Can we ever end tuberculosis (TB) - the deadliest
infectious disease on Earth - without ensuring that every single person who
takes an initial TB test receives a truly effective one? A test that accurately
and rapidly detects active TB disease. A test that misses no one. Because
finding TB early and accurately is not optional - it is the indispensable
lynchpin, the non-negotiable gateway to the entire treatment and care pathway.
"If we miss people with active TB disease due to
a poor test, then we fail to reduce avoidable human suffering and risk of TB
death. More worrying is that the infection keeps spreading," said
Prevent-Find-Treat ALL TB campaign leader Shobha Shukla. "There is no
excuse for inaction since WHO-recommended portable molecular tests have been
available since 2010. We must eliminate deadly delays between scientific
breakthroughs and the time by which they translate into public health
impact."
As per the latest WHO Global TB Report 2025, almost
half (46%) of the TB patients in 2024 worldwide received a poor test –
microscopy. Microscopy misses finding TB accurately in half (or more) of those
who take this test. It has been used for the last 144 years since Dr Koch made
this TB scientific breakthrough. But in the last two decades, science has
gifted us some highly sensitive and specific portable molecular tests to find
TB early and accurately - and quite a few of these are WHO-recommended.
That is why the highest-level leadership of the UN
health agency - World Health Organization (WHO)- had called upon the
governments (Find.Treat.All) in 2018 to completely replace microscopy with
upfront WHO-recommended molecular tests by 2027.
Before this, the Government of India’s National TB
Elimination Programme had released its National TB Elimination Strategy
2017-2025 under the visionary leadership of the then-head (Deputy Director
General) Dr Kuldeep Singh Sachdeva. This strategy had also set forth an
ambitious time plan to radically scale up upfront molecular TB testing in India
during 2017-2025. Indian government programme has surpassed several of the
indicators enlisted in that strategy.
In 2023, world leaders of 193 countries
unanimously adopted the Political Declaration to end TB at the United Nations
General Assembly High-Level Meeting. This Political Declaration also re-echoed
the promise to replace microscopy completely with the WHO-recommended molecular
test as an upfront or initial TB test by 2027.
Few days ago, a sign-on of 'Bangkok Declaration' is
circling around on social media that is asking people to sign in their
‘personal capacities’ to replace microscopy with upfront molecular testing for
TB by 2028. This supposedly came out from a meeting funded by the Gates
Foundation and organized by the Stop TB Partnership on near-point-of-care TB
tests in Thailand. But the 'Bangkok Declaration' does not mention who organized
it.
This 29-word Bangkok Declaration reads as follows: “We
commit, in our personal capacities, to a phased replacement of smear microscopy
with WHO-recommended molecular testing for the initial diagnosis of
tuberculosis, to be completed by 2028.”
It is absolutely undeniable what this Bangkok
Declaration states - "to phase out the replacement of smear microscopy
with WHO-recommended molecular testing for initial TB diagnosis." But we
do not agree with the timeline of 2028 - because we can do better now!
Why shift the 2027 goalpost?
With around 1 year 5 months left to deliver on 2027 TB
targets enshrined in the Political Declaration endorsed by all world leaders
unanimously in 2023 at UNHLM, why should we shift the goalpost on TB testing by
a year? Ensuring that the first initial or upfront TB test is a molecular test
is a non-negotiable when it comes to TB disease elimination strategy by 2030.
This is very doable too, as most countries have
significantly rolled out upfront molecular testing worldwide. For every US$
invested in TB prevention and control, there are health and economic returns of
US$ 43. So, TB investment is a smart investment too.
Deadly gap
As per the latest WHO Global TB Report 2025, globally,
54% of all TB patients notified in 2024 were diagnosed with an upfront
molecular test. In the African region, 53% of all TB patients notified in 2024
were diagnosed with an upfront molecular test. This number dips to 41% for the Southeast
Asian region, though.
38% of all notified TB patients in India, 56% in South
Africa, 65% in Indonesia, 69% in Nigeria, and 74% in the Philippines got an
upfront molecular test in 2024.
It is evident that for some years now, different
countries have been at different stages of replacing microscopy with upfront
molecular tests for TB diagnosis.
100% upfront molecular TB testing for high
TB risk homeless and migrant populations is possible, then why not for everyone
else?
In India - a country with the highest TB burden - and
in Delhi state - a state with the country's highest TB incidence, the
government TB elimination programme in partnership with Humana People to People
India was able to achieve 100% upfront molecular test diagnosis among
populations at very high TB risk: homeless and migrants.
When we can achieve 100% upfront molecular testing in high-risk
populations in Delhi, why cannot we ensure this for everyone else? The best time
to do the right thing was years back - the second best time is now.
There are more examples:
Goa state in India had completely replaced smear microscopy with upfront
molecular test TB diagnosis 5 years ago. Lakshadweep, a Union Territory in
India, had also achieved 100% upfront molecular test diagnosis and was recently
declared TB-free. Dr Rakesh PS, a noted TB elimination consultant, presented at
the AIDS 2026 Affiliated Independent Event on the theme: Rethink, Rebuild and
Rise to Put People First and deliver on ending AIDS and TB in the next 54
months (by 2030). Dr Rakesh PS shared that there were months every year when 10
of the inhabited Lakshadweep islands were very difficult to reach due to rough seas
or bad weather. TB diagnostics were decentralized with the WHO-recommended
molecular test on each of the 10 islands. Better technology alone is not enough,
but designing public health systems that respond to the local realities of the
people they serve is critical. Taking services closer to the communities was a
game changer, along with empowering local health workers to lead the response.
In the past five years, Stop TB Partnership's
introducing new tools project had also rolled out artificial intelligence-enabled
handheld ultraportable X-Rays along with portable battery-operated molecular
test Truenat and demonstrated strong impact in terms of finding TB early and
accurately - and helping save lives.
The uncomfortable question is why were
these high-impact interventions not taken to scale with urgency and immediacy?
So asked Sumit Mitra, a noted thought leader on
bridging the deadly diagnostic divide in the Global South, who was also among
the key speakers at AIDS 2026 Affiliated Independent Event hosted by over 30 organizations
collectively with Prevent-Find-Treat ALLTB campaign, CNS and UNAIDS.
All is not so bleak as there is hope too - again from
a country with the highest TB burden - India. Indian government's National TB
Elimination Programme, which was then headed (DDG) by Dr Urvashi B Singh, made
a foundational shift in how it finds TB on 7 December 2024. AI-enabled X-Rays
and portable molecular tests were supposed to be taken in a van (Ni-Kshay
Vahan) to high-risk communities and offer them TB screening and tests closer to
their homes. In the first 100 days, the government's programme found over
285,000 asymptomatic people with active TB disease - none of them would have
been found so early if such an approach was not driving the TB case finding. Dr
Urvashi B Singh was speaking at the AIDS 2026 Affiliated Independent Event.
India's health minister said on World TB Day 2026 that
in one year, the Indian government could find over 1 million (10 lakhs)
asymptomatic people with active TB disease - none of them would have been found
so early if such a science-based approach was not driving the efforts. Early
and accurate TB case finding is critical to prevent the spread of infection as
well as link people to lifesaving TB treatment, care and support.
Unless we use the right TB test and stop
missing TB cases among those who take a TB test, how will we ever eliminate TB?
Most strategic advocacy demands should not be to shift
the 2027 goalpost but instead call for rapid scale-up of upfront molecular
testing as soon as possible - and latest by end of 2027 as promised by world
leaders at the 2023 General Assembly.
The latest update to WHO TB Diagnostic Guidelines
around World TB Day 2026 was an important turning point as, among other
important recommendations, it also recommended a near-point-of-care portable
molecular test (30-minute TB test).
The list of WHO-recommended molecular tests is
expanding, but the pace at which these tests are being rolled out on the ground
is not matching the public health emergency and crisis which TB has posed
against us historically.
Bridge the gap: No one should remain
unreached
As per the latest WHO Global TB Report 2025, there
were an estimated 10.7 million people worldwide with active TB disease in 2024,
but four-fifths of them were diagnosed and linked to care. One-fifth (2
million) is the global gap between those we reach and those we need to reach to
find ALL TB and link them to lifesaving care.
In 2024, in the African region, out of an estimated
2.6 million people with TB disease, 1.9 million were notified. In the Southeast
Asia region, out of 3.7 million estimated people with TB disease, 3.1 million
were found.
In the same year, out of 2.7 million people with TB,
2.5 million were notified. Out of 249,000 people with TB in South Africa,
183,000 were notified. Out of 510,000 people with TB in Nigeria, 402,000 were
notified. And out of 724,000 people with TB in the Philippines,544,000 were
notified.
Unless we reach ALL people with active TB
disease early and diagnose ALL of them accurately, and link ALL of them to
standard TB treatment, care and support, how will we end TB?
Infection prevention remains a cornerstone. No one
should get infected with a disease that is preventable.
Person-centred, rights-based access to TB services is
an essential bedrock
TB diagnostic technology alone is not enough. Most
essential is to ensure that health and social support services of the
government, including those for TB, are person-centred, rights-based and gender
transformative. We need to dismantle social, structural, and systemic barriers
people face in accessing health and social services. When populations - who are
most at risk of TB - can access public services with equity, safety and
dignity, then only a real change will be possible in helping save lives from an
ancient disease like TB.
