Postpartum confinement is a traditional practice following childbirth. Those who follow these customs typically begin immediately after the
birth, and the seclusion or special treatment lasts for a culturally
variable length: typically for one month or 30 days, 26 days, up to 40 days, two months, or 100 days. This postnatal recuperation can include care practices in regards of "traditional health beliefs, taboos, rituals, and proscriptions." The practice used to be known as "lying-in", which, as the term suggests, centres on bed rest. In some cultures, it may be connected to taboos concerning impurity after childbirth.
Overview
A mother and her newborn rest in bed, breastfeeding
Postpartum confinement refers both to the mother and the baby. Human newborns are so underdeveloped that pediatricians such as Harvey Karp refer to the first three months as the "fourth trimester". The weeks of rest while the mother heals also protect the infant as it adjusts to the world, and both learn the skills of breastfeeding.
Almost all countries have some form of maternity leave. Many countries encourage men to take some paternal leave, but even those that mandate that some of the shared parental leave must be used by the father ("father's quota") acknowledge that the mother needs time off work to recover from the childbirth and deal with the postpartum physiological changes.
A 2016 American book describes the difficulties of documenting
those "global grandmotherly customs" but asserts that "like a golden
rope connecting women from one generation to the next, the protocol of
caring for the new mother by unburdening her of responsibilities and
ensuring she rests and eats shows up in wildly diverse places". These customs have been documented in dozens of academic studies, and
commonly include support for the new mother (including a release from
household chores), rest, special foods to eat (and ones to avoid),
specific hygiene practices, and ways of caring for the newborn.
Martha Wolfenstein and Margaret Mead
wrote in 1955 that the postpartum period meant a "woman can be
cherished and pampered without feeling inadequate or shamed". The 2016
review that quoted them cites customs from around the world, from
Biblical times to modern Greece:
From
the data it seems that women were housebound for a number of days after
the birth and the length of this period of seclusion varied by caste or
ethnic group [in Nepal]. This is a phenomenon found across the globe,
including in high-income countries in the recent past. The length of
time a woman is secluded or rested varied across different countries and
the principles underpinning this isolation (to heal vs. being unclean)
also seem to differ greatly. After the period of seclusion there is
often a ceremony to purify women to publicly accept them back into daily
life. The literature supports the concept of a resting – a lengthy
lie-in or lying-in period, a period of seclusion, as women need to rest
in order to heal, yet it may mean that they are neglected.
Health effects
Research on the health effects of postpartum confinement has produced
mixed findings. A 2009 systematic review of English-language studies on
Chinese confinement practices concluded, "There is little consistent
evidence that confinement practices reduce postpartum depression."
A more recent 2023 systematic review, which included sixteen
quantitative studies from China and Chinese immigrant populations
abroad, similarly found that "doing-the-month" failed to show a
significant overall protective effect against postpartum depression.
However, the review noted that four of the sixteen studies did find a
reduced risk, suggesting that the quality of and satisfaction with
confinement support—rather than mere adherence to the practice—may be a
more important factor in maternal mental health outcomes.
A 2024 qualitative meta-synthesis examining postpartum Chinese
women's lived experiences of confinement found that women valued the
physical rest, social support, and structured recovery period, but that
conflicts with caregivers—particularly mothers-in-law—over confinement
rules could contribute to psychological distress.
A 2007 qualitative systematic review of traditional postpartum
practices across multiple cultures found that common elements—including
social support, rest, and special nutrition—were widely perceived as
beneficial by mothers, though the review noted a lack of rigorous
controlled studies to confirm specific health outcomes.
By region
Asia
China
Chinese painting of a woman breastfeeding her baby, surrounded by supporters
Postpartum confinement is well-documented in China, where the tradition is known as "Sitting the month": 坐月子 "Zuò yuè zi" in Mandarin or 坐月 "Co5 Jyut2" in Cantonese. The earliest record of the Chinese custom of postpartum confinement dates back over 2,000 years ago in the Book of Rites, where it was known as yuè nèi (月内). Postpartum confinement is based on traditional Chinese medicine, with a special focus on eating foods considered to be nourishing for the body and helping with the production of breastmilk. Women are advised to stay indoors for recovery from the trauma of birth and for feeding the newborn baby.
The diets and traditions involved with postpartum confinement
greatly vary across different Chinese cultural regions. The length of
Chinese postpartum confinement ranges anywhere between 28 and 100 days. Medical opinion in China today generally recommends a confinement period of at least 42 days. In ancient China, the confinement period lasted for 100 days. This
custom is still observed in parts of northern China, such as Shanxi province. After 100 days, the Hundred Days Banquet (百日宴) is held to celebrate the
baby reaching 100 days old. In southern China, the confinement period
is significantly shorter, and usually lasts 30 days.
Because Chinese society is patrilocal,
women observing postpartum confinement are traditionally cared for by
their mother-in-law. In contemporary times, it is also possible for the
woman to be cared for her by her own mother or a hired female worker
known as a "confinement nanny" (陪月). In Hong Kong, the mother and baby
sometimes spend the month in special postpartum confinement clinics
rather than at home.
In ancient China,
women of certain ethnic groups in the South would resume work right
after birth, and allow the men to practice postpartum confinement
instead. (See Couvade).
Everyday habits and personal hygiene practices
Traditionally in China, the mother and child were kept separate from the rest of the household. The mother was not permitted to bathe, wash her hair, or weep, because
these activities were believed to put the mother at risk of falling ill
by catching cold and affect the quality of her breast milk.
Nowadays, however, new mothers may wash their hair or take a bath
or shower infrequently during the postpartum period, but it is claimed
to be important to dry their body immediately afterwards with a clean
towel and their hair properly using a hair dryer. It is also claimed to
be important for women to wrap up warm and minimize the amount of skin
exposed, as it was believed that they may catch a cold during this
vulnerable time. In Dalian, some women even take to wrapping themselves in plastic to avoid the wind.
Special foods
Pork knuckle with ginger and black vinegar
The custom of confinement advises new mothers to choose energy and protein-rich foods to recover energy levels, help shrink the uterus, and for the perineum to heal. This is also important for the production of breastmilk. Among the traditionally recommended galactogogues were rich porridge, fish soup, and hard-boiled eggs. Sometimes, new mothers only begin to consume special herbal foods after all the lochia is discharged.
In Guangdong, a common dish is pork knuckles with ginger and black vinegar
as pork knuckles are believed to help replenish calcium levels in
women. Ginger is featured in many dishes, as it is believed that it can
remove the 'wind' accumulated in the body during pregnancy. Meat-based
soup broths are also commonly consumed to provide hydration and added
nutrients.
In Shanxi, new mothers consume high-quality millet porridge and soup made from chickens at specific ages.
In Singapore, confinement dishes are thoughtfully crafted to
support postpartum recovery. Sesame Oil Chicken helps replenish blood
and keep the body warm, while Green Papaya Soup is known to boost breast
milk supply. Red Dates Tea restores vitality and maintains warmth, and
Black Vinegar Pig Trotters provide calcium and collagen to strengthen
bones and joints.
Rituals
In Guangdong province,
new mothers are barred from visitors until the baby is 12 days old,
marked by a celebration called 'Twelve mornings' (known as 十二朝). From
this day onwards, Cantonese families with a new baby usually share their
joy through giving away food gifts, while some families mark the
occasion by paying tribute to their ancestors. When the "month is fulfilled" (manyue) after 30 days, the mother receives relatives and friends who bring special foods such as Chinese red eggs.
Indian subcontinent
In parts of India it is called jaappa (also transliteratedjapa); in North India and Pakistan, sawa mahina ("five weeks").
Most traditional Indians follow the 40-day confinement and recuperation period also known as the jaappa
(in Hindi). A special diet to facilitate milk production and increase
hemoglobin levels is followed. Sex is not allowed during this time. In
Hindu culture, this time after childbirth was traditionally considered a
period of relative impurity (asaucham), and a period of confinement of 10–40 days (known as purudu)
was recommended for the mother and the baby. During this period, she
was exempted from usual household chores and religious rites. The father
was purified by a ritual bath before visiting the mother in confinement.
In the event of a stillbirth, the period of impurity for both parents was 24 hours.
Many Indian subcultures have their own traditions after birth.
This birth period is called Virdi (Marathi), which lasts for 10 days
after birth and includes complete abstinence from puja or temple visits.
In Pakistan, postpartum tradition is known as sawa mahina ("five weeks").
Iran
In Persian culture it is called chilla, i.e. "forty days".
Japan
In Japan, the traditional postpartum practice is known as satogaeri bunben
(里帰り分娩, "homecoming birth"). In this custom, a pregnant woman returns
to her parents' home in the late stages of pregnancy to give birth and
recover, typically staying for one to two months after delivery. The new
mother's own mother provides practical support including meals,
household tasks, and newborn care assistance.
Unlike Chinese zuo yue zi or Korean sanhujori,
Japanese postpartum care does not typically involve codified dietary
restrictions based on traditional medicine or strict prohibitions on
bathing or exposure to cold. Instead, the emphasis is on practical and
emotional support from the maternal family.
A study examining the relationship between satogaeri bunben
and postnatal depression found that the practice itself did not
significantly reduce the incidence of postpartum depression, suggesting
that the type and quality of support received may matter more than the
setting. A subsequent single-center analysis similarly found no significant
difference in postpartum depressive status based on the presence of
grandparents or the place of delivery.
Korea
In Korea, the traditional postpartum practice is known as sanhujori (산후조리), and women historically observed a confinement period called samchil-il (삼칠일, "three seven days," or 21 days). In the past, during the samchil-il period, geumjul (taboo rope) made with saekki
and various symbolic objects, such as chili peppers (for a boy) and
coal (for a girl), was hung over the gate to denote the childbirth and
restrict visitor access.
Sanhujori practices traditionally include consuming warm foods believed to aid recovery, such as seaweed soup (miyeokguk),
which is rich in iron and iodine and is considered essential for
postpartum mothers. New mothers are also encouraged to keep warm, rest
extensively, and avoid cold foods and environments.
Since the late 20th century, South Korea has seen the widespread
establishment of specialized postpartum care facilities known as sanhujoriwon
(산후조리원). These centers provide professional nursing care, newborn
monitoring, lactation support, and traditional postpartum meals in a
residential setting, typically for a stay of approximately two weeks. A
2023 study examining first-time mothers' satisfaction with sanhujoriwon found that both individual factors and environmental ecological factors influenced maternal satisfaction with these facilities.
The growth of sanhujoriwon parallels the development of postpartum care centers in Taiwan, reflecting a broader East Asian trend toward institutionalized postpartum recovery support.
Taiwan
Postpartum confinement is widely practiced in Taiwan, where it is commonly known as 做月內 (Tâi-lô: tsò-gue̍h-lāi).
While the practice shares historical roots with broader East Asian
postpartum traditions, postpartum confinement in Taiwan has developed
its own distinct forms shaped by local medical culture, social
structures, and modern healthcare systems. In Taiwan, postpartum
confinement is understood as a period of structured recovery for both
the mother and newborn, combining traditional beliefs with contemporary
medical advice.
Unlike in China, postpartum confinement in Taiwan is strongly integrated into the modern healthcare system. Since the late 20th century, Taiwan has seen the rapid growth of
specialized postpartum care centers (產後護理之家), which are licensed medical
facilities regulated by the Ministry of Health and Welfare.
These centers provide professional nursing care, lactation support,
neonatal monitoring, and nutritionally planned confinement meals,
allowing new mothers to observe confinement outside the home. This institutionalized model has become a defining feature of Taiwanese postpartum confinement and is far less common in China.
The typical confinement period in Taiwan lasts approximately 30
to 40 days, aligning closely with medical recommendations for postpartum
recovery. While some families may extend the period based on personal
or familial beliefs, extended confinements of 100 days—historically
documented in parts of China—are uncommon in contemporary Taiwanese
practice. Taiwanese medical professionals generally emphasize
flexibility, maternal comfort, and evidence-based care over strict
ritual observance.
Caregivers and living arrangements
Traditionally, postpartum women in Taiwan were cared for by female
relatives, particularly their mothers or mothers-in-law. However,
changing family structures, lower fertility rates, and increased
urbanization have led to a decline in multigenerational households. As a
result, many families now rely on professional confinement nannies (月嫂)
or postpartum care centers rather than extended family members. This shift has reduced the hierarchical dynamics historically
associated with patrilocal caregiving and reflects broader social
changes in Taiwanese society.
Everyday practices and hygiene
Traditional Taiwanese confinement customs emphasized keeping the
mother warm and limiting exposure to wind, echoing humoral concepts
shared across East Asia. In earlier generations, bathing and hair
washing were discouraged. In modern Taiwan, however, these restrictions
have largely been relaxed. Mothers are generally permitted to shower and
wash their hair during confinement, provided that they maintain warmth
and dry thoroughly afterward.
Diet and confinement foods
Diet plays a central role in Taiwanese postpartum confinement, with
an emphasis on warmth, nourishment, and recovery rather than strict
prohibitions. A defining feature of Taiwanese confinement cuisine is the
extensive use of sesame oil, rice wine, and ginger. One of the most
iconic dishes is sesame oil chicken, sio-tsiú-ke and ginger duck,
which is commonly consumed throughout the confinement period. Other
frequently served foods include liver dishes, fish soup, herbal broths,
and rice wine-based meals, which are believed to support blood
replenishment and uterine recovery.
Unlike in China, Taiwanese confinement diets are often carefully
calibrated by dietitians, especially in postpartum care centers, to
balance traditional principles with modern nutritional science. Alcohol content in rice wine-based dishes is frequently reduced or cooked off, particularly for breastfeeding mothers.
Contemporary perspectives
In Taiwan today, postpartum confinement is generally framed as a form
of maternal care rather than a rigid cultural obligation. Public
discourse increasingly emphasizes maternal autonomy, mental health, and
informed choice. While many Taiwanese families continue to value confinement as an
important recovery period, adherence to specific rules varies widely
based on personal preference, medical advice, and socioeconomic factors.
Distinct from ancient Chinese practices, Taiwanese postpartum
confinement represents a localized and evolving tradition that is
characterized by medical institutionalization, dietary specialization,
and a hybrid approach that integrates tradition with modern healthcare
norms.
Thailand
New mothers used to be encouraged to lie in a warm bed near the fire for 30 days, a practice known as yu fai. This has been adapted into a form of Thai massage. Kao krachome is a type of herbal medicine in which the steam from the boiled plants is inhaled. Ya dong involves herbal medicine taken internally. Thai immigrants to Sweden report using the steam bath to heal after childbirth, although the correct ingredients are not easy to find. Thai Australians who had had caesarian sections felt that they did not need to – in fact, ought not to – undergo these rituals.
Malaysia
In Malaysia, postpartum confinement is practiced across ethnic Malay,
Chinese, and Indian communities, each with distinct traditions. Malay
mothers typically observe a 44-day confinement period, during which they
undergo traditional practices including bertungku (application of a heated stone to the abdomen) and traditional massage (urut). Special herbal baths are also common throughout the recovery period. A comparative study of confinement practices in Singapore
found that Chinese and Indian mothers tended to follow more specific
dietary regimens than Malay mothers, and that Chinese mothers were more
likely to depend on confinement nannies for support.
Vietnam
Vietnamese postpartum confinement traditions emphasize keeping the mother warm to avoid gio
(wind), which is believed to cause headaches, joint pain, and other
long-term ailments. New mothers are encouraged to stay warm, avoid cold
water and drafts, and consume warming foods and herbal preparations. A
2021 meta-ethnography examining postpartum practices among Southeast and
East Asian immigrant mothers found that Vietnamese women, along with
Chinese, Korean, and Hmong women, frequently adapted their traditional
confinement practices when living abroad, negotiating between cultural
expectations and the realities of their new environments.
A mother in Florence lying-in, from a painted desco da parto or birth tray of c. 1410. As women tend to the child, expensively dressed female guests are already arriving.
The term used in English, now old-fashioned or archaic, was once used to name maternity hospitals, for example the General Lying-In Hospital in London. A 1932 Canadian publication refers to lying-in as ranging from two weeks to two months. These weeks ended with the re-introduction of the mother to the community in the Christian ceremony of the churching of women.
Lying-in features in Christian art, notably Birth of Jesus paintings. One of the gifts presented to the new mother in Renaissance Florence was a desco da parto, a special form of painted tray. Equivalent presents in contemporary culture include baby showers and push presents.
Special foods included caudle, a restorative drink. "Taking caudle" was a metonym for postpartum social visits.
Americas
Latin America
In Latin American countries, it is called la cuarentena ("forty days," a cognate with the English word "quarantine"). It is practised in parts of Latin America and amongst in communities in the United States. It is described as "intergenerational family ritual that facilitated adaptation to parenthood", including some paternal role reversal.
Diaspora and immigrant experiences
Immigrant mothers from East and Southeast Asian cultures often seek
to maintain postpartum confinement practices after relocating to Western
countries, though they may face challenges in doing so. A 2021
meta-ethnography of eight studies involving Vietnamese, Chinese,
Taiwanese, Korean, and Hmong
immigrant mothers found that women frequently adapted confinement
practices to their new environments, negotiating between traditional
expectations and the realities of life abroad.
Challenges documented in the literature include difficulty
accessing traditional confinement foods and herbal remedies, lack of
extended family support that would traditionally be available in the
home country, and cultural misunderstandings with Western healthcare
providers unfamiliar with confinement customs. A 2024 qualitative study of Chinese immigrant mothers in Switzerland
found that the postpartum period involved constructing new social
support networks to replace the extended family structures that would
traditionally provide confinement care.
In the United States and other Western countries, the growth of
confinement nanny agencies and specialized postpartum care services
catering to Asian immigrant communities reflects the demand for
traditional postpartum support in a diaspora context. Similarly, sanhujoriwon-style
postpartum retreat centers have begun appearing outside South Korea and
Taiwan to serve overseas Korean and Chinese communities.
Chest X-ray
of a person with advanced tuberculosis: Infection in both lungs is
marked by white arrowheads, and black arrows mark the formation of a
cavity.
Prevention of TB involves screening those at high risk, early detection and treatment of cases, and vaccination with the bacillus Calmette-Guérin (BCG) vaccine. Those at high risk include household, workplace, and social contacts of people with active TB. Treatment requires the use of multiple antibiotics over a long period of time.
It is estimated that one-quarter of the world's population, approximately 2 billion people, have latent TB. In 2024, TB incidence reached an estimated 10.7 million people and caused 1.23 million deaths, making it the leading cause of death from a single infectious agent worldwide.
Tuberculosis has been present in humans since ancient times. In the 1800s, when it was known as consumption, TB was responsible for an estimated quarter of all deaths in Europe. Both the incidence (new cases) and prevalence
(total cases) of TB declined significantly during the 20th century,
attributed to improved sanitation, the discovery of effective
antibiotics, and the introduction of the BCG vaccination. However, since the 1980s, antibiotic resistance has become a growing phenomenon, which led to a higher incidence of multidrug-resistant tuberculosis.
Although Richard Morton established the pulmonary form associated with tubercles as a pathology in 1689, due to the variety of its symptoms, TB was not identified as a single disease until the 1820s. Benjamin Marten conjectured in 1720 that consumption was caused by microbes that were spread by people living close to each other. In 1819, René Laennec claimed that tubercles were the cause of pulmonary tuberculosis. J. L. Schönlein first published the name "tuberculosis" (German: Tuberkulose) in 1832.
In 1865, Jean Antoine Villemin demonstrated that tuberculosis could be transmitted, via inoculation, from humans to animals and among animals. Villemin's findings were confirmed in 1867 and 1868 by John Burdon-Sanderson.
Robert Koch identified and described the bacillus causing tuberculosis, M. tuberculosis, on 24 March 1882. In 1905, he was awarded the Nobel Prize in Physiology or Medicine for this discovery.
Development of treatments
In Europe, rates of tuberculosis began to rise in the early 1600s to a
peak level in the 1800s, when it caused nearly 25% of all deaths. In the 18th and 19th century, tuberculosis had become epidemic in Europe, showing a seasonal pattern. Tuberculosis caused widespread public concern in the 19th and early
20th centuries as the disease became common among the urban poor. In
1815, one in four deaths in England was due to "consumption." By 1918,
TB still caused one in six deaths in France.
Between 1838 and 1845, John Croghan, the owner of Mammoth Cave
in Kentucky from 1839 onwards, brought many people with tuberculosis
into the cave in the hope of curing the disease with the constant
temperature and purity of the cave air; each died within a year.
Hermann Brehmer opened the first TB sanatorium in 1859 in Görbersdorf (now Sokołowsko) in Silesia. After TB was determined to be contagious, in the 1880s, it was put on a notifiable-disease
list in Britain. Campaigns started to stop people from spitting in
public places, and the infected poor were "encouraged" to enter
sanatoria that resembled prisons. The sanatoria for the middle and upper
classes offered excellent care and constant medical attention. Whatever the benefits of the "fresh air" and labor in the sanatoria,
even under the best conditions, 50% of those who entered died within
five years (c. 1916).
Robert Koch did not believe cattle and human tuberculosis were
similar, which delayed the recognition of infected milk as a source of
infection. During the first half of the 1900s, the risk of transmission
from this source was dramatically reduced after the application of the pasteurization process. Koch announced a glycerine extract of the tubercle bacilli as a "remedy" for tuberculosis in 1890, calling it "tuberculin.”
Although it was not effective, it was later successfully adapted as a
screening test for the presence of pre-symptomatic tuberculosis. World Tuberculosis Day is marked on 24 March each year, the anniversary of Koch's original scientific announcement. When the Medical Research Council was formed in Britain in 1913, it initially focused on tuberculosis research.
Albert Calmette and Camille Guérin
achieved the first genuine success in immunization against tuberculosis
in 1906, using attenuated bovine-strain tuberculosis. It was called bacille Calmette–Guérin (BCG). The BCG vaccine was first used on humans in 1921 in France, but achieved widespread acceptance in the US, Great Britain, and Germany only after World War II.
In 1946, the development of the antibiotic streptomycin
made effective treatment and cure of TB a reality. Before the
introduction of this medication, the only treatment was surgical
intervention, including the "pneumothorax technique", which involved collapsing an infected lung to "rest" it and to allow tuberculous lesions to heal.
By the 1950s, mortality in Europe had decreased by about 90%.
Improvements in sanitation, vaccination, and other public-health
measures began significantly reducing rates of tuberculosis even before
the arrival of streptomycin and other antibiotics, although the disease
remained a significant threat.
Drug-resistant tuberculosis
A graph showing the trend in estimated prevalence (total cases) and incidence (annual new cases) of MDR-TB from 1990 to 2021
A few years after the first antibiotic treatment for TB in 1943, some strains of the TB bacteria developed resistance to the standard drugs (streptomycin, para-aminosalicylic acid, and isoniazid).
Between 1970 and 1990, there were numerous outbreaks of
drug-resistant tuberculosis involving strains resistant to two or more
drugs; these strains are called multi-drug resistant TB (MDR-TB). The resurgence of tuberculosis, caused in part by drug resistance and in part by the HIV pandemic, resulted in the declaration of a global health emergency by the World Health Organization (WHO) in 1993.
Drug resistance to TB can come in two forms: primary and
secondary. Primary drug resistance is caused by person-to-person
transmission of drug-resistant TB bacteria. Secondary drug resistance
(also called acquired resistance) develops during TB treatment. A person
with fully drug-susceptible TB may develop secondary (acquired)
resistance during therapy because of inadequate treatment, not taking
the prescribed regimen appropriately (lack of compliance), or using
low-quality drugs.
To fully identify drug resistance and guide treatment, drug susceptibility testing (DST) determines which drugs can kill TB bacteria. WHO guidelines recommend a rapid molecular test, Xpert MTB/RIF, to diagnose TB and simultaneously detect rifampicin resistance. DST is crucial for fully identifying drug resistance and guiding treatment.
Rifampicin-resistant TB (RR-TB) is resistant to the drug rifampicin. Multi-drug resistant tuberculosis (MDR-TB) is defined as resistance to the two most effective first-line TB drugs: rifampicin and isoniazid. Extensively drug-resistant tuberculosis (XDR-TB) is resistant to rifampicin (and may also be resistant to isoniazid), and is also resistant to at least one fluoroquinolone (levofloxacin or moxifloxacin) and to at least one other Group A drug (bedaquiline or linezolid). A further categorization, totally drug resistant tuberculosis, has been used to describe strains with even greater drug resistance. As of 2025,
it has no accepted definition, but it is most commonly described as
'resistance to all first- and second-line drugs used to treat TB'. It was first observed in 2003 in Italy, but not widely reported until 2012, and has also been found in Iran, India, and South Africa.
As of 2023, the WHO estimates that 3.2% of new TB infections globally are RR-TB or MDR-TB; this went down from 4.0% in 2015. Among those who have been previously treated for TB, the proportion of
people with RR-TB or MDR-TB has also decreased from 25% in 2015 to an
estimated 16% in 2023.
Treatment of MDR-TB requires treatment with second-line drugs, which, in general, are less effective, more toxic, and more expensive than first-line drugs. Treatment regimens can run for up to two years, compared to the six months of first-line drug treatment. Treatment of MDR-TB is significantly more costly than treating regular
TB. As an example, in the UK in 2013 the cost of standard TB treatment
was estimated at £5,000 while the cost of treating MDR-TB was estimated
to be more than 10 times greater, ranging from £50,000 to £70,000 per
case.
In low-income countries,
the impact of MDR-TB on the families of its victims is severe,
affecting income, mental health, and social well-being. Families may
become impoverished due to the financial strain of MDR-TB treatment,
with studies reporting that a significant portion of household income
can be spent on healthcare.
Signs and symptoms
The main symptoms of variants and stages of tuberculosis are given, with many symptoms overlapping with other variants, while others are more, but not entirely, specific for certain variants.Tuberculosis of the lip, secondary to open pulmonary TB
There is a popular misconception that tuberculosis is purely a disease of the lungs that manifests as coughing. Tuberculosis may infect many organs, even though it most commonly occurs in the lungs (known as pulmonary tuberculosis). Extrapulmonary TB occurs when tuberculosis develops in organs other than the lungs; it may coexist with pulmonary TB.
The majority of individuals with TB infection show no symptoms, a state known as inactive or latent tuberculosis. This condition is not contagious, and can be detected by the tuberculin skin test (TST) and the interferon-gamma release assay (IGRA); other tests should be conducted to eliminate the possibility of active TB. Without treatment, an estimated 5% to 15% of cases will progress into active TB during the person's lifetime.
Pulmonary
If a tuberculosis infection does become active, it most commonly involves the lungs (in about 90% of cases). Symptoms may include chest pain, a prolonged cough producing sputum which may be bloody, tiredness, temperature, loss of appetite, wasting and general malaise. In very rare cases, the infection may erode into the pulmonary artery or a Rasmussen aneurysm, resulting in massive bleeding.
Tuberculosis may cause extensive scarring of the lungs, which
persists after successful disease treatment. Survivors continue to
experience chronic respiratory symptoms such as cough, sputum
production, and shortness of breath.
Pyopneumothorax is a rare and serious complication of pulmonary tuberculosis, with a high rate of morbidity and mortality. It is caused by both air and pus accumulating in the pleural space, simultaneously causing a pneumothorax and empyema, usually as the result of a rupture of a subpleural caseous necrosis (a collection of dead cells enclosed within a granuloma). Initial symptoms include abrupt onset chest pain, high fever with chills, severe dyspnea,
and less commonly pain & numbness in the extremities. In rare
cases, a pyopneumothorax can cause peripheral blood clots resulting in
an infarction, gangrene and tissue necrosis
of one or more limbs, requiring amputation unless caught early; death
can result if the gangrenous limb isn't amputated in time.
In 15–20% of active cases, the infection spreads outside the lungs, causing other kinds of TB. These are collectively denoted as extrapulmonary tuberculosis. Extrapulmonary TB occurs more commonly in people with a weakened immune system and young children. In those with HIV, this occurs in more than 50% of cases. Notable extrapulmonary infection sites include the pleura (in tuberculous pleurisy), the central nervous system (in tuberculous meningitis), the lymphatic system (in scrofula of the neck), the genitourinary system (in urogenital tuberculosis), and the bones and joints (in Pott disease
of the spine), among others. A potentially more serious, widespread
form of TB is called "disseminated tuberculosis"; it is also known as miliary tuberculosis. Miliary TB currently makes up about 10% of extrapulmonary cases.
Symptoms of extrapulmonary TB usually include the general signs
and symptoms as above, with additional symptoms related to the part of
the body which is affected. Urogenital tuberculosis,
however, typically presents differently, as this manifestation most
commonly appears decades after the resolution of pulmonary symptoms.
Most patients with chronic urogenital TB do not have pulmonary symptoms
at the time of diagnosis. Urogenital tuberculosis most commonly presents
with urinary 'storage symptoms' such as increased frequency and/or
urgency of urination, flank pain, hematuria, and nonspecific symptoms such as fever and malaise.
The principal microbial cause of TB is Mycobacterium tuberculosis (MTB), a small, aerobic, non-motile and rod-shaped bacillus. It divides every 16 to 20 hours, which is slow compared with other bacteria, which usually divide in less than an hour. Mycobacteria have a complex, lipid-richcell envelope, with the high lipid content of the outer membrane acting as a robust barrier contributing to their drug resistance. If a Gram stain is performed, MTB either stains very weakly "Gram-positive" or does not retain dye as a result of the high lipid and mycolic acid content of its cell wall. MTB can withstand weak disinfectants and survive in a dry state for weeks. In nature, the bacterium can grow only within the cells of a host organism, but M. tuberculosis can be cultured in the laboratory.
The term M. tuberculosis complex describes a genetically related group of Mycobacterium species that can cause tuberculosis in humans or other animals. Among its members are four other TB-causing mycobacteria: M. bovis, M. africanum, M. canettii, and M. microti. M. bovis causes bovine TB and was once a common cause of human TB, but the introduction of pasteurized milk has almost eliminated this as a public health problem in developed countries. M. africanum is not widespread, but it is a significant cause of human TB in parts of Africa.M. canettii is rare and seems to be limited to the Horn of Africa, although a few cases have been seen in African emigrants. M. microti appears to have a natural reservoir in small rodents
such as mice and voles, but can infect larger mammals. It is rare in
humans and is seen almost only in immunodeficient people, although its prevalence may be significantly underestimated.
There are other known mycobacteria which cause lung disease resembling TB. M. avium complex is an environmental microorganism found in soil and water sources worldwide, which tends to present as an opportunistic infection in immunocompromised people. The natural reservoir of M. kansasii is unknown, but it has been found in tap water; it is most likely to infect humans with lung disease or who smoke. These two species are classified as "nontuberculous mycobacteria".
Public health campaigns in the 1920s tried to halt the spread of TB.
Transmission
Tuberculosis spreads through the air when people with active
pulmonary TB cough, sneeze, speak, or sing, releasing tiny airborne droplets
containing the bacteria. Anyone nearby can breathe in these droplets
and become infected. The droplets can remain airborne and infective for
several hours, and are more likely to persist in poorly ventilated
areas. TB is not spread by shaking hands, sharing food, drinks, or utensils,
touching bed linens and toilet seats, sharing toothbrushes, or kissing.
Risk factors for TB include exposure to droplets from people with
active TB, as well as environmental and health-condition-related factors
that decrease a person's immune system response.
Close contact
Prolonged, frequent, or close contact with people who have active TB
is a high risk factor for becoming infected; this group includes health
care workers and children where a family member is infected.Transmission is most likely to occur from only people with active TB –
those with latent infection are not thought to be contagious. Environmental risk factors that put a person in closer contact with
infectious droplets from a person infected with TB are overcrowding,
poor ventilation, or proximity to a potentially infective person.
Environmental factors
Environmental factors which weaken the body's protective mechanisms
and may put a person at additional risk of contracting TB include air pollution, exposure to smoke (including tobacco smoke), and exposure (often occupational) to dust or particulates.
Immunodeficiencies
The most important risk factor globally for developing active TB is concurrent human immunodeficiency virus (HIV) infection; in 2023, 6.1% of those becoming infected with TB were also infected with HIV. Sub-Saharan Africa has a particularly high burden of HIV-associated TB. Of those without HIV infection who are infected with tuberculosis, about 5–15% develop active disease during their lifetimes; in contrast, 30% of those co-infected with HIV develop the active disease. People living with HIV are estimated 16 times more likely to fall ill
with TB than people without HIV; TB is the leading cause of death among
people with HIV.
Another important risk factor is the use of medications that
suppress the immune system. These include (but are not limited to), chemotherapy; medication after an organ transplant; and medication for lupus or rheumatoid arthritis. Other risk factors include: heavy alcohol use, diabetes mellitus, silicosis, tobacco smoking, recreational drug use, severe kidney disease, head and neck cancer, and low body weight. Children, especially those under age five, have undeveloped immune systems and are at higher risk.
Pathogenesis
The spleen in a patient with miliary tuberculosis showing granulomas (tubercles)
TB infection begins when a M. tuberculosis bacterium, inhaled from the air, penetrates the lungs and reaches the alveoli. Here it encounters an alveolar macrophage, a cell of the body's immune system, which attempts to destroy it. However, M. tuberculosis can neutralise and colonise the macrophage, leading to persistent infection.
The defence mechanism of the macrophage begins when a foreign body, such as a bacterial cell, binds to receptors on the surface of the macrophage. The macrophage then stretches itself around the bacterium and engulfs it. Once inside this macrophage, the bacterium is trapped in a compartment called a phagosome; the phagosome subsequently merges with a lysosome to form a phagolysosome. The lysosome is an organelle which contains digestive enzymes; these are released into the phagolysosome and kill the invader.
The M. tuberculosis bacterium can subvert the normal process by
inhibiting phagosome development and preventing fusion with the
lysosome. The bacterium can survive and replicate within the phagosome; it will
eventually destroy its host macrophage, releasing progeny bacteria which
spread the infection.
In the next stage of infection, macrophages, epithelioid cells, lymphocytes and fibroblasts aggregate to form a granuloma, which surrounds and isolates the infected macrophages. This does not destroy the tuberculosis bacilli, but contains them,
preventing spread of the infection to other parts of the body. They are
nevertheless able to survive within the granuloma. In tuberculosis, the granuloma contains necrotic tissue at its centre, and appears as a small white nodule, also known as a tubercle, from which the disease derives its name.
Granulomas are most common in the lung, but they can appear
anywhere in the body. As long as the infection is contained within
granulomas, there are no outward symptoms and the infection is latent. However, if the immune system is unable to control the infection, the
disease can progress to active TB, which can cause significant damage to
the lungs and other organs.
If TB bacteria gain entry to the blood stream from an area of
damaged tissue, they can spread throughout the body and set up many foci
of infection, all appearing as tiny, white tubercles in the tissues. This severe form of TB disease, most common in young children and those with HIV, is called miliary tuberculosis. People with this disseminated TB have a high fatality rate even with treatment (about 30%).
In many people, the infection waxes and wanes. Tissue destruction and necrosis are often balanced by healing and fibrosis. Affected tissue is replaced by scarring and cavities filled with
caseous necrotic material. During active disease, some of these cavities
connect to the air passages (bronchi),
and this material can be coughed up. It contains living bacteria and
thus can spread the infection. Treatment with appropriate antibiotics kills bacteria and allows healing to take place. Upon cure, affected areas are eventually replaced by scar tissue.
Diagnosis of tuberculosis is often difficult. Symptoms manifest slowly and are generally non-specific, e.g., cough, fatigue, fever, which have many possible causes. The conclusive test for pulmonary TB is a bacterial culture
taken from a sample of sputum, but this is slow to give a result, and
does not detect latent TB. Extra-pulmonary TB infection can affect the
kidneys, spine, brain, lymph nodes, or bones - a sample cannot easily be
obtained for culture. Tests based on the immune response are sensitive but are likely to give false negatives in those with weak immune systems such as very young patients and those coinfected with HIV. Another issue affecting diagnosis in many parts of the world is that TB infection is most common in resource-poor settings where sophisticated laboratories are rarely available.
A diagnosis of TB should be considered in those with signs of lung disease or constitutional symptoms lasting longer than two weeks. Diagnosis of TB, whether latent or active, starts with medical history
and physical examination. Subsequently several tests can be performed to
refine the diagnosis: A chest X-ray and multiple sputum cultures for acid-fast bacilli are typically part of the initial evaluation.
Mantoux test
The Mantoux skin test consists of an injection of a small quantity of PPD tuberculin just below the skin on the forearm.
The Mantoux tuberculin skin test
is often used to screen people at high risk for TB, such as healthcare
workers or close contacts of TB patients, who may not display symptoms
of infection. In the Mantoux test, a small quantity of tuberculin antigen is injected intradermally on the forearm. The result of the test is read after 48 to 72 hours. A person who has
been exposed to the bacteria would be expected to mount an immune
response; the reaction is read by measuring the diameter of the raised
area. Vaccination with Bacille Calmette-Guerin (BCG) may result in a
false-positive result. Several factors may lead to false negatives;
these include HIV infection, some viral illnesses, and overwhelming TB
disease.
Interferon-Gamma Release Assay
The Interferon Gamma Release Assay (IGRA) is recommended for those who are positive to the Mantoux test. This test mixes a blood sample with antigenic material derived from the
TB bacterium. If the patient has developed an immune response to a TB
infection, white blood cells in the sample will release interferon-gamma
(IFN-γ), which can be measured. This test is more reliable than the Mantoux test, and does not give a false positive after BCG vaccination; however it may give a positive result in case of infection by the related bacteria M. szulgai, M. marinum, and M. kansasii.
Chest radiograph
In active pulmonary TB, infiltrates (opaque areas) or scarring are
visible in the lungs on a chest X-ray. Infiltrates are suggestive but
not necessarily diagnostic of TB. Other lung diseases can mimic the
appearance of TB, and this test will not detect extrapulmonary infection
or a recent infection.
A definitive diagnosis of tuberculosis can be made by detecting Mycobacterium tuberculosis organisms in a specimen taken from the patient (most often sputum, but may also be pus, cerebrospinal fluid, biopsied tissue, etc.). The specimen is examined by fluorescence microscopy. The bacterium is slow growing, so a cell culture may take several weeks to yield a result.
Other tests
Nucleic acid amplification tests (NAAT) and adenosine deaminase testing may allow rapid diagnosis of TB. In December 2010, the World Health Organization endorsed the Xpert
MTB/RIF system (a NAAT) for diagnosis of tuberculosis in endemic
countries.
Blood tests to detect antibodies are not specific or sensitive, so they are not recommended.
Polymerase chain reaction testing of urine for Mycobacterium tuberculosis is often required for the diagnosis of urogenital tuberculosis and may also be used to diagnose tuberculosis in biopsy samples from tissues. It is highly sensitive and specific, with good turnaround time.
Prevention
The main strategies to prevent infection with TB are treatment of
both active and latent TB, as well as vaccination of children who are at
risk.
Although latent TB is not infective, it should be treated to
prevent its development into active pulmonary TB, which is infective. The cascade of person-to-person spread can be circumvented by
segregating those with active ("overt") TB and putting them on anti-TB
drug regimens. After about two weeks of effective treatment, subjects
with nonresistant
active infections generally do not remain contagious to others;
however, it is important to complete the full course of treatment, which
is usually six months.
The only available vaccine as of 2021 is bacillus Calmette-Guérin (BCG). In areas where tuberculosis is not common, only children at high risk
are typically immunized, while suspected cases of tuberculosis are
individually tested for and treated. In countries where tuberculosis is common, one dose is recommended in healthy babies as soon after birth as possible. A single dose is given by intradermal injection. Administered to
children under 5, it decreases the risk of getting the infection by 20%
and the risk of infection turning into active disease by nearly 60%.It is not effective if administered to adults.
Airborne infection control
Airborne infection control (AIC) for tuberculosis is a set of
administrative, environmental, and personal protective actions taken to
reduce the spread of TB through infectious airborne respiratory
particles. AIC is critical in prevention and treatment strategies for
the disease globally.
Hierarchy of controls
The WHO outlines a three‑level hierarchy of TB infection prevention and control measures:
Administrative controls – early identification of presumptive TB
cases, triage, separation of infectious patients, and rapid initiation
of treatment.
Environmental controls – ventilation systems (natural, mechanical, or mixed‑mode), use of negative‑pressure rooms, and germicidal ultraviolet (UV) light fixtures to reduce airborne particle concentration.
Respiratory protection – use of medical masks and particulate respirators (e.g., N95 or FFP2) by health care workers and surgical masks by TB patients in high‑risk settings.
Special situations
Airborne infection control measures are particularly important in
high‑risk environments such as prisons, refugee camps, homeless
shelters, and health care facilities with limited resources. WHO
recommends tailored interventions, including upper‑room germicidal
ultraviolet systems, air filtration, and strict respiratory hygiene
practices in these settings.
India: National TB Elimination Programme
In India, airborne infection control is a key component of the
National Tuberculosis Elimination Programme (NTEP). The programme
emphasizes contact tracing in high‑risk populations, airborne infection
control measures in health facilities, and a multi‑sectoral response to
address social determinants of TB. Infrastructure scale‑up has included the establishment of over 6,400
molecular diagnostic laboratories and 81 culture and drug susceptibility
testing centres, alongside infection control interventions in hospitals
and medical colleges.
End TB Transmission Initiative (ETTi)
The End TB Transmission Initiative (ETTi) – Powering Airborne IPC is a working group of the Stop TB Partnership
focused on strengthening airborne infection prevention and control for
tuberculosis and other airborne pathogens. It was established to
highlight the importance of airborne IPC following recognition of
airborne transmission of diseases such as TB, SARS‑CoV‑2, influenza, and measles. The initiative advocates for airborne IPC as a global priority,
supports research and evidence dissemination, and promotes capacity
building to prevent transmission in health care, community, and
congregate settings.
Monitoring and evaluation
WHO recommends regular monitoring of airborne infection control
implementation through facility risk assessments, data collection on
ventilation and protective equipment, and evaluation of TB incidence
trends. Annexes in the WHO handbook provide tools such as facility TB
risk assessment forms, health worker screening registers, and checklists
for programmatic review.
Public health
A tuberculosis public health campaign in Ireland, 1905
The first International Congress on Tuberculosis was held at Berlin in 1899. It was known by this time that tuberculosis was caused by a bacillus, thought to be passed by phlegm coughed up by a sick person, dried into dust, and then inhaled by a healthy person. Milk was known to be an important means of infection. Means of prevention included free ventilation of houses and wholesome
and abundant food. Milk should be boiled, and meat should be carefully
inspected, or else the cattle should be tested for infection. Cures for
the disease included abundant food, particularly fatty foods, and life
in the open air.
TB was made a notifiable disease
in Britain; there were campaigns to stop spitting in public places, and
the infected poor were pressured to enter sanatoria that resembled
prisons. In the United States, concern about the spread of tuberculosis played a
role in the movement to prohibit public spitting except into spittoons.
Worldwide campaigns
Royal Navy sailors being screened for tuberculosis (1940)
The World Health Organization (WHO) declared TB a "global health emergency" in 1993, and in 2006, the Stop TB Partnership developed a Global Plan to Stop Tuberculosis, which aimed to save 14 million lives between its launch and 2015. Several targets they set were not achieved by 2015, mostly due to the
increase in HIV-associated tuberculosis and the emergence of multi-drug
resistant tuberculosis.
In 2014, the WHO adopted the "End TB" strategy which aims to reduce TB incidence by 80% and TB deaths by 90% by 2030. The strategy contains a milestone to reduce TB incidence by 20% and TB deaths by 35% by 2020. However, by 2020 only a 9% reduction in incidence per population was
achieved globally, with the European region achieving 19% and the
African region achieving 16% reductions. Similarly, the number of deaths only fell by 14%, missing the 2020
milestone of a 35% reduction, with some regions making better progress
(31% reduction in Europe and 19% in Africa). Correspondingly, also treatment, prevention, and funding milestones
were missed in 2020, for example, only 6.3 million people were started
on TB prevention short of the target of 30 million.
The goal of tuberculosis elimination is being hampered by the lack of rapid testing, short and effective treatment courses, and completely effective vaccines.
Tuberculosis phototherapy treatment in Kuopio, Finland, 1934A monograph on the treatment of tuberculosis (dated 1891)
The antibiotic
drugs used for treating TB are generally classified as either
first-line or second-line. Treatment with a combination of first-line
drugs (Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol) is preferred; they are more effective, and have fewer side effects. Second-line drugs are used if a person's TB infection either develops resistance to one or more first-line drugs, or if the infection comprises a drug-resistant strain. The second-line drugs are generally less effective, have more severe
side effects, and must be taken over a longer period of time.
Drug susceptible TB
An infection is drug-susceptible if it has no resistance to any of
the first-line drugs. To prevent the tuberculosis bacterium from
developing drug resistance, the recommended treatment regimens combine
four drugs. These should be taken over a period of 4 or 6 months. The 6 month regime, known by the acronym HRZE, comprises all four
first-line drugs (Isoniazid (H), Rifapentine (R), Pyrazinamide (Z), and
Ethambutol (E)) taken daily for two months, followed by just the H and R
drugs for the remaining four months. Evidence indicates that it is
highly effective if followed through properly. The four-month regime,
known by the acronym HMPZ, has moderate evidence of effectiveness and
several contra-indications. For the first 2 months, four drugs are taken (Isoniazid (H), Rifapentine (P), Moxifloxacin (M), and Pyrazinamide (Z)); followed by two more months with the H, P, and M components.
Drug-resistant TB (DR-TB)
A particular issue with TB treatment arises when an infection is
resistant to one or more of the treatment drugs. If first-line treatment
does not work for a patient, then the infection should undergo drug susceptibility testing
(DST) to develop a tailored second-line treatment regimen which will be
more effective. Historically, treatment regimens for multi-drug
resistant (MDR-TB) have required multiple drugs taken over long periods -
between 18 and 24 months. The expense, duration, and adverse effects of
these treatments mean many patients did not complete the course.
As of 2025, WHO recommends two shorter 6-month regimens and two
9-month regimens for DR-TB and MDR-TB using a combination of second-line
drugs taken orally; all have good evidence of effectiveness. The 6-month regimens are known by the acronyms BPaLM and BDLLfx:
It can be difficult for patients to adhere to their TB treatment
regimen. Several drugs must be taken daily for a long period, often with
unpleasant side effects. There is often a rapid improvement in
symptoms, so that patients stop taking medication even though the
infection is still active and likely to reassert symptoms after a
period. In areas without public health systems, prolonged treatment is expensive. Failure to complete a course of treatment can result in the emergence of drug-resistant tuberculosis.
Public health bodies recommend supporting patients during the treatment period. One form of support is directly observed therapy - a healthcare worker
watches the TB patient swallow the drugs, either in person or online. Other forms of support include having an assigned case manager, digital
monitoring, health education, counseling, and community support.
Tuberculosis
(TB) is generally curable with prompt and appropriate treatment, but
can be fatal if left untreated. The prognosis depends on factors like
disease stage, drug resistance, and a person's overall health. While
treatment is effective, delays or inadequate treatment can lead to
severe illness and death.
Without treatment, about two-thirds of people with TB will die of the disease, on average, within three years of diagnosis.
Progression from TB infection to overt TB disease occurs when the
bacilli overcome the immune system defenses and begin to multiply. In
some 1–5% of cases, this occurs soon after the initial infection. However, in the majority of cases, a latent infection occurs with no obvious symptoms. Over an individual's lifetime, these dormant bacilli produce active
tuberculosis in 5–10% of these latent cases, often many years after
infection.
Tuberculosis (TB) prognosis is significantly worsened by HIV
co-infection, leading to higher mortality rates and poorer treatment
outcomes. People with HIV are much more susceptible to developing active
TB, and even with treatment, they face increased risks of unsuccessful
treatment and death compared to those without HIV.
Epidemiology
Reports of tuberculosis can be found throughout recorded history. In Europe, Hippocrates, writing around 400 BCE describes phthisis; in India, the Vedas (composed 1500–1200 BCE) refer to yaksma; both of these are generally equated with tuberculosis. Earlier evidence
of tuberculosis has been found in prehistoric human remains in Europe,
Africa, Asia, and the Americas, with the earliest dating to the early Neolithic era (approximately 10,000-11,000 years ago).
Phylogenetic analysis of DNA lineages
indicates that the ancestors of the tuberculosis bacterium adapted to
human hosts in Africa around 70,000 years ago, and spread across the
globe with migrating humans.
The World Health Organization estimates that roughly one-quarter of the world's population carry infection with M. tuberculosis (prevalence), with new infections occurring in about 11 million people each year (incidence). Most infections with M. tuberculosis do not cause disease, and 90–95% of infections remain asymptomatic.
TB infection disproportionally affects low-income populations and countries. Factors like poverty, inadequate living conditions, and poor nutrition contribute to higher TB prevalence and incidence in these settings. Globally, the highest burden of TB is concentrated in low-income countries.
People living with HIV have a significantly higher risk of
developing tuberculosis (TB) compared to those without HIV. HIV weakens
the immune system, making individuals more susceptible to TB infection
and increasing the likelihood of progression from latent to active TB.
TB is also a leading cause of death among people with HIV.
To a certain extent, newly diagnosed TB infections tend to cluster in spring and summer;
this is attributed in part to lower vitamin D levels and indoor
crowding during the colder seasons, combined with a lag between
infection and diagnosis. The strength of seasonality varies with
latitude, with stronger patterns observed in regions farther from the
equator.
Number of new cases of tuberculosis per 100,000 people, 2022
Map showing the rate of TB deaths worldwide in HIV-negative people, by country, 2023.
Tuberculosis deaths by region, 1990 to 2017
Deaths from tuberculosis, by age, World, 1990 to 2019
At-risk groups
People deemed to be at higher risk for exposure to or infection from
M. tuberculosis include those who frequently travel to or live in
countries where TB disease is common; residents and employees of
densely-occupied settings such as homeless shelters, detention and
correctional facilities, and nursing homes; health care workers;
populations defined locally as having an increased incidence of TB
disease; those who are malnourished; and residents of resource-poor
communities.
There is a strong correlation between the risk for TB and
socioeconomic status (SES). Specifically, people of low SES are more
likely to contract TB. They also have more risk factors for TB disease,
including malnutrition, HIV co-infection, more exposure to crowded and
poorly ventilated spaces, and limited access to healthcare. Moreover,
inadequate healthcare translates to those living with TB disease not
being diagnosed and treated promptly, resulting in continued spread of
the disease to others.
TB is the leading cause of death among people with HIV. In fact,
people living with HIV are 12 times more likely to develop TB disease
than people without HIV because HIV weakens the immune system, making
individuals more susceptible to TB infection and progression from latent
to active TB.
The incidence of TB varies with age. Globally, TB occurs mainly
in adults 15 years and older. Men are more likely to be infected than
women.There is some evidence that, in countries with a low burden of TB such
as Britain, Canada and the US, incidence rates among those 65 and older
are consistently higher than in other age groups. A large portion of
active TB cases in this age group are thought to be due to the
reactivation of previously dormant TB infections.
Globally, Indigenous peoples are disproportionately impacted by TB. Australian Indigenous populations face disproportionately higher TB
rates, more than four times those of non-Indigenous Australian-born. In 2023, the rate of TB disease among First Nations in Canada was over 3 times that of the overall Canadian population. Contributing factors are the result of ongoing inequities stemming from
historical and ongoing impacts of colonization including isolation from
health services, food insecurity, higher prevalence of health conditions such as diabetes, overcrowding, and poverty.
Global trends
Global tuberculosis rates per 100,000 population, from 2010 to 2023. Shaded areas represent 95% uncertainty intervals.
Since the late 19th century, a combination of improved living
conditions and public health measures has resulted in declines in case
and mortality rates in Western Europe and North America. This trend
accelerated in the 1950s when effective drug treatments first became
available. However progress stalled and even reversed in some regions after the
1990s due to factors like drug resistance and the HIV/AIDS pandemic.
Global monitoring of TB incidence is primarily done through
annual reports by the World Health Organization (WHO), which has been
collecting data and publishing comprehensive reports on the disease
since 1997.
Geographical epidemiology
The distribution of tuberculosis is not uniform across the globe; it
is concentrated in low- and middle-income countries, with high-burden
regions including the WHO South-East Asia, African, and Western Pacific regions. High incidence of TB is strongly correlated with poor literacy and sex (male). Hopes of totally controlling the disease have been dramatically
dampened because of many factors, including the difficulty of developing
an effective vaccine, the expensive and time-consuming diagnostic
process, the necessity of many months of treatment, the increase in
HIV-associated tuberculosis, and the emergence of drug-resistant cases
in the 1980s.
Approximately 87% of new TB cases occur in the 30 high TB burden
countries, with more than two-thirds of the global burden occurring in
Bangladesh, China, the Democratic Republic of the Congo, India,
Indonesia, Nigeria, Pakistan, and the Philippines.
It is estimated that approximately 40% of the population of India carry tuberculosis infection. This is attributed to widespread poverty, malnutrition, overcrowding,
and poor hygiene, which facilitate transmission and disease development.
Factors like stigma, lack of awareness, delayed diagnosis, and the high
financial burden of treatment hinder progress. The emergence of
multi-drug resistant TB, together with weak healthcare infrastructure
contribute to the persistence of the disease, despite national control
programs. Overall, the rate of TB incidence (the annual total of new infections) in India has decreased from nearly 300 per 100,000 population in 2010 to 200 in 2023.
Indonesia
TB is a major health challenge in Indonesia, with an estimated one million cases annually and around 134,000 deaths each year. Factors contributing to this include a family history of TB,
malnutrition, inappropriate ventilation, diabetes mellitus, smoking
behavior, and low income level. Incidence of TB infection increased in 2020 and subsequent years; this
has been attributed to strain on health systems caused by the COVID-19
pandemic.
The incidence of TB in China has decreased over time, from 67 new cases per 100,000 of population in 2010 to 40 in 2023. TB risk is not uniform across the country, with higher relative risks
observed in the poorer western and southwestern regions, such as Xinjiang and Tibet. Quality of care is inconsistent, despite efforts by the Chinese Center for Disease Control and Prevention to improve diagnosis, referral and treatment nationwide.
Philippines
As of 2023, the Philippines accounts for 6.8% of global TB cases, the 4th worldwide. Cases have increased from 520 per 100,000 people in 2007 to 625 cases
per 100,000 in 2024, following a spike in numbers during the Covid-19
pandemic. TB in the Philippines has been linked with poverty, overcrowded living
conditions, malnutrition, and health inequities; in addition
institutional discrimination and stigma may lead to delayed diagnosis
and ongoing transmission.
Lesotho
Lesotho has an estimated 664 new infections per 100,000 population in 2023. This compares favourably with the figure of 1,184 in 2010. It is still one of the highest TB incidence rates globally. A major factor is the extremely high prevalence of HIV in the adult
population (around 23%), with many TB patients being co-infected. Other factors include lack of funding, mountainous territory making
access to care difficult, and poor adherence to therapy regimens.
Society and culture
Names
In different ages and cultures, tuberculosis went by many names. Phthisis (φθίσις) in ancient Greek translates to decay or wasting disease, presumed to refer to pulmonary tuberculosis; around 460 BCE, Hippocrates described phthisis as a disease of dry seasons. Tabes in ancient Latin has a similar meaning. Consumption, derived from Latin root con meaning 'completely' with sumere
'to take up from under', was the most common nineteenth-century English
word for the disease, and was also in use well into the twentieth
century. In The Life and Death of Mr Badman by John Bunyan, the author calls consumption "the captain of all these men of death."[214] "Great white plague" has also been used.
Art and literature
Painting The Sick Child by Edvard Munch,
1885–1886, depicts the illness of his sister Sophie, who died of
tuberculosis when Edvard was 14; his mother also died of the disease.
In 19th-century New England, tuberculosis deaths were associated with vampires.
When one member of a family died from the disease, the other infected
members would lose their health slowly. People believed this was caused
by the original person with TB draining the life from the other family
members.
Law
Historically, some countries, including Czech Republic, England, Estonia, Germany, Israel, Norway, Russia and Switzerland had legislation to involuntarily detain or examine those suspected to have tuberculosis, or involuntarily treat them if infected. As of 2025, many countries require TB cases to be notified to a national surveillance organisation (UK, US, European Union.). Many countries make either short term or long term entry visas for potential migrants conditional on a negative TB test.
Stigma
Tuberculosis stigma
is discrimination experienced by many people with TB, which acts as a
major barrier to health-seeking, treatment adherence, and overall
disease control.Depending on the setting, between 42% and 82% of people with TB report experience of stigma. This prejudice leads to social exclusion, delayed diagnosis, poor
adherence to treatment regimens, and thus poor treatment outcomes.
Slow progress in preventing the disease may in part be due to stigma associated with TB. Stigma may result in delays in seeking treatment, lower treatment compliance, and family members keeping diagnosis and cause of death secret – allowing the disease to spread further. Stigma may be due to misconceptions about the disease's
transmissibility, cultural myths, association with poverty or (in
Africa) HIV/AIDS. Studies in Ghana have found that individuals with TB may be banned from attending public gatherings, and may be assigned junior staff in health facilities. In India, people with TB may lose their job or be unable to marry.
Global programs
Between
1995 and 2015, the World Health Organization formulated 3 strategies
for the control and ultimately the elimination of tuberculosis, with a
target date of 2035. This diagram charts how these are linked and build
on each other.
The World Health Organization has formulated and promoted several
strategies to combat TB globally. The first of these, launched in 1995,
was DOTS (Directly Observed Treatment, Short-course), which promoted a standard course of treatment together with the appropriate resources and state support. The DOTS program, implemented by the member nations of the World Health
Organization, led to significant reductions in TB incidence and
mortality by improving case detection and treatment success rates.
In 2006, WHO adopted the Stop TB Strategy which implemented millennium development goal 6c (by 2015, to halt and reverse the incidence major diseases). This included and continued the DOTS program, with additional emphasis
on sustainable financing, improved technology, and improved emphasis on
drug resistance and HIV co-infection. This program ran from 2006 (when TB incidence was estimated at 8.8 million new cases) to 2014, when TB incidence was estimated at 9.6 million new cases.
The Stop TB Strategy was followed in 2014 by the End TB Strategy.
This sets targets of a 90% reduction in TB deaths and 80% reduction in
TB incidence by 2030, followed by reductions of 95% and 90%,
respectively, by 2035. A third target is that no TB-affected households
experience catastrophic costs due to the disease by 2020. This incorporated the principles of the previous strategies, while
introducing objectives for prevention based on the identification and
treatment of individuals with latent TB infection.
In 2012, The World Health Organization (WHO), the Bill and Melinda Gates Foundation, and the U.S. government subsided a fast-acting diagnostic tuberculosis test, Xpert MTB/RIF, for use in low- and middle-income countries. This is a rapid molecular test used to diagnose TB and simultaneously
detect rifampicin resistance. It provides results in about 2 hours,
which is much faster than traditional TB culture methods. The test is
designed for use with the GeneXpert System.
Research directions
As part of the End TB strategy, the WHO has identified four
areas where research-based innovations are needed. These are 1)
diagnostics, 2) treatment of active TB, 3) treatment of latent TB, and
4) vaccines.
Diagnostics
Diagnosis of TB infection is difficult, slow, and expensive. This is
particularly true of latent TB infection, or infection outside the
lungs. Diagnostics can be improved by developing faster, more sensitive
tests, preferably based on molecular testing of a blood sample rather
than traditional cultivation of a sputum smear; as well as creating
ultra-portable diagnostic devices for point-of-care use.
Treatment
Treatment for TB generally involves taking a cocktail of (sometimes
expensive) drugs daily over a period of months. It is not surprising
that people forget to take their medication or drop out entirely before
completing a course of treatment. Shorter and simpler treatment
regimens, as well as the introduction of new drugs, have the potential
to improve adherence and thus improve outcomes.
There are two specific areas where research can lead to
improvements in treatment. The first is the treatment of active
tuberculosis, both drug-susceptible and drug-resistant strains. The
introduction of safer, easier, and shorter treatment regimens would
improve availability and adherence, giving better outcomes. The second
area is the treatment and elimination of latent TB infection to prevent
it from developing into the active form; again, improved treatment
regimens would lead to better outcomes.
However, there is limited evidence that improved treatment
regimens would improve outcomes. It will also be necessary to improve health literacy and support structures for persons with TB.
Vaccines
Although it was originally developed over a century ago, as of 2025, BCG remains the only vaccine that is licensed for use; this is despite it having highly variable effectiveness. A promising vaccine candidate, MVA85A, failed in 2019 to demonstrate effectiveness in clinical trials. There is an urgent need for improved vaccines, which could be effective both before exposure to TB and also post exposure.
Other areas of research
Fundamental research needs to continue into topics such as the interaction between the bacterium and its human host, details of the chain of steps which culminate in TB transmission, and the social and political obstacles to effective implementation of the elimination strategy.
Other animals
Members of the genus Mycobacterium infect many different animals, including birds, fish, rodents, and reptiles. The species Mycobacterium tuberculosis, though, is rarely present in wild animals. An effort to eradicate bovine tuberculosis caused by Mycobacterium bovis from the cattle and deer herds of New Zealand has been relatively successful. Efforts in Great Britain have been less successful.
As of 2015, tuberculosis appears to be widespread among captive elephants in the US. It is believed that the animals originally acquired the disease from humans, a process called reverse zoonosis.
Because the disease can spread through the air to infect both humans
and other animals, it is a public health concern affecting circuses and zoos.
Transmission of both Mycobacterium bovis and Mycobacterium tuberculosis
between humans and cattle has been documented, underscoring the
importance of zooanthroponosis (human‑to‑animal transmission) and
zoonotic tuberculosis (animal‑to‑human transmission). This highlights
the need for a One Health approach that targets all four recognized
reservoirs of tuberculosis—active TB disease and latent TB infection in
humans, and active TB disease and latent TB infection in animals—if
elimination is to be achieved. Diagnostic challenges further complicate
control efforts, as commonly used nucleic acid amplification tests
cannot reliably distinguish between members of the M. tuberculosis complex, and infections with M. bovis
are naturally resistant to the first‑line drug pyrazinamide, making
species‑specific diagnostic tools essential for effective treatment and
surveillance.
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![Map showing the rate of TB deaths worldwide in HIV-negative people, by country, 2023.[54]](https://en.wikipedia.org/wiki/File:TB_mortality_rates_in_HIV-negative_people_2023.webp)
![Tuberculosis deaths by region, 1990 to 2017[178]](https://en.wikipedia.org/wiki/File:Tuberculosis_deaths_by_region,_OWID.svg)
![Deaths from tuberculosis, by age, World, 1990 to 2019[179]](https://en.wikipedia.org/wiki/File:Tuberculosis-deaths-by-age.svg)
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