After steady declines in global and US incidence of TB for decades, this most fatal infectious organism of the modern era has been back on the rise since 2019.1 Suspected causes of the increase include less aggressive use of masking and isolation of at-risk patients at the conclusion of the COVID-19 pandemic and the current conflict in TB-endemic Ukraine and Russia.2 Today, most cases of active TB are thought to be due to progression of latent disease rather than new cases in previously uninfected individuals.
In the US, diagnosis and treatment of TB, coordinated mostly through local health departments, is hampered chiefly by socioeconomic and administrative factors. TB in patients in the US is overwhelmingly seen in immigrants and racial and ethnic minorities—groups much less likely to have access to the health care system. And while TB screening is federally required for immigrants annually who seek permanent resident status, no such requirement exists for those in the US on work or education visas or under refugee status. Further, health department funding for TB care can vary significantly based on state and locality.
Fortunately, there are a few hopeful developments for the care of these patients. A recent clinical practice guideline, which included experts from the American Thoracic Society, Infectious Disease Society of America, Centers for Disease Control, and European Respiratory Society, advocates for the use of shorter courses of treatment in both drug-susceptible and multidrug-resistant (MDR) TB.3 In patients with susceptible disease, rifapentine-based regimens that are four months rather than six months are now standard; and in patients with MDR TB, bedaquiline-based regimens that are six months rather than 15 months are now standard. These relaxed treatment duration standards are hoped to improve TB remission in those with active disease due to nettlesome adherence challenges with prolonged multidrug regimens.
Despite these advances, a recent study investigating genomic clusters of drug-resistant genes in MDR demonstrates that highly resistant organisms (strains resistant to rifampin, isoniazid, and an agent of bedaquiline-based regimens) are now present in at least 26 countries.4 Approximately 1% of patients diagnosed with TB in the US are infected by MDR strains.
We are approaching the final months of the CDC’s Division of Tuberculosis Elimination 2022-2026 Strategic Plan, which includes the ambitious goal of eliminating TB in the US by focusing on prevention, diagnosis, and treatment of historically unreached non-US-born, racial and ethnic minorities, and patients who are unhoused or imprisoned. Time will tell whether we are closer to seeing an end to this devastating disease.
References
1. Williams PM, Pratt RH, Walker WL, Price SF, Stewart RJ, Fan P-J I. Tuberculosis — United States, 2023. MMWR Morb Mortal Wkly Rep. 2024;73(12):265-270.
2. Hauer B, Kroger S, Haas W, Brodhun B. Tuberculosis in times of war and crisis: epidemiological trends and characteristics of patients born in Ukraine, Germany, 2022. Euro Surveill. 2023;28(24):2300284.
3. Saukkonen JJ, Munsiff SS, Winston CA, et al. Updates on the treatment of drug-susceptible and drug-resistant tuberculosis: an official ATS/CDC/ERS/IDSA clinical practice guideline. Am J Respir Crit Care Med. 2025;211(1):15-33.
4. Goig GA, Loiseau C, Maghradze N, et al. Transmission as a key driver of resistance to the new tuberculosis drugs. N Engl J Med. 2025;392(1):97-99.