How Pakistan is Accelerating TB Screening with Delft’s solutions


According to the World Health Organization (WHO), Pakistan, with an estimated 510,000 new TB cases emerging each year and approximately 15,000 developing drug resistant TB cases every year, is ranked fifth among the highest TB burden countries worldwide, and it accounts for 61% of the TB burden in the WHO Eastern Mediterranean Region. The country is also estimated to have the fourth highest prevalence of multidrug-resistant TB (MDR-TB) globally.

Already in 2013 , we provided nine stationary, multi-functional EasyDR X-ray system to Interactive Research and Development (IRD) in Pakistan, Bangladesh (ICDDR’b) and South Africa (Aurum). The EasyDR X-ray system came with the CAD4TB artificial intelligence software to support the automated detection of TB-related abnormalities in chest X-rays. The project was funded by TB Reach Wave 3 and led to the screening of 1 million people in 2016.

In 2016, the collaboration with IRD was further expanded to what became the largest project in the world to utilize artificial intelligence for the rapid screening of TB, using the CAD4TB software.

At least 76 CAD4TB boxes were installed in hospitals and mobile clinics, implemented by IRD. Our Computer-Aided Detection for Tuberculosis (CAD4TB) software quickly and accurately detects the likelihood of active TB in an X-ray image using revolutionary machine learning technology. This way, TB case detection accelerates, and a patient can be diagnosed and start treatment within a day. The project came with the relevant installation and training services.

Across 2017, 2018 and 2019, another 9 CAD4TB systems were delivered directly to the National Tuberculosis Program, and another 9 CAD4TB systems to MercyCorps. Then, in 2021, the National TB Program procured another 40 CAD4TB systems for Pakistan, with the relevant CAD4TB licenses to support TB screening nationwide.

In 2022 and 2023, the TB program in Pakistan further scaled up their infrastructure of X-ray imaging and CAD. In 2022, 12 mobile MAC X-ray systems were delivered to Pakistan, each including CAD4TB. The users of the MAC X-ray systems received onsite training and installation support. In 2023, three large-scale projects were rapidly implemented: one project included 25 Delft Light portable backpack X-ray systems, one for an additional 57 mobile MAC X-ray systems, and one for another 79 Delft Light X-ray systems. Each 104 Delft Light and 57 MAC X-ray systems included CAD4TB, and came with the necessary installation, training and maintenance services to implement the project effectively.

The results of the efforts in Pakistan, utilising Delft Light portable X-ray systems, MAC mobile X-ray systems and CAD4TB are outstanding: over 80,000 people are screened for TB every month. Over 5 million people have been screened with CAD4TB in Pakistan, making it the largest CAD for TB project in the world. The installed base of Delft Imaging solutions in Pakistan covers 69 mobile MAC X-ray systems, 104 Delft Light portable X-ray systems and over 267 sites using CAD4TB. To ensure an effective service and support infrastructure in Pakistan, Delft Imaging works closely with its local in-country partner for a rapid onsite support whenever needed.

In 2024, we provided 13 CAD4TBboxes, alongside perpetual licenses to Pakistan’s Ministry of Health.

For more information on how CAD4TB is extensively used throughout Pakistan, please view the story of ‘Using CAD in a High Throughput Settings,’ presented by Dr. Adeel Tahir, Senior Program Manger at MercyCorps in Pakistan. The story was presented during the Delft Q2 webinar of 2022. During the webinar, Dr. Tahir noted: “Pakistan is a big country, and the Mercy Coprs works in almost two-thirds of the nation. Many areas have issues with internet connectivity. In those settings, the CAD4TB boxes are helpful. It helps chest scan physicians even when radiologists are not present. Not only does it reduce human resources, but also reduces the cost of X-ray film printing. We only get scans printed once we get the score. We don’t print scans for people with lower scores, saving the costs. It also rationalises the use of Xpert testing. With CAD4TB software, we identify certain presumptions, and based on those presumptions, we go for Xpert testing.” You can watch it on our YouTube channel.

Making a Difference

Over the years, local stakeholders in Pakistan have published regarding the impact of CAD4TB in the nation. The most extensive TB screening program with CAD4TB in the world, its implementation has garnered much attention.

According to a 2020 paper, CAD4TB performed on par with expert human readers. While the cost per screened subject using the CAD4TB 6 is almost half compared to screening without, the daily throughput is nearly 2.5 times higher. They concluded that CAD4TB offers good diagnostic accuracy as a triage for TB screening among diabetes patients. A previous 2018 research paper, followed by another paper in 2020, proved that CAD4TB could save molecular tests like the Xpert tests.

In a 2021 study, researchers concluded that in low-income, high-burden TB settings, triage using AI-based CXR interpretation (incl. CAD4TB) could be cost-effective when compared to the standard practice among persons with suspected TB. Similarly, according to a study conducted in the same year, community-based screening with innovative activities, which comprises sensitive screening and diagnostic tools like digital X-ray and CAD4TB, effectively improves TB case detection.

Another study in Pakistan featuring the Zero TB initiative concluded that CAD4TB is a valuable tool for mass screening TB in high-burden developing countries. The results also suggest combining CAD and symptomatology to screen a symptomatic population is a more cost-effective and reasonably effective algorithm. In Pakistan, researchers realised that CAD4TB as a triage tool could minimise the use of expensive molecular tests in low-resource settings.

Case Study

Delve into these impactful case studies:

Active case finding at prison with CAD4TB in 2021: In a prison setting, systematic screening using CAD4TB and portable X-ray systems screened over 20,000 inmates, identifying a TB prevalence 1.8 times higher than the national average. Discover how this approach underscores the importance of regular TB screening in prisons, utilizing technology to facilitate mass screening and reduce transmission.

Active case finding using OneStopTB Clinic with CAD4TB in 2021: At community outreach camps, a massive active case-finding initiative screened over 62,000 individuals, identifying and diagnosing a significant number of TB cases, including drug-resistant strains. Learn how this approach is effectively uncovering missed TB cases, facilitating early diagnosis and treatment in challenging areas.