Forty-year-old Ranjit Singh stays at the night shelter on Asaf Ali Road in New Delhi where residents were recently screened and tested for tuberculosis (TB), as part of the Union Government's 100 Day Intensified Campaign on TB Elimination, which started on 7th December, 2024.

Singh, one among the 200 residents at the shelter, had been diagnosed with TB before, after his first symptoms appeared about four years ago.

“I vomited once after eating and noticed blood in it. I also had a persistent cough,” he recalled, sitting on the floor of the shelter, in an off-white shirt with faded stripes, its top buttons undone. His grey trousers were folded three times, a common trick among laborers to prevent their clothes from getting caught in the rickshaw pedals. His nearly grey beard framed a tired face, but the most striking feature was his watch — a thick shining white strap watch. “My body ached all the time, and I had constant fever,” he added.

Singh had sought treatment at Lok Nayak Hospital at the time, where doctors diagnosed him with the lung disease. “I took medicines for six months, and after another X-ray, the doctor said I was fine,” he said.

Singh was fine for a bit, but his symptoms soon returned. He, however, never went back to get treatment or even tested—until now.

About 100 residents of the shelter, who had suspected symptoms, were part of the the TB testing drive that was run in Delhi’s night shelter homes, prisons, and facilities for mentally challenged individuals, as part of the 100 day campaign, and Singh, a rickshaw puller, was one of them.

Singh lined up with other residents of the shelter, to get an X-Ray taken, after the caretaker of his shelter flagged his symptoms to the officials. As he was symptomatic, his sputum samples were also sent for a Nucleic Acid Amplification Test (NAAT), a more advanced method, rather than the traditional skin test or blood test.

A week later, Singh was called in by the caretaker of the shelter.

“The list has three names, and you’re one of them,” Vicky Sharma, the shelter’s caretaker, told Singh, confirming what he had feared—his TB was back.

“Soon, he’ll need to start treatment again,” explained Sharma when First Check visited the shelter last week. However, despite being advised to seek treatment, Singh is yet to do so—citing the loss of daily wages if he were to be admitted.

Singh’s case highlights some common challenges in TB care, especially in Delhi’s overcrowded night shelters—relapses due to incomplete follow-up, rising threat of multi-drug resistant variants, and the heavy costs associated with the disease.

India’s TB burden: Cases rose in recent years, after an initial dip

Tuberculosis is a contagious bacterial infection caused by Mycobacterium tuberculosis, primarily targeting the lungs but capable of spreading to other parts of the body. It spreads through airborne droplets when an infected person coughs, sneezes, or speaks, making it a silent threat in crowded, poorly ventilated spaces.

Symptoms—persistent cough, fever, weight loss, and night sweats—can take weeks to emerge, and in subclinical cases, they may remain hidden, allowing undetected transmission.

India alone bears 26% of the global disease burden. In 2023, the WHO African and South-East Asia regions accounted for 80% of global TB deaths among HIV-negative individuals, with India alone contributing 29% of these fatalities.

In March 2018, during the “End TB Summit” held in New Delhi”, Prime Minister Narendra Modi first committed to eliminate the disease by 2025. This target is five years before the World Health Organization’s (WHO) deadline. The efforts seem to have yielded some results.

“As per the World Health Organization’s Global TB Report, 2024, the incidence rate of TB in India has shown a 17.7% decline from 237 per lakh population in 2015 to 195 per lakh population in 2023, which is more than double the global reduction, while deaths due to TB has reduced by 21.4% from 28 per lakh population in 2015 to 22 per lakh population in 2023,” according to a recent parliament answer.

However, recent years have seen an uptick in cases. On 18 March 2025, just days before today’s World TB Day, Union Minister of State for Health and Family Welfare Anupriya Patel said that in 2023 and 2024, India reported 25.5 lakh and 26.07 lakh tuberculosis (TB) cases, marking the highest number of notified cases ever. According to the government, this is because they are “missing” fewer cases now, with a more comprehensive screening and detecting process.

Delhi’s night shelters: the ‘perfect’ TB hotspots

Delhi’s night shelters, like the one on Asaf Ali Road housing over 200 daily-wage laborers, are primed to become TB hotspots.

“Tuberculosis spreads easily in crowded and poorly ventilated spaces, making night shelters particularly vulnerable,” said Dr Kamal Chopra, Former Director, New Delhi TB Centre and State TB Training and Demonstration Centre, Delhi. He explained that infectious droplets remain suspended in the air, infecting others.

“Overcrowding is a big problem,” Sunil Kumar Aledia of the Centre for Holistic Development noted. Overcrowding forces residents into close quarters, increasing chances of a mass spread. “Malnutrition and compromised immunity heighten susceptibility,” he added.

The revised operational guidelines of the Scheme of Shelters for Urban Homeless notes, “For all the shelters, a space of 50 square feet per person will be taken as the minimum space to be provided.”

However, according to the updated report of the Delhi Urban Shelter Improvement Board, the capacity of the shelter home number 176 on Asaf Ali road, which First Check visited, is 290 and the build area is 4257 sq ft. This gives the space of approximately 14.67 sq ft. per person at the shelter.

“All the shelter residents— whether with TB or not– tend to use the same set of blankets,” Aledia, who has worked with Delhi’s homeless for decades said, highlighting how shared bedding and patchy sanitation compound the crisis.

Even after the screening, officials at the shelter had made no special provisions for those diagnosed with the highly contagious disease. Residents who were found to be infected were not isolated and they were made to share spaces with other residents, with little to no precautionary measures.

The challenges to TB eradication in Delhi’s night shelters: rise of Multidrug-resistant variants

The main challenge when it comes to eradicating TB, as underscored by Dr Soumya Swaminathan, former Director General of the Indian Council of Medical Research (ICMR) and former Chief Scientist at the WHO, is the lack of an “effective” vaccine against it. “No infectious disease has ever been eliminated without a vaccine, and TB still lacks an effective one,” she said. She noted that while India has made progress in reducing case burden, crowded settings like shelters remain a hurdle.

This is compounded by the rise of multidrug-resistant TB (MDR-TB).

"When people don’t complete their treatment or access to medication is inconsistent, MDR-TB becomes a bigger challenge — especially in shelters where follow-up care is difficult," a state TB officer, who led screening and testing drives in Delhi’s night shelters and wished to remain anonymous, said expressing concerns over the rising threat of such variants in these facilities.

Multidrug-Resistant Tuberculosis is a formidable strain of the disease caused by Mycobacterium tuberculosis that resists at least isoniazid and rifampicin, the two most effective first-line drugs used to treat standard variants of the illness.

This resistance emerges when patients like Ranjit Singh stop treatment prematurely— mostly due to lost wages and alcoholism—or when drug supplies falter, allowing the bacteria to mutate and survive.

“In Delhi’s night shelters, follow-up care is patchy at best; residents often vanish before completing months-long regimens, and overcrowded, unsanitary conditions amplify its spread through coughs and shared air,” Dr Chopra said.

“Epidemiologically, one untreated TB patient can infect 10–15 people per year, and with MDR-TB, the stakes are even higher because it requires up to two years of intensive treatment,” Dr Chopra added.

Unlike regular strains, MDR-TB requires up to two years of grueling treatment with drugs so harsh that many can’t stick with them, slashing cure rates to under 68%—far below the 88% seen with standard cases, according to the World Health Organization’s latest findings.

“Most TB patients now undergo drug resistance testing at diagnosis, ensuring appropriate treatment from the start,” Dr Swaminathan said, highlighting a key advancement. However, she cautioned that in high-burden areas like Delhi, “the availability and effectiveness of new drugs still need further expansion.”

Factors like malnutrition and poverty further weaken immunity, making people more susceptible. "Cold, damp conditions during Delhi’s winters, along with pollution, worsen respiratory health and increase the risk," Aledia explained.

"Many shelter residents don’t know enough about TB, which delays preventive actions and allows the disease to spread unnoticed," he said.

AI Advancements in testing, but ensuring treatment completion remains a challenge

As part of the 100-day campaign to combat the contagious disease, medical teams equipped with ultra-portable X-ray machines visited Delhi’s night shelters to conduct on-the-spot screenings. A state TB officer involved in the screenings said that portable X-ray machines have significantly improved disease detection, especially among vulnerable populations.

“These compact, tablet-sized devices can be easily transported and set up anywhere with a power source, making on-site screenings more accessible,” he explained. Each machine can screen up to 100 individuals in a session, enabling large-scale testing in a short time. “A key feature of these machines is their AI-enabled technology, which assists doctors in identifying abnormalities in scans,” he added.

He explained that with this, even in areas with limited medical expertise, the AI can flag potential cases, improving early detection. If an abnormality is found, a sputum sample is collected for molecular testing using nucleic acid amplification tests (NAAT), such as TB-NAT or TrueNAT. These tests deliver results within hours and determine whether the infection is drug-sensitive or drug-resistant—a crucial distinction, as treatment approaches differ for drug-resistant strains of the disease.

Despite these technological advancements, ensuring treatment completion remains a significant challenge, the state TB officer highlighted.

“Many shelter residents struggle to complete the six-month regimen due to their transient lifestyles. We train caretakers as Directly Observed Treatment (DOT) providers, but dropout rates remain high,” he said. He also noted that drug toxicity, compounded by substance use, makes adherence even more difficult.

Dr Swaminathan emphasized the need for a broader, community-driven solution. “We need an approach like we had for polio, with volunteers and increased budgets to ensure accessibility to diagnostics and treatments,” she said.

Heavy indirect costs despite free TB treatment

The government provides free care for tuberculosis under the National TB Elimination Programme, but a study published in the journal Global Health Research and Policy in December 2024 showed that about 45% of households with tuberculosis patients suffered catastrophic costs, which were more than 20% of annual household income.

Roughly two-thirds of the financial burden stemmed from indirect costs tied to lost productivity, as patients’ incomes plummeted compared to their pre-illness earnings, according to the study.

These costs soared because many survivors, predominantly from the unorganized sector, were pushed into lower-paying jobs with no safety nets like paid leave or employer-provided insurance. The study revealed that only 55.9% of the patients surveyed were actively employed, and just 33.6% served as their families’ primary breadwinners, underscoring the economic devastation wrought by the disease on an already vulnerable workforce.

Singh’s story reflects this struggle. A native of Rampur in Uttar Pradesh, he arrived in Delhi “three years before the metro started.” Speaking in a deep, husky voice, Singh recalled his years of survival through various odd jobs before settling into his current work — pedaling a rickshaw through Delhi’s busy streets. Managing TB, however, requires rest — something Singh feels he can’t afford.

“Who will pay for the days I lose my wages when I get admitted?” he asked.

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