Tuberculosis, a disease many thought was relegated to history books, is surging in the United States. More than 10,300 cases were confirmed in 2024, marking the highest annual count since 2013 and the third consecutive year of increases . This ancient bacterial infection, which has likely plagued humanity for over 70,000 years, remains the world's deadliest infectious disease, killing more people annually than any other single pathogen .

Why Is Tuberculosis Rising Again in America?

The resurgence of TB in the United States is largely a direct consequence of the COVID-19 pandemic's disruption to public health infrastructure. According to experts, the pandemic effectively halted TB screening and treatment programs across the country, allowing latent infections to go undetected and untreated . When these programs resumed, many people with dormant TB infections developed active disease, creating what doctors call a "rebound effect."

Beyond pandemic-related disruptions, several other factors are driving the increase. International travel has resumed, bringing TB from countries where the disease is more prevalent. Additionally, local and state public health TB programs became understaffed during the pandemic, and that capacity has not fully recovered . The combination of these factors has created a perfect storm for TB's resurgence.

Globally, the situation is more dire. The World Health Organization estimates that in 2024 alone, 10.7 million people fell ill from TB and 1.23 million died from it . More than 2 billion people worldwide are currently infected with the bacterium that causes TB, Mycobacterium tuberculosis.

What Makes Tuberculosis So Difficult to Combat?

TB is a uniquely challenging pathogen. The bacterium spreads through airborne particles when an infected person coughs, speaks, or sneezes, and it requires sustained, close contact to transmit . Once inhaled, the bacteria are consumed by white blood cells called macrophages, but these immune cells often cannot digest and kill the pathogen. Instead, the bacteria linger and hide within the body.

One of TB's most insidious characteristics is its ability to remain dormant for years without causing symptoms. About 25 percent of the global population is estimated to carry latent TB infection, meaning the bacteria are present but inactive and non-contagious . However, roughly 5 to 10 percent of people with latent TB will eventually develop active disease, where the bacteria multiply and cause illness .

The bacterium's complexity is staggering. With more than 4,000 genes, Mycobacterium tuberculosis has evolved sophisticated mechanisms to divert protective immune responses and evade treatment . When active TB develops, it typically affects the lungs in over 80 percent of cases, but it can spread to virtually any organ in the body, including the bones, brain, kidneys, and spine .

How to Identify If You're at Risk for Tuberculosis

• Travel and Immigration Status: People born in or who frequently travel to countries with high TB prevalence face significantly elevated risk and should discuss testing with their healthcare provider.
• Living Conditions: Individuals living in crowded conditions, homeless shelters, or congregate settings have higher exposure risk due to prolonged close contact with potentially infected individuals.
• Immune System Status: People who are immunocompromised, including those with HIV, diabetes, or malnutrition, are far more vulnerable to developing active TB disease from latent infection.
• Lifestyle Factors: Tobacco users, people with alcohol use disorders, and those experiencing food insecurity face increased risk, as these factors weaken immune function.
• Age Groups: Babies and young children are particularly vulnerable to severe TB disease if exposed to the pathogen.

The challenge with TB detection is that many people don't realize they have it. Symptoms like a persistent cough, chest pain, fatigue, and weight loss are often mistaken for allergies, smoking-related cough, or a cold that won't go away . In more severe cases, patients may cough up blood. Doctors typically use a skin test or blood test to detect TB infection, followed by imaging or sputum testing to confirm active disease .

"In Washington state, we know our TB. If there was any place in the country where I'd want to be, if I had TB, it's here," said Dr. Adrienne Shapiro, an infectious disease physician at Fred Hutch and the University of Washington who works to develop and implement TB prevention strategies.

Dr. Adrienne Shapiro, Infectious Disease Physician, Fred Hutch and University of Washington

Despite this optimism in certain regions, screening gaps remain widespread. In Washington state, only about half the people at risk for TB infection get screened, and of those with a positive TB test, fewer than 50 percent receive preventative treatment . These missed opportunities represent a critical failure in public health, as every person with TB disease represents a missed opportunity for prevention.

What Gives Experts Hope for TB Control?

While the current situation is concerning, scientists are optimistic about new developments in TB prevention and treatment. Several promising vaccines are currently in late-phase clinical trials, and recently developed preclinical models of TB disease point toward new treatment avenues . Researchers at institutions like Fred Hutch Cancer Center are leveraging expertise in immunology, clinical trial design, and biostatistics to accelerate progress.

"It's a very exciting time to be in TB science because our understanding of TB is changing rapidly," said Dr. Paul Edlefsen, a biostatistician at Fred Hutch who helps design and analyze clinical trials as a member of the HIV Vaccine Trials Network and the Immune Mechanisms of Protection Against Mycobacterium tuberculosis Centers Program.

Dr. Paul Edlefsen, Biostatistician, Fred Hutch

The good news is that TB is both preventable and treatable. The disease is cured with a combination of antibiotics, colloquially known as RIPE (isoniazid, rifampicin, pyrazinamide, and ethambutol), taken daily for four to six months . For latent TB, antibiotics can prevent progression to active disease entirely. If TB goes untreated, however, it is fatal in about half of its victims .

One surprising finding from recent research is the power of basic interventions. The RATIONS trial demonstrated that providing food supplementation to people with TB and their household members could reduce TB disease incidence by 40 percent . This highlights a fundamental truth: poverty is the primary driver of TB globally. The World Health Organization identifies five main contributing factors: malnourishment, smoking, diabetes, alcohol use disorders, and HIV .

"Globally, if we just gave people food, we would dramatically reduce the risk of TB disease," explained Dr. Adrienne Shapiro, noting that addressing basic needs may be as important as medical interventions.

Dr. Adrienne Shapiro, Infectious Disease Physician, Fred Hutch and University of Washington

The path forward requires renewed commitment to TB screening, treatment completion, and addressing the social determinants of health that enable the disease to flourish. As one expert noted, latent TB, which causes no symptoms and is not contagious, can be treated and cured before it ever progresses to active TB, which is infectious . Identifying and treating latent infection is one of the most powerful tools available for protecting both individual patients and the broader community.