Reappraising TB preventive treatment in India: programmatic and ethical implications of subclinical tuberculosis in household contacts

Abstract

India's pursuit of Tuberculosis (TB) elimination is contingent on the rapid universal scale-up of TB Preventive Treatment (TPT) for household contacts. However, current strategies largely neglect the asymptomatic active (subclinical) TB stage in terms of standardized diagnosis and optimized management. Consequently, administering TPT to individuals with unrecognized subclinical TB constitutes inadequate therapy that provides no patient benefit, enables community transmission, and risks minimal chances of iatrogenic drug resistance—violating the fundamental ethical principle of non-maleficence. We examine the tension between utilitarian public health goals and individual biomedical ethics, arguing for a transition within the National TB Elimination Program (NTEP) toward a rights-based framework prioritizing the clinical safety of household contacts. Crucially, the NTEP must institutionalize robust health education for contacts regarding the persistent risk of progression for at least 24 months post-TPT completion, coupled with sustained clinical surveillance to mitigate delayed health-seeking behavior. Further, sustained investment in digital diagnostics and translational research apart from addressing implementation gaps in the private sector is paramount to making TPT safe, evidence-driven, and ethically responsible.