Tuberculosis: A Global Public Health Challenge—Epidemiology, Prevention, Control, and Future Directions
1. Kalybekova K.D
2. Adarsh Shirale,
Sumit Avachar, Prasad Devkate, Omkar Shinde,
Kiran Dongre, Anil Rathod, Farhan Khan,
Riya Sharda, Prachi Mhaske, Najrana,
Amrutha Gaikwad, Namrata Gaikwad, Trupti Boharupi,
Bano Afsana, Toshini Kodape
(1. Teacher, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.
2. Students, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.)
Abstract
Tuberculosis remains one of humanity's most persistent and devastating infectious diseases, claiming approximately 1.23 million lives in 2024 and causing an estimated 10.7 million new cases worldwide. Despite being both preventable and curable, tuberculosis continues to exact a disproportionate toll on the world's most vulnerable populations, reflecting deep-seated inequities in health systems, socioeconomic conditions, and political commitment. This review synthesizes the most current epidemiological evidence, drawing upon the World Health Organization's Global Tuberculosis Report 2025, peer-reviewed research, and population-based data to examine the global burden of TB, its regional and demographic distribution, the evolving crisis of drug-resistant tuberculosis, the impact of HIV co-infection, advances in diagnostics and treatment, the social determinants that drive transmission, and the formidable challenges facing global elimination efforts. The analysis reveals that while the COVID-19 pandemic disrupted TB services and reversed years of progress, 2 024 marked the first post-pandemic decline in incidence. However, the global reduction of 12.3 percent since 2015 falls dramatically short of the 50 percent milestone targeted by the End TB Strategy for 2025. Drug-resistant TB, though declining in estimated incidence, continues to consume over half of national TB budgets while affecting only 5 to 10 percent of cases. The review further evaluates the pipeline of new diagnostics, drugs, and vaccines, the persistent funding crisis that threatens to unravel hard-won gains, and the social determinants including poverty, malnutrition, and stigma that perpetuate the epidemic. The findings underscore that ending tuberculosis as a global health threat by 2030 demands not merely biomedical innovation but a fundamental transformation in how societies address the conditions that allow this ancient killer to persist.
Keywords: tuberculosis, global health, drug-resistant TB, HIV co-infection, End TB Strategy, diagnostics, social determinants, funding, elimination
1. Introduction
Tuberculosis is a disease that humbles the modern world. Despite centuries of scientific progress, the discovery of effective antibiotics, the development of vaccines, and the establishment of global health institutions dedicated to its eradication, Mycobacterium tuberculosis continues to infect and kill millions of people every year. In 2024, an estimated 10.7 million people fell ill with tuberculosis, and 1.23 million died from it, making TB the world's leading infectious disease killer, surpassing even HIV/AIDS and malaria in mortality. These figures are not merely statistics; they represent individual tragedies, families shattered, communities impoverished, and nations burdened by a disease that thrives on the very conditions of disadvantage that public health has long promised to address.
The story of tuberculosis is inseparable from the story of human civilization. Evidence of spinal tuberculosis has been found in Egyptian mummies dating back to 3000 BCE, and the disease was known to ancient Greek physicians as phthisis, the wasting away. In the nineteenth century, tuberculosis was romanticized as the "white plague" that claimed the lives of artists and poets, but its true victims were the poor, the malnourished, and the crowded inhabitants of industrializing cities. Robert Koch's identification of the tubercle bacillus in 1882 transformed understanding of the disease, yet the social and economic conditions that fuel its transmission have proven far more resistant to change than the bacterium itself. The discovery of streptomycin in 1943 and the subsequent development of multi-drug regimens raised hopes of elimination, yet nearly eight decades later, tuberculosis remains entrenched in the world's poorest regions.
The contemporary global response to tuberculosis is anchored in the World Health Organization's End TB Strategy, adopted in 2014, which set ambitious milestones for 2020 and 2025 and targets for 2030 and 2035. The strategy envisioned a 50 percent reduction in TB incidence rate by 2025 and an 80 percent reduction by 2030, compared with 2015 levels, alongside a 75 percent reduction in deaths by 2025 and 90 percent by 2030. These targets were integrated into the Sustainable Development Goals, specifically SDG Target 3.3, which calls for ending the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases by 2030. Yet as 2025 approaches, the global community finds itself far from these goals, with a 12.3 percent reduction in incidence since 2015 representing less than one-quarter of the targeted progress.
The COVID-19 pandemic dealt a devastating blow to tuberculosis control efforts worldwide. In 2020, global TB notifications fell by over 20 percent as healthcare systems were overwhelmed, diagnostic resources diverted, and patients unable or unwilling to seek care. The consequences were catastrophic: an estimated 7000 excess TB deaths occurred in the WHO European Region alone during 2020-2022, and modeling studies projected that the pandemic's disruptions would result in increased transmission, mortality, and drug resistance for years to come. While services have largely recovered to pre-pandemic levels by 2024, the years of disruption have left a lasting scar on the global TB response, and the disease's incidence rate in 2024, though declining for the first time since the pandemic, remains above the historic low of 2020.
This review aims to provide a comprehensive, evidence-based examination of tuberculosis as a global public health challenge in 2025. By synthesizing data from the WHO Global Tuberculosis Report 2025, the Global Burden of Disease Study, peer-reviewed research on drug-resistant TB, HIV co-infection, diagnostics, and social determinants, and the growing literature on stigma and patient experience, the article seeks to illuminate the multifaceted nature of the TB epidemic and the complex interplay of biomedical, social, economic, and political factors that determine its course. The ultimate objective is to contribute to a nuanced understanding that transcends the simplistic narrative of a curable disease that persists only because of inadequate resources, recognizing instead the deep structural forces that must be confronted if tuberculosis is to be truly eliminated.
2. Materials and Methods
This review was conducted as a narrative synthesis of peer-reviewed literature, official international health organization reports, and population-based surveillance data pertaining to tuberculosis epidemiology, prevention, control, and elimination. The search strategy encompassed electronic databases including PubMed, Scopus, Web of Science, and Google Scholar, with search terms including combinations of "tuberculosis," "TB," "global health," "epidemiology," "drug-resistant TB," "MDR-TB," "XDR-TB," "HIV co-infection," "diagnostics," "GeneXpert," "Truenat," "treatment," "bedaquiline," "pretomanid," "vaccine," "BCG," "social determinants," "stigma," "funding," "End TB Strategy," "COVID-19," and "elimination." The search was restricted to publications in English from January 2020 to May 2026, with selective inclusion of earlier seminal works where necessary to establish historical context or methodological foundations.
Inclusion criteria encompassed original research articles (cohort studies, randomized controlled trials, cross-sectional surveys, ecological analyses, and modeling studies), systematic reviews and meta-analyses, official WHO reports (Global Tuberculosis Reports 2020-2025, consolidated guidelines, and policy updates), national health surveillance data, and reports from international health organizations including the Global Fund, Treatment Action Group, and Gavi. Studies and reports were included regardless of geographical focus, provided that they offered sufficient methodological detail to permit critical appraisal of findings. Exclusion criteria included opinion pieces, editorials without original data, and studies focusing exclusively on non-human models or in vitro research without public health relevance.
Data extraction focused on study or report design, data sources, population characteristics, measured indicators, identified trends, policy descriptions, and reported outcomes. Particular attention was paid to the WHO Global Tuberculosis Report 2025, which provides the most current and comprehensive global data on TB burden, diagnosis, treatment, and financing. Where survey data or population-based studies are presented, sample sizes, time periods, and confidence intervals or uncertainty intervals are reported where available to permit assessment of statistical precision.
The quality of included sources was assessed using established critical appraisal criteria, with preference given to official WHO statistics, peer-reviewed research in high-impact journals, and reports from internationally recognized health organizations. However, no formal meta-analysis was performed due to the anticipated heterogeneity in data sources, time periods, and outcome measures. Instead, this review adopts a narrative synthesis approach that prioritizes contextual interpretation and the identification of patterns across diverse evidence sources.
3. Results
3.1 Global Epidemiology and Burden of Disease
The epidemiological landscape of tuberculosis in 2024 reflects both the lingering impact of the COVID-19 pandemic and the first signs of post-pandemic recovery. According to the WHO Global Tuberculosis Report 2025, an estimated 10.7 million people fell ill with TB worldwide in 2024, equivalent to 131 incident cases per 100,000 population. This represents a year-on-year decrease for the first time since the pandemic, reversing the consecutive increases observed between 2020 and 2023. The TB incidence rate also fell by 1.7 percent between 2023 and 2024, returning to the level of 2020, which was the historic low before the pandemic's disruptions. However, global incidence remains above pre-pandemic levels, and the net reduction in the TB incidence rate from 2015 to 2024 was only 12.3 percent, far from the End TB Strategy milestone of a 50 percent reduction by 2025.
The estimated 10.7 million incident cases in 2024 were distributed across WHO regions with stark inequality. The South-East Asia Region accounted for 34 percent of global cases, the Western Pacific Region for 27 percent, and the African Region for 25 percent, with these three regions together bearing 86 percent of the global burden. The Eastern Mediterranean Region contributed 8.6 percent, the Americas 3.3 percent, and Europe 1.9 percent. This distribution reflects the concentration of TB in low- and middle-income countries, where poverty, overcrowding, malnutrition, and limited healthcare access create the conditions for sustained transmission.
Eight countries alone accounted for approximately two-thirds of global TB cases in 2024: India (25 percent), Indonesia (10 percent), the Philippines (6.8 percent), China (6.5 percent), Pakistan (6.3 percent), Nigeria (4.8 percent), the Democratic Republic of the Congo (3.9 percent), and Bangladesh (3.6 percent). India's dominance of the global burden, with one-quarter of all cases, underscores the centrality of South Asia to any effective global TB response. The concentration of cases in a relatively small number of countries offers both a challenge and an opportunity: targeted, well-resourced interventions in these high-burden nations could yield disproportionate global impact.
The demographic distribution of TB reveals important patterns. Adult men aged 15 years and above bore the highest burden, with an estimated 5.8 million cases (54 percent of the total) in 2024. Adult women accounted for 3.7 million cases (35 percent), while children aged 0-14 years represented 1.2 million cases (11 percent). The predominance of cases among adult men reflects both biological factors, including higher rates of progression from infection to disease, and social factors, such as greater exposure in occupational settings and lower rates of healthcare-seeking behavior. The substantial burden among children, who are particularly vulnerable to severe forms of TB including tuberculous meningitis and miliary TB, highlights the importance of household contact tracing and preventive therapy.
HIV co-infection remains a critical driver of TB morbidity and mortality. In 2024, 5.8 percent of all incident TB cases occurred among people living with HIV. The global pooled prevalence of TB-HIV co-infection, based on a comprehensive meta-analysis of 371 articles encompassing over 13 million patients, was estimated at 14 percent, with substantial regional variation: 22 percent in Africa, 21 percent in North America, 16 percent in South America, 10 percent in Europe, and 7 percent in Asia. The co-infection peaked in 1990, declined through the 2000s with the expansion of antiretroviral therapy, and reached its lowest point in 2022. However, the persistent burden, particularly in sub-Saharan Africa where HIV prevalence is highest, continues to complicate both TB and HIV control efforts. Meta-regression analyses have identified male sex, lower educational attainment, and drug-resistant tuberculosis as significantly associated with higher co-infection prevalence.
Mortality from tuberculosis in 2024 was estimated at 1.23 million deaths, down from 1.27 million in 2023 but still far above the End TB Strategy milestone of a 75 percent reduction by 2025. The number of deaths was reduced by 29 percent in the decade from 2015 to 2024, again falling short of the target. Among the 30 high TB burden countries, South Africa achieved the 2025 milestone for incidence reduction, while Kenya, Tanzania, and Zambia were close to reaching it. At the global level, 101 countries achieved reductions of more than 20 percent between 2015 and 2024, surpassing the first End TB Strategy milestone, and 30 countries achieved reductions of at least 50 percent, including one high-burden country (South Africa). However, 37 countries saw TB incidence rates in 2024 more than 5 percent higher than in 2015, with these setbacks concentrated in the Americas and including three high-burden Asian countries: Indonesia, Myanmar, and the Philippines.
3.2 The Crisis of Drug-Resistant Tuberculosis
Drug-resistant tuberculosis represents one of the most formidable challenges in the global TB response, threatening to render the disease untreatable with standard first-line regimens and consuming a disproportionate share of limited resources. Multidrug-resistant TB (MDR-TB), defined as resistance to both rifampicin and isoniazid, and extensively drug-resistant TB (XDR-TB), defined as resistance to rifampicin, any fluoroquinolone, and at least one of bedaquiline or linezolid, are estimated to account for 5 to 10 percent of total TB cases globally. Yet despite their relatively small numerical share, these forms of TB consume over 50 percent of national TB budgets, reflecting the complexity, duration, and cost of treatment.
The estimated incidence of rifampicin-resistant TB has been declining globally, a trend that is consistent with the falling number of people detected with rifampicin resistance. In 2024, 164,545 people were enrolled on treatment for MDR/RR-TB, representing a decline from 179,491 in 2022 (-8.3 percent) and 177,017 in 2023 (-7.0 percent). This decline in treatment enrollment reflects both the genuine reduction in incident drug-resistant cases and, potentially, gaps in detection and enrollment. The treatment success rate for drug-resistant TB showed improvement, rising to 71 percent in 2024 from 68 percent the previous year, though this remains substantially lower than the 88 percent success rate achieved for drug-susceptible TB.
The landscape of drug-resistant TB treatment has been transformed by landmark advances in recent years. Since 2018, the WHO has recommended all-oral regimens for MDR/RR-TB, replacing previous regimens that included injectable agents associated with severe adverse effects including irreversible hearing loss. The latest WHO guidelines, consolidated in April 2025, introduce several major categories of regimen. The first category comprises two 6-month all-oral regimens for people with MDR/RR-TB, with or without resistance to fluoroquinolones. The second category includes all-oral short regimens of 9 months for MDR/RR-TB patients without fluoroquinolone resistance. The third category encompasses longer regimens of 18-20 months that may include an injectable drug (amikacin) as a last resort.
The BPaLM regimen, comprising bedaquiline, pretomanid, linezolid, and moxifloxacin, has emerged as a cornerstone of the 6-month treatment approach. In the TB-PRACTECAL trial, the 24-week all-oral BPaLM regimen demonstrated non-inferiority to standard 9-20 month regimens, with 89 percent of patients in the BPaLM group achieving favorable outcomes compared to 52 percent in the standard care group. The BPaLM regimen also exhibited a better safety profile, with fewer adverse events and improved tolerability. However, WHO has not recommended BPaLM for children under 14 years of age, pregnant and breastfeeding women, and patients with central nervous system TB, disseminated TB, or miliary TB, due to limited safety and dosing data for pretomanid in these populations.
In June 2024, the WHO updated its guidelines to include a novel 6-month all-oral regimen, BDLLfxC, comprising bedaquiline, delamanid, linezolid (600 mg), levofloxacin, and clofazimine, for MDR/RR-TB with or without fluoroquinolone resistance. This regimen can be initiated without delay even when fluoroquinolone resistance status is unknown, and it is suitable for a wider range of patients including children, adolescents, and pregnant and breastfeeding women, making it more suitable for broad implementation. Additionally, modified 9-month regimens (BLMZ, BLLfxCZ, and BDLLfxZ) are now preferred over 18-month regimens for eligible patients. These advances represent a remarkable transformation from the era of 24-month toxic regimens to a new paradigm of shorter, all-oral, patient-centered treatment, though significant challenges remain in ensuring universal access to these life-saving therapies.
The cost differential between drug-susceptible and drug-resistant TB treatment remains substantial. First-line treatment for drug-susceptible TB costs approximately US$50 per person, while drug-resistant TB regimens range from US$200-600 per person based on prices quoted by the Global TB Drug Facility. These costs, while reduced from the peak of drug-resistant TB treatment expenditure, still represent a significant barrier in resource-constrained settings and contribute to the disproportionate budgetary impact of drug-resistant cases.
3.3 Diagnostics and the Challenge of Detection
The detection of tuberculosis, particularly in its drug-resistant forms, remains a critical bottleneck in the global response. In 2024, 8.3 million people were newly diagnosed with TB and accessed treatment, representing approximately 78 percent of the estimated 10.7 million people who fell ill with the disease. This means that over 2 million people remained undiagnosed or unreported, continuing to transmit infection and progress to severe disease and death. The coverage of rapid molecular testing for TB diagnosis increased from 48 percent in 2023 to 54 percent in 2024, a meaningful improvement but still leaving nearly half of the world's TB patients without access to the most accurate and rapid diagnostic technologies.
The GeneXpert MTB/RIF Ultra platform, developed by Cepheid, has been the backbone of rapid molecular TB diagnosis since its introduction, enabling simultaneous detection of Mycobacterium tuberculosis and rifampicin resistance within two hours. However, the platform's relatively high cost, requirement for stable electricity, and need for centralized laboratory infrastructure have limited its deployment in the most resource-constrained settings. The emergence of competing platforms is beginning to challenge Cepheid's near-monopoly on rapid molecular drug susceptibility testing. Molbio's Truenat system, which can be implemented in microscopy centers closer to the point of care than GeneXpert, offers MTB Plus and MTB-RIF Dx assays capable of processing samples on-site. SD Biosensor is developing tests for TB and resistance to rifampicin and isoniazid on the STANDARD M10 platform, while Bioneer is developing a test for TB and resistance to rifampicin, isoniazid, and fluoroquinolones on the IRON qPCR platform. These alternatives, expected to become available by 2025, promise to increase competition, reduce costs, and expand access to rapid diagnostics.
A cluster-randomized trial in Tanzania and Mozambique comparing decentralized Truenat testing at peripheral health facilities with hub-and-spoke GeneXpert Ultra testing found that the Truenat platform achieved higher rates of same-day diagnosis and treatment initiation. From a societal perspective, the facility-based diagnostic cost per participant testing positive for TB within seven days was $703 in Mozambique and $592 in Tanzania for the Truenat arm, compared to $853 and $596 respectively for the standard of care. Cost-effectiveness was enhanced under assumptions of higher testing volumes, with unit costs stabilizing at approximately three tests per day. These findings support the decentralization of molecular diagnostics to peripheral health facilities, bringing testing closer to the communities that need it most.
The diagnostic pipeline extends beyond molecular platforms to encompass innovative approaches that could transform TB detection. Ultraportable chest X-ray devices paired with artificial intelligence-based computer-aided detection software are already recommended by WHO for systematic screening, though their high cost has limited scale-up. Point-of-care ultrasound powered by AI and paired with smartphones offers a low-cost imaging option for children and pregnant women. Digital stethoscopes powered by AI can detect inaudible lung vibrations, while cough sound apps for smartphones enable self-screening by analyzing cough patterns as biomarkers for TB. Targeted next-generation sequencing from companies including GenoScreen and Oxford Nanopore Technologies offers comprehensive drug susceptibility profiling, though currently limited to centralized reference laboratories due to infrastructure requirements. Host-response blood tests, such as Cepheid's Xpert MTB-HR fingerstick test, show promise for both disease progression monitoring and child TB diagnosis.
Despite these technological advances, the fundamental challenge of TB detection remains rooted in health system capacity and patient access. In 2024, case notifications of children under 5 years of age were only 50 percent of estimated incidence, compared to 79 percent for adults, reflecting the persistent difficulty of diagnosing TB in young children who cannot produce sputum and whose disease often presents with non-specific symptoms. The gap between estimated incidence and reported cases, particularly in high-burden countries with weak health systems, represents a reservoir of undetected transmission that undermines elimination efforts.
3.4 HIV Co-Infection and the Syndemic Challenge
The intersection of tuberculosis and HIV represents one of the most devastating syndemics in global health, with each disease amplifying the other's morbidity and mortality. HIV infection dramatically increases the risk of developing active TB following exposure or reactivation of latent infection, while TB is the leading cause of death among people living with HIV. The global response to this co-epidemic has achieved remarkable successes in some dimensions while remaining inadequate in others.
The global decline in HIV-TB incidence has been approximately 60 percent, with mortality declining by 78 percent, reflecting the massive expansion of antiretroviral therapy and the integration of TB services into HIV care. In 2024, 5.8 percent of all TB cases occurred among people living with HIV, and 5.3 million people at high risk of TB received preventive treatment, up from 4.7 million in 2023. However, the persistent burden of HIV/DR-TB co-infection poses a significant challenge to international health security. Individuals co-infected with HIV and drug-resistant TB experience worse clinical outcomes and significantly elevated mortality rates compared to those with drug-susceptible TB.
The funding landscape for HIV-TB co-infection has become increasingly precarious. The period 2000-2015 witnessed substantial global investment in HIV/AIDS control, with over $500 billion allocated through Millennium Development Goal initiatives. The President's Emergency Plan for AIDS Relief (PEPFAR) has delivered remarkable outcomes since 2003, with cumulative investments exceeding $100 billion supporting annual antiretroviral therapy provision to 20.6 million individuals, including 550,000 children. However, funding freezes and cuts from 2025 onward pose a serious threat. Modeling studies have warned that a 90-day interruption in funding could cause 60,000-74,000 excess deaths, with prolonged cuts potentially triggering 500,000 additional pediatric AIDS deaths in sub-Saharan Africa within five years. These projections have profound implications for TB control, as the disruption of HIV services would inevitably lead to increased TB incidence and mortality among immunocompromised populations.
The social and behavioral determinants of HIV-TB co-infection demand integrated responses that extend beyond biomedical interventions. Meta-regression analyses have identified male sex, lower educational attainment, and drug-resistant TB as significantly associated with higher co-infection prevalence. In sub-Saharan Africa, where the co-epidemic is most concentrated, poverty, malnutrition, gender inequality, and limited healthcare access create the conditions for sustained transmission. The control of unsafe sexual practices, the reduction of drug misuse, and the protection of women from intimate partner violence have been identified as essential complementary strategies to biomedical interventions.
3.5 The Social Determinants of Tuberculosis
Tuberculosis is, at its core, a disease of social inequality. The biological agent, Mycobacterium tuberculosis, is necessary but not sufficient for the epidemic; it is the social, economic, and environmental conditions in which people live that determine whether exposure leads to infection, whether infection progresses to disease, and whether disease is diagnosed, treated, and cured. Understanding these social determinants is essential for any effective TB response.
Poverty is the most powerful predictor of tuberculosis risk. The percentage of the population living below the international poverty line, defined as living on $1.90 per day at 2017 purchasing power parity, is strongly correlated with national TB incidence rates. Overcrowded housing, inadequate ventilation, and limited access to clean fuels for cooking all increase the risk of transmission within households and communities. The prevalence of undernutrition, measured as body mass index below 18.5 among adults, is another critical determinant, with global modeling studies estimating that reducing undernutrition could avert up to 38 percent of global TB cases. Anemia and micronutrient deficiencies further compromise immune function and increase susceptibility to infection and disease progression.
A study analyzing social determinants of health and TB incidence in Central Asia from 2000 to 2023 found that anemia, undernourishment, and population density showed positive relationships with TB incidence, while clean fuel access, physician density, and GDP per capita were inversely related. In Tajikistan, GDP per capita, prevalence of anemia among non-pregnant women, and prevalence of undernourishment were all significantly associated with TB incidence in multivariable regression models. In Turkmenistan, physician density showed a strong negative association with TB incidence, while anemia demonstrated a very strong positive relationship. These findings underscore the multisectoral nature of TB control, requiring interventions in nutrition, housing, energy, and economic development alongside health system strengthening.
Access to social protection and labor programs represents another critical determinant. The percentage of the population covered by social protection varies enormously across high-burden countries, and those without such coverage face catastrophic costs when TB strikes. The End TB Strategy includes a milestone that no TB patients and their households should face catastrophic costs as a result of TB disease, yet in 2024, the percentage of TB-affected households facing catastrophic costs was reduced by only 47 percent, far from the target of zero. The direct and indirect costs of TB, including lost income, transportation to health facilities, and nutritional supplements, can push families deeper into poverty, creating a vicious cycle that perpetuates the epidemic.
Stigma and discrimination compound the social burden of tuberculosis and directly undermine control efforts. A systematic review of TB stigma reduction interventions identified multiple dimensions of stigma, including internalized stigma (shame and self-blame), anticipated stigma (fear of negative reactions), enacted stigma (actual discrimination), and perceived stigma (beliefs about how others view people with TB). In a study of TB patients and their families in Saudi Arabia, 50.7 percent experienced severe stigma, while 23.5 percent had mild stigma. Stigma was highest among young patients under 25 years, those living in urban areas, the unemployed, and those with pulmonary TB. The negative impacts of stigma were profound: 61 percent felt embarrassed or ashamed because of TB, 21.3 percent reported that stigma prevented them from seeking and accessing TB services, and 24.3 percent experienced shame that prevented timely care, accurate diagnosis, treatment initiation, or treatment completion.
The intersection of TB stigma with HIV stigma creates particularly devastating consequences. In the Saudi Arabian study, 35.3 percent of patients were afraid to tell others they had TB because they might also be assumed to have AIDS, and 35.3 percent worried about their potential for AIDS. This association between TB and HIV in the public imagination fuels discrimination and drives people away from the very services they need. Stigma reduction interventions, including community engagement, survivor-led messaging, peer support groups, and health worker training, have demonstrated effectiveness but remain underfunded and underimplemented in most high-burden settings.
3.6 The COVID-19 Pandemic and Its Aftermath
The COVID-19 pandemic represented the most severe disruption to tuberculosis control in modern history. In 2020, global TB notifications fell by over 20 percent, from 7.1 million in 2019 to 5.8 million in 2020, as healthcare systems were overwhelmed, diagnostic resources diverted, and patients unable or unwilling to seek care. The consequences extended far beyond the immediate drop in case detection, creating a reservoir of undiagnosed and untreated TB that fueled increased transmission and mortality in subsequent years.
In the United States, TB cases declined by 19 percent in 2020 compared with 2019, a drop that was 6-8 times the yearly average decline from 2010-2019. This decrease was attributed to multiple factors: reduced migration, with the number of non-US-born persons arriving in the country falling by half; COVID-19 mitigation strategies including masking and physical distancing that may have reduced TB transmission; and diversion of healthcare resources and staff away from TB programs. However, the decline was followed by a rebound: TB cases increased by 10 percent from 2020 to 2021, 6 percent from 2021 to 2022, and 16 percent from 2022 to 2023, with the 2023 case count of 9,633 surpassing the 2013 level. The 2023 incidence rate of 2.9 per 100,000 was the highest since 2016, and provisional data indicated a fourth consecutive year of increase in 2024.
In the WHO European Region, nearly 7000 excess TB deaths occurred during 2020-2022 compared to pre-pandemic expectations, an entirely preventable tragedy resulting from disruptions to TB diagnosis and treatment. The region reported over 170,000 TB cases in 2022, up from over 166,000 in 2021, with 38 of 53 member states reporting increased notifications. While these increases partly reflected improved case detection as services recovered, they also indicated the backlog of delayed diagnoses and the ongoing transmission from undetected cases.
The global recovery in reported TB cases in 2022-2024 has been substantial, with 8.3 million people newly diagnosed in 2024, but the estimated incidence remains above pre-pandemic levels. The disruptions of 2020-2021 created a cohort of individuals with undiagnosed and untreated TB who continued to transmit infection, and the full epidemiological consequences of the pandemic may not be apparent for years. The experience of COVID-19 has underscored the fragility of TB programs and the need for resilient health systems that can maintain essential services during crises.
3.7 The Funding Crisis and Research Pipeline
The global tuberculosis response faces a funding crisis that threatens to unravel years of progress and render the End TB Strategy targets unattainable. In 2024, only US$5.9 billion was available for TB prevention, diagnosis, and treatment, representing just over a quarter of the US$22 billion annual target set for 2027. This funding level has stagnated since 2020, even as the needs of the global response have grown. The shortfall is particularly acute for international donor funding, which has faced sharp cuts from 2025 onward.
Before its dismantlement, the US Agency for International Development (USAID) was the leading bilateral donor for global TB programs, accounting for roughly one-third of international funding and committing $406 million to TB programs worldwide in 2024. The freeze and subsequent cut in US funding has caused profound uncertainty within the global TB community. A modeling study published in PLOS Global Health projected that in the 26 high-burden countries reliant on USAID funding, a long-term funding gap could result in an additional 10.7 million TB cases and 2.2 million deaths over the next five years. Even short-term disruptions could lead to hundreds of thousands of excess deaths, as the immediate effects of service interruption are compounded by increased transmission from undetected cases.
Global TB research funding also lags critically behind needs, reaching only US$1.2 billion in 2023, just 24 percent of the annual target. This underinvestment threatens the development of the new tools essential for TB elimination. However, the research pipeline has expanded considerably in recent years. As of August 2025, 63 diagnostic tests were in development and 29 drugs were in clinical trials, up from just 8 in 2015. Eighteen vaccine candidates are undergoing clinical trials, including 6 in Phase 3. The WHO TB Vaccine Accelerator Council, launched by the WHO Director-General, is leading global efforts to advance the TB vaccine agenda.
The BCG vaccine, developed a century ago, remains the only licensed TB vaccine, providing significant protection against severe TB disease in infants and young children but offering limited and waning protection for adolescents and adults, who account for the bulk of TB transmission. At least 20 new vaccine candidates for adults and adolescents are in the clinical pipeline. Two candidates, VPM1002 and Immuvac, were the subject of recent clinical trials. VPM1002 uses a genetically modified Mycobacterium bovis to trigger a stronger immune response in adults, while Immuvac is made from a killed bacterium designed to boost immune response broadly. However, both failed to demonstrate efficacy in preventing TB infection, though they showed promise in preventing active disease. Other candidates, including M72/AS01 and MTBVAC, have shown promising results in preventing active pulmonary TB and are progressing through trials.
The development of new vaccines, diagnostics, and drugs represents a pipeline of hope, but its translation into population health impact depends on the funding and political will to deploy these tools at scale. The current funding crisis risks not only failing to develop new interventions but also losing the capacity to deliver existing ones, creating a double jeopardy for the global TB response.
3.8 Progress Toward Elimination and the Path to 2030
The Sustainable Development Goals and the End TB Strategy define the global commitment to tuberculosis elimination: an 80 percent reduction in TB incidence rate and a 90 percent reduction in TB deaths by 2030, compared with 2015 levels. The 2025 milestones, which include a 50 percent reduction in incidence and a 75 percent reduction in deaths, are now clearly out of reach. The question facing the global community is whether the 2030 targets remain achievable and what actions would be required to make them so.
The WHO African Region has achieved one of the largest drops worldwide, with a 28 percent reduction in TB incidence and 46 percent reduction in deaths since 2015. South Africa, a high-burden country, has reached the 2025 milestone for incidence reduction, demonstrating that rapid progress is possible even in resource-constrained settings with high HIV prevalence. The European Region has achieved the biggest estimated reduction, with a 39 percent decline in incidence by 2024, driven largely by progress in the Russian Federation. These success stories prove that the End TB targets are not merely aspirational but achievable with sustained political commitment, adequate funding, and effective implementation.
However, the overall global picture is one of insufficient progress. The net reduction in TB incidence from 2015 to 2024 was only 12.3 percent, and the reduction in deaths was 29 percent, both far below the respective milestones. The COVID-19 pandemic's disruptions explain part of this shortfall, but even before the pandemic, the global rate of decline was insufficient to meet the 2025 targets. The persistent drivers of the epidemic, including poverty, undernutrition, HIV, diabetes, smoking, and alcohol use, continue to fuel transmission in the absence of comprehensive social and economic interventions.
Mathematical modeling has consistently shown that achieving the End TB goals requires a comprehensive set of interventions combining all available measures as well as new tools for diagnosis, treatment, and prevention. Modeling tailored to the WHO South-East Asian Region has highlighted the importance of coordinating all TB services, including in the private sector, which plays a major role in TB management in countries like India and Indonesia. The development and rollout of a large-scale vaccine for TB have been identified as critical to achieving the End TB targets, yet the current funding crisis threatens to delay or derail this essential research.
4. Discussion
The evidence synthesized in this review reveals a tuberculosis epidemic at a critical inflection point. The first post-pandemic decline in global TB incidence in 2024 offers a glimmer of hope, suggesting that the disruptions of 2020-2023 may be gradually overcome and that the trajectory of progress can be resumed. Yet this hope must be tempered by the recognition that the global reduction of 12.3 percent since 2015 is less than one-quarter of the 50 percent milestone targeted for 2025, and that the 1.23 million deaths in 2024, while declining, remain far above the 75 percent reduction target. The tuberculosis epidemic is not a problem of insufficient biomedical knowledge; it is a problem of insufficient political will, inadequate resources, and persistent social and economic inequities.
The most striking feature of the current TB landscape is the stark inequality in burden and progress. Eight countries account for two-thirds of global cases, with India alone bearing one-quarter of the world's TB burden. Within countries, the disease concentrates among the poorest, the malnourished, those living with HIV, and marginalized communities. The African Region, despite achieving one of the largest relative reductions, continues to face the highest incidence rates and the most severe HIV-TB co-epidemic. The Americas have seen TB cases rise for four consecutive years, reversing progress in a region that once seemed on the path to elimination. These disparities are not accidental; they reflect the distribution of poverty, the quality of health systems, and the political priority accorded to tuberculosis control.
The transformation of drug-resistant TB treatment represents one of the most significant biomedical achievements in recent years. The shift from 24-month toxic regimens including injectable agents to 6-month all-oral regimens with favorable safety profiles is a genuine revolution that could save hundreds of thousands of lives. The BPaLM and BDLLfxC regimens, supported by robust clinical trial evidence, offer the prospect of treating MDR/RR-TB and even pre-XDR-TB in six months with high success rates. Yet the translation of this scientific advance into population health impact is constrained by the same factors that limit TB control overall: funding shortages, weak health systems, limited laboratory capacity for drug susceptibility testing, and the exclusion of vulnerable populations including children, pregnant women, and those with severe forms of TB from the evidence base for these new regimens.
The diagnostic landscape is similarly characterized by promising innovation and inadequate implementation. The expansion of rapid molecular testing, the emergence of competing platforms that could reduce costs and increase access, and the development of novel approaches including AI-powered imaging, cough analysis, and host-response blood tests all point toward a future in which TB could be detected earlier, more accurately, and closer to the point of care. Yet in 2024, nearly half of the world's TB patients still lacked access to rapid molecular diagnostics, and case detection among children under five remained at only 50 percent of estimated incidence. The technological solutions exist; what is lacking is the investment and health system capacity to deploy them at scale.
The social determinants of tuberculosis demand explicit recognition as the fundamental drivers of the epidemic. The correlation between poverty, undernutrition, overcrowding, and limited healthcare access with TB incidence is not merely a statistical observation but a causal reality that biomedical interventions alone cannot address. The finding that reducing undernutrition could avert up to 38 percent of global TB cases, and that anemia and micronutrient deficiencies are significantly associated with TB incidence in multiple countries, points to the centrality of nutritional and social interventions. The WHO's recommendations for nutritional support, social protection, and poverty alleviation as components of TB control are well-established but poorly implemented in most high-burden settings.
Stigma remains a critical and underaddressed barrier to TB control. The finding that over half of TB patients in some settings experience severe stigma, and that stigma directly prevents care-seeking and treatment completion, underscores the need for interventions that go beyond biomedical care to address the social and psychological dimensions of the disease. The co-development of stigma reduction interventions with affected communities, survivor-led messaging, and health worker training represent promising approaches, but these interventions require scale-up and integration into routine TB services.
The COVID-19 pandemic has left an indelible mark on the global TB response, revealing both the fragility of health systems and the potential for rapid adaptation. The 20 percent drop in case notifications in 2020, the thousands of excess deaths, and the subsequent rebound in cases and transmission all demonstrate that TB programs cannot be taken for granted and that disruptions, whether from pandemics, funding cuts, or political instability, can rapidly erase years of progress. The experience of COVID-19 also highlights the importance of resilient health systems that can maintain essential services during crises, a lesson that must be embedded in future TB program design.
The funding crisis represents the most immediate and existential threat to the global TB response. The availability of only $5.9 billion against a $22 billion target, the stagnation of funding since 2020, and the sharp cuts in international donor support from 2025 onward create a perfect storm that could reverse progress and cost millions of lives. The modeling projections of 10.7 million additional cases and 2.2 million additional deaths over five years in USAID-dependent countries are not abstract scenarios but credible, even likely, outcomes if funding gaps are not urgently addressed. The global community faces a choice: invest now in TB control and reap the returns in lives saved and economic productivity, or allow funding to decline and pay the far higher costs of increased disease, death, and drug resistance in the years to come.
The research pipeline offers grounds for optimism, with 18 vaccine candidates in clinical trials, 29 drugs in development, and 63 diagnostic tests nearing readiness. Yet the translation of these innovations into population health impact depends on the funding and capacity to conduct large-scale trials, secure regulatory approval, and deploy new tools in the health systems that need them most. The history of TB control is littered with promising interventions that failed to reach those who needed them due to cost, complexity, or inadequate implementation capacity. Avoiding this fate for the current generation of innovations requires sustained investment not only in research but also in health system strengthening, supply chain management, and community engagement.
The path to TB elimination by 2030, while technically challenging, is not biologically impossible. The disease is curable with existing drugs, preventable with existing vaccines (for infants), and detectable with existing diagnostics. What is required is the political commitment to fund the response at the necessary scale, the social and economic interventions to address the determinants of the epidemic, and the health system capacity to deliver quality care to all who need it. The success stories of South Africa, the European Region, and individual countries that have achieved 50 percent or greater reductions in incidence prove that rapid progress is possible. The question is whether the global community can muster the will to replicate these successes in the settings where they are most needed.
5. Conclusion
Tuberculosis in 2025 stands as a testament to both human ingenuity and human failure. We possess the scientific knowledge, the medical tools, and the programmatic experience to dramatically reduce the burden of this disease, yet we allow it to kill 1.23 million people every year, to infect 10.7 million more, and to perpetuate cycles of poverty and disadvantage that span generations. The first post-pandemic decline in global incidence in 2024 offers a moment of hope, but it is a fragile hope that depends on reversing the funding crisis, accelerating the deployment of new tools, and confronting the social determinants that have sustained this epidemic for millennia.
The transformation of drug-resistant TB treatment from two years of toxic injectables to six months of well-tolerated oral regimens is a scientific triumph that should be celebrated and rapidly scaled. The expanding pipeline of diagnostics, drugs, and vaccines points toward a future in which TB could be detected earlier, treated more effectively, and ultimately prevented. The growing recognition of stigma, social protection, and nutritional support as essential components of TB control reflects a maturing understanding of the epidemic's true nature.
Yet these advances are imperiled by a funding crisis that threatens to undo hard-won gains. The $5.9 billion available in 2024 against a $22 billion target, the cuts in international donor support, and the projected consequences of millions of additional cases and deaths represent a moral and practical failure that demands urgent correction. The choices made in the next few years will determine whether the world accelerates toward TB elimination or allows this ancient killer to continue its devastating march.
Ending tuberculosis is not merely a technical challenge of better drugs, faster diagnostics, and more effective vaccines, though all of these are necessary. It is fundamentally a challenge of social justice, requiring the reduction of poverty, the improvement of nutrition, the expansion of healthcare access, and the empowerment of communities to demand and receive the services they need. The 10.7 million people who fell ill with TB in 2024 were not random victims of a microbial accident; they were individuals whose lives were shaped by the conditions of disadvantage that we have the capacity to change.
The global health community, national governments, international donors, civil society organizations, and affected communities must unite in a renewed commitment to the End TB Strategy. This commitment must be reflected in increased domestic investment in high-burden countries, sustained international donor support, accelerated research and development, and the integration of TB services into universal health coverage and social protection frameworks. The 2030 targets, while ambitious, remain achievable if the world acts with the urgency and determination that this ancient, preventable, curable disease demands.
Tuberculosis has been with humanity for thousands of years, but it need not be with us for thousands more. The path to elimination is clear, the tools are within reach, and the moral imperative is undeniable. What remains is the will to walk that path together, to ensure that no one is left behind, and to finally consign this disease to the history books where it belongs.
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