Deep cuts to international aid by the United States and its peers have compromised tuberculosis (TB) and HIV care, vaccinations, and other vital public health services in low- and middle-income countries.

Tuberculosis, already the leading infectious disease killer, will thrive amid this uncertainty and deprivation. In 2024, an estimated 10.7 million people fell ill with the disease and 1.23 million died from it worldwide, but both incidence and deaths were on the decline relative to previous years. This progress is now at risk. One modeling study, published in PLOS last year, estimated that the termination of U.S. funding could result in 10.6 million additional TB cases and 2.2 million additional TB deaths from 2025 to 2030 across 26 high TB burden countries.

Even if those projections are overestimated, tuberculosis programs in low- and middle-income countries will have to learn to do more with less money and maintain investments in TB care and control while reducing their dependency on donors. Frugal innovations, especially from high TB burden countries, will become central to the next phase of TB elimination.

Innovators and partners in countries where TB is endemic are already driving uptake of such tools. In March, some were endorsed by the World Health Organization (WHO) in a landmark policy that can greatly enhance TB case detection and bring testing closer to people.

The WHO policy updates its recommendations to include near point-of-care (NPOC) molecular tests—portable assays that can be used outside laboratories or hospitals—and easy-to-collect tongue swab samples to simplify and expand access to TB testing. The new WHO recommendation, based on a review of evidence, recommends that in adults and adolescents with signs and symptoms of pulmonary TB, NPOC tests on sputum (mucus) should be used as the initial diagnostic for TB rather than smear microscopy. When sputum cannot be obtained, NPOC molecular tests on tongue swabs should be used first instead.

This change represents major progress for TB management for several reasons. NPOC tests can be used at primary care centers, where most people with tuberculosis first seek treatment. NPOC platforms can be used with either swabs dipped in sputum or tongue swabs. Existing molecular tools, such as the Xpert MTB/RIF from the California-based company Cepheid, have largely been deployed at large hospitals and centralized laboratories, limiting access to diagnostics.

Following the WHO's new guidance, high-burden countries can push to completely replace smear microscopy with molecular testing for all people with presumed TB, and meet the WHO diagnostic standard of achieving universal access to rapid diagnostics.

For example, China and India have validated tongue-swab–based molecular tests (which amplify and detect bacterial DNA) and demonstrated their application in low-resource settings. Examples of such tests include Minidock by China's Pluslife Biotech and the Truenat MTB Ultima test by India's Molbio Diagnostics. Currently, the Pluslife technology is endorsed by WHO and classified as NPOC.

For centuries, pulmonary TB detection relied on patients providing samples of sputum, or mucus coughed up from deep in the lungs. Nearly a quarter of adults, however, are unable to cough up mucus from deep within the lungs and children rarely produce sputum. Tongue swabs, on the other hand can be collected from everyone, offering a much-needed alternative to sputum samples. By using both sputum and tongue swabs, health workers can now test more people than they could earlier. Once TB is detected, additional drug-resistance assessments can be done using conventional molecular tests and cultures.