Innovations in Detection, Equity, and Socioeconomic Support

1. Impact and Effectiveness of Active Case Finding (ACF) Strategies

• ACF efforts in Karachi led to a notable reduction in TB prevalence, especially among men, and improved sputum testing participation.
• Children's TB infection risk was significantly lower in ACF areas (ARTI: 0.6% vs. 1.1%), suggesting community-wide benefits.
• Despite detection, treatment linkage remained weak, with only 26% starting treatment.
• In Vietnam, the Double X (2X) strategy (CXR + Xpert) was highly effective in diverse settings, improving TB detection and treatment initiation.
• The 2X strategy was cost-efficient, integrated into national guidelines, and particularly effective among high-risk groups like older adults and smokers.

See also: Lin TB Lab

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2. Diagnostic and Treatment Challenges

• Low treatment initiation despite diagnosis remains a critical issue (e.g., 57% of diagnosed cases in Karachi refused or were unreachable).
• Trace-positive Xpert Ultra results created diagnostic uncertainty.
• In the U.S., over half of TB patients require hospitalization, with treatment costs averaging $16,000–$23,000.
• Preventive care remains underused despite advances like IGRAs and rifamycin-based regimens.

See also: Benang Merah Research Center

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3. Health Inequities and Disparities

• In the U.S., racial and ethnic disparities heavily influence TB incidence, case-fatality, and QALY loss—Black, Hispanic, and Native groups are disproportionately affected.
• Disparity-linked TB cases may reach 45% of total U.S. cases by 2035.
• Social determinants like income, delayed care, and insurance gaps are central to persistent disparities.
• A call to action urges Medicare coverage of TB screening to address systemic barriers for high-risk groups.

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4. Socioeconomic Interventions for TB Control

• Conditional cash transfer (CCT) programs like Brazil's Bolsa Família were linked to significant reductions in TB incidence and mortality, especially in extremely poor and Indigenous populations.
• Even one-time cash incentives can drastically improve diagnostic process completion.
• Combining CCTs with counseling led to 82% treatment success vs. 66.9% in controls, reducing loss to follow-up.
• Socioeconomic stability (employment, food security) was closely tied to treatment success, reinforcing TB as both a medical and social issue.

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5. Drug-Resistant TB and Genomic Surveillance

• A Thai study revealed a dominant, highly transmissible MDR-TB strain (L2.2.M3) accounting for 84.4% of cases.
• Whole-genome sequencing showed sustained transmission over time and space, confirming clonal expansion and urgent need for targeted containment.
• Genomic analysis enabled tracking of resistance evolution and highlighted pre-XDR and XDR clustering within dominant lineages.

References:

1. Khan, P.Y., Paracha, M.S., Grundy, C., Madhani, F., Saeed, S., Maniar, L., Dojki, M., Page-Shipp, L., Khursheed, N., Rabbani, W. and Riaz, N., 2024. Insights into tuberculosis burden in Karachi, Pakistan: A concurrent adult tuberculosis prevalence and child Mycobacterium tuberculosis infection survey. PLOS global public health, 4(8), p.e0002155.
2. Innes, A.L., Lebrun, V., Hoang, G.L., Martinez, A., Dinh, N., Nguyen, T.T.H., Huynh, T.P., Quach, V.L., Nguyen, T.B., Trieu, V.C. and Tran, N.D.B., 2024. An effective health system approach to end TB: implementing the double X strategy in Vietnam. Global Health: Science and Practice, 12(3).
3. Swartwood, N.A., Li, Y., Regan, M., Marks, S.M., Barham, T., Asay, G.R.B., Cohen, T., Hill, A.N., Horsburgh, C.R., Khan, A.D. and McCree, D.H., 2024. Estimated Health and Economic Outcomes of Racial and Ethnic Tuberculosis Disparities in US-Born Persons. JAMA Network Open, 7(9), pp.e2431988-e2431988.
4. Murrill, M.T., Salcedo, K., Tschampl, C.A., Ahamed, N., Coates, E.S., Flood, J., Wegener, D.H. and Shete, P.B., 2025. Policy Impediments to Tuberculosis Elimination: Consequences of an Absent Medicare National Coverage Determination for Tuberculosis Prevention. Journal of Immigrant and Minority Health, pp.1-6.
5. Thipkrua, N., Disrathakit, A., Chongsuvivatwong, V., Mahasirimongkol, S., Ruangchai, W., Palittapongarnpim, P., Chaiprasert, A., Pungrassami, P., Kamolwat, P., Suthum, K. and Tossapornpong, K., 2025. A large geno-spatial cluster of multi-drug resistant tuberculosis outbreak in a western district of Thailand. Infection, Genetics and Evolution, 128, p.105715.
6. Ismail, Nazir, Harry Moultrie, Judith Mwansa-Kambafwile, Andrew Copas, Alane Izu, Sizulu Moyo, Donald Skinner et al. "Effects of conditional cash transfers and pre-test and post-test tuberculosis counselling on patient outcomes and loss to follow-up across the continuum of care in South Africa: a randomised controlled trial." The Lancet Infectious Diseases (2025).
7. Shete, P.B., Kadota, J.L., Nanyunja, G., Namale, C., Nalugwa, T., Oyuku, D., Turyahabwe, S., Kiwanuka, N., Cattamanchi, A. and Katamba, A., 2023. Evaluating the impact of cash transfers on tuberculosis (ExaCT TB): a stepped wedge cluster randomised controlled trial. ERJ open research, 9(3).
8. Jesus, G.S., Gestal, P.F., Silva, A.F., Cavalcanti, D.M., Lua, I., Ichihara, M.Y., Barreto, M.L., Boccia, D., Sanchez, M.N. and Rasella, D., 2025. Effects of conditional cash transfers on tuberculosis incidence and mortality according to race, ethnicity and socioeconomic factors in the 100 Million Brazilian Cohort. Nature Medicine, pp.1-10.

Yoseph Leonardo Samodra

TBC 064