Tuberculosis Elimination in India: Way Forward

India’s tuberculosis (TB) journey marks a shift from control to an elimination-oriented response driven by measurable systems change. In 2015, India bore a very large share of the global TB burden, with substantial under-detection and under-notification, and the next decade was therefore defined as much by building visibility within the system as by delivering treatment. By the early 2020s, India’s surveillance and service delivery began to show durable improvements, and by 2015–2024, the country recorded an estimated ~29% reduction in TB mortality along with parallel reductions in incidence – progress that outpaced global averages despite the enormous starting burden and the coronavirus disease 2019 (COVID-19) shock.[1] Importantly, these gains were not the product of a single intervention; they emerged from the convergence of better notification, rapid diagnostics, treatment modernisation and social support. A critical achievement across this decade has been the progressive closure of the ‘missing TB’ gap. The decline in missing cases – from 1.5 million in 2015 to a small residual gap of less than 1 lakh by 2023–2024 – matters because untreated pulmonary TB sustains transmission and amplifies mortality through delayed care. The transformation of surveillance into patient-level accountability through Nikshay has been central to this shift, as it enabled tracking from diagnosis to outcome, facilitated lab-treatment linkage and supported monitoring of treatment initiation and completion across public–private interfaces.[2] In elimination terms, this digital backbone is not merely an IT upgrade; it is a governance tool that makes delays, drop-outs and inequities visible – and therefore addressable. Diagnostics were a decisive inflection point in this period. In 2015, India had fewer than 1000 CBNAAT machines, largely confined to tertiary centres and smear microscopy remained the dominant diagnostic modality. Over the next decade, sustained investment expanded the molecular diagnostic network to more than 9000 CBNAAT and other indigenously developed molecular diagnostic platforms by 2025, decentralising bacteriological confirmation and rifampicin-resistance testing to district and sub-district levels.[1] This expansion shortened diagnostic delays, increased microbiological confirmation and enabled earlier initiation of appropriate therapy, particularly for drug-resistant TB. The public-health significance of this scale-up lies not only in detection, but also in its ability to compress the interval between symptom onset, diagnosis, and treatment – an interval that strongly determines both transmission and survival. The decade, however, also exposed fragility. The COVID-19 pandemic interrupted TB services, reduced access to diagnostics and treatment and contributed to excess TB mortality through delayed presentation and deferred care. India’s notification decline during 2020–2021 and the subsequent rebound underline two truths: First, TB services must be ‘disaster-proofed’, and second, recovery is possible when programmes rapidly restore diagnostic throughput and treatment linkage.[1] The pandemic’s TB consequences and the opportunities it created for integrated screening and resilient service redesign have been explicitly analysed in the Indian academic work from this period and remain relevant for the way forward.[3] Achieving TB elimination in India requires deliberate prioritisation of vulnerable populations who disproportionately contribute to ongoing transmission and adverse outcomes. These include household contacts of infectious cases, undernourished individuals, people with a history of TB in the preceding 5 years and those living with HIV or diabetes, all of whom carry an elevated risk of progression from infection to active disease. Advanced age, chronic smoking and harmful alcohol use further impair host immunity and treatment outcomes, while people residing in congregate settings such as prisons, orphanages and old-age homes, as well as those living in densely populated urban slums, face sustained exposure and delayed access to care. Focused screening, preventive therapy, nutritional and social support and integration of TB services with non-communicable disease and social welfare programmes in these high-risk groups are essential to translate elimination targets into equitable population-level impact. Undernutrition remains a dominant driver of TB incidence and a powerful determinant of poor outcomes; population-attributable risk estimates suggest that undernutrition contributes to nearly one-third of TB incidence in India and is strongly associated with delayed recovery and mortality. India’s policy response – nutritional support through Nikshay Poshan Yojana and community participation through Nikshay Mitra – is therefore not optional welfare; it is core TB epidemiology translated into practice. The biological and clinical importance of nutrition in TB outcomes has been repeatedly highlighted in Indian scholarship, reinforcing why nutrition support must be protected and tightened rather than treated as an add-on.[4] An important yet underappreciated enabler of TB elimination in India is the broader national focus on nutrition through the Rashtriya Poshan Yojana. By addressing undernutrition, anaemia and food insecurity at a population level, the programme indirectly targets one of the strongest biological drivers of TB susceptibility and poor treatment outcomes. Improved nutritional status enhances immune resilience, reduces progression from latent to active disease and improves tolerance to therapy, underscoring that TB elimination cannot be achieved in isolation from wider nutritional and social reforms. Tobacco exposure is another mortality amplifier that can blunt elimination gains even when diagnostics and drugs are strong. Tobacco dependence worsens disease severity, delays sputum conversion and is associated with higher case fatality, particularly when it coexists with poverty and undernutrition. Indian evidence from recent reviews shows that tobacco dependence modifies pharmacological response and treatment outcomes, underlining that cessation must be embedded within TB care pathways rather than addressed in parallel.[5] This is especially relevant in urban poor settings, where tobacco use, indoor pollution and overcrowding converge. The most important emerging gap is the weight of comorbidities in TB mortality. Diabetes is now a defining syndemic partner of TB in India. Patients with diabetes have a 2–3-fold higher risk of developing active TB, are more likely to present with advanced disease and experience higher rates of adverse outcomes, including death. Long-term Indian data have demonstrated a strong bidirectional relationship between pulmonary TB and diabetes, highlighting why routine bidirectional screening and integrated management are no longer optional.[6] More recent Indian commentary has framed TB and diabetes as a syndemic that India cannot afford to ignore, particularly in the context of rising diabetes prevalence in both urban and semi-urban populations.[7] In practical terms, many TB deaths now reflect failure to manage comorbid disease rather than failure of anti-tubercular drugs. Post-TB lung disease affects nearly 50% of patients following microbiological cure, manifesting as residual fibrosis, bronchiectasis, calcification, lobar collapse, obstructive airway disease or a destroyed lung phenotype. These sequelae result in persistent airflow limitation, impaired gas exchange, exercise intolerance and recurrent infections, leaving many patients chronically symptomatic and functionally disabled. Despite being labelled as treatment successes, a substantial proportion remains unable to resume productive work. Addressing this hidden burden requires structured post-TB care pathways incorporating pulmonary rehabilitation, vocational rehabilitation, long-term respiratory support and palliative and end-of-life care for advanced disease. In the current TB programme, post-treatment follow-up is largely limited to 2 years and focuses primarily on relapse detection. This approach overlooks the substantial burden of long-term morbidity that persists after microbiological cure. There is a need to extend follow-up beyond 2 years to systematically address post-TB lung disease, functional impairment and chronic respiratory symptoms. TB elimination must therefore adopt a life-course approach that prioritises long-term health and quality of life, not treatment completion alone. Urban slums and informal settlements deserve explicit prioritisation because they concentrate transmission drivers and mortality risks: Overcrowding, poor ventilation, migration, occupational exposure, delayed care seeking, undernutrition and economic compulsion to continue work despite illness. As national incidence declines, residual TB increasingly localises into such micro-epidemics. Environmental and socioeconomic determinants of TB have been clearly documented in the Indian settings, supporting the need for place-based strategies rather than reliance on district-level averages that mask high-risk pockets.[8] Slum-focused screening, mobile diagnostics, active contact investigation and community-anchored follow-up must therefore be central to the post-2025 agenda. There is a timely need to intensify public awareness and strengthen engagement of the private sector along with key non-health sectors such as education, Panchayati Raj institutions, industry and the labour department. High-risk occupational groups including gig workers, restaurant workers, coal miners and individuals exposed to silica, dust, smoke and industrial fumes remain underserved despite elevated vulnerability to TB. Meaningful intersectoral collaboration is essential to enable targeted screening, preventive interventions, workplace protection and early linkage to care, ensuring that TB elimination efforts extend beyond healthcare facilities into the environments where risk is generated. On prevention and screening, India needs tools that match its scale. Cy-TB should be understood correctly as a diagnostic skin test, designed to combine the operational simplicity of the Mantoux test with greater specificity approaching IGRA performance. Such tools may allow broader, field-friendly risk stratification when paired with confirmatory testing and clear algorithms, particularly in high-burden environments and slum settings where latent infection and progression risk are high.[1] The goal is not technological substitution, but operational feasibility at scale. For drug-resistant TB, the elimination narrative depends on regimen transformation. Shorter, all-oral regimens such as BPaL fundamentally changed programmatic feasibility by improving outcomes compared with older, prolonged regimens.[9] The next challenge lies in optimising safety while scaling up, particularly with respect to linezolid toxicity. Evidence from open-label randomized trials evaluating different linezolid doses within bedaquiline–pretomanid-based regimens provides critical guidance for balancing efficacy and tolerability in the real-world scale-up.[10] We also need sustained public awareness to address the persistent social stigma and gender-based discrimination associated with TB, particularly amongst women. These social barriers continue to delay diagnosis, undermine treatment adherence and compromise equitable access to care, making community education and gender-sensitive approaches integral to true TB elimination.[11] Finally, the way forward must explicitly address severe TB and early deaths. A significant fraction of TB deaths occur before treatment initiation or early during treatment, reflecting late presentation, advanced disease and gaps in referral and supportive care. Elimination beyond 2025 therefore requires an explicit TB–acute care interface: Early identification of high-risk patients, rapid referral pathways, infection-control-ready stabilisation and the clinical capacity to manage respiratory failure, massive hemoptysis, sepsis and drug toxicity. In practice, this means building TB-ICU readiness – not necessarily standalone units everywhere, but TB-competent critical-care pathways integrated with Ni-kshay so that deaths are visible, reviewed and prevented rather than passively accepted. In conclusion, the decade from 2015 to 2025 delivered real progress – reduced missing cases, stronger digital accountability, massive CBNAAT scale-up, expanded rapid diagnostics and measurable declines in mortality, including an estimated ~29% reduction over 2015–2024.[1] The post-2025 agenda is now clearer and harder: prevent avoidable deaths by integrating comorbidity care, nutrition, tobacco cessation and severe-TB pathways; localise strategy to slum hotspots and socioeconomic micro-epidemics; and scale modern DR-TB regimens safely. Elimination will be judged not by national averages alone, but by whether the system reaches the most vulnerable early enough – and keeps them alive long enough – to make TB truly rare. The Pradhan Mantri TB Mukt Bharat Abhiyan must evolve from a programmatic initiative into a nationwide public movement, comparable in scale and visibility to the Pulse Polio Abhiyan. TB elimination cannot be achieved through health systems alone and requires sustained mass awareness, political ownership and social participation. A coordinated national campaign that actively engages the medical fraternity alongside communities, civil society and local leadership – from the Pradhan at the village level to the Pradhan Mantri at the national level – is essential to normalise screening, reduce stigma and drive collective accountability in the fight against TB. Authors’ contributions This manuscript has only one author who is responsible for the entire work.