sensors

Article
Evaluation of an AI-Based TB AFB Smear Screening System for
Laboratory Diagnosis on Routine Practice
Hsiao-Ting Fu 1,2 , Hui-Zin Tu 3 , Herng-Sheng Lee 3 , Yusen Eason Lin 4 and Che-Wei Lin 2,5,6,7, *

1 Division of Laboratory Medicine, Kaohsiung Veterans General Hospital Tainan Branch, Tainan 701, Taiwan
2 Department of Biomedical Engineering, National Cheng Kung University, Tainan 701, Taiwan
3 Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital,
Kaohsiung 813, Taiwan
4 Graduate Institute of Human Resource and Knowledge Management, National Kaohsiung Normal University,
Kaohsiung 813, Taiwan
5 Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
6 Medical Device Innovation Center, National Cheng Kung University, Tainan 701, Taiwan
7 Institute of Medical Informatics, College of Electrical Engineering and Computer Science, National Cheng
Kung University, Tainan 701, Taiwan
* Correspondence: [email protected]

Abstract: The most robust and economical method for laboratory diagnosis of tuberculosis (TB) is
to identify mycobacteria acid-fast bacilli (AFB) under acid-fast staining, despite its disadvantages
of low sensitivity and labor intensity. In recent years, artificial intelligence (AI) has been used in
TB-smear microscopy to assist medical technologists with routine AFB smear microscopy. In this
study, we evaluated the performance of a TB automated system consisting of a microscopic scanner
and recognition program powered by artificial intelligence and machine learning. This AI-based
system can detect AFB and classify the level from 0 to 4+. A total of 5930 smears were evaluated
on the performance of this automatic system in identifying AFB in daily lab practice. At the first
stage, 120 images were analyzed per smear, and the accuracy, sensitivity, and specificity were 91.3%,
Citation: Fu, H.-T.; Tu, H.-Z.; Lee,
60.0%, and 95.7%, respectively. In the second stage, 200 images were analyzed per smear, and the
H.-S.; Lin, Y.E.; Lin, C.-W. Evaluation
accuracy, sensitivity, and specificity were increased to 93.7%, 77.4%, and 96.6%. After removing
of an AI-Based TB AFB Smear
disqualifying smears caused by poor staining quality and smear preparation, the accuracy, sensitivity,
Screening System for Laboratory
Diagnosis on Routine Practice.
and specificity were improved to 95.2%, 85.7%, and 96.9%, respectively. Furthermore, the automated
Sensors 2022, 22, 8497. https:// system recovered 85 positive smears initially identified as negative by manual screening. Our results
doi.org/10.3390/s22218497 suggested that the automated TB system could achieve higher sensitivity and laboratory efficiency
than manual microscopy under the quality control of smear preparation. Automated TB smear
Academic Editor: Giacomo Oliveri
screening systems can serve as a screening tool at the first screen before manual microcopy.
Received: 2 October 2022
Accepted: 26 October 2022 Keywords: acid-fast bacilli; tuberculosis; artificial intelligence
Published: 4 November 2022

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1. Introduction
iations. Tuberculosis is an emerging infectious disease worldwide that is treatable, preventable,
and curable. However, due to its slow decline, tuberculosis remains a global public health
threat. In 2019, about 10 million people fell ill with tuberculosis, and 1.4 million died, more
than any other infectious disease [1,2]. Due to the COVID-19 pandemic, there has been a
Copyright: © 2022 by the authors. large global drop in the number of people newly diagnosed with TB and an 18% decline,
Licensee MDPI, Basel, Switzerland.
from 7.1 million in 2019 to 5.8 million in 2020, was reported [3]. Sixteen countries accounted
This article is an open access article
for 93% of this reduction, with India, Indonesia, and the Philippines the worst affected.
distributed under the terms and
According to the report in 2019, one year before the COVID-19 pandemic, the 30 high TB
conditions of the Creative Commons
burden countries accounted for nearly 90% of new TB cases. Eight countries accounted
Attribution (CC BY) license (https://
for two-thirds of the total, with India leading the count with 26%, followed by Indonesia
creativecommons.org/licenses/by/
4.0/).
(8.5%), China (8.4%), the Philippines (6.0%), Pakistan (5.7%), Nigeria (4.4%), Bangladesh

Sensors 2022, 22, 8497. https://doi.org/10.3390/s22218497 https://www.mdpi.com/journal/sensors

Sensors 2022, 22, 8497 2 of 10

(3.6%), and South Africa (3.6%) [1]. Heads of state and government representatives from
all UN members are committed to taking major steps toward building a tuberculosis-free
world, including ambitious goals to treat more than 40 million people with tuberculosis
and to prevent at least 30 million from becoming ill between 2018 and 2022, through
the provision of tuberculosis preventive treatment. According to the data from Taiwan
National Infectious Disease Statistics in 2019, there were 3.7 new TB cases and 0.23 deaths
per 100,000 people in Taiwan. The tuberculosis treatment success rate of new cases and
culture-positive cases were 72.1% and 68.9%, respectively [4].
The most robust and economical method recommended by the World Health Orga-
nization (WHO) for the first line of laboratory diagnosis of pulmonary tuberculosis is the
acid-fast stain method of sputum smears which relies on manual microscopic examination
for acid-fast mycobacteria bacilli (AFB). Although smear microscopy is a low-cost and
widely used method, its sensitivity is only 50–60% in pulmonary TB [5]. The fluorescence
microscopy is more sensitive than Ziehl–Neelsen stain smear microscopy, but the specificity
is similar [6]. The WHO suggested that 1.1 microscopy laboratories should be available
for every 100,000 people, and be able to perform quality-assured AFB microscopy [2]. To
increase the positive rate, it requires three sputum samples in a row for each potential
TB patient (72% at the first samples to 76% with three samples’ examination) [7]. AFB
smear microscopy is labor-intensive work, and sensitivity may vary with the experience
of examiners, smear quality, eye fatigue, etc. Although some molecular-based methods,
such as GeneXpert MTB/RIF can assist in the identification of TB, its high cost means it is
unlikely to be affordable in many high TB-burden countries [8]. The gold standard for the
diagnosis of tuberculosis is still AFB and the fluorescent microscopic examination of smear
or bacteriological confirmation by the culture method. Recently, some automated TB smear
microscopy systems have been developed based on artificial intelligence (AI) and big data
analysis, which may significantly increase the sensitivity of TB smear microscopy [9–13].
Although all these studies reported better performance than human microscopic examina-
tion, most are still in development. Furthermore, this system adopted the idea from digital
pathology and used a whole slide scanner to randomly capture the images from the smears.
However, the image results are not satisfactory, because TB sputum smears are prepared by
hand and the specimens are not smoothly placed onto the glass slide for scanning, unlike
the liquid-based cytological smear. An automatic AFB detection system, equipped with a
20× objective lens and an eight-slide loading tray, was applied in daily routine practice
for TB sputum smear in our lab. In this study, we evaluated the accuracy of this system
compared to traditional manual smear screening in actual practice on routine screening TB
smears. We would also like to figure out the key factors that affect the performance when
applying the automated TB smear screening system to replace human manual screening.
We found the key parameters that effect the accuracy were mostly smear quality and
amount of image capture in a constant area. The outcome of an automatic analysis mainly
replies on the input images and setting. For achieving the best performance in automation
AI-based systems or devices, we think it is necessary to combine the automation of sample
preparation and the image recognition algorithm in a whole system.

2. Materials and Methods

2.1. Study Design
This was a single-center, retrospective, and double-blind study. The study was ap-
proved by Kaohsiung Veterans General Hospital Institutional Review Board (KSVGH22-
CT4-04). A total of 5930 TB sputum smears were evaluated in this study, collected from the
microbiology lab at Kaohsiung General Hospital. The data was collected from December
2018 to January 2020. The evaluation periods were divided into two stages. In the first stage
(from December 2018 to March 2019), 1014 smears were analyzed based on the original
setting of the machine, which randomly captured 120 images per smear. In the second stage
(from April 2019 to January 2020), the image captured field was increased to 200 images
per smear, and 3902 smears were analyzed.
 stage (from December 2018 to March 2019), 1014 smears were analyzed based on the orig-
inal setting of the machine, which randomly captured 120 images per smear. In the second
Sensors 2022, 22, 8497 stage (from April 2019 to January 2020), the image captured field was increased to3 of
200
10
images per smear, and 3902 smears were analyzed.

2.2.
2.2. Procedures
Procedures
The
The sample
sample collection,
collection, handling,
handling, preparation,
preparation, and and AFB
AFB smear
smearmicroscopy
microscopy were
were based
based
on
on the lab guideline authority by the biosafety committee. The sputum samples were
the lab guideline authority by the biosafety committee. The sputum samples were
spread
spread onon aa fixed
fixedarea
areaofof1 1cm
cm××2 2cmcmonon thethe slide
slide andand treated
treated withwith Ziehl–Neelsen
Ziehl–Neelsen stainstain
[14].
[14].
All ofAlltheofslides
the slides
werewere
loaded loaded intoautomated
into the the automated system system and scanned
and scanned by theby the system.
system. After
After the system
the system finished
finished the reading,
the reading, the slides
the slides were were reviewed
reviewed by abymicrobiological
a microbiological med-
medical
ical technologist
technologist without
without knowing
knowing thethe results
results of of
thethe system.Both
system. Bothsides
sides of
of the
the results
results were
were
checked
checkedby byan anindependent
independentmicrobiology
microbiology medical
medical technologist. TheThe
technologist. general workflow
general workflowdi-
agram was illustrated in Figure
diagram was illustrated in Figure 1. 1.

Figure 1.
Figure The general
1. The general workflow
workflow of
of image
image processing
processing and comparison of performance.

2.3. AI-Based Automatic TB Detection Device

2.3. AI-Based Automatic TB Detection Device
An automated microscope system (µ-Scan 1.1, Wellgen Medical, Kaohsiung, Taiwan)
An automated microscope system (µ-Scan 1.1, Wellgen Medical, Kaohsiung, Taiwan)
was used for TB detection [15]. The system consists of two components: hardware and
was used for TB detection [15]. The system consists of two components: hardware and
software. The hardware included an eight-slide tray and a microscopic digital camera
software. The hardware included an eight-slide tray and a microscopic digital camera
with an auto-focusing and slide-scanning mechanism to cover the specimen based on
with an auto-focusing and slide-scanning mechanism to cover the specimen based on
WHO recommendations (300 fields @1000× oil lens) (Figure 2a). The system is designed
WHO
to onlyrecommendations
scan the 1 cm × (300 2 cmfields
fixed @1000×
area andoilcapture
lens) (Figure 2a). The
the images system
(Figure 2b).is The
designed
fixed
to only scan the 1 cm × 2 cm fixed area and capture the images (Figure
1 cm × 2 cm area was divided into ten parts and was scanned one by one (Figure 2b). The fixed 1 cm
2c).
×The
2 cmsoftware uses an image recognition algorithm to detect and classify positive soft-
area was divided into ten parts and was scanned one by one (Figure 2c). The AFB
ware
from uses
levelan image
0 to recognition
4+ (Figure algorithm
3). This device to
candetect and classify
be loaded positive
with eight AFB
slides onfrom
a traylevel
per
0run,
to 4+ (Figure 3). This device can be loaded with eight slides on a
and each slide takes about 4 min to scan and obtain results. The microscopictray per run, and each
images
slide
were takes about
digitally and4 randomly
min to scan and obtain
captured andresults.
stored. The microscopic
In the imagescandidate
detection phase, were digitally
AFBs
and
were marked and differentiated from other substances and tissues in thewere
randomly captured and stored. In the detection phase, candidate AFBs smear marked
based
and differentiated
on color from other features.
and morphological substances Inand
the tissues in the smear
classification phase,based on color
the feature and mor-
parameters
phological features. In the classification phase, the feature parameters were
were extracted from AFB candidates as the input parameters to a proprietary classifier. extracted from
The results were recorded as positive if any AFB was identified in the image of the slide.
Senior medical technologists reviewed all the images and slides to confirm the consistency
and evaluate the system’s performance. The training system is a hybrid system including
supervised training (targeting bacilli-like objects) and unsupervised training (putting the
bacilli-like objective into the convolutional neural network (CNN) for deep learning).
 Table 4. The performance of the automated TB smear microscopy system and manual microscopy
after
AFBremoval of inadequate
candidates cases.
as the input parameters to a proprietary classifier. The results were rec-
orded as positive if any AFB was identified in the image of the slide. Senior medical tech-
Automated System Manual Microscopy
Sensors 2022, 22, 8497 nologists reviewed all the images and slides to confirm the consistency and evaluate4 of the
10
True positive 406 389
system’s performance. The training system is a hybrid system including supervised train-
True negative 2634 2719
ing (targeting bacilli-like objects) and unsupervised training (putting the bacilli-like ob-
False positive 85 0
jective into the setting
The algorithm convolutional neural network
was developed (CNN) for deep
by the manufacturer learning).
(µ-Scan 1.1, The algorithm
Wellgen Medica,
False negative
setting was developed by the 68
manufacturer (µ-Scan 1.1, Wellgen 85
Medica, Kaohsiung, Tai-
Kaohsiung, Taiwan). The system applied supervised training to identify the targets of
Total
wan). cases 3193 training to identify the targets3193
interest based on the morphology (e.g., color, size, length-to-width ratio, etc.) of a on
The system applied supervised of interest based TB
Sensitivity
the morphology size,85.7% 82.1%
bacillus. All the (e.g., color,
targets of interest length-to-width
were processed ratio, etc.) of
through a TB bacillus.
a deep learningAll the targets
algorithm for
Specificity
of interestbacillus
acid-fast were processed
recognition through96.9%
based aondeep learning algorithm
the convolutional networkfor work100%
acid-fast bacillus
(CNN) recog-
framework
Accuracy
nition based
and other on the methods
modified convolutionalto 95.2%
network
fine-tune thework adjusting97.3%
(CNN)byframework
algorithm andthresholds.
the other modified
Then
methods to fine-tune the algorithm by adjusting the thresholds. Then
the certified medical technicians reviewed the results from the algorithm validation as the certified medical
Table 5. The
technicians
the gold precision
reviewed
standard, and
theerror
and rate of
results
identified the
from automation
thepositive
false system
algorithm andnegative
andvalidation
false manual microscopy.
as the of The
gold standard,
targets “True”
and
interest to
represents
identified the cases
false diagnosed
positive and correctly;
false The “False”
negative targetsrepresents
of theto
interest cases
be of wrong diagnosis.
re-enrolled into the da-
be re-enrolled into the dataset by the machine learning framework to further improve
taset by the machine learning framework to further improve
the algorithm. Manualthe algorithm.
Microscopy
FinTotal Case No. 3902
True False
3567 90
True
Automated 91.41% 2.31%
system 243 2
False
6.32% 0.06%

Table 6. The precision and error rate of the automation system and manual microscopy. The “True”
represents the cases diagnosed correctly; the “False” represents the cases of wrong diagnosis, after
removal of inadequate cases.
(a) (b) (c)
Figure 2. The automated microscopy system: (a) an eight-slide Manual
tray inMicroscopy
one run. (b) The fixed 1 cm ×
Figure 2.TotalTheCase
automated microscopy3193 system: (a) an eight-slide tray in one run. (b) The fixed
2 cm area where microscopy scanning. The slides of 1, 2True and 3 were inadequate smears, Falsethe slides
1 cm × 2 cm area where microscopy scanning. The slides of 1, 2 and 3 were inadequate smears, the
of 4 and 5 (marked with red square) were adequate smears. The
2957 number represents the five different
83
slides of
slides. (c)4The
andfixed
5 (marked
1 cm × with
2 cm red square)
True
area were was
on the slide adequate smears.
divided into 10 The number
small areas represents the one
to be scanned five
differentAutomated
slides. (c) The fixed × 2 cm
1 cmwith 92.61% 2.60%
by one. The 10 areas were marked the area on the
number fromslide
1 towas divided
10. When theinto 10 smallbacteria
suspicious areas toare
be
scanned one
detected, system
the by one. will
system The indicate
10 areas the
were marked
location ofwith
area the 151
number
number. from 1 to 10. When the 2 suspicious
False
bacteria are detected, the system will indicate the location 4.73%
of area number. 0.06%
2.4. Data Interpretation
The evaluation of test performance is based on overall accuracy, sensitivity, and spec-
ificity. Statistical analysis was performed using IBM SPSS Statistics, Version 25.0. Armonk,
NY, USA.

3. Results
3.1. The Performance of the Automation System
When AFB the study
0 started in December 2018, the first test results (from
AFB Trace AFB 1+December 2018
to March 2019, n = 1014) were as follows: the sensitivity and specificity were 60% (75/125)
and 95.7% (851/889). After a series of imaging training and testing and an increase in the
scanning area by 40% (from 120 digital images to 200), the second test results (from April
2019 to January 2020, n = 3902) were improved: the sensitivity and specificity were 77.4%
(460/594) and 96.6% (3197/3308), respectively (Table 1). During the study, some smears
were not as consistent during the sampling process. A total of 709 smears were later ex-
cluded from this study due to incomplete stain removal (n = 325), smear location shift (n
AFB 2+ AFB 3+ AFB 4+
= 89), smear being too thick (n = 49), smear being too thin (n = 110), smear dropping off (n
=Figure
96), and
Figure other
3.3.The
The AFBreasons
AFB stainingdue
staining to atypical
images
images from mycobacterial
fromtrace
traceto
to4+.
4+. morphology (n = 40) (Table 2, Figures
2b and 4). Thus, the overall results of accuracy, sensitivity, and specificity were 95.2
2.4. Data Interpretation
(3040/3193), 85.6% (406/474), and 95.2% (2634/2719), respectively (Table 1).
The evaluation of test performance is based on overall accuracy, sensitivity, and
specificity. Statistical analysis was performed using IBM SPSS Statistics, Version 25.0.
Armonk, NY, USA.

3. Results
3.1. The Performance of the Automation System
When the study started in December 2018, the first test results (from December 2018
to March 2019, n = 1014) were as follows: the sensitivity and specificity were 60% (75/125)
Sensors 2022, 22, 8497 5 of 10

and 95.7% (851/889). After a series of imaging training and testing and an increase in
the scanning area by 40% (from 120 digital images to 200), the second test results (from
April 2019 to January 2020, n = 3902) were improved: the sensitivity and specificity were
77.4% (460/594) and 96.6% (3197/3308), respectively (Table 1). During the study, some
smears were not as consistent during the sampling process. A total of 709 smears were later
excluded from this study due to incomplete stain removal (n = 325), smear location shift
(n = 89), smear being too thick (n = 49), smear being too thin (n = 110), smear dropping
off (n = 96), and other reasons due to atypical mycobacterial morphology (n = 40) (Table 2,
Figures 2b and 4). Thus, the overall results of accuracy, sensitivity, and specificity were 95.2
(3040/3193), 85.6% (406/474), and 95.2% (2634/2719), respectively (Table 1).

Table 1. The performance of the automated TB smear microscopy system.

Stage 1 Stage 2
Included Cases with
19 December 2018– 29 March 2019– Adequate Smear
Period
28 March 2019 31 December 2019
True positive 75 460 406
True negative 851 3197 2634
False positive 50 111 85
False negative 38 134 68
Total cases 1014 3902 3193
Sensitivity 60.0% 77.4% 85.7%
Specificity 91.3% 96.6% 96.9%
Accuracy 95.7% 93.7% 95.2%

Table 2. The factors that influence the smear microscopy.

No. of Cases Percentage (%)

Incomplete stain 325 45.9%
Smear too thin 110 15.5%
Smear dropped off 96 13.5%
Smear location shift 89 12.6%
Smear too thick 49 6.9%
Sensors 2022, 22, x FOR PEER REVIEW Atypical TB shape 40 5.6% 7 of 11
Total 709 100%

False positive AFB 3+ False positive AFB 4+

Figure
Figure4.4.The
Thetwo
twofalse-positive
false-positivecases
casesdue
duetotothe
thepoor
poorsmear
smearstaining
stainingquality.
quality.

We also compared the performance of the automated TB smear microscopy system

with manual microscopy performed by medical technologists. Manual microscopy was
superior to the automated TB smear microscopy system. The sensitivity, specificity, and
accuracy of manual TB smear microscopy were 84.5%, 100%, and 97.6%, respectively,
while those of the automated system were 77.4%, 96.6%, and 93.7%, respectively (Table 3,
Figure 5). However, after excluding inadequate cases, the sensitivity of the automation
system increased to 85.7%, which is higher than manual microscopy with a sensitivity of
82.1% (Table 4 and Figure 6). Furthermore, about 91.4% of cases were reported as positive
by both the automation system and technologists, and only <0.1% of cases were missed and
Sensors 2022, 22, 8497 6 of 10

reported as negative by both. Overall, the error rate of the automation system (6.32%) was
higher than our technologists (2.31%) (Table 5). After excluding the inadequate cases, the
error rate of the automation system decreased to 4.73%, while that of technologists slightly
increased to 2.6% (Table 6). There were two positive cases missed out by both of them.
Sensors 2022, 22, x FOR PEER REVIEW 7 of 11

Table 3. The performance of automated TB smear microscopy system and manual microscopy.

Automated System Manual Microscopy

True positive 460 502
True negative 3197 3308
False positive 111 0
False negative 134 92
Total cases 3902 3902
Sensitivity 77.4% 84.5%
Specificity
False positive AFB 3+ 96.6%
False positive AFB 4+ 100%
Accuracy 93.7% 97.6%
Figure 4. The two false-positive cases due to the poor smear staining quality.

Figure 5. The confusion matrix of automation system with 200 images capture setting.
Figure 5. The confusion matrix of automation system with 200 images capture setting.

Table 4. The performance of the automated TB smear microscopy system and manual microscopy
after removal of inadequate cases.

Automated System Manual Microscopy

True positive 406 389
True negative 2634 2719
False positive 85 0
False negative 68 85
Total cases 3193 3193
Sensitivity 85.7% 82.1%
Specificity 96.9% 100%
Accuracy 95.2% 97.3%

Figure 6. The confusion matrix of automation system with 200 images capture setting after removal
of inadequate cases.
Sensors 2022, 22, 8497 7 of 10
Figure 5. The confusion matrix of automation system with 200 images capture setting.

Figure 6.
Figure The confusion
6. The confusion matrix
matrix of
of automation
automation system
system with
with 200
200 images
images capture
capture setting
setting after
after removal
removal
of inadequate
of inadequate cases.

Table 5. The precision and error rate of the automation system and manual microscopy. The “True”
represents the cases diagnosed correctly; The “False” represents the cases of wrong diagnosis.

Manual Microscopy
FinTotal Case No. 3902
True False
3567 90
True
Automated 91.41% 2.31%
system
243 2
False
6.32% 0.06%

Table 6. The precision and error rate of the automation system and manual microscopy. The “True”
represents the cases diagnosed correctly; the “False” represents the cases of wrong diagnosis, after
removal of inadequate cases.

Manual Microscopy
Total Case 3193
True False
2957 83
True
Automated 92.61% 2.60%
system 151 2
False
4.73% 0.06%

3.2. The Consistency between the Automated System and Manual Microscopy
In our result, the consistency between the automated system and manual microscopic
examination was 100% on AFB results on 2+ to 4+ smears (within ±1 to 2 levels were
acceptable). The consistency discrepancy mainly came from smears in trace and 1+ and
trace, 39.1%, and 89.1%, respectively (Table 7). This system recovered 85 smears initially
found negative from manual microscopic examination (one smear from 2+, 19 smears from
1+, and 65 smears from scanty). However, the automatic system missed 66 smears reported
as positive from manual microscopic examination (5 smears from 1+ and 61 smears from
scanty) (Table 8).
Sensors 2022, 22, 8497 8 of 10

Table 7. The consistency between the automated TB smear microscopy system and manual micro-
scopic examination.

Manual Microscopy Automated System Consistency (%)

Trace 192 75 39.1
AFB 1+ 137 122 89.1
AFB 2+ 89 89 100.0
AFB 3+ 47 47 100.0
AFB 4+ 37 37 100.0
Not Found 3308 3308 100.0

Table 8. The number of missed cases by the automation system and manual microscopy.

Missed by System Missed by Manual Examination

Trace 61 65
1+ 5 19
2+ 0 1
Total 66 85

4. Discussion
In the microbiology laboratory, the AFB staining and fluorescence microscopy of
sputum smear is still considered standard procedures to confirm Mycobacteria. They are
also the most economical, rapid, and readily available methods. However, AFB smear
microscopy is labor-intensive work, and the sensitivity may vary with the experience of
examiners, smear quality, eye fatigue, etc. Thus, the application of an automatic AI-based
system in TB smear examination may provide a constancy of performance and assist medical
technologists in carrying out the first screen. We hope such automatic AFB screening system
can perform high-throughput screening to increase the positive detection rate.
We applied an automatic TB screening system on AFB smear microscopy in our
hospital. In our on-site test, the automated TB scan system achieved an accuracy of 95.2%,
sensitivity of 85.7%, and specificity of 96.9%. When comparing the smear microscopy results
with culture, the manual microscopy’s overall performance was superior to the automation
system. However, after excluding inadequate cases, the sensitivity of the automation
system increased to 85.7 from 77.4%, which was higher than manual microscopy with a
sensitivity of 82.1%. The error rate of the automation system was 3.7% higher than manual
microscopy (2.6%). The design of an image recognition algorithm is to maximize sensitivity,
therefore false positives may occur, and those cases need to be ruled out by technologists.
All the false positive cases were trace or 1+ levels and accounted for 1.7% in total cases and
11.1% in positive cases detected by the automated system. The automation system showed
acceptable consistency with manual microscopy at the higher level, such as 2+, 3+, and 4+.
It may save 24.5% of screening time on positive cases for manual microscopy.
In 2012, Lewis et al. reported a smear microscopy system with the sensitivity and
specificity of 75.8% and 43.8% [9]. In 2019, Lopez-Garnier et al. reported a CNN automatic
TB diagnostic system with high accuracy (96.6%, and a sensitivity and specificity ranging
from 91% to 99%. From 2012 to now, numerous AI-based images diagnosis systems have
been reported, and the overall performance showed dramatic improvement. Such an
improvement in AI development may be due to the progress of algorithms and computing
capability. However, we found training images had very different qualities, such as color
pixels; this may lead to overfitting outcomes. That may imply that most systems might not
be universal. Compared to those studies, our proof-of concept study showed acceptable
results. For seeking the best performance, we think the standardized sample preparation
and customized algorithm fine-tuning are needed.
Furthermore, we found several issues worth mentioning when applying automated
microscope systems in clinical laboratories: (a) the smear location: the manual smear
technique needs to be standardized so that the smear location is systematically the same
Sensors 2022, 22, 8497 9 of 10

place. If the smear location is not standardized, it may affect the accuracy of the automated
system. (b) Stain quality: the manual stain technique also affects the automated system’s
performance, since the recognition software uses color as an important parameter for detect-
ing AFB. An automatic smear and stain system, in addition to our automated microscope,
may improve the quality of the smears. The main purpose of developing an AI-based TB
automatic screening system is to save the technician’s workload and focus on the suspected
positive slide of AFB. We consider such AI-based TB automation system as an assistance
tool, instead of a replacement for the diagnosis from medical technologists. This system
can facilitate the junior technicians to minimize error rate, due to the lack of experience.
Through advances in artificial intelligence (AI), machine learning (ML), and deep
learning technology (DL), medicine is shifting into the digital medicine era. Computer
technology not only can be used to make medical records, transport data, or in analysis,
but also be expected to function with AI to diagnose diseases, make medical decisions,
give health suggestions, and even treat patients [16]. AI has been massively applied in the
development of medical devices and software. In the medical laboratory, most works still
rely on pathologists, cytopathologists, and medical technologists, and manual operation
remains. With a large number of samples needing to be handled in medical laboratories
every day, the role of AI in laboratory medicine is expected to improve the accuracy of
detection and laboratory workflow, help avoid diagnosis errors, and increase efficiency.
Based on a survey, about 15.6% of organizations currently use AI in lab diagnosis. However,
most still remain uncertain about adopting AI in medical diagnosis. One concern is the
lack of proven clinical benefits. Therefore, our lab-side routine practice data showed
promising results and support and ensured the reliability of AI-based medical devices’
performance [17]. The proof-of-concept of this AI-based medical devices at our lab can
provide reassurance to other laboratories when they were considering the installation of
such expensive automation systems or devices.
This TB smear automatic screening system is rapid and easy to operate for lab staff.
The light and neat device design can easily settle on the table in any laboratory space.
A good medical device design should consider the applicability and convenience of the
potential users. The standard AFB staining for TB diagnosis only requires simple sputum
smear preparation. With the help of automatic TB bacteria detection systems, the capacity
of AFB tests per year can be increased. Automatic TB bacteria screening systems equipped
with AI should be installed in high tuberculosis burden countries with limited medical
resources, especially in developing countries or remote areas.
Besides bacteria morphology, gene identification, chest X-ray images, and biosensor
medical devices, such as electronic noses, can detect tuberculosis via patient’s breath and
even culture samples of Mycobacterium tuberculosis. The odor of bacteria itself or patients
with TB infection can be analyzed via e-nose [18]. These need machine learning and deep
learning to set up algorithms to work on the device. In the future, AI can help develop
needed tools for TB diagnosis and increase the accuracy of current TB diagnosis methods.

5. Conclusions
In conclusion, the automated TB microscopy system can achieve the same high per-
formance as manual microscopy. We found that the accuracy of this system was mainly
influenced by the scanning area and the smear staining quality. By increasing the number
of captured images on each slide, the positive rate of TB screening will also be increased.
To achieve better staining quality, the establishment of standardized staining procedures is
essential. It could assist medical technologists in screening positive cases, which may be
missed by manual microscopy screening. The standardized smear preparation protocol is
needed for the adoption of the automation system. A regularly updating algorithm from
clinical data for training, validation, and testing may improve the accuracy.
Sensors 2022, 22, 8497 10 of 10

Author Contributions: Conceptualization, H.-Z.T.; methodology, H.-Z.T.; software, Y.E.L.; validation,

H.-T.F. and H.-Z.T.; formal analysis, H.-T.F.; investigation, H.-T.F. and H.-Z.T.; data curation, H.-Z.T.;
writing—original draft preparation, H.-T.F.; writing—review and editing, C.-W.L.; visualization,
H.-T.F.; supervision, C.-W.L.; project administration, H.-S.L.; funding acquisition, H.-S.L. All authors
have read and agreed to the published version of the manuscript.
Funding: This work was funded by Kaohsiung Veterans General Hospital Research Program (grant
KSC-110-072) in Kaohsiung Veterans General Hospital in Taiwan.
Institutional Review Board Statement: The study was approved by Kaohsiung Veterans General
Hospital Institutional Review Board (KSVGH22-CT4-04), Taiwan.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: This work was funded by Kaohsiung Veterans General Hospital Research
Program (grant KSC-110-072) in Kaohsiung Veterans General Hospital in Taiwan. We also expressed
our sincere appreciation to Febryan Setiawan, Hoang Trang Nguyen, and Maydiana Nurul Kurniawati
for their assistance in the document editing of the manuscripts.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or
in the decision to publish the results.

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