The Return of an Old Killer: Tuberculosis Cases Hit 30-Year Highs in the United States

After nearly three decades of steady decline, tuberculosis is reasserting itself in the United States. In 2024, the country recorded 10,388 TB cases—an 8% jump from 2023 and the highest annual count since 2013 [1]. The incidence rate climbed to 3.1 per 100,000, reversing a downward trend that had cut cases by 68% since its modern peak in 1989 [1]. Preliminary data from several states suggest 2025 will be worse still, with some jurisdictions reporting case increases of 10% to 20% over 2024 levels [2].

The resurgence raises questions that go beyond epidemiology: How did a country that spent decades beating back TB lose ground so quickly? Who bears the burden? And are the policy tools available to contain it adequate for the task?

The Scale of the Reversal

The pandemic year of 2020 marked the modern low point. TB diagnoses fell to 7,170—a 19% drop from 2019—as COVID-19 consumed public health resources, disrupted healthcare access, and suppressed immigration [3]. That artificial trough set the stage for what followed: cases rebounded 10% in 2021, another 6% in 2022, then surged 16% in 2023 to reach 9,633 [3]. The 2024 figure of 10,388 continued the climb [1].

The increase is geographically widespread. From 2023 to 2024, 39 of 52 reporting jurisdictions saw case counts rise, with five jurisdictions posting increases of 50% or more [1]. Half of all U.S. TB cases concentrate in four states: California (2,109), Texas (1,279), New York (1,083), and Florida (675) [1]. But the highest incidence rates per capita tell a different geographic story: Alaska leads at 12.3 per 100,000, followed by New York City at 9.8 and Hawaii at 8.1 [4]. Kansas experienced a 148% rate increase in a single year, from 1.6 to 3.9 per 100,000 [4].

Source: CDC / Reported Tuberculosis in the United States, 2024

Data as of Mar 24, 2026CSV

Who Is Getting Sick

The demographic profile of TB in America is sharply stratified. Non-U.S.-born individuals accounted for 77% of all cases in 2024, with an incidence rate of 15.7 per 100,000—nearly 20 times the rate of 0.8 per 100,000 among U.S.-born persons [1]. Among non-U.S.-born cases, 24% were diagnosed within their first year in the country, while 51% had been in the U.S. for five or more years [1], indicating that reactivation of latent infections acquired abroad—not recent transmission—drives the majority of these cases.

By race and ethnicity, Hispanic or Latino individuals accounted for the largest share of cases (3,882), followed by Asian (2,998) and Black or African American (2,063) populations [1]. The highest incidence rates were among Native Hawaiian and Pacific Islander populations at 37.2 per 100,000, followed by Asian populations at 13.6 [1].

Socioeconomic risk factors remain pronounced. Among persons aged 15 and older, 9% of TB cases reported a history of homelessness, and 7% had been homeless in the year before diagnosis [1]. Another 9% reported a history of incarceration, with 4% incarcerated at the time of diagnosis [1]. Diabetes, a known risk factor for TB progression, was present in 22% of cases, while 5% of TB patients were co-infected with HIV [1].

A critical distinction emerges in transmission patterns. Among U.S.-born persons, 33% of cases were attributed to recent transmission—meaning they were likely infected by someone in their community [1]. For non-U.S.-born persons, only 7% were attributed to recent transmission [1]. This suggests that while the overall numbers tilt heavily toward the foreign-born population, active disease spread within the U.S. is disproportionately a domestic phenomenon.

The Pandemic's Long Shadow

COVID-19 did not cause the TB resurgence, but it created the conditions for one. A study published in Emerging Infectious Diseases documented the mechanisms: 52% of TB programs reported reduced diagnostic capacity during the pandemic, overseas medical examinations for immigrants with TB indicators dropped 74%, and international arrivals to the U.S. fell 49% in 2020 [3].

The practical consequences were stark. Patients with respiratory symptoms were assumed to have COVID-19, delaying TB diagnosis. Screening programs in shelters, correctional facilities, and community health settings were suspended or scaled back. The number of first-year TB diagnoses among non-U.S.-born persons fell 60% in 2020, then exploded upward—227% in 2021 and 70% in 2022—as delayed cases surfaced [3].

The rebound is not simply a statistical correction. By 2023, TB cases had surpassed 2013 levels, reaching incidence rates not seen since 2016 [3]. The share of cases among U.S.-born persons also shifted, dropping from 33% of the caseload during 2010–2019 to 26% during 2020–2023 [3], reflecting the outsized role of disrupted immigrant screening and delayed reactivation diagnoses.

How the U.S. Compares Globally

Among high-income nations, the United States occupies an unusual position. Its 2023 TB incidence rate of 3.1 per 100,000 is lower than those of the United Kingdom (8.6), Australia (6.2), Canada (6.2), and Germany (5.6), according to World Bank data [5]. Japan's rate of 9.8 per 100,000, though falling rapidly from 17 in 2015, remains substantially higher [5].

Source: World Bank / WHO Global TB Programme

Data as of Feb 24, 2026CSV

But this favorable comparison masks a troubling internal disparity. The U.S. rate among non-U.S.-born persons (15.7 per 100,000) exceeds the national rates of most European countries [1]. And while Germany and Canada saw their rates fluctuate modestly over the past decade, the U.S. experienced a sharper V-shaped trajectory—falling to 2.4 in 2020 before snapping back to 3.1 by 2023 [5]. The trajectory suggests a system that, rather than steadily eliminating TB, lost its footing during the pandemic and has not recovered.

Globally, the net reduction in TB incidence from 2015 to 2024 was 12.3%, far short of the WHO End TB Strategy milestone of 50% by 2025 [6].

Drug Resistance: Low but Not Zero

Drug-resistant TB remains rare in the United States, but the numbers bear watching. In 2024, 115 cases of multidrug-resistant TB (MDR-TB)—defined as resistance to at least isoniazid and rifampin, the two most potent first-line drugs—were identified, representing 1.5% of tested cases [7]. Of these, 12 were classified as pre-extensively drug-resistant and 5 as extensively drug-resistant (XDR-TB), up from just 1 XDR case in 2023 [7].

Isoniazid resistance alone was found in 681 cases, or 9.1% of those tested [7]. Among U.S.-born persons, fewer than 1% had MDR-TB [8]. The overall rarity of drug resistance in the U.S. reflects the effectiveness of supervised treatment protocols, but the fivefold increase in XDR cases—from 1 to 5 in a single year—warrants surveillance attention even if the absolute numbers remain small.

The Cost of Treatment and the Gaps in Coverage

Treating TB is expensive and prolonged. A standard 4- to 6-month regimen for drug-susceptible pulmonary TB costs approximately $23,000 per patient [9]. Hospitalization adds substantially to that figure—estimated at roughly $28,000 per hospitalized patient in inflation-adjusted terms [10]. MDR-TB treatment, which can extend to 18 months or longer and requires more toxic second-line drugs, costs several times more.

Public funding covers the vast majority of these expenses. Federal, state, and local governments and public hospitals pay more than 85% of TB hospitalization costs, with private insurance covering about 9% [10]. This reflects the reality that TB disproportionately affects populations with limited or no insurance: recent immigrants, people experiencing homelessness, incarcerated individuals, and low-income communities.

A persistent gap exists in coverage for latent TB infection (LTBI), where an estimated 13 million people in the U.S. carry dormant Mycobacterium tuberculosis that could reactivate into active disease. Testing and treatment for LTBI is not uniformly covered as a recommended preventive service without cost sharing [10], creating a financial barrier to the most cost-effective intervention available—preventing active disease before it starts.

Funding Under Pressure

The domestic TB control apparatus is facing its most significant funding challenge in years. The administration's FY 2026 budget proposal would fold TB prevention into a $300 million block grant to states that also covers sexually transmitted infections and viral hepatitis—replacing a $1.5 billion set of dedicated programs [11]. The net reduction amounts to roughly $77 million across the combined portfolio, and eliminates categorical funding that ensured TB received dedicated attention [11].

Internationally, the picture is more dramatic. The FY 2026 budget requests $178 million for global TB efforts, a $228 million reduction from prior levels [12]. USAID, historically the world's third-largest TB research funder, saw 79% of its awards that included TB activities terminated following a stop-work order [12]. An internal USAID assessment warned that ceasing TB control programs could increase global TB incidence by 28–32% [12].

The global cuts carry domestic implications. TB does not respect borders. Weakened detection and treatment programs in high-burden countries—18 of which depended on U.S. funding for 89% of their expected TB budgets [13]—mean more people arriving in the U.S. with undetected infections. Harvard researchers projected that the loss of U.S. bilateral health aid could result in 2.5 million additional pediatric TB cases and 340,000 additional child deaths in low- and middle-income countries between 2025 and 2034 [14]. Congress has partially blunted these cuts, amending a rescission package to exempt TB from some reductions and reducing proposed global health cuts from over $1 billion to $500 million [12].

Mortality: Stable Rates, Rising Concern

In 2023, 572 deaths were attributed to TB on death certificates, a rate of 0.2 per 100,000 that has held steady even as case counts climbed [15]. A more detailed accounting from the National Tuberculosis Surveillance System found 858 deaths among persons with TB in 2022, of which 349 (41%) were directly related to TB disease or its treatment [1].

The stable mortality rate amid rising cases reflects the continued effectiveness of U.S. treatment infrastructure for those who access it. But it also obscures a demographic pattern: racial and ethnic disparities in TB outcomes persist, and modeling suggests these disparities could account for 45% of U.S.-born TB cases and 44% of TB deaths through 2035 [15].

Screening, Civil Liberties, and the Policy Debate

TB control has always existed at the intersection of public health authority and individual rights. The disease is one of a handful of conditions for which U.S. law permits involuntary detention of patients who refuse treatment—a power rooted in the principle that an untreated, infectious TB patient poses a direct threat to others [16].

The current framework relies on a combination of overseas screening for immigrants, domestic contact tracing, and directly observed therapy (DOT), in which health workers watch patients take every dose. Active screening at ports of entry yields roughly 3.5 TB cases per 1,000 persons screened, with higher yields among refugees (11.9 per 1,000) than regular immigrants (2.7 per 1,000) [17]. But the system has gaps: during 2013–2016, 35.5% of newly arrived at-risk immigrants and refugees did not complete post-arrival evaluation or their data were not reported to CDC [17].

Epidemiologists emphasize that strengthening domestic contact tracing and LTBI treatment would have a larger impact than tightening border screening alone. Reactivation of latent infection—not recent transmission—accounts for approximately 85% of all U.S. TB cases [17]. This means the 13 million Americans estimated to carry latent TB represent a reservoir that border screening cannot reach.

Privacy advocates and civil liberties organizations have long raised concerns about mandatory reporting requirements, DOT programs that effectively surveil patients for months, and involuntary detention provisions. The tension is not theoretical: New York City's 1993 amendment to its health code authorized detention of even non-infectious individuals deemed unlikely to complete treatment—a standard based on predicted compliance rather than demonstrated danger [16]. The CDC's 2017 disease control rules expanded active screening and social distancing powers at airports, drawing criticism from civil liberties groups [16].

Proponents of more aggressive measures argue that TB's airborne transmission, lengthy treatment course, and potential for drug resistance development make some degree of coercion unavoidable. Critics counter that coercive approaches disproportionately burden marginalized communities—immigrants, people experiencing homelessness, racial minorities—and that trust, not force, is what sustains the treatment adherence needed to prevent resistance.

What Comes Next

The TB resurgence in the United States is not a crisis of the same magnitude as the disease's global toll—10.8 million new cases and 1.25 million deaths worldwide in 2023 [6]. But it represents a failure to maintain momentum toward elimination in a country with the resources to achieve it.

The pandemic exposed the fragility of a system that had been quietly underfunded for years, staffed by an aging workforce of TB specialists, and dependent on a small number of overburdened state and local health departments. The post-pandemic rebound is compounding that strain. Preliminary 2025 data suggesting further 10–20% increases [2] would push the U.S. past 11,000 annual cases for the first time in decades.

The path forward requires sustained investment in LTBI screening and treatment among high-risk populations, restoration of disrupted immigrant screening pipelines, and maintenance of the domestic public health infrastructure that makes supervised treatment possible. Whether those investments will materialize amid competing fiscal pressures and shifting political priorities remains the central uncertainty.