From DOTS to DOST: a new framework for TB elimination in India.

Abstract

India bears a quarter of the global tuberculosis (TB) burden and nearly one-third of TB related deaths, but substantial regional heterogeneity demands tailored elimination strategies. We propose the Dual-phase Operational Strategy for Tuberculosis elimination (DOST), a roadmap that explicitly addresses TB as both an infectious disease and a structural challenge. Phase 1 focuses on rapidly reducing transmission through intensified case-finding, upfront molecular diagnosis, and strengthened treatment, as demonstrated by India's 100-Day TB Campaign, which expanded community screening and accelerated therapy initiation. Phase 2 pivots to preventing disease progression by scaling up TB preventive treatment and addressing key drivers such as undernutrition, HIV, and diabetes. DOST emphasizes subnational adaptation: high-burden states prioritize disease reduction, while states nearing low incidence shift toward preventing flare-ups and sustaining progress. Rooted in the Hindi word dost (friend), this person-centered approach integrates medical and social support, recognizing that eliminating TB in India requires compassion paired with structural action. By sequencing and localizing proven interventions, DOST offers a pragmatic pathway from TB response to TB elimination.