and Southeast Asia, but recent reports suggest a worrisome reversal in several countries (Garcia-Bereguiain et al. , 2025;Pan American Health Organization, 2023). To assess regional progress, we analyzed trends in TB incidence rates across countries and dependent territories in the Americas, based on the most recent Global TB Report by WHO, available under the goals of the End TB Program. The American continent comprises 58 geopolitical entities: 35 sovereign countries and 23 dependent territories. According to the WHO Global TB Report datasets for 2015 (baseline year) and 2024 (most recent year available), data were reported for 45 entities (for at least one of the two years). We excluded five entities (Anguilla, Bermuda, British Virgin Islands, Montserrat, and Barbados) because incidence data were missing for either 2015 or 2024. The final analysis included 40 entities: 3 in North America, 7 in Central America, 18 in the Caribbean, and 12 in South America. We extracted the WHO variable "eᵢnc₁00k", defined as the estimated TB incidence rate (all forms) per 100, 000 population from the Global TB Report 2025. This variable aligns directly with the End TB Strategy milestone, which is defined as the reduction in the incidence rate relative to 2015. The percentage change between 2015 and 2024 was calculated for each entity, followed by analysis by subregion (country-by-country), and compared with the regional trend for the continent reported by the WHO (2024WHO (vs. 2015) ). According to the Global TB Report 2025, the net increase in TB incidence for the Region of the Americas was +13. 0%. This represents a 63-percentage-point deviation from the 2025 target of a 50% reduction. In our analysis, we found that only six territories achieved or surpassed the 2025 target of a 50% reduction in incidence rate: Cuba (-85. 3%), Saint Kitts and Nevis (-73. 8%), Antigua and Barbuda (-71. 1%), Grenada (-61. 4%), Jamaica (-55. 8%), and Dominica (-54. 5%). Two additional territories were within 10 percentage points of the target: Haiti (-45. 0%) and Curaçao (-41. 7%). Nine other entities showed reductions ranging from -34. 3% to -2. 9%. In contrast, 22 countries and territories experienced increases in TB incidence rate, ranging from +3. 0% to +2650. 0%. Entities exceeding the continental mean (+13. 0%) included Brazil (+19. 5%), Canada (+21. 6%), and Guatemala (+21. 7%). A group of countries and territories with higher increases included Sint Maarten (+30. 2%), Uruguay (+43. 1%), Aruba (+43. 1%), Paraguay (+47. 3%), Venezuela (+48. 4%), Colombia (+48. 5%), Trinidad and Tobago (+50. 0%), Turks and Caicos Islands (+56. 4%), Argentina (+57. 1%), and Ecuador (+57. 1%). But the most pronounced and worrying increases were observed in El Salvador (+118. 9%), the Cayman Islands (+345. 5%), Saint Lucia (+600. 0%), Costa Rica (+675. 0%), and Puerto Rico (+2650. 0). Table 1 summarizes the TB incidence results for each country and territory in the Americas. To further explore the potential impact of the COVID-19 pandemic on TB incidence trends, we conducted an additional regional analysis comparing pre-pandemic (2019) and postpandemic (2024) incidence rates with the 2015 baseline. Antigua and Barbuda was excluded from this analysis due to missing data, leaving 39 countries and territories included (Table 1). Regional TB incidence rates were calculated as population-weighted estimates using the formula: (sum of estimated TB cases/sum of population) × 100, 000. Incidence values for the Americas and their subregions in 2015, 2019, and 2024 are presented in Supplementary Figure 1. At the continental level, TB incidence increased by 3. 0% in 2019 and by 12. 3% in 2024 relative to 2015 (based on our group of 39 countries and territories). At the subregional level, the Caribbean, Central America, North America, and South America showed changes of -19. 9%, +13. 4%, -6. 3%, and +8. 2% in 2019, respectively. By 2024, these variations had shifted to -41. 1%, +34. 2%, +3. 0%, and +23. 7%, respectively. Overall, the post-pandemic period was associated with a more pronounced deterioration in TB incidence trends than the pre-pandemic period, with the exception of the Caribbean region. However, importantly, most subregions already showed unfavorable trajectories before the COVID-19 pandemic, suggesting that the current failure to meet the End TB milestones cannot be attributed exclusively to pandemic-related disruptions. Among the analyzed subregions, the Caribbean showed the largest reduction relative to 2015 levels, although this finding should be interpreted cautiously given the influence of low baseline incidence and small-population territories. According to the WHO Global Tuberculosis Report 2025, the Region of the Americas experienced the largest net increase in TB incidence between 2015 and 2024, with a rise of 13. 0%, followed by the Western Pacific Region with a modest increase of 1. 7%. In contrast, only two WHO regions achieved substantial reductions during this period: the European Region (-39%) and the African Region (-28%), although both remain short of the 2025 milestone targets. Overall, these trends indicate that the 2025 End TB milestones for a 50% reduction in TB incidence are being widely missed globally. The Americas show the most unfavorable trajectory among WHO regions, with the vast majority of countries far off track. The heterogeneity observed across sub-regions is noteworthy. On the one hand, there is enormous variability across the Caribbean region. Eleven of 18 countries in the region show decreases ranging from -85. 0% (Cuba) to -13. 6% (Dominican Republic) ; however, the remaining seven show increases ranging from +30. 2% to the outlier figure for Puerto Rico, at +2, 650. 0%. Central and North America follow similar trends. In the case of South America, following the same pattern as in 2023 (Garcia-Bereguiain et al. , 2025), only three countries show a decrease: Suriname at -2. 9%, Bolivia at -7. 3%, and Guyana at -34. 3%; the rest (9 out of 12) show increases ranging from +5. 6% (Chile) to +57. 1% (Argentina). Moreover, we call attention to the fact that extreme percentage increases observed in certain territories are largely driven by very low baseline incidence rates in 2015, where small absolute changes translate into disproportionately large proportional shifts. For example, Puerto Rico's increase from 2 to 55 cases per 100, 000 population represents a +2650. 0% change, reflecting the mathematical sensitivity of percentage change when starting from near-zero values. Similar dynamics may partially explain sharp increases in Costa Rica (+675. 0%) and Saint Lucia (+600. 0%). These findings highlight the need for cautious interpretation of percentage changes in low-incidence settings, where modest absolute fluctuations or model-based revisions can lead to exaggerated relative trends. Furthermore, it is important to note that extreme proportional increases should be interpreted in the context of broader epidemiological and health system data of each territory. It is important to note that the COVID-19 pandemic caused major disruptions in TB diagnosis, treatment, and prevention services worldwide (Falzon et al. , 2023). WHO documented sharp declines in TB case detection in 2020-2021, followed by partial recovery in subsequent years (World Health Organization, 2022, 2023). In some settings, increases in estimated incidence may reflect delayed detection, accumulated transmission during service disruptions, or improved post-pandemic surveillance. However, the magnitude of increases in several countries suggests that structural determinants are also contributing. On the other hand, socioeconomic instability, migration, urban overcrowding, incarceration, and rising prevalence of comorbidities such as diabetes may have amplified TB vulnerability in parts of Latin America (Liu et al. , 2024;Pan American Health Organization, 2008;Ramos-Rincon et al. , 2024;Rodríguez-Pazmiño et al. , 2025). TB is widely recognized as a disease strongly shaped by social determinants, including poverty and inequality (Lönnroth et al. , 2009). Economic downturns during and after the pandemic may have reversed prior gains in TB control. Additionally, financing gaps remain substantial. The persistent shortfall in TB research and program funding undermines the implementation of innovative diagnostics, the expansion of preventive therapy, and the development of shorter treatment regimens (World Health Organization, 2025). Without accelerated investment, the End TB milestones may remain aspirational rather than achievable. This study has several limitations that should be considered when interpreting the findings. First, the analysis was based on aggregated country-level estimates from the World Health Organization, which may be affected by differences in surveillance systems, case detection capacity, reporting quality, and diagnostic access across countries in the Americas. Furthermore, although these estimations represent the best available standardized metric for cross-country comparison, they are not direct measurements and rely on the good faith of the data each country presents, which may be influenced by a controversial political context (Garcia-Bereguiain et al. , 2025). Second, because this was an ecological and descriptive analysis, the observed temporal changes cannot establish causal relationships between the COVID-19 pandemic and trends in tuberculosis incidence or mortality. Third, the use of selected time points and regional averages may mask important within-country heterogeneity and subnational dynamics. Finally, although the analysis identifies broad regional trends before and after the pandemic period, more sophisticated longitudinal approaches, including interrupted time-series analyses or countryspecific modeling, would be necessary to better quantify the direct and indirect impacts of the pandemic on tuberculosis indicators in the region. Despite these limitations, the findings raise concerns about the trajectory of TB control in the Americas. With the 2025 milestone imminent (results will be presented in the 2026 Global TB Report) and the 2035 SDG targets approaching, intensified multisectoral action will likely be required. However, the present analysis was not designed to directly determine the relative contributions of specific factors underlying the observed trends, and further studies incorporating population-level data, longitudinal approaches, and modeling analyses will be important for better understanding the drivers of the regional setbacks observed after the COVID-19 pandemic. If current patterns persist, the probability of achieving the 2035 elimination targets appears low for much of the continent. Reaching a 90% reduction would now require not only reversing recent increases but also sustaining historically unprecedented annual declines over the next decade. Modeling analyses have previously warned that even before the COVID-19 pandemic, global progress was insufficient to meet long-term End TB milestones (Reid et al. , 2019;Tovar et al. , 2022). The pandemic-related disruptions, combined with persistent social inequities and financing gaps, have further widened this gap (Tovar et al. , 2022;World Health Organization, 2025). Future research should also explore the influence of social determinants, healthcare disruptions, financing gaps, and diagnostic access on country-specific TB trajectories in the Americas. Without accelerated investment, strengthened health systems, expanded preventive therapy, and structural interventions to address the social determinants of TB, the 2035 targets may remain aspirational rather than attainable in the Americas. Urgent, region-specific strategies will be required to realign the continent with the End TB pathway.
Rodríguez-Pazmiño et al. (2026) studied this question.