Background: Undernutrition is the leading driver of tuberculosis incidence and poor treatment outcomes, yet its impact on post-tuberculosis lung disease (PTLD) is poorly understood. Methods: Adults (>18 years) with drug-sensitive pulmonary tuberculosis were prospectively evaluated during and after tuberculosis treatment in India. We measured the association of nutritional markers – baseline body-mass index (BMI), premorbid BMI, mid-upper arm circumference (MUAC), and 2-month weight gain – with post-treatment lung function, chest radiography scores, six-minute walk test (6MWT) distance, and St George’s Respiratory Questionnaire (SGRQ) scores. Plasma cytokines were measured at baseline and month-2 for causal mediation analysis of the undernutrition-lung function association. Findings: Of 156 participants, 76 (48%) had post-treatment ventilatory defects; 52 (33%) had airflow obstruction and 24 (15%) had restrictive spirometry. Each unit higher baseline BMI lowered odds of any ventilatory defect by 22% (aOR 0·78; 95% CI 0·67, 0·89), while BMI <16 kg/m² conferred a five-fold increased risk (aOR: 5·08; 95% CI: 1·76, 16·02). Similar associations were observed for premorbid BMI and MUAC. Underweight individuals had lower FEV₁ and FVC z-scores, greater lung pathology on chest X-ray, reduced 6MWT distance and worse SGRQ scores. Higher levels of systemic inflammation measured by IL-6, TNF-α and IFN-γ concentrations during early tuberculosis treatment were observed among undernourished individuals and mediated up to one-third of the BMI-lung function association. Interpretation: Undernutrition is a strong, potentially modifiable determinant of PTLD, acting through both inflammatory and non-inflammatory pathways. Nutritional interventions may represent a scalable host-directed therapy to reduce long-term disability among tuberculosis survivors.

Tuberculosis (TB) rarely occurs in isolation; most people with TB experience multiple coexisting conditions, including HIV, diabetes, undernutrition, depression, and substance use disorders, which worsen disease severity and compromise treatment outcomes. Although the World Health Organization has issued disease-specific guidance for managing key comorbidities, TB care remains largely siloed and poorly equipped to address the growing burden of multimorbidity, particularly in African health systems. In this perspective article, we propose a phased framework for multimorbidity-centered TB care. The first phase emphasizes systematic screening for common comorbidities and establishment of basic referral pathways. The second phase focuses on strengthening coordination between TB programs and existing health and social services, including task sharing and longitudinal follow-up. The third phase advances toward fully integrated, co-located, multidisciplinary models of care that embed TB services within broader multimorbidity platforms. Together, this framework offers a pragmatic roadmap for TB programs to deliver more person-centered, equitable, and efficient care, strengthen primary care systems, and accelerate progress toward ending TB as a public health threat in Africa.

BACKGROUND:Current efforts to reduce global tuberculosis incidence have proved insufficient, highlighting that urgent action is needed to address underlying modifiable risk factors such as undernutrition. We aimed to estimate the global impact of eliminating undernutrition on tuberculosis incidence among adults, accounting for varying nutritional status by country, sex, and age, in addition to incorporating the continuous, non-linear relationship between BMI and tuberculosis risk. METHODS:For this modelling study, we used a continuous risk framework to consider the population-level implications of BMI distributions for tuberculosis incidence in adults aged 15 years or older in 2023. We generated BMI distributions for each country, sex, and age group, and applied a bilinear model for the logarithmic relative risk of tuberculosis incidence at different BMI values. We assessed the impact of eliminating moderate-to-severe undernutrition (BMI <17 kg/m2) or all undernutrition (BMI <18·5 kg/m2) on tuberculosis incidence by constructing counterfactual BMI distributions that redistributed those with low BMI to high BMI, proportional to the remaining density. FINDINGS:We estimated that eliminating moderate-to-severe undernutrition could avert 1·4 million (95% uncertainty interval 1·1-1·7) tuberculosis episodes globally, representing 14·6% (12·6-16·6) of global adult incidence in 2023, while eliminating all undernutrition could avert 2·3 million (1·8-2·7) episodes, representing a reduction in global tuberculosis incidence of 23·7% (20·9-26·5). The largest proportional reductions in tuberculosis incidence could be achieved by eliminating undernutrition in the WHO African, South-East Asia, and Eastern Mediterranean regions; in females; and in adolescents or older adults. INTERPRETATION:Almost a quarter of global tuberculosis incidence in adults could be averted by eliminating undernutrition, approximately two-and-a-half times higher than current estimates. These findings highlight the urgent need to scale up population-level nutritional interventions, which could have myriad social and health benefits beyond tuberculosis, alongside research to establish optimal implementation strategies and impacts. FUNDING:None.

Background: Tuberculosis (TB) remains a major global health threat, particularly in low- and middle-income countries, with TB infection (TBI) serving as the primary source of TB disease. While HIV infection has long been recognised as a major risk factor for TB progression, the rise of Non-Communicable Diseases (NCDs), which may exert immunosuppressive effects, further compounded by their treatment, contributes to increased TB susceptibility. This scoping review synthesises evidence from systematic reviews on medical and behavioural risk factors for TBI progression to TB disease, for both asymptomatic and symptomatic disease. Methods: A preliminary literature search was conducted on 11 January 2025, in PUBMED using the keywords “tuberculosis,” “asymptomatic or subclinical tuberculosis” “risk factors,” and “systematic review” followed by targeted reviews on the identified medical and behavioural risk factors for TB infection progression to TB disease. Results: A total of 25 systematic reviews were included. Medical risk factors for progression from TB infection to TB disease included diabetes mellitus (DM), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), undernutrition (including iron and vitamin D deficiency), cancer—particularly haematological malignancies—and immunosuppressive therapies (TNF-α inhibitors and glucocorticoids). Iron and vitamin D deficiency, particularly severe deficiency, is linked to increased TB risk, especially among people living with HIV. Behavioural risk factors, including tobacco, drug, and alcohol use, were also highlighted. Geographic variations in TB prevalence, diagnostic practices, and healthcare systems contributed to differences in risk estimates across reviews. No systematic reviews were identified that examined risk factors for asymptomatic TB. Conclusions: The convergence of TB with NCDs, compounded by immunosuppressive therapies, poses a public health challenge in high TB burden settings. Effective TB prevention requires targeted screening, along with enhanced management of these NCDs. Nutritional support, particularly screening and treatment of anaemia and vitamin D deficiency, may benefit individuals with TBI, comorbid NCDs, and HIV. A multidisciplinary approach, integrating behavioural interventions and tailored prevention strategies, is essential to achieving WHO’s End TB targets. Addressing the evidence gap on risk factors for asymptomatic TB is also critical to improve early detection and interrupt transmission.

Rising global temperatures are predicted to increase the time individuals spend in under-ventilated indoor spaces, especially in tropical and subtropical regions, and to enhance the transmission risk of respiratory pathogens. We studied the impact of ventilation on the transmission risk and basic reproductive number (R0) of common respiratory viruses that have pandemic potential, namely SARS-CoV-2 and influenza, in Puducherry, India.Transmission risk and basic reproductive number (R0) of SARS-CoV-2 under different ventilation conditions and viral shedding potentials.1A) Box plots of transmission risk using base estimate of q= 28.0 for high viral shedding potential and q= 4.0 for low viral shedding potential, across three ventilation conditions tested. Solid line at top denotes Wilcoxon rank sum test comparing closed and open conditions for each viral shedding potential; M denotes mean, SD denotes standard deviation. 1B) Box plots of R0 for each ventilation condition and viral shedding potential. Bright red line denotes R0 of 1.Transmission risk and basic reproductive number (R0) of influenza under different ventilation conditions and viral shedding potentials2A) Box plots of transmission risk using base estimate of q= 68.0 for high viral shedding potential and q= 3.2 for low viral shedding potential, across three ventilation conditions tested. Solid line at top denotes Wilcoxon rank sum test comparing closed and open conditions for each viral shedding potential; M denotes mean, SD denotes standard deviation. 2B) Box plots of R0 for each ventilation condition and viral shedding potential. Bright red line denotes R0 of 1. We measured ventilation in air changes per hour in homes and healthcare offices using a carbon-dioxide decay technique. We applied the Wells-Riley equation to estimate the transmission risk and R0 of SARS-CoV-2 and influenza in these settings, as well as under different ventilation conditions and viral shedding levels. We conducted 45 ventilation measurements across 13 homes and 7 offices; four of five air conditioning (AC) measurements were in offices. In the closed condition (doors/windows closed, fans off), mean SARS-CoV-2 transmission risk was high for high virus shedders (62.6%, SD 25.2%) and lower for low shedders (28.4%, SD 21.5%) (Figure 1A). Risk decreased significantly in the open condition (doors/windows open, fan on) for both high (29.3%, SD 15.1%; p< 0.001) and low shedders (6.3%, SD 4.4%; p< 0.001). Under AC, transmission risk remained similar to the closed condition for low shedders but was highest for high shedders (74.1%, SD 4.9%). For high shedders, R₀ equaled or exceeded 2 in both the closed (1.9, SD 0.76) and AC (2.2, SD 0.13) conditions, but stayed below 1 for low shedders across all ventilation scenarios (Figure 1B). Similarly, for influenza, transmission risk was high in the closed condition for high virus shedders (76.8%, SD 20.4%) and decreased significantly in the open condition (47.5%, SD 18.7%; p< 0.001) (Figure 2A). For low shedders, transmission risk remained low in both the closed (24.9%, SD 19.9%) and AC (25.2%, SD 5.0%) conditions. The R₀ for influenza exceeded 2 in the closed and AC conditions for high shedders (Figure 2B). The transmission risk of respiratory viruses in homes and healthcare spaces is high, particularly with the use of AC. Under-ventilation increases R0 above 1 among high virus shedders. Ralph P. Brooks, MS, Merck: Stocks/Bonds (Public Company) Sheela Shenoi, MD MPH, Merck Pharmaceuticals: My spouse worked for Merck 1997-2007 and retains company stock in his retirement account. There is no conflict of interest with this work. Lauren Pischel, MD, Auxa Health: Advisor/Consultant

Tuberculosis (TB), a leading cause of global mortality, disproportionately affects low socioeconomic households and deepens poverty. In India, persons with TB (PWTB) and their families face disrupted education and reduced income, further limiting access to care. TB must be recognized not just as a clinical condition but as a social disease—intertwined with education, nutrition, and economic stability—if elimination goals are to be met. Household Income Over Course of Treatment by Education Discontinuation StatusFigure 1.Comparison of household income over course of TB treatment between households that have at least one individual who experienced educational disruption versus the control group.Multidimensional Poverty Index Score Comparison Based on Education StatusFigure 2.Comparison of Multidimensional Poverty Index score between households that have at least one individual who experienced interrupted schooling We used data from the RePORT India cohort, which follows PWTB in Puducherry, Tamil Nadu, Maharashtra, and Telangana. Participants were assessed at baseline; months 1 and 2 (intensive phase); month 6 (treatment completion); and at 6 and 12 months post-treatment. Clinical data included symptoms, treatment history, BMI, and Karnofsky scores. Structured interviews assessed TB’s socioeconomic effects using the Multidimensional Poverty Index (MPI), which includes education, living standards, and household composition. Among 663 households surveyed, 14% reported disrupted education, 85% of which involved household contacts of PWTB. Disruption often affected multiple members; 26 unique households reported educational interruption. Households without disruption showed steady income gains between months 2 and 6 post-treatment, while those with disruption exhibited fluctuating income, suggesting prolonged vulnerability. MPI scores averaged 38.4 in disrupted households vs. 30.8 in others (poverty threshold: 33). TB’s impact extends beyond the patient, disrupting education and eroding household resilience. Each missed year of schooling reduces lifetime earnings by ∼8%. Protecting education during TB illness is critical to achieving household stability and national TB elimination targets. Robert C. Bollinger, Jr., MD, MPH, [SCENE] Health: Advisor/Consultant|[SCENE] Health: Board Member|[SCENE] Health: Stocks/Bonds (Private Company)|Merck: Advisor/Consultant|miDiagnostics: Co-inventor of IP owned by Johns Hopkins University|miDiagnostics: Eligible for equity and royalty payments received by Johns Hopkins University

SUMMARY BACKGROUND Undernutrition is the leading risk factor for tuberculosis (TB), yet evidence on programmatic nutritional support during treatment is limited. Benin and Togo are neighboring West African counties. Benin provides in-kind food support to all people with drug-susceptible TB; neighbouring Togo does not. This created the opportunity for a natural experiment. METHODS We conducted a prospective cohort study at 13 sites in Benin and Togo (September 2023-June 2024). We compared recipients of nutritional support with non-recipients, using Beninese non-recipients as an internal comparison. Primary outcomes were ≥5% weight gain at month 2, change in 6-minute walk test (6MWT) distance, and pill-count adherence. We used multivariable regression adjusted for pre-specified covariates. RESULTS Of 769 participants, 450 received nutritional support and 319 did not. Recipients had higher odds of ≥5% weight gain at month 2 (adjusted odds ratio [aOR] 1.57, 95% CI 1.13–2.19) and ≥10% at month 6 (aOR 1.92, 1.35–2.74), greater 6MWT improvement (adjusted β 40.6 m, 26.5–54.6), and higher adherence (aOR 3.43, 1.81– 6.51). Mortality was lower among recipients (aOR 0.32, 0.11–0.93). Sputum conversion and treatment success did not differ. Beninese non-recipients resembled Togolese participants across outcomes. CONCLUSION Programmatic nutritional support was associated with improved weight gain, functional recovery, adherence, and lower mortality during TB treatment, supporting its integration into national TB programmes.

BACKGROUND:Undernutrition is the leading population-attributable risk factor for tuberculosis (TB), yet whether associated immune impairments are reversible with nutritional rehabilitation remains unclear. METHODS:In TB LION (Puducherry, India), 105 QuantiFERON-positive household contacts were stratified by BMI (<18.5 vs ≥18.5 kg/m2). Participants with low BMI (n=53) received 6 months of food rations plus daily multiple micronutrient supplement (MMS) without iron. Fourteen cytokines were measured by Luminex in supernatants from the unstimulated (Nil) and M. tuberculosis (Mtb)-antigen-stimulated (TB2) IGRA assay at baseline and 6 months; 11 with acceptable detection rates constituted the primary analytic set. Linear regression tested associations of weight and hemoglobin change with composite immune pathway scores. RESULTS:At baseline, participants with low BMI had attenuated Mtb-specific Th1 cytokine responses (interaction GMR 0.70 for IFN-γ, 0.55 for IL-2; both p=0.005), despite comparable or elevated innate and regulatory cytokines. After 6 months, Th1 responses increased (IFN-γ change GMR 1.41, 95% CI 1.10-1.80, p=0.005, q=0.06; IL-2 1.63, 1.01-2.63, p=0.046, q=0.25, suggestive). This increase reflected falling unstimulated background, not higher stimulated output. Weight gain was unrelated to composite scores but associated with elevated concentrations of 7 of 14 cytokines (all p<0.05). Hemoglobin gain was inversely associated with Th17 and pro-inflammatory scores but not Th1. CONCLUSIONS:Six months of combined food rations and daily MMS was followed by improved antigen-specific Th1 cytokine responses, suggesting this impairment may be partially reversible on a clinically feasible timescale. As a single-arm study without a concurrent comparator with undernutrition measured at follow-up, observed changes cannot be causally attributed to the intervention. Trial registration: NCT03598842.

Abstract Soil-transmitted helminths (STH) are a plausible but under-characterized comorbidity in tuberculosis. In this prospective South Indian cohort, multiplex stool PCR detected STH in 43% of 137 adults with pulmonary tuberculosis and 34% of 230 household contacts. Food insecurity independently predicted co-infection. Current adult deworming gaps warrant evaluation.

Abstract Background Despite rising enthusiasm for active case-finding for TB, there have been concerns about conducting simultaneous HIV screenings due to perceived stigma, although the evidence to support this concern is scarce. We assessed the acceptability of integrated HIV–TB community screening and characterised participants’ motivations and prior testing history. Methods The SLIM study was a non-interventional cross-sectional study conducted in Puducherry (February 2023 – January 2024). In two community health camp-style screening events (one urban and one peri-urban), adults ≥18 years were offered TB screening via portable chest X-ray with AI-assisted interpretation (qXR, Qure.ai), plus sputum testing (Truenat), alongside point-of-care HIV testing. Structured questionnaires captured sociodemographics, prior testing history, and motivations for participation. Acceptability was pre-specified as >50% uptake. Results Of 273 eligible adults approached, 264 (96.7%) accepted integrated screening, nearly double our pre-specified threshold. Participants were predominantly low-income with limited formal employment. The dominant motivation was a desire to know one’s health status (HIV: 74.8%; TB: 73.7%), followed by convenience (16–17%). Prior HIV and TB testing was rare (7– 13% and 15–18%, respectively). Participation was uniformly high across demographic groups; however, the screened population skewed older and female (mean age 58 (standard deviation: 12.6) years; 67% female). Men under 45 comprised only 3.7% of participants — substantially below their 24.7% share in the Puducherry population per the most recent census. Conclusions Integrated HIV–TB screening achieved near-universal uptake in a socioeconomically vulnerable population with little prior testing exposure, contradicting concerns that community HIV screening would be poorly accepted in India. Integrated community-based screening should be scaled up as a cornerstone of TB elimination in high-burden settings. Crucially, because TB incidence in India peaks in the 15–45 age group and disproportionately affects men, targeted strategies to bring younger men and women into community screenings are essential.

Objectives: Rising global temperatures are expected to increase time individuals spend in under-ventilated spaces and to increase transmission of respiratory pathogens. We studied the impact of ventilation on transmission potential and basic reproductive number (R0) of respiratory viruses in Puducherry, India. Methods: We measured ventilation in thirteen homes and seven healthcare offices. We applied the Wells-Riley equation to estimate the transmission potential and R0 of SARS-CoV-2 and influenza under different ventilation conditions and viral shedding levels. Results: Viral transmission potential was high when doors and windows were closed and highest in the air conditioned (AC) condition. Transmission potential decreased significantly with natural ventilation. R₀ equaled or exceeded 2 in the closed and AC conditions for medium and high virus shedders. Conclusion: The transmission potential of respiratory viruses in underventilated homes and healthcare spaces is high, particularly with AC use. Natural ventilation does not reduce R0 below 1 for super shedders.

Background: Tuberculosis (TB) remains a major global health challenge, with Mycobacterium tuberculosis (M. tuberculosis) causing significant morbidity and mortality mainly in high-burden countries. Following exposure to M. tuberculosis, individuals may become infected, developing TB infection (TBI) through inhalation of the bacillus: this affects approximately one-fourth of the global population and serves as a critical reservoir for potential disease reactivation and transmission. The risk of being infected with M. tuberculosis is shaped by bacterial load of people with TB, contact patterns, environmental factors, and host susceptibility, particularly in high-risk congregate settings. Elucidating these determinants is instrumental for optimising TB prevention and control strategies. Methods: A preliminary PubMed search was conducted on 25 August 2024, using the keywords “latent tuberculosis infection,” “risk factors,” and “systematic review.” Targeted reviews were then performed in November 2024 to examine factors influencing progression from exposure to M. tuberculosis to TBI. Systematic reviews published between January 2000 and November 2024 were included. Results: The scoping review analysed eight systematic reviews, grouping findings into three key themes: (1) proximity and behavioural risk factors; (2) environmental risk factors; and (3) host immune vulnerabilities. Close contact with people with TB in crowded settings, such as dormitories, healthcare facilities, and prisons, was strongly associated with an elevated risk of TBI. Healthcare workers travelling from low- to high-incidence regions faced the highest risk due to frequent exposure to M. tuberculosis, while military personnel and general travellers had lower risks. Environmental exposures, including second-hand smoke and inadequate ventilation, further heightened susceptibility among children and adults. Host immune risk factors, such as advanced age, low body mass index, lack of BCG vaccination, and metabolic disorders such as diabetes, markedly increase susceptibility to TBI. The interplay between proximity, behavioural and environmental risk factors, and host immune vulnerabilities highlights the multifactorial nature of TBI risk. Conclusion: Effective TBI control demands a multifaceted approach, combining robust infection prevention and control measures, comorbidity management, and mitigation of behavioural risk factors like smoking. Tailored strategies are crucial for high-risk settings such as healthcare facilities and prisons. Multisectoral collaboration is essential to address key risk factors and protect vulnerable populations from progressing to TBI.

This prospective cohort study evaluated rifampin pharmacokinetics in pregnant and nonpregnant women with tuberculosis in India. Pregnant women had significantly lower drug exposure, with <20% of the participants achieving target concentrations at any trimester. Findings highlight potential underdosing in pregnancy and underscore the need for dedicated pharmacokinetics studies in pregnancy, and revised rifampin dosing guidelines.

India accounts for 26% of the global tuberculosis (TB) burden and 29% of TB-related deaths. Extrapulmonary TB (EPTB) makes up 15–24% of TB in India, yet mortality risk by anatomical site is poorly characterized.Figure 1:Relative prevalence and contribution to MortalityFigure 2:Adjusted odds ratio for mortality for different EP sites compared to lymph node TB calculated by controlling for age, sex, body mass index, HIV status, diabetes, tobacco, and alcohol use. We analyzed data from adults (≥15 years) with EPTB reported to India’s national TB database between September 2022 and December 2024. We assessed site-specific mortality using multivariable logistic regression to estimate adjusted odds ratios (aORs) for death, controlling for age, sex, body mass index (BMI), HIV status, diabetes, tobacco use, and alcohol use, with lymph node TB as the reference category. We also conducted site-stratified analyses to evaluate the association of HIV, diabetes, alcohol use, and tobacco use with mortality within each EPTB site, adjusting for age, sex, and BMI.Figure 3:Adjusted Odds of Mortality by Site of Extrapulmonary Tuberculosis (EPTB) and Comorbidity. Among 1,029,599 persons with EPTB, 777,512 (75.5%) had outcome data; 23,892 (3.1%) died. Those who died were older (mean 53 vs. 37 years), more often male (62.5% vs. 48.5%), and more likely HIV-positive (6.8% vs. 1.6%). The most common sites were pleural (20.4%), lymph node (18.5%), and abdominal (9.5%). Pleural TB accounted for one-third of EPTB deaths. (Figure 1) Tuberculous meningitis (TBM) accounted for just 3.2% of cases but 14.5% of EPTB deaths. TBM carried the highest mortality risk (aOR 12.05, 95% CI: 11.21–12.97), followed by miliary (5.03, 4.38–5.77), and pericardial (3.77, 3.10–4.56). (Figure 2) HIV infection was consistently associated with increased mortality across nearly all extrapulmonary TB (EPTB) sites, with the highest adjusted odds observed in “Other” (aOR 5.58), lymph node (aOR 4.86), and miliary TB (aOR 4.26). (Figure 3) Diabetes was also strongly associated with higher mortality in genitourinary (aOR 4.55), pericardial (aOR 2.79), and spinal TB (aOR 2.43)—while the effects of alcohol and tobacco use were more smaller and less-consistent across sites. This is the largest EPTB cohort to date, and it shows that mortality risk varies widely across EPTB sites. Pleural TB, TBM, miliary TB, spinal TB, and pericardial TB account for a disproportionate share of EPTB deaths and require prioritized diagnosis and treatment. EPTB mortality risk is markedly elevated in persons with HIV or diabetes. All Authors: No reported disclosures

BACKGROUND:Undernutrition is the leading cause of tuberculosis (TB) globally, but nutritional interventions are often considered cost-prohibitive. The RATIONS study demonstrated that nutritional supplementation to household contacts of persons with TB can reduce TB incidence, yet economic evaluations of such strategies remain limited. METHODS:Using a Markov model, we assessed the cost-effectiveness of a RATIONS-style intervention (monthly food basket providing 750 kcal, 23 g of protein, and a multi-micronutrient tablet daily) for household contacts of persons with TB, as compared to no nutritional support. We calculated health outcomes (TB episodes, TB deaths, and disability-adjusted life years [DALYs]) over the lifetime of intervention recipients and assessed costs from healthcare and societal perspectives. We tested the robustness of results to parameter changes via deterministic and probabilistic sensitivity analysis. FINDINGS:Over 2 years, household contacts receiving the RATIONS intervention experienced 38% (95% uncertainty interval [UI]: 23-52) fewer TB episodes and 58% (95% UI: 44-70) fewer TB deaths. Over the lifetime of a cohort of 100 000 household contacts, the intervention was projected to avert 11 524 DALYs (95% UI: 7446-17 393) and was cost-effective from both the healthcare (incremental cost-effectiveness ratio [ICER]: $289 per DALY averted [95% UI: 156-537]) and societal perspectives ($229 per DALY averted [95% UI: 102-468]). Cost-effectiveness was most sensitive to the cost of the nutritional supplement. CONCLUSIONS:Prompt nutritional support for household contacts of persons with TB disease would be cost-effective in reducing TB incidence and mortality in India.

Importance:Tuberculosis preventive therapy is central to reducing tuberculosis, and foreign-born individuals account for most US tuberculosis cases. Current US Preventive Services Task Force guidance recommends testing and treating all foreign-born individuals regardless of age or time since immigration, yet the risks of disease progression and of treatment-related harm are not uniform across these groups. Objective:To evaluate the cost-effectiveness and health outcomes of tuberculosis infection treatment strategies among immigrants from high-burden settings, stratified by age and time since immigration. Design:Decision analytical model using individual-level microsimulation (Markov model) over a 30-year horizon, with deterministic and probabilistic (second-order Monte Carlo) sensitivity analyses. Costs and outcomes were discounted at 3%. Setting:US TB and primary care clinics (healthcare-sector perspective), using observed data from the Boston Medical Center/Boston Public Health Commission tuberculosis clinic and published literature. Participants:A simulated cohort of 10 000 IGRA-positive, foreign-born adults from high tuberculosis incidence settings (excluding immunosuppressed individuals), modeled as recent or non-recent (immigrated 25 years earlier) immigrants at ages 35 and 65 years. Interventions:Rifampin daily for 4 months, isoniazid daily for 9 months, or no preventive therapy. Main Outcomes and Measures:Costs, disability-adjusted life-years (DALYs), incident tuberculosis cases and deaths, treatment completion, and incremental cost-effectiveness ratios (ICERs), with the proportion of simulations in which each strategy was optimal at a willingness-to-pay threshold of $50 000 per DALY averted. Results:Among recent immigrants, rifampin was the dominant strategy at ages 35 and 65 years (optimal in 88.5% and 93.9% of simulations), yielding the fewest tuberculosis cases (119.44 and 82.31 per 10 000) and the highest treatment completion (71.4% and 67.7%). Among non-recent immigrants, rifampin remained the dominant strategy (optimal in 53.41% of simulations), followed by no treatment. In 65-year-olds who did not immigrate recently, no treatment was optimal in 94.7% of simulations. ICERs for treatment versus no treatment were unfavorable ($193 600 and $412 857 per DALY averted for rifampin and isoniazid, respectively, at age 65). Conclusions and Relevance:In this decision analytical model, rifampin was cost-effective for recent immigrants, whereas no treatment was optimal for older immigrants with remote arrival date. Age and time since immigration may help risk-stratify tuberculosis infection treatment and reduce unnecessary treatment in lower-risk populations.

Among 61,925 adults initiating tuberculosis treatment in Delhi, India, higher ambient PM2.5 exposure during the 30 days before treatment was independently associated with increased mortality, most pronounced at the highest exposures. These findings highlight short-term air-pollution exposure as an underrecognized, modifiable risk factor for tuberculosis mortality in high-burden urban settings.

India bears a quarter of the global tuberculosis (TB) burden and nearly one-third of TB related deaths, but substantial regional heterogeneity demands tailored elimination strategies. We propose the Dual-phase Operational Strategy for Tuberculosis elimination (DOST), a roadmap that explicitly addresses TB as both an infectious disease and a structural challenge. Phase 1 focuses on rapidly reducing transmission through intensified case-finding, upfront molecular diagnosis, and strengthened treatment, as demonstrated by India’s 100-Day TB Campaign, which expanded community screening and accelerated therapy initiation. Phase 2 pivots to preventing disease progression by scaling up TB preventive treatment and addressing key drivers such as undernutrition, HIV, and diabetes. DOST emphasizes subnational adaptation: high-burden states prioritize disease reduction, while states nearing low incidence shift toward preventing flare-ups and sustaining progress. Rooted in the Hindi word dost (friend), this person-centered approach integrates medical and social support, recognizing that eliminating TB in India requires compassion paired with structural action. By sequencing and localizing proven interventions, DOST offers a pragmatic pathway from TB response to TB elimination.