s TB programme in each state. However, many STDCs were underutilized, with gaps in staffing, financing, access to programme data, and functions beyond classroom-based training. The 2017–2025 National TB Elimination Plan (NTEP) mandated STDC revitalization but provided limited guidance on implementation pathways. Evidence on how such subnational technical institutions can be operationally strengthened and integrated into decentralized programme management remains limited. Methods We conducted a retrospective descriptive case study of STDC revitalization between April 2021 and March 2025. Programme documents, policy records, training and monitoring records, and project reports were reviewed to document changes in STDC functioning. Interventions and changes were organized using the six WHO health system building blocks, while implementation strategies and responses to operational barriers were documented using an iterative problem-solving approach. Results Changes were documented across all six WHO health system building blocks. Key changes included revised STDC guidelines endorsed in 2023; access to NIKSHAY data for all 26 STDCs; strengthened digital learning and monitoring systems, including training records and certification; strengthened infrastructure for digital training; integration of STDC activities with other health programmes; development of cadre-specific training and skills; and submission of state budget requests for STDC activities. Five STDCs were designated as Centres of Learning. Best practices were documented and available for cross-learning of other STDCs. STDC roles were expanded to include monitoring of cascade training, support to State TB Cells in programme monitoring, routine data review with District TB Officers, and supportive supervision. Conclusion The experience demonstrates that policy revision, data access, workforce development and financing mechanisms can be combined with iterative implementation support to strengthen subnational technical institutions. Longer-term evaluation is needed to determine whether these system-level changes translate into improved programme performance and epidemiological outcomes.
Background Community-wide active screening is increasingly recognized as an important strategy for accelerating tuberculosis (TB) case detection in high-burden settings. In 2025, a community-wide TB screening intervention using ultra-portable chest X-ray devices and artificial intelligence (AI)-assisted interpretation was implemented in urban slums of Delhi, India. Methods A concurrent mixed-methods evaluation was conducted in April 2026 across the urban slum clusters, using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Quantitative data were obtained from a real-time programme management information system, an independent cluster household survey, and programme records. Qualitative data were collected through document review, field observations, and key informant interviews. Descriptive statistics and thematic analysis were used. Results Between July 2025 and March 2026, 3,566 screening camps were conducted and 168,568 individuals aged ≥15 years underwent chest X-ray screening. Among the 18,377 individuals with presumed TB, 16,866 (91.7%) completed molecular testing. A total of 877 bacteriologically confirmed TB cases were identified, yielding 520 cases per 100,000 individuals screened and a number needed to screen of 192. Household survey findings estimated screening coverage at 30.5% (95% CI: 24.3–36.8%). Key barriers to participation included low perceived need for screening among asymptomatic individuals and competing work responsibilities, while engagement of ASHAs and doorstep service delivery facilitated uptake. Equipment downtime was low, accounting for 3.5% of planned operational days. Conclusions Community-wide AI-assisted chest X-ray screening was feasible to implement at scale and achieved high completion across the diagnostic cascade. Strengthening community participation may enhance the public health impact of similar strategies in high-burden urban settings.
Background To guarantee the access, coverage and quality of the TB Services, India's National TB Elimination Programme (NTEP) depends on a large, diverse health workforce operating at national, state, and district levels. This workforce requires continuous training to align with the rapidly evolving programmatic needs. In the past, training delivery was fragmented across multiple institutions utilizing varied curricula and platforms, constrained by limited infrastructure, non-standard training time, and weak monitoring of training quality and outcomes. Aligning with the National Strategic Plan for TB Elimination (NSP 2017-25) and informed by a structured Training Needs Assessment (TNA), the Modernized Training System (MTS) comprising three subsystems addressing Training content development, Training Delivery and related operations, and Monitoring and Evaluation of trainings was developed. This paper describes the design, implementation, and early outcomes of the Training Operations subsystem of the MTS. Methods A clear hierarchy of training institutions, namely- National Institutes, State TB Training and Demonstration Centres, and District TB Centres formed the basis to design the Training Operations subsystem. Each of these institutions are responsible for training designated cadres, and are supported by the Master Trainers, Trainers, and Training Coordinators. An annual planning tool guided the scheduling of different types of training, viz. Induction, Update, and Refresher training based on individual training needs. A blended learning model combining self-paced content, virtual webinars, in-person sessions, demonstrations of processes and procedures, field visits, and role-plays; a standalone chatbot-based tool- Nikshay Setu, for continuous on-job learning forms the backbone of the subsystem. A dual-level Internal and External Quality Assurance framework for monitoring training delivery and outcomes ensures standard training quality. The system integrated a Learning Management System, Swasth-eGurukul, for training content delivery, assessments, and certification. Results Three national institutes and five state-level training institutions deployed the training Operations subsystem initially. The operations were scaled up one cadre at a time based on content availability from the Content Development System. Between 2023 and 2025, the system delivered 381 training batches across 11 cadres, training 30,830 personnel. Training volume varied by cadre, ranging from single batches for specialised cadres such as PPM Coordinators to 141 batches for ASHA/Community Health volunteers, being the largest cadre with 20,785 personnel trained. The system has been fully transitioned to NTEP for long-term operational use and sustainability Conclusion The architecture of the Training Operations subsystem exemplifies a structured, technology enabled approach to standardizing training delivery, integrating blended learning, digital tools, and with established quality assurance within a large national public health programme. The training of 30,830 staff across 11 cadres within three years shows that country-wide implementation is feasible. The system offers a replicable model for modernising training delivery in other large-scale, multi-cadre health programmes.
Background Ending tuberculosis (TB) requires sustained multisectoral action, as emphasized in the WHO Multisectoral Accountability Framework and India's National Strategic Plan for TB Elimination. India's corporate sector, with its extensive workforce, resources, and community reach, has significant potential to contribute to TB elimination. However, the absence of a structured and scalable engagement mechanism has limited consistent corporate participation. Intervention The Corporate TB Pledge (CTP) was developed as a structured engagement framework to mobilize and channel corporate sector contributions toward India's End TB efforts. Coordinated through a dedicated secretariat, the initiative engaged corporates through government-led advocacy, direct outreach, business associations, and peer-led corporate engagement. Participating corporates committed to tiered levels of engagement: Silver, Gold, Platinum, and Diamond; ranging from workplace policy endorsement to implementation of TB-specific projects and mobilization of other corporates. The secretariat provided technical assistance to design, implement, monitor, and document workplace and community-level TB interventions aligned with the National TB Elimination Program (NTEP). Results Between 2020 and 2024, 461 corporates across diverse sectors took the pledge, initiating 202 TB-related interventions, including 65 TB-Free Workplace initiatives and 137 community-based projects. Collectively, these interventions screened over 5 million individuals for TB, tested 238,010 individuals, diagnosed 8910 people with TB, and linked them to care. Additionally, 52,570 individuals with TB received nutritional support through corporate contributions. The total estimated value of corporate investments, including financial and in-kind contributions, was USD 7.5 million. Conclusion The Corporate TB Pledge demonstrates that a structured, pledge-based engagement mechanism can effectively mobilize corporate accountability, resources, and innovation to complement public sector TB elimination efforts. This model shows promise for scalability, sustainability, and replication to support multisectoral action for TB and other public health priorities.
Background Tuberculosis (TB), although less commonly reported in the developed world, still contributes to a major disease burden in developing countries. Due to the high population burden of these developing nations, TB is still considered a major disease burden worldwide, such as in India. Due to persistent chronic inflammation, pulmonary tuberculosis (PTB) is considered a risk factor for thrombosis, and pulmonary thromboembolism (PTE) may be an underdiagnosed complication in severe disease. Methods This is a prospective, observational imaging study conducted at the largest government referral hospital in North India. Study duration was from July 2024 to December 2025. The primary objective was to determine the prevalence of pulmonary thromboembolism (PTE) among patients with pulmonary tuberculosis (PTB) presenting with severe respiratory symptoms. Results Of the 87 patients screened, 71 (81.6%) were diagnosed with PTB, while 16 (18.4%) had different diagnoses. Among patients with tuberculosis, PTE was identified in 16 (22.5%), whereas 55 (77.5%) had no evidence of PTE on imaging.The duration of tuberculosis-related symptoms was longer in the PTE group than in the non-PTE group (median 45 vs 30 days), with borderline statistical significance (p = 0.05). Patients with PTE had significantly lower room-air oxygen saturation than those without PTE (median SpO2 83% vs 86%; p = 0.044). No independent predictors of PTE were identified on multivariate analysis. Conclusion This prospective CT-based study demonstrates a high prevalence of pulmonary thromboembolism among patients with severe pulmonary tuberculosis. These findings highlight the need for heightened clinical suspicion for PTE in PTB patients with severe hypoxemia or disproportionate respiratory compromise.
Background Drug-resistant tuberculosis (DR-TB) remains a major challenge to global tuberculosis elimination efforts. Despite substantial expansion of diagnostic and treatment services under India's National TB Elimination Program (NTEP), variability in advanced clinical expertise and management of difficult-to-treat DR-TB cases continued to affect quality of care. To address these gaps, selected high-performing Nodal DR-TB Centers were strengthened and operationalized as DR-TB Centers of Excellence (CoEs). Objectives To describe the framework, implementation process, and early programmatic experiences from establishment of DR-TB Centers of Excellence under NTEP, India. Methods A descriptive programmatic study using mixed-methods program assessment data was conducted under NTEP between 2022 and 2024. A structured institutional strengthening framework and hub-and-spoke model linking CoEs with nodal and district DR-TB centers were operationalized through a five-phase implementation process involving institutional assessment, gap filling, designation, mentoring, and implementation of advanced DR-TB services. Program implementation experiences were documented through contextual enquiries, review of institutional records and meeting minutes, and analysis of quarterly performance reports. Results Eight institutions were assessed for potential designation as CoEs, of which five were formally designated in October 2022. The CoEs were linked with 9–17 spoke institutions each and provided advanced clinical consultations, tele-mentoring, technical guidance, and capacity-building support for management of difficult-to-treat DR-TB cases. Key programmatic innovations included establishment of pulmonary rehabilitation services, palliative care models, and thoracic surgery training programs. The CoEs also supported implementation of newer DR-TB regimens, including BPaLM-based treatment approaches. Important operational learnings included the need for strong administrative commitment, dedicated human resources, robust governance systems, and improved access to program-level performance data for supportive supervision. Conclusion The DR-TB CoE initiative under NTEP operationalized a structured institutional strengthening model integrating advanced clinical expertise, mentorship, innovation, and decentralized dissemination of best practices. The framework provides a scalable approach for strengthening DR-TB care and institutional capacity in high-burden settings.
Background India accounts for over a quarter of the global tuberculosis (TB) burden, with a significant proportion of TB care being provided in non-programmatic settings, where irrational prescriptions continue to be a challenge despite ongoing programmatic efforts. This study aimed to quantify and contextualise incorrect anti-tuberculosis (anti-TB) prescribing in India's non-programmatic healthcare settings by evaluating the prevalence, estimating the national burden of faulty prescriptions based on private-sector treatment volumes, and examining regional and temporal patterns, as well as differences across provider types. Methods A systematic review and meta-analysis was conducted in accordance with the PRISMA 2020 guidelines (PROSPERO: CRD42024609657). Thirty-four studies published between 1991 and 2024, encompassing 3834 real-world anti-TB treatment records that evaluated prescription accuracy, were included. A random-effects model was used to pool the estimates, and meta-regression and time-trend analyses were performed. Projections for 2025–2030 employed an advanced machine learning approach, extreme gradient boosting (XGBoost), with conformal prediction to quantify uncertainty. Results The pooled prevalence of incorrect prescriptions was 53.3% (95% CI: 42.2–64.1), indicating that one in two prescriptions was faulty. Error rates were higher in studies involving both allopathic and indigenous practitioners (59.0%) than in allopathic-only studies (51.1%), although the difference was not statistically significant (p = 0.74). Crude prevalence of faulty anti-TB prescriptions declined from 68.6% during 1990–1999 to 32.6% during 2020–2024. Weighted linear regression demonstrated a significant annual reduction of 1.38 percentage points (β = −1.3842; 95% CI: −2.4564 to −0.3120; P = 0.013), corresponding to an estimated decline of 45.7 percentage points in faulty prescribing, from 79.4% in 1991 to 33.8% in 2024. For the projection period spanning 2025–2030, the estimated prescription error rate was 49.7% ± 9.0% (mean ± standard deviation), with a median of 50.7% and a range of 37.1% to 62.1%. Thus, over the past three and a half decades in non-programmatic settings, almost every second anti-TB prescription has been faulty, and this trend is likely to persist in the future.In practical terms, this translates into a substantial burdenin India's non-programmatic healthcare sector, an estimated 2–3 million TB prescriptions are likely to be incorrect each year, corresponding to roughly 4–5 faulty prescriptions every minute. Regional analysis of 3817 prescriptions revealed substantial inter-state variation. Madhya Pradesh, Haryana, Gujarat, Karnataka, Uttar Pradesh, Delhi, Maharashtra, and Uttarakhand reported faulty prescription rates exceeding the overall crude prevalence of 50.8% observed across the included studies. Notably, five of the ten states with the highest TB case notifications—Uttar Pradesh, Maharashtra, Madhya Pradesh, Gujarat, and Delhi—not only exceeded this overall prevalence but also contributed disproportionately to private-sector TB drug sales, highlighting their critical influence on the national TB care landscape and the urgent need for targeted interventions. Conclusion Faulty anti-TB prescriptions in India's private sector remain widespread, undermining TB elimination efforts. Strengthening programmatic care, regulating private-sector practices, and expanding Public-Private Mix (PPM) models are crucial for enhancing treatment quality, ensuring adherence to standardised protocols, and accelerating progress toward national TB elimination goals.
To tackle the tuberculosis (TB) burden, it is crucial to develop effective therapeutics, such as vaccines. Currently available serological assays utilize various antigens from Mycobacterium tuberculosis (M. tb), which are either poorly expressed or presented to B/T-cells in situ for generating effective immune responses. To this end, we identified several peptides from clinical isolates of M. tb that can activate both humoral and cellular immune responses. Using the bioinformatic tool, BCPRED we identified various B-cell epitopes present in the clinical isolates of M. tb and evaluated the antibody response against these epitopes among Pulmonary Tuberculosis (PTB) patients and healthy individuals.Competitive ELISA revealed significantly higher antibody response in PTB patients compared to healthy individuals (p < 0.0001) against these peptides. Demonstrating antigen re-call response in the serum of patients. Suggesting that these peptides can augment antibody responses. Also advocated their potential in designing peptide-based vaccines against TB.
