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Since a surge of tuberculosis in the 1990s, New York City has made significant progress in controlling the spread of the world’s leading infectious disease killer. But in recent years, cases in the city have started to tick up again.
In 2023, the city reported 684 confirmed TB cases, a 28% increase from 2022 and the highest number of confirmed cases since 2011, according to data from the New York City Department of Health and Mental Hygiene. Last year, the numbers rose again, to 839 confirmed cases, according to recent data from the agency.
That increase is concerning, said Dr. Barun Mathema, an associate professor of epidemiology at the Columbia University Mailman School of Public Health. While TB is an infectious disease, spread through the air, it is socially complex, he said, and is closely linked to a community’s health and well-being.
Controlling TB is resource- and time-intensive, involving contact tracing and ensuring adherence to long courses of treatment. But it also requires tackling social issues that contribute to the disease prevalence, like access to housing, employment, and food. When public health infrastructure falters or loses resources, experts say, TB can start to re-emerge.
Here’s what to know about TB and why cases have been on the rise in recent years.
What is tuberculosis?
TB is an infectious bacterial disease that primarily affects the lungs but can spread to other parts of the body. The bacteria can stay in a person’s body for years or even decades without making them sick or being transmissible to other people, in what is called latent TB.
But if a person’s immune system can no longer control the infection, latent TB can develop into active TB, which can lead to sickness or even death, especially if left untreated. TB germs can spread through the air when a person with active TB coughs, speaks, or sings. In comparison to highly transmissible diseases like measles, TB typically requires prolonged, close contact to spread.
In the United States, those at higher risk of disease exposure include people who live in certain congregate settings like homeless shelters or prisons, as well as people traveling from countries where TB is common, according to the Centers for Disease Control and Prevention. People at risk of developing the disease, if infected, include those with immune systems that are weakened due to medications, or conditions like cancer or HIV/AIDS.
In its primary stage, TB manifests with flu-like symptoms, like a low fever, tiredness and cough. Active TB disease can result in coughing up blood or mucus, chest pain, fever, and chills, among other symptoms.
How is tuberculosis treated?
The disease is treated through the use of antibiotics, and a patient is typically required to take daily medications over many months.
“Treatment adherence is something of a problem,” said Dr. Don Des Jarlais, a professor of epidemiology at the NYU School of Global Public Health. “Health departments try to have outreach workers who visit people who have TB to remind them to take their medication.”
In New York City, every person with active TB is assigned a case manager who educates the patient and ensures attendance at medical appointments, said Dr. Joseph Burzynski, assistant commissioner for the city Health Department’s Bureau of Tuberculosis Control. Contact tracers also work to track down other people who might have been exposed and get them tested.
“The case manager makes sure that the patient goes all the way from testing through treatment, makes sure that the patient has access to the medications, and takes their medication every day — all the way to the end of treatment,” Burzynski said.
The Health Department runs three TB clinics, which provide low- to no-cost testing and treatment for the disease. The medical services offered are confidential, and do not require health insurance or revealing one’s immigration status.
Globally, a growing issue of drug-resistant TB complicates the work of controlling this disease. Drug-resistant TB doesn’t respond to common medications and requires more complex treatment. The World Health Organization describes multidrug-resistant TB as a public health crisis, noting that worldwide, only about 2 in 5 people with drug-resistant TB accessed the treatment in 2023.
Although TB is preventable and curable, about 8.2 million people were newly diagnosed with TB in 2023, the highest number since global monitoring began in the 1990s, and 1.25 million people died from the disease that year, according to the WHO.
City brought down tuberculosis surge in 1990s
In the late 1980s and early 1990s, New York City saw an explosion of TB cases, driven by a confluence of health and social issues, including the HIV/AIDS epidemic, homelessness, and substance use.
From 1984 to 1992, the number of TB cases in the city rose 139%, according to data from the Health Department. For a few years in the early 1990s, the city recorded more than 3,500 TB cases annually.
“Back in the ’90s, the big problem was really HIV infection making people much more susceptible to TB, and a fair number of them died from TB because of their weakened immune system,” said Des Jarlais, who at the time worked to expand TB testing at syringe exchange programs in the city.
In addition to the HIV/AIDS epidemic, an increase in people coming to New York and disinvestment in public health resources in the late 1980s helped create the conditions for TB cases to spike in the city, Burzynski said.
“We had a very small program, and part of the success in the response at that time was a major reinvestment in public health, and particularly in TB control,” he said. “We got a huge amount of money with additional staff, increased case management capabilities, and increased public health laboratory capabilities.”
The number of TB cases in the city has fallen dramatically since then, with a 83% decrease from 1992 to 2013. Experts attribute that decline to the city’s creation of a robust TB control program, as well as to successful efforts to control HIV.
But eventually, TB started to re-emerge. From 2013 to 2023, the city recorded an 18% increase in TB cases, including a 28% increase from 2022 to 2023.
Between 2023 and 2024, the rate of TB in the city rose from 7.8 to 9.5 per 100,000 people. Last year’s data show that 18 neighborhoods have TB rates higher than the citywide rate, especially in the Bronx and Queens.
Why have tuberculosis cases increased?
There isn’t one explanation for why TB cases have started to rise again, but there are multiple contributing factors, experts say.
The recent low of 444 confirmed TB cases in 2020 reflects, in part, the impact of Covid-19. The pandemic limited TB control work, as New Yorkers avoided medical care, and case management and contact tracing became more difficult, Burzynski said.
“Now that things have reopened up, there are more people coming into New York City, more people coming here from places with high rates of TB,” he said.
In recent years, New York City has experienced a surge in migration, but that doesn’t fully explain the increase in TB. In 2024, among non-U.S. born people, the average number of years in the United States at the time of TB diagnosis was 12 years, according to city data.
TB cases also closely track the public health cycle of investment during crises and disinvestment when crises wane, experts say.
In recent years, the city’s TB division has struggled with staffing shortages. The division continues to face vacancies among case managers, contact tracers, and epidemiologists, Burzynski said.
In fiscal year 2024, agency positions budgeted for TB prevention and treatment had a 16% vacancy rate, a small improvement on the 20% vacancy rate the prior year, Crain’s reported last year.
With more robust funding, the Health Department would be better positioned to quickly respond to new TB cases, Dr. Michelle Morse, the Health Department’s acting commissioner, has previously told Healthbeat.
Dramatic federal health policy decisions have also impacted the city’s TB control work. Earlier this year, seven employees of the CDC who worked at the Health Department, including on TB case management, outreach, surveillance and data collection, were terminated amid mass layoffs at the federal agency. And the $100 million in federal funding cuts that the city Health Department faces will likely impact its ability to track and respond to infectious diseases.
“We are hoping that we will have continued investment in public health resources to be able to do our work, because as cases go up, if there’s disinvestment, we’ll be less able to perform the work that’s really important for TB control,” Burzynski said.
Since New York City has historically been such a leader in TB control, Mathema, the Columbia epidemiologist, said it’s “particularly disheartening” to see cases start to rise again.
“The numbers are the numbers,” he said. “I hope that it’s a bit of a call to our policy makers to turn the ship around.”
Eliza Fawcett is a reporter covering public health in New York City for Healthbeat. Contact Eliza at efawcett@healthbeat.org.
