Revolutionising tuberculosis diagnosis: AI-powered ultrasound technology at Stellenbosch University
Image: RON AI
In a significant leap forward in the battle against tuberculosis (TB), Stellenbosch University (SU) researchers are spearheading a pivotal global trial aimed at revolutionising TB diagnosis through the innovative use of artificial intelligence (AI). The project seeks to create and validate an algorithm designed to empower healthcare workers at primary care facilities to identify potential TB cases swiftly and accurately, utilising a handheld ultrasound device that connects to a smartphone.
'TB remains the world's deadliest infectious disease, yet it is massively underdiagnosed,' explained Prof Grant Theron, a leading expert in Clinical Mycobacteriology and Epidemiology at SU and the trial coordinator. He said the critical challenges faced in diagnosing TB, where many patients undergo unnecessary testing, while others who desperately require screening are overlooked. 'There's an urgent need for accessible, affordable, and scalable diagnostic tools for TB triage,' he asserts.
This ambitious project, titled 'Computer assisted diagnosis with lung ultrasound for community based pulmonary tuberculosis triage in Benin, Mali, and South Africa' (CAD LUS4TB), involves an esteemed consortium of 10 health and research institutions across Africa and Europe, with financial backing of €10 million (over R200 million) from the European Union's Global Health EDCTP3 Joint Undertakings.
The study plans to enrol 3,000 adult patients, aiming to assess the efficacy of AI-driven ultrasound technology in enhancing TB detection and management. The overarching goal is to significantly increase access to TB screening for symptomatic adult patients at the primary healthcare level, ensuring timely intervention where it is needed most.
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'Point-of-care lung ultrasound employs sensitive, handheld imaging devices capable of detecting body abnormalities, including those characteristic of TB,' Theron said. Historically, this technology has suffered from a dependency on specialised expertise for image analysis. However, thanks to advancements in AI, there is a newfound opportunity to automate image interpretation, enabling even minimally trained health workers to swiftly discern which patients require additional testing. The CAD LUS4TB initiative thus heralds a transformative, specimen-free diagnostic solution in the ongoing fight against TB.
In collaboration with European partners, SU will delve into developing and validating cutting-edge machine learning algorithms, leveraging the expertise of Prof Thomas Niesler's Digital Signal Processing group within SU's Faculty of Engineering. The goal is to craft a sophisticated algorithm compatible with portable ultrasound devices linked to smartphones. This innovation promises to provide automatic assessments of ultrasound images for TB indicators, all encapsulated within a user-friendly mobile application ready for widespread use.
The project is set to commence on September 1, 2025, under the dynamic co-leadership of Dr Veronique Suttels from The Swiss Federal Technology Institute of Lausanne and Prof Ablo Prudence Wachinou from the National Teaching Centre for Pneumology & Tuberculosis in Benin. Together, they aim to lay the groundwork for a brighter future in TB diagnostics.
The CAD LUS4TB consortium is committed to generating robust, population-specific evidence while advocating for the integration of computer-assisted diagnosis (CAD) powered by AI, thereby influencing healthcare policies related to lung ultrasound implementation.
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Maybe most notably, in the 2010s, a drug called bedaquiline replaced older DR-TB drugs that were associated with hearing loss. A slightly older antibiotic called linezolid also became a cornerstone of DR-TB treatment. Today, in South Africa, 'normal' drug-susceptible TB (DS-TB) in adults is treated with a six-month treatment course – consisting of four drugs for two months and then two drugs for the next four months. A four-month treatment course has been shown to work in a clinical trial, but is not yet routinely provided in the country. Kids are typically treated for four or six months. DR-TB is treated with anything from three to six drugs, for any time from six to 24 months. How someone's TB is classified is largely determined by which drugs their particular strain of TB is resistant to. Lindsay McKenna, co-director of the TB Project at the Treatment Action Group, suggests thinking of it as a ladder. If the standard four drugs all work for your TB, then you don't have to climb any rungs. If rifampicin doesn't work for you, you have rifampicin-resistant TB (RR-TB) and must climb to the first rung to find drugs that work. If both rifampicin and isoniazid no longer work, you have multi-drug-resistant TB (MDR-TB) and must climb another rung. If you have resistance to even more drugs and you have pre-extensively drug-resistant TB and after that, extensively drug-resistant TB. (In practice, TB programmes often classify RR-TB and MDR-TB together since the same medicines are used to treat them.) All of the above treatments are for people who are ill with TB disease. There is also so-called TB preventive therapy, which aims to kill the TB bacteria in the lungs of someone who is infected, but who hasn't yet become ill with TB disease. These preventive treatments typically involve taking one or two medicines for one to six months, depending on the specific treatment regimen. It is possible that new long-acting formulations could allow for an entire course of preventive therapy to be administered as a single injection, though that research is still at an early stage. How the treatments work One reason for the complexity of TB treatment is the bacterium's large and complex genome. Meintjes says that HIV has nine genes, while TB has around 4,000. Having so many genes means the bug has lots of potential to bypass the effect of drugs targeting certain molecules or pathways and still survive. On the other hand, the many genes, at least in theory, provide many potential targets for antibiotics to attack. As noted, to cure TB, one typically has to attack the bug with at least three or four drugs. Meintjes says it is like a group of lions taking down a large buffalo – each one targeting a different part of the buffalo. Along these lines, TB drugs can broadly fit into different categories based on which part of the bacterium they target. Some drugs attack the way the bacterium builds its cell wall, others disrupt how the bug makes its protein, yet others interfere with how the bacterium produces or gets energy, and finally, some sabotage the way TB replicates. As Meintjes explains, isoniazid targets the cell wall of the bacterium by affecting the formation of molecules within the wall, ultimately causing it to leak and die. Rifampicin targets the genetic mechanisms of the TB bacterium, which prevents it from replicating. Bedaquiline works by targeting the mechanisms that allow the bug to metabolise energy, essentially starving it of fuel. A class of antibiotics called fluoroquinolones, specifically levofloxacin and moxifloxacin, target the TB bacteria's DNA while it's trying to copy itself and stops that process, explains Furin. Another drug, linezolid, interferes with how the bacterium makes proteins, which it needs to survive. It is not entirely clear how some other drugs, like clofazimine and pyrazinamide, work, says Furin. Even when attacking TB with several drugs and from multiple angles like this, it can still take months for all the bacteria in someone's body to be killed and for them to be cured. This is because, according to Furin, sometimes the protective wall formed by the immune system to contain the TB becomes too thick for the drugs to get through. And the environment inside the wall is often very acidic and deactivates some of the drugs that do manage to get in. How treatment could improve Novelist George Orwell, who was diagnosed with TB in 1947, was one of the first people to be treated with streptomycin. 'I am a lot better, but I had a bad fortnight with the secondary effects of the streptomycin. I suppose with all these drugs it's rather a case of sinking the ship to get rid of the rats,' he wrote in a letter at the time. More than 75 years later, TB treatments have improved massively, but drug side effects remain a real problem, especially when treating DR-TB. Some older treatments for TB involved injections of toxic drugs and had horrible side effects, including hearing loss and kidney damage. While newer drugs are better, there are still issues. Linezolid, for example, can cause peripheral neuropathy (painful tingling in the hands and feet) and anaemia. McKenna says none of the TB drugs is 'necessarily a walk in the park' and all come with side effects. This is because of the drugs themselves, the dosages required to kill the TB bacterium, and how long the drugs need to be taken. Because of this, much of the focus in TB research has been on finding drug combinations that can reduce the duration of treatment and the severity of side effects. For Furin, an ideal future regimen includes 'fewer pills' – she's hoping for one pill once a day for no more than eight weeks, 'fewer side effects', and doing away with the one-size-fits-all approach. Her reference to the 'one size fits all approach' points to one of the central tensions in TB treatment programmes. People with TB often do not get optimal treatment based on the specific characteristics of their own illness. For example, in countries with limited testing for drug resistance, people might be treated with medicines that their specific strain of TB is resistant to. They might thus suffer the side effects of that medicine without any of its benefits. This is less of an issue in South Africa than elsewhere, since the country's health system provides routine testing for resistance against several of the most important TB drugs. There are also questions about whether everyone really needs to be treated for six months to be cured. A landmark study called Truncate has shown that many people can be cured in two months. The difficulty is that we can't currently predict who will be cured after two months and who will need the full six months, or even longer. Figuring this out, as McKenna points out, would enable more personalised care that would mean fewer people are over- or under-treated. Some in the TB world have argued for the development of a pan-TB regimen – a combination of three or so drugs that nobody is resistant to and that accordingly could be given to everyone with TB, no matter what strain of TB they have. The benefit of such a pan-TB regimen would be that it would dramatically simplify the treatment of TB if it worked. But the experts interviewed by Spotlight agree that resistance is likely to develop against the drugs in such a regimen, and as such, testing people for drug resistance will remain necessary, as will alternative treatment regimens. Furin also points out that pharmaceutical companies have a greater incentive to invest in a pan-TB regimen since its potential market share is bigger than for drugs in a more fragmented treatment model. A hard task, getting harder One of the biggest obstacles in the way of finding new TB treatments is that there really aren't any reliable shortcuts when it comes to doing the research. With HIV, one can get a good idea as to whether a treatment is working by looking at biomarkers such as a person's viral load and CD4 count. TB, by contrast, doesn't have any similarly clear biomarkers that tell us whether a treatment is working or not. Arguably, the most promising biomarker for TB is bacterial load – essentially, how many bacteria are left in someone's sputum a while after treatment has begun. Having a high TB bacterial load is associated with a poor treatment outcome, but the problem is that it is difficult to measure reliably. Without a good biomarker, the only way to measure how well treatment is working is to follow patients for a long time and see if they are cured, and if they are, whether they suffer a relapse. Because of this, TB treatment trials often take several years to complete. Despite these challenges, there has been a good deal of activity in recent years. 'There are about 20 different new drugs in clinical trials at the moment – either early or later phase,' says Meintjes. But much of that momentum might now be lost because of the United States' abrupt slashing of research funding, including much TB research. The US government has until now been the largest funder of TB research by some distance. It spent $476-million or over R8.7-billion through its agencies on TB research in 2023, according to a report by TAG. Many ongoing US-funded TB clinical trials have already been affected, according to McKenna, although there have recently been indications that some research funding might be restored. Where does this leave us? That most people with TB can be cured is something worth celebrating. That treatment for DR-TB has become a lot better and shorter over the past two decades is also something to be grateful for. But as we have shown in this Spotlight special briefing, TB is a tough and ancient adversary and keeps adapting. The treatments at our disposal today are far from as good as we'd like them to be. The treatment side effects are often horrible, and many people find it very hard to take these drugs for month after month. We didn't linger on it, but many people who are cured struggle with post-TB lung disease for the rest of their lives – meaning the bug might be gone, but that person's lungs are never the same again. The scientific search for better TB treatments is not a matter of convenience. It is critical to reducing the suffering that several million people will endure just this year. It is also vital for reducing the number of lives that are still being claimed by this age-old disease. And of course, TB will keep mutating, and we will likely see more and more resistance developing against the drugs that we are depending on today. That is why it is imperative that governments, donors, and pharmaceutical companies all maintain and increase their investment in the search for better TB treatments. After all, TB claims more lives than any other single infectious agent on the planet. If that alone doesn't warrant more investment, what does? But there is also a case to be made that we should change the way we conduct TB research. Ideally, more research should be driven, and informed by, what actually matters to people with TB and to people in the communities where TB is rampant. After all, when given the choice, who wouldn't opt for more personalised and more respectful treatment and care? 'The TB community keeps making the same mistakes over and over and then acts mystified when things do not turn out the way they want,' says Furin. 'All the new drugs and new regimens in the world will never be enough if we do not listen to what impacted communities need, and follow their lead.' DM Additional reporting by Marcus Low.
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