The Return of America's Oldest Killer: Tuberculosis Rebounds After Decades of Decline

For the fourth consecutive year, tuberculosis cases in the United States have risen, reaching 10,388 in 2024—the highest count since 2011 [1]. The increase reverses a nearly seven-decade decline that once made elimination seem inevitable. Preliminary 2025 data from some states suggests case growth of 10% to 20% over the prior year [2]. The resurgence arrives as federal funding for TB prevention faces deep cuts, public health infrastructure contracts, and the populations most vulnerable to TB—people experiencing homelessness, formerly incarcerated individuals, and recent immigrants—continue to grow.

The Numbers: How Far the Comeback Has Gone

The low-water mark came in 2020, when the U.S. recorded just 7,170 TB cases at a rate of 2.2 per 100,000—partly a genuine trend, partly an artifact of reduced testing during the COVID-19 pandemic [3]. Since then, the trajectory has reversed sharply. In 2024, 39 of 52 reporting jurisdictions saw increases in both case counts and rates [1]. Five jurisdictions reported jumps of 50% or more: Kansas saw a 159% increase (44 to 114 cases), and Utah, Maine, Wyoming, and American Samoa each saw increases of at least 50% [4].

Geographically, the burden remains concentrated. Four states—California (2,109 cases), Texas (1,279), New York (1,083), and Florida (675)—account for roughly half of all U.S. TB cases [4]. But the highest incidence rates per capita tell a different story: Alaska leads at 12.3 per 100,000, followed by New York City at 9.8, Hawaii at 8.1, and California at 5.3 [4].

Source: CDC TB Surveillance Report 2024

Data as of Mar 26, 2026CSV

Mortality has been more stable. In 2023, the most recent year with complete death data, 572 TB-related deaths were reported nationally, a rate of 0.2 per 100,000 [3]. That figure has held roughly steady even as cases climb—a reflection of treatment effectiveness when patients are diagnosed and complete therapy. In 2022, 87% of eligible patients completed treatment within one year, and 91% received at least some directly observed therapy (DOT), in which a health worker watches the patient take each dose [1].

Who Gets TB: Demographics and Disparities

The demographic profile of TB in the United States is marked by stark disparities. In 2024, 77% of TB cases occurred among people born outside the country, at an incidence rate of 15.7 per 100,000—compared to 0.8 per 100,000 among U.S.-born individuals [1]. The top countries of origin for non-U.S.-born cases were Mexico, the Philippines, India, Vietnam, and Haiti [1]. Among non-U.S.-born patients, 24% were diagnosed within their first year in the country [1].

By race and ethnicity, case counts were highest among Hispanic or Latino individuals (3,882), followed by Asian (2,998) and Black or African American (2,063) populations [1]. Incidence rates reveal an even sharper disparity: Native Hawaiian or Other Pacific Islander populations had a rate of 37.2 per 100,000—nearly 100 times the rate among white Americans (0.4 per 100,000). Asian Americans had an incidence of 13.6, Hispanic or Latino 5.7, and Black or African American 4.8 [1].

Social determinants compound biological risk. In 2024, 866 TB cases (9% of those aged 15 and older) occurred among people experiencing homelessness, and 824 cases (also 9%) occurred among people with a history of incarceration [1]. People in shelters face TB rates roughly 11 times the national average—approximately 36 per 100,000 compared to 3.1 overall [5]. Over the past two decades, a disproportionate number of U.S. TB outbreaks have originated in homeless shelters in cities like Atlanta, Jacksonville, Los Angeles, and Seattle; from 2009 through 2015, 8 of 21 tracked outbreaks involved overnight facilities for people without stable housing [5].

Diabetes is the most common medical risk factor, present in 22% of TB cases. HIV coinfection was reported in 5% [1].

Domestic Roots vs. Cross-Border Transmission

A central policy question is whether the resurgence is driven primarily by immigration or by domestic conditions. The epidemiological data suggests a more nuanced picture than either explanation alone.

CDC genotyping data from 2023–2024 found that 12% of sequenced TB cases (1,804 of 14,648) showed evidence of recent transmission—meaning the infection was likely acquired in the United States rather than abroad [1]. Six states reported active outbreaks ranging from 10 to 64 cases, and nearly 80% of outbreak cases were identified through contact investigations [1]. These outbreaks overwhelmingly occur in congregate settings: shelters, correctional facilities, and dense urban housing.

At the same time, the 20-fold difference in incidence rates between U.S.-born and foreign-born populations (0.8 vs. 15.7 per 100,000) reflects the reality that most TB cases in the U.S. originate from infections acquired in high-burden countries [1]. Many of these patients carry latent TB infection (LTBI)—a dormant form that can reactivate years or decades after initial exposure—meaning the infection itself predates arrival in the United States.

Public health researchers have argued that both factors are inseparable. A 2024 study published in BMC Global and Public Health concluded that achieving TB elimination in North America requires "giving equal weight to domestic and international efforts," including expanded screening for LTBI in immigrant populations alongside investment in the social conditions that drive outbreaks among the U.S.-born [6].

How the U.S. Compares to Other Wealthy Nations

Source: World Bank / WHO Global TB Database

Data as of Mar 26, 2026CSV

World Bank data shows the U.S. had a TB incidence rate of 3.1 per 100,000 in 2023, lower than the United Kingdom (8.6), Japan (9.8), and Germany (5.6), but comparable to Canada (6.2) when adjusting for reporting differences [7]. Japan, despite higher current rates, has achieved consistent annual reductions—from 20 per 100,000 in 2013 to 9.8 in 2023—through aggressive active case-finding, mandatory screening, and universal healthcare coverage [7].

The UK has seen its own rebound, with TB increasing by 30% among foreign-born residents in 2024 compared to 2022 [8]. Germany saw an uptick following the 2015 refugee influx but has since stabilized [7]. What distinguishes the countries maintaining downward trajectories—notably Japan and, until recently, the UK—is sustained investment in screening infrastructure, universal access to treatment regardless of immigration status, and routine TB testing in healthcare settings and congregate living facilities.

The United States, by contrast, lacks universal healthcare coverage, and Medicaid coverage gaps in non-expansion states leave many high-risk individuals without consistent access to care. Routine TB screening in correctional facilities varies widely by state, and there is no federal mandate for shelter-based screening.

Drug Resistance: Low but Not Zero

Drug-resistant TB remains statistically rare in the United States but demands disproportionate resources when it occurs. In 2024, 115 cases of multidrug-resistant TB (MDR-TB)—defined as resistance to at least isoniazid and rifampin, the two most effective first-line drugs—were identified among 7,475 tested cases (1.5%) [9]. Five cases met the criteria for extensively drug-resistant TB (XDR-TB), up from just one case in 2023 [9].

The long-term trend is favorable: MDR-TB cases have fallen from 484 (2.7% of tested cases) in 1993 to 115 in 2024 [9]. But the cost differential between drug-susceptible and drug-resistant treatment is enormous. Treating a standard drug-susceptible TB case in the U.S. costs approximately $18,000 to $23,000. An average MDR-TB case costs $154,000. XDR-TB treatment can reach $494,000 to $568,000 per patient [10]. These figures do not include productivity losses from the extended treatment periods—MDR-TB regimens can last 18 to 24 months, compared to 4 to 6 months for drug-susceptible disease.

At 1.5%, the U.S. MDR-TB rate is far below the global average in high-burden countries, but the five-fold increase in XDR-TB cases in a single year—though from a very small base—warrants monitoring [9].

Funding Under Pressure

The federal infrastructure for TB prevention is facing its most significant contraction in decades. The proposed FY 2026 budget requests $178 million for global TB efforts, a decrease of $228 million from prior appropriations [11]. Domestically, a $1.5 billion CDC program for preventing viral hepatitis, STDs, and tuberculosis would be consolidated and reduced to $300 million under the proposal [12].

The effects are already visible through administrative channels. By August 2025, the CDC's National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention had disbursed $167 million less than its historical average [13]. The reduction occurred not through formal congressional appropriation cuts but through administrative mechanisms: reduced apportionments from the Office of Management and Budget, additional layers of grant review, and delayed funding calls for 2025 applications [13].

Personnel cuts have also affected TB capacity. CDC layoffs in early 2025 included 150 to 200 employees in programs managing tuberculosis and sexually transmitted disease [14]. While approximately 200 workers in the HIV and TB prevention center were later reinstated following legal challenges, many programs experienced months of disrupted operations [15].

Internationally, the dissolution of USAID and the termination of 79% of TB-related foreign aid awards have drawn warnings from the WHO and academic researchers. A Harvard/Boston University modeling study estimated that the withdrawal of U.S. support from the Global Fund to Fight AIDS, Tuberculosis, and Malaria could result in 8.9 million additional child TB cases and 1.5 million child deaths globally [16].

Administration officials have characterized the domestic restructuring as providing states "more flexibility" in spending consolidated grant funds [12]. Critics counter that TB, unlike many chronic conditions, requires highly specialized public health infrastructure—contact tracing, directly observed therapy, and laboratory capacity—that general-purpose block grants are unlikely to sustain.

The Cost of Inaction vs. the Cost of Elimination

The United States published its national strategic plan for TB elimination in 1989, defining success as fewer than one case per million population annually [17]. Thirty-seven years later, the country stands at 31 cases per million—and the rate is climbing rather than falling. Achieving the elimination target by 2050 would require annual incidence reductions exceeding 10%; over the past decade, incidence was essentially flat before beginning to rise [17].

The math of TB economics favors prevention. CDC modeling tools estimate that each prevented case avoids $18,000 to $568,000 in direct treatment costs, depending on drug susceptibility, plus productivity losses and downstream transmission [10]. Outbreak investigations themselves are expensive—a single outbreak in a homeless shelter can cost a local health department hundreds of thousands of dollars in staff time, testing, and treatment [18].

Conversely, the investments needed to bend the curve back downward are well-characterized: expanded LTBI testing and treatment among high-risk populations, universal screening in correctional facilities and homeless shelters, sustained funding for contact investigation teams, and addressing the social determinants—housing instability, poverty, lack of insurance coverage—that create the conditions for transmission [6][17].

Whether TB's resurgence represents a temporary post-pandemic correction or the beginning of a structural reversal depends on decisions being made now. The disease's long latency period means that infections acquired today may not manifest as active cases for years or decades. Every year of reduced screening and treatment creates a reservoir of future illness that will be more expensive to address later.

The Missed Window

TB experts have long warned that the United States was squandering an opportunity. A 2017 article in the New England Journal of Medicine called for "renewed action" on TB elimination, noting that complacency and underfunding had stalled progress even when case counts were declining [19]. A 2018 transmission modeling study found that elimination by 2050 was achievable but only with immediate and sustained investment in LTBI treatment at a scale the country had never attempted [17].

Those warnings went largely unheeded. Federal TB funding remained flat in inflation-adjusted terms for most of the 2010s, even as the homeless population grew, the opioid crisis created new congregate-living risks, and immigration from high-burden countries continued. The COVID-19 pandemic then diverted public health resources and reduced routine screening, allowing latent infections to progress undetected.

The current moment represents a convergence: rising case counts, contracting federal capacity, growing vulnerable populations, and a global TB crisis that the U.S. can no longer insulate itself from. TB killed an estimated 1.25 million people worldwide in 2023, making it the leading infectious disease killer globally—surpassing both HIV and malaria [20]. The U.S. is not immune to the forces driving that global toll. Whether it chooses to act on that recognition is a policy choice, not an epidemiological inevitability.