Constant innovation: A proven way to strengthen tuberculosis care

March 18, 2022 by Elizabeth Black

PATH and its partners are powering progress in tuberculosis care by advancing groundbreaking tools and systems.

Laboratory technician prepares the reagents for SARS-CoV-2 gene sequencing. Photo: PATH.

Laboratory technicians in India prepare reagents for gene sequencing—a crucial surveillance measure for infectious diseases like tuberculosis and COVID-19. Photo: PATH.

For the first time in ten years, tuberculosis (TB) deaths are increasing due to the disruption of essential TB care during the COVID-19 pandemic.

While the severity of TB must not be understated—it is the second deadliest infectious disease after COVID-19 and the thirteenth leading cause of global deaths—there is reason for optimism: innovative tools and health systems are paving the way for more affordable, efficient, and effective screening, diagnosis, and treatment.

“Innovation is crucial for making progress,” says PATH Global TB Technical Director Shibu Vijayan, MBBS. “At PATH, we are constantly adapting and upgrading our methods to meet the current challenges of TB and that’s been integral in reducing TB infections, improving standards of care, and building better health systems.”

Innovation across the health system

One person infected with TB can infect up to 20 healthy people, making it imperative that communities have access to high-quality health care that can reduce the spread of TB-related infection and death. PATH and our partners have had success facilitating this access through two approaches

1. Engaging the private sector

In India, which has more TB cases than any other country in the world yet faces overburdened public health care facilities, 70 percent of TB patients turn to the private sector for care. But missed and delayed diagnosis, gaps in quality of care, and high financial burden made private-sector TB treatment out of reach for many, exacerbating the transmission of TB across the country.

Recognizing this issue, PATH, the World Health Organization, and the government of India established the Private Provider Interface Agency (PPIA), a groundbreaking model that drastically improved the efficiency and quality of screening, diagnosis, and treatment in Mumbai.

By engaging private health care providers and TB patients, facilitating access to digital technologies and tools to improve quality of care, and providing free resources for presumptive TB patients, the agency was able to offer PPIA services to 186,000 clients, diagnose more than 60,000 new TB patients, screen 7,000 TB patients for co-infection with HIV, and foster an 80 percent treatment success rate.

“The market-driven approach of the PPIA was revolutionary because it proved that it’s possible to engage the private sector in TB management and quickly scale up high-quality care for patients,” says Vijayan.

This award-winning model was ultimately so successful that a large-scale version, the Joint Effort to Eliminate Tuberculosis, was launched across India.

Oxford Nanopore MinION sequencer is used to provide rapid sequencing. Photo: PATH.

An Oxford Nanopore MinION sequencer is used to provide rapid sequencing. PATH supported procurement and introduction of MinION sequencers in early-adopter regions of India. Photo: PATH.

2. Strengthening genome sequencing and surveillance

Genome sequencing and surveillance are also important innovations for bolstering health system preparedness and resilience against TB.

Genome sequencing (which interprets the genetic material found in a virus) and genomic surveillance (which uses sequence data to identify new variants and track existing ones) inform real-time testing, diagnostics development, and treatment protocols, making it possible for policymakers and health care providers to adapt their TB response in real time.

Both technologies are well known for identifying and tracking new coronavirus variants, but they are less well known for the powerful role they play in tracking and managing TB and other diseases.

For that reason, PATH is supporting laboratories in India to strengthen genome sequencing and surveillance, specifically for their use in assessing antimicrobial resistance in TB, which can lead to drug-resistant (DR), multidrug-resistant (MDR), or extremely drug-resistant (XDR) TB.

Such assessments ensure that TB patients are on the most effective and efficient treatment regimen for their specific case. Not only does this improve TB patients’ chances of recovery, says PATH Project Leader Praveen Kandasamy, it strengthens public health systems’ ability to “get ahead” of TB and other diseases in real time.

“Innovative technologies like gene sequencing enable public health providers to identify patients with TB and identify resistance patterns to 13 drugs in less than 24 hours, which is crucial for starting treatment early and reducing transmission of infection to healthy individuals,” says Kandasamy.

Computer-aided detection software and artificial intelligence is used to evaluate a chest X-ray. Photo: Stop TB Partnership.

Computer-aided detection software and artificial intelligence are used to evaluate chest X-rays to identify probably cases of TB, making diagnosis faster and easier for patients and health care providers. Photo: Stop TB Partnership.

Artificial intelligence–supported case findings and diagnostics

While high-quality private-sector health care and genome sequencing are key innovations for managing the entire TB cascade of care, patients first need access to accurate and quick TB diagnoses. One way to expand access is through computer-aided detection software and artificial intelligence (AI).

“X-ray is an important tool for screening for TB and aiding diagnosis,” says Kandasamy. “But especially in low-resource settings, X-rays are expensive, time consuming to interpret, and are subject to inconsistency and variability between radiologists—if health facilities have radiologists on staff. This can lead to underdiagnosis or overdiagnosis of TB.”

To address these challenges, PATH joined forces with partners in India, Myanmar, and Vietnam to facilitate the use of innovative computer-aided detection software and AI, which can accurately and rapidly identify probable TB and confirm what type of TB a patient has (sensitive TB or DR-TB), while reducing the patient’s cost and time burden.

Specifically, PATH worked to test, validate, and scale up’s computer-aided detection tool, qXR, whose AI algorithm helps identify lung abnormalities to aid in diagnosis of diseases like TB and COVID-19. By partnering with governments, donors, and organizations to facilitate the use of diagnostic tools such as qXR, increase market competition, and generate global TB guidance for the use of AI-supported chest X-rays, PATH has helped improve access to better, faster TB diagnosis.

Beyond TB, this work is paving the way for the use of AI technologies in lung cancer and other lung disease screening.

A pharmacist at the Chuong My district health center in Vietnam reviews supply of medicine for TB treatment. Photo: PATH/Matthew Dakin.

A pharmacist at the Chuong My district health center in Vietnam reviews supply of medicine for TB treatment. PATH has supported research on a variety of TB treatment regimens—some of which have shown improved cure rates. Photo: PATH/Matthew Dakin.

Toward timely, high-quality treatment

The current treatment regimen for TB can be time intensive, expensive, and cause severe side effects. For MDR-TB, treatment can take anywhere from 18 to 24 months, posing obstacles to patients and health care providers who may not have the necessary resources to sustain this level of long-term care.

To meet the demand for timely, high-quality TB treatment, PATH, alongside our nongovernmental organization partners, has supported inaugural operations research for two new, shorter TB treatment regimens: (1) a six-month BPaL-based regimen for pre-XDR-TB and difficult-to-treat MDR-TB and (2) a 39-week modified regimen for DR-TB.

These new regimens are revolutionary because they drastically improved cure rates and reduce treatment times and side effects; cure rates jumped to 80 percent compared to 50 percent with previous regimens.

PATH is also working with national TB programs in Ukraine and Peru to develop roadmaps for the introduction and scale-up of the BPaL-based regimen, as well as supporting Ukraine to create costing estimates for TB treatment under the new BPaL-based regimen.

By facilitating costing, roadmaps, partnerships, and the early adoption of innovative BPaL regimens, we aim to reduce treatment time and lessen the burden on patients and health systems.

Embracing change to improve care

For PATH and our partners, adapting and strengthening innovative new tools and systems that fit within local systems and contexts has been central to our ability to reduce the prevalence and incidence of TB.

As we continue to prioritize constant innovation in our work, we’ll be better equipped to strengthen high-quality primary health care and reimagine integrated person-centered care.