Diminishing Returns of Risk Based Tuberculosis Control and the Case for Comprehensive Strategies for Elimination

Background Current tuberculosis (TB) control programs, including India's National TB Elimination Programme (NTEP), heavily rely on risk-based screening that prioritizes high-risk individuals. Evidence suggests that a significant portion of TB cases are not from these defined high-risk categories, questioning the adequacy of this approach as the primary strategy for elimination. Methods This cross-sectional study included data of 2,664 patients notified under the NTEP from January 1 to December 31, 2024 and available on the Nikshay portal. After extraction, the data was transferred into excel sheets and analysed using SPSS version 22. Results The mean age of patients was 47.7 years, with a male predominance (67.2%). The majority of patients (67%) were in the economically productive 18–60 age group. Pulmonary TB accounted for the majority of cases and was mostly diagnosed microbiologically (61.1%), whereas extra-pulmonary TB was mostly diagnosed clinically (30.2%). Key risk factors were present in a minority of patients: 14.5% had diabetes, 10.6% were smokers, and 1.3% were HIV-positive. In contrast, undernutrition was highly prevalent, with 51.3% of patients belonging to the underweight category. Conclusion The study highlights the diminishing returns of a purely risk-based TB control strategy. Risk is a by-product of working through probabilities, said to have arisen from more than one event. Once the number of events (TB cases) starts declining (as is happening at the elimination stage of TB), the value of a risk-based approach will diminish.